In the Journals

Team approach to quality improvement initiatives reduces cath lab inefficiencies

A systematic, team-based approach to developing and implementing quality improvement initiatives may reduce cath lab inefficiencies and streamline processes, according to new data.

Operational inefficiencies are often seen in cath labs across institutions, but little data exist on how best to address these problems. To learn more, Grant W. Reed, MD, from the Heart and Vascular Institute at Cleveland Clinic, and colleagues developed and implemented a quality improvement program in their own cath lab and analyzed data on all elective and emergent procedures for 1 year before and 2 years after the program’s implementation in June 2014.

Reduced inefficiencies

For the program, a leadership team that included the physician cath lab director, nursing manager, nursing supervisors, department administrators and interested physicians created a process flowchart that followed each step of patient care. Using nursing records, electronic cath lab documentation and feedback forms, they identified areas where time lapse could be reduced, developed specific steps to address these issues and implemented changes using the plan-do-study-act (PDSA) cycles. The team also regularly assessed the changes’ effects on care using Shewhart control charts and additional steps were made over time.

Study efficiency endpoints included room turnaround time and lab utilization, and study productivity endpoints included the number of full-time employees and the proportion of shifts that were after hours, on weekends or overtime.

After implementation of the program, start times of cases improved an average of 17 minutes and the proportion of cases starting on time increased from 61.8% to 81.7% (P = .0024), which translated to an additional 136 minutes of potential productivity per day. The majority of cases could also be completed earlier in the day, according to the data.

Furthermore, room turnaround times decreased from 20.5 minutes to 16.4 minutes (P for trend < .0001). The proportion of days at full lab utilization increased from 7.7% to 77.3% (P < .00001) after implementation of the program, but there were no increases in overtime, night or weekend cases. Additionally, from 2013 to 2016, the number of full-time employees decreased from 36.1 to 29.6 and employee satisfaction, as assessed by Press Ganey surveys, improved.

Program details

Staffing bandwidth and communication were identified as areas for improvement. To resolve these issues, the program moved from a “block” nursing schedule to a “pyramid” structure. The implementation of a web-based electronic cath “white board” system, which replaced the physical board located in a central hallway, facilitated communication by providing decentralized, real-time notification of scheduling changes and where the patient was in the process that could be accessed from any computer. With the adoption of the electronic white board, room turnaround time was also reduced through “Project Scrub Broken,” an automated process that reduced lags in communication by immediately notifying staff after the physician scrubbed out that a patient was ready for transport and the room was ready to be cleaned.

Michael R. Massoomi

Physicians also increased communication regarding their start times by emailing staff the night before. Moreover, they were made aware of their own average start times, delays and case duration per type so they could schedule accordingly.

The program also introduced a central stocking location so that nurses would not be searching rooms for supplies and streamlined nursing documentation.

In an accompanying editorial, R. David Anderson, MD, and Michael R. Massoomi, MD, both from UF Health at the University of Florida, wrote that buy-in from all cath lab staff and the team approach were likely central to the program’s success.

“While some of the quality improvements studied by the authors may be applicable to many or most institutions, the concept of creating a team from those who deliver the care daily can certainly be universally applied,” Anderson and Massoomi, a Cardiology Today Next Gen Innovator, wrote. “Most or all institutions will have to come to terms with their own version of quality or process improvement. It is certainly more desirable that the stakeholders drive the process before an outside entity does it for us.” – by Melissa Foster

Disclosures: The authors report no relevant financial disclosures. Anderson reports he is a consultant for Biosense Webster. Massoomi reports no relevant financial disclosures.

A systematic, team-based approach to developing and implementing quality improvement initiatives may reduce cath lab inefficiencies and streamline processes, according to new data.

Operational inefficiencies are often seen in cath labs across institutions, but little data exist on how best to address these problems. To learn more, Grant W. Reed, MD, from the Heart and Vascular Institute at Cleveland Clinic, and colleagues developed and implemented a quality improvement program in their own cath lab and analyzed data on all elective and emergent procedures for 1 year before and 2 years after the program’s implementation in June 2014.

Reduced inefficiencies

For the program, a leadership team that included the physician cath lab director, nursing manager, nursing supervisors, department administrators and interested physicians created a process flowchart that followed each step of patient care. Using nursing records, electronic cath lab documentation and feedback forms, they identified areas where time lapse could be reduced, developed specific steps to address these issues and implemented changes using the plan-do-study-act (PDSA) cycles. The team also regularly assessed the changes’ effects on care using Shewhart control charts and additional steps were made over time.

Study efficiency endpoints included room turnaround time and lab utilization, and study productivity endpoints included the number of full-time employees and the proportion of shifts that were after hours, on weekends or overtime.

After implementation of the program, start times of cases improved an average of 17 minutes and the proportion of cases starting on time increased from 61.8% to 81.7% (P = .0024), which translated to an additional 136 minutes of potential productivity per day. The majority of cases could also be completed earlier in the day, according to the data.

Furthermore, room turnaround times decreased from 20.5 minutes to 16.4 minutes (P for trend < .0001). The proportion of days at full lab utilization increased from 7.7% to 77.3% (P < .00001) after implementation of the program, but there were no increases in overtime, night or weekend cases. Additionally, from 2013 to 2016, the number of full-time employees decreased from 36.1 to 29.6 and employee satisfaction, as assessed by Press Ganey surveys, improved.

Program details

Staffing bandwidth and communication were identified as areas for improvement. To resolve these issues, the program moved from a “block” nursing schedule to a “pyramid” structure. The implementation of a web-based electronic cath “white board” system, which replaced the physical board located in a central hallway, facilitated communication by providing decentralized, real-time notification of scheduling changes and where the patient was in the process that could be accessed from any computer. With the adoption of the electronic white board, room turnaround time was also reduced through “Project Scrub Broken,” an automated process that reduced lags in communication by immediately notifying staff after the physician scrubbed out that a patient was ready for transport and the room was ready to be cleaned.

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Michael R. Massoomi

Physicians also increased communication regarding their start times by emailing staff the night before. Moreover, they were made aware of their own average start times, delays and case duration per type so they could schedule accordingly.

The program also introduced a central stocking location so that nurses would not be searching rooms for supplies and streamlined nursing documentation.

In an accompanying editorial, R. David Anderson, MD, and Michael R. Massoomi, MD, both from UF Health at the University of Florida, wrote that buy-in from all cath lab staff and the team approach were likely central to the program’s success.

“While some of the quality improvements studied by the authors may be applicable to many or most institutions, the concept of creating a team from those who deliver the care daily can certainly be universally applied,” Anderson and Massoomi, a Cardiology Today Next Gen Innovator, wrote. “Most or all institutions will have to come to terms with their own version of quality or process improvement. It is certainly more desirable that the stakeholders drive the process before an outside entity does it for us.” – by Melissa Foster

Disclosures: The authors report no relevant financial disclosures. Anderson reports he is a consultant for Biosense Webster. Massoomi reports no relevant financial disclosures.