Regional Time Sensitive Care Coalitions Toolkit

Every community/region has a system of care (SOC) for each time sensitive condition. In many communities, the SOCs evolved organically in response to various economic and political factors and events. Often, these SOCs have not been formally conceived or designed across entire regions. When systems systems of care are not carefully designed and formally managed, the resulting processes can be inconsistent and inefficient, leading to sub optimal outcomes and waste of time and resources.

There are many clinical and operational issues that time sensitive conditions have in common, yet most communities have separate systems of care initiatives for the various conditions. This contributes to duplication of efforts, waste of resources and loss of opportunities to learn, share and collaborate among various time sensitive condition groups.

The goal is for every community/region to have a high-performing system of care that addresses all time sensitive conditions. Instead of operating in silos, the conditions are managed through a single regional time sensitive care coalition (RETSCO). The organizational structure for the RETSCO should have the flexibility to address issues in common between time sensitive conditions collectively, while preserving the ability to tackle condition-specific issues separately.

The RETSCO is managed through collaboration and consensus between the various stakeholders. They establish processes for all time sensitive conditions regarding quality improvement, governance, sustainable funding, data sharing, reporting, transparency and accountability.

The RETSCO model can also be used for single condition initiatives (e.g., establishing and operating a regional STEMI system of care group) as well as multiple conditions.

Each RETSCO should take responsibility for the following:

• Creating their formal or informal organizational structure (either a separate organization or embedded within an existing organization). Note: If you choose to create a formal organization then the role of the RETSCO should not fall to one of the clinical provider organizations in order to minimize real or perceived biases favoring that organization. The regional EMS regulatory agencies or public health departments may make a better home for the RETSCO.
• If there are existing condition-specific time sensitive systems of care groups in the region/community (e.g, for STEMI, trauma, stroke, etc.), incorporate them into the RETSCO as condition-specific committees. The chair of each condition-specific committee should also serve as an ex-officio member of the RETSCO Stakeholder Committee.
• Determine which time sensitive conditions the RETSCO will address formally. The RETSCO may start out with only one or two conditions and add more over time as the group develops and refines it processes, procedures and secures additional support resources.
• Perform a baseline assessment of systems-level performance in each of the time sensitive conditions if they are not already being measured on a regular basis. These baseline performance levels should be measured as soon as possible in as many time sensitive conditions as possible to support planning, helping to secure resources and to allow any progress to be measured.
• Perform regular re-assessments of systems-level performance in as many time sensitive conditions as possible to monitor changes over time and inform prioritizations.
• Focus on improvement projects that can be conducted at a system-level (e.g., across multiple organizations).
• Share information between condition-specific committees and their respective improvement project teams to promote cross-pollination of ideas, collaboration, and learning.
• Support the efforts of each of the condition specific committees.
• Seek ways to leverage resources across participating organizations and condition-specific committees.
• Aggregate data across conditions to regularly calculate a general time sensitive condition performance index that can be easily reported to the public.

ROLES AND RESPONSIBILITIES OF THE RETSCO MANAGER

If able, each RETSCO should consider having a formally designated RETSCO manager. If the RETSCO is established as its own organizational entity, the manager would be employed by the RETSCO directly. Or, if the RETSCO has a less formal organization structure, the manager may be employed by one of the stakeholder organizations – preferably a regulatory/oversight agency, health department, or similar. Regardless of which organization the RETSCO manager is employed, the RETSCO manager plays a key role in coordinating efforts between the participating organizations and the condition-specific groups within the RETSCO.

The RETSCO manager's specific responsibilities may include:

• Being the primary point of contact for matters related to the RETSCO
• Ensuring coordination for the various meetings and projects of the RETSCO Stakeholder Committee, condition-specific sub-committees and ad hoc improvement project teams
• Work with the participating organization staff members that may be assigned to provide administrative support to the committees and teams (e.g., staff that work for the various committee and project team chairs and committee members). Note that there may be cases where the RETSCO is established as a separate organization or where the function of the RETSCO is part of the role of an existing organization (e.g., a regional EMS regulatory agency or public health department). The role of the RETSCO may then be assumed by someone in that organization, who may have their own staff or colleagues that also can help support RETSCO operations.

Click here to view/download a sample job description for the RETSCO Manager.

As an initial step, the champion (who may be an individual or an organization) for establishing the RETSCO should consider what the catchment area of the RETSCO will be. The catchment area could be the geographic area within a single municipality (e.g., city, county, town or similar), a group of contiguous municipalities, or an entire region or state. Ideally, the catchment area should encompass the actual incoming referral patterns between tertiary and referral hospitals with consideration of the jurisdictional areas of the 911 communications centers, non-transport medical first response agencies, and ambulance services that interact with the tertiary centers. Consideration should also be given to the service areas for the long-term acute care facilities, rehabilitation centers, and secondary prevention providers that work with the tertiary centers.

At a minimum, a RETSCO should include at least one tertiary receiving hospital (e.g., emergency PCI hospital; level 1 or 2 trauma center; primary or comprehensive stroke center) and at least one ambulance service that routinely responds to 9-1-1 calls within the catchment area. Other hospitals and healthcare provider and stakeholder organizations should be also strongly encouraged to participate in the RETSCO to include: 9-1-1 communications centers, non-transport medical first response agencies, EMS regulatory agencies, EMS medical direction providers, hospital associations, rehabilitation departments or facilities, secondary prevention providers, CMS recognized QIOs, public health departments, payers, senior appointed or elected officials from units of local government, and patient representatives / advocates.

The champion(s) for establishing the RETSCO should attempt to catalog any initiatives, past or present, for a broad range of high-risk time sensitive conditions. The conditions to include in this assessment may include, but are not limited to:

• Major trauma
• Out-of-hospital cardiac arrest
• Acute myocardial infarction
• Stroke
• Sepsis
• Pulmonary embolism
• Opiate overdose
• Ruptured aortic aneurism

These initiatives, if any, may have been undertaken at a regional/systems level by multiple provider organizations working together; by individual tertiary receiving hospitals working just with the referral hospitals and ambulance services that bring them patients; by a public health department; or EMS regulatory agency.

Efforts should also be undertaken to get a current baseline on how well care is being delivered in those conditions, as measured by key outcome and process measures.

Another option is to focus on one high-risk time-sensitive condition (e.g. STEMI). Throughout this document, the steps described for establishing and operating a RETSCO may be applied with minor modification to efforts for a single-condition system of care initiative.

Finding Meeting Sponsors

The initial meeting of executives to consider forming the RETSCO may have associated expenses, particularly if a meal is to be served or a room has to be rented. Having these discussions over a meal or refreshments is strongly suggested as it tends to increase attendance and participation. Sponsor possibilities include:

• Organizations affiliated with the champion(s) trying to form the RETSCO
• Hospitals or hospital foundations
• Pharmaceutical companies or device manufacturers with an interest in time-sensitive care conditions (e.g, stroke thrombectomy device makers, thrombolytic drug companies, defibrillator / monitor companies, etc.)
• Local foundations with an interest in healthcare innovations
• Major payers
• Local physician groups with an interest in time sensitive care (emergency medicine, cardiology, or surgical group practices – alone or with multiple group practices as sponsors)
• Local government or their agencies may be an option, but they may have financial restrictions if meals and beverages are involved.

Suggested Invitees

Click here to view a comprehensive list of organizations and titles of individuals to consider inviting to the initial coalition formation meeting. Some of the titles listed may not match the titles of the appropriate representatives in a specific region or community. Use these as a guide.

Government operated EMS provider agencies (such as, 911 communications centers, fire/rescue departments, and ambulance services) may be represented by their city or county administrators or elected officials that the provider agency reports to. Including the senior appointed or elected officials are the higher priority, but it is acceptable to have the senior leaders of the provider agencies that report to them. It is also appropriate to include the EMS regulatory agencies, which are not provider agencies, in the meeting to form the coalition. Finally, invite senior leaders from private ambulance services and separately governed fire protection districts to the meeting.

Click here to view a sample invitation letter that describes the reason for the meeting. It is appropriate for this invitation to come from a very senior public official, such as a mayor, chair of the local county commission, city manager, or county administrator – or a local equivalent thereof (e.g., county judges in Texas) – on their official letterhead. Another option is for the letter can come from the champions on behalf of the ACC and/or NACCHO. If there is another scenario that is likely to result in good attendance, these options should not be considered restrictive. For example, a local EMS council, hospital association, public health department, may also have a neutral standing along with enough political influence or gravitas to compel attendance by hospital CEOs and other senior officials. The date may be left open to allow scheduling to occur based on the availability of those who express interest in attending.

Follow up with those who do not respond to the RSVP.

Scheduling

1. Working in conjunction with the organizational sponsor(s), determine when and where to have the first organizing meeting to discuss forming the RETSCO.
2. When selecting a meeting date give priority to the availabilities of leaders of existing time sensitive care groups, hospital C-suite representatives, senior appointed/elected government officials, and payers. Their attendance, input and support is crucial.
3. Poll availability of those who express interest in attending (e.g. Doodle poll)
4. Once a time and location are determined, send a follow-up letter with the specifics to the entire group of invitees – including those who did not respond the RSVP.

Initial Meeting

Click here to view a guide for setting the agenda for the initial meeting.

Consider using a neutral facilitator for the meeting – especially if the champion for this meeting is from a provider organization. The facilitator should be a neutral party so that all attendees feel their interests are not being diminished by real or perceived facilitator bias. A local health department or EMS regulatory official may be an appropriate choice if they have good facilitation skills. A good way to start the meeting is to have the champion and a high-ranking public official or major payer executive give opening remarks to underscore the need for the RETSCO.

Ask the champion to introduce the guiding principle for the meeting – that patient and community interests need to be prioritized over the proprietary interest of any individual group or organization in the formation and operation of the RETSCO.

Outcome goals for the meeting should include:

• Decision on formation and support of the RETSCO
• Decision of which time sensitive conditions to initially include with inclusion / establishment of condition-specific committees
• Get commitments for each organization to have a single executive level representative serve on the Stakeholder Committee
• Agreement to send names and contact information to the meeting organizer on persons to invite to participate on each of the condition-specific committees.
• Have an initial discussion on RETSCO organizational structure – informal coalition (not a legal entity); a new legal entity (e.g., create a 501(c)(3) organization); place it within an existing entity to fulfill RETSCO role; or other options. This might not get decided at the first meeting if several alternatives need to be explored and presented back to the group.

These objectives provide focus to the discussions and serve as calls to action.

At this early stage, it is particularly important to have higher level decision makers involved who can commit on behalf of the organizations they represent. Generally, these attendees are C-suite hospital executives, very senior level government officials (e.g., city managers, county administrators) and the owners/directors of ambulance services or rescue squads that are not operated by units of local government.

Representatives at this level should be able to make decisions on behalf of their organizations to:

• Participate in the RETSCO
• Agree to the general goals and rules by which the RETSCO will operate
• Authorize financial and other types of resource allocations
• Appoint/designate/nominate representatives from their organizations to participate in the condition-specific committees.

Follow-Up

All of the attendees and invitees to the initial coalition formation meeting should get a follow-up email and/or letter. It should thank them for their attendance or effort to attend and provide a very concise set of minutes. Decisions made and action items for follow-up should be highlighted.

Appendix 5 contains information that may be included in a brochure sent out with the follow-up letter reinforcing key points regarding formation of the RETSCO.

Armed with the information from the preliminary assessment, discussions from the initial RETSCO formation meeting and recommendations from attendees on the names of individuals from their organizations to invite onto RETSCO committees, you can begin establishing an initial set of committees.

Stakeholder Committee

Once the decision to form the RETSCO moves ahead, ask senior/executive level representatives to continue to work with the group as members of the Stakeholder Committee.

Include these Stakeholder Committee members:

• Senior and executive level representatives from hospitals, EMS provider and regulatory agencies, 911 communications centers, elected/senior appointed local government officials (e.g., mayors or city council members, county commission chairs or members, city managers, county administrators)
• Senior representatives from healthcare payer organizations (which can include major employers with self-funded health plans)
• Senior public health officer(s) for the region
• Chairs of the condition-specific committees
• Former patients/patient advocate representatives

The intention of the Stakeholder Committee is to provide high-level accountability for making progress, address political and financial issue, and to aid in removing roadblocks, as needed, that the condition-specific committees or ad hoc QI project teams may encounter.

The intention of RETSCO Stakeholder Committee is to serve the following objectives:

• Create accountability for progress in results from the condition-specific committees and ad hoc improvement project teams
• Be accountable to the community for systems-level performance
• Address issues that affect more than one of the targeted time sensitive conditions (e.g. improving the speed of emergency interfacility transfers to definitive care) OPTION: The RETSCO may choose to establish a cross-condition subcommittee that addresses more clinically oriented issues that impact multiple conditions and allow the stakeholder committee to focus on more of the political, financial and broader policy issues.
• Ensure appropriate coordination of efforts between condition-specific committees and improvement project teams
• Make multi-condition systems-level policy recommendations and/or consensus decisions
• Make recommendations for organizational level policies (e.g., that all PCI hospitals enact policies that allow for activation of cardiac cath lab teams/trauma teams/stroke teams prior to ambulance arrival to the hospital)
• Issue an annual report on the state of time-sensitive emergency care in the community/region.

The agenda for these meetings should be driven by these objectives. The stakeholder committee should meet at least on a quarterly basis. Click here to view a sample Stakeholder Committee Agenda.

Condition Specific Committees

For each targeted condition designated by the RETSCO Stakeholder Committee, they should establish a condition-specific committee (e.g., a STEMI committee). This is where hospital service line administrators, medical directors and quality managers; as well as ambulance, fire-rescue, and 911 center supervisors, quality managers and medical directors will likely participate. There may also be some front-line clinical staff involved at this level. If the RETSCO has several condition-specific committees, the same person from each EMS agency and the same person from each emergency department should not be the primary representative on every one of these committees. However, key individuals, such as an ED or EMS medical director, can attend any of the meetings as they deem necessary.

If an existing condition-specific system of care group or groups are incorporated into the RETSCO, that can provide the starting point for the new committee.

The chair of each condition-specific committee should serve in an ex-officio capacity on the RETSCO Stakeholder Committee (and the cross-condition committee, if one is established).

Click here to view a sample meeting agenda for condition-specific committee meetings.

Regardless of the type of organizational structure that's  chosen for the RETSCO, a set of bylaws or similar document should spell out how  the RETSCO operates. The bylaws address how to appoint and rotate the steering  committee and condition specific-committee members; how to make decisions; and  other operating policies. A more formal and comprehensive set of bylaws are  needed if the RETSCO is fully independent 501(c)(3) not for profit corporation  versus an informal coalition. Make this early agenda item for the Stakeholders

Another early issue for the Stakeholders Committee is the consideration of funding needs, developing a budget, and identifying on-going sources of funding. Again, an informal coalition will have different needs than a formal 501(c)(3) structure. Another consideration is the need for a coordinator or director. Click here for a sample job description for a RETSCO Manager.

Funding options may include annual funding assessments to the participating organizations and grants. Grants may be helpful initially but may not be appropriate for the long term. With an informal organizational structure, participating organizations may simply agree to share costs on an ad hoc basis or rotate the responsibility and costs for hosting meetings, etc.

Aligning Incentives

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.

In the longer term, the RETSCO should seek ways to align financial incentives – and that's where engagement of payers and regulators 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. The incentive for an organization to have high performance, becomes protecting and enhancement of its reputation – increasing rather than decreasing its "political capital."

Establishing Transparency and Accountability

At the launch of the RETSCO, focus on reporting performance. Once trust among participants builds as the group works together on some systems-level improvement projects, set specific performance goals. Those goals can be set at both a systems and organizational level.

For example: in STEMI performance, there might a be a symptom onset to device time goal at a system level for a median of 90 minutes or less when the patient arrives by ambulance directly to a PCI capable hospital.

The group may set a goal for ambulance services having 10 minutes or less from first medical contact to contacting the receiving hospital with a STEMI Alert on qualifying cases. Emergency PCI capable hospitals might have a goal for a door to device time of 45 minutes or less when EMS declares a STEMI Alert from the field and the patient is taken directly from the scene to a PCI hospital.

An initial goal may be for on-time reporting of performance levels. The next goal could include on-time submission of performance data for system-level aggregation, reporting their respective organizational performance levels and meeting the performance goals.

The long-term goals might be more stringent or there might be an expectation for everyone to work towards incremental and break-through improvements over time.

Accountability Within the Coalition

Initially, the accountabilities might just be within the group. Give everyone involved 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, approximately a year. When available, the group may decide to utilize a formal clinical registry for specific clinical conditions to support the data calculation, performance calculations, and aggregation of results to the systems level. This approach 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 a state and national levels. These registry results may include risk-adjustments to make the results comparisons even more valid. During that time, share systems level reporting among the participating organizations within the group before the reporting and accountabilities are made public at a community level.

It can be helpful to have neutral third party serve as a data aggregator. 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 can serve in this role. Some clinical registries offer regional reporting services that can also serve this purpose for a group-defined set of organizational participants.

Public Accountability

After the "ramp-up" phase, move forward to full public accountability. Public reporting is a common form of transparency in healthcare. It takes many forms, so ensure that you do not place publicly reported information in an obscure place and undermine transparency. Here are some suggested destinations for distribution of publicly reported information on systems of care performance:

• Quarterly performance summary to the media and elected officials
• Quarterly performance detail report to the RETSCO Steering Committee
• Monthly updates on performance summary figures displayed on a readily accessible public web page. Create a vanity web address to increase accessibility (e.g., yourwebsitename.org/performancereport).
• Monthly updates on performance details displayed on a web page primarily designed for RETSCO participants. That page should also be publicly accessible through a link on the summary page designed for the general public.

Service Level Agreements, MOUs and Contracts

The organizations in the RETSCO can choose to formalize their commitments for data submission and strive to reach target performance levels in a variety of ways. Start with verbal commitments from C-suite members on the RETSCO Stakeholders Committee. It is helpful to have in writing the commitments of senior officials so that the position stays at the organization. The RETSCO can ask organizations to sign a simple letter of commitment that states the organization agrees to abide by the bylaws or some other document with the ground rules for RETSCO participation and do its best to participate in establishing and maintaining transparency and accountability.

Elected officials or senior executive officers from units of local government (e.g., city councils, mayors and city managers; county commissions and county administrators) should directly participate on the RETSCO Steering Committee. Like C-suite hospital officials, they oversee their various EMS related departments 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 (SLAs), which functions 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 service and provides non-transport medical first response services. 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 explicit accountabilities, it can be difficult to get government agencies, including fire departments, government operated ambulance services and 911 communications centers to fully cooperate.

Municipalities can set similar expectations to private ambulance services. Local government is usually able 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 designated to provide emergency and non-emergency ambulance service. When a private ambulance organization is granted emergency and/or non-emergency ambulance service market rights, that can come with a performance-based contract. That contract, like the SLA for a government operated service, 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 have financial penalties or loss of market rights to a private ambulance provider.

Payer Engagement

At the time of this writing, the U.S. healthcare system is in transition from a fee for service model to an "alternative" payment models. In general, the alternative payment models are moving towards formulas and strategies that reward both quality and efficiency. These are also referred to as value-based payment models.

In these alternative payment models, there are incentives for payers and providers to reduce total healthcare costs and improve quality. These goals can be achieved by having high functioning systems of care for time sensitive conditions.

For example: If a STEMI patient is diagnosed quickly by EMS, and the EMS promptly notifies the hospital then the hospital promptly activates the cardiac cath lab team. If that patient is moved quickly into the cath lab upon hospital arrival and if the occluded coronary artery is quickly opened, then the size of the myocardial infarction (muscle damage) is minimized. The reduced infarct size makes it less likely that the patient will have short- or long-term complications. This contributes to a lower total cost for treating the STEMI while also improving the quality of care.

Therefore, "at-risk" payers gain from supporting high functioning systems of care for STEMI and the other high-risk time sensitive conditions that the RETSCO targets. The financial upside for the at-risk payers can make them strong allies for systems of care improvement and to potentially provide support for the efforts of the RETSCO.

Here are additional documents, organizations, and information that may be useful in the development and operation of RESTCOs and condition specific systems of care.

Documents:

Implementation Checklist https://cvquality.acc.org/docs/default-source/clinical-toolkits/systems-of-care-toolkit/soc_1_implementation_checklist.pdf

Information Brochure on Systems of Care for Time Sensitive Conditions https://cvquality.acc.org/docs/default-source/clinical-toolkits/systems-of-care-toolkit/soc_3_information_brochure_on_soc_for_time_sensitive_conditions.pdf

Sample Meeting Agenda and Discussion Points for Initial Formation Meeting https://cvquality.acc.org/docs/default-source/clinical-toolkits/systems-of-care-toolkit/soc_6_sample_meeting_agenda_and_discussion_points_-initial_tscc_formation_meeting.pdf

Sample Regional Report Elements Template https://cvquality.acc.org/docs/default-source/clinical-toolkits/systems-of-care-toolkit/soc_-9_sample_regional_report_elements_(ami)__-template.pdf

Time Sensitive Care Coalitions MOU with Participating Organizations https://cvquality.acc.org/docs/default-source/clinical-toolkits/systems-of-care-toolkit/soc_10_tscc_mou_with_participating_organizations__template.pdf

Preliminary Assessment Checklist https://cvquality.acc.org/docs/default-source/clinical-toolkits/systems-of-care-toolkit/soc_11_preliminary_assessment_checklist.pdf

Ad Hoc Improvement Project Team Charter Template https://cvquality.acc.org/docs/default-source/clinical-toolkits/systems-of-care-toolkit/soc_12_ad_hoc_improvement_project_team_charter__template.pdf

Ad Hoc Improvement Project Team Charter Example https://cvquality.acc.org/docs/default-source/clinical-toolkits/systems-of-care-toolkit/soc_13_ad_hoc_improvement_-project_team_charter__example.pdf

Community Dashboard Template https://cvquality.acc.org/docs/default-source/clinical-toolkits/systems-of-care-toolkit/soc_14_community_dashboard__template.pdf

EMS Performance Accountability Agreements Templates https://cvquality.acc.org/docs/default-source/clinical-toolkits/systems-of-care-toolkit/soc_15_ems_performance_accountability_agreements__templates.pdf

Videos:

Lesson 1 - Overview - https://youtu.be/RdMcte2bCRU

Lesson 2 - Roles - https://youtu.be/QDP1UEBKkyI

Lesson 3 - Catchment Area - https://youtu.be/rghXMRPf4Lg

Lesson 4 - Preliminary Asseessment - https://youtu.be/bVAQjvQKuUo

Lesson 5 - Preparing for the Initial Meeting - https://youtu.be/QnUdotjq8WQ

Lesson 6 - Conducting the Initial Meeting - https://youtu.be/e0RVQghXx3w

Lesson 7 - Condition-Specific Committee Meetings - https://youtu.be/9ZpUNh-lEJQ

Lesson 8 - Accountability, Transparency, Celebration - https://youtu.be/8bJYr3JBF4c