Definisi dan Kriteria Pusat Layanan Unggulan (Center of

Excellence)
Putu Eka Andayani
Pengantar
Karena tuntutan persaingan maupun faktor perubahan lingkungan lainnya,
RS di Indonesia – for profit maupun not-for-profit – mengembangkan
berbagai strategi guna dapat bertahan hidup dan berkembang. Salah satu
strategi yang populer adalah mengembangkan layanan unggulan. Investasi
yang dikeluarkan pun tidak sedikit – biasanya untuk gedung dan peralatan
canggih – namun tidak jarang yang berakhir sebagai “pelayanan biasa”
karena tidak jelas indikator keunggulannya. Perlu keseriusan dalam
memahami konsep, merancang, mengimplementasikan hingga
memonitoring dan mengevaluasi suatu pusat layanan agar dapat disebut
sebagai pusat layanan unggulan.
Definisi
Ternyata ada berbagai definisi layanan unggulan rumah sakit yang mulai
dikembangkan sejak akhir tahun 80-an. Sebagaimana yang dikutip oleh
Sharon Khrumm (2004) ada publikasi di tahun 1987 yang mengidentifikasi
layanan unggulan dengan tiga elemen penting, yaitu adanya kelompok
dokter/spesialis/keahlian tertentu yang spesifik, adanya program penelitian
klinis dan medis, dan ditunjang fasilitas yang difokuskan untuk keunggulan
layanan pada pasien (teknologi terkini dan perawat yang berkompetensi
tinggi). Ada juga yang mendefinisikan sebagai suatu program pemberian
layanan kesehatan dengan karakteristik utama yaitu tersedianya layanan
dengan kualitas tertinggi. Definisi lain menyatakan bahwa layanan
unggulan adalah suatu RS atau unit di dalam RS yang ditandai dengan
kinerja teknis, sumber daya yang ekspansif, volume (kunjungan) pasien,
dan dibuktikan dengan dedikasi terhadap mutu layanan. Selain itu, definisi
lain menambahkannya dengan layanan yang terspesialisasi.
Apapun definisi yang digunakan, layanan unggulan mengandalkan pada
mutu layanan yang berasal dari perpaduan antara kompetensi SDM,
teknologi dan komitmen untuk menjadikannya sebagai yang terbaik. Yang
menarik adalah, dengan adanya perpaduan tersebut maka RS justru akan
menjadi lebih mudah dalam mengelola pasien yang jumlahnya begitu
besar. Banyak ahli setuju bahwa dengan menjadi center of
excellence maka akan lebih mudah bagi RS untuk menyatukan para dokter
dalam upaya peningkatan mutu, menekan biaya melalui efisiensi besar-
besaran, menciptakan diferensiasi pasar melalui layanan klinis
yang excellent, dan mencapai kepuasan pasien yang tinggi, Sebagai
contoh ada sebuah layanan kesehatan yang harus menghadapi ribuan
pasien rawat jalan per hari dengan kasus yang beraneka ragam. Dengan
adanya pusat-pusat layanan unggulan (center of excellences), misalnya
layanan unggulan ibu dan anak, layanan unggulan jantung, layanan
unggulan kanker dan sebagainya, maka populasi pasien yang sangat
besar tersebut dapat dikelompokkan menjadi sub-populasi dengan kondisi
kasus yang cenderung lebih homogen. Pengelolaannya pun menjadi tidak
serumit jika seluruh pasien tersebut digabung dalam satu unit layanan.
Pusat layanan unggulan juga memungkinkan para dokter, perawat,
administrator dan klinisi lainnya untuk saling berdiskusi, sharing ide dan
berkoordinasi dalam menghadapi kasus pasien-pasiennya.
Untuk dapat mewujudkan pusat layanan unggulan yang sesuai dengan
definisi diatas, maka setiap pusat harus dipimpin oleh dokter, berpartner
dengan perawat (dengan kompetensi terpilih), serta didukung oleh
administrasi yang handal. Berikut ini adalah contoh susunan tim dari
beberapa pusat layanan unggulan yang terdapat di Beaumont Health
System. Selain anggota tim tersebut, juga ada supporting staff yang
membantu dalam hal pengambilan keputusan klinis, marketing, urusan
komunitas dan advokasi, perencanaan, komunikasi korporat, manajemen
proyek, yayasan serta hubungan-antar-dokter.

Berbagai Kriteria Pusat Layanan Unggulan

 Layak tidaknya suatu layanan dikatakan sebagai Pusat Layanan Unggulan
dapat dilihat dari berbagai jenis kriteria. Jenis-jenis kriteria ini tergantung
pada dari sudut mana Pusat Layanan Unggulan dilihat. Khrumm mengutip
dari The Advisory Board Company, Washington DC bahwa berbagai
perspektif ini antara lain dari sudut pandang asuransi dan stakeholders.
Dari sudut pandang asuransi, sebuah pusat layanan unggulan harus
bermutu tinggi, berbiaya rendah dan memiliki jaringan (kerjasama) rujukan
dengan pusat layanan kesehatan lain. Dilain pihak, salah satu tujuan RS
mengembangkan pusat layanan unggulan adalah untuk meningkatkan
kinerja keuangan, yang diperoleh dengan penghematan biaya. Misi
penghematan biaya ini dapat berbenturan dengan kriteria layanan berbiaya
rendah yang diajukan oleh perusahaan asuransi kesehatan. Oleh
karenanya, perlu ada semacam kompromi serendah atau setinggi apa
biaya yang dapat diterima agar menghasilkan layanan dengan mutu yang
dikehendaki. Maka ditetapkanlah kriteria dari sebuah pusat layanan
unggulan dari kacamata asuransi sebagai berikut:

1. kriteria outcome yang meliputi: AvLOS, angka infeksi nosokomial, angka

tindakan/operasi ulang, angka kematian, volume kegiatan
2. kriteria kualitas yang meliputi: akreditasi atau sertifikasi, survey kepuasan
pasien, CV para dokter, kinerja dokter (jumlah operasi/tindakan per tahun,
angka harapan hidup, biaya (bukan tarif, pen.) per tindakan)
3. kriteria biaya yang meliputi biaya (bukan tarif, pen.) per tindakan, angka
kasus/kesakitan global

Dari perspektif stakeholders, ada kriteria yang lebih bervariasi tergantung

pada siapa stakeholders yang dimaksud.

1. Perspektif Pembayar yang meliputi: volume kegiatan, jumlah dokter umum

dan spesialis, mutu, kinerja keuangan, kepuasan (pasien dan staf), lingkup
layanan
2. Perspektif Pasien yang meliputi: fasilitas, layanan emergency, akses dan
citra RS
3. Perspektif Dokter yang meliputi: hubungan dokter/RS, teknologi yang
dimilikip pusat tersebut, kegiatan penelitian dan pembelajaran
4. Perspektif Dokter untuk atribut yang lebih tinggi yang meliputi: organisasi
dan hubungan dengan pembayar
5. Perspektif Program Kemitraan yang meliputi sistem informasi serta
program kesehatan dan kesejahteraan
6. Perspektif Program Kemitraan untuk atribut yang lebih tinggi yang meliputi:
peningkatkan kinerja, manajemen penyakit dan integrasi klinik

Dari definisi dan berbagai kriteria di atas jelas bahwa tidak mudah untuk
menjadikan suatu layanan atau instalasi di RS sebagai pusat layanan
 unggulan. Perlu perancangan mulai dari input hingga proses dan output
yang biasanya membutuhkan waktu bertahun-tahun. Waktu yang
digunakan untuk merancang suatu pusat layanan unggulan bisa saja
dipersingkat, namun itu berarti banyak detil yang berpotensi terlewati yang
dapat berdampak pada “tidak unggul”nya layanan tersebut saat mulai
beroperasi.
Sumber:

1. Cancer of Excellence (cinjweb.umdnj.edu)

2. Beaumont Health System
3. Becker’s Hospital Review
Developing Centers of Excellence - Key
Concepts, Strategies and Tactics
April 06, 2009 | Print | Email
1
inShare

The importance of developing outstanding programs, often referred to as

“Centers of Excellence,” in specific specialties has taken on new importance in
critical specialties such as orthopedics, neurosurgery and spine, cardiology
and oncology. This article discusses how developing a grand vision or plan
comprised of clear goals can guide the development of a Center
of Excellence. This article then examines specific strategies and tactics that
can be used to implement such a plan.

Systems that develop dominant service lines can attract more patients, higher
margins and more physicians. An outstanding or dominant service line can
make a hospital a destination in an area of care and serve as a magnet for a
range of opportunities. Thus, many hospitals and systems are constantly
considering plans to develop a specialty Center of Excellence in conjunction
with a group of physicians within that practice area. Such efforts, if developed
well, can also provide physicians who are involved in the effort a competitive
advantage in recruiting additional physicians and attracting patients.

Physician-hospital relationships
There are currently a great number of changes evolving in physician-hospital
relationships. These include substantial changes in the way in which hospital
and physicians interact with each other. The overall landscape as to what
types of relationships are being undertaken is moving very fast. These
relationships again, in return to a 1990’s strategy, include employment of
physicians and acquisitions of practices as well as many variations in
relationships. The employment efforts may prove to be beneficial or may again
lead to serious financial problems for systems.

There are more legal concerns with regard to physician-hospital relationships

than ever before. This is likely to complicate the development of Center
of Excellence concepts. These concerns arise, for example, under the Stark
Act, the Federal Anti-Kickback Statute, the Tax Exempt Rules and
Regulations applicable to exempt hospitals, the False Claims Act and state
laws. Every week there appears to be a report of a new case or settlement
related to hospital-physician relationships or other payment relationships
involving providers. These types of settlements relate not only to bigticket,
substantial investigations and behaviors but also to small seemingly
inadvertent errors and mistakes under the acts.
A leader of a hospital or health system driving the development of a specialty-
driven program must be able to defend his or her tactics both from a legal and
business perspective. To a great degree, the question will ultimately come
down to, “Is the system developing and engaging in a grand plan for a specific
area of care?” or “is it simply utilizing tactics to capture referrals?”

Develop an overall vision

A grand, overall vision or plan is critical for a facility or program to become
dominant in a specialty area. Specific strategies are then developed in light of
this plan. If strategies are not utilized in connection with a grand plan, it is
much more likely that the efforts will fall short, from a business perspective. It
also increases the chances that the implementation will simply look like
payments for referrals as opposed to tactics aligned an overall plan.

Clear and big goals

There are a few critical efforts that need to be made early on at the inception
of a plan. First, the hospital or system and its physician leadership must define
its overall goal — i.e., what is it trying to accomplish? For example, is the
program trying to be the best orthopedic program in the state? Is it trying to be
a program that does more procedures of a certain type than any other
system? Or, in contrast, is it trying to be a global leader in orthopedics and to
develop an international brand in orthopedics or spine? Will the grand plan
include a research or teaching function

The system, in addition to this grand vision, may have other specific goals
such as cost savings, improving trauma care, reducing wait times, providing
all services or offering pediatric orthopedics. A grand vision with a clear goal is
a prerequisite for determining the tactics that will be implemented by the
parties to help the specialty program meet that goal. At the end of the day, the
more that a system builds a grand vision and a clear plan as to what it wants
to be known for, the easier it is to build tactics and strategies around those
plans.

Senior leadership must drive the plan

Hospital and physician leadership must not delegate the plan. Rather, the
highest level of leadership should be involved in the plan from the very
beginning and all the way through implementation and operation. The more
that the system sees leadership such as the CEO and top physicians in the
specialty involved in every meeting related to the plan, the easier it will be for
the hospital and physicians to take action and gain buy-in throughout both
systems. Delegating a critical plan and not involving key leadership throughout
almost always leads to the ultimate failure of the plan.

Role model hospital or program

As a system begins to form a concept or idea for its grand plan, it is very
helpful to seek a role model hospital or center to use as a guide
in developing its own plan. For example, can you find two or three hospitals or
systems that have the attributes that your system or plan desires? Is there a
great example that you could model your plan after? After determining a role
model hospital or program and finalizing your own grand plan, one starts to
determine tactics and strategies that will support and comprise the plan. Many
of these will be similar to those used by the model system.

Tactics and strategies

There are several tactics and alignment options that can be used to implement
a plan. The tactics utilized range from full integration tactics to minimal
integration efforts to a number of hybrid efforts. All tactics used should be
targeted to meeting the big goals.

Full integration
There are at least two core types of full integration models. The less common
example of a full integration model is a whole hospital joint venture between a
hospital and physicians. One example of this type of venture is the Institute for
Orthopaedic Surgery in Lima, Ohio, between St. Rita’s Medical Center and
physicians. The Institute, a specialty orthopedic hospital, is majority owned by
St. Rita’s. However, physicians also have a financial stake in the facility. The
Institute was originally developed by physicians.

Another increasingly common type of full integration model involves a situation

where the physicians become employees of the hospital or a related
subsidiary. For example, the dominant orthopedic group in Greenville, S.C.,
was acquired by a local hospital system a few years ago. This has become
more common again in critical specialties. A few years ago the idea of large
orthopedic groups or neurosurgeons being acquired by hospitals would have
been immediately disposed of. Now, employment is often a critical part
of developing a dominant service line.

Semi-integrated models
Many parties pursue different types of semi-integrated ventures. These can
include joint ventures for surgery centers, joint ventures for equipment and
real estate, joint ventures which will provide management services and
several other types of joint ventures. Here, one big distinction between true
provider joint ventures such as those involving ownership of a whole hospital
or a surgery center are that physicians can own an interest in the venture,
derive the real profit from the venture and take real risk with the venture. In
contrast, with equipment or real estate joint ventures, the payment to the
lessor entity must be fixed fair market value and cannot vary based on the
volume of business performed at the provider that the lessor leases to. In
essence, there will not be any revenue or profit and loss congruence between
the leasing entity and the provider that leases the equipment or real estate.

These semi-integrated models may be one dimension of an overall plan to

develop a dominant service line.
Compensation relationships
A third type of integration effort revolves around compensation relationships.
These include many different types of arrangements. These can include call
coverage arrangements, trauma arrangements, medical directorships, gain
sharing arrangements, teaching relationships, research relationships,
administrative/management relationships and several other types of payment
relationships. The more that these are developed in light of a core, overall
vision and clear plan for what the system desires to accomplish, the easier it is
to reasonably justify having several different types of relationships with your
physician specialists which the center of excellence is being built around.
Almost all of these arrangements must be in writing and almost universally
cannot vary or have payments tied to the volume or value of referrals by the
physicians. This can be a critical part of developing leadership in an area of
care.

Managed care strategies

A last general model of integration revolves around integrating and
coordinating managed care functions. These can involve physician-hospital
organizations that serve as managed care entity contracting ventures or
bundled price initiatives. For example, a party might work on an alternative
pricing model whereby the physicians and hospital jointly sell an entire
package related to the top 10-20 most important orthopedic procedures or
cardiovascular procedures. This has been experimented with in some circles
and was experimented with to a greater level 10-12 years ago. However, with
increased consolidation of payors, this approach again offers a way for
providers to attempt to band together in the marketplace. As such, we are
seeing an increase in this activity.

Four more examples

Four other examples of working together with physicians towards
development of a dominant position in a service area are as follows:

Co-marketing and branding. Certain systems have evolved outstanding co-

marketing efforts with independent group physicians to jointly demonstrate the
strength in the services and build a brand around those services. A great
example of this involves the Rush University Medical Center and the
orthopedic program at Rush. The joint marketing program which highlights
and includes the physician leadership is outstanding and its overall focus on
the Rush orthopedic program is excellent.

VIDS approach. Another concept that parties use to jointly align services is
something that we have seen called a virtually integrated delivery system.
Here, independent parties, such as a hospital and lead group of physicians,
subject to certain anti trust requirements, work closely together to decide how
they can approach the market in as aligned a manner as possible. This may
include weekly strategic meetings on how they approach the market and
several different implementation alternatives. This may or may not include
various different financial relationships.

Acquisition of practice. We are again seeing many systems examine

acquiring practices (and then employment of the physicians) to provide a
beachhead in certain service lines. This again is an example of a full
integration model. This may be aimed at having more critical mass in an area
than any other competitor or to acquire specific expertise.

Professional services agreement. We see some situations where a hospital

will buy a certain amount of professional services to provide them some
contingent in a specialty where they are otherwise completely reliant on
independent contractors or staff physicians. This may include a professional
services agreement whereby a system buys the services of three full-time
orthopedic physicians from a group. The group and the individual physicians
are generally required to be on the contract pursuant to Stark Act and billing
requirements.

Choosing a few key strategies

Given that there are several different, major categories of ways to work with
physicians to develop a dominant program and then numerous
different tactics within those, we often recommend that a party choose no
more than two or three key strategies to really pursue as part of establishing
and implementing a plan. This might be the mix of a joint venture strategy
together with employment models or a mix of employing some physicians but
much more heavily relying on other types of compensation agreements with
others to align efforts with the core goals.

This is intended as a summary of some of the planning

and strategies involved in developing a specialty-driven area of dominance or
a Center of Excellence. Should you have further questions as to these issues,
please contact Scott Becker at (312) 750-6016 or at
sbecker@mcguirewoods.com.
© Copyright ASC COMMUNICATIONS 2017. Interested in LINKING to or REPRINTING this content? View
our policies by clicking here.
Centers of Excellence: An evolving
concept—and controversy
By James J. Hamilton, MD, and Steven E. Fisher, MBA

The term “Center of Excellence” first came into general use in 1991 when the
Centers for Medicare & Medicaid Services (CMS) started its Medicare
Participating Heart Bypass Center Demonstration project. Initially, designation as a
“Center of Excellence” had nothing to do with providing excellent health care;
instead it described hospitals participating in the project, which had lowering
health care costs as a primary goal

A hospital was deemed a “Center of Excellence” if it teamed up with CMS (then

known as the Health Care Financing Administration, or HCFA) to negotiate a
package price for an episode of care. That package price combined physician and
hospital fees into a single payment to the hospital. The hospital then distributed
shares of the payment to all the providers involved in the provision of care
(including the hospital itself). This was seen as a way of “aligning the interests” of
physicians and health care institutions.

From the beginning, physicians had concerns about the designation. When a
proposal to expand the demonstration project to total joint replacement was
developed in 1996, the AAOS issued a position statement opposing the designation
of hospitals as “Participating Centers of Excellence” and the use of the term as a
marketing device. In part, the statement read:
The American Academy of Orthopaedic Surgeons continues to believe that the
hospitals participating in this demonstration project cannot be deemed
“Participating Centers of Excellence” because there is no conclusive evidence to
show that they are better providers of care than nonparticipating facilities. The use
of this term by HCFA is a serious misrepresentation to Medicare beneficiaries and
an egregious violation of the public trust.

The AAOS Board of Directors even authorized the preparation of legal documents
for a possible request for a court injunction to prevent the use of the term in
connection with the demonstration project. The Academy’s letter to then Secretary
of Health and Human Services Donna Shalala pointed out that “There is nothing to
suggest that HCFA has gathered any data to determine what constitutes a ‘center of
excellence’ as it relates to joint replacement surgery.”

Although slated to begin in early 1997, the hip and knee replacement
demonstration project never got under way. By 1999, budget constraints caused by
issues surrounding Y2K and the Balanced Budget Act forced another delay. A
proposal to revive the project in 2001 was abandoned a year later, in part because
the agency’s proposed bundled payment was so low that it didn’t cover either the
physicians’ or the hospitals’ costs.

Nonetheless, the term “Center of Excellence” has persisted. Other government

agencies—including the National Institute of Allergy and Infectious Disease, the
Health Resources and Services Administration and the National Women’s Health
Information Center—use it in conjunction with their initiatives. Many academic
health care institutions have set up “Centers of Excellence” in one or more
specialty areas, including orthopaedics. Recently, the AAOS has received a
number of inquiries from private practitioners who are interested in using the
designation.

What’s in a name?

For the term “Center of Excellence” to have any meaning, it must be more than
simply a self-designated marketing tool to attract more patients. Consumers who
see the term may readily conclude that the “Center” has subjected itself to, and
successfully “passed,” a certification protocol conducted by an official and
independent screening entity.

The majority of institutions and their physicians develop Centers of Excellence to

more successfully integrate and carry out three primary missions: provision of
clinical services, teaching and research. Their intent is to create high-quality
products that can be offered to patients, employers, payers and others at a
competitive price. Although marketing the products is clearly a necessity, this is
ancillary to the creation of the Center, not central to it.
Given the absence of any official criteria developed by a third party, it is up to each
institution to decide what constitutes a “Center of Excellence.” Ideally, every
institution should establish, and widely disseminate, formal guidelines in this
regard. The existence (and consistent application) of creation and performance
standards are what confer credibility on a “Center of Excellence,” not the simple
use of the words in its name. At a minimum, this guidelines document should
contain the following sections:

1. Purpose of the Center

2. Benefits to patients, payers, employers, participating physicians and the

institution

3. Criteria for establishing the Center

4. Procedures to create a Center

5. Elements required to propose the formation of a Center

6. Organization of the Center

7. Nature of financial and other support that will be provided by the institution

8. Center assessment and life span

Following is a sample set of guidelines tailored for a hypothetical orthopaedic

center in a medical school environment. The guidelines presuppose that the
physicians are employees of the hospital/health care institution and not in an
independently constituted solo or group practice. Physicians in private practice
who wish to designate their practices as “Centers of Excellence” would need to
modify these guidelines appropriately, but should clearly identify the purpose,
benefits and criteria used to justify the designation.

Purpose

The purpose of the [ABC Medical Center’s] Orthopaedic Center of Excellence

Program is to:

• Provide superior musculoskeletal care to patients in the [DEF] metropolitan area.

• Encourage multidisciplinary collaboration between departments, including

Orthopaedics, Physiatry, Rheumatology, Radiology and Physical Therapy.

• Provide opportunities to integrate clinical care with teaching and research.

• Engage in clinical research to determine which treatment modalities yield the best
results.

• Promote the Center’s services to the public, payers, employers and grantors of
research funding.

Benefits

The Orthopaedic Center of Excellence Program shall produce the following

benefits for the [ABC Medical Center]:

• An interdisciplinary approach to diagnosis and treatment of musculoskeletal

problems

• An efficient system for treatment of patients dependent upon their diseases,

disorders and conditions

• The provision of both surgical and nonsurgical solutions to patients’ problems

• The objective assessment of different treatment modalities to determine their

benefits

• Efficient use of resources

• A competitively priced product that can be marketed to payers and employers

• Demonstration of decreased period of disability with more rapid return of

function for its patients

• A high level of patient satisfaction

Criteria

The following criteria for establishing the [ABC Medical Center’s] Orthopaedic
Center of Excellence must be met:

• It must enhance the orthopaedic and related services of the [DEF] metropolitan
area.

• The Center of Excellence must build on the [ABC Medical Center’s] strengths.

• It must be collaborative and serve as a mechanism for the creation of a

multidisciplinary community of scholars specializing in the musculoskeletal
specialties.
• It must demonstrate the potential for attracting support from outside parties for
research.

Procedure

The procedure outlined below must be followed to create an Orthopaedic Center of

Excellence:

• There must be demonstrated support for the idea of a Center of Excellence at the
department and medical school level, as indicated by letters from the Orthopaedic
Department Chair person and Dean.

• There must be a formal written request to the Associate Vice Chancellor for
Research containing the elements described in the next section, “Elements required
to propose the formation of a Center.”

• The proposed Center Director must make a presentation regarding the proposed
Center to the Associate Vice Chancellor and the Vice Chancellor for Academic
Affairs

• The Vice Chancellor for Academic Affairs will approve or deny the proposal, or
he or she may request additional information.

• Notification will be forwarded to the requesting party.

Elements

Elements required to propose the formation of a Center include:

• A Mission Statement that includes the purpose of the Center, its focus and the
way in which it dovetails with the mission of [ABC Medical Center]

• Demonstration of why the Center is needed and the market for the services of the
Center

• Definition of the Center’s goals and the activities it would engage in

• A list of the space, facilities and equipment required and how these would be
funded

• A clear delineation of the Center’s organization and governance

• Responsibilities of the administration and support staff

• A proposed budget for the Center for the first three years with the criteria/metrics
used to assess the achievement of goals (meeting budget, patient satisfaction
surveys, etc.)

• A discussion of how the activities of the Center will be sustained after the initial
years of support

Organization

Within the [ABC Medical Center], the Orthopaedic Center of Excellence will be
organized under the following guidelines:

• The Center Director will be appointed, with a term specified in the appointment
letter.

• Upon approval, the Center Director shall create a set of operating guidelines
addressing the internal governance and membership criteria for the Center as well
as identify an internal/external advisory group.

• The Center may not offer any form of course, academic program, degree or
certificate.

• The Center must provide an annual report of activities to the Vice Chancellor for
Academic Affairs, as well as to its members, the advisory group and other
stakeholders.

Financial support

The [ABC Medical Center] will provide the following financial and other support
to the Orthopaedic Center of Excellence:

• A stipend for the Director of the Center

• Access to secretarial and other administrative, clerical and clinical support

• Compensation to the Director’s home department, using associate faculty rates

• Operational funds (salaries and expenses, travel, etc.)

• Funding for a graduate assistant or release time for other faculty

• Duration of funding (specify period)

• Expectation of the Center becoming self-sufficient at end of support

Assessment/life span
Anticipated assessment criteria and the expected life span of the Orthopaedic
Center of Excellence in the [ABC Medical Center] follow:

• The Orthopaedic Center of Excellence is intended to have an indefinite

institutional life.

• As stated above, it will not receive funding from the [ABC Medical Center]
beyond the start-up period.

• Every three years, the Center must undergo a comprehensive program review.

• The Center will remain in existence only as long as it is deemed to be fulfilling its
purpose and performing the functions for which it was established.

• If the Center ceases to accomplish its objectives, or if the objectives may be met
more effectively some other way, or if there is insufficient funding from internal or
external sources, the Center may be discontinued at the discretion of the Vice
Chancellor.

The evidence-based connection

With the increasing emphasis on evidence-based guidelines and pay-for-

performance standards, any health care professional who adopts the appellation
“Center of Excellence” must have strict standards and the facts and figures to
substantiate that title. Although a growing body of evidence indicates that certain
surgical procedures exhibit a “volume-outcome” relationship in which a higher
volume of patients undergoing a particular procedure at a hospital is associated
with better outcomes for those patients, such a relationship is not a predictive one.
Hospitals and providers should be using an array of measures in addition to
“volume” to assess their quality of care.

James J. Hamilton, MD, is chairman of the department of orthopaedics at the

University of Missouri in Kansas City and chairman of the AAOS Academic
Business and Practice Management Committee. He can be reached
at james.hamilton@tmcmed.org or (816) 404-5404. Steven E. Fisher, MBA, is the
AAOS manager of practice management affairs. He can be reached
at sfisher@aaos.org or (847) 384-4331.

The Bulletin welcomes your comments on this issue. Send your letter to the Editor,
Bulletin, AAOS, 6300 N. River Rd., Rosemont, Ill. 60018. Fax (847) 823-0668 or
e-mail aaoscomm@aaos.org
Hospital Centers of Excellence
A good way to attract patients is to create niche programs that deliver high-quality
care.
April 11, 2013

Marcy T. Rogers

0 Comments

Hospitals not only are faced with declining reimbursement, market share and
revenue challenges, but they also must find ways to remain a provider of choice for
patients and physicians. One way hospitals, along with health systems and payers,
are addressing these concerns is by distinguishing themselves through niche
programs.

Referred to as centers of excellence, these programs have been developed in a

number of specialty fields, including diabetes, neurosciences, spine, craniofacial
surgery, musculoskeletal and orthopedics, cardiology and interventional pain. This
model likely will grow in importance and may be as close as possible to a perfect
model for care in this changing environment.

Why the Model Works

Centers of excellence are built on a comprehensive continuum that allows for the
operative, allied health and nonoperative components of care. They are an optimal
response to the growing need for disease-based medical management of chronic-
type conditions and the requirement to demonstrate efficacy and superior outcomes.
Because a multidisciplinary team approach is central to the model, the primary,
secondary and tertiary needs of patients can be addressed from diagnosis to
discharge in a seamless, coordinated manner.

Whether the millions of new patients expected from the extension of health benefits
receive coverage through an affiliation with an accountable care organization or
direct payer contracting, these specialized centers likely will receive a significant
portion of patients with disease-state conditions that generate recurring symptoms
and high cost. The center of excellence team deals with the same diseases every
day and focuses on treating all ancillary, primary and secondary diagnoses. At the
same time, they can command appropriate reimbursement as long as they're
transparent and accountable through dissemination of case reports, collection of
quality outcome data, and the use of metrics and standards.

Directing these patients to the centers frees up the ranks of internal medicine,
primary care and family practice to treat urgent, non-chronic problems.
Examples of Successful Programs

There are numerous successful centers of excellence that show the tremendous
value of the model: The Rothman Institute in Philadelphia has dominated the
marketplace on a local, regional, national and international level in bringing
multidisciplinary care to patients with hip, knee and joint disease. The Barrow
Neurological Institute in Phoenix has become a global force in the neurosciences.

Becoming a successful center of excellence does not require a location in a major

market. In one year, a spine center in Sioux Falls, S.D., saw such rapid growth that it
brought in additional neurosurgeons to address the demand from patients within the
community and surrounding states. Within about two years, the center saw 5,000
new patients. That center of excellence virtually became a major market destination
center for spine care.

Why was this center so successful? There are hundreds of millions of people who
suffer from spine-related pain around the world. The pain comes from many different
sources, including a genetic or congenital problem; a tumor or condition like
fibromyalgia that causes bone overgrowth; or a work-related injury, car accident,
personal injury or sports injury. Factor in an aging population and you have a vast
number of people searching for services in spine care.

One of the most significant benefits of these niche programs is their ability to direct
incremental and spin-off business to the hospital. Data indicate that about 80 percent
of the spine patients coming through the door of the Sioux Falls center do not require
surgery, but are identified to have comorbidities and other conditions that ultimately
feed the entire hospital — the cardiologists when a patient has congestive heart
failure or chronic obstructive pulmonary disease; the endocrinologist for diabetic-type
problems; the orthopedic surgeon for hand and joint issues. This doesn't even
include patients' diagnostic needs.

Developing Centers of Excellence

Developing successful centers of excellence always starts with a vision, physician

champions and planning. A market analysis, feasibility study and business plan are
critical to understanding opportunities, threats, risks and rewards in the immediate
market and surrounding areas. Will your center cater to the local community, or is
there an opportunity to attract patients from outside your immediate market? Is there
the potential for an international program that targets patients as medical tourists?
Will you start with a virtual center before developing a concrete entity? Do you want
to create a stand-alone building on the campus of a hospital or build a separate
medical campus?

After the planning stage, you have to be able to implement the program. The first
steps include creating an operational plan for each section of the center and a
patient through-put algorithm to process patient flow. You also need to build a team
of physician leaders to run the clinic. Then you will need to create payer, patient,
medical, employer and consumer education programs to build awareness and
interest in the center.
Another critical component is team building for the individuals who support each
niche program. Often, the individuals identified as the team members for a center of
excellence were never in the same room or talked with one another until the center
started coming together. Once a month, you'll need to hold team conference staffing
of patients, as it's vital to building group cohesiveness and team leadership. You also
need to assemble a clinical operating committee tasked with overseeing the center,
handling the clinical affairs, and ensuring continuous quality improvement and
analysis of the provider base.

Finally, you must create a system or standard for measuring all the services offered
at the center, and constantly monitor the data to see how well your center is
performing against internal benchmarks, peers, literature and any accrediting agency
or payer standards. If there are service areas that are lacking — for example, if it
took several hours for a patient to receive labs or if radiology is backlogged for
months — there must be processes in place for immediately rectifying and
addressing these deficiencies.

Centers of excellence are patient-focused, patientcentric organizations. They excel

through efficiencies and standardization, through collecting and using their data.
They become opportunities to differentiate an institution in a market by offering
measurable, high-quality care in an era of accountability.

Marcy T. Rogers is president and CEO of SpineMark Corp. in San Diego.

Is Center of Excellence Investment the
Silver Bullet Healthcare Has Been
Looking For?
Written by Sabrina Rodak | March 04, 2013 | Print | Email

13
inShare

Healthcare leaders generally recognize that there is no "silver bullet" to any of

the challenges the industry presents today — aligning with physicians,
improving quality while lowering costs and differentiating oneself in an
increasingly competitive market. However, there are some strategies that
resemble the proverbial silver bullet more than others — strategies that, while
not solving every problem in one go, make significant progress on a wide
range of issues. One such strategy (a silver-plated bullet, if you will) that plays
a central role in many healthcare organizations' strategic plans is investment
in centers of excellence.

Developing centers of excellence can provide a platform for hospitals and

health systems to align physicians in quality improvement, reduce costs
through greater efficiencies and create market differentiation through clinical
excellence and high patient satisfaction.

Target 1: Enhanced quality

As the name suggests, centers of excellence are
primarily designed to deliver high-quality care
consistently. Developing standardized, evidence-
based care processes that ensure high-quality
outcomes not only sets the foundation of a center of
excellence, but also helps hospitals reach quality
standards that are included in federal reimbursement
models such as value-based purchasing and bundled
payments. Thus, investing in a center of
excellence enables hospitals to differentiate
Faye Deich themselves through top-tier care and gain cost savings
under new payment models.

"Right now, there is so much pressure on the cost side that sometimes quality
takes a backseat," says Steve Moreau, president and CEO of St. Joseph
Hospital in Orange, Calif. "But that is not going to be sustaining. That's why
focusing on excellence is such an important effort. We can't take our eye off
quality by focusing exclusively on cost reduction." Mr. Moreau says a key
aspect of centers of excellence is their consistency, reliability and minimal
variation. Reducing variation can improve outcomes as well as patient
satisfaction, another aspect of healthcare quality.

Patient satisfaction
"The more we become responsible in every aspect of care, the better patients
seem to feel about [the hospital]," says Marc Sakwa, MD, chief of
cardiovascular surgery at Beaumont Hospital, Royal Oak (Mich.) and chair of
Beaumont Health System's Heart and Vascular Center of Excellence, which
was created about three years ago. "Patients are aware that their wait times
are less, that the nurse is there to answer their call buttons quicker. We
measure patient satisfaction on a regular basis; it's only gone up since we
started doing these centers of excellence." Patients with better experiences
are more likely to return to the hospital, generating greater revenue and a
stronger reputation for the hospital.

Target 2: Physician alignment

Physician alignment is both a necessity and a consequence of
developing centers of excellence.

Physician alignment as necessity

To create standard protocols that will increase quality, physicians' and
hospitals' incentives should be aligned.
 Incentivizing physicians for low variation, high patient Pat LuCore
satisfaction and overall high quality can ensure
everyone works collaboratively to meet the goals of a center of excellence.

For example, Sacred Heart Hospital in Eau Claire, Wis., aligned with
physicians for its robotic surgery center of excellence. By giving physicians a
leadership role on a robotic surgery committee, the hospital and physicians
reached alignment on goals and approaches to quality care. "What brought
our success so far is our active robotics committee. We have representation
from administration, surgery and technicians," says Pat LuCore, RN, MHA,
assistant administrator of the hospital.

Physician alignment as consequence

Establishing a vision for a center of excellence can also facilitate physician
alignment with administrators because they have a shared goal of high quality.
Dr. Sakwa says center of excellence development can also align physicians
with other clinicians and staff. "The concept of a center of excellence is to
work together with staff to come up withways to improve," he says. "As
doctors, we found that nurses were hungry for more communication. They
wanted to come on rounds with us; they wanted to improve quality. They
respected the fact that we were taking an interest in it, and realized that
together we would be able to make dramatic changes."

Pursuing center of excellence development as a strategy can thus create a

platform for aligning physicians and creating a stronger level of integration of
physicians in the hospital.

Target 3: Attract physicians

Besides aligning with physicians who are currently partnered with the
hospital, centers of excellence can also attract physicians to a hospital. "What
attracts doctors is they want the best tools to treat patients. If better
technology results in better patient outcomes, they're going to go to the
organizations that have the best technology," Mr. Moreau says. Sacred Heart
Hospital's development of a center of excellence around the da Vinci robot
helped recruit physicians to the hospital. "It helped attract new physicians that
are very skilled, focused and interested in this," says Faye L. Deich, RN, MS,
NEA-BC, senior vice president of division operations and COO of Sacred
Heart Hospital. "Some physicians would not have come to our community if
the robot was not available for them to use because they trained on it."

Target 4: Setting industry standards

In addition to improving quality within the center of
excellence itself, standardizing evidence-based
practices can improve quality within an entire health
system and in health systems across the country.
"Once we develop different ways to improve care, we
go back to other physicians within the system — other
cardiologists or referring physicians — and show them
how we improved; by improving, it also helps them,"
says Dr. Sakwa.
Steve Moreau
Similarly, best practices developed at a center of
excellence can be shared with other health systems so everyone can benefit
from processes proven to be successful in improving quality and lowering
costs. "The fact that centers of excellence have contributed to improving
quality and developing evidence-based practices that others can see has
impacted care and the standard of excellence across the country," Mr. Moreau
says.

Moreover, the ability of centers of excellence to set industry standards and

examples of best practices helps create a reputation of innovation, leadership
and quality at the hospital. "When your organization is successful and has
demonstrated practices leading to better outcomes, you get greater visibility,"
Mr. Moreau says. "You begin to get regional or national visibility because
you're asked to write papers or make presentations across the country, which
then become national best practices." For example, St. Joseph is asked by
Premier, a best practice organization, to make presentations several times a
year to share best practices with the national healthcare community,
according to Mr. Moreau.

Investing in centers of excellence as part of a hospital's overall strategy can

pay significant dividends in elevating the organization's brand and reputation
to a national level. "As we improve even more, the entire hospital brand
improves," Dr. Sakwa says. "In [the heart and vascular] area, Beaumont's
brand had already been very strong; over the last three years, it's only gotten
stronger and more visible."
Target 5: Market differentiation
By standardizing best practices and aligning
physicians and staff to improve quality, centers of
excellence differentiate hospitals from their
competitors. Centers of excellence can become
destination sites for patients by guaranteeing a
level of value that similar organizations do not offer
— at least not as conveniently. "One of our
Dr. Marc Sakwa
strategies is how to differentiate ourselves in a
market that has very strong, high-quality providers,"
Ms. Deich says. "Our strategy is [looking at] where we can do very well and
developing specialty services locally so people don't have to be referred
outside. It's the direct opposite of what has been the strategy of our
competitor." By offering robotic surgery in several specialty areas, Sacred
Heart Hospital has set itself apart from other providers that do not have this
service.

St. Joseph Hospital has created differentiation in two areas of cancer care —
outreach to the underserved population and services. St. Joseph
Hospital received funding from the National Cancer Institute to develop its
cancer program for the underserved. "That's an example of a differentiation
that gives us a lot of visibility regionally and to an extent nationally," Mr.
Moreau says.

Center of excellence development as part of a strategic plan can help set

hospitals apart through quality and unique offerings, which can give hospitals
the edge they need to win out over competitors.

Target 6: Cost savings

Centers of excellence provide an avenue for cost reduction through
standardization and quality improvement. As mentioned earlier, meeting
quality metrics is necessary to share savings in models like bundled payments
and value-based purchasing. By creating standard protocols, healthcare
teams can more consistently meet quality targets and improve care efficiency,
which creates cost savings that can then be reinvested in quality and patient
experience, according to Dr. Sakwa. "Having a well organized center of
excellence is one of [Beaumont's] key strategies. It helps us not only improve
research and quality, but also financial performance; it aligns our physicians
and makes sure we're on the same strategy page as our administration," he
says.

Center of excellence investment as key strategy

By investing in centers of excellence, hospitals and health systems can
improve quality, which can help align and attract physicians as well as create
market differentiation. Standardizing evidence-based practices and eliminating
wasteful processes can position hospitals for success as reimbursement
models take into account quality and patients seek top-tier care.

More Articles on Centers of Excellence:

How Bundled Payments in Orthopedics Can Help Build the Foundation for a
Center of Excellence
Including Center of Excellence Development in a Hospital's Strategic Plan
Developing Successful Spine Centers of Excellence and Managing Quality

© Copyright ASC COMMUNICATIONS 2017. Interested in LINKING to or REPRINTING this content? View
our policies by clicking here.

To receive the latest hospital and health system business and legal
news and analysis from Becker's Hospital Review, sign-up for the
free Becker's Hospital Review E-weekly by clicking here.