Workflow in the Lab: Going from Stuck to Steady

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 - Gregory J. Mishkel, MD
Gregory J. Mishkel, MD

Nothing irritates cardiologists in cath and electrophysiology labs more than trip wires that bring workflow to an abrupt halt. Backups, bed shortages, AWOL equipment and interruptions can delay and disrupt procedures, undermine patient care and create waste. Many of these situations are avoidable, but sometimes, like it or not, slowdowns are necessary.  

The greater good

Gregory J. Mishkel, MD, executive medical director of the Prairie Heart Institute in Springfield, Ill., knew changing the process for documenting appropriateness would not be popular with cardiologists at their eight inpatient and two outpatient catheterization labs. He recognized putting electronic quality control processes in place likely would be perceived as a burden by some of the 15 interventional cardiologists and seven electrophysiologists who use the labs. And he acknowledged that in a facility that performs more than 7,000 procedures annually, making physicians adapt their work patterns might take a toll on efficiency, at least for a while.

But, in his words, this was mission-critical. Having the best intentions means little if the site is questioned and can’t substantiate that physicians provided high-quality care. Worst case scenario: audits, fines and maybe even time in prison.

“Clearly we don’t want to put impediments in front of physicians practicing productively,” he says. “The more you make people document appropriateness, potentially the more you will affect productivity.”

The challenge for Prairie Heart, which is housed at Hospital Sisters Health System’s flagship St. John’s medical center, was a disconnect between high-quality care and the ability to prove it. It is not that the facility lacked a system for documenting appropriateness of care. Physicians filled out a paper form at the end of each case with boxes they could check for indications. But that in itself was not enough.

“We did an audit and came to realize that we couldn’t find 80 percent of those forms in the hospital’s electronic medical record,” Mishkel recalls. The printouts were being scanned into an EMR but not consistently warehoused. “If we wanted to audit them, could we demonstrate to somebody that in fact we filled them out appropriately? That was the first tipoff that there was a workflow issue.”

To assess appropriateness, they looked at the published appropriate use criteria and other resources, settling on the Society for Cardiovascular Angiography and Intervention’s (SCAI) quality improvement toolkit. The toolkit can be integrated into electronic platforms, which allowed Prairie Heart to make the worksheet accessible at all points of care with the patient. They placed computers in every cath lab or viewing station and then decided to add wireless printers so physicians could use mobile devices and still be able to print out forms for archiving.

So far so good. Buying and installing a wireless printer took several months, though. “It is $150 but it turns out the hospital has a contract with Dell, so it has to be Dell and then it has to go through the IT people,” he says. “It has to have service agreements and it has to be hooked up to the network. It became extraordinarily complicated.”

Bureaucracy behind them, they set up a standardized and reviewable process that ensured they could document all points of contact between interventional cardiologists and patients. That now allows them to conduct ad-hoc random audits internally and be prepared if ever they face an external audit.

Not that all the doctors embraced the change, he admits. Integrating the documentation protocol into their existing workflow helped to diffuse dissent, though, since cardiologists already had to open the EMR for other functions. “We said, what is the big deal of opening up another screen, since every computer will have that SCAI form in it? We had pushback and grumbling,” Mishkel says. “Most people, even the ones who grumble, realize that it is like medicine: It is for your own good.”

Process improvement 

Some bumps in workflow may be inevitable as teams adjust and adapt to new technologies like EMRs. Some are just legacy processes that need to be re-examined and revised. As Tyrone Collins, MD, director of the cardiac cath lab at Ochsner Medical Center in New Orleans, and his managers see it, hard stops imposed on staff in the cath lab who failed to complete paper work created inefficiencies when they first switched to an EMR. But education and maybe a bit of tough love changed that.

“People know the patient is not going to get on the table until the paper work is done,” says Vico Marziale, who manages the cath labs for Ochsner’s main campus and multiple hospitals. “The paper work gets done.”

And then there are the bottlenecks that can slow workflow to a trickle. At Ochsner, it was outflow. At Prairie Heart, it was intake. Both required a retooling of existing processes that started with identifying obstacles and then changing a process.

Ochsner assigns a nurse, “a flight controller of sorts,” Collins says, to direct the transport of patients to and from the cath lab, among other duties. When the hospital is short of beds, the nurse ends up tending patients until a bed becomes available. In the meantime, he or she may be pulled away from intake duties, which can delay the start of cases. “If you add that on every front and back end of a case you can see that it significantly impacts on your efficiency,” Collins says, adding that it is his biggest headache.

He has been given some relief in the form of an escalation plan. Marziale’s team met with staff who handle resources to identify alternatives when the cardiac care unit is at capacity or facing turnaround delays. “Now they will look at the [post-anesthesia care unit] or the surgical [intensive care unit] as potential places to put these patients where they will be safer than a holding area in the cath lab,” Marziale says. One month into the system, the escalation plan is working “about half of the time.”

Parallel with Prairie Heart’s appropriateness initiative, St. John’s Hospital hired a process improvement specialist to help weed out systemic problems at the institute. Mishkel says they knew from Press Ganey patient satisfaction survey results that patients complained about redundant questioning, first at pre-admission and again at admission. They put the specialist on the task, who observed and listened as patients went through the process to find duplication and streamline the questioning.

“Within two weeks of doing this, we knocked 30 minutes off the average phone call of the pre-admission testing people when they called patients,” Mishkel says. “Now the clerks are more productive because they are putting patients through and patients are happier, their experience is better and there are fewer complaints.”

Process improvement can have benefits beyond physician and patient satisfaction. Inefficient equipment management and inventory control at Ochsner used to create another dam that potentially could jam up workflow, Collins recalls. About six years ago, Marziale hired Dale Clewis and tasked him to manage inventory at the cath labs.

“While our technologists were assigned certain products, there was no rhyme or reason as to when they were ordering or how much they were ordering and why,” Clewis recounts. They replaced that approach with one daily report showing products used the day before and another that signals when an item had dropped to a key level and needs replenishing. That helped keep inventory growth in check and allowed them to set yearly goals to reduce inventory further.

“The big kicker we found was having more control over expiring equipment,” Clewis says. “We were able to work with our vendors, replenishing material that was expiring and making sure we used material before it expired.”

The process has saved the hospital $200,000 annually for the past two years, money they then use to negotiate bulk buys with discounted prices. Beyond the financial success, consistently having supplies available has eliminated frustration and waiting time in the cath lab. “This is instrumental in us being able to improve our efficiency, not only in the flow of the case, but not being struck with something unavailable that you had last week,” Collins says.

Demands on EP labs

Electrophysiology labs share many of the same workflow challenges as cardiac cath labs, but they also differ in key ways. The field has matured over the past decade, shifting from what electrophysiologist E. Kevin Heist, MD, PhD, calls mom-and-pop operations to high-volume programs that no longer have to wait to use cath labs at off hours or during down times. Now programs may be more like his at Massachusetts General Hospital in Boston: a totally separate facility. And with that comes pressure to maximize efficiency and control costs.

Patient flow is more predictable in electrophysiology labs. “Cath labs operate a bit differently in the sense that they are used to dealing with urgent/emergent procedures: MIs and middle-of-the-night [procedures, among other things]. That is rarely the case in EP,” Heist says. Scheduling for complex cases requires finesse, though, because they can range between two and five hours. Go wrong on either side and you have staff idle or in overtime. To adjust for that, they perform complex cases early in the day and schedule the more predictable ones at the end of the day. 

Last year Heart Rhythm Society Consulting Services invited Heist and a handful of other physicians and lab directors to powwow about management practices and complete a benchmark survey. The eight participants identified workflow throughput and scheduling among key components in a well-run lab. Heist, who co-authored a summary of the meeting, says that sharing data on volumes and turnover times allowed him to put his own program in perspective.

“It was eye-opening to see what some of the facilities have been able to accomplish—things that have always been issues for us, like room turnover, maximizing efficiency of nursing staff, etc.,” he says. He has taken lessons learned from the other participants to refine workflow at his hospital and make scheduling more transparent and efficient.

With the appropriateness campaign a success with interventional cardiologists, Mishkel is now working with Prairie Heart’s electrophysiology leaders on quality metrics. As with the cath lab, he acknowledges that the change may add some burden, for instance, by finding processes to ensure accuracy of data entered into the National Cardiovascular Data Registry (NCDR). From experience, he knows that improper coding and not improper care often is the cause of what he calls metric creep.

“It is not because appropriateness has all of a sudden fallen off the wagon,” he says. More likely it boils down to a change in documentation or staffing that can then be corrected. “Ultimately, the most accurate way to do this is have the physicians fill in the NCDR database themselves for the hospital. Obviously, that is definitely going to be an impediment.”

The larger challenge is to develop a robust system that is still flexible enough to accommodate change, Heist says. But don’t then ignore it. “It is easy to get comfortable and think it is all fine,” he observes. “Unless you keep maintaining the system you created, it will start to have issues and failings; and then things change technologically, procedurally, the billing landscape, etc., and you won’t keep up with it.”   

Mishkel also warns to avoid complacence. Prairie Heart works on the assumption that all physicians put the patient first, and the documentation process then allows them to demonstrate the patient received quality care, he says. But it also can be an early flag if there is an issue with a physician or the hospital.

“You can get into a groove where you have the data plugged in and it is getting cranked out,” he says. “But you always have to monitor those metrics and you have to be alerted to when there is a problem. One day it may come up that it is not a documentation problem. You may actually have a quality problem.”