Optimizing your cath lab activity levels
Seven deadly sins in cath lab operations management
Dit artikel is in 2017 verschenen in Cathlab Digest, Amerikaans vakblad voor Cardiologen.
This article describes seven deadly sins related to Cath Lab operations management. Many Cath Labs globally suffer from most of these sins. For a medium-sized Cath Lab with four procedure rooms, the yearly potential loss is equivalent to 2,400 cases per year. Fixing these shortcomings result in a higher Cath Lab utilization, lower operating costs and ultimately higher activity levels and an increased revenue.
Historically, the Cath Lab has always been the domain of the Cardiologist. Until recently, attention to Cath Lab efficiency was limited. With healthcare costs rising and budgets being cut worldwide, the focus of Cath Lab operations management has shifted towards improving efficiency and not just clinical outcomes. A key driver is to either be able to deliver more cases with the same amount of resources, or to do the same number of cases with fewer resources. In Table 1 the three most important Key Performance Indicators (KPIs) related to Cath Lab efficiency (and indirectly to activity levels as well) are given. For the average Cath Lab, there is usually a lot of improvement potential. By increasing productivity and utilization and by decreasing the overall procedure time, the number of cases done within the same amount of time and with the same amount of staff can grow significantly. This also creates additional revenue opportunity for the hospital.
As already mentioned in Teulings2015, the primary focus in the Cath Lab is on clinical performance, and therefore planning of cases, staff, rooms and beds is typically handled by non-specialized staff. Due to the complexity in the Cardiology domain many common Hospital Information Systems (HIS) do not fully support the Cardiology patient care trajectory. For example, they may be unable to support the following: (1) a diagnostic procedure can precede the actual procedure; (2) new patients are distributed over Cardiology and Cardio-Thoracic surgery; (3) complex medical decision making takes place in multi-disciplinary meetings; and (4) the Cardiology environment is highly technological and material and equipment intensive. As a result, Cardiology departments and heart centers tend to run their own Cardiovascular Information Systems (CVIS). These CVISs usually do a good job in supporting the medical decision-making process, however the planning & scheduling components are minimal, resulting in manual processes, limited performance measurement and ample room for improvement efforts.
This article identifies seven deadly sins in Cath Lab operations management and suggests ways to improve. By eliminating these sins, the best-in-class figures as given in Table 1 can be attained.
Deadly Sin 1: Absence of a Well-Defined Planning and Scheduling Process
Within planning & scheduling, three different levels can be distinguished, namely strategic planning, tactical planning and operational scheduling. Each level has its own planning horizon. Table 2 summarizes the characteristics of the three planning levels (based on Hulshof2012). In a well-defined planning & scheduling process, sufficient attention is paid to all levels and the planning & scheduling process follows a yearly cycle (see Figure 2).
Deadly Sin 2: Only Clinical Information is Captured in the HIS/CVIS
Next to the clinical monitoring of the procedure and the patient, the patient preparation process and patient flow on the day of the procedure is also captured in the HIS/CVIS. Communication of real-time procedure schedules helps all concerned parties stay informed regard-ing the status of procedures in process, and keeps the catheterization sched-ule transparent for improved physician relations.3
Deadly Sin 3: Poor Patient Preparation
The first step to the actual cath lab procedure is the patient preparation. In a well-organized patient preparation pro-cess, a timeline exists where all required steps in this process, their chronological relationships (if any), responsible health-care provider(s), and required timespan are all defined.
The process is supported by the HIS/CVIS, keeping track of the progress of all preparation activities, and pushing alert messages to the planner and re-sponsible healthcare providers if a delay occurs. Patients can only be put onto the actual cath lab planning if all the required preparation tasks have been completed. The patients’ complex-ity can be characterized by the Pareto principle, where approximately 20% of patients account for 80% of preparation work. Separating the low- from the high-complexity patient flows allows for a faster work-up of the first catego-ry, while providing tailored preparation for the latter category.
Deadly Sin 4: Cardiologists’ Schedules Include Only ½ Days or Less in the Cath Lab
A pre-condition for high cath lab ef-ficiency is that cardiologists are present in the cath lab all day. Increase or de-crease in the length of the morning cath lab shift can then easily be accounted for in the afternoon shift, since it is car-ried out by the same physician, thus introducing more flexibility in online case and staff planning. In the electro-physiology domain, it is quite common to work for an entire day in the electro-physiology lab, due to the usually long (2-4 hours) duration of the procedures. In some labs, however, interventional cardiologists tend to work only morn-ing or afternoon shifts in the cath lab, while having other obligations (outpa-tient clinic, teaching) for the other half of the day.
In an average cath lab, it is evident that there is huge improvement potential. The focus on operational excellence through addressing the ‘seven deadly sins’ described in this article can allow teams to perform up to 50% more procedures with the same level of resources.
Deadly Sin 5: Infrastructure Does Not Support Patient Flow
In an ideal world, the hospital infra-structure in and around the cath lab sup-ports patient flow. There is an adequately staffed patient preparation (‘holding’)/recovery area in or near to the cath lab. In this area, patients can be prepped, monitored pre- and post- procedure, and await transport to the nursing wards after their procedure. For day surgery patients, the best practice is to co-locate an outpatient unit near the cath lab to reduce patient transport re-quirements. Within the cath lab, patient, staff and material flow are separated as much as possible. The corridors are wide, to allow for easy bed and material handling. The cath lab has a clear entry, equipped with a reception desk or an automated access management system, thus preventing patients, relatives, carers and non-cath lab staff from entering the clinical area. The rooms are spacious, easy to clean, and efforts have been made to reduce noise. All common quality and safety regulations are in place.
Deadly Sin 6: No Daily Coordinator Role in the Team
During the day, the progress of the cath lab program is closely monitored by a team member. This is (for facilities with four labs or more) a dedicated role, fo-cusing on starting on time, scheduling of emergency and semi-urgent cases within the elective program, eliminating delay between two consecutive cases, finishing the cath lab program on time, and deal-ing with unforeseen circumstances. The coordinator role may alternate between team members, but it needs a clear man-date, and clearly structured roles and re-sponsibilities within the cath lab.
Deadly Sin 7: Unclear Division of Roles Between Cath Lab Nursing and Support Staff
There is a clear division of roles, based on patient demand and the skill set of nursing staff. All non-clinical work is done by dedicated support staff, including case and staff scheduling. Since recruiting cath lab nurses is becoming a bigger chal-lenge every day, this is very important.
In an average cath lab, it is evident that there is huge improvement potential. The focus on operational excellence through addressing the ‘seven deadly sins’ de-scribed in this article can allow teams to perform up to 50% more procedures with the same level of resources. When a cath lab team gets this right, there is also an add-on effect, delivering improvements in patient safety and clinical quality of care. When the operational running of an area is smooth, clinical staff are freed up to focus on delivering outstanding care to their patients.
1. Teulings MF. Seven deadly sins in cath lab material management. Cath Lab Digest. 2015; 23(9). Available online at: http://www.cathlabdigest.com/article/Seven-Deadly-Sins-Cath-Lab-Material-Management. Accessed April 29, 2017.
2. Hulshof PJH, Kortbeek N, Boucherie RJ, et al. Taxonomic classification of planning decisions in health care: a structured re-view of the state of the art in OR/MS. Health Systems. 2012; 1(2): 129-175.
3. Regas P. Cath lab scheduling: making the move to electronic remote display systems. Cath Lab Digest. 2008; 16(10). Available online at http://www.cathlabdigest.com/articles/Cath-Lab-Scheduling-Making-Move-Electronic-Remote-Display-Systems. Accessed April 29, 2017.
- Absence of a well-defined planning & scheduling process
- Only clinical information is captured in the HIS/CVIS
- Poor patient preparation
- Cardiologists’ job plans are only ½ days or less in the Cath Lab
- Infrastructure does not support patient flow
- No daily coordinator role in the team
- Unclear division of roles & responsibilities between Cath Lab nursing and support staff
Symptoms of Sin 1
- Focus is exclusively on the operational planning level
- Cath lab time is not distributed optimally over the patient mix
- Long wait list and access times for certain procedures; simultaneously unused cath lab capacity for other procedures due to a lack of patients
- No clustering of procedures
- Not allocating (sufficient) time to (semi-) urgent and inpatients; urgent cases come as a surprise
- Disruptions, chaos and elective patient cancellations, high levels of firefighting
- Inefficient use of cath lab time (utilization <70%)
- Storage locations far from labs
Symptoms of Sin 2
- Difficult and time-consuming for planner to obtain an overview of all patients on the waiting list and their current status
- No overview during the day on the progress of procedures and pos-sible delays
- Difficult to fit in emergency and semi-urgent patients
- Planning and scheduling is a time-consuming process, involving a lot of ad hoc activities and (too) many stakeholders
- Use of paper records, agendas or calendars, excel sheets, word doc-uments, and stand-alone tools
- Issues with document ownership and keeping track of changes within documents
- Patient records need to be manually entered into other IT systems
- Lack of management information to monitor patient flow, production, etc.
Symptoms of Sin 3
- Non-adherence to medical protocols• Quality and safety issues
- Patients arriving at the cath lab not correctly prepared for the procedure
- Unavailability of material and devices
- Last-minute (in-lab) patient cancellations
- Last-minute changes in planning
- Low patient satisfaction
Symptoms of Sin 4
- Introduction of a second start-up moment around noon and thus additional delay
- Limited possibility to switch patients between the morning and after-noon shifts or vice versa, due to planning inflexibility and differences in physician skills
- Extremely long changeover times (1-2 hours) between the last morn-ing patient and first afternoon patient
- An average of 1-2 cases lost per room per day
- Low cath lab utilization (<70%)
Symptoms of Sin 5
- Waiting for patient transport to and from the cath lab
- Delay in patient transport due to waiting for elevators
- Long distance to between the cath lab and wards, including CCU/ICU
- Cath lab nursing staff need to monitor patients before and after the procedure
- Limited number of patients (<50%) in outpatient procedure program
- Conflicting patient, staff and material flow; small corridors and rooms which are difficult to clean, leading to quality and safety risks
- Delay in the cath lab program due to waiting for patients to arrive
Symptoms of Sin 6
- Late starts
- Long changeover times
- Complicated decision-making processes, especially where last-minute changes in the program are required, for example, due to emergency patients being admitted
- Staff regularly work overtime
- Many of the last cases of the day are cancelled, resulting in early finishes
- Rescheduling of elective cases
- Difficult to accommodate emergency and urgent patients
- The coffee/break room has a higher utilization than the cath labs
- Working in overtime in one lab and an early ending in another lab at the same time
- Absence of a single contact point for hospital staff within and outside the cath lab
Symptoms of Sin 7
- Cath lab nurses are also responsible for materials management, case scheduling, staff scheduling, cleaning, etc.
- Team member with coordinator role is also scheduled as procedure nurse
- The cath lab is overstaffed, but at the same time, cases cannot be scheduled due to a lack of nursing staff with the right skill set