‘Factory-managed’ care raises quality, cuts costs in cardiac surgery

By implementing a hybrid model of healthcare inspired by industrial engineering concepts, the Mayo Clinic improved the quality of care and reduced costs in its adult cardiac surgery program, its designers reported in the May issue of Health Affairs.

David J. Cook, of the clinic’s Center for the Science of Health Care Delivery in Rochester, Minn., and colleagues integrated a “focused factory” standardized approach into cardiac surgical care in an effort to reduce variation in practice. That variation stems from a culture dominated by surgeon decision making, which depends on an individual physician’s training, experience and judgment.

Cook et al identified hospital-based surgery as a stronghold for what they termed “solution-shop thinking.” Solution-shop thinking is important in a high-acuity, full-service setting, they noted, but a uniform approach for delivering care might better serve the less challenging segment of the patient population needing cardiac surgery.

“[F]or a full-service hospital, the critical questions are which problems or populations of patients are best addressed by solution-shop models and which by focused-factory models, and how those models should interact,” they wrote.

Their initial analyses focused on practice variation, resource use and management tools to develop a focused-factory model for cardiac surgery. They used their health IT system to identify and segment patients into factory-focused care group and assessed each step in the care process to establish protocols. The model was put in place between late 2009 and 2011.

To evaluate the effectiveness of the hybrid approach, Cook et al designed a pre-post study (2008 and 2012) using the clinic’s data in the Society of Thoracic Surgeons database. They selected a sample of 769 matched patients from each year to assess outcomes, resource use and costs.

In 2012, 67 percent of cardiac surgery patients received factory-focused care. The researchers didn’t observe any increase in the rates of inhospital complications, 30-day mortality or morbidity outcomes or readmissions with factory-focused care. Factory-focused care was associated with better outcomes for sepsis, renal failure and pneumonia.

Length of stay was shorter in 2012 after propensity score matching for total hospital stays as well as in the operating room, progressive care unit and the intensive care unit. Mean per patient standardized costs, adjusted for inflation, decreased 15 percent compared to 2008 and median costs dropped 14 percent.

“With our hybrid structure—a focused factory operating in parallel with a solution shop—care is comprehensive,” they wrote. “Particularly with an electronic health record system that supports the longitudinal management of patient data, all patient needs can be readily supported by having the solution shop as an available resource, and potential conflict of interest is avoided.”

The cultural change was challenging, they acknowledged, but because outcomes and costs in the standardized factory-focused group are fairly predictable, the clinic is now better positioned to participate in bundling and value-based payment models.