Welcome back to the Regional Time-Sensitive Care Coalitions course, and you're now watching Lesson 8, our final lesson. If any questions come to mind or if there's any feedback you'd like to share regarding the course or toolkit, please send an email to ncdrmail at acc.org. Let's do a quick recap of what we've covered so far. Lesson 1 made the case for why a community or region should establish a Regional Time-Sensitive Care Coalition, or RETSCO. In the second lesson, we covered the roles and responsibilities of the RETSCO and the RETSCO manager. In the third lesson, we discussed ways to define the catchment area for the RETSCO and which organizations to invite to participate in its creation. The fourth lesson described how to make a preliminary assessment of time-sensitive systems of care efforts within that catchment area. The fifth lesson covered how to get things set up for a meeting of executive-level representatives from the stakeholder organizations to discuss formation of the RETSCO. The sixth lesson talked about how to conduct the RETSCO formation meeting. Lesson 7 talked about how to conduct the condition-specific committee meetings. And in this eighth lesson, we're going to talk about accountability, transparency, and celebration. We will want to have some accountability and transparency from the RETSCO for system performance. To do that, the participating organizations are going to have to be accountable and transparent to the RETSCO. A key element in proactive design for a system of care is finding ways to align the incentives for organizations and individuals to the goals for getting the right things done at the right times and in the right places. Those goals become the basis for design of the system of care and the processes therein. While clinical outcomes are best with the right care at the right time and in the right place, there may not be good alignment politically, financially, and operationally. That's why it's in the best interests of all parties that the RETSCO find ways to facilitate an alignment of incentives. And that's where engagement of payers and regulatory agencies comes into play. In the short to medium term, the most straightforward and effective means of aligning incentives is by creating transparency and establishing accountability. With transparency and accountability, a strong alignment of incentives emerges to protect and even enhance organizational reputations, thereby increasing rather than decreasing an organization's political capital. At the launch of the RETSCO, it may be enough to start with just reporting on performance. Over time, trust between participants should build and the group will have had a chance to work on several systems-level improvement projects together. The time usually comes when the group members feel more comfortable and set some specific performance goals. Those goals can be set at both a systems-level and an organizational level. For example, at a systems-level and STEMI performance, the RETSCO might set a symptom-onset to device-time goal for the overall system to average 90 minutes or less when the patient arrives by ambulance directly at an emergency PCI-capable hospital. Meeting that goal is a joint responsibility of EMS providers and hospitals. As an example at an individual organization level, the RETSCO may set a goal for ambulance services across the entire system having 10 minutes or less from first medical contact to first 12-lead ECG on qualifying cases. Even though the RETSCO set the goal, meeting that goal is under the operational control of each individual ambulance services, although non-transport medical first response providers might be contributing to meeting that goal as well. Initially, the accountability between organizations may be for just on-time reporting of their performance levels. After the group sets goals, the accountability may be ratcheted up slightly to include on-time submission of performance data for system-level aggregation, reporting their respective organizational performance levels, and meeting the performance goals. In the longer term, goals might be made more stringent. Hopefully, as trust builds and the willingness to collaborate becomes easier, everyone will participate in efforts to work towards incremental and breakthrough improvements over time. Also, in the early phases of the RETSCO, the reporting for accountability might just be within the group. Everyone involved would be given some time for a ramp-up phase to establish their processes for collecting data, calculating performance levels, and begin to undertake efforts to improve their performance. The RETSCO may strive to have all hospitals utilize a formal clinical registry for specific clinical conditions to support the data collection, performance calculations, and the aggregation of results to the system's level. This approach also has the advantage of using nationally standardized data collection and analysis tools, as well as the ability to make apples-to-apples comparisons of local results to state and national levels. These registry results may also include risk adjustments to make the results comparisons even more valid. This group should set a time limit for the ramp-up phase, perhaps a year. During that time, systems-level reporting would be shared among the participating organizations within the group before the reporting and accountabilities are made public. It can be extremely helpful to have neutral third parties serve as data aggregators. Participating organizations may not be comfortable sharing their specific performance results with competitors. A trusted and neutral third party can be used to receive the individual organizational results and do the roll-up calculations to generate the system-level performance results. An independent EMS regulatory agency or public health agency may be well-suited for such a role. Some clinical registries may offer regional reporting services that can also serve this purpose for a group-defined set of organizational participants. After an appropriate ramp-up phase, the RETSCO should try to move on to full public accountability. Public reporting is a common form of transparency in health care. It can take many forms, so caution should be taken in making sure that the objectives of transparency are not circumvented by placing publicly reported information nine clicks down in an obscure website. To avoid this, consider broadly distributing the information on systems for the various time-sensitive conditions. That might include a quarterly performance summary to the RETSCO Stakeholders Committee. The local media and elected officials. Maybe monthly updates to graphs that summarize performance results that are displayed on a readily accessible public webpage. Try to make it no more than one click to reach reports from the top-level web address you publicize. A custom web address to a subdomain can enable zero clicks. That may be something like performancereport.yourwebsite.com. Maybe monthly updates with more detailed reporting on a webpage primarily designed for RETSCO participants. That page should also be publicly accessible through a link on the summary page designed for the general public. The organizations in the RETSCO may choose to formalize their commitments for data submission and striving to reach target performance levels in a variety of ways. Verbal commitments from C-suite members on the Stakeholders Committee is a good first step, but to preserve those commitments past the tenures of individuals present at the formation of the RETSCO, having those commitments in writing can be extremely helpful. To that end, the RETSCO might ask organizations to sign a simple letter of commitment or some other document affirming their willingness to participate in the RETSCO and support its efforts for improvement, transparency, and accountability. Elected officials or senior executive officers from units of local government, like city councils, mayors, and city managers, county commissions, and county administrators, should directly participate on the RETSCO Stakeholders Committee. Like C-suite hospital officials, they oversee various EMS-related government agencies that are directly involved in patient care for time-sensitive emergencies. They are in a position to require their EMS fire and 911 department heads to actively participate in the RETSCO by providing the requested data and actively participating in RETSCO meetings and improvement projects. Those expectations can be formally stated in service-level agreements, or SLAs. SLAs function like a contract between different parts of the same unit of government. For example, a city manager can put an SLA in place with the local fire rescue agency that operates the ambulance services and provides non-transport medical first response service. That SLA can require the fire rescue agency to submit data, strive to meet performance targets, and publicly report performance levels as set forth by the RETSCO. This creates a clear expectation and accountability directly between that city manager and the fire rescue department that these requirements are to be taken very seriously. Without these sorts of explicit accountabilities in some communities, it may be very difficult to get government agencies, including fire departments, government-operated ambulance services, and 911 communication centers to fully cooperate. Similar expectations can be set forth by municipalities to private ambulance services. Local government is usually in a position to allocate ambulance market rights. This could be to their local fire department, government-operated ambulance service, a private ambulance service, or a combination thereof being designated to provide emergency and non-emergency ambulance service. When a private ambulance service is granted emergency and or non-emergency ambulance service market rights, those market rights can be contingent upon accepting the terms of certain performance and reporting requirements. Those requirements might be spelled out in a contract, just like the SLA for a government-operated service, the contract can explicitly state requirements for data submission, achieving specific performance levels, and public reporting. In addition to loss of political capital when high-profile public reporting reveals performance shortcomings, failure to meet performance requirements can also be associated with financial penalties or even a loss of those market rights to a private ambulance provider. The U.S. healthcare system is in transition from a fee-for-service model to so-called alternative payment models. In general, the alternative payment models are moving towards formulas and strategies that reward both quality and efficiencies. These are also referred to as value-based payment models. In these payment models, incentives are in place for both payers and providers to reduce total healthcare costs and improve quality. These two goals can be simultaneously achieved by having high-functioning systems of care for time-sensitive conditions. For example, if a STEMI patient is diagnosed quickly by EMS, if EMS promptly notifies the hospital, if the hospital promptly activates the cardiac cath lab team, if the patient is moved quickly into the cath lab upon arrival, and if the occluded coronary artery is quickly opened after cath lab arrival, then the size of the myocardial infarction and associated muscle damage will be minimized, thereby reducing the size of the infarct. The reduced infarct size will make it less likely that the patient will have short-term complications and will be less likely to suffer from chronic complications like congestive heart failure. All of these actions contribute to a lower total cost for treating the STEMI in the short and long term. All of this makes for improved quality of care at lower total cost, which equates to better healthcare value. Therefore, at-risk payers have a lot to gain from supporting high-functioning systems of care for STEMI and the other time-sensitive conditions that the RESCO targets. The financial upside for at-risk payers can make them strong allies for systems of care improvement and to potentially provide support for the efforts of the RESCO. To cap this off, I'd like to talk a little bit about celebration. In the Stakeholder Committee and in all of the condition-specific committees, time should be taken to recognize the efforts of any improvement project teams, regardless of the outcome of their projects. Indeed, to foster a culture of innovation within the RESCO, projects with negative or inconclusive results should be celebrated as much or even more vigorously than the projects with positive results. The RESCO Stakeholders Committee should strongly consider an annual recognition event where improvement project teams, condition-specific committees, individual provider organizations, and other participating or supporting organizations can all be recognized for their efforts in support of the RESCO's mission to improve care delivered by the system to the entire region. And that wraps things up for Lesson 8 and the course. Check out the toolkit that goes along with this course at cvquality.acc.org slash systems of care for more information. Please do not hesitate to reach out if you have questions or would like to see other support resources made available to assist your efforts to implement the RESCO model. Just send an email to ncdrmail at acc.org. On behalf of the American College of Cardiology, I'm Nick Gunderson. Thanks for watching.

accountability

transparency

celebration

incentives

time-sensitive care