What it takes to keep patients, profits, and referring docs in today’s changing landscape
Cardiac cath labs operate in an increasingly challenging environment, contending with a variety of clinical, demographic, regulatory and competitive factors. Patients are growing older, leading to more comorbidities, and, at the same time, new hospitals and private practices are diving into the cath lab market, which can make it more difficult to maintain patient volume and referring physician relationships.
Despite the challenges, cath labs across the country are surviving, and in some cases, thriving. Many are fine-tuning their business to stay ahead of the game. Others are re-inventing themselves, turning to technology and new business models to deliver profitability.
Some secrets to success include collaboration (think shared, multi-discipline labs) and old-fashioned common sense. In other words, offer high-quality service and build and maintain relationships with key players—referring physicians and staff.
Read on to learn more about how a few labs are making it work in the current environment.
The single-discipline cardiac cath lab may soon be extinct. The advent of multipurpose imaging equipment able to accommodate peripheral vascular procedures has led to a new paradigm. Beaumont Hospital (Royal Oak, Mich.) sits on the leading edge of the hybrid model. The hospital has embraced the multipurpose heart and vascular concept in its cardiac cath labs, which are equipped with Siemens Medical Solutions Axiom Artis and Philips Healthcare Allura Xper FD 20 imaging systems and handle cardiac cath, peripheral vascular and neuro-
The shared lab provides a number of advantages over the traditional single lab model, says Victoria Hollingsworth, administrative director of heart and vascular services. The concept offers flexibility and scalability and facilitates improved patient care. Although one specialty like interventional radiology may be the primary user of a given room, each lab can handle vascular surgery or cardiac cath procedures. As volume among the various specialties ebbs and flows, procedures can be shunted to other suites, enabling the hospital to maximize real estate, equipment and staff. In addition, patients don’t need to be moved if they require both cardiac and vascular procedures or if a cardiac event occurs during a neuroradiology procedure; however, only one room meets OR specification for vascular surgery.
Washington Hospital Center (Washington, DC) also uses the multipurpose approach. The center’s 11 labs are outfitted with Philips Healthcare Allura Xper FD 10 and FD 20 imaging equipment. Most systems are the FD 20, a larger field of view system sized to accommodate peripheral vascular work. The cath labs offer comprehensive services including stents, peripheral vascular procedures, brachytherapy, patent foramen ovale (PFO) and atrial septal defect (ASD) closure and percutaneous valve replacement. The primary advantage of the hybrid approach, says Vice President of Heart and Vascular Services Elizabeth Wykpisz, is flexibility. Patients and physicians can stay in a single room for multiple types of procedures. In fact, the hybrid model contributes to Washington Hospital Center’s highly efficient patient throughput, with the labs completing an average of 50 cases daily and effectively handling up to 80 cases a day.
Peripheral pros (and cons)
Many cath labs are open for peripheral vascular business as well as conventional cardiac cath procedures. The rationale for accommodating peripheral vascular procedures is clear. It offers an additional business line and can help sites maximize their investments.
What does it take to accommodate peripheral procedures? The key differences are the competency of the staff, imaging equipment and supplies such as stents, lasers and software applications. Peripheral rooms require a larger field of view x-ray system and different stents and grafts than traditional cardiac cath rooms. Due to the complex supply management associated with peripheral vascular procedures and the different types of procedures (i.e. carotid, renal), a dedicated inventory area is available at Washington Hospital Center.
It is important to remember, however, that there are downsides to the combination approach. A multipurpose lab requires a larger camera, which can get bulky especially during pediatric and cardiac procedures, says Joel Sandler, administrative director of cardiovascular services at Florida Hospital (Orlando, Fla.). It’s also more difficult to obtain images at steep angles with larger equipment. Finally, the multipurpose cameras and related software cost more than their single function counterparts. Florida Hospital strives for balance; two of its cardiac labs are equipped for peripheral vascular procedures, and one lab is a dedicated vascular center. The remaining three labs are dedicated to cardiac procedures. The vascular center is outfitted with a 16-inch image intensifier to accommodate vascular procedures and a wider array of stents, grafts and coils than cardiac cath peers.
Still, Hollingsworth says hybrid labs are the wave of the future. “Don’t box yourself in. If current volume is 500 cardiac and 500 vascular procedures annually, don’t build two dedicated rooms. Outfit one or two combination labs.”
Handling the competition
Competition is growing increasingly fierce in the cath lab market. Private practices are offering everything from echocardiography and noninvasive testing to cardiac CT and MR. In many locations, the stage is set for turf wars over patients, referring docs and staff. Unfortunately, there is no magic bullet to cure competitive woes. The answers include both continued investments in clinical and IT resources and slow but essential relationship-building.
Florida Hospital operates one of the largest cardiology programs in the country, yet the mega-enterprise admits to a decrease in cath lab volume in the last three years. The main campus houses seven cardiac cath labs and four electrophysiology labs equipped with a variety of GE Healthcare Innova x-ray imaging systems, and the vascular center uses Siemens Medical Solutions Axiom Artis. Sandler attributes the decline to multiple factors. “Better living through chemicals is keeping patients out of the cath lab. Patients are benefiting from statins, drug-eluting stents and healthier lifestyles. Plus, physicians who previously turned to the cath lab as the first intervention are opting for other first-line treatments.” The final insult? Every cardiology practice in the area has opened an outpatient cath lab, which carries a double whammy. Competition for patients is intense, and patients referred to Florida Hospital tend to be sicker, translating into longer hospital stays, more stents per procedures and longer case times. “All of these factors cut into our profit margin,” states Sandler.
Florida Hospital has adopted a multi-pronged approach to the competitive challenges. It maintains a strong focus on the patient and physician experience, striving to ensure efficient case flow to optimize physician time. For example, the hospital tries to arrange the schedule so each physician’s procedures are back to back, even with add-on cases. Another focus is reducing room turnaround time; Lumedx Apollo Advance ClinDoc provides time-saving templates to minimize dictation and support real-time reporting. “If we’re wasting physicians’ time, we’re costing them money,” says Sandler. Cost containment is another arrow in the quiver. The cath lab keeps a lid on costs by partnering with interventional radiology; the specialties achieve economies of scale as they negotiate with vendors to stock stents, grafts and coils. Florida Hospital also uses the data from ClinDoc to drive a marketing program that focuses on quality rather than specific physicians, sharing data like its sub-90 minutes door-to-balloon time with the area patients and physicians.
Similarly, Beaumont Hospital faces mounting competitive pressure. This year, two new hospitals will open cath labs within ten miles of Beaumont Hospital. The hospital has invested in state-of-the-art CT and MR scanners dedicated to the cardiology department, and it stays on the cutting edge by participating in cardiac and vascular research like CT-Stat—(Coronary Computed Tomography for Systemic Triage of Acute Chest Pain Patients to Treatment).
|William Beaumont Hospital Cath Lab Statistics|
|At the William Beaumont Hospital cath labs, the average patient age has increased from 2002 to 2007, while the number of diagnostic caths has decreased. The number of patients and interventions (coronary and peripheral) have fluctuated, with both experiencing a decrease from 2006 to 2007.|
“It’s always a challenge to hire and retain staff,” admits Beaumont’s Administrative Nurse Manager Sara May, who credits the cath lab’s low staff turnover to the hospital’s consistent ranking as one of the top local places to work. “We’re proactive, and we listen to our staff,” explains May. For example, after several techs complained about on-call hours, the department responded to staff needs by adding a midnight shift to minimize night calls. May reminds employees of the big picture; staff at small hospitals may be forced to take call five nights a week, and while some may appreciate the financial benefits of on-call pay, most do not want on call nightly. May also ensures the hospital’s call pay remains in line with other local cath and vascular labs.
While money talks, it isn’t the only way to retain staff. Cath labs can hold on to their best and brightest staff by investing in professional development and continued growth, exposing techs to cutting-edge research procedures like PFO closures and cross-training them to handle vascular or neuroradiology work. Cross-training can be a win-win situation as it keeps staff sharp and facilitates flexibility. Florida Hospital plans to roll out a clinical ladder, a career progression model that rewards the contributions of the team member to the organization. For example, if a tech can work in multiple areas, she obtains a higher level due to the value and efficiencies provided to the department. The model addresses cross-training, precepting, clinical expertise and leadership. Newly implemented productivity incentives align rewards with the hospital’s goals. Equally important, the hospital is proactive in hiring decisions. “We focus on fit and function, hiring the right team and good managers, and training them as needed,” shares Sandler.
Washington Hospital Center employs a two-pronged approach to recruitment and retention. The hospital houses an on-site technologist school that not only offers clinical experience for new technologists, but also serves as a feeder program for the cath and electrophysiology labs. A shared governance model that invites employees into the education and decision-making processes helps engage employees and boosts retention, says Wykpisz. Staff training is ongoing and includes a SimLab that simulates various scenarios like emergency situations, live case demonstrations and Saturday skills days, during which staff rotate through various centers to refine or learn new skills.
Similarly, referring physicians are not immune to the lure of a new hospital and state-of-the-art equipment. “We keep them involved in hospital processes via collaborative work teams that focus on challenges like efficiency, communication and turnover,” says Hollingsworth. The cath lab also invites private practice staff to visit the lab on a quarterly basis, so staff better understands what physicians do at the hospital. An added benefit? “They develop a new appreciation for completing standard forms like patient history and pre-admissions,” notes Hollingsworth.
Washington Hospital Center touts its physician extender model, which employs cardiology hospitalists and nurse practitioners to support private practice physicians who use the hospital’s cath labs. Beaumont Hospital keeps physicians engaged and minimizes turf wars between various specialists via multi-disciplinary quality assurance teams. For example, a team recently developed credentialing guidelines to determine which physicians should be allowed to offer carotid stent placement in the Heart and Vascular Labs.
Unlike many of its colleagues across the country, Washington Hospital Center has not seen its cath lab volume decline in the last three to five years. Patient age and comorbidities have held steady as well, says Wykpisz; however, the hospital traditionally handles the most complex cases.
Washington Hospital Center continues to evaluate and implement strategies to maintain a steady cath lab volume. This includes education to physicians from referring hospitals, and use of helicopters in the community to assist in timely patient transportation. “Our focus has always been on making the cath lab the best in the area, which includes high quality staff and easy access for physicians and patients,” shares Wykpisz.
Investing in IT
As cardiac cath labs are pressed to do more (and better) with less, IT assumes a new level of importance. Key factors guiding IT purchases include a system’s ability to help the lab leverage patient data for effective and efficient workflow and clinical improvements.
Beaumont Hospital, for example, aims to deploy new software to facilitate data collection, structured reporting and outcomes research. The new software will be integrated with Epic Systems Corporation EpicCare EMR; the project will enable physicians completing procedures in the cath lab to view data from all imaging modalities on the same platform. That is, a cardiologist can view CT, MR, echo and cardiac cath data concurrently. In addition, techs will input data into the report during the procedure with physicians adding information after the procedure. Patient reports will be faxed to the referring physician, and specialty areas like nursing and inventory management will receive relevant reports and data following each cath procedure.
“The new software will increase throughput and reduce errors,” predicts Hollingsworth. That’s because the software can be configured to leave a case open until the tech populates all variables necessary for regulatory compliance. And the system can be integrated to American College of Cardiology (ACC), American Heart Association (AHA) and Centers for Medicare & Medicaid Services (CMS) databases to streamline reporting processes.
Florida Hospital also turns to software to trim costs. “Lumedx Apollo ClinDoc system is our best tool,” shares Sandler. The software puts a variety of information at users’ fingertips, tracking outcomes, utilization and case length. “We need to know if we’re using 1.6 rather than 1.5 stents per case because we aren’t reimbursed for each stent,” states Sandler. The next step is a pilot of WaveMark CIMS RFID tracking system. The goal, says Sandler, is to better match inventory to caseload. Sandler hopes to integrate the RFID and clinical documentation systems to gains efficiencies.
Efficiency is the operative word for all cath labs. Best practices dictate a comprehensive approach. Take Washington Hospital Center. Intravascular ultrasound (IVUS) is in high demand during cath procedures. Rather than sharing systems between rooms and asking physicians to wait, the hospital provides a flexible approach to supporting physicians that require the use of IVUS. This includes dedicated, fixed IVUS units in many of the labs as well as portable ones. Senior technologists are trained in multiple procedures (including use of IVUS technology) to provide staffing flexibility and efficiency as the case load and procedure type fluctuate. Reporting is streamlined and user-friendly, too. Technologists begin data input as patients arrive, and physicians can complete the case via either voice recognition software or a clinical documentation system. Conventional dictation remains an option for the physicians who prefer that model.
Staying ahead in the cath lab business is a challenge, but not an insurmountable one. Smart labs can turn a profit even during tough time. It requires multiple strategies fine-tuned to the particular needs of the local marketplace. Common themes include hybrid labs and a strong focus on clinical quality. Staff retention and physician satisfaction are essential, too. Cross train and reward staff, and assess physicians’ needs to keep them satisfied. Think workflow, efficiency and simplicity. Don’t forget about cutting costs. Consider buying collaboratively with another department and an RFID inventory management tool to better track stock and prevent loss.
Treating Cardiac Disease on South Long Island
South Nassau Communities Hospital recently opened a $17 million Center for Cardiovascular Health. The center is the cornerstone of South Nassau’s cardiac care initiative to meet the pressing need for advanced, interventional cardiology services in Nassau County.
The 21,000 square-foot center includes two state-of-the-art digital cardiac catheterization rooms, 18 dedicated preparation/recovery spaces, decentralized nursing stations, doctor’s offices, examination rooms, family waiting areas and conference rooms.