One of the biggest opportunities and challenges I have had during my early career is building a heart failure clinic. Internal medicine residency and cardiology fellowship prepares us to care for the cardiac patient but building and developing a clinic is a whole new experience requiring a unique and very different set of skills. While challenging, the professional satisfaction of building a structure and team to care for underserved patients is immense.

Step 1: Define the Population

To develop a clinic requires a population level understanding of the "why." Who are the patients currently being served in a particular catchment area?  Who are the underserved patients? What is the purpose of developing a new clinic? Is it to improve efficiency, organization, and structure? Is it to reach a specific population that don't currently have access to specialty care? How does the population interact with the other levels of specialty care?  What care is currently available?  How does the timing coincide with population growth, decline, or migration? How does the system interact with other organizations in the area in which patients live? These are the many complex questions that must be asked and answered prior to building a clinic. As with writing a paper or developing a speech, one must know the audience and the purpose of the presentation.

Step 2: Find the Team

In medicine, we are trained to care for the patient to the best of our ability. In building a clinic, one must consider all the different stakeholders and interactions among them to develop a successful organization. As trainees, we are spoiled since the structure and organization has already been built and refined over prior generations.  In building a clinic, one must consider every level of health care provider, from the physicians to the advanced practicing providers, from the registered nurses to the pharmacists, from the schedulers to the medical assistants, with whom patients often have first contact.  One must understand the number of staff required for a functioning clinic. An upside-down pyramid of staff, for example, would not be able to stand very well.  Furthermore, one must consider the stakeholders and how each individual component of the organization are affected.  Everyone has their own dreams and desires: the goal is to channel everyone's motivations toward a common goal and purpose.

Step 3: Refine the Scope

How is the clinic unique? The goal of developing a specialized clinic should enable providers to better focus on their areas of expertise, particularly in this new era of increasingly complex cardiovascular care. For example, a chronic heart failure management program would encourage referrals to focus on up-titration of guideline directed medical therapy, to free up a primary cardiologist's time and allow them to focus on other important cardiovascular topics. At the same time, the specialized clinic allows for streamlined efficiency in caring for patients, such as with prescriptions and prior authorizations, as well as standardization and tracking of such care delivery for quality improvement. The development of specialized clinics, such as cardiomyopathy clinic, also increases awareness and provides hope to patients seeking specialized care that they may not otherwise have access to. Given these goals, it is important to understand the epidemiology of the disease as well as the availability of specialized care and expertise of a particular practice group.

Step 4: Iterative Feedback

All the planning cannot account for real world conditions, and therefore one cannot expect the launch of any new initiative to be perfect the first time around. In developing a car, computational fluid dynamics are essential, but nothing can replace actual track time.  There are human elements that continue to fluctuate through time.  It is therefore essential to develop a good feedback loop mechanism to understand challenges as they arise and have a systematic method by which problems can be addressed and improved. This is perhaps the most important element in ensuring a dynamic and flexible system that every member of the team can contribute to. This further improves staff morale as members feel they are part of building something new and meaningful.

In summary, developing a new clinic is challenging but in a very different way than direct clinical care. It requires a ten-thousand-foot view of the patient population, stakeholders, and organizational structures. Though exceeding complex, the rewards are immense when the new functioning organization succeeds in enabling access to care that was not previously available for underserved populations.

This article was written by Siu-Hin Wan, MD, FACC, Director of Outpatient Heart Failure at Minneapolis Heart Institute – United. His interests include diabetic cardiomyopathy, cardiac amyloidosis, cardiac sarcoidosis, and hypertrophic cardiomyopathy.