Continuous quality improvement (CQI) is frequently discussed and emphasized in healthcare organizations. But what is “quality improvement”? How is it defined, implemented, and practiced in the cardiac cath lab? Ultimately, the purpose of continuous quality improvement is for cath labs to promote and sustain their presence on the cutting edge of optimal patient care. If patient outcomes and satisfaction are at the center of improvement strategies and processes, the end result is a win for all invested parties. This article is designed to offer definitions of continuous quality improvement, practical applications for the cardiac cath lab, tools for implementing high-caliber quality improvement programs, and sample processes and projects that can enhance the effectiveness of cath lab performance and outcomes. Our discussion will offer an opportunity to review, retool, and reinvest in the essential elements of a high-caliber CQI program.
What is CQI in the Cardiac Cath Lab?CQI includes a wide array of concepts such quality control, key performance or quality indicators, resource management, value-added processes, process improvements, organizational mission and vision philosophies, and strategic planning. These ideas were traditionally included in a concept known as ‘quality assurance.’ However, quality assurance was based on reviews of selected outcomes, and how practice and recommended standards matched up. Continuous quality improvement implies a process that is proactive and identifies opportunities for the improvement of processes, structure, performance and outcomes.1 It takes a determined and well-thought-out approach to create, develop and maintain an organization that is invested in the dynamic, proactive ideals of CQI. Fundamentally, CQI incorporates innovative and interactive solutions to challenging issues in the contemporary cath lab. It allows the creation and maintenance of a cath lab that is proactive, flexible, and current with best practices. A cath lab with an effective CQI program should constantly reflect upon its mission, vision and purpose, and strive to improve outcomes and performance. Such a philosophy encourages cath lab staff to recognize and implement the best practices, processes and standards to improve staff performance, as well as patient safety and outcomes.
How Do We Take the First Steps?Since positive patient outcomes and satisfaction should be the end result of an effective CQI program, cath labs should constantly review and retool practices as necessary to reach this goal. Most regulatory and quality improvement organizations focus on two critical indicators to ensure CQI: 1) performance indicators, such as meeting door-to balloon times, and 2) patient outcomes, such as reductions in post procedural complication rates. Whether it is the American College of Cardiology (ACC), the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS), Pennsylvania Healthcare Quality Alliance (PHQCA), or other key healthcare organizations, there is a general consensus that these two indicators are fundamental to a successful CQI program. Using cath lab performance and outcomes measurements as primary criteria for quality assurance programs places the emphasis where it belongs: on the patient.2 The HCAHPS website (www.hcahpsonline.org) is an important CQI tool. Hospitals implement HCAHPS under the auspices of the Hospital Quality Alliance (HQA), a private/public partnership that includes major hospital associations, government agencies, consumer groups, measurement and accrediting bodies, and other stakeholders that share a common interest in improving hospital quality. 2 This comprehensive approach is the hallmark of effective CQI. This philosophy is also supported and supplemented by other organizations like the Pennsylvania Healthcare Quality Alliance (www. phcqa.org) which measures core performance indicators such as the management of acute myocardial infarctions, and other metrics that allow hospitals to review and revisit their practices. 3 In the cath lab, it is the responsibility of every team member, as well as management and other public and private parties, to work cohesively to improve quality. Because standards, processes and scopes of practice vary among cath labs, each lab needs to understand its unique scope of practice, organizational philosophy and community responsibilities. According to the ACC, there are presently no standards for defining quality assurance in the cardiac cath lab. 1 While all labs are emphasizing similar key performance indicators such as door-to-balloon times, reducing complications, improving cost containment, and implementing best current practices, each lab has different structure, scopes of practice, and different types of patients. Even the equipment, logistics, and staff experience levels may vary widely from lab to lab. Therefore, an effective program needs to be individually tailored by each cath lab. There are many entities that can assist with improving quality in the cath lab. The Joint Commission, ACC, American Heart Association (AHA), and for-profit organizations all offer their services to enhance care delivery and improve cath lab operational efficiency. Internal staff development resources and third parties, such as product vendors and professional societies, also offer important tools. Therefore, cath labs have many options at their disposal to create an organization that excels at quality improvement. All of these options are predicated on a proactive organization that values its employees, allows them to be part of organizational improvement, and is willing to have objective scrutiny of their operations to make meaningful change. 4
What Should We Focus on and Encourage?Involve Staff: Shared Governance. At Pennsylvania Hospital, there are several processes that greatly enhance CQI in the cath lab. Shared governance committees are in place for each area of the hospital, including cardiology services. These committees allow the staff to share intimate knowledge about their specific area of practice and to make significant internal improvements and reforms as needed. They meet on a monthly basis, and address quality and safety, professional development, evidence-based practice, and resource management. For instance, in January 2010, the shared governance agenda for the cardiac cath lab included review of Avoximetry and Hemochron QC procedures, development and implementation of clinical ladders for registered cardiovascular invasive specialists (RCISs) and registered radiologic technologists [RT(R)s], and ensuring that the advanced skill sets of cardiology service nurses were being fully understood by the Clinical Advancement and Recognition program (CARP) committee, which reviews clinical ladder advancement. Other topics included updating the cardiology services website and having staff members provide “Flash Huddle” in-services that allow cardiac cath lab staff to provide education to post-procedural care units during the course of the day. Huddles include topics such as post procedural care of cath lab patients and maintain our proactive philosophy of reducing post-cath complications. The in-servicing is interactive and done during work hours on patient care floors. Discussions of comprehensive post-procedural management of patients include reviews of closure and hemostasis devices. Staff is also provided with a decision-making tree allowing for rapid diagnosis of potential problems, in a process similar to advanced cardiac life support (ACLS) algorithms. Ultimately, such inservicing promotes staff relations, intradepartmental communication, staff development, and patient safety and outcomes. Adopt a Patient-centered Philosophy. Pennsylvania Hospital also adheres to the “relationship-based care” philosophy developed by Koloroutis. 5 Relationship-based care places the patient and their families at the center of all delivery models. It emphasizes resource utilization, leadership, interdepartmental communication and collaboration, professionalism, and care delivery.5 Pennsylvania Hospital regularly reviews and discusses this philosophy, both formally and informally. The hospital encourages all staff to participate in optimizing patient outcomes, and ensures that all quality improvement creates greater awareness of the needs of patients and their families. This tool is invaluable for organizations that want to improve their patient care philosophy and invest the entire staff in proactive solutions to healthcare. Encourage and Support Education. Performance improvement also requires the creation and sustenance of learning and knowledge-based organization, which reflects, reviews, retools and reinvents itself on a continuous basis. The University of Pennsylvania Health System, of which Pennsylvania Hospital is a member, is dedicated to the pursuit of continuous staff development and education. Continuous education is essential to guaranteeing CQI. The Health System offers generous educational benefits, provides comprehensive internal staff development, skills fairs to maintain clinical proficiency, and the renewal and updating of mandatory competencies to maintain a well-prepared staff. Pennsylvania Hospital also offers its facilities to local universities and colleges to develop the next generation of nurses and technologists in cardiology services. This broad-based commitment to knowledge and learning promotes a well-educated staff that is able to constantly challenge and critique itself. Staff members are encouraged to use their talents to enhance performance and patient outcomes. Cath lab members serve on patient safety committees, assist in inventory management, staff and student development, clinical precepting, and advanced technology applications. Communication is improved as a result of these actions, the staff grows from constructive dialogue, and stays current with standards and best practices. Clinical competency is enhanced, and staff members are encouraged to reflect upon and review procedural outcomes and processes to improve practice.
What Tools Should We Use? PDCAThe classic tools for designing quality assurance projects are PDCA models, which have been used successfully in the business world for many years. At Pennsylvania, there are PDCA models prominently displayed throughout the hospital to emphasize the continuous and proactive philosophy that the hospital has established as a hallmark of excellence. The PDCA model uses a 4-four step approach to designing, evaluating and improving CQI: Plan, Do, Check, Act. A project “plan” requires commitment, knowledge and research to design improvement initiatives. “Do” requires action and persistence to see ideas reach fruition. The “check” process requires regular reviews to ensure that projects are being retooled as necessary. Finally, the “act” element demands a dynamic organization that will review and upgrade processes as necessary to make sure they are practical, useful and relevant.
Sample CQI Project: Using PDCA to Create a Clinical LadderCQI projects may include reviewing and updating patient care standards, processes, performance standards, and/or staff development. The cath lab at Pennsylvania Hospital is presently designing clinical ladders to recognize the contributions and talents of the RT(R)s and RCISs. Ladders enhance patient outcomes by developing clinical excellence and tapping into the diverse talents of staff members. Clinical scholarship and performance are improved when a clinical ladder encourages staff to implement ideas, launch projects, become more involved in staff development, and share tacit knowledge and expertise with other staff members. For this particular project, the PDCA method is being used to create, evaluate and implement a clinical ladder program. Plan. The planning phase involved reviewing existing templates for other allied health areas. Since diagnostic imaging closely parallels the clinical skills of cath lab technologists, this template and others were reviewed to develop a clinical ladder process. Pennsylvania Hospital also has a program called the Clinical Advancement and Recognition program (CARP), which emphasizes four primary criteria for clinical advancement: 6 • Clinical judgment and decision-making • Staff/patient relationships • Clinical leadership • Clinical scholarship These criteria enabled the staff to design a comprehensive, rigorous, and dynamic clinical ladder process. The clinical ladder process was initially requested by the technical staff, and supported by management and the education department. The impetus to develop the ladders was also encouraged after receiving inquiries from other hospitals about clinical ladder processes for cardiac cath lab technologists. These forces created a strong push to develop ladders for the cath lab technologists and to share this process with other cath labs. The ladders were designed by senior technologists, and received the assistance and active support of the nursing education department and cardiology services management. Clinical ladders were modified from the radiology services template and adjusted for the cath lab. The scope of practice for technologists was evaluated, and critical criteria were identified to assess clinical judgment, leadership and scholarship, as well as staff-staff and staff-patient relationships. A point value is assigned to a wide array of benchmarks to determine whether a candidate is qualified for clinical ladder advancement. Some of the criteria include providing inservices, reviewing and writing policies, serving on hospital committees, publishing articles for professional societies, and being a ‘super user’ on advanced technology and procedures such as intravascular ultrasound, rotational atherectomy, non-cardiac interventions and quality control processes. It is important to note that the planning stage of the clinical ladders is worthless if the process does not have the support and input from the staff that is necessary for its practical application. It will also be necessary to determine who will be reviewing the candidates, and ensure that they are qualified to review and approve applications. Do. Cath lab staff is presently reviewing and modifying the initial template. This refinement will allow vital input from all team members. In March 2010, clinical ladders were submitted for administrative review and feedback. After this process is completed, the clinical ladders will be integrated into practice, and used to promote staff performance and development. Check. After clinical ladders are implemented, they need to be assessed to see if candidates are applying for and receiving the clinical ladder advancement for which they are striving. If the ladders are practical, then qualified candidates should emerge. Act. Finally, there needs to be regular checks and upgrades made to the clinical ladder process. As cath labs become more complex, and new procedures and practices are assimilated into practice, it will be necessary to retool the ladder process. Therefore, there needs to be a continuous and proactive commitment to the long-term success of this initiative.
Where Else Can We Use PDCA?At Pennsylvania Hospital, PDCA is also used to assist staff in developing and reviewing processes that improve staff performance and patient outcomes. Door-to-Balloon Times. The most emphasized quality improvement process in the cath lab concerns door-to-balloon (D2B) times. This national effort for quality improvement was a collaborative movement by the major forces in cardiac cath lab care, and has made a significant impact on patient outcomes and staff performance. D2B times have improved significantly since the inception of the D2B Alliance program in November 2006. The D2B Alliance is a quality improvement effort by the ACC (with the AHA) to coordinate research, evidence-based strategies, and proven protocols in an attempt to standardize and improve D2B times in patients with a ST-elevation myocardial infarction (STEMI). The goal of the Alliance is to achieve a D2B time of 90 minutes from the time of hospital presentation in more than 75% of patients with STEMI. Since its launch, the D2B Alliance has enrolled more than 70% of the hospitals performing PCI. It has helped hospitals improve outcomes by providing toolkits and guidelines for a systematic approach to reducing D2B times. 7 It is also strongly reinforced by the Joint Commission and the Centers for Medicare and Medicaid Services (CMS). It is now a normal function of cath labs to do their utmost to fully comply with the D2B Alliance initiative, and to constantly review and attempt to improve their D2B processes. At Pennsylvania Hospital, D2B times are regularly reviewed by a multi-disciplinary panel. Patient outcomes are tracked both internally and via the ACC database to optimize patient care. Each case is discussed with the cath lab director within one business day of the procedure to review the procedural flow and patient outcomes. There is also a hospital committee that regularly meets to review all acute MIs and D2B performance indicators. This committee includes cardiologists, cath lab management, staff members, emergency room personnel, the rapid response team, and other vested parties. This monthly review provides regular communication and feedback between all parties involved in the D2B process. Through this process, communication is enhanced, procedures are more coordinated, processes become more streamlined, and outcomes are rigorously scrutinized. Quality control (QC) processes are also rigorously reviewed and updated. For example, in January 2010, the staff had an interactive session to review and update QC protocols for the cath lab. In February, the topic was the proper settings and test modes for recto-linear, biphasic defibrillators. By conducting these “flash in-services,” and raising these topics during the monthly shared governance meetings, there is a regular review of all cath lab functions and processes. These topics are the focus of patient safety, compliance with mandated standards, and the maintenance and function of essential and expensive hospital resources. The PDCA model has been instrumental in creating an effective QC program because there is a strategic plan to maintain and enhance QC. All staff members are capable of performing comprehensive QC and are in-serviced regularly on the procedures. Understanding QC is so important that point-of-care testing is part of the mandatory competency checklist for all cath lab staff. There are regular reviews of QC effectiveness, and any deficiencies are addressed informally, and through collaboration with point-of-care testing, nursing education, and product manufacturers and vendors.
ConclusionsThere are innumerable ways to create and sustain an organization that truly practices continuous quality improvement. CQI needs to be constantly reinforced and worked upon in order to maintain proficiencies, stay current with new technologies, and develop the best practices, processes, and procedural care standards. It also helps staff to become more deeply invested in performance and outcomes. The more interactive the staff is with CQI, the more valuable their contributions will be. Performance management and improvement requires a close relationship between management and staff, together with the ability on the part of managers to act on results. Most importantly, a CQI program will only work if it is given authority and support to make meaningful change. 8 If you aren’t sure where to begin, it is helpful to review an organized, concise format such as the online PowerPoint presentation “Cardiac Catheterisation Laboratory,” by Faiyaz. 9 It offers an excellent overview of the design of a cath lab. A concise presentation, it organizes the cath lab by historical progression, quality assurance, radiation safety and equipment, as well as other vital components that are useful in understanding the complexity of the cardiac cath lab. By reviewing and understanding the structure, function, mission and vision of a cardiac cath lab, it becomes easier to identify and improve organizational effectiveness and patient outcomes. Do you have ideas to promote excellence, make change, and improve the quality of your lab? Whether it is inventory management, education, quality control policy and procedure reviews, or serving on safety committees, there are limitless opportunities to make meaningful contributions to organizational effectiveness. Look at your cath lab’s processes, practices, procedures, performance and outcomes. If you excel in area, share it with your peers. If there are opportunities to excel, capitalize on them. If you identify a process that can be improved, act on it. Share your knowledge and skills to make your cath lab a center of excellence, one that constantly strives to optimize performance, and produce excellence inpatient care and outcomes. The authors can be contacted at firstname.lastname@example.org
1. Dehmer GJ, Hirshfeld JW, Ogden WJ, et al. (2004). CathKit: Improving quality in the cardiac catheterization laboratory. J Am Coll Cardiol 2004;43:893-899. 2. HCAHPS: Patients’ Perspectives of Care Survey. Centers for Medicaid and Medicare Services. Available at http:// ww.cms.hhs. gov/HospitalQUALITYINITS/30_HOSPITALHCAHPS.ASP. Accessed March 5, 2010. 3. Heart Attack. Quality Measures. Pennsylvania Healthcare Quality Alliance. Available at http://www.phcqa.org/measures/category.php?category_id=1. Accessed March 5, 2010. 4. Joint Commission on Accreditation Of Healthcare Organizations. (2009). 5. Koloroutis M, ed. Relationship-Based Care: A Model for Transforming Practice. Minneapolis, MN: Creative Health Care Management, Inc.; 2004. 6. University Of Pennsylvania Health System Intranet. Nursing education: CARP U.P.H.S. Clinical Advancement & Recognition Program. Available to employees only at http://uphsxnet.uphs.upenn.edu/[ahhome/nursingeducation/CARP/whatiscarp.htm. Accessed February 15, 2010. 7. Bradley EH, Nallamothu BK, Herrin J, et al. National efforts to improve door-to-balloon time results from the Door-to-Balloon Alliance. J Am Coll Cardiol 2009 Dec 15;54(25):2423-2429. 8. Martinez J. Assessing quality, outcome and performance management. Workshop on Global Health Workforce Strategy, Annecy, France, 9-12 Dec 2000. Paper commissioned by the World Health Organization, 2001. 9. Faiyaz A. Cardiac Catheterisation Laboratory. Available at: http://www. slideshare.net/altaf _faiyaz/cardiac-catheterisation-laaboratory-altaf-faiyaz-presentation. Accessed March 5, 2010.