Author + information
- Received July 11, 2017
- Revision received September 5, 2017
- Accepted September 11, 2017
- Published online February 19, 2018.
- Grant W. Reed, MD, MSc,
- Scott Hantz, RN, MBA,
- Rebecca Cunningham, BSN, RN,
- Amar Krishnaswamy, MD,
- Stephen G. Ellis, MD,
- Umesh Khot, MD,
- Joe Rak, MBA and
- Samir R. Kapadia, MD∗ ()
- Heart and Vascular Institute, Department of Cardiovascular Medicine, Cleveland Clinic, Cleveland, Ohio
- ↵∗Address for correspondence:
Dr. Samir R. Kapadia, Heart and Vascular Institute, Cleveland Clinic, 9500 Euclid Avenue, Desk J2-3, Cleveland, Ohio 44195.
Objectives This study sought to report outcomes from an efficiency improvement project in a large cardiac cath lab.
Background Operational inefficiencies are common in the cath lab, yet solutions are challenging. A detailed report describing and providing solutions for these inefficiencies may be valuable in guiding improvements in productivity.
Methods In this observational study, the authors report metrics of efficiency before and after a cath lab quality improvement program in June 2014. Main outcomes included lab room start times, room turnaround times, laboratory use, and employee satisfaction. Time series analysis was used to assess trend over time. Chi-square testing and analysis of variance were used to assess change before and after the initiative.
Results The principal changes included implementation of a pyramidal nursing schedule, increased use of an electronic scheduling system, and increased utilization of a preparation and recovery area. Comparing before with after the program, start times improved an average of 17 min, and on-time starts improved from 61.8% to 81.7% (p = 0.0024). Turnaround times improved from 20.5 min to 16.4 min (trend p < 0.0001), and the proportion of days at full lab utilization improved from 7.7% to 77.3% (p < 0.00001). There were no increases in overtime, night, or weekend cases. There was a reduction in full time employees from 36.1 in 2013 to 29.6 in 2016, with an improvement in employee satisfaction.
Conclusions A systematic approach to reducing inefficiencies can improve cath lab start times, turnaround times, and overall productivity. This knowledge may be helpful in assisting other cath labs in similar efficiency improvement initiatives.
Providers are facing tremendous pressure to maximize value by improving patient outcomes while minimizing cost across all aspects of health care in today’s economic climate. Key to realizing these goals is identifying and eliminating operational inefficiencies (1), which may be due to redundancies or impediments in direct medical service delivery, whereas others may be logistical or administrative in nature (2). Identification of these inefficiencies can fuel targeted operational improvement initiatives (3), and is best achieved through studying and making incremental changes to delivery processes at a systems level.
The cardiac cath lab is particularly prone to operational inefficiencies as it is typically a complex, fast-paced, procedural environment. Identification and elimination of inefficiencies may allow for improved productivity (1), which could help offset recent declines in reimbursement for cardiac catheterization and percutaneous coronary intervention (PCI) (4), and improve satisfaction for patients and health care providers. However, there is heterogeneity in how modern cath labs are operated across institutions, and metrics of efficiency in cath lab operations are not standardized. Indeed, public reports of successful quality improvement initiatives in the cath lab setting have been scarce to date. Such a report could serve as a valuable example to guide meaningful changes and improve efficiency in cath labs across various institutions. As most labs have quality assessment processes in place, this would be especially relevant and applicable to labs seeking process improvement.
With this understanding, we conducted a quality improvement program to identify the operational inefficiencies in our large, quaternary care center cath lab, with the intent of reporting our results broadly. We report specific metrics of operational efficiency before and after system-based changes that we describe in detail, in an effort to demonstrate and quantify the improvements in efficiency we have realized with a systematic approach to quality improvement.
The program start date was June 1, 2014. All elective and urgent procedures were analyzed for 1 year before and 2 years after the start date (May 1, 2013 to April 31, 2016). Diagnostic coronary angiograms, PCI procedures, right heart catheterizations, myocardial biopsies, peripheral vascular interventions, and structural heart interventions were included. Emergent cases including primary PCI for ST-segment myocardial infarction were excluded as these cases follow a separate, unique workflow. The cath lab at our institution is a closed lab with 10 cath lab rooms, accommodating a single physician practice of approximately 20 hospital employed physicians (interventional or invasive, diagnostic, heart failure, and electrophysiology cardiologists). The study was approved by the institutional review board.
Efficiency improvement program
The first step was to establish a program leadership team consisting of the physician cath lab director, nursing manager, nursing supervisors, department administrators, and interested physicians that studied the workflow in the cath lab by creating a process flowchart mapping every step in the continuity of a typical patient’s care (Figure 1). The goals were to completely understand the patient, technologist, nurse, and physician duties in a usual case, document all material and information flows, determine time elapsed at each step, and identify potential bottlenecks and sources of redundancy.
Nursing staff was required to time stamp each step in the delivery process, fill out feedback forms if room turn around time was >22 min or if there were issues they felt were impeding care delivery, and comment on improvements that could be made. Timestamps for each component of the delivery process were then collected via review of nursing records and the electronic cath lab documentation system. This, in combination with the feedback forms allowed for granularity in determining which steps in the care delivery process could be targeted for reducing time lapse and thus improving efficiency. The leadership team then performed an exhaustive review of the workflow process and identified several specific steps where systematic inefficiencies existed using root cause analysis and the feedback forms. Changes to the cath lab delivery process were then implemented via Plan Do Study Act cycles, and the team met weekly to assess whether these changes were having desirable effects on workflow with the use of Shewhart control charts, as these are commonly used tools in quality improvement methodology (5,6). Additional changes were made in an iterative, step-wise fashion over time while evaluating the key metrics of efficiency described below. Physicians, nurses, and support staff were given feedback once a month during this process improvement project.
Study efficiency endpoints included room start time, the duration of time between cases (room “turnaround time”), and lab room utilization (Table 1). Study productivity endpoints included the number of full-time employees (FTEs), and the proportion of shifts that were after hours, on weekends, or overtime. To determine the effect of these changes on employee satisfaction, Press Ganey surveys were conducted at time points before and 1 year after most changes had been made. These goals were established based on what would constitute a meaningful improvement based on historical trends in our institution.
All study endpoints were assessed chronologically on a both monthly and yearly basis to evaluate trends over time, as well as before and after the program start date of June 1, 2014. Continuous outcomes are reported as mean ± SD, and categorical endpoints are presented as proportions. Time series analyses utilizing regression modeling were performed to assess trend in outcomes over time. In addition, 2-way analysis of variance and 2-sample chi-square testing for equality of proportions with continuity correction were used to determine whether the differences were significantly different before and after the program start date, where appropriate. Statistical significance was determined as p < 0.05. All statistical analyses were performed using R version 3.3.2 (R Project for Statistical Computing, Vienna, Austria).
Cath lab workflow
The cath lab workflow process is described in Figure 1. The major operational inefficiencies identified and the changes made to address these issues are described in detail subsequently, and summarized in Table 2.
Inefficiencies in case scheduling
Case volume averaged 48.1 ± 4.5 cases/day distributed across 8 possible rooms, totaling 731.0 ± 50.4 cases/month after accounting for lab closures (Figure 2). The trend of case volume did not significantly vary over the years. Before any changes, the lab functioned on a “block” schedule, whereby 4 to 5 rooms were open between 7:30 am and 7:00 pm. By rearranging the nursing schedule, resources could be redirected to allow for more cases to be completed earlier and avoid late cases. The schedule was thus changed from a “block” to a “pyramid” structure, in which 7 to 8 rooms were opened at 7:30 am and 3:30 pm, afterward only 1 to 2 rooms remained open until 7:30 pm, and between 7:30 pm and 7:30 am a single nursing team was available to finish late cases and for acute cases if needed. With this change, approximately 80% of cases could be completed by 3:30 pm, allowing a greater number of urgent and add-on cases to be completed earlier in the day.
Room starting times
The average room start time at the beginning of the program was 7:58 am, with only 63.9% of cases starting at the on time goal of 7:45 am (Table 3, Figure 3). Start times improved over the course of the study, with 89.1% of rooms starting on time in 2015, and 88.8% rooms on time in 2016 (trend p = 0.190). Before start of the program (before June 2014), the average start time was 7:59 am, with only 61.8% on-time starts, whereas after the changes the average start time was at goal of 7:42 am, with 81.7% on-time starts (p = 0.0024). This gain of 17 min per room across 8 rooms allowed for 136 min (2.3 h) of additional potential productivity per day.
The main reasons for start time delays were discerned to be a lack of nursing resources early in the day and communication issues between the preparation area and the cath lab teams. Nursing staff bandwidth limitations were addressed by the pyramidal scheduling structure (described previously). Communication issues were addressed by 2 major changes:
Electronic cath “white board” system
Traditionally, cases were scheduled on a physical board that served as a central terminal for all workers, located in the cath lab hallway. This relied on physically viewing this board or verbal communication to follow the daily schedule. To address this, this physical board was replaced with an electronic “white board” (Siemens Healthcare, Erlangen, Germany). This web-based interface allows for decentralized, real-time notification of patient arrival, when prep is complete, when cases are finished and transport is needed, and scheduling changes. It can be viewed on any computer, and is displayed in each room, thus enhancing and speeding up communication for all workers. This not only contributed to improved start times, but also reduced time spent transitioning between several steps in the delivery process (further described subsequently).
Physician start time and case duration notification
To improve knowledge of each operator’s schedule, every physician was asked of his or her start time the day before. An email was sent out to the entire department and the electronic whiteboard updated the night before with the start times included. To promote timely arrival of staff to their cases, the staff cardiologist was paged within 5 min of patient arrival. If the physician was unable to start the case within 15 min of the planned start time (or within 30 min if in an unavoidable meeting), it was his or her responsibility to find another physician to do the case or risk losing the preference to start early the next time they were in the lab. In addition, physicians were made aware of their average start times, delays, and case duration per type of case to facilitate avoiding scheduling several long cases in any given day.
Room turnaround times
Room turnaround times were routinely above the goal of <17 min, however significantly improved over time (trend p < 0.0001) (Table 3, Figure 4). Illustrating this, before the start of the program in June 2014, the average room turnaround time was 20.6 ± 0.8 min, which improved to 17.1 ± 1.8 min after the program (p = 0.044). Turnaround time improved further to 16.4 ± 1.0 min in 2016. This gain of 3.5 to 4.1 min per case, averaging 48 cases per day, amounted to a gain of 168 to 196.8 min (2.8 to 3.3 h) of added potential productivity each day. The key changes implemented to realize these gains were as follows:
“Project Scrub Broken”
In cases of a turnaround time >22 min, nurses were required to fill out a form explaining why. The most common reasons were delays in the patient preparation and recovery area, usually in obtaining consent, placing intravenous access, and patient use of the restroom. In addition, there were often lags in communication from the cath lab nurses that the room was clean, and from the prep/recovery nurses that the next patient was ready. This process was automated in an initiative called “Project Scrub Broken” once the electronic whiteboard was adopted. In this project, the moment the physician scrubbed out of the “current” case, the charge nurse prompted the case to turn red on the electronic whiteboard. This visually notified custodial staff to clean the room, the transport team to move the patient out of the room, and the preparation and recovery area to finish preparing the next patient. This decreased the need for verbal communication, and sped up overall communication between the cath lab and preparation and recovery areas.
Patient transfer process
Common reasons for delays in patient transport were final destination beds not being available on the floor, delays in nurse-to-nurse verbal report, and nursing shift changes. To address this, nursing duties were clearly defined such that among the 3 nurses (or 2 nurses and 1 tech) assigned to a room, 1 would get the new patient, 1 would transport the old patient, and the other would assist with room turnover. Manual sheath pulls in the cath lab were eliminated except in special circumstances (reduced to 3% to 5% of cases/month). If the final destination room for the patient was not yet available, the patient was transported to wait in the preparation and recovery area rather than kept in the cath lab room (except if going to an intensive care unit). In addition, the implementation of the electronic whiteboard allowed for patients’ locations to be tracked, and if there were delays in the availability of transport staff to bring a hospital inpatient to the lab, it became the responsibility of a lab nurse to assist in physically transporting the patient. Further, there were delays in nurses stocking rooms between cases, and at times needing to search between rooms for supplies during cases. This was addressed by utilizing a central supply room with a mobile cart in each room with frequently used supplies to reduce time spent looking for supplies.
Lab room utilization
Cath lab room utilization was calculated as the ratio of the number of hours staffed to the number of hours utilized, excluding weekend cases and cases beginning after the lab’s end time, after adjusting for room closures. A turnaround time of 18 min was added for each case (25 min were added before January 2015 before we realized our gains). Room utilization improved from 2013 to 2016 (Table 3) (p for trend = 0.177). Illustrating this, daily room utilization was 91.1 ± 9.1% before the start of the program in June 2014, and increased to 105.5 ± 6.9% afterward (p < 0.0001) (it was possible for utilization to be >100% if the number of cases performed was more than the maximum expected given the staffing hours available). Further, the proportion of days in which the entire lab was operating at full utilization capacity improved from 7.7% to 77.3% comparing before to after the start of the program (p < 0.00001).
Productivity per FTE
In 2013, the number of FTEs was 36.1, which was reduced to 29.6 by 2016. There was no significant change in case volume of the number of physician operators in the lab over this time. No staff were terminated; rather, a small number were not replaced after turnover occurred. This lower nursing FTE versus cath lab volume ratio indicated that despite a reduction in 6.5 FTEs, productivity and efficiency increased with the changes made over this time.
After hours cases, weekend cases, and overtime hours
There was no discernable difference in the number of cases started after hours over the years (p for trend = 0.431), or before or after the program (1.67% vs. 1.84% of shifts; p = 0.927) (Figure 2). There was also no change in our ability to accommodate emergency cases. Similarly, there was no difference in the number of cases worked on the weekend over the years (trend p = 0.148), or before or after the program (1.81% vs. 2.00%; p = 0.922) (Figure 2). The proportion of hours that were overtime did not increase as a result of the program (4.7% in 2013, 5.1% in 2015, 3.9% in 2015, and 3.8% in 2016; trend p = 0.341; p = 0.812 before and after the program).
The effects on cath lab nursing and support staff employee experience were quantified by Press Ganey surveys before and after program (Table 4). Employees were surveyed on their level of engagement, perception of action planning readiness, workplace safety, managerial effectiveness, and overall satisfaction. Among managers at our institution, a change of 0.20 is generally considered meaningful in any category, or 10 points in action planning readiness. Overall, the program had a positive effect on each aspect of the employee experience, resulting in a meaningful improvement in overall employee satisfaction.
In this study, we demonstrate that a systematic approach to quality improvement in the cath lab can reduce operational inefficiencies and streamline workflow processes. Through targeted process improvement, we saw an increase in the proportion of cases starting on time, a reduction in room turnaround time, and an increase in lab utilization. In addition, we were able to realign nursing resources and reduce the number of FTEs while maintaining the same case volume and without increasing the proportion of weekend, after-hours, or overtime shifts. In total, our changes lead to a gain of approximately 5.1 to 5.6 h/day in lab utilization due to improved start times and reduced turnaround times. Further, there were improvements in all measured aspects of employee experience including employee satisfaction. Our experience may serve as an example to other institutions that process improvement initiatives such as ours can lead to significant efficiency gains in the cath lab.
Operational efficiency is a core competency of a successful business, yet a more challenging concept to apply to the cath lab given the many components involved in every episode of care. To minimize input and maximize productivity in the most effective means, we studied the variables that influence efficiency of cath lab care (Figure 5). The changes with the most impact on efficiency seemed to be switching from a block to a pyramidal nurse staffing system to address scheduling inefficiencies, instituting an electronic whiteboard to decentralize communication between caregivers, and reducing barriers to patient transfer through increased utilization of a preparation and recovery “holding” area. In our experience, human resource management by promoting a culture of continual improvement and teamwork where each caregiver is appreciated and constructive feedback embraced was essential to realizing our goals and fostering employee “buy-in” to the changes implemented (7). We did not use incentives; however, this may be another option to encourage provider participation in quality initiatives. Further, although most often applied to patient outcomes, internal peer review may be a valuable tool in improving operator efficiency (8).
To the best of our knowledge, this is one of the first and most comprehensive reports of a quality improvement initiative in a large cath lab made publically available to date. Although not a project focused on quality of care, the term quality improvement project is often used to describe projects such as ours focused on improving efficiency and systems of care. The only other report of a similar quality improvement initiative in a cath lab was previously published by our group, evaluating a narrower set of metrics from 2009 to 2012 (2,9). Institutions should be encouraged to study their own care delivery processes, individualize specific productivity goals, and be encouraged to share details on their cath lab operations and efficiency improvement initiatives so others can learn from them. This may also allow for comparison and standardization of delivery metrics in lab operations (such as turnaround time) across hospitals and various care models. Although our project focused on improving the efficiency of cardiac, peripheral, and structural procedures, the changes outlined in our study could be applied to improve the delivery of any procedure provided in the cath lab, including electrophysiology, aortic endovascular, and interventional radiology procedures. We plan to continue this initiative and find ways to expand it to other service lines in the future.
A philosophy of problem solving, teamwork, and leadership can lead to gains in efficiency and patient satisfaction, which define operational excellence (10). Although gains in efficiency are key to streamlining care delivery processes, operational excellence in the cath lab can only truly be realized after efficiency is maximized, after which focused attention can be placed on each patient’s overall experience, maximizing patient satisfaction, keeping employees empowered and attitudes positive, and embracing a culture of continuous improvement. An efficient organization can better focus on the needs of each patient during each episode of care in the cath lab, which in turn can help maximize each patient’s cath lab experience and satisfaction.
The Affordable Care Act and Medicare Access and CHIP Reauthorization Act are moving toward a reality in which the majority of cardiovascular care will be reimbursed through alternative payment models that emphasize quality over quantity of care, such as bundled payments (11,12). In a bundled payments environment, the onus will be on the hospital and provider to use a fixed amount of resources to complete a given case, and thus reducing costs and utilizing resources as effectively and efficiently as possible will be paramount. It is with this realization that quality improvement projects such as this one are essential to maintaining the financial health of providers and institutions.
This project was conducted in a large, quaternary care center cath lab and thus results may not be generalizable to smaller institutions. That said, the outcomes we assessed (i.e., lab turnover time and start time) are common problems at many institutions, and thus relatable to cath labs of all sizes. Although the changes implemented had no negative effect on patient care, patient outcomes were not assessed as a part of this study. We acknowledge that some of the changes we implemented required capital investment, modest monetary investment, and flexibility from our hospital administration, which may not be available at all centers. The pyramidal nursing schedule we introduced did require several labs and availability of more staff earlier in the day, however, could be adopted to labs of smaller sizes as well. In addition, we were unable to determine the effect of our project on overall cost; however, this is less relevant, as cost will vary from institution to institution, and we have demonstrated improved productivity with the changes we made, which should have a positive effect on overall cost. Indeed, project cost may be counterbalanced by the cost savings obtained by realizing operational efficiencies. Further, it is difficult to fully discern which changes had what effect on efficiency as several changes were made at once; we can only say that all of these changes together allowed for the gains in efficiency we have seen.
A systematic approach to process improvement can reduce operational inefficiencies in the cath lab. Through a stepwise implementation of specific changes over a 3-year period, we have realized improved cath lab start times, reduced turnaround times, increased overall productivity, and an improvement in employee satisfaction. Knowledge of our experience may be helpful in guiding other cath labs in similar quality improvement initiatives toward realizing operational excellence.
WHAT IS KNOWN? Operational inefficiencies are common in the cardiac cath lab, yet solutions for these issues are challenging.
WHAT IS NEW? We show that a systematic, team-based approach to quality improvement can lead to improved room start times, turnover times, and utilization with increased employee satisfaction. The principle changes implemented included use of a pyramidal nursing schedule, an electronic scheduling system, and a preparation and recovery area to increase efficiency.
WHAT IS NEXT? There is a need for cardiac cath labs to publish results from quality improvement initiatives to guide improvements in efficiency and productivity across institutions.
The authors would like to acknowledge the nurses, technologists, and support staff of the Cleveland Clinic Sones Catheterization Laboratories for their hard work and tremendous commitment to excellent patient care every day.
Dr. Khot is a consultant for AstraZeneca. All other authors have reported that they have no relationships relevant to the contents of this paper to disclose.
- Abbreviations and Acronyms
- percutaneous coronary intervention
- full-time employee
- Received July 11, 2017.
- Revision received September 5, 2017.
- Accepted September 11, 2017.
- 2018 American College of Cardiology Foundation
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