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.