Sixty UCSF Stanford cardiologists, cardiothoracic surgeons, cardiac anesthesiologists and nuclear radiologists heard presentations by me and by newly-appointed cardiac service line director Bruce Reitz. Following the presentations the group split up into seven affinity groups to discuss specific areas of clinical collaboration. A talk by Chief Executive Officer Peter Van Etten rounded out the day.

The discussions ranged from nuts and bolts to larger concepts.

"We're taking both a macro and a micro approach to organization," said cardiac service line administrator Karen Rago, who served in that role for Stanford Health Services (SHS) prior to the merger that created UCSF Stanford Health Care. "At the macro level, the major accomplishment has been to get both sites to agree to a new common clinical data system for measuring outcomes. We have agreed on the Seattle system, which will allow us to easily share our data and monitor quality. In cardiac services, purchasers pay close attention to outcomes data, so it is critically important that we have a reliable system for adjusting severity and measuring the differences between expected vs. observed outcomes."

At the micro level, Rago expects that a great deal of the work will be accomplished in affinity groups created around patterns of clinical practice. The groups are general cardiology, noninvasive cardiac imaging, interventional cardiology, heart failure/post heart transplant, electrophysiology, cardiac surgery and thoracic surgery. "When we look at opportunities to build programs, or to cut costs, for that matter, it's important to focus in fairly narrowly. At the same time we need to manage the larger issues, such as funds flow and facilities, that will affect the service line as a whole."

Both Reitz, a cardiovascular surgeon and acting chair of surgery at Stanford, and Rago are strong advocates for the service line approach in heart care. Rago says, "Our approach in managing the service line has been to measure everything - from patient satisfaction to clinical outcomes and cost reduction. We use the continuous quality improvement model to keep benchmarking and moving forward on critical indicators."

Reitz is enthusiastic about the potential of service lines to improve patient care. "Cardiologists, electrophysiologists and cardiothoracic surgeons are natural collaborators. The service line will help create the context and setting for that collaboration. Many clinical problems can legitimately be treated in several different ways, but patients should not have to decipher contradictory advice given by different specialists."

Cardiac services is the largest service line at UCSF Stanford Health Care, and it is poised to become even larger, according to leaders on both campuses. Cardiothoracic surgeon Scot Merrick, acting director of UCSF Adult Cardiothoracic Surgery, says there is considerable room for growth in the San Francisco and North Bay market. "I expect that managing adult cardiac services as a service line will be very important to the UCSF program. We need an organized effort with a lot of individuals pulling in the same direction in order for consistent program development to take place. In the past, the UCSF program has been recognized for its excellence in innovative mitral valve surgery, but program growth has been hindered by space constraints. After a successful re-engineering effort, our costs are now quite competitive and we are eager to expand.

"We have a number of innovative programs on the drawing board. One is a new approach to minimally invasive cardiac surgery, and another is to collaborate with community hospitals in the placement of ventricular assist devices for patients awaiting transplants," Merrick says.

Overall, cardiac services represent nearly one-third of the activity of the entire enterprise. There are more than 60 cardiologists and cardio-thoracic surgeons, treating more than 6,200 inpatients annually.

When it comes to cardiac procedures, bigger programs tend to be better. Studies have repeatedly found that for procedures such as heart transplants, angioplasty and coronary artery bypass grafts, high volume is directly correlated with a lower incidence of morbidity and mortality. Payors - in particular, the Health Care Financing Administration (HCFA) - are recognizing and rewarding the volume/quality link.

Size was one of the key eligibility factors for programs applying to participate in a series of highly visible HCFA demonstration projects prior to the merger. The Stanford program was large enough to qualify while the smaller UCSF program was not. "UCSF focused on building its children's cardiac surgery program, which is about as large as Stanford's adult program," says Rago. "A key goal of the service line will be to grow the adult cardiac program at UCSF."

The chief of cardiology at UCSF, Bill Grossman, is looking forward to the increased volume because of the increased opportunities for clinical trials when the two organizations combine their numbers. "When you can provide a larger patient population, more pharmaceutical and device companies want to work with you. The more desirable we are as a clinical trials center, the better deals we can cut. We will then be in a leadership role for translating these new discoveries to the bedside."

Tom Quertermous, the recently appointed chief of cardiology at Stanford, sees room for growth at both campuses. "I can see room for our clinical activity increasing about 10 percent," he says. One initiative he believes will attract patients is the creation of a women's heart center. "There are only a few of these programs in the country, but I know that the one at the University of Michigan is doing extremely well," Quertermos says.

The leaders of the cardiac service line are looking forward to having more control of resources. Although service line funds flow is not expected to be complete until year three of the merger, Reitz has volunteered the adult cardiac service line as a test case for funds flow. "All of our important goals - market growth, cost management and clinical collaboration - would be much more easily achieved if we had control of resources and could reward appropriate behavior. Ultimately, it's a question of accountability. If you have something at stake, you are much more likely to actively participate in making the service line a success," Reitz says.

President of the Medical Staff

Chief Medical Officer, UCSF Stanford Health Care

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