For Want of a Nail
For want of a nail, the shoe was lost.
For want of a shoe, the horse was lost.
For want of a horse, the rider was lost.
For want of a rider, the message was lost.
For want of a message, the battle was lost.
For want of a battle, the kingdom was lost.
And all for the want of a horseshoe nail.
— Old English Rhythm
Where is my stent? I need it now! What do you mean you don’t have one!!!
Please note there is no question mark in the last sentence.
Inventory is the lifeblood of the cardiac cath lab. Be it a stent or a three-way stopcock, without the tools and supplies, you can’t complete the procedure and deliver the exceptional healthcare to every person we have the privilege to serve. Patient care and satisfaction require that you have the tools, the supplies, and the staffing to get the job done. You don’t want a your rhythm to end with “for want of a stent, the life was lost.”
Having a well-stocked inventory should not be that hard a task! The cardiac cath lab is a profitable department in the hospital. Therefore, extra efforts should not be required to make sure that the cardiac cath lab is a well-stocked, smooth-sailing department in the hospital.
At least, that is what one would think. Well, I am the manager. I have been working in cardiac cath labs since 1972. I am here to tell you that I do manage. I am not in control. The dynamics fluctuate daily. I make things work by management and the help of the good Lord. Take a walk in my shoes for a mile or so, and see what you think. Perhaps you may understand better the want of supplies.
First of all, you can’t afford nor do you have room to stock all the variety of supplies in the cardiac cath lab. Yet some of the cardiologists do not even agree on using the same type of gloves, let alone the same type of introducer sheaths, guide catheters, and or the $2,500 stents. They want what they want when they want it! (see Act 2, Song 1, Mlle. Modiste)
Meeting your customer’s every expectation is aiming high, but that is what is expected. When you try to get agreement across the board, you may find that some cardiologists may think the following: that you are picking on them, or you are trying to deprive them of what they view as an essential need to do a procedure, or that you are biased and like the other cardiologist better. That supply is their trademark. They have always used that product. The worst accusation is that you are doing this for your personal gain. Make sure that is not true!
These are just a few of the views on changing supplies or conformity with inventory. Good luck in changing minds or requirements. Yet as a leader, you must keep on trying to standardize and upgrade to new products. Just remember not to ask is to accept “no” as the answer.
Try different approaches at different times. Engage your staff and have them on the same page for standardized supply. Encourage your staff and the cardiologists to discuss the pros and cons. Ask and then listen to why they need this particular item. Provide opportunities for training for staff and cardiologists on the suggested standard item. Work with your vendors to provide evidence of the value to the cardiologists of their product being the standard and consolidate your inventory. Cardiologists want to be heard and be involved in the process, especially when these are the tools they use. Therefore, standardizing supplies is not an easy task. This problem is also not true of all cardiologists.
Second, materials management has a very different view of inventory. Money on the shelf is not money in the bank. Therefore they try to keep par levels low and reorder points minimal. They have never heard of the rule “One item for the table and one item for the floor!”
When there is only one product left and it becomes contaminated and cannot be used, the cardiologist may start speaking in flowery foreign languages that usually include a lot of four-letter words. Those words may be accompanied by the facial expressions and body language that leave memories of this situation that will last a lifetime. Therefore, follow the Noah’s Ark rule – always have two of critical supplies.
Work with material management so that when shortages occur or supplies are on back order, and yes, errors are made in ordering supplies, you have options. Can you get supplies from a neighboring cardiac cath lab? Are there other cardiac cath labs in your system from which you can access supplies? Can the vendor find cardiac cath labs that haven’t used their supply? Is there a substitute product that will meet the need? Have options for securing supplies in your plan: what will you do if you need to find supplies elsewhere in a short amount of time? Materials management can help!
Third, supplies expire. It happens. When you least expect it, looking at the expiration date on a product, you suddenly become aware we are not in 2014 anymore. Now you have four bottles of Rotoblator lubricant, but it is all out of date. Then you may borrow from the nearest hospital only to find as you are rushing out their door that their lubricant is also out of date. Now quickly drive on to the next hospital and next, until you can bring home some safe non-expired product before 1:00 pm. As Ronald Reagan said, “Trust, but verify.” Double-check your supplies monthly to avoid speeding tickets and disgruntled cardiologists.
Fourth, vendors send their representatives to get you to buy and use their products. The representatives also speak with materials management and the physicians. This is a classic case of “what we have here is a failure to communicate.” Physicians expect this new and improved product now, materials management has a process in place that calls for product analysis for fiscal responsibility (cost impact or cost savings), and any new product has to go through the facility’s New Product Review committee that typically takes place once a month. Now, you are meeting with the representative this afternoon, but forced to wait on materials management to run through their processes before moving forward with any new request.
Representatives are very useful. They are my spies. I send them to other facilities, because I don’t have the time to go myself. They report back on the activity, environment, and demands at other places which saves me the time and bother of checking on the trends outside my hospital.
Fifth, and probably the hardest management or judgment call, is the crystal ball. Seeing the future and predicting future activity is a guessing game. Years ago in Johnstown, Pennsylvania at Conemaugh Memorial Hospital, we were starting a new cardiac cath lab. We did our homework and predicted 200 cases for our first year. We were well stocked for our opening, but quickly ran out of supplies as we did over fifty cases the first month and over a thousand cases the first year! I was on the phone and in the car trying to keep the cardiac cath lab running, as we were quickly running short or out of even the most common supplies due to the high demand for service. We did not see or imagine such a high demand coming, but it was there before we knew it!
This works both ways. In the 1990’s, we did three or four rotational atherectomy cases a day and now we do three or four every two months, and this is declining. There is still a need, but the volume has diminished to the point that some 8 French guide catheters are not available. The technology is changing and in some instances, it becomes obsolete. Yet some cardiologists may believe this is the best treatment for their patient. Make your cardiologists aware of manufacturing changes and end of life for equipment and supplies.
The best predictor of future demands is past demands. The demand does change. Look for patterns of service. Before holidays, are there more or less? Are certain cardiologists on vacation? Will they do a heavier load before leaving or coming back? Is technology in transition? Are you going towards more radial cases and less femoral cases? Are there more peripheral cases? Just keep in mind, things change and anticipate so you can be ready. Sometimes you are left holding the bag. Supplies sitting on the shelf will eventually expire. This is a double expense to the hospital when it was originally intended to generate revenue through use. If you don’t use it, you lose it!
The gist of this article is to not be “in want of a nail.” Do your due diligence. Work with the cardiologists and staff to agree on what is needed. Work with materials management and have the product available. Be prepared for shortages, back orders, and errors in ordering supplies. Have option B in your game plan if you need to find supplies elsewhere in a short amount of time. Keep track of expiration dates. Vendors can help you see activity in other cardiac cath labs. In the end, be cautious and be prepared for changes in inventory.
Part 2: Smooth sailing with supplies and inventory!
So how do we sail through this choppy water that sometimes seems like twenty-foot waves? Communication and cooperation with the cardiologists, staff, and material management are the keys to success with inventory:
A) If you tell physicians when and what supplies you are running low on, they will work with you to avoid crisis situations. When supplies are going to expire in a month, they can adjust their techniques to use the supplies in a timely fashion before they expire. The cardiologists can tell you what supplies they need and don’t need any more. You can encourage them to discuss standardizing supplies. Do all of these things on a monthly basis, if possible.
B) The most valuable inventory or resource you have is your staff. Retention of good staff is important. Staff with training and knowledge of inventory is highly prized. This staff can alert you to changes in demand. This staff can warn you when supplies are getting low. This trained staff can prevent the use of expired product. Their engaged minds are really of value, so when you ask…your staff can even provide great ideas for saving inventory and money in the cardiac cath lab.
Many times you are dealt a handful of cards (or staff) that you may not be pleased with. We may want to discard a few and hope for replacements that will leave us holding a better hand. I warn you. This is a gamble. You may get dealt a worse hand than you started with. Replacing staff costs time and money. Yet what is not considered is the cost in trust and relationships. Your old staff will pay some of this price as well.
My general recommendation is to spend the time retraining and motivating the existing staff. Transform what you have on hand. Change routines, start with building the team and have them double-check the work. When the baseball gets through the infield, the outfielders don’t say – that was their job, I’m not going to pick up the ball. They are a team. The outfielder tries to stop the forward advance of the batter, even if there is an error by the infield.
True, too, in healthcare. We double-check and sometime triple-check to avoid errors in medication, procedures, allergies, billing, and expiration dates of supplies. The team has different positions with different responsibilities, yet only when we communicate and work together is there a smooth-running organization!
C) Having an inventory buyer and material management stock clerk in the cardiac cath lab will help eliminate many problems. A dedicated buyer and stocker should be a part of your department, part of your team, and working side by side with you and your staff daily to create smoother operation.
This concept has worked. In discussing it with my director of materials management, he shared that in his last hospital that is exactly what he did. He put an inventory control tech and a buyer right in the department. They became part of the team, and their operation greatly improved the workings of the cath lab. Expectations grew, demands met, inventory turned, trust developed, relationships happened, and all because they were right there to handle any possible situation that could come up. They were one team, unified to accomplish the same goals to better serve their physicians and patients.
Unfortunately, this cannot always be the case. The lack of adequate materials management personnel is an age-old problem. Your push for adequate materials management support will be a constant battle and challenge in today’s economy.
D) Finally, cardiologists, staff, materials management, and vendors may be most helpful at times. However, what we tend to remember are the negative and tough times we have with folks. This is good when we fail forward; when we learn from our mistakes. When resources are so tight that inventory is a daily dilemma, then something is wrong. A different road needs to be chosen.
“Insanity: doing the same thing over and over again and expecting different results.”
— Albert Einstein
So, how can you be prepared? Supplies are the lifeblood of the cardiac cath lab. There is no single answer. Certainly, this is not a simple resolution to a problem that has taken years to evolve. Hopefully, you have this mostly under control. If re-supplying the cardiac cath lab is a constant headache, then take the time to assess the situation. I know that “when you’re up to your neck in alligators, it’s easy to forget that the initial objective was to drain the swamp.”
Just as in the clinical cardiac cath lab, you need to assess the situation (patient) before you do anything. Make sure that the “chemistry” is safe before performing a cardiac cath on a patient. Make sure your chemistry with cardiologists, staff, and materials management is appropriate. Communicate well with the cardiologists. Have them make a shopping list at least 48 hours (if not a week) before scheduling unique cases requiring special equipment. Just having a shopping list for each case is not a bad idea (thank you, Dr. Paul A. Slota!)
You may even have a shopping list on the scheduling board to keep everyone alert to needed inventory. At your morning huddle, every day, bring up the topic of supplies and inventory. Not only ask what is running low and what the physicians are trending to use more of, but let your staff know what is on back order and what new products and supplies are being considered to replace current inventory.
Develop a good relationship with materials management. Work with your re-supplier. Learn to speak their language. What you call a TR Band, they call a 309265, Device, Compression Radial. You almost need a Rosetta Stone to translate. If possible, have a dedicated materials management person in your cardiac cath lab to improve service. They should be able to interpret between your staff and materials management. Their duties would include checking for low stock levels, expiring inventory, and ensuring that bar codes are current and standardized. Bar codes can change as quickly as the weather and this causes more inefficiencies. Either the product does not get charged for and reordered, or worse, the wrong item is charged for.
When there is no cavalry coming to your rescue, you need to use your own troops to get the job done. This comes under all other duties as assigned. There is no productivity associated with this maintenance of inventory, but the cost of not having appropriate levels of in-date inventory is staggering. You know your losses better than I do, but I have seen some cases where the inventory loss was over $10,000 per month. This was due to lack of inventory loss, lack of scanning and expiration of product.
Consignment can help, but not every company will be willing to keep their inventory in your lab. Working with the vendors, you may be able to get some items on consignment (remember, if you don’t ask, the answer is always “no!”).
What is the takeaway from this lamentation of supplies and inventory? There are many challenges to keeping your cardiac cath lab well stocked. It can only be accomplished with a team effort. Your staff, the cardiologists, materials management, administration, and the vendors all must communicate and coordinate their needs, their options, and their alternatives to meet the needs of your cardiac cath lab.
For want of attention to the details, the whole cardiac cath lab may suffer. Pay attention to the details (for want of a nail!). Delegate responsibilities with trust, but verify that the responsibilities are met. You can make the cardiac cath lab a smooth-sailing operation.
Bonne chance et bon courage!
The authors can be contacted via Marshall Ritchey at Marshall.Ritchey@tenethealth.com.