Cardiac System Design Plan

Design, service and
infrastructure plan for

Victoria’s cardiac system
Design, service and infrastructure
plan for Victoria’s cardiac system
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© State of Victoria, Department of Health and Human Services, May 2016
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design-planning
(1512012)
ii Design, service and infrastructure plan for Victoria’s cardiac system
Contents
From the steering committee 1

Executive summary 2
Introduction 4
A vision for the cardiac system 5
Where we are now 6
The burden of disease 6
Impact of comorbidity 6
The current service system 9
What has been achieved 13
What we could do better 14
Priorities for system reform 16
Priority 1: Better patient access, experience and outcomes 16
Priority 2: A coordinated cardiac system of care 22
Priority 3: Effective and innovative cardiac services 31
Implementation plan 38
Appendix 1: Victorian Cardiac Plan Steering Committee 43
Appendix 2: Victorian cardiac system 44
Appendix 3: OECD comparison 47
Appendix 4: Draft cardiac system design framework 49
Abbreviations 51
Endnotes 53
iii
From the steering committee
On behalf of the steering committee, I am very pleased to be able to present this Design,
service and infrastructure plan for Victoria’s cardiac system, which addresses the future
design of the cardiac system in Victoria.
As Victorians, many of us are fortunate to have access to an excellent system of care,

supported by dedicated and committed clinicians and professionals working to provide
quality care. However, access is not equal for all, and the health system can never remain
static. It must continue to evolve in response to changes in health conditions, improved
models of care, new and emerging technology and to embrace new initiatives and
opportunities.
This plan responds to these challenges for cardiac care. It contains three components,
beginning with a snapshot of where the cardiac service system is currently placed.
The second component identifies priority themes for reform, each with defined aims or
objectives. The third essential component provides the way forward through a detailed
implementation plan.
I would like to thank the Minister for Health for the opportunity to contribute to
reforming the cardiac service system. The Minister, the cardiac service sector and
the department are to be commended on their commitment to review and to look for
opportunities to move forward in this area of healthcare, which is so critical to the
wellbeing of all Victorians.
This is an exciting time to be involved with health reform as the government looks to
respond to challenges with a new approach and a commitment to do things differently.
I believe the approach and key themes adopted in this plan provide a template that
can be applied more broadly to achieve improved system design and configuration
across many areas.
I would like to thank all members of the steering committee for their input and advice.
I also wish to thank all those from public and private health services and the individuals
who took the time to participate in consultation forums and provide input to contribute
to development of priorities and actions.
I recommend this plan to the Minister and look forward to seeing the identified priorities
contribute to ongoing reform of the Victorian cardiac system of care.
Fran Thorn
Chair, Steering Committee,

Victorian Cardiac Plan
1
Executive summary
The Design, service and infrastructure plan for Victoria’s cardiac system (the cardiac
plan) provides a clear picture of the future of the cardiac system of care across the
state. It proposes continuing reform to ensure people with heart disease achieve the best
possible outcomes, with a health system that is efficient and of high quality. The plan
builds on reform of the cardiac service system already underway, but also recognises
the opportunity for system improvement presented by the government’s commitment
to build a stand-alone cardiac centre of excellence – the Victorian Heart Hospital.
The vision of the cardiac plan is improved care and outcomes for Victorians with, or
at risk of, heart disease, which means person-centred care from early diagnosis of
heart disease in the community to end of life care. This will be supported through
developing new models of clinical engagement that promote collaboration, and through
encouraging health service partnerships and relationships based on the needs of
patients. The future cardiac system of care will be viewed and supported as a system,
rather than a collection of individual agencies. This will support a more area-based
service approach to better address the access needs of vulnerable groups and
areas of disadvantage.
The plan describes three priority themes for driving change in the way care is provided.
Figure 1 summarises these priorities, with clear objectives defined for each.
2 Design, service and infrastructure plan for Victoria’s cardiac system

Figure 1: Priorities for system reform
Better patient access, experience and outcomes

1. People at risk of heart disease are better identified and managed in primary care.
2. People experiencing an acute event receive the right care as quickly as possible.
3. Patients needing specialist care are transferred at the right time, based on
clinical need.
4. Continuous improvement embeds innovative models of care across all services.
A Coordinated cardiac system of care

1. Health services recognise roles and responsibilities within a coordinated
system of care.
2. Designated specialist services take a lead role in coordination of cardiac care.
3. Complex cardiac care is consolidated to fewer facilities, with general cardiac
care distributed to support the right care in the right place.
4. The Victorian heart hospital makes a significant contribution to the cardiac
system of care.
5. Opportunities for partnerships between the public and private sectors
are maximised.
Effective and innovative cardiac services

1. Designated specialist cardiac services provide clinical leadership across
the system.
2. Continuous service improvement is driven by monitoring of performance
and outcomes.
3. Better access to clinical information benefits both patients and providers.
4. Clinical practice is improved through ongoing medical research.
5. The cardiac workforce is supported to provide quality care.
To ensure accountability and measurement of progress against the priorities, a detailed

implementation plan has been developed. This will support collaboration between the
Department of Health and Human Services, the Victorian Cardiac Clinical Network,
health services and other key stakeholders. This strong clinical and sector engagement
will ensure reform is led by those best placed to drive change across the cardiac
system of care.
3
Introduction
We are fortunate in Victoria to have a world-class cardiac service system. However,
increasing demand and community expectations, evolving models of care and new
technology means the system must constantly evolve to meet changing circumstances.
The cardiac plan provides a way forward for the cardiac system across Victoria. It
describes priorities and objectives of system reform, recommends actions in accordance
with these objectives and, importantly, outlines a clear plan to implement the actions.
The focus of the plan is the public health system, while recognising the significant
contribution the private sector makes to the provision of a comprehensive system of
care. The plan also recognises the significant opportunity to refocus the cardiac system
presented by the Victorian Government’s commitment to develop the Victorian Heart
Hospital (VHH). This will be Australia’s first specialist heart hospital and will provide a
centre of excellence for cardiac patient care, research and education.
The plan builds on and continues the evolution of the cardiac system outlined in
Heart Health: improved services and better outcomes for Victorians (Heart Health)1
released by the department in 2014. Heart Health was developed with input from the
Victorian Cardiac Clinical Network (VCCN) and the health sector and provided a
five-year plan for cardiac service development. It recognised the importance of
prevention and early intervention in managing heart disease, and addressed care along
the full continuum from early intervention to rehabilitation, long-term care of those
with progressive heart failure and end-of-life care. It also recognised the importance of
patient outcomes and the need to focus efforts on not only improving outcomes but also
maintaining health in people living with chronic heart disease. Many of the actions and
projects recommended by Heart Health are still ongoing and will continue, albeit with
increased focus and energy.
Development of this cardiac system design plan has been led by a steering committee,
which has brought together representatives of major public health services providing
cardiac care, the clinical network, the Heart Foundation, Monash University and other
relevant stakeholders. Membership of the steering committee is provided at Appendix 1.
Development of the plan has also been informed by extensive consultation with
clinicians and community stakeholders representing health services, consumers and
professional groups.
The process was managed by an independent consultant and was conducted through
targeted interviews, small group discussions and a public forum. The department also
consulted directly with health services and other stakeholders.

A vision for the cardiac system
The vision of the cardiac plan is improved care and outcomes for Victorians with, or at
risk of, heart disease. This means person-centred care from early diagnosis of heart
disease in the community to care at end of life so that intervention can prevent further
deterioration; local access to the best possible treatment in an emergency is reliable;
evidence-based and high-quality care in specialist cardiac centres is available when
required; and care for ongoing management of heart disease is well coordinated.
This will be supported by developing new models of clinical engagement that promote
collaboration, and through encouraging health service partnerships and relationships
based on the needs of patients. The future cardiac system of care will be viewed and
supported as a system, rather than a collection of individual agencies. This will support
a more area-based service approach to better address the access needs of vulnerable
groups and areas of disadvantage.
‘The building blocks alone do not constitute a system, any more that
a pile of bricks constitutes a functioning building. It is the multiple
relationships and interactions among the blocks – how one affects
and influences the others, and is in turn affected by them – that
convert these blocks into a system.’
de Savigny D, Taghreed A (eds) 2009, Systems thinking for health systems strengthening, Alliance for
Health Policy and Systems Research, World Health Organization, Geneva
5
Where we are now
The burden of disease
Cardiovascular disease (CVD) remains a leading cause of death and a major contributor
to the illness burden of Victorians, and is therefore one of the greatest cost burdens on
the healthcare system. In addition to costs associated with acute care for patients
with cardiac disease, millions more are spent on emergency care and related services
and treatment.
In 2013 coronary heart disease and related conditions was the underlying cause of
death for almost 7,500 Victorians,2 which equates to 21 per cent of all deaths. This
actually represents a decrease in the proportion of deaths over the past 10 years from
24 per cent (7,852) in 2004. In addition to being a leading underlying cause of death,
heart disease is also a contributing factor in deaths from other causes. From 1997 to
2007, heart disease was a leading contributory cause for all Australian deaths involving
selected chronic diseases, including 47 per cent of deaths involving diabetes and 39 per
cent involving chronic and unspecified kidney failure.3
Much of the decline in the death rate from heart disease can be attributed to improved
interventions in primary care, such as pharmacological control of blood pressure and
lipid disorders, as well as improved acute hospital interventions. Medications to manage
risk factors for heart disease, reduce cholesterol and lower blood pressure are now some
of the most commonly used medicines in Australia.
While the death rate from heart disease is declining, the prevalence of disease in the
community continues to grow. This is the result of a number of factors, including the
significant number of people surviving acute events but then living longer with ongoing
chronic heart conditions, and the growing prevalence of cardiac disease associated with
both ageing and with other chronic conditions. For example, the prevalence of aortic
stenosis, atrial fibrillation and chronic heart failure increases with the proportion of
people 65 years of age or older. As a result, significant numbers of adult Victorians are
now living with heart disease, reducing their quality of life and increasing their risk of
a further life-threatening cardiac event or stroke.
Impact of comorbidity
Self-reported data from the Australian Bureau of Statistics 2011–12 Australian
Health Survey provides information on the prevalence of comorbidity among the
Australian population.4
Comorbidity refers to any two or more diseases that occur in one person at the same
time. This may occur simply by chance, but diseases often occur together because there
is some association between them. In some cases diseases share risk factors such as
smoking, or one disease may actually be a risk factor for another. For example, diabetes
is a well-known risk factor for CVD, possibly due to diabetes increasing atherosclerosis,
which is the underlying cause of most CVD in Australia. Ageing also has a particularly
strong association with comorbidity. As older people are more vulnerable to the onset of
many diseases, an increased life expectancy in Australia leads to greater opportunity for
multiple conditions to arise.

The following two figures show the proportion of multiple chronic diseases for people
with one of eight identified chronic diseases. Figure 2 shows the age group 0–44 years
and Figure 3 the proportion for those over 45 years of age.
Figure 2: Proportion of people with additional chronic diseases (none, 1, 2 and 3

or more) among those with select chronic diseases, 0–44 years of age, 2011–12
Per cent
100 3+
2
80
1
60 0
40
20
0
Arthritis Asthma Back Cancer COPD CVD Diabetes Mental
problems health
Source: ABS Australian Health Survey 2011–12 (National Health Survey component)
People aged 45 or older are more likely than those aged 0–44 to have comorbidities
across all eight chronic diseases.
Figure 3: Proportion of people with additional chronic diseases (none, 1, 2 and 3 or

more) among those with select chronic diseases, 44 years of age or older, 2011–12
Per cent
100 3+
2
80
1
60 0
40
20
0
Arthritis Asthma Back Cancer COPD CVD Diabetes Mental
problems health
Source: ABS Australian Health Survey 2011–12 (National Health Survey component)
A 2015 report released by the Organisation for Economic Co-operation and Development
(OECD)5 contends that while mortality from cardiovascular disease has dropped over
the last few decades faster than mortality from other causes, prospects for making
further inroads are now threatened by rising levels of obesity and by the lack of
adherence to recommended treatments.
7
The report focused on cardiovascular disease and diabetes and contends that simply
allocating more resources to acute care is not enough to deliver good outcomes and
reduce unacceptable variation in performance. Both cardiovascular disease and
diabetes are complex diseases to manage and treat effectively. Good primary care
and early diagnosis is needed to manage risk factors such as high blood pressure and
cholesterol and to avoid unnecessary long-term damage caused by the diseases. Both
require timely services from the onset of disease through to later stages when specialist
and hospital treatment is necessary. Both also require continuity and integration of
services across the entire clinical pathway.
Therefore, the majority of patients with multiple morbidities require multidisciplinary

care and access to the full range of specialist services, preferably close to home.

The current service system
To appropriately manage people with, or at risk of, heart disease requires all parts of the
healthcare system to work together to contribute to provision of comprehensive care
aimed at improving outcomes.
The recognised roles of healthcare providers vary across sectors and along the
continuum of care and include: management of risk factors in primary care; emergency
management of acute events in the pre-hospital environment; urgent care in emergency
departments; acute care in public and private health services; long-term management
of the effects of chronic disease and support for end-of-life care in both hospitals and
primary care.
Inpatient cardiac care is currently provided by almost every public hospital in Victoria,
but the range and extent of service delivery varies considerably. The highest level of
specialist cardiac services for adult patients is provided by six services: The Alfred,
Austin Hospital, University Hospital Geelong, Monash Health Clayton, The Royal
Melbourne Hospital and St Vincent’s Hospital. The Royal Children’s Hospital is the major
provider for paediatrics and adolescents.
An additional six public health services have cardiac catheterisation laboratories that
provide emergency and elective interventions. There are also nine private hospitals
performing cardiac surgery and 19 with cardiac catheterisation laboratories providing
a mix of urgent and elective procedures, primarily in the metropolitan area.
In many cases cardiac services have developed independently within agencies, resulting
in some service inconsistency and lack of clarity about roles. There also remains
disparity across Victoria in both rates of potentially avoidable coronary heart disease
and mortality from heart disease, with significantly higher rates in rural and regional
areas compared with metropolitan areas. This is demonstrated through the Victorian
Heart Maps,6 developed by the Heart Foundation in partnership with the cardiac
network. These show that the highest rates for heart attack and cardiac arrest are in
regional areas, so it is essential that strategies to improve referral are continued.
Planning is currently underway to build new cardiac catheterisation laboratories and

expand services at Sunshine Hospital, Albury–Wodonga Health, Ballarat Health Services
and Latrobe Regional Hospital.
Further details of public and private health service provision, by facility, are provided in
Appendix 2.
Ambulance Victoria (AV) plays a pivotal role in the emergency response, pre-hospital
care and interhospital transfer of acute patients across the public and private system,
including when a cardiac condition is suspected. AV also supports timely access to
pre-hospital reperfusion therapy for patients having a heart attack in regional areas of
Victoria, with thrombolysis now administered by trained paramedics.
AV operates Adult Retrieval Victoria (ARV), which is responsible for coordinating

interhospital transfers of critically ill and time-critical adult patients, and access to
critical care beds. In 2013–14 cardiac patients comprised the single largest clinical case
type for ARV, being 1,085 cases or 26 per cent of total cases.
9
Activity
For the six-month period from January 2015 to June 2015 Ambulance Victoria attended
more than 25,000 patients presenting with cardiac problems as determined by
attending paramedics. This represents approximately 10 per cent of AV’s emergency
workload for the period, and includes patients with chest pain, acute coronary
syndrome, angina, arrhythmia, acute myocardial infarction (AMI), hypertension and
other cardiac problems. AV also attended about 2,700 patients in cardiac arrest and
more than 6,000 patients presenting with shortness of breath.
In 2013–14 there were about 126,700 separations from public and private hospitals
defined by major clinical related groups (MCRG) as cardiac, with 69 per cent of this
activity occurring in public hospitals (see Table 1). Private hospitals are also major
providers of cardiac care, particularly interventional cardiology and cardiac surgery.
For the purpose of this plan, service activity is described in three broad categories
of care:
• cardiothoracic surgery – bypass, valve and other surgery
• interventional cardiology – percutaneous coronary intervention, insertion and
management of internal cardiac defibrillators and pacemakers, invasive cardiac
procedures and intracardiac electrophysiology study (EPS)
• clinical or medical cardiology – investigation, diagnosis and management of AMI,
arrhythmia, conduction disorders and atypical chest pain, and management of
congenital heart disease.
Table 1: Public and private cardiac separations by major category, 2013–14
Private Public Total % Total % Public

Cardiothoracic surgery 3,291 4,647 7,938 6.3% 58.5%
Interventional cardiology 21,021 18,138 39,159 30.9% 46.3%
Clinical cardiology 15,047 64,606 79,653 62.8% 81.1%
Total 39,359 87,391 126,750 100.0% 68.9%
Source: VAED mapped to MCRG/CRG groups (excludes Albury, NSW and heart/heart lung transplants)
Cardiothoracic surgery and interventional cardiology are specialist services requiring

clinical input from staff trained in cardiac procedures, working in defined facilities.
Together these represent just over one-third of all cardiac-related admissions.
International comparisons can show levels of intervention, to indicate an appropriate

rate. The Australian rate of total revascularisation procedures is comparable to that of
many other OECD countries at 226 per 100,000 people, which is only slightly higher than
the group average of 221 per 100,000 people. Comparison of coronary angioplasty with
the OECD average shows that Australia is slightly below average for the group, with
angioplasty accounting for 75 per cent of all activity compared with an average of 78 per
cent. The growth in coronary angioplasty between 2000 and 2011 coincided with a period
of growth in graduates of cardiac procedural training, but the rate still remains below
average for the group.

Details of OECD comparisons of revascularisation procedures are provided in Appendix 3.
By far the largest group of people are those admitted for medical treatment of cardiac
conditions, including those identified with complex chronic disease. A significant
percentage of these patients have all their care managed within public emergency
departments, particularly in short stay units.
Projected growth in demand

Victoria uses demand projection modelling to forecast trends in hospital activity over
the medium term. While recognising limitations of methodology, it is possible to see likely
trends in cardiac activity. Figure 4 identifies the projected growth in inpatient activity for
the three patient cohorts identified – cardiothoracic surgery, interventional cardiology
and clinical or medical cardiology.
Figure 4: Historic and projected public and private separations by cardiac MCRGs
120,000
110,292
Clinical cardiology
100,000
Separations (Incl ED)
76,073
80,000
55,532
60,000
Interventional
38,298 cardiology
40,000
20,000 11,247
8,133
Cardiothoracic surgery
0
2004–05
2005–06
2006–07
2007–08
2008–09
2009–10
2010–11
2011–12
2012–13
2013–14
2016–17
2018–19
2021–22
2026–27
Note: The apparent decline in clinical cardiology in 2012-13 reflects a change in emergency department
admission policy, where patients managed exclusively within an emergency department are no longer
included as an admission.
These projections indicate a number of impacts for the cardiac service system:
• There is modest growth projected in cardiac surgery, with thoracic surgery and valve
surgery representing the two areas of highest growth.
• There is significant growth projected in interventional cardiology. The largest
proportion of this work is angiography and invasive procedures without AMI.
A growing trend in cardiac catheterisation laboratory activity is management of
rhythm disorders, including through EPS. In 2013–14 this represented only 6 per cent
of total catheterisation laboratory activity but is expected to increase as
technology improves.
• The area with the greatest projected growth is clinical or medical cardiology,
where management of heart disease may be only one element of the patient’s
chronic and complex care needs. This area of cardiology is most often managed by
general physicians within a general acute hospital setting. Approximately 35 per cent
of this patient activity is managed entirely within public emergency department short
stay units.
11
As ongoing research demonstrates the effectiveness of techniques and drug therapies, this may
affect demand for various types of cardiac procedures and interventions. One example of this
impact is recent research suggesting that treating cardiac patients who also have diabetes through
surgical intervention rather than PCI significantly improved patient outcomes and reduced the
risk of death at five years by one-third.7, 8, 9, 10 The implication of this finding is that the demand
for interventions may reduce and demand for surgery increase as the number of patients with a
comorbidity of diabetes increases.
From a planning perspective, it is important to consider the expected geographic dispersal of

growth. As Figure 5 highlights, the areas of most significant growth in public service demand over
the next 10–12 years will be the west and south metropolitan growth corridors, followed by the north
metropolitan area.
Figure 5: Average percentage per annum growth for all public and private separations
by area of residence, 2012–13 to 2016–17
Average growth per annum (Public) Average growth per annum (Private)
East 1.4% 2.1%

Interventional cardiology Cardiothoracic surgery
North 3.4% 1.6%
Peninsula 3.2% 2.2%
South 3.8% 2.0%
West 3.9% 2.3%

Rural 1.4% 1.0%
East 2.5% 2.6%
North 3.2% 2.7%
Peninsula 3.1% 4.2%
South 3.1% 2.8%
West 3.5% 4.3%

Rural 1.9% 1.7%
East 2.8% 1.7%

Clinical cardiology
North 3.4% 1.2%
Peninsula 2.5% 1.6%

South 4.0% 1.3%
West 4.3% 1.9%
Rural 1.7% 0.5%
5.0% 4.0% 3.0% 2.0% 1.0% 0.0% 1.0% 2.0% 3.0% 4.0% 5.0%
It is important to recognise that other factors may influence or alter the projections, including
developments or advances in medical technology or treatment and increased rates of
comorbidities and other risk factors in the community. However, the key indicators are central to
consideration of how the system should develop to better meet future demand and respond to
advances in care and treatment models.

What has been achieved
Since the release of Heart Health in 2014, the commitment of the clinical network,
the department and health services to implement the recommendations has seen
improvement across the continuum of care for people with, or at risk of, cardiac disease.
There has been significant investment in cardiac services to improve care options,
increase system efficiency and deliver better patient outcomes.
Part of this commitment has been to develop models of care for both heart failure and
cardiac rehabilitation that address service gaps and better meet people’s needs. While
projects are still ongoing, there have already been improvements to date. These include:
• introduction of rapid access to pre-hospital thrombolysis for people experiencing a
heart attack in rural areas, administered by AV paramedics
• development of innovative models of care based on evidence of best practice to
improve outcomes for people living with heart failure. Programs have improved
clinical education and patient health literacy, mapped the patient experience and
improved models of service delivery to target high-risk groups
• secondary prevention through improved models of care for cardiac rehabilitation,
with a focus on increased participation
• development of specialist education programs for clinical staff in rural and
regional communities, with linkage opportunities to support work with colleagues in
metropolitan centres
• expansion of monitoring of cardiac interventions and outcome measurement through
collection of statewide clinical performance data.
Work to date has engaged health professionals and helped raise awareness about
the need to improve coordination between primary and acute care providers and the
benefits of collaboration with key stakeholders such as Ambulance Victoria and the
Heart Foundation. Collectively these initiatives are contributing to improvement in the
system of care for people wherever they live in Victoria.
13
What we could do better
The cardiac plan provides an opportunity to continue to review and redesign the service
system to provide more coordinated and efficient care for patients. The priorities and
objectives described are also consistent with broader healthcare reform.
Health 2040: A discussion paper on the future of healthcare in Victoria,11 was released in
2015 to start the conversation on future directions for the Victorian health system.
The subsequent Victorian Health Reform Summit identified ten key principles to guide
future reform:
1. Person-centred care with equitable access: We need to move to person-centred and

person-directed care, valuing and respecting patients and their preferences, taking
into account the whole person and what is important to the individual. We also need
to address disparities in access and outcomes for individuals and communities
across the state.
2. Integration: While the system is made up of many individual services – public and
private – we need to get better at ensuring that the patient experiences this as
one system.
3. Prevention and early intervention: We need to invest in prevention, acknowledging

that the payoff is long-term rather than short-term, and ensure that when treatment
is needed, it is provided early.
4. Technology and data: We need to reduce the barriers to sharing information across
providers, make better use of information to improve services and utilise new
technologies to improve patient care and outcomes.
5. Workforce: We need to make better use of the skills of our health care workforce if we
are to provide better services.
6. Transparency and accountability: Greater transparency about system performance

and accountability of all health service providers for the outcomes they deliver will
drive system improvement and improvements in care.
7. Evidence-based care: We need to ensure interventions are evidence-based, reduce

low-value and futile care, and commit to ongoing and rapid translation of new
evidence into service delivery.
8. Sustainable: We need to ensure that our health system remains affordable for both
taxpayers and individual patients.
9. Innovation: There is strong support for a new systemic approach to innovation, to

ensure that we make best use of the great ideas developed by individuals working
across our health system.
10. M
edical Research: We need to strengthen medical research, and support the
translation of new discoveries into practical treatments, technologies and tools to
improve patient care and outcomes.

Using these principles to focus on the cardiac system of care identifies a number of
areas where we could do better:
• People must always be at the centre of system design, with care at the right time and
in the right place.
• Better education in the community could avoid disease progression and better risk
assessment in primary care could improve early intervention.
• Access to time-critical and specialist care could be improved, particularly in rural
and outer metropolitan areas. Rural and regional clinicians would be better able
to manage suspected cardiac patients if they could access specialist advice and
support, with appropriate timely transfer when required.
• Better management of ongoing heart failure would reduce the number of people who
return to hospital for unnecessary, unplanned admissions. This should involve well-
planned and coordinated disease management programs, with appropriate linkages
between primary and specialist care.
• Referral pathways need to be formalised while strengthening the important regional
relationships that currently exist.
• Provision of cardiac care should be based on best practice guidelines developed
to address time-critical care, coronary angiography and intervention, and patient
referral for both complex care and cardiac rehabilitation.
• Care provision should involve delivery of well-planned, multidisciplinary and
coordinated disease management programs, with strong linkages between primary
care and specialist services to support the full cardiac care continuum, including
cardiac rehabilitation.
• A more coordinated cardiac system of care, with health service roles and
responsibilities better defined, would support services to work collaboratively with
others. This requires the department to take a more active role in system-level
planning, including how and where services are provided.
• Clinical leadership can drive improvements across the system. Change should
be clinically led, guideline-driven and implemented collaboratively, with
community input.
• The relationship between volume, quality and service efficiency needs to be
recognised, along with the implications this has for service configuration.
• Cardiac rehabilitation supports people to manage their health following an acute
episode and is an essential component of care. Improved access to comprehensive
cardiac rehabilitation tailored to the identified needs of patients would improve
patient outcomes.
• Data should be used to drive quality and to hold services accountable for
patient outcomes.
• E-health solutions are needed to allow sharing of patient information across
multidisciplinary healthcare teams.
• Improved access to services should retain rates of procedural intervention that are
comparable with other countries in the OECD.
• Investment in specialist equipment and infrastructure should be planned to ensure
appropriate patient access, balanced with return on investment. New developments
should be evidence-based, with equal consideration given to the issue of
disinvestment in services for which no evidence base exists.
15
Priorities for system reform
The plan identifies three key priorities for system reform, along with clear objectives and
actions required to deliver them. Responsibility for progress of these actions will rest with
the department and the clinical network, in partnership with health services at all levels
of the system.
Priority 1: Better patient access, experience and outcomes

Why this is important
It is always better to prevent rather than treat disease, so work with the primary care
sector remains an important driver of continuing reform. Adoption of consistent risk
assessment processes and tools can support these prevention efforts.
To enhance the patient experience and support high-quality patient outcomes, it is

important that care be coordinated, with clear patient referral pathways to avoid delays
in providing care. Timely access to the right care at the right time and in the right place
is an objective of all service reform. In the case of cardiac care this can be either rapid
access to intervention such as reperfusion or surgery for people experiencing a heart
attack, or improving access to complex cardiac intervention or surgery for a patient
considered stable but still requiring timely access to definitive care.
This care should be provided in accordance with clinical guidelines and protocols for
safe and effective practice, where these exist. This ensures clinical evidence drives the
way healthcare services are delivered, including the way services are organised and
coordinated, the timeliness of care and the processes by which outcomes are monitored.
What this would look like

People will continue to be encouraged to protect the health of their hearts through
programs to support healthy living and reduce risk factors. For those with risk
factors or early signs of disease, thorough assessment will support earlier primary
care intervention and early referral to specialist support, where this is appropriate.
Information available in service directories and databases such as that maintained by
the Australian Cardiovascular Health and Rehabilitation Association12 can help people
locate the services they need within their local areas.
For people experiencing an acute cardiac event the service system will respond with
an appropriate level of care as quickly as possible, and when patients need referral to
specialist services for complex care or surgery the coordinated cardiac system will allow
this to occur without delay.
Patients throughout the state will benefit from a system of continuous improvement, Better risk
with introduction of proven innovative processes and models of care. assessment
1.1 People at risk of heart disease are better identified and managed in primary care will help
The onset of CVD can be delayed or prevented through reduction of risk factors such people
as lowering cholesterol, managing blood pressure, following a healthy diet and avoiding maintain
smoking.
healthy
hearts

This priority builds on the recommendations of Heart Health to promote healthy living
and improve detection of the early stages of heart disease to avoid progression. With
up to 80 per cent of heart disease preventable, there is a clear rationale to develop
systematic risk assessment and risk reduction programs that will reduce the number of
people going on to have a heart attack.
The system needs to evolve from reviewing risk factors in isolation (relative risk) to a
model of absolute risk, which considers the synergistic effect of multiple risk factors.
An absolute risk approach is able to predict the percentage probability of a heart attack
or stroke occurring in a five-year period based on a person’s risk factors. This approach
enables meaningful risk stratification of individuals into low, moderate or high-risk
categories, as described in Table 2, and allows prevention approaches to be matched
based on this risk profile. This means prevention programs and resources can be
directed to those people who have the most to benefit.
One option is to adopt the National Health and Medical Research Council (NHMRC)
endorsed Guidelines for the management of absolute cardiovascular disease risk 2012,
which provides a framework for reducing heart attack and stroke risk in the population.
If this was to be implemented, all Victorians over the age of 45 (35 for Aboriginal and
Torres Strait islander people) would receive a heart health check in general practice and
be linked to appropriate risk reduction programs based on their level of risk. This would
bring Victoria into line with international best practice and ensure that resources are
focused on those people who are at the highest level of risk.
Table 2: Recommended approach for intervention following assessment of risk
Intervention type Low Moderate High

(< 10 per cent) (10–15 per cent) (> 15 per cent)
Lifestyle Appropriate Enrolment in risk Intensive support to
advice modification programs manage lifestyle risk
factors
Pharmacotherapy Not routinely Pharmacotherapy Pharmacotherapy to be
recommended only if 3–6 months of commenced concurrently
lifestyle change does with lifestyle support
not reduce risk
Aspirin is not routinely recommended
Review 2 years 6–12 months According to clinical

context
Source: Heart Foundation
17
Management of risk in primary care also includes recognition of the risk of subsequent
events once an acute event has occurred. Recovery from acute events and ongoing
patient management with secondary prevention strategies is a key part of the care
continuum and will improve patient outcomes.
As part of their role in improving the health of the communities they serve, health
services will be expected to work with community health services and primary care to
support patient management. This will include introduction of absolute risk assessment
and management as a key platform for primary prevention and a strengthened focus on
secondary prevention strategies to manage ongoing heart disease.
This will facilitate better assessment of people at risk of heart disease and also
support appropriate management processes and referral pathways. Partners with
health services will include Primary Care Partnerships (PCPs), local Primary Health
Networks (PHNs), community health services, Aboriginal health services and local
government agencies.
1.2 People experiencing an acute event receive the right care as quickly as possible Rapid
A complex pathway of services is involved in emergency care for patients suffering a response to
heart attack or cardiac emergency, with a well-functioning pathway or chain of events
essential from the moment the person suffers a cardiac event. A well-functioning chain
emergencies
is one where: people recognise early signs and call for immediate assistance; bystanders will save lives
recognise symptoms and take action; first medical responders are on the scene in the
fastest possible time and provide appropriate diagnosis, care and transport; and, once
in hospital, the patient receives the right care at the right time provided by the right
clinical staff.13
This chain of events has already been supported in Victoria with the increased number
of defibrillators now available in community agencies and facilities, including sporting
clubs, and the provision of pre-hospital thrombolysis by Ambulance Victoria paramedics
in rural areas, in accordance with treatment protocols.
Emergency calls to triple zero are often the first point of care for those presenting
with a cardiac emergency and for patients with exacerbation of existing disease. The
identification of patient needs, immediate treatment and management and transport to
the most appropriate facility is the primary function of Ambulance Victoria. Paramedic-
based assessment, decision making and care must always be evidence-based and
linked seamlessly to the remainder of the health system.
Transport of patients requiring hospital care should be to the most appropriate facility
capable of meeting the patient’s needs. At times this will mean bypassing a local
facility for an appropriate specialist centre based on agreed guidelines. Improved
links to service providers offering alternate cardiac care pathways where ambulance
transport is not necessary is an ongoing priority for the future. Ambulance Victoria will
also continue to partner with the broader system in research to ensure patients receive
contemporary care.
A process for improving provision of clinical advice will be included in the development
of specialist cardiac services aligned to geographical areas.

Quality care 1.3 Patients needing specialist care are transferred at the right time, based on
clinical need
in the right
Existing retrieval services work to both facilitate timely transfer of patients and to
place at the provide expert advice and clinical guidance to health service staff. For adult patients
right time Ambulance Victoria provides advice, referral and transport for patients where clinical
management is beyond the resource or clinical capacity of the managing health service.
Where urgent transfer to a specialist hospital is required Adult Retrieval Victoria will
coordinate patient transport in accordance with defined cardiac transfer guidelines.14
Retrieval will occur through either air- or road-based transport and with paramedics or
doctors providing care as determined by the patient’s condition.
However, there remain instances where patients considered non-urgent wait longer
than optimal times for transfer to specialist services, often from regional or outer
metropolitan areas. In many cases these patients are in hospital waiting for transfer but
are waiting in hospitals not appropriate to their needs. This can result in unacceptable
patient delays and poorer outcomes.
The Integrated Cardiac Care Pathway project began in 2014, under the auspices of the
clinical network. The project is ongoing and is working to improve cardiac care pathways
and escalation protocols. While recognising this work, the cardiac plan recommends that
further action be taken to develop default referral pathways for all patients requiring
access to a higher level of care. These referral pathways would not necessarily replace
the important existing network of clinical relationships; however, they would provide a
default pathway to enhance the existing relationships and help to provide increased
access in a timely manner. The development of specialist cardiac centres will provide
the opportunity for this, but the work can commence in advance of these centres being
established, based on existing service configuration.
This will involve the following:

• Each local hospital will be linked to a regional health service that will coordinate care
for all patients from that region.
• Each regional health service will be formally linked to a defined tertiary centre or
designated specialist cardiac centre.
• The defined specialist centre will be required to provide advice and consultation to
all patients from its associated regional health services, and will accept all patients
referred to it by that regional service, subject to clinical assessment, within the
prescribed timeframe.
• The regional health service and local hospital will agree to accept patients back from
the specialist centre within the prescribed timeframe.
• No centre will refuse a patient requiring advice or admission for a higher level of
care based on bed availability. This principle will be a vital element to removing the
existing delays that often occur. All patients and organisations should benefit from the
improved flow that this will generate.
19
1.4 Continuous improvement embeds innovative models of care across all services
Recent targeted investment in cardiac services has supported projects to develop new
models of care, improve service delivery, increase system efficiency and deliver better
patient outcomes. This work has particularly supported the program of pre-hospital
thrombolysis in rural Victoria and development of improved models of care for chronic
heart failure and cardiac rehabilitation.
For the significant group of patients with heart failure, programs have developed
innovative models of care to improve service delivery and involve patients in their own
ongoing care. Cardiac rehabilitation and other secondary prevention programs have
benefited by better targeting of packages to meet people’s needs and provision of
information to patients before discharge has been improved, to better empower patients
and families.
Another example of innovative development was work begun by the Heart Research
Centre to create a forum for ongoing support and motivation for heart attack patients
to make lifestyle changes and to reduce stress, anxiety and depression through social
connection. This increased focus on wellness programs and peer support in managing
chronic conditions may be a valuable part of the recovery pathway for heart disease.
The next phase of work is to ensure that where projects can demonstrate improved
outcomes, these innovative services and models are disseminated and made available
system-wide to benefit all Victorians, regardless of location. The process must be
ongoing for all new developments, so must be built into future project processes
and evaluation.
This will ensure successful developments are systematised and applied broadly, rather
than occurring in isolation within specific organisations.

Priority 1: Summary of actions
1. Encourage health services to work in partnership with primary care and other
stakeholders to promote better assessment of people at risk of heart disease and
support appropriate management processes and referral pathways.
2. Review arrangements for providing clinical advice and patient retrieval for
time-critical care as part of establishing designated specialist cardiac services.
3. Develop default referral pathways for all patients requiring access to a higher
level of care. These default referral pathways would operate regardless of
bed status.
– Regional health services and designated specialist cardiac services take a

lead role in coordinating patient referrals between services and disseminating
proven models of care within their recognised areas.
– Develop agreed time-based metrics for transferring patients to and from

tertiary or specialist centres, and monitor performance against these
standards.
4. Accelerate programs to embed innovative new models of care into routine

service delivery and achieve benefit across the whole system:
– Entrench the delivery of pre-hospital thrombolysis as routine practice

across Victoria.
– Implement quality statewide models of care for those admitted for medical
treatment of complex and chronic cardiac conditions.
– Develop a system-wide plan for improved cardiac rehabilitation and other

secondary prevention programs. This will ensure all patients have access to
information and services in a format that will meet their needs.
– Establish a cardiac wellness program and models of care that focus on patient
wellbeing and the psychological and psychosocial aspects of living with
ongoing heart disease.
21
Priority 2: A coordinated cardiac system of care
Health services and providers can only provide person-centred care when they
recognise they are part of a larger system of care and work together to reduce
fragmentation and provide people with integrated care across the continuum. People
need clear pathways to ensure their care is provided within the right timelines and in
the most appropriate setting to meet their needs. Where this is not provided, delays in
treatment and inefficient patient management can lead to poor outcomes for people
and for the health system.
Cardiac care is currently widely dispersed across health services. This supports care
close to home for clinical cardiology, care for those with multiple chronic diseases and
to support timely response in an emergency, but potentially leads to service duplication
and inefficiency for more complex, low volume surgical procedures and interventions.
Quality of outcomes may also be compromised in low volume settings.
A more coordinated, area-based approach based on partnerships and collaboration will

support effective service provision across all levels of care, from local services to regional
and specialist services. Improved system coordination will also change the current ad
hoc nature of patient referrals to one that better aligns service partners within the same
geographic areas or zones, and supports patients to access timely care.
This approach is not designed to remove autonomy from service providers or limit
capacity to respond to the needs of their communities, but to support services to
recognise their role within a coordinated system that supports appropriate care and
accountability for patient outcomes.
This includes a responsibility to provide an effective pathway through the health system.

A more coordinated system would improve services for people, as appropriate care
would then be provided in the right place, with specialist support available as required
through recognised patient pathways. Patients and care providers would recognise
the system of cardiac care in their area and be able to navigate through the system
more clearly and effectively. This approach would encourage collaboration between all
elements of the system.
A major change from the current service configuration will be identification of a limited
number of specialist cardiac services or formal collaboratives to build clinical leadership,
coordinate care, drive improvement in research and expand innovative models of care
to benefit all Victorians.
The new Victorian Heart Hospital will be established as the specialist centre for the
southern and eastern areas, noting the ongoing role of The Alfred in transplantation
services. Further detailed work will consider the best model for a specialist centre or
collaborative for northern and western parts of the state.

These specialist cardiac services will have a role in both direct provision of complex care
and in support for other service providers and the community within their areas. This
will support a population health approach and contribute to improvement in community
health and wellbeing.
System coordination and collaboration will be improved for all agencies, with greater
clarity of health service capability, roles and responsibilities within the cardiac system
of care.
A cardiac 2.1 Health services recognise roles and responsibilities within a coordinated
system of system of care
care Cardiac service providers will have their roles and responsibilities redefined into a more
organised system of care. Delineation of roles will improve coordination and ensure
patients receive the right care in the most appropriate setting to meet their needs.
Better role clarity will help increase service effectiveness by ensuring high-complexity,
low-volume procedures are provided efficiently while supporting timely interventions
and ongoing clinical care in the community.
The commitment to develop a specialist heart hospital as a centre of excellence in

cardiac care provides a renewed opportunity to assess the current provision of services
and refine service roles. Clear delineation of roles will ultimately result in some changes
to service configuration, particularly for specialist cardiac services, but will also improve
system collaboration through strengthened agency partnerships and improved patient
referral within and across geographic areas.
To take this forward the plan proposes a system design framework be developed and
implemented for Victoria, based on delineation of roles and service capability. The
framework will define levels of capability and determine the range of services to be
provided at each level, based on clear assessment of patient characteristics and risk.
The framework will address issues such as relationships, resources, infrastructure and
support services required to safely and sustainably deliver care at varying levels of
complexity. The framework will also address service linkages, quality standards and
roles in education, training and research. This will support the provision of integrated
services across Victoria based on a consistent approach and understanding of health
service capability.
This approach is consistent with and informed by work in other jurisdictions.15, 16, 17, 18
The National Heart Foundation has recently released a capability framework for acute
coronary syndromes,19 so this will also inform development.
A draft high-level system design framework defining five levels of cardiac care is
provided in Appendix 4.
When the detail of the system design framework has been completed, further work will
be undertaken by the department, in conjunction with the clinical network and service
providers, to determine the role of individual health services and agencies within the
framework. This will include development of regional and subregional cardiac plans to
recognise roles and relationships within and across areas.
23
Development of cardiac services will be undertaken in conjunction with the 20-year
service and infrastructure plan arising from the Travis Review.20 This plan will help to
prioritise capital and recurrent investment over the next two decades to ensure the
health system is better able to meet future demand.
2.2 Designated specialist services take a lead role in coordination of cardiac care Clinical
Within the system design framework, two to four specialist cardiac centres or leadership
collaboratives will be designated the highest level of care. One of these specialist cardiac
centres will be the new heart hospital, which will focus on the south-east of Victoria.
will support
coordination
Cardiac services from the northern and western areas will be supported to work together
to determine the best configuration for those areas, noting that planning data identifies
the north and west as major areas for population and activity growth. The designated
specialist collaborative for the north and west will be delivered through a partnership
model and not be reliant on new infrastructure. There is no expectation that a second
stand-alone cardiac centre will be developed.
2.3 Complex cardiac care is consolidated to fewer facilities, with general cardiac care
distributed to support the right care in the right place
With clearer roles and responsibilities for each health service, it follows that some
service reconfiguration will be necessary. Improved delineation of roles will promote
consolidation of complex services to a smaller number of services but wide distribution
of general cardiology and re-vascularisation services.
Complex care
The establishment of two to four designated specialist cardiac centres will, over time,
result in complex cardiac interventions and surgery being directed to these sites, based
on international benchmarks reflecting the relationship between volume, quality and
patient outcomes. This will increase volume at each specialist centre and support
improved efficiency, as well the ability to raise clinical standards and provide more
opportunities for training and clinical education.
Complex services currently considered for consolidation can be identified, but with
continuing development these may become ‘routine’ over time, so ongoing review and
adaptation will be necessary.
The current range of services identified as appropriate for consolidation include:
• cardiac surgery, particularly complex surgery such as percutaneous valve repair and
replacement or transcatheter aortic valve implantation (TAVI).
• electrophysiology studies
• arrhythmia services
• specialised lipid, hypertension and diabetes clinics.
The recommendation to consolidate specialist, low volume services is supported by
international benchmarks and practice. Table 3 outlines the current, widely recognised
benchmarks for the volume of procedures that an agency should perform in order to be
regarded as a specialist centre for teaching and training purposes.

Table 3: Facility volume recommendations
Source Coronary artery Percutaneous Primary PCI Adult

bypass graft coronary electrophysiology
intervention (PCI) studies
CSANZ >200 per year • 75+ elective per Outcomes appear 120-150 per year
year for each to be optimal for training
individual. when the centre is requirements
• 200+ elective per treating more than
year for the centre 36 STEMIs with
primary PCI per
It is not ideal
year (>11 cases per
that low volume
year per operator)
operators (<100 PCI
per year) perform
PCI in low volume
centres (<400 PCI
per year)
RACS - - - -
Leapfrog Group >450 per year >400 per year
USA: Programs with >200 total and
ACC/AHA <125 CABG per >36 primary PCI
year be affiliated procedures per
ACCF/AHA
with high-volume year
tertiary centres
Europe: Institutional Operator >75 per
ESC and EACTS volume of >200 per year at institutions
year performing >400
PCI per year with
an established 24/7
service for ACS
Analysis of admitted activity shows that not all current cardiac service providers achieve these
benchmarks, highlighting the opportunity that exists for change.
However, not all complex care can be or needs to be directed to defined specialist centres. Complex
care for some specific groups will remain as it is, including the Royal Children’s Hospital as the
primary service provider for paediatric patients and The Alfred as the statewide provider of heart
transplantation.
The clinical network will take a lead role in review and agreement of protocols or standards to define
what complex care should be consolidated to a limited number of specialist sites for Victoria. This
will include confirmation of quality of care standards, service benchmarks and patient volume
thresholds. The methodology should be consistent with that used by the state trauma system,
including guideline education and compliance monitoring through a central registry.
25
General care
General specialty cardiology and routine interventional services will remain widely
distributed and locally accessible so patients are able to access this care as close
to home as possible. Acute coronary syndromes, especially ST elevated myocardial
infarction (STEMI) are time-critical, with the outcome depending on how soon effective
thrombolysis or primary coronary angioplasty is administered. Current guidelines21
recommend that treatment for STEMI should ideally be instigated within one hour from
onset of symptoms. Therefore, interventional cardiology and non-complex procedures
performed in cardiac catheterisation laboratories need to remain distributed across the
state to support patient access within defined timelines.
Clarification of agency roles will mean increasing development of specialist cardiology

services in regional areas, with regional health services taking more of a leadership
role in coordinating the cardiac service system within their geographic areas. The
department is supporting regional health services through programs such as the
Strengthening our Regional Hospitals initiative,22 which is focused on supporting outer
metropolitan, rural and regional health services to actively work together to deliver
more sustainable services to local communities. Clarification of agency roles supports
the development of service partnerships within regional areas and more coordinated
patient pathways to improve access to appropriate care for people living in rural and
regional Victoria.
The government has committed to developments in Albury–Wodonga, Ballarat and

Latrobe health services to further enhance response capability, which is consistent with
this approach.
Many patients with chronic heart disease also have other chronic and complex
conditions requiring management and treatment. The interdependencies of these
conditions is best managed through multispecialty and multidisciplinary care, so these
patients will continue to receive their care in a general acute hospital closer to home,
with access to the full range of specialist services.
Non-admitted services and support will remain distributed, with improved coordination
and collaboration between services. Secondary prevention and cardiac rehabilitation
services must also be widely distributed to support easy access close to home.
2.4 The Victorian Heart Hospital makes a significant contribution to the cardiac
system of care
Establishment of the Victorian heart hospital is a significant development for the
cardiac service system in Victoria and will be the first such facility in Australia. The
development will benefit all Victorians with, or at risk of, heart disease as it provides an
opportunity to: strengthen clinical leadership; build on the existing cardiac system of
care; improve research and clinical education; and expand innovative models of care for
cardiac conditions, including use of new technology. This new facility will raise the profile
of cardiovascular disease treatment and prevention both locally and internationally, and
play a key role at the national level in cardiac research, teaching and training.

The heart hospital will expand existing cardiac service capacity, with an innovative
facility design that will be patient-centred and service-oriented to enhance both patient
experience and seamless patient flow.
The hospital will be a stand-alone centre on the grounds of Monash University. The
model of a stand-alone cardiac service is in place internationally, where services have
proven able to function effectively with strong relationships with acute service providers
and clear agreement of roles and responsibilities between services.
The system design framework will ensure the addition of the heart hospital strengthens
the existing cardiac service system, builds targeted research capacity and promotes
innovation that can contribute to better patient outcomes for all Victorians.
Service profile
In order to benefit the cardiac system of care and support patient safety, the heart
hospital will have a clearly defined service profile. The following profile is proposed, and
will be confirmed as the facility is further developed:
• It will be developed as the specialist cardiac centre for the south-east of Melbourne
and Victoria, with the exception of transplantation services. Care provided will be up
to the highest level of complexity to the adult population, consistent with roles defined
by the delineation framework.
• It will provide a clinical leadership role, including care coordination to enhance patient
referral, remote consultations and provision of 24/7 specialist advice for clinicians,
including general practitioners (GPs).
• It will be developed as a centre of excellence for both the state and nationally in
the areas of research, teaching and training. This will be collaborative, multiagency
and include a focus on new technology, improving population health outcomes and
translation.
• It will provide leadership, in collaboration with others, in promoting research and
clinical practice developments that will improve population health outcomes related
to heart disease.
• It will undertake private activity. This will be both local and international, with the
option of providing cardiac procedures such as bypass and valve replacement to
residents of countries within the region.
• It will support the current distribution of general cardiac services to ensure timely
local access for people across Victoria.
• The emergency service at the heart hospital will need to be designed by the governing
body to ensure appropriate access to specialist care, mindful of the risks associated
with operating an emergency service remote from a general acute hospital. The final
model will depend in part on the hospital staffing profile, and the emergency model
of care may well evolve over time. As a starting point, the governing body should
consider a model that involves the establishment of an acute cardiac assessment
service, but one which may not include direct self-referral by patients. Such a model
would include:
– short stay beds to support rapid stabilisation and treatment and early discharge
(patient length of stay would be up to 48 hours)
– a secondary referral service accepting referrals only in accordance with specified
agreed criteria, with referral sources potentially to include:
27

• Ambulance Victoria paramedics for patients with clear ST segment changes

consistent with heart attack and potentially ventricular arrhythmias or complete
heart block
• the Monash emergency department, where criteria are met
• regional and other hospitals with high-risk non-ST elevation acute coronary
syndrome
• private cardiologists, directly from rooms
• GPs, in accordance with specified criteria
– support for the major patient groups of heart attack, high-risk chest pain
considered to be cardiac, cardiac failure and selected arrhythmias
The final emergency service model should not impact on the large cohort of patients
who present to emergency departments across the state with chest pain and are
successfully managed through short stay models of care.
• The range of services provided will be consistent with those able to be safely provided
in a stand-alone cardiac site, and is therefore not envisaged to include:
– heart and heart/lung transplants, given the requirement for a large respiratory
service, intensive care, nephrology, immunology and other specialties. However,
further work should be undertaken in the future, after the heart hospital is
established, to consider the rationale and impact of not having transplant services
located at the specialist hospital
– trauma services and general emergency care
– care for neonatal or complex paediatric patients.
Facility development
The development of the heart hospital infrastructure will be based on the government’s
election commitment, aligned to the capital funding strategy.
Indicative projections of future activity for the heart hospital have been based on the
service profile, which will inform the capital business case. Projections have been based
on a number of assumptions:
• The hospital will not provide general cardiology and routine interventional services
currently provided by other local services.
• Cardiac activity will include transfer of cardiac surgery and interventional cardiology
services from Monash Health and Jessie McPherson Private Hospital.
• Continued growth from the south and eastern areas of Victoria will be directed to the
heart hospital.
• The heart hospital will target expanded private activity, including growth in
international activity.
These projections clarify the proportion of public cardiac activity the heart hospital will
provide, to assist in planning what capacity the hospital will have available for private
activity, and for teaching and research purposes.

The heart hospital will be a catalyst for consolidation only in respect of complex
interventional and cardiac surgical services. In regard to cardiac surgery, it is clear from
the projections that a strong case exists for consolidating activity for the south and east
of Victoria at the heart hospital. Without this, the volume of surgery may not be optimal
for clinical outcomes. However, with transplantation services remaining at The Alfred, it
is essential that sufficient activity is retained at that site to support the maintenance of
skills and experience necessary to perform the transplantation activity.
Further consideration may be given to transplantation services in five to 10 years,

after the heart hospital has been established, to determine optimal future service
arrangements.
Research, teaching and training

The heart hospital will be a driving force for innovation and research at both statewide
and national levels. A vision for research, teaching and training has been developed by
the partners involved in developing the hospital, being Monash University, Baker IDI and
Monash Health. This vision will be pursued through the hospital’s development, in order
to benefit the whole of Victoria and Australia.
For clinical education, the Monash Health and Monash University partnership will
provide training options for undergraduate and postgraduate medical, nursing and
science students, subspecialty training for cardiologists and cardiac surgeons, an export
business for the education of international health professionals and provision of PhD
and masters placements for doctors, nurses, cardiac technologists and allied health
professionals.
The research component of the hospital will bring together existing research expertise
and provide capacity to expand activities and projects to include clinical trials, contact
research, registries, research partnerships and translational research.
In order to achieve a statewide benefit, the hospital will work within the following
principles:
• The cardiac research strategy is ‘inclusive’ and not ‘place-based’. This means
researchers from other locations should be connected to the hospital in order to
achieve critical mass and to best promote Victoria as a centre of excellence for
cardiac research.
• Further consideration is given to the role of the Advanced Health Research and
Translation Centres, notably Monash Partners, in promoting strong, statewide
collaboration in cardiac research.
• The hospital is a major centre for the teaching and training of all cardiac professional
staff including:
– postgraduate medical trainees
– cardiac technologists
– cardiac nurses
– allied health staff
29
• The hospital will function as a ‘hub’ for the training and development of staff
from across all disciplines, ensuring the development of skilled staff for the whole
of Victoria.
• The hospital will lead research across the full range of cardiac conditions, including
reducing the incidence of heart failure.
• The hospital will be a central repository for cardiac clinical data to assist with
research and improved understanding of clinical outcomes, with the ability to
disseminate this data to all relevant parties.
2.5 Opportunities for partnerships between public and private sectors are maximised
The private sector is a major contributor and provider of cardiac care, particularly
cardiothoracic surgery and interventional cardiology. Increased collaboration and
partnership arrangements between the public and private sectors would bring benefits
to both patients and clinicians so will be supported to increase system effectiveness.
Opportunities for partnerships between public and private sector agencies for activities
such as research and training could also be further developed so that all Victorians have
the opportunity to benefit from innovative developments.

1. Define the roles and responsibilities of all cardiac service providers. This will be
supported by development of a system design framework, based on role and
capability, completed in collaboration with the clinical network, health services
and other stakeholders. The impact and role of primary care will be considered
in the development of the framework.
Detailed regional and subregional cardiac plans will then be developed to

recognise roles and relationships within areas.
2. Confirm two to four designated specialist cardiac centres or collaboratives,

with one of these being the Victorian Heart Hospital. Partners from across the
northern and western areas will be supported to work together to determine the
best configuration of services in those areas.
3. Develop protocols to define complex care for consolidation to limited specialist

sites. This will be in conjunction with confirmation of quality of care standards
and benchmarks for use in Victoria.
– A
ssess available guidelines and literature to confirm service benchmarks
and patient volume thresholds required to safely and sustainably deliver
procedural work.
4. Confirm the role and scope of the Victorian Heart Hospital, to be built as a
stand-alone specialist hospital. The department will work with the governing
body to confirm the detailed model of care, consistent with the principles and
system role defined in this plan.
5. Explore opportunities for greater collaboration and partnering with the private
sector in all aspects of care, including prevention and cardiac rehabilitation, to
ensure all patients have access to quality services.

Priority 3: Effective and innovative cardiac services
The previous two priorities have focused on improvements to the cardiac system of care.
To provide comprehensive care the system also needs effective leadership driving
continuous quality improvement. These related areas are key to enabling and
supporting overall system development and reform.

Effective and innovative cardiac services will capitalise on opportunities to continuously
improve how services are provided. Designated specialist services will provide clinical
leadership in care and support for services across geographical areas through
partnerships and innovative models of care.
Patients will be provided with care that is evidence-based, and services held
accountable for care provided and outcomes achieved. Ongoing research and service
development will improve care provided, as new technology and new methods of
care are adopted into clinical practice. Finally, the essential cardiac workforce will
be supported and developed to respond to growing demand and continue to provide
quality care to all Victorians.
3.1 Designated specialist cardiac services provide clinical leadership across

the system
Driving change across the cardiac system of care will require system leadership, with
development of partnerships between specialist cardiac services and other cardiac
service providers. The defined system leaders will be those services at the highest level
of capability, including the heart hospital for the south-east and the arrangement for the
north-west area defined through the development of a coordinated system of cardiac
care described in Priority 2.
These specialist cardiac centres will then take a lead role in developing partnerships
with service providers at other levels of capability. Together they will provide care at
the highest level of complexity and lead improvement of cardiac services across the
continuum of care.
Specific clinical leadership will achieve the following:

• It will improve access to specialist expertise and clinical advice, using telehealth, to
support clinicians in rural areas without local access to cardiologists. This is intended
to strengthen local decision making to risk-stratify suspected cardiac patients and
determine appropriate treatment pathways. This will enhance access to up-to-date,
evidence-based clinical care across regional areas and build on established systems
that already reach all providers, such as Trauma Victoria.23
• It will help improve triage, referral pathways and care coordination based on objective
assessment of risk, with guaranteed access to specialist cardiac interventional
services, including surgery as required.
• It will support education and training of cardiac clinicians and support staff, in
collaboration with partners.
31
• It will help maintain skills and expertise in regional and rural services through
innovative solutions such as combined education programs, joint appointments and
staff rotations.
• It will provide oversight of services to make sure care is evidence-based, with
encouragement for expansion of services with a solid evidence base of positive
patient outcomes. Equal consideration should be given to disinvestment in services
for which no evidence base exists. Linkages to the Choosing Wisely24 initiative, which
is aimed at reducing unnecessary procedures, should be developed.
The development of cardiac centres or defined collaboratives to drive improvement in
cardiac service provision and patient outcomes will mean these services will be held
accountable for the patient outcomes within their recognised areas, which will require a
broader focus than just their own caseload and immediate catchment population.
The role of regional health services will be strengthened to provide clinical leadership,
oversight and coordination within their regional areas.
3.2 Continuous service improvement is driven by monitoring of performance and Data will drive
outcomes
continuous
Monitoring of clinical performance measures the effectiveness of the system in
improving health outcomes, improving system efficiency and providing clinically and
service
cost-effective care. To effectively integrate evidence-based recommendations into improvement
practice and lift overall standards of care it is important to measure and compare
service activity and improve benchmarking of hospital performance. This can reduce
variability in quality and improve patient outcomes.
To achieve this there must be improvement in the way data is collected and monitored.
One specific example includes reviewing compliance with the coronary care unit
component of the bed status website to provide visibility of hospital capacity
and potential expansion to include cardiac catheterisation laboratory availability
and capability.
Key performance indicators (KPIs) measure system performance and allow comparisons
between services to measure system improvement. Improved data collection and
analysis will support development of a suite of KPIs for regular monitoring, such as:
• time from contact to thrombolysis, where this is clinically appropriate treatment
• door-to-balloon time
• percentage of patients discharged on aspirin/beta-blockers
• mortality/complication rates
• unplanned readmission rates for patients with heart failure
• the percentage of patients participating in cardiac rehabilitation
• patient outcome measures to determine performance and effectiveness
of care provided.

In addition to these indicators, others will be developed for the designated specialist
centres to monitor the effectiveness of referral processes and clinical leadership. These
could include:
• the percentage of patients from an identified referral zone accepted for treatment
within defined times
• the percentage of patients referred back to local health services for ongoing
management
• the percentage of patients accepted back by the referring hospital within
defined times
• population health measures for heart disease.
The Australian Commission on Safety and Quality in Health Care have developed a
suite of clinical care standards for acute coronary syndromes,25 which will inform the
development of Victorian performance indicators.
3.3 Better access to clinical information benefits both patients and providers
Better patient data collection and information systems would contribute to benefits
across the system. For patients, sharing of up-to-date data between providers through
developments such as standardised or patient-held electronic health records would
support coordinated service delivery and reduce duplication. For health services better
access to data would improve capacity to measure patient outcomes and monitor
and compare performance. For the system as a whole, improved data would improve
capacity for research and improve understanding of patient outcomes and trends.
The healthcare system already collects a large amount of patient-related data, with
multiple stakeholders collecting data related to the incidence, prevention and treatment
of cardiovascular disease. However, this is often maintained in separate databases and
not readily available beyond the individual agency.
The development of clinical registries such as the Victorian Cardiac Outcomes Registry
(VCOR) has helped collect a range of health data. VCOR currently collects data about
PCI procedures performed by all public and private providers and will be gradually
expanded to include outcomes in other areas such as thrombolysis, implantable
electronic devices and anticoagulation therapy for atrial fibrillation.
As the VCOR database continues to develop it will allow healthcare providers to

benchmark their performance against services provided both nationally and
internationally. Better linkages between new and existing data collections and registries
will further increase the value of the available information, provide an evidence base
for research and model of care development and improve the effectiveness of service
performance monitoring.
The clinical network is working with stakeholders on initiatives to improve data collection
and to strengthen the capacity of researchers to access data. This includes options
to develop a data collaborative as a way of providing expertise, coordination and
leadership in data collection.
A collaborative could lead development of a coordinated approach to data collection,

support integration and data linkages and improve clinician access to meaningful data.
33
3.4 Clinical practice is improved through ongoing medical research Research and
Development of a number of specialist cardiac centres for cardiac research and innovation
specialist workforce development will improve the capacity for research across multiple
services and the translation of this into ongoing change in clinical practice.
will address
changing
This additional capacity will build on innovative work to date, particularly with
new technology. Potential also exists to explore tissue engineering, smart drugs, needs
nanotechnology and new biomaterials. There is potential to support targeting of
those at increased risk through genetic testing to facilitate access to personalised
medicine therapies.
New service models and treatment regimens have the capacity to improve quality of
life for those with chronic heart failure and heart disease in the aged, and therefore to
reduce unplanned readmissions to hospital. This is a clinical group with scope for service
improvement through applying new technology and innovation in treatment modalities.
There is also scope for further development of models of care to support patient
wellbeing and increase the focus on psychological and psychosocial aspects of living
with heart disease.
The specialist heart hospital will provide an opportunity to enhance and develop cardiac
research, and to establish Victoria as a national leader in this field. Other universities,
institutes and research groups will also have key roles to play, with organisations such as
the Baker IDI central to the future of cardiac research in Victoria, given their established
expertise. A prerequisite for Baker IDI to maintain its contribution to cardiovascular
health is maintaining a reasonable size and broad range of clinical cardiology activity at
The Alfred hospital campus.
Research at the heart hospital will benefit from proximity to some major research
infrastructure on the Monash Clayton campus and nearby. Strong basic science,
bioengineering, medicine and related faculties will have the opportunity to extend their
findings into the clinical domain. This will require a new workforce of clinical academics
experienced in translational research and commercialisation.
The clinical network is currently supporting development of the Victorian Cardiovascular

Clinical Trials Accelerator to facilitate the coordination and expansion of cardiovascular
clinical research capacity and participation across Victoria. The increasing burden
of cardiovascular disease in the community presents a strong case to establish
a coordinated approach to clinical trials. At present there is fragmented practice
across cardiology units and lack of a critical mass in terms of patient recruitment
and economic viability. As a result there are few opportunities for hospitals to run
cardiovascular clinical trials.

There is also limited access for rural patients and community clinicians to participate in
research. This means there is an untapped and underdeveloped market of patients and
clinicians available to support cardiovascular clinical trial activity. Studies in ambulatory
patients, such as those with hypertension, lipid disorders and heart failure, are
increasingly difficult to manage from hospital departments as fewer of these patients
are treated in the hospital setting, and there is a lack of suitable infrastructure.
The creation of the clinical trials accelerator will address the need for a coordinated
approach to cardiovascular clinical trials in Victoria. The objectives of the project are to:
• develop coordinated processes, infrastructure and governance arrangements to
support cardiovascular clinical trials activity
• centralise the cardiovascular clinical trials process to increase access and
participation
• position Victoria as a world-leading location to conduct high-quality independent
clinical trials
• increase engagement of the cardiovascular clinical community to participate and
support clinical trials
• develop a network to facilitate collaborative projects between groups and facilitate
strong and robust interactions with the community, primary care and rural clinical
researchers
• develop a critical mass of clinical research activity that focuses on international
competitiveness
• significantly increase international clinical trial activity, with several multinational
pharmaceutical companies indicating such an initiative would increase the likelihood
of partnership with Victoria.
3.5 The cardiac workforce is supported to provide quality care

An adequately trained and available workforce is critical to providing a comprehensive
cardiac system of care. Victoria’s health workforce is facing challenges, with increasing
demand for services and demographic change resulting in relative shortages in
some traditional groups. For cardiac care this is particularly evident in rural and
regional Victoria.
Responding to the changing nature of demand creates opportunities for a different

workforce mix or for innovative ways in which services can be provided. Continuing
development of telehealth models of care is one element, with other options including
expansion of alternative roles such as nurse practitioners, general practitioners upskilled
in managing heart disease and the potential for a greater contribution to monitoring
and risk assessment by community pharmacists.
Increasing development of technology such as imaging will lead to increasing demand

for radiologists and cardiac technicians. Concurrent development of specialist cardiac
centres, redistribution of services and expansion of cardiac services in regional areas
will require changes to roles and redistribution of the workforce over time. It should
encourage the development of models that better support availability of a skilled
workforce in regional areas such as joint appointments, co-operative models and other
forms of close collaboration with specialist centres.
35
With the projected increase in demand for cardiac services, an increase in numbers of
training places in interventional cardiology would be expected to ensure the delivery of
high-quality healthcare. However, as mentioned earlier in this plan, Australia is providing
a level of cardiac intervention comparable to other OECD countries, so this level of
overall activity should be maintained. It is important that increasing training places
for interventional cardiologists does not in itself encourage an increase in levels of
intervention in excess of that currently provided, without clear evidence of patient need.
Estimation of the total medical workforce required to meet increasing demand and
best practice guidelines must take into consideration quality and safety related to
minimum patient volumes per centre. Minimum activity volumes have been defined
by the Australian and New Zealand Society of Cardiac and Thoracic Surgeons and
the Cardiac Society of Australia and New Zealand and will impact on both the number
of catheterisation laboratories in Victoria and the workforce required to manage the
activity. As described in Priority 2, the clinical network will take a lead role in confirming
benchmarks and volume thresholds for Victoria.
The cardiac plan does not include a detailed workforce plan but recognises the impact
changing service models will have on the current and future workforce. Further analysis
of the impact of change will be considered as the priority areas recommended by the
plan are actioned.

1. Develop a coordinated cardiac system to support improved clinical leadership, with
specialist cardiac centres or collaboratives to take this leadership role. This will
affect a number of elements:
– It will support the establishment of partnerships between services in defined
areas. The first will be the southern and eastern areas of Victoria, based around
the Victorian Heart Hospital.
– It will improve access to specialist cardiac advice to support clinicians in areas
without local access to cardiologists.
– It will reinforce the role of regional health services in providing clinical leadership,
oversight and co-ordination.
2. Review compliance with the coronary care unit component of the bed status
website to provide visibility of hospital capacity. Explore potential expansion to
include cardiac catheterisation laboratory availability and capability.
3. Improve data collection across the continuum of care and develop KPIs to monitor
service effectiveness and the ongoing impact of new practice initiatives:
– KPIs will include measures relevant to both patient experience and outcomes and
system performance.
– KPIs will be regularly monitored to ensure agency adherence to best practice,
with benchmarking between hospitals to drive service improvement.
4. Improve data collection systems to strengthen the capacity of researchers to
access useful data:
– Continue to expand datasets such as the VCOR and improve linkages with other
relevant data collections.
– Work with VCOR and other datasets to identify opportunities to use the data
available to support research, innovation and improvements in practice across
the care continuum.
– Improve data collection and strengthen the capacity of researchers to access
data collected. This will include options to develop a data collaborative as a way
of providing expertise, coordination and leadership in data collection.
5. Support increased focus on research and effective translation into clinical practice
for new treatments, technologies and models of care by:
– D
eveloping the Victorian Cardiovascular Clinical Trials Accelerator to facilitate
expansion of cardiovascular clinical research capacity and participation in
clinical trials.
– Focusing on particular aspects of care such as genetic testing to facilitate
access to personalised medicine therapies and heart failure and heart disease
in the aged.
– Using the research program to benefit the broader health sector, including
private services, primary care providers and the community.
6. Identify and develop innovative service arrangements and partnerships to
maximise utilisation of the existing workforce. This may include joint appointments
or other co-operative arrangements.
37
Implementation plan
Development and implementation of the priorities and actions described in the cardiac
plan will improve provision of services for all Victorians, but the vision will only be
realised if the plan is supported by all those involved in providing cardiac care.
Instead of supporting incremental change in services and service mix, this plan
forecasts a significant commitment to reforming the cardiac care system. These
changes will require action and alignment at all levels of the system, aimed at
supporting clinicians to provide the best possible service for Victorians with,
or at risk of, heart disease.
The department will be responsible for leading and coordinating implementation of the
cardiac plan, and will marshal appropriate resources to support implementation over
the life of the plan. The department will work in conjunction with the clinical network,
health services and other key stakeholders as part of the implementation. Clinician
engagement is essential in realising the vision for cardiac services in Victoria, and the
clinical network will be the point through which engagement is achieved. Making the
change happen will require a change in approach by both the department and by
health services.
The actions committed to in this cardiac plan include tasks that will drive significant
change, as well as development opportunities for longer term and ongoing system
improvement. To begin the process of change and to achieve real system improvement
significant tasks will be tackled first, with action beginning in 2016. The continuing
development of the Victorian Heart Hospital will sit outside of this, to be managed
by the governing body and the department as per the established process for major
capital developments.
The following table identifies the project lead and partners for each identified action or
task, with a timeline to indicate the order of work to be undertaken.

Priority Actions Year 1 Year 2 Ongoing Project Partners
theme lead
1.1 Encourage health services to work in partnership Work with Develop Evidence-based DHHS Health services
with primary care and other stakeholders to promote partners and implementation risk assessment PHN, PCP, CHS
better assessment of people at risk of heart disease stakeholders to plan to introduce in primary care Aboriginal health
and support appropriate management processes and assess existing consistent, services
referral pathways. programs and evidence-based Local
agree approach risk assessment Government
1.2 Review arrangements for providing clinical advice Develop Develop Specialist advice DHHS VCCN
and patient retrieval for time-critical care, as part of specifications specialist advice service available Health services
establishing specialist cardiac services. for the advice service as across the state
(Development linked to coordinated cardiac system service component of
with improved clinical leadership by specialist cardiac role of Level 5
centres.) services
1.3 Develop default referral pathways for all patients Define default Refine processes Standard agreed VCCN DHHS
requiring access to a higher level of care. These default pathways and and implement pathways in Health Services
referral pathways would operate regardless of bed processes, in agreed referral place across the
status. selected areas pathways across state
– Regional health services and specialist cardiac all areas
services will take a lead role in coordinating patient
referrals between services and disseminating proven
models of care within their recognised areas.
– Develop agreed time-based metrics for transferring
patients to and from tertiary or specialist centres,
and monitor performance against these standards.
1.4 Accelerate programs to embed innovative new models Support All Victorians DHHS VCCN
of care into routine service delivery and achieve benefit development benefit from new Ambulance
across the whole system: of programs model of care Victoria
– Entrench the delivery of pre-hospital thrombolysis as at identified developments Health services
routine practice across Victoria. services
– Implement quality statewide models of care for those
admitted for medical treatment of complex and
chronic cardiac conditions.
– Develop a system-wide plan for improved cardiac
rehabilitation and other secondary prevention
programs. This will ensure all patients have access to
information and services in a format that will meet
their needs.
– Establish a cardiac wellness program and models
of care that focus on patient wellbeing and the
psychological and psychosocial aspects of living with
ongoing heart disease.
39
40
theme lead
2.1 Define the roles and responsibilities of all cardiac Confirm Develop detailed Health services DHHS VCCN
service providers. This will be supported by development framework regional and will function in Health services
of a system design framework, based on role and based on levels subregional accordance with Regional offices
capability, completed in collaboration with the clinical of service plans to acknowledged
network, health services and other stakeholders. The capability recognise roles roles and levels
impact and role of primary care will be considered in the and relationships of service
development of the framework. within areas capability
2.2 Confirm two to four designated specialist cardiac Confirm heart Support services DHHS Health services
centres or collaboratives, with one of these being the hospital and to develop and
Victorian Heart Hospital. Partners from across the partners for implement Level
northern and western areas will be supported to work south-east 5 role
together to determine the best configuration of services Identify
in those areas. collaborative for
north and west
2.3 Develop protocols to define complex care for Review available Measure current Monitor VCCN ARV
consolidation to limited specialist sites. This will be guidelines to services against throughput and Health services
in conjunction with confirmation of quality of care confirm service confirmed activity DHHS
standards and benchmarks for use in Victoria. benchmarks and benchmarks
– Assess available guidelines and literature to confirm thresholds for
service benchmarks and patient volume thresholds procedural work
required to safely and sustainably deliver procedural in Victoria
work.
2.4 Confirm the role and scope of the Victorian Heart Initial scope Development of DHHS VHH
Design, service and infrastructure plan for Victoria’s cardiac system

Hospital, to be built as a stand-alone specialist hospital. confirmed VHH As per capital
The department will work with the governing body to process
confirm the detailed model of care, consistent with the
principles and system role defined in this plan.
2.5 Explore opportunities for greater collaboration and Private providers DHHS Public and
partnering with the private sector in all aspects of care considered in private health
including prevention and cardiac rehabilitation, to development of services
ensure all patients have access to quality services. service areas
theme lead
3.1 Develop a coordinated cardiac system to support Linked to DHHS VCCN
improved clinical leadership, with specialist cardiac system design Health services
centres or collaboratives to take this leadership role. framework Emergency Care
This will affect a number of elements: Clinical Network
– It will support the establishment of partnerships
between services in defined areas. The first will be the
southern and eastern areas of Victoria, based around
the Victorian Heart Hospital development.
– It will improve access to specialist cardiac advice to
support clinicians in areas without local access to
cardiologists.
– It will reinforce the role of regional health services
in providing clinical leadership, oversight and co-
ordination.
3.2 Review compliance with the coronary care unit Review existing Expand Ongoing DHHS Health services
component of the bed status website to provide visibility data collection collection to monitoring and VCCN
of hospital capacity. and identify include details of review
– Explore potential expansion to include cardiac options for cath labs
catheterisation laboratory availability and capability. improvement
3.3 Improve data collection across the continuum of care Review existing Trial monitoring Ongoing DHHS Health services
and develop KPIs to monitor service effectiveness and data collections and feedback of monitoring VCCN
the ongoing impact of new practice initiatives: and identify new indicators and review of
– KPIs will include measures relevant to both patient options for performance
experience and outcomes and system performance. expansion or according to KPIs
– KPIs will be regularly monitored to ensure agency improvement
adherence to best practice, with benchmarking Agree range of
between hospitals to drive service improvement. cardiac KPIs
3.4 Improve data collection systems to strengthen the Continue work Continue to DHHS VCOR
capacity of researchers to access useful data: with VCOR improve data Monash
– Continue to expand VCOR and improve linkages with collection University
other relevant data collections. systems to VCCN
– Work with VCOR to identify opportunities to use the strengthen the
data available to support research, innovation and capacity of
improvements in practice. researchers to
– Improve data collection and strengthen the capacity access data
of researchers to access data collected. This will
include options to develop a data collaborative
as a way of providing expertise, coordination and
leadership in data collection.
41
42
theme lead
3.5 Support increased focus on research and effective Scoping and Development Ongoing DHHS Health services
translation into clinical practice for new treatments, preliminary work of a Victorian program of Universities
technologies and models of care by: on a Victorian Cardiovascular research and Baker IDI
– Developing the Victorian Cardiovascular Clinical Cardiovascular Clinical Trials development VCCN
Trials Accelerator to facilitate expansion of Clinical Trials Accelerator
cardiovascular clinical research capacity and Accelerator Models of care
participation clinical trials. At least one developed and
– Focusing on particular aspects of care such as Scoping and evidence-based rolled out across
genetic testing to facilitate access to personalised preliminary work care model the cardiac
medicine therapies and heart failure and heart on care model developed and system
disease in the aged. development documented (for
– Using the research program to benefit the broader priorities either priority
health sector, including private services, primary care patient segment
providers and the community. or process
improvement)
3.6 Identify and develop innovative service arrangements Plans DHHS Health services
and partnerships to maximise utilisation of the existing developed with
workforce. This may include joint appointments or other identification
co-operative arrangements. of service areas
and agency roles
Design, service and infrastructure plan for Victoria’s cardiac system

Appendix 1: Victorian Cardiac Plan
Steering Committee
A steering committee was established to coordinate the development of the plan, and to
endorse the plan for submission to the Minister for Health.
The steering committee had an independent chairperson, with membership comprised

of selected senior leaders representing health service, research and education agencies.
Members were selected on the basis of their experience and ability to take a broad
system perspective.
Chair: Ms Fran Thorn, Partner, Deloitte (former Secretary of the Department of Health)
Membership:
Professor David Ashbridge, Chief Executive Officer, Barwon Health
Dr Gareth Goodier, Chief Executive, Melbourne Health
Ms Diana Heggie, Chief Executive Officer, The National Heart Foundation

(Victorian Division)
Professor Garry Jennings, Director, Baker IDI
Professor Christina Mitchell, Dean of Medicine, Monash University
Ms Shelly Park, Chief Executive, Monash Health
Associate Professor Tony Walker, Acting Chief Executive Officer, Ambulance Victoria
Associate Professor Andrew Way, Chief Executive, Alfred Health
Associate Professor Andrew Wilson, Chair, Victorian Cardiac Clinical Network
In attendance as advisors:
Ms Frances Diver, Deputy Secretary, Health System Performance and Programs,
Department of Health and Human Services
Mr Adam Horsburgh, Director, Health System Planning, Department of Health

and Human Services
43
Appendix 2: Victorian cardiac system
Public cardiac services
Campus Public health services ED ICU CCU Procedural services Cardiac Cardiac Heart
type imaging rehab failure
Cath lab Cardiac
CT/MRI care
surgery
Major Alfred, The 3(2) 3 3 3 3 3 3 3
Austin Hospital 3 3 3 3 3 3 3 3
University Hospital 3 3 3 3 3 3 3 3
Geelong
Monash Clayton 3 3 3 3 3 3 3 3(1)
Royal Children’s 3(2) 3 3 3 3
Hospital
Royal Melbourne 3(2) 3 3 3 3 3 3 3
Hospital
St Vincent’s Hospital 3 3 3 3 3 3 3 3
Metro Box Hill Hospital 3 3 3 3 3 3 3

regional 3 3 3 3 3
Dandenong Hospital
Frankston Hospital 3 3 3 3 3 3 3
Northern Hospital 3 3 3 3 3 3
Sunshine Hospital 3 3 New 3 New 3 New

Western Hospital 3 3 3 3 3 3
Metro Angliss Hospital 3 Planned 3

local 3
Casey Hospital Planned
Maroondah Hospital 3 3 (3)
Mercy Werribee 3 Planned
(3)
Rosebud Hospital 3
Sandringham Hospital 3
Williamstown Hospital 3
Rural Albury Wodonga Health 3 3 (3) Planned 3 3

regional 3 3 3 3
Ballarat Health Services 3 (3) CTCA
Bendigo Hospital 3 3 (3) 3 3 3 3
Shepparton Hospital 3 3 (3) 3 3
Latrobe Regional 3 3 (3) Planned 3 3

Hospital
Wodonga Hospital 3

Campus Public health services ED ICU CCU Procedural services Cardiac Cardiac Heart
type imaging rehab failure
Cath lab Cardiac
CT/MRI care
surgery
Rural Bairnsdale Hospital 3 3 3
sub- 3
Sale Hospital
regional
Echuca Hospital 3
Hamilton Hospital 3 3 3 3
Mildura Base Hospital 3 3 3 3
Wangaratta Hospital 3 3
Warrnambool Hospital 3 3 3 3
Swan Hill Hospital 3
Warragul Hospital 3
Wonthaggi Hospital 3
Horsham Hospital 3 3 3 3
Other metropolitan 26 10
public health and
community services
Other rural public 42 18
health and community
services
(1) Heart failure services provided at Dandenong and Casey hospitals
(2) Statewide trauma services
(3) Combined ICU/CCU service
(4) Williamstown Emergency department is not a 24-hour service
45
Private cardiac services
Hospital ED ICU CCU Procedural services Cardiac Heart

rehab failure
Cath lab Cardiac
surgery
Albury Wodonga Private 3
Hospital
Avenue Private Hospital 3
Cabrini Hospital Malvern 3 3 3 3 3 3
Cotham Private Hospital 3
Donvale Rehabilitation Hospital 3 3
Dorset Rehabilitation Hospital 3
Epworth Eastern Hospital 3 3 3 3 3
Epworth Hospital Richmond 3 3 3 3 3 3
Epworth Rehabilitation 3 3
Geelong Private Hospital 3
Jessie McPherson Private 3 Use

Hospital facilities of
Monash
John Fawkner Private Hospital 3 3 3 3 3
Knox Private Hospital 3 3 3 3 3 3 3
Linacre Private Hospital 3
Melbourne Private Hospital 3 3 3 3 3
Peninsula Private Hospital 3 3 3 3
St. John of God Ballarat 3 3 3
St. John of God Bendigo 3 3 3 3

St. John of God Geelong 3 3
St. John of God Nepean 3 3

Rehabilitation
St Vincent’s Private Hospital 3 3 3 3
Valley Private Hospital 3 3 3 3 3 3
Warringal Private Hospital 3 3 3 3 3
Western Private Hospital 3 3

0
100
200
300
400
500
30
50
70
90
Germany
Per cent
418
France
87
Spain Israel
87
Israel Belgium
86
Norway
Austria
Netherlands
Per 100,000 population
307 301 300 296

Germany
Austria
286
Sweden
84 84 83
United States
272
Italy
Hungary
Ireland
83 83
Iceland
Estonia
83
Estonia
Slovenia
Czech Republic
Switzerland
82 82
Switzerland
Hungary
82
Luxembourg
257 255 254 253 252 252
2000
Netherlands
Denmark
82
Coronary angioplasty
Luxembourg
81
Italy
Coronary revascularisation procedures, 2011
Czech Republic France
2005
United Kingdom
Sweden
80 80
Norway
Australia
232 232 227 227 226
79
2011
OECD28
OECD29
78
Iceland Canada
221 212
78
Coronary bypass
Belgium Finland
77
Finland Slovenia
206 204
76
Australia Poland
75
Portugal New Zealand
Appendix 3: OECD comparison
75
New Zealand Portugal
163 161 158
75
Canada United Kingdom
154
72
United States Spain
140
71
Ireland
125
Denmark
Chile
Coronary angioplasty as a share of total revascularisation procedures, 2000–2011
26
Poland 68 68
6
Mexico Mexico
47
Appendix 4: Draft cardiac system
design framework
For some years cardiac services have been informally classified in a four-level
structure, based on planning frameworks developed by other jurisdictions and adopted
by the Victorian Cardiac Clinical Network. Each level builds on the previous level of
capability, and all health services are expected to provide care that is culturally and
linguistically appropriate.
The agreed planning framework now includes an additional level to recognise the new
service of a ‘heart hospital’, which will be defined as level 5. This new service level may
provide care at similar clinical complexity to level 4 but will have a more expansive role
in clinical leadership and support, education, training and research programs.
Consideration will need to be given to how level 5 roles may vary depending on whether
the service is stand-alone cardiac only, or a comprehensive service capable
of managing a range of conditions.
49
Level Description Expected
number of
services
Level 1 Commonly located in rural areas and provide care for the least complex patients. All public
Manage initial resuscitation, stabilisation and care of emergency cardiac hospitals
patients prior to early transfer to a higher level service.
Limited inpatient care for low-complexity patients with chronic cardiac
conditions but not patients with acute cardiac conditions.
Level 2 Manage medium-complexity cardiac patients and chronic cardiac conditions, Up to 11
24/7 emergency care of acute cardiac patients, with transfer to a higher level subregional
service as required. hospitals
High dependency or coronary care services, non-invasive cardiology services
and diagnostics, cardiac rehabilitation, heart failure programs and some
outpatient cardiac services. No cardiac catheterisation laboratories or
cardiothoracic surgery.
Level 3 Manage most acute and chronic cardiac patients and conditions, including Up to nine
high-complexity and higher risk patients. Acts as a referral centre for the regional centres
regional area.
Invasive and non-invasive cardiac services including 24/7 PCI service.
Have cath labs for interventional diagnostics but no cardiothoracic surgery.
Level 4 Highest level of service complexity including both interventional cardiology and Up to four,
cardiothoracic surgery; manages complex acute and chronic cardiac patients; including
major cardiac referral centre; services include most complex and advanced Geelong
diagnostics and treatments.
Provides a wide range of ambulatory and outpatient cardiac services including
cardiac rehabilitation, heart failure programs and specialist outpatient cardiac
services.
Level 5 Specialist cardiac centre providing local/regional service plus designated Up to two for
provider of specific high-complexity/low-volume services; leading role in south-east
teaching, training and research – including support to other providers. Victoria
Cardiac treatment and intervention will be equal to level 4, with some services
additional Up to two for
to level 4: north-west
• clinical leadership role within their defined area of Victoria Victoria
• care coordination to enhance patient referral within their defined area
• 24/7 specialist advice for clinicians within their area, including GPs
• remote consultations through telehealth
• clinical education and training
• coordination of cardiac research programs.
Some services will have a defined specialist statewide role, such as cardiac
transplantation, complex EPS, complex valvular interventions or paediatric.
Note: Level 5 may need to be further refined according to capacity to support
patients with multiple chronic or complex conditions.

Abbreviations
ACC American College of Cardiology
ACCF American College of Cardiology Foundation
ACS Acute coronary syndrome
AHA American Heart Association
AMI acute myocardial infarction
ARV Adult Retrieval Victoria
AV Ambulance Victoria
CABG coronary artery bypass graft
cath lab cardiac catheterisation laboratory
CCU coronary care unit
CHS community health services
COPD Chronic obstructive pulmonary disease
CSANZ Cardiac Society of Australia and New Zealand
CT Computerised Tomography
CTCA CT Coronary Angiography
CVD cardiovascular disease
EACTS European Association for Cardio-Thoracic Surgery
ED Emergency Department
ESC European Society of Cardiology
EPS electrophysiology studies
GP general practitioner
ICU intensive care unit
KPI key performance indicator
MCRG Major clinical related group
MRI Magnetic Resonance Imaging
NHMRC National Health and Medical Research Council
OECD Organisation for Economic Co-operation and Development
PCP Primary Care Partnership
PHN Primary Health Network
PCI percutaneous coronary intervention
RACS Royal Australasian College of Surgeons
STEMI ST elevation myocardial infarction
TAVI transcatheter aortic valve implantation
VCCN Victorian Cardiac Clinical Network
VCOR Victorian Cardiac Outcomes Registry
VHH Victorian Heart Hospital
51
Endnotes
1 Department of Health 2014, Heart health: improved services and better outcomes for
Victorians, State Government of Victoria, Melbourne
2 Australian Bureau of Statistics 2015, 3303.0 Causes of death, Australia, 2013, ABS,
Canberra
3 Australian Institute of Health and Welfare 2012, Multiple causes of death in Australia:
an analysis of all natural and selected chronic disease causes of death 1997–2007,
AIHW, Bulletin 105.
4 Reference: www.aihw.gov.au/chronic-diseases/comorbidity
5 OECD 2015, Cardiovascular disease and diabetes: policies for better health and
quality of care, OECD Health Policy Studies, OECD Publishing, Paris.
6 Reference: www.heartfoundation.org.au/programs/victorian-heart-maps
7 Kappetein AP, Head SJ 2013, CABG or PCI for revascularisation in patients with
diabetes? Published online: Lancet; 13 September Reference: http://www.thelancet.
com/pdfs/journals/landia/PIIS2213-8587(13)70114-1/abstract
8 Verma S, Farkouh ME, Yanagawa B, et al. 2013, ‘Comparison of coronary artery bypass
surgery and percutaneous coronary intervention in patients with diabetes: a meta-
analysis of randomized controlled trials’, Lancet. Reference: http://www.thelancet.
com/pdfs/journals/landia/PIIS2213-8587(13)70089-5/abstract
9 Farkouh ME, Domanski M, Sleep LA, et al. 2012, ‘Strategies for multi-vessel
revascularization in patients with diabetes’, N Engl J Med, no. 367, pp. 2375–2384.
Reference: http://www.ncbi.nlm.nih.gov/pubmed/23121323
10 Aggarwal B, Goel S et al. 2013, The FREEDOM trial: In appropriate patients with
diabetes and multivessel coronary artery disease, CABG beats PCI. CCJM 2013
Aug;80(8):515-523.
11 Department of Health and Human Services 2015, Health 2040: A discussion paper on
the future of healthcare in Victoria, State Government of Victoria, Melbourne.
12 Reference: http://www.acra.net.au/cr-services/cr-directory/
13 Reference: http://circ.ahajournals.org/content.83.5/1832.full.pdf
14 Reference: http://www.ambulance.vic.gov.au/Main-Home/Arv/Resources.html
15 Queensland Health 2014, Clinical services capability framework for public and
licensed private health facilities v3.2, Queensland Government Department of
Health, Brisbane
16 Northern Territory Health 2014, Hospital Services Capability Framework, Northern
Territory Government, Darwin
17 Tasmanian Health 2015, One state, one health system, better outcomes. Tasmanian
role delineation framework, Working Draft, Government of Tasmania, Hobart
18 Department of Health 2015, WA Health clinical services framework 2014–2024,
Government of Western Australia, Perth
53
19 National Heart Foundation of Australia 2015, Australian acute coronary syndromes
capability framework, National Heart Foundation of Australia, Melbourne
20 Travis Review: Increasing the capacity of the Victorian public hospital system for
better patient outcomes, Melbourne 2015
21 Chew DP, Aroney CN, Aylward PE, Kelly AM, White HD, Tideman PA, Waddell J, Azadi
L, Wilson AJ, Ruta LAM 2011, ‘2011 addendum to the National Heart Foundation
of Australia/Cardiac Society of Australia and New Zealand guidelines for the
management of acute coronary syndromes (ACS) 2006’, Heart, Lung and Circulation,
no. 20, pp. 487–502
22 Reference: https://www2.health.vic.gov.au/about/health-strategies/health-reform/
better-health-for-people
23 Reference: http://trauma.reach.vic.gov.au/health-strategies/
24 Choosing Wisely Australia is an intuitive of NPS MedicineWise.
See <www.choosingwisely.org.au>.
25 AustralianCommission on Safety and Quality in Health Care, Acute Coronary
Syndromes Clinical Care Standard, Sydney: ACSQHC, 2014

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Cardiac System Design Plan

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Design, service and

infrastructure plan for

Authorised and published by the Victorian Government, 1 Treasury Place, Melbourne.

© State of Victoria, Department of Health and Human Services, May 2016

From the steering committee 1

As Victorians, many of us are fortunate to have access to an excellent system of care,

Chair, Steering Committee,

2 Design, service and infrastructure plan for Victoria’s cardiac system

Better patient access, experience and outcomes

A Coordinated cardiac system of care

Effective and innovative cardiac services

To ensure accountability and measurement of progress against the priorities, a detailed

4 Design, service and infrastructure plan for Victoria’s cardiac system

6 Design, service and infrastructure plan for Victoria’s cardiac system

Figure 2: Proportion of people with additional chronic diseases (none, 1, 2 and 3

Figure 3: Proportion of people with additional chronic diseases (none, 1, 2 and 3 or

Therefore, the majority of patients with multiple morbidities require multidisciplinary

8 Design, service and infrastructure plan for Victoria’s cardiac system

Planning is currently underway to build new cardiac catheterisation laboratories and

AV operates Adult Retrieval Victoria (ARV), which is responsible for coordinating

Table 1: Public and private cardiac separations by major category, 2013–14

Private Public Total % Total % Public

Cardiothoracic surgery and interventional cardiology are specialist services requiring

International comparisons can show levels of intervention, to indicate an appropriate

10 Design, service and infrastructure plan for Victoria’s cardiac system

Projected growth in demand

From a planning perspective, it is important to consider the expected geographic dispersal of

East 1.4% 2.1%

North 3.4% 1.6%

Peninsula 3.2% 2.2%

South 3.8% 2.0%

West 3.9% 2.3%

East 2.5% 2.6%

North 3.2% 2.7%

Peninsula 3.1% 4.2%

South 3.1% 2.8%

West 3.5% 4.3%

East 2.8% 1.7%

North 3.4% 1.2%

Peninsula 2.5% 1.6%

12 Design, service and infrastructure plan for Victoria’s cardiac system

1. Person-centred care with equitable access: We need to move to person-centred and

3. Prevention and early intervention: We need to invest in prevention, acknowledging

6. Transparency and accountability: Greater transparency about system performance

7. Evidence-based care: We need to ensure interventions are evidence-based, reduce

9. Innovation: There is strong support for a new systemic approach to innovation, to

14 Design, service and infrastructure plan for Victoria’s cardiac system

Priority 1: Better patient access, experience and outcomes

To enhance the patient experience and support high-quality patient outcomes, it is

What this would look like

16 Design, service and infrastructure plan for Victoria’s cardiac system

Table 2: Recommended approach for intervention following assessment of risk

Intervention type Low Moderate High

Review 2 years 6–12 months According to clinical

18 Design, service and infrastructure plan for Victoria’s cardiac system

This will involve the following:

20 Design, service and infrastructure plan for Victoria’s cardiac system

– Regional health services and designated specialist cardiac services take a

– Develop agreed time-based metrics for transferring patients to and from

4. Accelerate programs to embed innovative new models of care into routine

1. Person-centred care with equitable access: We need to move to person-centred and

3. Prevention and early intervention: We need to invest in prevention, acknowledging

6. Transparency and accountability: Greater transparency about system performance

7. Evidence-based care: We need to ensure interventions are evidence-based, reduce

9. Innovation: There is strong support for a new systemic approach to innovation, to

– Regional health services and designated specialist cardiac services take a

– Develop agreed time-based metrics for transferring patients to and from

4. Accelerate programs to embed innovative new models of care into routine

– Entrench the delivery of pre-hospital thrombolysis as routine practice

– Develop a system-wide plan for improved cardiac rehabilitation and other

Detailed regional and subregional cardiac plans will then be developed to

2. Confirm two to four designated specialist cardiac centres or collaboratives,

3. Develop protocols to define complex care for consolidation to limited specialist