Inova Health System
Cardiovascular Disease Task Force
Report of Task Force Findings and Recommendations
Working Draft 6-28-04
I. Introduction
The following is a summary of the findings, conclusions and recommendations of the
Cardiovascular Disease Task Force. The Cardiovascular Disease Task Force was
convened to review the concept of a long-term, exclusive agreement for cardiac surgery
services between Cardiovascular and Thoracic Surgery Associates (CTSA) and Inova
Health System.
II. Background
For some time, ongoing discussions had taken place between Inova Health System and
Cardiovascular and Thoracic Surgery Associates (CTSA) about establishing an exclusive
agreement for cardiac surgery. Pending execution of a definitive exclusive agreement,
Inova and CTSA entered into a letter of agreement granting CTSA exclusivity for cardiac
surgery services. Prior to finalizing the long-term exclusive agreement, Inova
administrators spoke with cardiology leaders who expressed significant concerns about
establishing such an agreement.
The cardiologists' concerns related to perceived inequities in relationships between
cardiologists, cardiac surgeons and the Inova administration. It was their belief that an
exclusive agreement did not fit with the private practice medical model of the Inova
hospitals and that such an agreement could make cardiac surgeons less responsive to the
needs of cardiologists. Concerns also were expressed about maintenance of quality and
the adoption of new technology and techniques by the present cardiac surgery group. At
a special meeting of the Cardiology Section in November 2003 members voted
unanimously against the establishment of an exclusive agreement for cardiac surgery.
In response to the cardiologists' concerns about maintaining quality care and ensuring
access to state-of-the-art cardiac surgery under a long-term exclusive agreement with
CTSA, Tim Wright, MD, president of the medical staff, Inova Fairfax Hospital and Inova
Fairfax Hospital for Children, convened the Cardiovascular Disease Task Force on
December 19, 2003. The task force was asked to:
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Facilitate direct communication between cardiac surgery, cardiology and other
representatives of the medical staff and administration around this issue
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Determine how to ensure and enhance the quality of cardiac surgery and cardiology at
IFH and IFHC
Review best practices and models for cardiac surgery and cardiology
Determine the impact of potential multiple cardiac surgery groups on the quality and
future of cardiac surgery at IFH and IFHC
Review issues, old and new, concerning cardiac surgery and cardiology
The task force, chaired by Richard Binder, MD, has meet every two weeks since January
13, 2004 to accomplish the assignment. The members of the task forces are as follows:
Ali Assefi, MD
Barry Dicicco, MD
Kristen Edminston, MD
Cleveland Francis, MD
Seymour Hepner, MD
Samuel Jones, MD
Joseph Kiernan, MD
Edward Lefrak, MD
John Maddox, MD
Paul Massimiano, MD
Robert Mesrobian, MD
Harvey Sherber, MD
Alan Speir, MD
Anne Summers, MD
ShahramYazdani, MD
Doug Cropper
Candice Saunders
To assist the group, Tom Warren, executive vice president, New Option Group, an
outside professional group facilitator was engaged. Mr. Warren interviewed all of the
task force members using a structured interview process and questionnaire.
In addition to the interview findings, the task force members requested the following
information to assist them in forming a final recommendation:
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What are the strategic vision and goals of the Inova Heart and Vascular Institute?
What are the key elements of an exclusive agreement and what is the relevant
historical information on the exclusive agreement discussions?
What are the perspectives of the hospital, cardiac surgery and cardiology related to
the advantages and disadvantages of an exclusive agreement?
What have other programs done (exclusive/open model)?
What can be learned from the Cardiology Roundtable regarding national experience
with exclusive/non-exclusive agreements?
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III. Summary of Findings from Research Conducted to Provide Information
Requested by Task Force Members
A.
Summary of Interview Findings conducted by Tom Warren:
New Options Group conducted thirty minute, face to face or telephone interviews
with the following doctors: Assefi, Edmiston, Francis, Hepner, Jones, Kiernan,
Lefrak, Maddox, Massimiano, Mesrobian, Sherber, Speir, Summers and Yazdani.
This group has over 252 years in practice and 218 years of Inova experience and
identified with one of the following groups: ‘Other’ Medical Staff, Cardiologist,
or Cardiac Surgeon. In addition, we spent time with Candice Saunders, and Doug
Cropper (Administration).
The expected outcome of the dialogue was to increase the understanding of the
current issues to be addressed by the task force.
Generally, the following questions were asked to achieve the stated outcome.
1. Think back through your career in the heart program. Locate a moment that
was a high point, when you felt the program performed really well. Describe
what made the situation possible.
2. Knowing what you know about Inova Fairfax Hospital and Inova Fairfax
Hospital for Children’s heart program today rate the following statement:
Today Inova Fairfax Hospital and Inova Fairfax Hospital for Children’s heart
program is an industry leader. Strongly Agree (6) – Agree (5) – Slightly
Agree (4) – Slightly Disagree (3) – Disagree (2) – Strongly Disagree (1).
Why did you rate the program the way you did?
3. What do you value most about being a part of this program? Why?
4. What do you wish could be different? Why?
5. Describe a time in this program when you observed an extraordinary display
of collaboration between the members. What made that collaboration
possible?
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Interview Results:
All four groups clearly articulated the primary and most critical issue as: the need to
improve trust and communication between the groups. In addition, all agreed that the
Inova Heart Program, specifically cardiology and cardiac surgery, provides excellent
patient care and outcomes across the program; they described the program as progressive
and efficient and there is “not much you can’t get done here.” While there are concerns,
all felt the physicians get what they need for their patients. In response to question 2 they
rated the program overall 4.8 out of 6.
All concurred that in order to move the heart institute forward there must exist a high
level of truth and transparency from all parties involved, a collaborative effort starting
immediately, improved communications and data on models that work for the best patient
outcomes.
Cardiac surgeons and cardiologists voiced concerns over how to improve research for the
Institute. However, their perspectives differed in that the cardiologists spoke of a
concern for compensation while the surgeons are concerned that the cardiologists do not
have the section infrastructure to facilitate research.
Lack of cohesiveness of the Cardiology Section came up frequently as a concern by all
parties interviewed. The group expressed concerns over the cardiologists’ inability to
speak with one voice and to develop and articulate a clear unified section plan in support
of the Institute.
The cardiologists and other medical staff spoke of a potential “slippery slope,”
threatening the private practice model enjoyed at Inova Fairfax Hospital. In addition, both
groups felt the cardiovascular surgeons treat the rest of the medical staff with
indifference. Both spoke of a lack of equity in benefits provided by the hospital as well
as a perceived lack of physician input in decisions that shape their sections.
The cardiologists feel disengaged from administration, who seem to favor and grant more
time, resources and access to the cardiac surgeons.
B.
What are the strategic vision and goals of the Inova Heart and Vascular
Institute?
The following vision and goals were developed as part of the Inova Heart and
Vascular Institute business plan in 2001.
Mission:
To provide quality care and to improve the health of the diverse communities we
serve.
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Vision:
The Inova Heart and Vascular Institute will achieve distinction as a top ten
program nationally through:
 Unsurpassed clinical quality and patient care service
 Exceptional ease of use
 Unmatched comprehensive and compassionate care for all
 Integration of leading technology and clinical care
 National recognition for research and education
Goals:
Medical Staff Relationships
Create an environment that is responsive to physicians needs and supports a
positive working relationship.
Marketing and Referral Development
Achieve 26 percent growth (over 2001 volume) in cardiac discharges by 2006.
Operational Excellence and Facility
Create a superior patient care model that incorporates patient and clinician ease of
use (access and flow) and delivers the best possible clinical outcomes.
Technology
Become an early adopter of state-of-the-art clinical and state-of-the-market
information technology to obtain a competitive advantage through advancements
in outcomes, access, and communication.
Research
Become a top-tier site for multi-center trials, a preferred site for pharmaceutical
and device trails, and originator of clinical research protocols.
Education
Create exceptional educational opportunities and symposia that improve physician
and clinician expertise and become a vehicle for regional and national visibility.
Fundraising
Establish a fundraising committee to pursue donations to fund research and new
Program development.
Wellness
Offer a coordinated cardiac prevention and education program to the community.
Workforce
Build a dedicated cardiac workforce through recruitment, development,
recognition, and retention of superior employees.
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C.
What are the key elements of a proposed exclusive agreement and what is the
relevant historical information on the exclusive agreement discussions?
Historical Information
 CTSA restarted the cardiac surgery program at Inova Fairfax Hospital in the
fall of 1977. Edward Lefrak, MD, was the founding member of CTSA
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Currently there are 11 cardiovascular surgeons, all members of CTSA
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CTSA has practice locations at Fairfax, Alexandria, Arlington, and Bethesda
Naval Hospitals
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Services offered include comprehensive cardiac surgery for neonates, children
and adults, vascular and thoracic surgery and involvement in state-of-the art
procedures, e.g.,
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Heart and lung transplant
Robotic heart surgery
Left ventricular assist devices
Minimally invasive approaches to heart surgery
Thoracic surgery – not part of exclusive contract
Vascular Surgery – not part of exclusive contract
Transmyocardial laser revascularization
Complex thoracic aortic surgery
Ross procedure
Maze procedure
Key Elements of a proposed Exclusive Agreement
General:
 Scope of exclusive agreement: cardiac surgery (does not include vascular or
thoracic surgery)
 Terms related to recruitment and retention of physicians with benchmarks for
triggering recruitment of additional physicians (expansion and succession
planning)
 Provisions for the mentoring and training of new physicians – succession plan
Customer Service:
 Standards for physician access and availability i.e. scheduling, timeliness, etc.
 Responsiveness to referring physicians and patients in resolving clinical issues
 Meeting attendance to provide information/education
 Promote and comply with established service standards for patients and staff
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Reducing Variability and Cost Management:
 Write and update protocols regularly to provide guidance to staff and decrease
variability in practice – standardization for care management
 Work collaboratively with leadership and staff to plan and implement surgical
services in the most effective and efficient manner
 Monitor individual practitioner performance and assume responsibility for
controlling costs and decreasing variability
 Establish annual goals to increase efficiency and decrease costs
Quality Improvement and Physician Performance Review:
 Establish a clear plan for orienting and monitoring all new physicians in the group
 Meet or exceed national benchmarks with outcome indicators
 Peer review with quarterly reporting and evidence of appropriate actions
 Annual independent external peer review
D.
What are the perspectives of the hospital, cardiac surgery and cardiology
related to the advantages and disadvantages of an exclusive agreement?
Potential Advantages:
 Facilitates clinical management and efficiency
 Attempts to improves quality of care outcomes
 Provides consistent peer review efforts with action plans
 Ensures availability of services to all hospital patients
 Fosters joint development of physician and staff recruitment and retention
plans, based on national benchmarks and programmatic needs
 Leads and participates in hospital committees and planning efforts
 Avoids political issues of multiple groups
 Oversees and supervises the teaching program
 Ensures physician succession planning
 Leads clinical pathway development and outcome research
 Participates actively in quality and utilization management programs
 Facilitates communication
 Takes an active role in cost management and vendor relations
 Simplifies and streamlines decision making
 Can include an effective non-compete provision in contract
 Relationships are performance based, with continued pursuit of excellence
(“raising the bar”)
 Provide mechanism to promote communication and transparency
Potential Disadvantages:
 Less incentive to focus on customer service
 Less incentive to be aggressive in keeping up with the market needs
 Lack of incentive to continue to recruit and retain
 Less motivation to add new skills
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E.
Group issues and problems with physician recruitment, retention or quality of
care directly affect the hospital
Potential conflict with cardiology groups who may want to employ cardiac
surgeons
Patient volume for the hospital is dependent on the quality of the exclusive
group and their relationship with referring physicians
Implementation of an exclusive agreement may be difficult to dissolve
What have other programs done (exclusive/open model)?
David Ashman, an internal consultant, added to benchmark information the
collection of which began two years ago. Data was collected from interviews
with hospitals listed as Solucient Top 100 Cardiovascular Hospitals and U.S.
News and World Report Top 50 Heart and Heart Surgery Centers. Best practice
calls to health systems with large cardiac programs were conducted and data from
the Healthcare Advisory Board (HCAB) was also used as a resource. Key
consideration were hospitals with a cardiac program similar in size and scope to
Inova Fairfax Hospital. The findings from the interviews are summarized in an
attachment.
Summary of Benchmark Research:
 After reviewing the benchmark research, task force members concluded that a
program can achieve distinction and excellence in many different ways. We
talked with organizations that had exclusive agreements for cardiac surgery
only, exclusive agreements for cardiac surgery and cardiology as well as open
staff models.
 Overall, administrators contacted a who had an exclusive agreement for
cardiac surgery noted that exclusivity in their institution has proved to be
beneficial for the hospital’s open heart surgery program:
 Increased efficiencies / standardization of care from exclusive agreement
model
 Improved clinical outcomes
 Many of the hospitals received initial push back from cardiologists related
to exclusive agreements
 No major legal issues have arisen from exclusive arrangements
 Key success factor for hospitals – maintaining an open cardiology
department
Suggestions from centers about exclusive contracting with cardiac surgeons
or cardiologists
 Anticipate future needs of the hospital and physicians
 Succession Planning
 Growth
 Services offered
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Evaluate the exclusive group’s performance during contract renewals
 Quality
 Growth
 Cost
 Patient Satisfaction
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Maintain an open cardiology department
 Do not hinder access to hospital services or to other specialties
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Establish process for external peer review
IV. Conclusions
Task Force members represented had a broad range of opinions and perspectives about
exclusive contracts, in general and specifically about an exclusive agreement for cardiac
surgery. Following are the conclusions drawn by the task force:
1. After reviewing the benchmark research, task force members concluded that a
program can achieve distinction and excellence in many different ways. Further, they
agreed that pursuing an exclusive contract needs to align with the overall strategy of
the program and the market conditions of the location.
2. The task force also concluded that quality is not an issue with the present cardiac
surgry group; rather there is an acute need for a forum to foster ongoing
communication.
3. The task force concluded that routine meetings of the cardiologists, cardiac surgeons
and administration are needed to facilitate dialogue on clinical and business
outcomes, patient satisfaction, adoption of new technology/procedures and
performance metrics related to the vision of achieving distinction as a top ten heart
and vascular institute.
4. Based on the overall strategic vision and goals of the new Inova Heart and Vascular
Institute, administration believes that an exclusive agreement for cardiac surgery will
help Inova continue to create a superior patient care model that delivers the best
possible clinical outcomes.
5. The cardiologists identified numerous issues about their relationships with
administration, cardiac surgery and other groups. Concerns about relationships
amongst the cardiologists as a group were discussed and the task force recommended
that the issues identified be addressed through the newly formed Cardiology Council.
6. Task force members agreed that the meetings with the open discussions have fostered
a better understanding of the facts around a potential exclusive agreement for cardiac
surgery and that the open discussions must continue between administration, cardiac
surgery and cardiology.
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7. The task force concluded that the present cardiac surgery service works.
Nevertheless, both administration and the cardiac surgeons are concerned about the
erosion of cardiac surgery volumes related to the availability of less invasive
therapies to treat heart disease. The cardiac surgeons are concerned that decreasing
cardiac surgery volumes will compromise their ability to support the comprehensive
services they now provide. They discussed that they can afford to provide services
like pediatric cardiac surgery and heart/lung transplant as part of their overall
commitment to the program despite the financial burden associated with these
programs because adult volumes help support these programs.
8. The cardiologists on the task force remain concerned that implementation of a longterm exclusive agreement for cardiac surgery will be difficult to dissolve. They also
understand that opening the cardiac surgery service may disrupt the program at a
vulnerable time in light of the opening of the new heart hospital in October 2004 and
the unknowns related to the cardiac surgery volumes.
9. Based on these conclusions, a two-year moratorium on changes to the present cardiac
surgery physician agreement was proposed. This would allow the administration,
cardiac surgery and cardiology to continue the open dialogue and to put into place
some of the changes discussed. At the end of the two-year period an assessment of
the progress made will be conducted. Input will be sought from the appropriate
sections and a final decision regarding a definitive exclusive agreement for cardiac
surgery will be made. The task force members supported this proposal with the
requirement that a work group with representatives from administration, cardiac
surgery and cardiology be formed immediately to address the issues and opportunities
identified.
10. During the two-year period, every six-month update on the work group’s progress
will be given to the Medical Executive Committees (MEC). At the end of the twoyear period a recommendation regarding a long-term exclusive agreement for cardiac
surgery will be made to the MEC.
V. Recommendations:
1. A two year moratorium will be put in place to maintain the present cardiac
surgery physician model. Hospital administration will work with legal counsel to
develop the vehicle to facilitate this.
2. A written and verbal report of the Cardiovascular Task Force will be presented to
the Sections of Cardiology, Pediatric Cardiology and Cardiac Surgery to inform
them and solicit comment by the section members prior to presentation to the
Medical Executive Committee.
3. A collaborative system-wide Inova Heart and Vascular Institute Council will be
formed and begin to meet in July 2004.
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The goal of the systemwide council will be to achieve distinction as Top 10 heart
and vascular institute. The council will:
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Develop and implement a strategy to achieve distinction as top 10 heart and
vascular institute.
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Provide on-going review of best practices and models for cardiology and
cardiac surgery
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Establish and evaluate outcomes/performance indicators for cardiovascular
services on a quarterly basis
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Serve as a vehicle for communication
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Serve as an interdisciplinary forum to provide input on new services,
technology, etc
The members will consist of representatives from Cardiology, Pediatric
Cardiology, Cardiac Surgery and Administration. The Section Chiefs of
Cardiology, Pediatric Cardiology and Cardiac Surgery will work with
Administration to develop the list of council members
4. Reports of the Council's activities and results will be given to the Medical
Executive Committee, Sections of Cardiology, Pediatric Cardiology, Cardiac
Surgery and Vascular Surgery on a quarterly basis.
5. The Council representatives will meet with the Cardiovascular Disease Task
Force members annually to provide a progress report.
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