Introduction
Academic health care systems have struggled to maintain financial health while pursuing their historic missions of patient care, teaching, research, and community service. The healthcare market economy has become increasingly competitive, making it all the more important to respond to service demands and to achieve cost efficiency while maintaining high-quality patient care. The ability of academic health care centers to quickly respond to external competitive pressures is frequently compromised by departmental structure, which tends to compartmentalize patient care, leading to internal competition for access to patients and innovative diagnostic and therapeutic technologies. Such internal competition frequently results in costly duplications, redundant capital investments, and ambiguous institutional marketing strategies. One approach to this challenge has been to utilize the concept of the product line, which is a horizontal matrix of independent clinical units that focus on specific patient populations and clinical expertise. Product line strategy targets institutional areas for focused clinical specialty growth in order to improve continuity of care, to develop innovations in service delivery, and to focus resource allocation to services that support patient care strategies.

Clinical components of the product line organization are specialty care units (service lines), which are vertically oriented groups that focus on service to specific patient populations with similar care requirements. The objective of these units is to integrate physicians and administrators into patient care services, to improve resource management, and to realign marketing to meet expectations of patients, families, payors, and referring physicians. Service lines are managed by clinician director(s) and an administrative liaison that collectively have oversight responsibility for program development, regional marketing, resource allocations, and contract negotiations. Each service line submits its business plan and budget to the product line administrative council that allocates institutional resources, such as marketing, regional development, and decision support. Capitol allocations based on service line business plans and needs are preferentially prioritized to the service lines after indirect institutional costs are addressed. The service line organizations enable point-of-service decision making and create a line of administrative responsibility for meeting clinical and financial objectives. Service line leadership reports directly to the institution’s chief operations officer.
This manuscript focuses on the development of a cardiovascular service line and its performance at the University of Wisconsin Health Care Center (UWHC).

Methods
In 1999, the UWHC undertook a strategic planning process to address regional health care needs and future medical center development. After extensive internal review and external consultation, the decision was made to pursue product line development and to invest in the development of clinically focused patient care service lines that met regional needs and exhibited institutional excellence in patient care and research.
The cardiovascular service line was one of the first entries into the product line matrix. Prior to its formal organization, the chief of peripheral vascular surgery and the chief of cardiovascular medicine met to discuss common institutional-based problems. These included endovascular program growth and development, fellowship training opportunities, and the need for hospital financial support of new clinical programs. At the time, vascular surgeons needed an endovascular workplace and a clinical partner to advance their catheter skill sets. Interventional radiology was not interested in providing such opportunities. At the same time, cardiovascular medicine was expanding its clinical program to include peripheral vascular medicine. Cardiologists needed access to peripheral vascular cases, and both services needed more options for fellowship training.

In September 2000, the UWHC strategic business plan to target specific areas for regional clinical growth was adopted by the hospital administration, and in March 2001, the service line organization was formally initiated. The heart and peripheral vascular patient groups were one of three selected for service line development based on regional care needs and institutional quality of service. The others included pediatrics and oncology. The goal of service line development was to provide streamlined, efficient, and focused patient care. Initial service line evaluations were designed to evaluate financial performance, operational efficiency, and patient satisfaction. Financial parameters included: net revenues, margins (profits), and payor mix. Operational efficiency assessment monitored patient volume change, case volume change, patient length of stay, and patient satisfaction, which was measured by National Press Ganey Surveys. More recently, quality score cards have been developed for each service line. Quality measures include resident training opportunities, new clinical services and outcomes, community service, and translational research.

Results
The cardiovascular service line became part of the product line matrix in 2002. By consensus, the service line was named Heart and Vascular Care (HVC) to reflect the critical components of the service line focus. The initial leadership for the service line included the chief of peripheral vascular surgery and cardiovascular medicine and a dedicated liaison from hospital administration. In 2003, cardiac surgery was added to the service line. The following objectives were outlined as part of the service line business plan:

1) To improve endovascular case volume and patient throughput;
2) To improve efficiency in care of heart and vascular patients with decreased length of stay and hospital costs;
3) To develop regional marketing for new and unique clinical services and to develop community outreach clinics;
4) To develop a combined heart and vascular non-invasive service and to provide community screening programs;
5) To obtain financial support for service line infrastructure growth.

To achieve these objectives, the service line took the following actions. First, cardiovascular medicine and peripheral vascular surgery staff agreed to share access to the interventional cardiology catheter lab. The agreement to share access to the interventional lab made it necessary to assign block times to both vascular and cardiology staff. Patient acuity criteria were agreed upon for access to the lab in urgent and emergent clinical situations. An essential inventory of catheters and stents commonly used for both cardiac and peripheral vascular procedures was kept in the cardiac cath lab. A satellite inventory specific for aortic endografts was kept in the operating room. All diagnostic arteriograms and stent procedures, both cardiac and peripheral vascular were performed within the cath lab. An upgraded OEC imaging was used in the operating room for aortic endograft placement and for hybrid open and endovascular surgical procedures. A critical part of the service line business plan was to centralize patient services in geographical areas of the hospital dedicated to care and management of heart and vascular patients. This included a relocation and redesign of hospital units and diagnostic facilities. Administrative support made it possible to reorganize and geographically relocate care units within the hospital and to adopt universal nursing practices on these units for patients that had similar care requirements. All patient rooms on these adjacent units were enlarged and made intensive care capable. These specialty units were supported by hospital-funded nurse practitioners and discharge planners, which helped improve patient throughput and protected against resident work-hour violations. As part of the reorganization process, a combined non-invasive echo and peripheral vascular diagnostic laboratory managed by a cardiologist and vascular surgeon was redesigned and relocated to address problems of patient access, technician staff retention, and infrastructure support. Echo and peripheral vascular technicians were crosstrained in each other’s specialty in order to improve salary structure and reduce night call requirements, and to streamline infrastructure support by having only one lab operation site. Additional hospital-supported improvements included construction of two additional catheter labs and an adjacent 15-bed recovery unit to enhance patient throughput and reduce congestion in the hospital care areas.

The heart and vascular service line was the first to be evaluated for operational performance in 2005. The year 2000 was used as an institutional reference standard for the combined services prior to implementation of the HVC service line. Compared to pre-service line performance, total patient volume significantly increased, along with the open and endovascular caseload. The hospital percent margin (profit) improved and patient satisfaction was enhanced. Dramatic reductions in hospital length of stay were achieved as well (Tables 1–3).
The first quality outcomes evaluation for the HVC service line was completed in 2006. Performance measures included patient satisfaction (Press Ganey Surveys), new clinical services, community service, endovascular training opportunities, and translational research (Tables 4 and 5).

Discussion
Academic health systems are finding it increasingly important to identify areas where cost efficiencies can be achieved without threatening the quality of patient care. This requires that there be accountability and responsibility for decision making at the point of service, for meeting financial targets, and developing efficient models for patient care. Product line development is one such strategy for achieving clinical success. Product lines are horizontal organizations which harness individual, disease-based business units into a common standard of practice and shared vision. This manuscript describes the organizational design and focus of a cardiovascular service line and its impact on healthcare services in a mid-sized academic center.
A growing number of academic centers in the United States have embraced the service line paradigm, including John Hopkins University, MD Anderson Cancer Center, Torrance Memorial Hospital, Long Beach Memorial Medical Center, The Moffit Cancer Center, Henry Ford Healthcare Systems, The Scripps Institute, Dane Farber Cancer Center, USC Norris Cancer Center, and Cedars Sinai Medical Center. The rationale for developing service line models is to improve continuity of care in focused patient populations, to integrate physicians into planning and management, and to establish responsibility and accountability for point of service decisions. For these organizational paradigms to work, they must focus on areas of clinical excellence and must have strong physician champions to work with administrators in order to achieve financial and clinical objectives. Such organizations are destined to failure if the system is imposed by administrative edict without physician support, if the departmental chairs fail to embrace the process and if a distinct line of responsibility and authority is not clearly established.

In our model, the chiefs of peripheral vascular surgery, cardiac surgery, and cardiology collectively oversee program development, regional marketing, and resource management. Our administrative liaison has effectively communicated program and business plan needs to the hospital and provides our physician leadership with performance data critical for fiscal and clinical planning.

For a service line to achieve efficiency in clinical and fiscal operations, physicians providing specialty care to focused patient populations must agree to work collaboratively, even when their area of expertise overlaps with others in the service line. Conceptually, a service line should embrace all essential services required for focused care delivery. Failure to participate in a successful service line operation can negatively affect nonparticipants with regards to case volumes, referrals, and teaching opportunities for students and residents.

The HVC service line has utilized increasing endovascular case loads to more effectively train vascular and cardiac fellows and has used the combined echo and peripheral vascular noninvasive lab as a training resource for both groups of residents. A major part of this service line strategy has been to develop community service. Outreach clinics staffed by surgeons and cardiologists, quarterly free cardiovascular screening, and second opinion clinics are a few such initiatives. New collaborative clinical programs have been developed and provide smaller surrounding communities with treatment options not previously available (Table 4).

Successful integration of service line units in our institution has resulted from the ability to develop clinical plans that complement the goals and objectives of the School of Medicine and Public Health and the University Medical Foundation (practice plan) and the University Hospital. These new programs have resulted in referrals from market areas that typically do not refer to our hospital and a changing pattern in market share and preferred provider organization status for cardiac and peripheral vascular services. The HVC service line has improved institutional financial health by reducing redundancies and capital investments, enhancing contracts with regional healthcare providers and industry, and increasing diagnosis-related group returns from significant reductions in patient length of stay. There is less internal competition between departments for access to patients and therapeutic technologies and patient satisfaction surveys are at an all time high. The service line has been effective in developing and marketing new and unique clinical programs and has enabled greater efficiency in the use of institutional resources.