Outsourcing Is In: Developing & Integrating Cath Lab Best Practices & Standardization

Sometimes a move in the right direction starts with a good hard look in the rearview mirror, then breaking it off to start anew with greater wisdom.

That’s the strategy of the Cardiovascular Service Line within Ascension Wisconsin. Like other interventional programs across the country, the CVSL is realizing industry partners play a key role in helping to share, develop and implement practices that seek to reduce variance, improve quality, increase operational efficiency, establish new standards of care and eventually reduce costs.

Spearheading the effort is VP of the Cardiovascular Service Line Suzette Jaskie, MBA, who took the helm nine months ago. As she says, “Offering the best care starts with having the best practices.”

Jaskie knows strategy well as an MBA in strategic planning with many years of experience in the CV world leading, managing and advancing cardiovascular programs within health systems, consulting groups and commercial vendors.

Ascension Wisconsin’s CVSL is already a top performer. But Jaskie wants to transform and elevate it, taking a page from business guru Peter Drucker’s book: while it’s management’s role to do things right, it’s leadership’s role to do the right things.

The right things for Ascension Wisconsin are to measure and establish a baseline in their cath labs in partnership with Terumo’s practice consulting arm, Terumo Business Edge, and commit to a plan to make and implement improvements one project at a time. Terumo brings to the table its global experience in transradial solutions, offering tools and processes to deliver higher quality care, increase patient and staff satisfaction, and optimize operational outcomes.

This alliance is part of an increasingly popular trend that allows the transference of knowledge and practices from many health systems via the advisory services of vendor partners. Jaskie and her team are benefitting from a skilled team they trust that brings a bigger picture perspective paired with a drill-down into their own data. The goal is to establish a system approach to quality and process across their cath labs.

“We went into this to develop and implement better practices and a system approach to quality, standards and operational efficiency,” Jaskie says. “The patient is first in all of this; he or she is our catalyst. That’s why we’re doing this. Eventually it will become part of the way we operate.”

As she points out, quality performance “is often relegated to the quality department in our old-fashioned way of thinking. That’s not effective. Administrators have a role in leading the development of the platform and culture. It’s imperative that people are getting better every day.”

Planning the ascent

The Cardiovascular Service Line Jaskie runs sits within Ascension Wisconsin, a health system within a health system as part of Ascension, one of the country’s leading non-profit and Catholic health systems. Ascension operates more than 2,600 sites of care—including 151 hospitals and more than 50 senior living facilities—in 21 states and the District of Columbia. The ministries are divided and managed by state. Ascension Wisconsin’s 26 hospitals are concentrated in Milwaukee and across the southeastern part of the state. A dozen of the hospitals have cath labs, while seven perform open heart surgeries.

Ascension Wisconsin is comprised of four formerly independent health systems that became part of Ascension in 2016. Those systems used to do everything themselves, differently, Jaskie explains, which illuminates some of the challenges in putting together a comprehensive and consistent approach to cardiovascular services. All of the cath labs operated independently of each other, even within systems. Clinical IT systems, EMRs and billing were all different too.

Being the new captain, Jaskie wanted to establish a baseline to measure and know where the team was starting from. “We knew we needed to start measuring if we ever wanted to get where we need to be,” she says.

To measure, administrators provided preliminary data around quality, operations and costs ahead of onsite visits at three cath labs. Terumo analyzed the data and went onsite for a week of observing, interviewing and interacting. They walked a patient path from registration through to the end of a procedure. They watched procedures and interviewed a lot of staff, physicians and administrators. Terumo prepared a customized report out around best practices with a focus on key quality metrics. Then they shared feedback with all those involved, including Jaskie. A readout meeting offered a big picture view of the three sites.

What did they learn? Far more than they expected. As Jaskie says, “When you bring in an independent, knowledgeable consultant with fresh eyes, two things happen. They apply their incredible experience and knowledge and immediately see things that are good and others that need to be addressed. Second is their ability to get honest feedback from staff to a degree we as a health system could never achieve internally. Staff are willing to share more when there is that independence. We need to know, truthfully, how satisfying is it to work here? What are your challenges? What concerns you? Having that freedom for staff to give honest feedback enables us to make changes to make things better.”

Feedback showed there was lingering apprehension in the culture around the integration of the four systems and the impact on the workforce. Performance around their registries also was less than they’d hoped. Issues with process and variability and lack of standardization of care by physicians surfaced. Missing data and lags in data flow became evident too, causing bottlenecks from office locations into the hospital. 

A closer look at door-to-balloon times showed they weren’t where they wanted to be on that score either. “Even though the standard is under 90 minutes, which all of our sites meet, they benchmarked at a low rate,” Jaskie explains. “That was a big shocker. If you’re not getting better, you’re getting worse. When you’re at 70 minutes, as anexample, you’re at something like the 10th percentile, even though you’re performing above the standard. That was very eye-opening for our group.”

The Ascension Wisconsin team further discovered they were overtreating outpatients with a level of nursing care and assessment appropriate to inpatients. This was slowing the process and keeping people hospitalized longer than necessary. “At the end of the day, it’s not about bad people, it’s about bad processes,” Jaskie quips.

So they made process changes on the front lines and worked with physicians to create standards and consistency. Each of the three sites took on a specific project, each focusing on a phase of care: pre-procedure, procedure and post-procedure. The first is establishing an evidence-based hydration protocol. “This is going to positively impact our kidney injury rate in a big way,” Jaskie says. “It’s not a hard change, it was just realizing we needed to have a protocol and making that happen.”

The second project is looking at intra-procedure bleeding events. The onsite team, along with a local team of physicians and leaders, reviewed all aspects to reduce bleeding complications from screening to access site. The program identified a need to grow radial access beyond the national average of 40 percent. As Jaskie notes, staying at the average means falling behind. The goal of growing their radial program not only reduces bleeding complications but also improves their position on same-day discharge, which is the focus of the third project. They hope to improve operations by establishing a same-day discharge program. “We knew their ability to do it was there but their practice of doing same day was pretty low,” Jaskie notes. “We are fixing that and then will extend to our other sites.”

Team building

A team at each of the three sites is running the project using Agile methodology organized in a 90-day sprint. A health system quality team works with each site, pairing with the local team to solve the individual problems. Once complete, each site will move on to conquer a new project under the same timeframe. The health system will jump in to share the methodology across all 12 cath labs. “This is what sets us up for a continuous quality improvement approach, with the scope across all cath labs,” Jaskie says.

Slowly but surely—Jaskie’s words—they’re going to create consistency so patients at every facility get the same experience. And with better quality will come lower costs. “In my mind, performing from a cost perspective is performing from a quality perspective and vice versa,” she says. “To the extent that we’re successful in creating good processes, we will impact quality, impact costs and remove wasteful activity out of the processes themselves. For example, if we are successful in developing a same-day discharge approach, we’ll create hospital capacity. There will be the cost of an individual hospitalization and we will create hospital capacities. Those are two big impacts to cost and revenue. All of these are building blocks towards creating a system-wide, statewide approach to cardiovascular care.”

Coaches and champions

Health system-vendor collaboration is a sign of things to come. Jaskie sees the consultants she works with as coaches assessing stats, skill and form, providing a national perspective, pushing the CVSL team to be its best.

“Just like a baseball team or a swim team, we’re never there,” she says. “We always need to hone our skills to get better. We need independent and objective partners and coaches to get us there. Good people bring us good experience and practices from other good healthcare facilities. We also need physician champions to be part of each project. It’s all about nurturing a culture that insists on always looking at performance. Hopefully someday we’re creating the bar instead of raising the bar.”

The partnership is a reflection of how industry relationships have changed over the last few years. What vendors bring to the table is vast experience with high-performing labs, visiting tens and even hundreds of cath labs over time. “There is real value to that national big picture perspective,” Jaskie notes. “Isolation and quality just don't go together.”

Outsourcing additionally empowers staff to learn what constitutes high performance and how they can achieve it. “Bringing in an outside team, even over a short period of time, you're able to totally turn around how your work processes happen in the same period that you’re taking care of patients well.”

At Ascension, all purchasing goes through their resource group. Permission for this initiative came from that group. “They made sure there weren’t any conflicts of interest being created. That was really important,” Jaskie says. “I’ve worked with vendors over the years and they have been very helpful without having anything to do with buying a product. I think that’s critical to making things work.”

But is there a risk of too much transparency? Jaskie shakes her head no. “Only if people don’t understand what they’re looking at and making sure it’s handled well,” she says. “The vendors have to be careful in how they use the data to retain the trust.”

Jaskie sees this as a valuable journey others should embark on too.

“As leaders in a crazy time in healthcare, we need to be willing to dive in with our teams into self-reflection and self-exploration,” she says. “There’s always room for improvement. Every program that is highly regarded needs to do this. We use the expression, ‘it’s like stripping and going naked’ because you’re letting people into your house to see what’s really going on. To be totally willing to be transparent is better for our patients. If we can create an environment for folks to believe that’s the right way to work, we've really done something.”

Building ‘better’

With three projects underway, the benefits remain to be seen at Ascension. But success so far for Jaskie is judged by
two things. “We had good attendance at our meetings. People showed up and wanted to see the answers at the readout. That’s the first test. And second, physicians and staff are engaged and taking the follow up work seriously. We’ll see in six months if we've implemented the changes and are going on to the next round. That will be the next test. And I do believe our consultants will ask us how we’re doing, which is a little bit of built-in accountability for all of us.”

Through all of this, the Ascension Wisconsin teams are creating the transparency, flow, expectation and culture that is one system, not 12 different cath labs, to benefit from each other.

“We are creating a high reliability, high performing environment to do the right thing at the right place for the right patient,” Jaskie says. “That becomes more finely tuned the more time we spend reviewing and committing to improving. We have looked backwards and measured backwards. Now we are focused forward on projects to perform better in individual labs and sharing that across our statewide service line. It needs to be continual improvement. We are already stronger for embarking on this journey.”