With ongoing advances in medical diagnostics and therapeutics, interventional pulmonology (IP) is playing an ever more impactful role in health care. This is becoming more evident with the increasing focus on costs and quality care, leading to the concept of value-based programs. Value-based programs are patient-centered and use a coordinated team-based approach with an overall goal to improve quality of care. IP is well suited in this concept, as established and nascent IP programs continue to develop, providing more and more communities with access to expertise and efficient and quality care. In the effort to build and develop a new IP program, multiple factors should be considered and addressed.
When contemplating the initiation of a new service or product, a comprehensive needs assessment should be performed. This would include evaluating specific factors in the intended community or region: the burden of disease of interest, competing and collaborating specialties (such as pulmonary, thoracic surgery, oncology, radiology, pathology, and others), associations (such as local or regional groups, professional societies), accessible equipment and supplies, and the focus and resources of the institution. For example, if considering initiating an advanced diagnostic procedure such as endobronchial ultrasound (EBUS), one would need to consider the burden of lung cancer in the area of interest. This would help to guide expectations for the utility of the intended service. An area with a high burden of lung cancer would then be expected to generate a large number of EBUS referrals. Additionally, the current referral patterns for lung cancer would also need to be evaluated to ensure patients are directed to the appropriate service. Further, one would also need to assess if any other physicians (whether within the same group or even a competing practice) are already performing EBUS. Initiating a new service would ideally avoid undue competition or cannibalizing the practice to facilitate growth of the service. Lastly, one would need to consider available location(s) to perform and store equipment and supplies. Given the finite amount of space in most health care facilities, determining where the procedure will be performed (more details later) in addition to the areas for equipment and supply storage is essential. One would need to be sure the equipment is stored and secured in an appropriate area to provide efficient and effective service, as one would not want to be “hunting” for the EBUS console and supplies while awaiting the procedure. Additionally, the proximity of other EBUS sites would also need to be considered so as to balance the efficacy of each site without competing or unnecessarily duplicating equipment. In the situation of multiple sites performing EBUS, one would aim to ensure each site would be able to be utilized appropriately and avoid any redundancy. If sites are too close in proximity or there are insufficient referrals and procedures, then one or multiple sites will be underutilized. If there is only one physician performing the procedures, then having more than one site may also be ineffectual and inefficient not only for that particular site but also for the physician’s lost productivity due to the inefficiency of travel time.
New or updated resources are essential to maintaining or starting an IP program, and these require capital funding. To outline a method to achieve projected goals, a business plan details projections over 3–5 years and includes a market analysis, service line analysis, marketing, and financial overview.
A market analysis delineates the target of the service or product and is one of the most important components to the business plan. In the case of IP, the target is broad and includes the entire health care community as a whole including the physician groups, hospitals, and patients. One would need to consider the demand for the IP service, potential growth, and barriers to the service. Demand will very likely be low initially until there is increased awareness and the benefit and success of the service are demonstrated. As this improves, growth and increased revenue will follow. Barriers that should be considered include the support of and goals of the practice or administration, practice and referral patterns, as well as competition from other practices or services.
Service Line Analysis
A service line analysis incorporates the specifics of the intended IP service, the organizational structure, operation, equipment, and personnel. An obvious component to this would be defining the specific procedures to be provided by the IP service ( Box 19.1 ). Identifying an organizational structure to the program as a part of the broader general pulmonary/critical care, thoracic surgery, or other department, is important to establish and develop the service. A thorough SWOT (strength, weakness, opportunity, and threat) analysis of the organization and service line should be performed. In addition, one needs to outline the location or locations in which procedures are performed and the clinical contexts that apply, such as inpatient or outpatient, procedure suite, operating room, and so on. Locations may be different depending on staff and resources with some centers choosing to have one dedicated procedural suite and others moving the procedures to an endoscopy suite, operating room, radiology suite, or other locations. This may be informed by available space, fixed locations of equipment, availability of supporting services (i.e., anesthesia, ultrasound, etc.), staffing, or other local factors. Scheduling protocols for clinical evaluations and procedures should also be established. The appropriate equipment, supplies, and technology should also be incorporated as part of this analysis. For instance, for bronchoscopy this would include a full range of bronchoscopes, EBUS, bronchoscope towers, associated supplies and disposables or any other intended equipment, cleaning equipment and space, and related supplies. Such an analysis revolves around the specifics of a procedure with different procedures such as thoracoscopy, tracheostomy, pleural procedures, and so on, each having unique needs. All this requires defining the range of the IP services ( Box 19.1 ) and the role of the IP team in the process. One should consider where the IP service fits in the initial evaluation and management (E/M), perioperative, and longitudinal care for the patient. An active clinical presence in outpatient and inpatient setting would serve to aid in building rapport and broaden the referral base, hence further developing the IP practice. One must also consider the efficiency of care and to centralize the service line to avoid redundancies and duplication of equipment unnecessarily, as referenced earlier. The specific IP team members need to be identified, which may include medical assistants, nurses, respiratory therapists, and advanced practice providers such as an advanced practice nurse or physician’s assistant. Each team member’s roles should also be clearly defined in terms of the IP service and in the general practice.