Expert answer:Open Heart Surgery
Solved by verified expert:Open Heart SurgeryFor this assignment, read attached caseWhy is the hospital considering this additional service?Does the hospital and community really need this service? Why or why not?What should be the most important characteristics of a hospital in which one would want to have an open heart surgery?Is it financially viable for a hospital to offer this service? What costs and revenues would you predict to know the viability? Would any revenues cover the costs of offering this service?In addition to the above, state any three instances that could go wrong if this service is offered.Support your responses with examples in a 2-4 page APA formatted Word Document. Include an introduction and conclusion. Cite sources in APA format.
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CASE
The Case for Open
19
Heart Surgery
at Cabarrus
Memorial Hospital
Situation
It was a clear, crisp October morning in Concord, North Carolina.
The board of trustees of Cabarrus Memorial Hospital gathered in
the windowless, walnut paneled boardroom for its monthly meeting (see Exhibit 19/1 for board members). Board chairman George
Batte opened the meeting saying, “Because we do not have an
open heart surgery program, patients needing open heart surgery
or coronary angioplasty have to be transferred to another hospital, causing inconvenience to the patient’s families and risks from
delayed treatment. There are several questions we have to answer in
addressing this issue. Should we add open heart surgery to the mix
of cardiac services we offer? Does the hospital’s existing service area
provide adequate patient volumes to support the program? What
This case was written by Fred H. Campbell, The University of North Carolina at
Charlotte, and Darise D. Caldwell, Executive Vice President and Chief Operating
Officer, Northeast Medical Center. It is intended as a basis for classroom discussion
rather than to illustrate either effective or ineffective handling of an administrative
situation. Used with permission from Fred Campbell.
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Exhibit 19/1: CMH Board of Trustees
Mr. George A. Batte, Jr., Chairman (Retired Manufacturing Executive)
Mr. L. D. Coltrane, III, Vice Chairman (Telephone Company President)
Mr. Robert L. Wall (President, Cabarrus Memorial Hospital)
Mr. Dan Gray, Secretary (Executive Director, Charitable Foundation)
Mr. Durwood Bost, CPA (Retired Manufacturing Executive)
Mr. S. W. Colerider, Jr. (Retired Manufacturing Executive)
Mr. Gene Verble (Merchant and Retired Major League Baseball Player)
Mrs. Margaret C. West (Civic Leader)
role should the Duke University Medical Center play in the proposed program? Will
we be able to obtain the required certificate of need [CON] from the State of North
Carolina’s Department of Health and Human Services? Will there be opposition
to the CON from surrounding hospitals? What costs are likely to be incurred in
the required renovation, construction, medical equipment, and staffing?”
He continued, “As you all know, one of the factors pressing a quick decision
is the desire of Dr. R. S. “Chris” Christy to return to the staff of the hospital after
completing his fellowship in cardiovascular surgery. He is being heavily recruited
by other medical centers.”
Mr. Batte then asked Bob Wall, president of Cabarrus Memorial Hospital
(CMH), to address the board on the issue. Mr. Wall said, “As we all know, our
cardiac catheterization service is run by a Duke Medical Center physician. Our
intent has been for the surgical portion of the heart program to be provided
by Duke. Dr. Christy is completing a heart surgery residency through the Sanger
Clinic and wants to return to Concord to practice. Needless to say, we face a
dilemma and there are very different points of view in our medical staff as to the
structure and relationship involved in developing a full-fledged heart program
at CMH. I bring this to your attention now because Dr. Christy has to make a
career choice before January 1st.”
Trustee Batte reminded everyone, “Dr. Christy grew up in our community and
worked part-time in the hospital while in high school and college. After medical school and a residency in general surgery, he practiced here at CMH prior
to leaving to complete his fellowship in cardiovascular surgery. Dr. Christy was
very popular among the staff and patients and I, for one, very much want to see
him return.” (See Exhibit 19/2 for Dr. Christy’s biography.)
The board had to make its decision about the future of the cardiac program at
CMH before offering Dr. Christy a position; however, it was clear that Dr. Christy
could not wait too much longer to be offered a position by CMH. He had received
multiple offers but, if he delayed, the offers might be withdrawn.
History of Cabarrus Memorial Hospital
The General Assembly of North Carolina passed legislation in 1935 that enabled
Cabarrus County to establish a public hospital. Through the guidance of
Mr. Charles A. Cannon, owner of Cannon Mills, the area’s largest employer, and
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Exhibit 19/2: Dr. R. S. “Chris” Christy
Ralph S. “Chris” Christy was born July 26, 1957 at Cabarrus Memorial Hospital. He was one of two
children born to Steve and Rachel Christy, hardworking owners of Christy’s Nursery in Concord. Chris
was educated in the Cabarrus County School system and played football for NorthWest Cabarrus
High School. He married Kay Moore, also from Concord, in 1977 and together they embarked on the
adventure of Chris becoming a physician. Chris graduated from Davidson College with a BS and
the University of North Carolina at Chapel Hill with a medical degree. He then attended a surgical
residency program at Memorial Medical Center in Savannah. After his residency, Chris returned
to Concord and joined the surgical practice of Flowe, Crooke and Chalfant. Two years later, Chris
entered the Cardio-Thoracic and Vascular Fellowship program at Carolinas Medical Center in Charlotte,
North Carolina. Under the tutelage of Dr. Frances Robicsek, a well-known and respected pioneer in
open-heart surgery, Dr. Christy developed the expert cardiac surgery skills that he wanted to bring
to Cabarrus Memorial Hospital.
other community leaders, Cabarrus Memorial Hospital was established and opened
for patients on July 26, 1937. The original facility had 50 inpatient beds and a staff
of 19 employees. The first addition of 100 beds was completed in 1940. A second
addition opened in 1951 and brought the total bed capacity to 339. A construction
and renovation program, started in 1969, expanded the total licensed capacity to
350 acute care beds and 30 bassinets. The adult bed capacity was increased to
457 beds through a 1982 construction project that modernized and consolidated
many of the hospital’s services.
Duke Medical Center – CMH Affiliation
CMH had several educational affiliation programs and extensive in-service and
continuing education programs, including a unique teaching arrangement with
Duke University Medical Center. The formal affiliation with Duke included regular
sessions on general and specialty medical topics and patient-directed teaching
conferences used as an additional education tool (see Exhibit 19/3). This Duke
affiliation had begun to seed many specialists at CMH, including a cardiologist,
whose practice was rapidly growing.
CMH was a modern, well-equipped facility. Mr. Cannon, as owner of the large
Cannon Mills, had wanted the thousands of Cannon Mills’ employees to have the
very best health care. His generosity and interest in the hospital had made the Duke
affiliation possible. It has been said that he carried the hospital on the mill’s books
as “plant 13.” Certainly his philanthropy had in fact made it a much more advanced
medical center than those in other communities the size of Cabarrus County.
The Cardiac Program at CMH
For several years, Cabarrus Memorial Hospital had increased the availability
of diagnostic and therapeutic cardiovascular services to the community. CMH
had as members of the active medical staff one invasive cardiologist and three
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Exhibit 19/3: Cabarrus Memorial Hospital – Duke University Medical Center Education
Affiliation
As early as 1966, the United States government launched a series of planning grants for regional
medical programs for heart, cancer, and stroke patients. Under this federal proposal Cabarrus Memorial
Hospital was to be affiliated with Duke University Medical Center. The Duke –CMH program began in
1968 with Duke faculty members leading training sessions for CMH’s doctors and nurses at Salisbury’s
Rowan Technical Institute.
Dr. George Engstrom recalled, “CMH medical staff wanted a more direct educational affiliation
with Duke. Dr. Ladd Hamrick, CMH internist, talked with Dr. Eugene Stead at Duke and a stronger
affiliation was proposed. After the discussions with Duke, CMH president Wall, Dr. Bob Hammonds,
and Dr. Hamrick took the proposal for the expanded educational affiliation proposals to George
Batte, chairman of CMH board’s executive committee.” Dr. Engstrom continued, “They presented the
program in 15 minutes and Mr. Batte’s response was, ‘Do you think it will work?’ The answer was
‘yes’ and his response was, ‘I think we can get the money . . .’ The critical funding for the program
came from The Cannon Foundation through the leadership of Mr. Batte.”
As Dr. Hamrick said, “The affiliation forged in 1972 became ‘a powerhouse.’” The successful
Duke –Cabarrus liaison was to become a model program for other health centers, for it brought not
only Duke medical specialists to CMH, but also spurred seminars, classes, and studies with other
nationally recognized physicians and researchers.
The basic agreement was that fellows “from five of Duke’s divisions of internal medicine began to
travel for two 48-hour periods per month to function as educational consultants to the general internists.”
Actually, Duke faculty members from other departments began to travel to Cabarrus. The affiliation
required that patient contact with Duke physicians be educational for Cabarrus doctors. The Cabarrus
activities were to include consultations on educational matters, presenting conferences, reviewing clinical
studies, assisting in surgery, and teaching new or different procedures and techniques, among others.
In 1973, Dr. Galen Wagner of Duke’s Cardiology faculty, was appointed Department of Medicine
coordinator. In 1974, Dr. Tom Long of Duke’s gastroenterology faculty was named Cabarrus-based
coordinator for the Department of Medicine. He ultimately moved to Cabarrus County where he continued his medical practice and affiliation work.
Under the affiliation, visiting medical professors from such highly regarded universities as Harvard,
Stanford, Vanderbilt, University of Pittsburgh, and even medical leaders from foreign countries, came
to teach and consult at Cabarrus Memorial Hospital.
According to Dr. Long, “By 1992 there had been 14,703 Duke visits to Cabarrus; 55,826 clinical
consultations; 7,636 physicians conferences; and 77,792 continuing medical education hours credited
to CMH physicians.” He further noted the many benefits to CMH: “Cabarrus doctors received continuing education through Duke conferences; quality physicians were attracted to the community;
conferences between Duke and Cabarrus doctors about patients were free; medical expertise and
new skills were provided; doctor interest in sophisticated patient care was maintained; and new
‘cutting edge’ technology was developed.”
internists that specialized in treatment of heart diseases. A second invasive
cardiologist and another noninvasive cardiologist were expected to join the staff
in the next year. Dr. Christy would potentially become the first cardiovascular
surgeon on the staff if the board elected to proceed and was successful in receiving the CON.
The scope of the CMH cardiology services included an emergency room staffed
and equipped for treatment of cardiac emergencies, an eight-bed coronary care
unit, cardiac catheterization, and cardiac rehabilitation. (See Exhibit 19/4 for a
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glossary of related medical terms.) In addition, the hospital had capabilities
for numerous cardiovascular diagnostic and therapeutic services. Electrodiagnostic services included electrocardiograms, cardiac Doppler studies, echo
EKGs, exercise EKG studies, and Holter monitoring. The magnetic resonance imaging (MRI) unit had cardiac imaging capabilities. The nuclear medicine department
had equipment for nuclear cardiac and thallium scanning. Temporary and permanent pacemaker insertions, thrombolytic therapy through streptokinase and TPA
infusions, and Swan Ganz catheter insertions were examples of the hospital’s
treatment capabilities.
The new program being considered would include one open heart surgical suite
for adult procedures, with the capacity for 400 procedures per year. Angioplasty
would be offered in the existing cardiac catheterization laboratory. It was
projected that by the end of the third year, three dedicated cardiac surgical ICU
beds and seven telemetry beds would be required to support the open heart
Exhibit 19/4: Glossary
Angioplasty – The insertion of a catheter into the coronary arteries including inflation of a balloon
to squeeze coronary artery plaque formation to decrease blockages
Cardiac Doppler Studies – An imaging study of the heart using ultrasound that involved measurement of pressures in different chambers of the heart, also used to evaluate the valves of the
heart
Cardiologist – A physician who attained fellowship training in diseases of the heart and cardiovascular system
Certificate of Need (CON) – Authorization by the State of North Carolina, Department of Health
and Human Services, Division of Facility Services to proceed with expenditures for new health
facility/equipment
Echocardiography – Diagnostic heart study using ultrasound technology to demonstrate the physical
functioning of the heart
Electrocardiogram (EKG) – A trace of the electrical currents that initiated the heartbeat; used to
diagnose possible heart disorders
Epidemiology – The study of the health and diseases of populations
Exercise EKG – An electrocardiogram performed when the patient was exercising, usually on a
treadmill
Holter Monitor – A diagnostic tool that utilized an extended wearing of an electrocardiogram monitor with which the patient transmitted events telephonically
Intensive Care Unit (ICU) – A specialized patient care unit within a hospital utilized by patients who
required constant, high level of care
Invasive Cardiologist – A cardiologist who performed invasive procedures such as angioplasty
Noninvasive Cardiologist – A cardiologist who specialized in medical treatment of heart disease rather
than performing invasive procedures
Nuclear Medicine – A field of diagnostic imaging that utilized nucleotide particles injected into the
patient, then evaluated with a nuclear camera to produce an image
Swan Ganz Catheter – A pressure catheter that was inserted into the right side of the heart to
measure the performance of the heart
Telemetry – The monitoring of the conduction patterns of the heart through radio wave transmission
from a remote area to a central location
Thrombolytic Therapy – The use of “clot dissolving” drugs to open blocked arteries
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surgery program. Existing space would need to be renovated to accommodate
the various service components.
The additional cardiac service being considered would provide patients of
CMH with a full-service cardiology program consistent with programs available
at other community hospitals and with service areas comparable in size to the
CMH service area. The programs and large expenditures would assure continuity
of care for patients who received initial cardiac care at CMH. If the board decided
not to commit to expanding the cardiac program, CMH patients needing open
heart surgery or coronary angioplasty would continue to be transferred to another
hospital in the region, such as Duke.
Decision Factors
A major part of the board of trustees’ consideration was whether or not there
existed a large enough service area to sufficiently support open heart surgery
and the expansion of the existing cardiac services. They wanted to know what
population threshold would be required. Did they have enough population in the
hospital’s existing service area? The trustees, in making their expansion decision,
looked at a number of factors. They included: (1) the primary and secondary service
areas based on historical data; (2) population growth; (3) population epidemiology;
(4) availability of existing open heart surgery medical centers; (5) accessibility
to cardiac surgery programs; (6) continuity of cardiology care; and (7) rate of
demand for open heart surgery. The hospital’s planning staff, directed by vice
president Glenn Reed, provided data on each of the areas.
1. Primary and Secondary Service Areas
To determine the service area for the proposed heart program expansion, the
existing service area for the hospital was identified by examining the hospital’s
patient database and noting the patients’ residential addresses, particularly zip
codes. Second, they mapped this service area and evaluated the road and transportation network, travel times, and other hospitals in the region. (See Exhibits
19/5 and 19/6.)
In board discussions, president Wall advised the trustees that hospital planners had looked at patient origins for an existing tertiary program – radiation
oncology. This study showed that its major source of patients had been Concord
and Kannapolis, with the remainder widely spread over 23 other communities.
Mr. Wall asked, “Does this give us reason to believe we can expect referrals to
CMH for open heart surgery to come from a wider service area than the hospital average?” (See Exhibits 19/7 and 19/8.)
To further look at the question of patient origins, CMH studied zip code
origins for its cardiac catheterization patients. Again, a large number of patients
had Concord and Kannapolis zip codes and generally reflected patient origins
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Exhibit 19/5 Cabarrus Memorial Hospital Patient Origin
County
% Patient Origin
Cabarrus
Rowan
Stanly
Other
80.1
9.4
7.2
3.3
TOTAL
100.0
Note: “Other” includes Union, Mecklenburg, Davie, Davidson, Iredell, and Lincoln counties.
Source: Hospital Patient Origin Report (North Carolina Medical Database Commission).
Exhibit 19/6: Map of CMH Service Area
I
R
E
D
E
L
Key: 1.
2.
3.
4.
5.
6.
7.
8.
9.
L
601
2 29
Salisbury
R
9*
Mooresville
*
O
W
A
Cabarrus Memorial Hospital
Rowan Memorial Hospital
Stanly Memorial Hospital
Union Memorial Hospital
University Memorial Hospital
Mercy Hospital
Presbyterian Hospital
Carolinas Medical Center
Lowrance Hospital
N
85
C
A
B
A
Kannapolis
R R U
S
*1
49
77
29
*
Albemarle
*3
Concord
5
S
85
8 Charlotte
*
7* * 6
T
A
N
L
Y
601
M E C K L E N B U R G
Monroe
4*
U
N
I
O
N
601
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Exhibit 19/7: CMH Patient Origin (%) Previous Year
County
Radiation Oncology
Heart Catheterization
57.4
16.0
19.7
6.9
59.3
30.4
7.3
3.0
100.0
100.0
Cabarrus
Rowan
Stanly
Other
TOTAL
Exhibit 19/8: Proposed CMH Open Heart Service Population
County
Cabarrus
Rowan
Stanly
Union
Mecklenburg
Iredell
Population
Market
69,255
40,813
7,661
1,516
1,534
651
70.0
36.9
14.8
1.8
0.3
0.7
similar to those of the radiation oncology program. Again the board wondered if
this indicated the open heart program would draw patients from a service area
that would include parts or all of six counties: Cabarrus, Rowan, Stanly, Union,
Iredell, and Mecklenburg. The outside boundaries of these counties are within
60 miles of Concord, the site of CMH.
Mr. Wall questioned, “What would further analysis of the historical data lead
planners to conclude about the program’s primary service area? Could it serve as
much as 70 percent of Cabarrus and a third of Rowan County? Would the second …
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