TriHealth Bethesda North Hospital’s Cath Lab LEAN Throughput Project

The authors can be contacted at Jean_Ackner@trihealth.com or Beth_Solomon@trihealth.com.

An introduction to TriHealth

TriHealth is a large, multihospital healthcare system in Cincinnati, Ohio, providing the region’s leading heart and vascular program. The TriHealth Heart Institute has highly trained cardiologists, and cardiac and vascular surgeons who offer the most cutting-edge, comprehensive treatments.

• Bethesda North Hospital is a 2012 Truven award winner for Top Cardiovascular Hospitals and was recently rated the US News and World Report’s #1 hospital in the Cincinnati metro area, and among the best hospitals nationally.
• We are a top provider of acute heart attack care and consistently beat national benchmarks for time to treatment by 30 minutes.
• Our Heart Institute is a leader in the diagnosis and treatment of arrhythmia, and offer a full range of options for the treatment of atrial fibrillation, including catheter ablation and mini-maze.
• TriHealth is a regional leader in cardiac research and clinical trials, offering our patients access to treatment options not available elsewhere.
• TriHealth has Cincinnati’s most experienced hospital in minimally invasive heart and vascular procedures and surgeries.
• TriHealth is the regional leader in robotic-assisted surgery, including cardiac bypass surgery and valve repair and replacement. We train surgeons around the world in cardiac robotic surgery.
• TriHealth has one of the first hospitals in the United States — and one of four in Ohio — to offer transcatheter aortic valve replacement, a minimally invasive alternative to open heart valve replacement. 
• TriHealth has the first hospital in Cincinnati to repair aortic aneurysms with custom-built stents, known as fenestrated stents.

The Bethesda North Hospital Cath Lab

The Bethesda North Hospital Cath Lab consists of three diagnostic and interventional cath labs and two electrophysiology labs, treating almost 4,000 patients per year. 

Starting in late 2012, the cath lab department began to experience some challenges. Revenues and productivity were decreasing. Overtime costs were increasing, and staff morale was very poor. The creation of the TriHealth Heart Institute in the fall of 2012 led to additional challenges with cath lab scheduling and provider coverage. Most important was that the patient satisfaction had dropped significantly. 

The Bethesda North Hospital Cath Lab LEAN throughput project was chartered in June 2013 to identify and reduce waste to improve the patient and family experience. A multidisciplinary team of cath lab and cardiology office staff was assembled to study the process. Cath lab physicians were included ad hoc, and were very open to process observations and sharing their ideas. To get started, the team completed a review of LEAN principles and concepts. A LEAN Value Stream analysis was completed around the critical cath lab processes. Detailed flow charts and throughput data were added to provide the team with a common understanding of how things really worked. The cath lab throughput data showed a total average time from patient arrival to recovery of almost four hours — against a value-added time of three hours.

Process steps with the greatest waste included:

1.  Cath lab prep time;
2. On-time case starts; 
3. Post procedure meeting with patient and family.*

1) Cath lab prep time:

• Cath lab prep time includes assuring the patient has an updated history and physical (H&P), pre cath orders, lab work, and informed consent.

• H&Ps and cath lab orders were often missing or incomplete. Lab tests were not consistently completed ahead of time for the outpatients. Prep delays caused an average delay of 20 minutes or 33% of the total waste.

Solutions (implemented November and December 2013): 

• The team set up a process so that the patients could complete their lab work at the time of the cardiology office visit. All patients are now given a list of lab draw sites when the cath is scheduled with the instruction that labs are required prior to cath day.

• Now, instead of arriving 2 hours before the cath, most outpatients have their labs drawn ahead of time and arrive 1 hour ahead. This saves time for the patients and the cath lab staff.

• For the cath lab orders and H&Ps, the physicians were trained one-on-one to complete standardized cath lab orders and H&P templates from their cardiology offices using the Epic EMR system.

2) On-time starts:

• Cath labs commonly have unplanned add-on cases and emergencies that can throw off the schedule, but the first case of the morning is important to the day’s throughput.

• The data showed that 80% of the time, cases were not starting within the 15 minutes of schedule goal. 

• The team discovered that part of the problem was due to an unrealistic schedule and physician meeting conflicts.

Solutions:

• Improvements were made to the cath lab schedule so that procedures and cardiologists are matched with realistic times between cases.

• As a result, cath lab flow improved so that the cardiologists are in the procedure room in a more timely manner after the patient is ready. 

• Cardiologist start times improved from the beginning of the data collection and from the team improvements.

3) Post procedure meeting with patient and family: 

• Following a cath procedure, patients and their families are very anxious to know how things went. The data showed a wide variation among physicians (17 min to over an hour). Some physicians were “batching” cases by not completing this step before starting on the next case, causing a backlog of anxious and sometimes angry families.

Solutions:

• The inefficiencies of batching were shared with the physicians, along with the LEAN concept of single flow of work.
• The physicians are better about completing each case’s work before moving on to the next case.
• Patient satisfaction 

Delays in the cath lab are a daily challenge due to unexpected events. Patient satisfaction suffered because patients did not understand delays and were not kept informed.

Solutions:

• The cath lab staff makes every effort to keep patients and families informed of delays and to provide reassurance. Staff was asked to document when patients were informed about delays in nursing notes.
• The patients were also provided with improved patient education materials to present a realistic picture of the cath lab day and the expected length of stay.

Results (measured in January and February 2014)

Throughput times were remeasured after improvements were implemented.

• Overall cath lab throughput time (from arrival to recovery) improved from the near 4-hour baseline to 3 hours, 4 minutes — a 27% decrease in cath lab time.
• Post case meetings with patients and families improved from 46 minutes on average to 20 minutes. 
• Over half of the outpatients are scheduled to arrive 1 hour ahead of the case instead of 2 due to the improvements in pre-procedure requirements.
• On-time starts have improved from 30 minutes past scheduled time to    less than 20 minutes.
• Patient satisfaction has increased significantly from 82.4 to 94.4% — which far exceeds the benchmark.

Sustaining the gains

• The team continues to meet monthly to review throughput data and patient satisfaction results to address any gaps to target.
• There is more of a team atmosphere in the cath lab and with the physician practice, and staff is more satisfied with the better flow and efficiencies.
• Physicians are kept informed of data results and encouraged to participate in resolution of issues.