Bigger, Better, and Worse – Trajectories of Congenital Heart Centers

For Heart Centers, becoming ‘Bigger’ is often thought to lead to improvement in the quality of care (e.g. Better). Conversely, we often assume that being ‘Better’ will lead to programmatic growth (e.g. Bigger). Examination of trends in publicly reported outcomes - and my personal experience trying to help Heart Centers with team optimization, however, suggests that the trajectory of a Heart Center navigating major changes in clinical volume can be highly variable.

Better can lead to Bigger:

Market forces - In a competitive market, a Heart Centers’ sole and ethically sound method of competing is to deliver the highest possible quality care to patients/parents and referring providers. Consistent delivery of an excellent ‘product’, is expected to lead to increasing referrals and programmatic growth.

Ethical imperative – “If we are delivering better care than any center in the region, then are we morally obligated to treat as many patients as possible”. This rationale can be a rallying cry for a Heart Center to foster growth – and motivate the team to accommodate higher workloads at the limits of available resources. The ‘ethical imperative’ implies that being Better (than our competitors) implies that we should become Bigger to create the largest possible beneficial impact in accordance with the missions of our Heart Center and Hospital.

Bigger can lead to Better:

Heart Center Remuneration and Non-Cardiac Hospital Priorities- Caring for more patients provides a financial benefit to the hospital which, in turn supports the hospital’s overall mission. Because remuneration for cardiac patients is relatively high in comparison to other specialties, a larger Heart Center can generate more funds to support non-cardiac hospital priorities. Increasing the strength of non-cardiac services can indirectly improve the quality of care for cardiac patients requiring those services.

Heart Center Remuneration and Cardiac Priorities- Some of the increasing remuneration from a growing cardiac program can be directed into the Heart Center to broaden the Heart Center’s scope of offered services (e.g. the new echocardiogram machines, developing a transplant/VAD program, 3-D printing, dedicated radiologists, etc…). These additional resources can lead to provision of more comprehensive and better care. Thus, Bigger provides the financial source of additional resources - which can be directed to enable Better.

Building Resilience and ‘Single Points of Failure’– In the ideal Heart Center, the presence (or absence) of any single individual would have a negligible impact on the overall quality of care delivered. Smaller Heart Centers, however, are often dependent upon a few key individuals whose presence (or absence) can create a dramatic shift in the capacity of the program to deliver optimal care – and these ‘single points of failure’ represents important vulnerabilities for a small Heart Center. As clinical volume grows across specific volume thresholds, however, there are new opportunities to attract and recruit additional individuals to fill key roles. A common example of eliminating a ‘single point of failure’ is achieving a volume threshold that permits the retention of two ‘full service’ surgeons. But the concept is equally valid when considering interventional catheterization cardiologists, electrophysiologists, anesthesiologists, intensivists, etc… In nearly every specialty, there is a threshold which enables the appointment of multiple key personnel to protect against vulnerability to single points of failure. Becoming Bigger and crossing these critical volume thresholds to eliminate single points of failure leads to Better care.

Bigger Comes at a Price: Strain and Change

There is an old adage: “Everyone likes progress, as long as they don’t have to change…” Growing clinical volumes can strain the clinical team. I have often heard caregivers in rapidly growing Heart Centers lament the sensation that ‘this place is out of control’ as they grapple with increasing workloads and the reluctant/skeptical adoption of new ways of doing things that they feel are being forced upon them.

Key clinical leaders might also feel that they are losing control of a Heart Center as clinical volumes grow. These leaders may have often started from a position where it was possible to know every detail about every patient at all times – only to find that their new success in programmatic growth has led to a state where they must trust others to manage issues that are increasingly falling outside of their purview. As growth crosses new thresholds, changes must occur in the processes of daily work with deliberate emphasis on the four competencies of high performing teams (from McChrystal et al).

1.?Trust – Faith in the benevolence, capability, and reliability of your colleagues becomes important when the volume of patients begins to outstrip the ability of an individual to literally ‘see’ every patient. Others must be trusted to manage care. In a very small program, it is relatively easy to have intimate knowledge of the activity, skill-level, and trustworthiness of every member of your team. As a Heart Center grows, the intimacy is dispersed and Trust becomes an increasingly critical commodity.

2.?Common purpose – Ensuring that everyone is ‘on the same page’ is not a problem when a small group of tightly integrated individuals run a Heart Center. In a larger system, however, effective handoffs and sign-outs become more challenging as patients move through a more complex system composed of increasingly diverse groups of caregivers. Maintaining clarity on the patient care plan becomes more challenging as a team grows beyond the limit of a single key provider’s capability to participate in every critical decision in every patient’s care.

3.?Shared Consciousness – As a Heart Center grows, the logistical challenge to move clinical data with enough fluidity to ensure that every caregiver has the complete data available to make every decision becomes more difficult. In the largest programs, maintaining shared consciousness is a critical challenge.

Furthermore, lack of shared consciousness in the interpretation of untoward events can become a problem when different groups of caregivers have differing interpretations of clinical events – often filling in the gaps with erroneous interpretations of clinical events. This lack of shared consciousness as a program grows can lead to rumor progression and toxic offline discussions which are not fully informed and degrade overall team performance.

4. Empowered Execution – As the patient population grows beyond the ability of a small group of key individuals to control of every decision, the necessity of empowering others to make decisions and take action becomes more important. Empowered execution requires provision of adequate training, resources, and authorization for a front-line caregiver to independently make decisions and take action up to the level of their training. Empowered execution, does not, however, imply that we are free to make decisions without oversight. Critical review of performance in a forum which encourages transparency, trust, and dispassionate discussion creates a positive learning environment – which sounds simple, but is increasingly difficult to maintain as a program grows.

How does your Heart Center manage strain and change?

Some Heart Centers are ill-equipped to envision, implement, and manage the new processes needed to care for escalating workloads. These teams tend to resist the necessary adoption of new processes and cling tenaciously to the way they have always done things. Caregivers can get progressively burned out as clinical volumes grow and the impossibly difficult standard of being involved in every detail creates an atmosphere of ineffective micro-management with subsequent frustration and anger directed against the concept of growth. A Heart Center in this state feels ‘out of control’ and growth is not universally acclaimed as beneficial.

Other teams, however, will have developed a culture that relishes the opportunity to continuously refresh their approach to patient care. These Heart Centers will endorse critical self-examination and, when necessary, redesign of the processes of care to accommodate the new considerations associated with programmatic growth. Survey of these teams will demonstrate a well-defined common purpose, pervasive trust, systems that promote shared consciousness, and empowered execution where the talent of each individual is maximally leveraged to optimize team performance.

Bigger, Better, or Worse?

It may seem intuitive that programmatic growth is always a good idea, but the challenges that arise from programmatic growth are substantial. In the accompanying plot, the trajectory of changes in volume and outcomes is examined. Notwithstanding the inherent coarseness of using overall O/E ratios as a surrogate for ‘Better’, the overall message is clear: Bigger can (but does not always) lead to Better.

Deeper understanding of how Heart Centers manage the complexities of rapid programmatic growth might help to improve the overall quality of delivered care. Team Optimization is likely to be an increasingly important arbiter of success as a Heart Center grows.

?Personal note: I have spent many (many) years trying to understand how to improve care in the Heart Centers where I was posted. During one of my tenures, we brought in professional ‘external perspective’ (in this case, from the McChrystal group) and my appreciation for this topic grew exponentially as I enjoyed one of my career’s steepest learning curves. Among many lessons, I learned that knowledgeable external perspective can provide insights to solutions that are often difficult to see from within. Since then, I have engaged in many subsequent opportunities to provide ‘external perspective’ to help other Heart Centers grappling with challenges. It is an endlessly complex and fascinating topic!

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