There is a growing interest among many hospitals—community and academic alike—to migrate toward alternative service delivery models referred to as “service lines.” The concept with clinical service lines is to shift the hospital’s care delivery model from the traditional specialty silos to a more horizontal organizational structure that is focused on patient-centric care delivery within a particular clinical affinity area. Cardiovascular and musculoskeletal service lines are common examples. The idea is to organize all related services under one broad program umbrella, and work to manage those services better and more efficiently. When well designed and implemented, service lines can be helpful to patients in their accessing one-stop care in a way that improves coordination and outcomes, and results in a measurably better patient experience. Service lines also hold the promise of bringing together related specialists and providing them opportunity for collaboration and innovation that would not have been possible while practicing in separate subspecialty departments or offices. When cardiologists and cardiac surgeons and cardiac anesthesiologists all work for a hospital’s cardiovascular service line and thus collaborate freely and with focused purpose, for instance, remarkable innovations in patient care are possible.
At Brigham and Women’s Hospital (BWH) in Boston, we have been involved with clinical service line development for more than a decade. Our progress has been slow—purposely so. Service lines represent a major paradigm shift for large AMCs, like BWH, that continue to be steeped in a long and successful history of clinical care delivery within traditional departments and specialties. While there is much to be gained with service lines that are set up and implemented well, abandoning the successful business model of care delivery that has powered AMCs to endure and thrive over the past many decades is wisely approached with caution. At BWH, we have begun a journey toward service lines for eight centers of excellence. Each looks and feels different, matures at a different pace, and has different governance and management structures; however, all are on the same journey: to offer more focused, evidenced-based, and efficient care to our patients, with outcomes that exceed those that could be achieved in our traditional care models. BWH’s goal for our service lines is to bring together the best of what our organization has to offer to our patients in a new way that yields differentiated value to them.
The most successful service lines seem to have several common attributes:
- Most service lines are multi-disciplinary, spanning the boundaries of traditional specialties, bringing together clinicians of many disciplines to focus on a particular disease or broad condition.
- At their best, service lines are patient-centered, coordinating all aspects of the diagnosis and care around the patients and their needs, not around the preferences or convenience of the providers.
- More progressive service lines also tackle governance, management, resources, and funds flow challenges head-on, and are bold about realigning these structures to enhance stakeholder communication and serve the goals of the service lines.
- If a service line is fortunate enough to have a dedicated building, such as the Shapiro Cardiovascular Center at BWH, all the better; co-location of all inpatient, outpatient, diagnostic, and procedural services for a service line centralized in the same tower dramatically enhances integrated care and the patient experience.
Developing service lines is not without challenges. Most hospitals do not have revenue cycle systems that can be readily redirected to account for the financial life of a novel structure like a service line. While all hospitals can calculate basic financial metrics for the entire institution, and perhaps for certain major departments or functions, their doing so for horizontal carve-outs like service lines is not easy. Monitoring the business progress of a service and knowing where to invest resources is difficult without clear accounting and financial reporting. The clinical and administrative structures that are necessary to operate service lines well are often—at least temporarily—redundant with those of the traditional hospital structure, and thus are a potential challenge to the efficiency that service lines are designed to promote. And finally, service lines challenge the traditional leadership hierarchy within most hospitals. The horizontal nature of service lines requires leadership to span historical departments and specialties and operating areas, necessarily introducing new decision-makers onto the home turf of proudly independent and important institutional leaders. When interdepartmental roles are in conflict with the goals and management of service lines, and when the structure of the service lines lacks accountability and good analytics for decision-making, success will be elusive.
Clinical service lines are not a panacea. And there is no detailed roadmap for the journey. The concept is simple to describe, and very challenging to implement. A hospital must insist on clear purpose and a strategy for its service lines. Strong and definitive leadership from the very top of the organization is essential for success, since many toes will be stepped upon along the way, and this change must be managed skillfully. The jury is still out on how comprehensive and successful service lines will be. But early results do seem to indicate that service lines are moving us in the direction of more efficient care with better outcomes, and patient satisfaction seems to follow. This may be reason enough to begin the journey.
David McCready is Senior Vice President of Surgical, Procedural, and Imaging Services at Brigham and Women’s Hospital, where he also serves as the executive leader for the BWH Heart & Vascular Center and the BWH Musculoskeletal Center.