Quality Improvement in Cardiac Electrophysiology

Podcast discussion with Jose Osorio, MD, and Paul C. Zei, MD

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Any views and opinions expressed are those of the author(s) and/or participants and do not necessarily reflect the views, policy, or position of EP Lab Digest or HMP Global, their employees, and affiliates. 

In this episode, we feature a discussion with Jose Osorio, MD, from HCA Florida Mercy Hospital in Miami, Florida, and Paul Zei, MD, from Brigham and Women's Hospital in Boston, Massachusetts. Drs Osorio and Zei discuss quality improvement in electrophysiology (EP), with the focus on building a high-quality, comprehensive atrial fibrillation (AF) program. 

This podcast episode is also available on Spotify and Apple Podcasts!

Jose Osorio, MD: Hello, everyone. My name is Jose Osorio. I am an electrophysiologist who has recently moved to Miami, Florida, where I'm going to be practicing at the HCA Florida Mercy Hospital. I am joined by a good friend, Dr Paul Zei. Our goal is to have an open dialogue about quality improvement in EP with the focus on building a comprehensive AF program. Paul, it is good to have you here and have this opportunity to talk to you.

Paul C. Zei, MD: Thank you, Jose. Yes, I am Paul Zei. I'm also an electrophysiologist. I am at Brigham and Women's Hospital in Boston, Massachusetts, and I am the director of our AF program. I am excited to spend this time with my good friend Jose to talk about something I think we're both quite passionate about and I think will hopefully make an impact on the listener as well. So, why don't we start? Jose, I think the first thing we want to talk about is what we would consider the pillars or key points of developing a high-quality, high-value AF program.

Osorio: That's a great question, and the best way for me to answer is to go back in my journey with quality improvement in this AF program. I left an academic institution over a decade ago and wanted to start a clinical trial program, and was fortunate to be joined by a very experienced former research nurse. When she joined me, she said, "You're nowhere near. You need to focus on the quality of the program first. We need to build the pillars and the highway, so that we will eventually be able to participate in clinical trials."

That was in 2013. At that point, I made a strategic decision that was career-changing for me, which was to take care of all my patients as if they were in a clinical trial. There is very good data that shows that patients do better compared to the general population when they are in a clinical trial, even if they're in a placebo group. Other studies have shown that it's not because of the clinical trial itself, but rather because of the standardization of care and having a process that allows patients to flow through that journey from diagnosis to initial treatment to ablation and follow-up. Having it all standardized provides better care. Using that model to take care of all our patients was the decision we made over a decade ago when building this program.

So, what I have focused on and works quite well is to first standardize care. What do I mean by standardizing care? Much like in a clinical trial, you want to decide when you are going to see your patients, at what time intervals, the tests your patients need for a comprehensive evaluation, and if you choose to send this patient for an ablation, how will the procedure be carried on, and when they will be seen at follow-up.

Standardization of care is a very important way to reduce cost and remove variation. For most patients, you can put them in a very defined pathway. Once you standardize care, particularly if you're focusing on performing an increased number of AF ablations, you must collect outcomes. For me, outcomes data collection is the second pillar of a quality program in EP. It's important to collect outcomes for all your procedures. If you're doing an invasive procedure that is elective and has risks, you need to know your complication rates, your outcomes at one-year post ablation, how many of your patients are doing well and feeling better.

Then, only when you have standardized care, you're collecting outcomes, and you understand what's happening in your EP lab and with your patient population, you should start focusing on efficiency. I think the EP lab itself is the last thing we should focus on. That's when we start focusing on efficiency. You can't focus on efficiency until the quality component of your program is strong. We should never try to just be faster with our procedures.

To summarize, the 3 pillars are standardization of care, outcomes data collection—particularly when you're doing a high volume of AF ablations, and lastly, EP lab quality and efficiency.

Zei: Jose, I've listened to you give presentations on this topic countless times, and I think your message is very clear. From my perspective, your principles are universal. They're not just for private practice—they very much apply to academic centers. My personal journey is trying to take those concepts and see what we can do in the framework of an academic center. It's important to note that wherever your institution is, there is very clear applicability of these principles in trying to create an efficient, effective, and high-quality program.

Osorio: I agree. It doesn't matter where you are. We can all similarly work on these principles and quality will pay off. Focusing on standardization of care, you will achieve efficiency and quality. Those are all important principles. Tell me a little about where are you in your EP lab right now and where you stand in that journey. Do you think there is still room for improvement? How much progress have you made at your own institution?

Zei: That is a good question. I think along those same lines of the 3 pillars. When I arrived back at Brigham and Women’s Hospital after being at a different institution for quite some time, I wanted to help continue to build and make further improvements on an AF program that already was quite high volume. Therefore, the first thing was trying to make sure every patient had the same level of quality of care. How do you measure and track that data? How can you make sure you are seeing where you're currently at and where you need to get to?

That is the first step, in my opinion. Learning to better measure our outcomes and efficiency measures was the first step in implementing how to do that in a systematic way across our EP lab and institution. Once we could see the data and had a good way to achieve that consistently, then we could start identifying areas of improvement. The key, especially in a comprehensive program, is finding areas of efficiency. How are you getting your patients through the door? What time does it take for getting a patient through the door and scheduled for a procedure?

Then, you go through the whole procedure day for the patient, from the pre-op area to the EP lab to the recovery area to follow-up, and beyond. Again, that is part of the measurement issue. We implemented several measures to track those steps. 

This gets me to the third point, which is the Lean Six Sigma model of following the patient journey from their perspective as they go through the whole system. I know you've done that as well. When a patient first shows up at your clinic door through to the point of one-year follow-up, where are the issues that you can have an impact on? We looked at each of those components and made what efforts we could to improve each of those steps.

Osorio: For the listener, I invite you to map your entire patient journey. From the day the patient is referred to you, what is the referral process like to clinic evaluation? If there is a decision about referral for a procedure, how is the consent done? How are you documenting shared decision-making? How is the patient scheduled? You need to map each step, because that's the only way to identify the bottlenecks. For some of us, the problem may be in the EP lab, where you're often scheduling 3 months from now. That can suddenly cause problems if you're seeing patients in clinic and you don't have a place to add those patients for potential procedures.

The only way to understand your pain points is to map them out. When I started at my prior institution, I formed a team comprised of the CNO of the hospital, the prep and recovery director, the EP lab manager, and a physician, tech, and nurse from the EP lab, and we literally walked the patient journey in the hospital. Together, we documented how that journey should go and what our expectations were. For example, we expect the patient to arrive at 5:30 at registration.

If you follow the Lean Six Sigma approach, efficiency and quality can go hand in hand. You can't look at just doing more procedures more quickly—that's not the right way to do it. However, standardizing everything, mapping out the process, and following the Lean Six Sigma approach is the recipe for success.

Paul, I want to hear your opinion on this, but for me, a lot of the need for outcomes data collection came from learning how to do procedures with zero fluoroscopy. At the time, we were pushing the boundaries and doing something that was different. It was 2013 or 2014, and we were frequently talking about this and making sure we were doing the right thing for our patients. In EP, we're innovating so much all the time. A good example now is left bundle and conduction system pacing. With new innovations, we owe it to our patients to be collecting outcomes, because that is the only way to know that you're doing the right thing. So, how do you see the continuous innovation in our field and outcomes data collection playing a role in what you do at an academic institution?

Zei: That's exactly right. Zero-fluoroscopy ablation was an important part of this because almost 10 years ago when a lot of us were first starting to do this, we got a lot of feedback about potential concerns about whether it was right for the patient in terms of safety. That, along with other issues, created a strong impetus to measure those outcomes to make sure that this was a safe thing to do for the patient and that it wouldn’t degrade outcomes or efficiency. I think that helped to drive things and brought both of us to the same aligned goals.

That brings us to the idea of innovation and how to incorporate that into efficiency and quality practices. Maybe you have a good workflow now and feel like you're reasonably efficient. There may be some things that can be further improved upon in various aspects of your workflow. Then, a new advance such as pulsed field ablation or physiologic pacing becomes available. It’s important to be adaptable to those changes and learn how to incorporate them so that workflow remains effective, safe, and efficient.

Osorio: We started working together because of zero fluoroscopy over 10 years ago. As we started our own journeys on outcomes data collection and quality improvement within our institutions a few years ago, I believe we did something that would be considered disruptive, which was making outcomes data collection a team sport by including physicians that were outside the boundaries of the institution. We have now built outcomes data collection and quality improvement into a team sport, with dozens of institutions and over 100 electrophysiologists, using similar outcomes data collection approaches so that we can collectively share data, learn from each other, and achieve quality improvement. How do you see that where you are today regarding outcomes data collection and quality improvement performed in a large EP lab?

Zei: This is what I was alluding to earlier in terms of incorporating innovation and new approaches in the lab, but also staying focused on outcome measures. When we first discussed this many years ago, we agreed we didn't just want to see what each of us was doing at our individual institutions—we wanted to try making this a broadly applicable concept and process to ensure this was reproducible not just in our own institution but across multiple institutions, and hopefully become a standard of practice.

This started off as an industry-sponsored registry looking at low-fluoroscopy users in high-volume academic and private centers. We created this concept of tracking outcomes in a uniform way where all of us used the same standard of practice and had an interest in and willingness to measure our outcomes and feeding that back into quality improvement.

What that resulted in, in this initial registry, has become a disruptive approach to how AF ablation, and more broadly, the EP field, can advance in this novel way. Heart Rhythm Clinical Research Solutions (HRCRS) is trying to generalize the concept of how to improve EP as a field by having this shared mindset among all who are interested in continual process improvement and working with each other to look at our collective outcomes.

At each of these participating institutions, there is a policy that if a particular institution, investigator, or participant has an interest in a specific area of improvement in their lab, that can be taken to the entire group and be developed into a study or investigation to evaluate whether that specific intervention can improve outcomes in a certain way. The investigation uses the collective power across all our participating institutions for evaluation.

The investigators, whether in an academic center or private practice, are egalitarian. This can be seen in our published and presented outcomes at various meetings over the last several years. We've had broad participation across operators and centers.

Osorio: Ultimately, what I see us building is a learning health system. We now have several physicians collecting outcomes, sharing data, benchmarking quality improvement, and learning from one another. It is likely that there are pain points one or more institutions may share, so why should we go it alone? Why not make this a team approach?

Similarly, if one of us learns a technique at our institution that can improve the safety or efficiency of a procedure, we should teach each other. We need to find ways to more expeditiously collaborate and share knowledge. Therefore, how do you see one starting this journey at their institution? If you were to advise someone about starting an EP quality improvement program, where should they start?

Zei: It comes back to the fundamentals you emphasized at the beginning of our conversation, which is if you want to embark on this journey, you must first measure those outcomes. What tools do you need to see where you're at, what your patients are going through, and what your outcomes are? Identify those measures and find like-minded stakeholders at your institution who are willing to go on that journey with you. 

Second, given that data, how do you then make sure that your patients are receiving high-quality care and how are you standardizing that care? That is going to be a process of continual improvement through feedback. The HRCRS is an excellent way for like-minded EPs who are interested in this kind of a process on a larger scale.

Osorio: I'll add 2 quick points. First, I used some of the EP accreditation programs as my script to help us build a quality EP program. Accreditation programs can give you a gap analysis of what you have and don't have, as well as protocols and standardization. That really facilitated it. Also, if you're going to start at your institution, the first step is to find your followers. Your first follower is the more important one. If you're interested in quality improvement, know that it's a team sport, so you need to find other like-minded individuals, not only physicians, but leadership, nurses, and technicians, who want to be on that journey with you. Then, once you've started at your institution, join others like us. I hope this was a helpful discussion. I'd be happy to discuss with anyone that is interested in continuing this conversation. Thank you for the opportunity, EP Lab Digest.

Zei: Yes, thank you.

The transcripts have been edited for clarity and length.