1. Healthcare Transformation: From Service Lines to Programs
Michael N. Brant-Zawadzki, MD, FACR
Executive Medical Director, Physician Engagement
Executive Medical Director, Neurosciences Institute
Hoag Memorial Hospital Presbyterian
1 Hoag Drive, PO Box 6100
Newport Beach, CA 92658
mbrant@hoag.org
(949) 764-5942 office
(949) 764-6789 fax
Jack L. Cox, MD, MMM
Senior VP &Chief Quality Officer
Hoag Memorial Hospital Presbyterian
Jack.Cox@hoag.org
Allyson Brooks, MD
Executive Medical Director, Women’s Health Institute
Hoag Memorial Hospital Presbyterian
Allyson.Brooks@hoag.org
Junko Hara, PhD
Program Development and Scientific Advisor
Orange County Vital Brain Aging Program
junkoh@shankleclinic.com

2. ABSTRACT
The AffordableCare Act (ACA) helpedfocusour country’sneedfor more effective andmore cost-efficient care that
alsoimproves the patientexperiences - the so-calledTripleAim. One of that aim’s greatest challenges is the
ongoing fragmentation of providers. This is particularly true among specialists, but lack of integration also
exists at the primary care and specialized services interface. Traditional hospital and medical staff
organizations contribute to the un-coordination of patient care. Transformation of care delivery methods to
overcome this challenge is needed. Wehere describe our organization’s recent experience with a model for
achieving the Triple Aim in a variety of areas – some inpatient, some ambulatory – even community-based,
by creating programmatically driven infrastructure under an Institute umbrella. This may be a useful tactic
towards such transformation.
Introduction
Though often labeled as “healthcare reform”, the Affordable Care Act’s (ACA) major initial
impact has been on healthcare payment reform through re-structuring of the insurance model
(including a shift of some payer burden to patients). The ACA did provide direction towards
patient oriented, performance and cost accountable healthcare, but the tactics of transforming
healthcare delivery at the point of service remains a significant challenge for providers. The
ACA’s model of at risk primary care medical homes as the major management tactic of
healthcare delivery has been challenged by sub-optimal attention to the appropriate value of
specialized services [Ref 1, 2], with substantial “leakage” to non-aligned specialty services.
Clearly, closer teamwork amongst all providers, as well as the patient (now customer)
community, is needed.

3. As Peter Drucker said, the most efficient organizations require well integrated specialists [Ref 3].
However, to date, specialized health care services have been largely fragmented, inefficient, and
in part for those reasons, excessively expensive. Their incentive has been volume rather than
value as many have stated, lacking true metrics of the latter. Incentives aside, most of the
expense of healthcare care resides in specialized services, as complex healthcare problems
require relatively expensive technology, dedicated facilities, and rely on more costly professional
expertise, because that requires years of training and financial sacrifice on the parts of the
providers. Yet specialized care is indispensable.
Methods: The Program Model
The program model is one solution to the challenge posed by the above realities. This model
integrates multidisciplinary specialists, focuses them on patient outcomes, and connects them to
the health care access and triage functions of primary providers. Organizations like the
Cleveland Clinic have pioneered this approach, and we have adapted it to a community hospital
setting. In our growing health system affiliation, the program concept has been piloted in our
hospital for the past 7 years. Our programs create and continually improve care pathways, each
care pathway focusing on a specific patient condition or disorder.
Historically, hospitals have been structured around internal operations, and for financial
accounting, as geographically functional units and cost centers (hospital “departments” - in the
non-academic sense). For instance, the emergency room, the angiography suite, operating room
suite, floor and intensive care nursing units, are “cost centers”. Aggregating operational units
(“cost centers”), such as the catheterization laboratory, the arrhythmia ablation suite, the cardiac

4. operating room, the cardiac ICU and floor unit with the work of variably aligned cardiologists
and cardiac surgeons, has been termed a “service line”. Such units and service lines are
internally focused, and measured by process efficiency, contribution margin, and perhaps
transactional service satisfaction surveys of patients [Ref 4].
The program approach transcends the relatively short term orientation of this organization-
centric infrastructure, to one focused on the longer term interests of the patient and their payer
(increasingly the same entity). Programs measure the true value (outcomes/cost) of the health
care delivery process [Ref 5]. Programs expand administratively led and administratively
accountable service line entities to physician led, multidisciplinary teams accountable for process
efficiencies, financial, but most importantly clinical outcomes. It has been shown that physician
leadership is the key to improving quality [Ref 6-7]. As stated, each program focuses on a
specific patient condition, disease, or disorder. Our programs include a spectrum of very
common and basic conditions such as mother and baby (maternity), memory and cognitive
disorders in our aging population, to much more intensive diseases such as stroke, cardiac
valvular disease, cardiac arrhythmia, joint replacement, and a variety of organ specific cancer
programs (brain tumor, melanoma, etc.), as examples.
Programs themselves are aggregated based on commonality and overlap of organ structures
affected, and similarities of needed human as well as facility resources, under an “Institute”
umbrella. Thus, the stroke, brain tumor, memory and cognitive disorders programs are some of
the Neurosciences Institute’s programs. The Institute serves the executive function of strategy
development, resource procurement and allocation, and value monitoring. The Institute

5. coordinates the common resources used by the programs (imaging technology, nursing floors,
information systems, etc.), and marshals support from finance, IT, marketing, philanthropy, and
other non-clinical but mission critical components of the organization (Figure1). Representatives
from each support department participate in the regularly scheduled institute and program
leadership committee meetings ad hoc.
Coordination and cross-integration is essential. For example, a patient in the brain tumor
program may develop seizures requiring close coordination of their care with the epilepsy
program. A new mother in the Women’s Health Institute’s maternity program may develop
post-partum depression requiring the services of the Neuroscience Institute’s neurobehavioral
program. Critical to such integration is the presence of nurse navigators, each patient having
access to a navigator who coordinates care amongst the various services provided throughout the
entire organization, linking the in-patient and out-patient continuum. The navigators also lead
the programs’ clinical metrics management, including aggregation of outcome data.
Programs deliver community education, as well as continuing education of providers, and
manage relevant clinical research projects. They are the engine of care innovation and also a
magnet for philanthropy.
Results: Case studies.
Stroke Program: In 2003, our “stroke service line” was marginal, and lagged in providing
evidence-based or even organized care for stroke patients. The numerous private community
general neurologists were hamstrung by their off-site location and demands of office patient
practice. They couldn’t respond rapidly enough given the evolving guidelines in management of

6. acute ischemic stroke. Lack of specialized stroke experience lowered their comfort level with
anticoagulants and the emerging use of intravenous thrombolytic therapy on-call after hours.
Likewise, neurosurgical availability for acute hemorrhagic stroke with limited. Though there
was a foundation of advanced neuroimaging and intra-arterial neurointerventional capability for
treatment of stroke and aneurysms, the general neurologists did not utilize those resources well.
The various operational units (emergency department, intensive care unit, nursing floor) were not
organized around, or focused specifically on stroke patients. As a result, there was a low
utilization of then evidence-based intravenous thrombolytic therapy with only a handful of
patients receiving the treatment annually. The complication rate for such therapy was above the
study group rate as published in the NIDS trial [Ref 8]. Length of stay and costs for treating
stroke patients, who were housed throughout the hospital with non-specialized nurses were
above national benchmarks. Patient and family dissatisfaction was high. No process metrics or
clinical outcomes were available.
The needed transformation to programmatic change started with the recruitment of a dedicated
stroke neurologist as the program director with support for his administrative time, and creation
of a services agreement that facilitated attracting a team of neurohospitalists, (one of the first in
the region). The team began creating evidence-based order sets for ischemic stroke that targeted
the emergency department and a nursing floor, where initially 8 beds (now 20) were dedicated as
the “stroke unit” with designated nursing staff. Evidence-based clinical pathways for ischemic,
intracerebral, and subarachnoid hemorrhagic strokes were created. Standardized order set
protocols provided guidelines with inclusion and exclusion criteria for intravenous
thrombolytics, aiding community neurologists who still participated in after hour and weekend

7. stroke call. Education also targeted ED and intensive care physicians. Advanced CT techniques
including CT angiography and perfusion were standardized, aiding rapid interpretation by
neuroradiologists to speed triage of patients, including protocol directed intra-arterial
revascularization for eligible patients.
Examples of tactics in the program include the critical development of the “Code 20” flow
process (Figure 2), aimed at obtaining a comprehensive CT angiographic and perfusion analysis
within 20 minutes of documented symptom onset (both for patients brought into the ED and in-
house stroke onset patients). This required the creation of a “Stoke Swarm” of designated
individuals in the ED, and also on the floors for in-patient stroke onset. Daily interdisciplinary
“huddle” rounds were initiated in the stroke unit. Focused care pathway education for nurses,
with specific components such as NIH stroke scale evaluation, dysphagia screening, sleep apnea
screening, etc., was instituted. Physical therapy was initiated on day one. Patient and caregiver
education booklets specific to the patients risk factors and diagnosis were developed. The local
county emergency medical services teams were educated raising awareness of rapid transport, a
major factor in stroke rescue. Local interaction with emerging teams in nearby hospitals with
stroke care capabilities created leadership advocacy that lobbied the Orange County supervisors
for the creation of a county-wide comprehensive stroke receiving center network, our hospital
being a founding member.
Our program now sees over 800 stroke patients annually, a volume facilitating the program’s
high level care as well as clinical research activities (which are served by 2 dedicated
neurosciences clinical research coordinators), including involvement in several NIH trials. The

8. continuing quality improvement of the stroke program is guided by the Stroke Process
Improvement Team (SPIT) which is interdisciplinary, manages process performance, conducts
peer review, and oversees protocol evolution. The SPIT group includes physicians from the
various operational units including ED, intensive care, and neuroradiology, and also social work,
case management and physical therapy representatives. The team meets monthly, with a stroke
steering committee subcomponent meeting weekly. The “Get with the Guidelines” metrics of
the American Heart Association are now strictly observed. The stroke program also includes
public education of stroke awareness, including a recent “Strike Out Stroke” event at Angel’s
Stadium (Anaheim, CA). Routine follow up in the stroke clinic is arranged. More recently, with
the expansion of our hospital to a second facility in Irvine, CA, telemedicine has been adopted
with a stroke robot interfacing the acute stroke neurologist either from the flagship hospital or
home (after hours), allowing extension of the stroke program’s capabilities to that facility, which
now too has a small stroke unit.
The current quality “scorecard” of the stroke program is demonstrated in figure 3. Our average
door to CT scan time for acute stroke patients is now 16 minutes. Over the last measurement
year, 100% of patients eligible (by guidelines) to receive intravenous thrombolytic therapy got it
(this is much higher than in previously reported community trials). Patients are routinely placed
on guideline directed medications, including antiplatelet and statin therapy. Most importantly,
our program measures the clinical outcomes of patients at 30, 60 and 90 days. 63% of our
patients return to self-sufficiency at 90 days (modified Rankin score – a standardized metric – of
0-2). The mortality rate for ischemic stroke is 0.55 versus a CMS expected mortality of 5.46%.
The average length of stay is superior to expected, at 3.4 days. The average cost per discharge

9. has been driven below to $7,700. Patient satisfaction exceeds 95%. Perhaps reflecting the
community’s acceptance of its partnership role in improving the quality of their health care, and
the documentation of our results, philanthropy for the program has flourished into eight figures.
The program’s efforts and quality achievements have been recognized with numerous awards,
most recently the Gold Plus Award from the American Heart Association, Stroke Care
Excellence Award from Healthgrades (ranking our program #1 in Orange County, and in the
country’s top 5%), and it has achieved mention in national publications, including U.S. News
and World Report. Our next challenge is the creation of a post-acute physical rehab unit on our
campus, as that critical component of stroke recovery is currently out-sourced. This missing
piece prolongs in-patient length of stay, and detracts from patient and family satisfaction with
our services.
Mother and Baby: Maternity is a health condition, not a disease or disorder in most cases,
which makes it somewhat different than other programs. It resides in the Women’s Health
Institute, along with other programs like Breast Care, Gynecological Oncology, etc. A major
interface to our community, the maternity experience has a major impact on our reputation and
referral patterns for other health care needs. Thus the programmatic strategy became critical.
Originally, the maternity “service line” consisted of 52 independent private practice obstetricians
(OBs) competed for patients, caring for common obstetrical conditions and complications such
as preeclampsia, preterm labor, premature rupture of membranes, etc. All OB patients stayed on
a single unit regardless complexity, their evaluation and care coordination predominantly

10. provided by OB designated nursing staff, aided by primary OB phone consults and outpatient
based perinatologists when needed - as available by office schedule. Pay for night call was
provided to any willing individual OBs. Evidence-based pathways were lacking. Care was
physician centric. “Convenience” inductions of labor and elective primary cesarean sections
were commonly scheduled. Wide variation in length of stay for routine deliveries, induction
rates, cesarean section (CS), vaginal births after CS (VBAC) rates, and cost-per-discharge were
unexplained by patient acuity.
Programmatic transformation started with recruitment of an integrated hospital-based OB
intensivist group, allowing immediate consultations for acute OB conditions, both maternal and
fetal. As the group leadership and its relationship with the community OBs matured, co-
management of perinatal patients in the ICU evolved, and nursing education blossomed
including emergency simulation drills, and multidisciplinary labor and delivery rounds were
instituted with nursing and care planning with pharmacist, nutritionist, respiratory/physical
therapist. Educational seminars with ED, ICU and Hospitalist care teams, also started. The in-
house group then expanded to provide emergency and after hour laborist services as well.
Additional innovations included: Creation of separate 14-bed antepartum unit: Implementation of
a licensed 4 bed OB emergency department: Development of condition-specific order sets and
clinical pathways for emergencies like fetal heart rhythm deceleration, and maternal hemorrhage:
Participation in a risk-sharing ACO with a maternity goal to reduce cesarean section rate, LOS
and cost-per-discharge: Offering of advanced remote patient care monitoring and expanded use
of tele-health technology. Program coordination with our outpatient Diabetes Center for optimal

11. management of gestational and type I diabetics and creation of a Maternal Fetal Board to
develop antepartum care pathways for complicated obstetrical cases occurred. Routine maternal
education (e.g. Waiting for Baby video) and support, post-discharge phone calls, and satisfaction
surveys were developed.
The program now represents a large proportion of in-patient activities, is growing despite a
regional declining birth rate in OC, with over 6000 deliveries and 450 NICU babies per year; it
partners with Children’s Hospital of Orange County for higher levels of care. The leadership
team continues to monitor the flow process, to refine evidence based care pathways for simple as
well as complicated deliveries, and to select best-practice benchmarks for measuring processes
and outcomes while searching for innovative solutions to drive down the cost of care, as
financial metrics are in its scope of management. A portion of the “scorecard” for the program,
which embraces the triple aim is shown in figure 4.
The reduction of CS and episiotomy rates, and the rising rates of vaginal deliveries after CS
represent desirable outcomes engineered by the team. Numerous other process and outcome
metrics are routinely followed by program and Institute leadership. The program spans the
continuum of care service lines from wellness and prevention, through acute care and
procedural/surgical services to post-acute care and primary care hand-offs. The multidisciplinary
approach includes primary care physicians, obstetricians, laborists, neonatal care r67iririand
primary care pediatricians, as well as affiliated caregiver staff. Accolades include the Women's
Choice Award for Obstetrics and Patient Experience 2011-2014, and inclusion in Becker's Top
100 for Women's Services.

12. Memory and Cognitive Care Program: The decision to develop a memory and cognitive
program within the Neurosciences Institute was driven by the looming epidemic of age-related
cognitive disorders in our country. Every day, 10,000 Americans turn 65, and the prevalence of
cognitive impairment including Alzheimer’s dementia (AD) in those individuals is
approximately 1 in 8 [Ref 9, 10]. Indeed, the prevalence of all memory disorders in this age
group (including reversible ones due to depression, medication side effects, etc.) is
approximately 1 in 4 [Ref 11,12]. The cost of care for a Medicare recipient is 3 to 4 fold higher
when dementia is present [Ref 12, 13]. Such financial, as well as societal and individual quality
of life issues compelled us to create a programmatic strategy based in the out-patient community
setting.
Initially, a neurologist was recruited, one with research expertise and a passion for age-related
cognitive disorders, who shared our vision for a populational, community based approach to the
problem. Almost immediately, the clinical practice of the program mushroomed, and the need
for involvement of community primary care physicians and general neurologists to handle
demand became obvious. An advisory panel of interested community neurologists and primary
care physician leaders was convened to help guide strategy. The vision of a multidisciplinary
team with skills in neuropsychology, social work, informatics, grant administration, and clinical
research was supported initially by philanthropy of grateful patients. A grant proposal was
generated focusing on community primary care physician education, creation of care pathways,
and triage tools for management of patients with mild to moderately advanced cognitive
disorders, and creation of a patient portal. The UniHealth Foundation awarded the program 6

13. years of funding for a project based on an aspirational road map of the Leon Thal Symposium
[Ref 14-17] to prevent dementia (a paradigm for the Obama administration’s subsequent
National Alzheimer’s Project Act of 2011- Public Law 111-375). Thus the “Orange County
Vital Brain Aging Project” was born, and a resource rich web portal established for the
community and physicians (www.ocbrain.org).
Through the program, primary care and other physicians are taught best practice in standardized
memory testing yearly (Medicare now mandates testing of cognition with the annual physical).
The team selected an easily administered, validated, highly sensitive test differentiating
abnormal memory impairment from the normal memory alteration of aging [Ref 18-19].
Physician and office staff are offered support to test properly, and for appropriate triage of
abnormals. A major component of the educational effort was the aggregation of literature-based
behavioral and lifestyle prevention guidelines aimed at the 3 in 4 individuals who test normal. A
formal set of evidence-based directives for appropriate blood tests and other diagnostics in the
minority who test abnormal was incorporated into a booklet created by the program director and
the advisory panel, as were the appropriate guidelines for combination drug therapy once the
diagnosis of AD is established [Ref 20-21]. Collaboration with advocacy and support groups,
e.g. Council on Aging, Alzheimer’s Association, is active.
The program combats the nihilism around AD, including the notion “nothing can be done, so
why bother screening?”, alleviates anxiety in 3 of four who test normal, aims to reverse memory
impairment from treatable causes (e.g. depression, medication side effects), and plans to verify
that early behavioral interventions combined with appropriate use of medication can delay the

14. onset or progression of early AD – a potentially successful approach studies are beginning to
support [Ref 22-23]. To document cost savings through such interventions, the program is
collaborating with our at-risk primary care group to gather data. Also, the program facilitates
meaningful clinical research in potentially efficacious emerging diagnostics and therapies.
Over the past 5 years, the program produced 43 Continuing Medical Education (CME) lectures,
for over 1,000 Orange County primary care physicians. A new grant is funding a web-based
CME module for physicians. Seventy five community lectures have been provided as of this
writing, with over 12, 000 individuals educated about healthy brain aging. Over 3,500 self-
referred individuals have been screened through testing provided by the program’s employees in
senior centers, community centers, throughout our region. An additional 13,000 memory
assessments have been performed in the offices of affiliated physicians. A “brain fitness class”
is available to those with early mild cognitive impairment. Ten active clinical research trials o
evaluating new pharmaceuticals and imaging techniques are running. Cross institute
partnerships have developed, for instance a project on cancer and cognition targeting “chemo
brain”, and another to better manage and reduce post-operative delirium in older patients
undergoing orthopedic surgery by identifying cognitively at-risk patients.
The up-front financial benefits of this program are relatively minor for our organization. It is
difficult to account for the elimination of unnecessary brain imaging in those individuals worried
about memory loss who were previously administered costly examinations such as MRI
inappropriately. The down-stream savings could be significant [Ref 12]. Given that 3 of 4
concerned individuals screened test normal, considerable diagnostic expense may be eliminated.

15. Lowering hospitalizations when impaired patients remember (or are reminded) to take
appropriate medications for mild infections, their diabetes or hypertension as directed is a goal.
Optimizing the ability to remain at home instead of institutionalization by adhering to behavioral
tactics such as exercise, social habits, and healthy diets, are also a part of the program’s targeted
cost benefit research.
Discussion
The above three case studies were selected from our spectrum of highly procedural to out-patient
continuum of care programs, illustrating their design, strategy and deliverables to date. Over
65% of our hospital organization’s revenues now flow through the institute/program
infrastructure, a number that has grown over time and will increase further as new institutes
stand up (a Digestive Disorders Institute is being added to the existing Neurosciences, Women’s
Health, Cancer, Heart and Vascular, and Orthopedic ones). The financials are but the by-product
of the “why” – the sustainable delivery of integrated specialized services coupled to the
continuum of care from prevention and wellness, through episodic acute care, to chronic disease
management. That coordinated continuum of care is facilitated through the programmatic team
approach we champion - one that intertwines focused specialized services with the primary care
providers, while delivering demonstrably superior value from the patient’s perspective.

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18. Figure 1

19. Figure 2

20. Figure 3

21. Figure 4