This article describes seven deadly sins related to cath lab operations management. Many cath labs globally suffer from most of these sins. For a medium-sized cath lab with four procedure rooms, the yearly potential loss is equivalent to 2,400 cases per year. Fixing these shortcomings results in higher cath lab utilization, lower operating costs, higher activity levels, increased revenue, and ultimately, better patient access to care.
Historically, the cath lab has always been the domain of the cardiologist. Until recently, attention to cath lab efficiency was limited. With healthcare costs rising and budgets being cut worldwide, the focus of cath lab operations management has shifted towards improving efficiency and not just clinical outcomes. A key driver is to either be able to deliver more cases with the same amount of resources, or to do the same number of cases with fewer resources. In Table 1, the three most important key performance indicators (KPIs) related to cath lab efficiency (and indirectly, to activity levels as well) are given. For the average cath lab, there is usually significant improvement potential. By increasing productivity and utilization, and by decreasing the overall procedure time, the number of cases done within the same amount of time and with the same amount of staff can grow significantly. This also creates additional revenue opportunity for the hospital.
As already mentioned by Teulings1, the primary focus in the cath lab is on clinical performance, and therefore planning of cases, staff, rooms, and beds is typically handled by non-specialized staff. Due to the complexity of the cardiology domain, many common hospital information systems (HIS) do not fully support the cardiology patient care trajectory. For example, they may be unable to support the following: (1) a diagnostic procedure can precede the actual procedure; (2) new patients are distributed across cardiology and cardio-thoracic surgery; (3) complex medical decision-making takes place in multi-disciplinary meetings; and (4) the cardiology environment is highly technological, and material and equipment intensive. As a result, cardiology departments and heart centers tend to run their own cardiovascular information systems (CVISs). These CVISs usually do a good job in supporting the medical decision-making process; however, the planning and scheduling components are minimal, resulting in manual processes, limited performance measurement, and ample room for improvement efforts.
This article identifies seven deadly sins in cath lab operations management and suggests ways to improve. Through systematic elimination of the ‘cath lab sins’, it is possible for best-in-class performance to be achieved.
Deadly Sin 1: Absence of a Well-Defined Planning and Scheduling Process
Within planning and scheduling, three different levels can be distinguished; namely, strategic planning, tactical planning, and operational scheduling. Each level has its own planning horizon. Table 2 summarizes the characteristics of the three planning levels (based on Hulshof PJH et al2). In a well-defined planning and scheduling process, sufficient attention is paid to all levels, and the planning and scheduling process follows a yearly cycle (Figure 2).
Deadly Sin 2: Only Clinical Information is Captured in the HIS/CVIS
Next to the clinical monitoring of the procedure and the patient, the patient preparation process and patient flow on the day of the procedure is also captured in the HIS/CVIS. Communication of real-time procedure schedules helps all concerned parties stay informed regarding the status of procedures in process, and keeps the catheterization schedule transparent for improved physician relations.3
Deadly Sin 3: Poor Patient Preparation
The first step to the actual cath lab procedure is the patient preparation. In a well-organized patient preparation process, a timeline exists where all required steps in this process, their chronological relationships (if any), responsible healthcare provider(s), and required timespan are all defined.
The process is supported by the HIS/CVIS, keeping track of the progress of all preparation activities, and pushing alert messages to the planner and responsible healthcare providers if a delay occurs. Patients can only be put onto the actual cath lab planning if all the required preparation tasks have been completed. The patients’ complexity can be characterized by the Pareto principle, where approximately 20% of patients account for 80% of preparation work. Separating the low- from the high-complexity patient flows allows for a faster work-up of the first category, while providing tailored preparation for the latter category.
Deadly Sin 4: Cardiologists’ Schedules Include Only ½ Days or Less in the Cath Lab
A pre-condition for high cath lab efficiency is that cardiologists are present in the cath lab all day. Increase or decrease in the length of the morning cath lab shift can then easily be accounted for in the afternoon shift, since it is carried out by the same physician, thus introducing more flexibility in online case and staff planning. In the electrophysiology domain, it is quite common to work for an entire day in the electrophysiology lab, due to the usually long (2-4 hours) duration of the procedures. In some labs, however, interventional cardiologists tend to work only morning or afternoon shifts in the cath lab, while having other obligations (outpatient clinic, teaching) for the other half of the day.
Deadly Sin 5: Infrastructure Does Not Support Patient Flow
In an ideal world, the hospital infrastructure in and around the cath lab supports patient flow. There is an adequately staffed patient preparation (‘holding’)/recovery area in or near to the cath lab. In this area, patients can be prepped, monitored pre- and post- procedure, and await transport to the nursing wards after their procedure. For day surgery patients, the best practice is to co-locate an outpatient unit near the cath lab to reduce patient transport requirements. Within the cath lab, patient, staff and material flow are separated as much as possible. The corridors are wide, to allow for easy bed and material handling. The cath lab has a clear entry, equipped with a reception desk or an automated access management system, thus preventing patients, relatives, carers and non-cath lab staff from entering the clinical area. The rooms are spacious, easy to clean, and efforts have been made to reduce noise. All common quality and safety regulations are in place.
Deadly Sin 6: No Daily Coordinator Role in the Team
During the day, the progress of the cath lab program is closely monitored by a team member. This is (for facilities with four labs or more) a dedicated role, focusing on starting on time, scheduling of emergency and semi-urgent cases within the elective program, eliminating delay between two consecutive cases, finishing the cath lab program on time, and dealing with unforeseen circumstances. The coordinator role may alternate between team members, but it needs a clear mandate, and clearly structured roles and responsibilities within the cath lab.
Deadly Sin 7: Unclear Division of Roles Between Cath Lab Nursing and Support Staff
There is a clear division of roles, based on patient demand and the skill set of nursing staff. All non-clinical work is done by dedicated support staff, including case and staff scheduling. Since recruiting cath lab nurses is becoming a bigger challenge every day, this is very important.
In an average cath lab, it is evident that there is huge improvement potential. The focus on operational excellence through addressing the ‘seven deadly sins’ described in this article can allow teams to perform up to 50% more procedures with the same level of resources. When a cath lab team gets this right, there is also an add-on effect, delivering improvements in patient safety and clinical quality of care. When the operational running of an area is smooth, clinical staff are freed up to focus on delivering outstanding care to their patients.
- Teulings MF. Seven deadly sins in cath lab material management. Cath Lab Digest. 2015; 23(9). Available online at: http://www.cathlabdigest.com/article/Seven-Deadly-Sins-Cath-Lab-Material-Management. Accessed April 29, 2017.
- Hulshof PJH, Kortbeek N, Boucherie RJ, et al. Taxonomic classification of planning decisions in health care: a structured review of the state of the art in OR/MS. Health Systems. 2012; 1(2): 129-175.
- Regas P. Cath lab scheduling: making the move to electronic remote display systems. Cath Lab Digest. 2008; 16(10). Available online at http://www.cathlabdigest.com/articles/Cath-Lab-Scheduling-Making-Move-Electronic-Remote-Display-Systems. Accessed April 29, 2017.
Maartje Zonderland is an Integrated Health Solutions managing consultant at Medtronic. In this role, she gained experience in cath labs across the globe. To date, 110 cath labs and operating room departments have selected Integrated Health Solutions to manage the full scope of their operations. Maartje has been leading multiple cath lab quick scans and operational excellence improvement projects. She holds a PhD in applied mathematics and operations research from the University of Twente in the Netherlands, dedicated to planning and scheduling in hospitals.