Cath Lab Work Flow Redesign New Horizons Using Lean Tools

1Michael Heinrichs, BS, Pharm D, Associate Administrator Clinical Support Services; 2Gerard Leone, MSIE, MBA, Senior Partner; 1Beth Hamstra, RN, RCIS, PhD, Clinical Manager Invasive Cardiology Services; 1 Oda Roozeboom, RN, MNA, Clinical Manager Non-Invasive Cardiology Services
1Michael Heinrichs, BS, Pharm D, Associate Administrator Clinical Support Services; 2Gerard Leone, MSIE, MBA, Senior Partner; 1Beth Hamstra, RN, RCIS, PhD, Clinical Manager Invasive Cardiology Services; 1 Oda Roozeboom, RN, MNA, Clinical Manager Non-Invasive Cardiology Services
The department of non-invasive cardiology offers echocardiography, peripheral vascular and nuclear imaging, and a complete offering of ECG-related procedures. Non-invasive cardiology services are offered to all patient age groups, including neonates. This department has over 15,000 patient visits annually.
The invasive cardiology department serves greater than 3,000 patients annually and performs over 7,000 procedures per year. Services include invasive diagnostic cardiac catheterizations, interventional procedures, a complete line of electrophysiology services and peripheral vascular procedures. The department has four procedure rooms. Two are dedicated to cardiac catheterization, one room is dedicated to electrophysiology and the fourth room is dual-purpose, used for both electrophysiology procedures and peripheral vascular procedures.
In the beginning of 2004,the invasive cardiology department was facing a number of significant challenges. Medical staff was disappointed with the inability of the cath lab team to start cases as scheduled and to turn over rooms promptly for the next case. Additionally, medical staff felt unfairly pressured by cath lab administration to be timely in cases that often started late. In the face of ever-growing patient loads, cath lab staff was expected to start cases on time and to turn over rooms for new cases as quickly as possible. The staff grew more frustrated as work demands increased. There was less flexibility to recover from ever more complex and stressful work. The cath lab team felt pressured to work harder for the same rewards, without additional staff or tools to alleviate the stress of their workload.
In the spring of 2004, the invasive cardiology department teamed with the Business Process Consulting Group (BPCG, Inc., Littleton, Colorado). BPCG was tasked with evaluating, redesigning, and improving the workflow in the cath lab using the methodology of a lean workflow improvement process. Primary objectives were to improve patient throughput in the cath lab, improve on-time starts, maintain the high quality of care delivered by the patient care team and produce these improvements within existing budget constraints. This article will describe the process and results of the lean workflow re-design project implemented in the third quarter of 2004 in the cath lab at Memorial Hospital Colorado Springs. What is a Lean Methodology? In the past three decades, manufacturing companies applied the tools and techniques of lean workflow and made great gains in productivity, efficiency, quality and safety. The concept of lean workflow focuses on the elimination of wasteful activities through the linking and balancing of the work steps required to complete a case, transaction, or product. In essence, lean refers to the tools used to drive waste out of a set of processes.1 By eliminating process waste, lean increases value. The definition of value within the complex healthcare environment depends on the type of transaction and the customer under analysis. In some cases, the patients are the recipients of that value, sometimes the physicians, and other times it is the insurance providers.
As has been proven in manufacturing and office environments, lean increases value for all stakeholders in the process through the elimination of waste. Implementing a lean workflow links and balances the work steps along the value stream. Why Lean? The key reason to pursue a lean strategy is because there are benefits to be realized that result in higher value for all stakeholders. Many businesses, large and small, dealing with physical or transactional products and in different cultural environments, have enjoyed the benefits of a lean strategy for decades, and their achievements are well-documented. We have lately begun to see documented benefits in the administrative2 and healthcare environments as well.3,4,5,6
Some of the benefits lean practitioners achieve are: Faster response. By driving out waste from the process, only the productive elements of work remain, allowing the response time to a patient or case to be much faster. Improved patient satisfaction. When a healthcare professional has less wasteful activities to worry about, she/he has more time to dedicate to patient care. The linking and balancing of processes, inherent to a lean design, will also greatly reduce patient wait times. Improved quality. By linking and balancing processes, the elements of work are communicated, allowing for cross-checking techniques like Check-Do-Check that can greatly reduce the impact of unavoidable human mistakes, thus improving quality and safety. Improved staff satisfaction. By conducting a structured analysis and redesign of processes, necessary staff activities like breaks, lunches, and quality improvement meetings are designed into the process and no longer considered a luxury, but rather a necessity. The Lean Workflow Methodology Used at MHCS The implementation of lean workflow in healthcare must follow a clear and methodical path in order to ensure success. These methods can be found in many specialty books. However, there are no texts as yet dedicated exclusively to healthcare. The tools and techniques of lean workflow for healthcare as described in the reference book chosen by MHCS are as follows:7 Defining a Target Area In a single project, attempting to implement lean workflow across an entire healthcare facility can be a daunting task, leading to frustration, delayed results or even premature abandonment of the project. A well-defined and focused project area will ensure a clear proof of concept within a reasonable period of time and serve as a model of performance for other departments to emulate.
Taking a team approach and bringing together individuals from all affected areas in the research, design and implementation is also crucial to success. The more that staff, physicians, etc., view the redesign as a collaborative product of their efforts, the more likely it is that the process redesign will function effectively long-term. Identifying Transactions/Case Types This step in the lean workflow implementation requires the team to identify all the types of cases that are performed in the cath lab. The following are examples of case types at MHCS: Adult diagnostic Adult diagnostic with intervention Adult intervention Pediatric diagnostic Pediatric diagnostic with intervention Pediatric intervention Adult implant Emergency Understanding the case types will allow the implementation team to assign desired capacity volume to each type of case. The sum of all case volumes is the total cath lab capacity. Using this figure, we calculate the cath lab processing rate and figure out the number of required resources to service all the defined case types. Identifying Processes For the purpose of our cath lab methodology, a process is defined as a series of interrelated tasks that move a case from inception to completion. A process can also be understood as work performed by a person, a machine or combination of both. Some examples of processes the team identified in the MHCS cath lab were: Check-in. A process containing tasks associated with welcoming and registering the patient until the moment they are ready to be received in the pre-procedure room. Holding. For our case study, the Holding Room is the pre-procedure room where many important tasks are performed, including IV starts, pre-procedure sedation, patient preparation for procedure, and carrying out patient assessment. This process encompasses all tasks between check-in and the actual cath lab procedure. Procedure. This process identifier refers to all the activities from gloves on to gloves off. Creating Process Flow Diagrams Once we know what we do (the case type) and how we do it (the processes), we need to describe how the processes required for a specific case type are related to each other. As an example, let’s look at the process flow diagram (PFD) for an outpatient adult diagnostic case: Pre-admission Check-in Holding Procedure Recovery Discharge This PFD shows not only the processes involved in the completion of the case but also the sequence in which these processes take place. For the process designer, a PFD is one equation in the mathematical model necessary to calculate the required number of resources in the MHCS cath lab. The Process Flow Map A Process Flow Map is a matrix that shows all case types (rows) and all processes (columns). The first goal of this tool is to display the process commonalities among the various case types. A simplified example of a Process Flow Map is below: This map will help us identify groups of cases that share the same processes. These groupings are referred to as Case Families. Case Families play a critical role in the re-alignment of resources based on process commonalties. Understanding Case Volumes Once the team has a list with all case types, we must assign a volume to each type to populate the required-resource calculation model and ultimately, determine a target goal. After statistically analyzing the caseload for the last 24 months, hospital management and BPCG decided to re-design the cath lab processes for a 20% increase in throughput capacity. Calculating the Processing Rate Once we know the volume requirements per case type, we can calculate the processing rate. The processing rate establishes the average time for the MHCS cath lab to complete a case. It is also a key factor for calculating the number of required resources per process. Standard Work Definitions Every X in the Process Flow Map above indicates that there is work being performed by a person, a machine, or a machine attended by a person. To delve into the detail of each process, we use a form called the Standard Work Definition (SWD). The SWD allows us to document the work elements, standard times, resources, and quality criteria for every case/process relationship. Some of the most important data SWDs provide us with is: A detailed description of work steps The divisibility of work. Can a task be divided into sequential steps, allowing for work balancing, as well as for the implementation of the Check-Do-Check Total Quality Management (TQM) technique? Standard work times, categorized as performed by a machine resource, a people resource or a combination of both. The Total Standard Time per category will allow us to calculate the number of resources required to support the planned throughput capacity for the cath lab. Additional quality management: what the person performing a task must check before completing the task (self-check) and whether or not another person must check the same point afterwards (TQM cross-check). Calculating Required Resources We set up a calculation model to identify the amount of each resource type required in order to support the planned increased capacity for the cath lab and all its associated processes. The model results from the repeated application of a very simple algorithm applied to every process independently: Number of Resources = Standard Time (per case per process)/ Processing Rate (average time to complete a case) Defining the Optimized Workflow We now have calculated the required number of resources per process (i.e., staff, recovery beds, procedure rooms). The next step was physically to arrange these resources so that a case could be completed without interruptions or delays. We came up with an ideal process design, and adapted it to the cath lab’s physical constraints and interdependencies by the testing and retesting of our assumptions. At the completion of this stage, all aspects of the newly redesigned workflow were defined and documented. Balancing Work Steps Significant differences in the amount of work content, if not addressed, would negatively impact the cath lab throughput. To balance work steps, the team followed a methodical approach that included the elimination of unnecessary work elements, as well as adjusting staffing requirements for the steps with higher required work content. Creating a Deployment Plan The implementation team developed a detailed project plan describing all the steps necessary to bring ˜live’ the newly redesigned cath lab. With management approval, the team installed the new design into the procedure rooms and general department area, and initiated patient procedures. The new area was closely monitored, further adjustments were made as necessary, staff feedback was elicited and data was collected to measure performance improvements. Results The primary objectives of lean implementation were to improve room turnover time and improve on-time starts in the cath lab while avoiding sacrificing quality or increasing staff. The Memorial Hospital cath lab does not use block time methodology to schedule cases and staff is not contracted with the hospital. Therefore, the most accurate predictor of workflow redesign success related to room turnover came from measuring wheels-out, wheels-in time (wowi). Processes were put in place to measure the wowi time prior to the start of the lean project.
By analyzing work steps using Standard Work Definitions, tasks that delay the room turnover time were eliminated without impacting the staff’s ability to perform quality work. As a result, the redesign of the workflow in the cath lab resulted in a substantial reduction in the wowi time to turn over a cath lab procedure room (Figure 1). Immediately following the deployment of the workflow redesign, wowi room turnover improved by 25%. The post-implementation gains have stayed consistent well past the initial implementation phase.
The ability of staff to turn over procedure rooms from one procedure to the next more efficiently meant each cath lab procedure room could accomplish up to 20% more procedures per room. From the pre-implementation period to the post-implementation period, the patient volume in the cath lab has increased by 20%. During that same time period, the total worked hours per patient decreased by 5% (Figure 2). The improvement in cath lab productivity was accomplished as a result of lean processes to optimize and balance workflow.
The cath lab at MHCS measures and reports the percent of on-time starts for all cases, not just the first case of the day. However, the only metric available to evaluate on-time starts in the cath lab included on-time starts for all cases started in the invasive cardiology department, not just the cath lab. Therefore, reported results of on-time starts include cases started in the electrophysiology lab and the peripheral vascular procedure room. These are areas that were not impacted by the lean workflow project. Pre-implementation, cases began on-time an average of 83% of the time. Following the lean process improvement implementation, all cases start on time an average of 89% of the time (Figure 3).
It is common to see beneficial by-products resulting from lean implementations. The elimination of wasteful activities and cross-communication of processes used at MHCS’s invasive cardiology department uncovered some hidden opportunities. While the lean process improvement resulted in achievement of the desired primary goals, the project also resulted in a number of important secondary improvements. Secondary objectives resulting in gains included improving the patient experience, improving staff morale and increased respect of medical staff opinion.
The most dramatic secondary gain was the improvement in patient experience. Patient wait time to be registered for both invasive cardiology and non-invasive cardiology (outpatient) procedures was dramatically improved by the application of a number of steps and phases to improve the patient wait experience. The patient registration experience was plagued with several barriers to rapid patient registration. Communication failures with scheduling services, physician offices, registration customer representatives and patients were among the most significant challenges. The implementation team developed a series of Process Flow Diagrams (PFD) of the front office area in order to understand the steps that patients went through in order to get to their scheduled procedures. Through the analysis of the detailed work steps, the resulting optimized workflow eliminated significant amounts of waste (Figure 4).
To overcome the major challenges facing rapid patient registration, cardiology leadership needed to overcome traditional policies and procedures, inter-departmental silos and an inefficient physical layout. Utilizing lean re-design tools to analyze process interrelationships and effective teamwork, the barriers to improved patient registration were surmounted. Patient wait experience improved a remarkable 85% (Figure 5).
A historical perspective in healthcare holds that improving quality requires additional staff. The improved cardiology patient registration process further demonstrates that significant quality gains can be had without additional staffing. Productivity in the cardiology front office improved 30% over the pre-implementation and post-implementation period (Figure 6).
As was described earlier, prior to the lean implementation process, staff morale was clearly impacted by challenging working conditions. Ever-increasing expectations to improve performance and meet customer demands created ongoing frustration among staff, and tension between staff and departmental leadership. In the fall of 2004 and 2005, MHCS conducted employee satisfaction assessments utilizing the Business Practices Assessment by Success Profiles, Inc. (Bozeman, MT).
Employee satisfaction survey results from MHCS demonstrate that lean workflow improvements led to growth in invasive cardiology employee satisfaction. In the key category of Job Role, reflecting employee responses related to performing work effectively, authority to make decisions and the understanding of roles and responsibilities, invasive cardiology employee responses improved greater than 6% from 2004 to 2005. In the category of Work Environment, which assesses staff responses to factors such as involvement in change processes, ability to work together as a team and interdepartmental teamwork, employee responses improved by more than 18% from 2004 to 2005. For the two categories of Job Role and Work Environment, invasive cardiology employee satisfaction exceeded hospital-wide results.
Prior to lean workflow improvements in the cath lab, the medical staff was highly critical of the room turnover time and frustrated with the perceived failure to start cases on time. The ability to start cases on time and to quickly turn over procedure rooms came to be seen as a primary demonstration of hospital leadership’s ability to effectively manage the cath labs. In the spring of 2004, medical staff was surveyed on a number of questions related to performance in the cardiovascular service line. Physicians were asked, How satisfied would you be with a turnover time of 20 minutes or less in the cath lab? The majority of physicians responding to the survey said that they would be very satisfied with a turnover time of less than twenty minutes. Following the lean process improvement in the fall of 2004, cath lab room turnover time was reduced to an average of 18 minutes. In the 2005 survey of cardiologist satisfaction, invasive cardiologists responded that they were satisfied with the turnover time in the cath lab.
An important goal of the lean process improvement was to deliver efficiencies via throughput increase without having a negative impact on the overall quality of patient care. Mortality, morbidity, and adverse event rates in the cath lab have not been affected by the lean project. In fact, one quality indicator positively influenced by the lean process was door-to-balloon time. An organization-wide effort, chaired by the invasive cardiology manager, who was influenced by the impact of lean methodology, led to significant improvement in door-to-balloon times for patients presenting at MHCS. The door-to-balloon across the lesion time for all patients presenting with ST-elevation myocardial infarctions has improved from an average of 300 minutes to It is important to note that a number of improvements may be understated in our results analysis. Most notably, results related to on-time starts, as well as invasive cardiology productivity, may be understated. The lean improvement process was directed at throughput and other activities related to the cath lab at Memorial Hospital. However, the invasive cardiology department also provides extensive electrophysiology services and peripheral vascular services. On-time starts are reported here for the whole of invasive cardiology, including electrophysiology cases and peripheral vascular cases. There was no process in place to report on-time starts in the cath lab as an isolated metric. Therefore, it is possible that late starts in the electrophysiology and peripheral vascular lab may have diluted the resulted improvement in on-time starts for the department of invasive cardiology. This may be further supported by the fact that electrophysiologists, on the 2005 physician satisfaction survey, were dissatisfied with the efficiency of the electrophysiology service.
In addition, worked hours in the department of invasive cardiology are reported as worked hours for all employees, including staff that work in the cath lab, holding room, the electrophysiology lab and the peripheral vascular lab. As a result, productivity figures may be diluted or even negatively impacted by areas not impacted by the lean process improvement. It is therefore reasonable to conclude that productivity improved to a greater degree in the cath labs than the results reported in our experience.
Aside from the obvious value delivered to the staff, customers and patients of the invasive cardiology department, it is also important to consider the costs and financial benefits of a lean engagement. The experience of other healthcare providers who have employed lean production changes tell us that using expert consulting services are recommended to successfully launch a lean effort in a healthcare system.4,5 As such, if expert services are engaged to lead the lean improvement process, it is vital to demonstrate the financial value of such an engagement. Considering solely the productivity gains associated with this project, the five-year net present value of the lean engagement in invasive cardiology exceeded $350,000. If the project is evaluated based on increased throughput, providing that cath lab volume will increase to meet capacity, the five-year net present value of the lean improvement will exceed five million dollars. Obviously, less tangible assets such as improved employee satisfaction and retention, as well as medical staff satisfaction and retention, would significantly improve the net present value analysis if we apply financial figures to these assets. Conclusion In conclusion, the application of lean principles in an invasive cardiology department can result in profound benefits. All the players in the invasive cardiology space benefit from such an engagement. Patients benefit from a safer and more efficient work environment. Medical staff benefits from improved workflow and more satisfied patients. Employees win as a result of the elimination of wasteful work, resulting in a less-stressful work experience and improved productivity. Finally, the value recovered by lean implementation benefits all hospital stakeholders, from staff who enjoy a better working environment to physicians who can plan for their procedures to start on time, to the community at large, whose hospital gains the capacity to deliver care to more people. The authors can be contacted at michael.heinrichs@memhospcs.org, gleone@bpcg.us, beth.hamstra@memhospcs.org or oda.roozeboom@memhospcs.org
1. Womack J and Jones D. Lean Thinking: Banish Waste and Create Wealth in Your Corporation. 2nd ed. New York: Simon Shuster, Inc., 1996.

2. Leone G and DiFraia P. "Extend the benefits of flow throughout your enterprise, Hearing device maker adopts flow manufacturing." Advanced Manufacturing Magazine January 2001:19-22.

3. Panchak P. "Lean Health Care? It Works!." Industry Week 11 2003. 11 Mar 2004. Accessed at http://www.industryweek.com/ReadArticle.aspx?ArticleID=1331.

4. Wysocki B. "To Fix Health Care, Hospitals Take Tips From Factory Floor." Wall Street Journal April 9, 2004: A1.

5. Womack J, Byrne A, Fiume O, Kaplan G. Going Lean in Health Care. Cambridge: Institute for Healthcare Improvement, 2005.

6. Condel J, Sharbaugh D, Raab S. "Error-free pathology: applying lean production methods to anatomic pathology." Clin Lab Med 2004:865-899.

7. Leone G and Rahn RD. Fundamentals of Flow Manufacturing. 1st ed. Boulder: Flow Publishing, 2002.