The Service Line Model: A Lasting Facility Trend for Operational Success

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A CASE STUDY IN DESIGN

By Katherine Kay Brown

Healthcare organizations today are increasingly focused on designing facilities to more closely support efficient operations, especially as industry attention and scrutiny moves from volume of services to value of care.  Consumers often focus on their experience, and are becoming more selective with their choice of hospitals as they share in more of the burden of payment. 

Medicare under the new administration, along with Bundled Payment for Care Improvement (BPCI) Advanced and private insurers continue to funnel more reimbursement on the value their enrollees receive through ‘bundled payment’ contracts.  This new model combines all that is required to treat a patient for a specific medical condition across a full cycle of care into a bundled ‘episode’.  Therefore, to ensure success with these payment models, hospitals must be able to understand the outcomes (cost AND quality) that their services produce for an episode of care…and not only during the hospital stay in one specialty area, but across the continuum, and for the critical timeframe of 90 days post-discharge.



Corazon has long-believed that an effective way of providing expert care across a clinical specialty is through service line management.

Cardiovascular patients are often focused on in this model, as CV hospital discharges rank the highest among all disease categories. More importantly, this disease is also prevalent and growing in the outpatient and post-acute care settings.  In fact, the American Heart Association estimates that by 2030, 40.5% of the US population will have some form of cardiovascular disease.

Under the umbrella of a successful cardiovascular service line, clinical specialties are organized across the full continuum of care, from a preventive focus with office and clinic visits, through the procedure or inpatient stay, to post-discharge. The clinical teams seen below in Figure 1 are led by physicians and staff experts in that specific sub-specialty. They are supported by hospital leadership with infrastructure focused on service line leadership, quality, data/information technology, growth/strategy, finances, and efficient operations.

Figure 1: The Cardiovascular Service Line

MidMichigan Medical Center:  A Case Study in Service Line Design and Organization

To aggressively compete by highlighting their CV service line, the following hospital integrated outpatient and inpatient care into a new campus building attached to the acute care hospital. Throughout the following example, you will read about how MidMichigan Medical Center (MMC), a 324 licensed-bed hospital affiliated with University of Michigan Health System located in Midland Michigan,  incorporated innovative design trends into their facility build.

MMC is the flagship hospital within the health system that serves a 23-county region. Its robust cardiovascular service line is co-led by a hospital administrator and a cardiologist, both of whom have been integral in creating an infrastructure that supports the clinical teams in preparing for bundled payment. The infrastructure includes a focus on clinical outcomes, readmissions, length of stay, post-discharge care, and the patient experience.

MMC’s CV offerings had been expanded to include highly-advanced cardiovascular services such as invasive cardiology, open heart surgery, TAVR, and electrophysiology care, all of which attract patients from afar. MMC also provides prevention and chronic disease management services through outpatient visits for heart failure and vascular disease. Although this continuum of services is the most advanced in the region, MMC was without an integrated approach or co-located space for this service line. Cardiology offices were scattered and CV diagnostic testing volumes were lost due to the need for numerous patient visits to multiple locations.

In order to grow the CV service line into a recognized ‘Center of Excellence’, hospital leadership wanted to create a facility that would assemble a patient-centered care approach under one roof as a means to encourage multiple evaluations during the same visit. The patient would understand their ‘itinerary for the day’ and receive a plan of care determination prior to leaving. The vision from the physicians and staff was a Cardiovascular Center designed with a strong presence and a ‘front door’ that would convey a top-notch brand of healthcare.  Further, the facility aimed to meet high consumer expectations since comfort and convenience are now just as critical as the clinical reputation of the hospital.

After an in-depth planning and design project, the CV Center has been organized as a complete and integrated service line.  The MidMichigan Heart and Vascular Center will be attached to the hospital, with the first floor programmed for clinic space along with its own dedicated parking, drop off, and entrance area.  The goal: a welcoming and non-stressful patient journey.  Being a regional referral hospital, patients with complex conditions may be seeing multiple specialties and spending a portion of their day at the Center. A welcoming environment with an indoor garden, outside green space, and access to daylight offers a competitive edge to the facility’s design.

By combining multiple offices within the integrated CV center, the hospital will realize gains in efficiency, especially with clerical functions. They will be able to reduce duplication in scheduling, check-in, and check-out by centrally-locating these related services.  Standardizing these processes is not an easy feat, however, as each small specialty office was used to their own staff.  In the integrated center, consistent clerical practices across the CV service line will set clear expectations for the consumer (patients and referral physicians to name a few).

The clinics are composed of highly-developed teams with specialty physicians and their expert clinical staff. The new building will house medical cardiology, cardiac and vascular surgery, electrophysiology, heart failure, and structural heart in standardized, co-located pods (see Figure 2 below). Instead of experiencing the common disjointed day of waiting and multiple scattered office visits to the provider, MidMichigan is creating a patient-centric approach by bringing the appropriate provider(s) TO the patient.

The office co-locations also promote intra- / inter-specialty provider collaboration by facilitating daily informal ‘curbside hallway consults’. This face-to-face sharing of expertise occurs more frequently and captures issues before they escalate to requiring formal, handwritten consults. Because the pods are standardized in their design, surgeons and cardiologists will be able to flow into adjacent pods and accommodate peaks and valleys in patient visit volumes, thus avoiding empty rooms due to inefficient procedural schedules.

Figure 2: First Floor – Co-Located Specialty Pods

The floor above the clinics in the CV center is dedicated to non-invasive cardiovascular testing, including echocardiography, holter monitoring /EKG, stress testing, nuclear studies, and vascular doppler studies. Patients can now travel to see their CV physician with testing performed earlier in the day that can be reviewed during the same visit. Since the building is attached to the hospital, the non-invasive area will perform more efficiently, servicing both inpatients and outpatients.  The CV diagnostic testing floor has been designed with different circulation paths to reduce the co-mingling of inpatient and visitor traffic, creating a streamlined flow and enhancing privacy for the inpatients.  Being attached to the hospital, the CV center will allow practitioners to see patients in their office, oversee diagnostic tests, and cross over to the inpatient arena to perform invasive procedures and provide clinical inpatient care.  The efficiencies gained by the practitioners will be crucial when competing in a value-based reimbursement environment.  The more efficient the care delivery, the better the margin on the payment received for the care ‘bundle.’

The office pods are also designed to enhance the patient’s experience and promote the expertise of each clinical team by housing a distinct specialty in each cluster of exam rooms. The exam rooms provide two-door access in order to support separate patient and staff circulation. All staff will be located within the pod, while patients enter and exit from the outside corridor with the exam rooms as buffers between the patient and clinical zones. This separation aims to provide a quieter and less stressful patient experience. For staff, the dedicated space supports daily collaboration and a team approach to patient care. Being offstage, real-time clinical discussion is enhanced with less concern of any HIPAA violations. Organizing the exam rooms around the care team provides line of sight to all rooms and facilitates more efficient room turnover.

Within the pods, work-zones have been created to support ‘like’ functions as seen below in Figure 3. At the front of each pod are medical assistants in shared cubicles. They are closest to the waiting areas as they facilitate patient movement through the exam rooms.  The waiting areas are designed near each specialty clinic in a more intimate, distributed fashion to minimize noise and reduce walking distances.

Deeper in the pod where the cubicles are quieter are the registered nurses who focus on patient education, medication management, and troubleshooting. The mid-level practitioners and physicians will be located at the back-end of the pod in more traditional office space, allowing privacy for phone conversations and consultation. The highlighted cardiac and vascular surgery pod is more unique, as it serves patients with a complex check-out process. As discussed earlier, the standard clerical office check-out has been consolidated in one location with multiple stations, eliminating waits when leaving the office. The patients requiring surgery need additional education and procedural planning, therefore this pod was designed to house two private consult / education rooms to allow for additional time with the patient and not disrupt the flow within the rest of the exam rooms. 

Figure 3:  Cardiovascular Surgery Pod

The continued shift to value-based care has also encouraged savvy CV service lines to program space for population health management and increasingly invest in preventative care to keep people well. At MidMichigan, wellness programs are offered across the continuum of care – before, during, and after acute episodes to promote ‘health care’ not ‘sick care’ as seen in Figure 4. Cardiac rehab, complete with a walking track, will be located at the front of the building, showcasing to patients what they will be capable of after treatment while also highlighting the import role that rehabilitation plays in long-term patient success. MMC felt that the integration of this service in the CV Center will increase the likelihood of patient participation, which can grow into a self-pay extended wellness business. Flexible space was also built to provide multiple community outreach programs such as cooking classes, yoga / stress relief skills, and other educational offerings.

Figure 4:  Population Health Space       

The MidMichigan Heart and Vascular Center not only highlights key trends in healthcare construction, but also showcases the impact that a facility designed around CV service line operations has on success within a value-based reimbursement environment.  Indeed, Corazon believes that a design based on creating functional and efficient spaces that aid in operations is the idea way to approach a facility construction project, whether building or expanding new space or refurbishing existing spaces. 

Before designing the CV center, MidMichigan had a strong offering of clinically-expert physicians and technology to support state-of-the-art procedures. Unfortunately, because these services were scattered, the patients and community often did not see them as a complete entity.  By enveloping their diverse service line elements within one physical structure, MidMichigan has found success with focusing on their overall brand of clinical excellence and changing community awareness of their quality reputation.  According to their CV service line administrator, Dr. Sunita Vadakath, the new facility will allow MidMichigan to fulfill their vision of ‘keeping patients close to home and close to their loved ones by providing seamless, coordinated care’… a worthwhile goal for any service line in today’s competitive and highly-scrutinized healthcare environment.  And one both a hospital and its community can get behind. 

Katherine Kay Brown is Vice President for Corazon, Inc.

Corazon offers consulting, recruitment, interim management, and information technology services to hospitals and practices in the heart, vascular, neuro, and orthopedics specialties.  Find Corazon on facebook at www.facebook.com/corazoninc or on LinkedIn at www.linkedin.com/company/corazon-inc.  To learn more, call 412-364-8200 or visit www.corazoninc.com. To reach the author, email kbrown@corazoninc.com

The project detailed in this article was a combined engagement with Corazon and Hord Coplan Macht, an award-winning integrated design firm offering planning, architecture, landscape and interior design and historic preservation services with offices in Baltimore, Denver and Alexandria. HCM uses a collaborative programming and design process that results in beautiful, environmentally responsible, user-friendly spaces. To learn more visit http://www.hcm2.com/ or email Project Lead and Principal Jim Albert, AIA, ACHA, LEED AP at jalbert@hcm2.com

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