The uncertainty surrounding the Affordable Care Act, coupled with difficult economic times, has caused a number of healthcare organizations to pause and reassess whether or not to move forward with new cath lab construction and/or renovation of existing space. In some cases, financial factors have strained the ability of administrators to secure the capital funding required to construct, upgrade, or update space.
According to the results of a survey by Health Facilities Management Magazine and the American Society for Healthcare Engineering, one-third of planned hospital renovation projects will be delayed or might not move forward.1 From this survey, relatively smaller renovations are not down as much as the large construction projects, but have declined from past years as well. However, despite the implications of a downward trend in expansions or renovations, Corazon believes the delay in making changes to add capacity may, in fact, be a blessing in disguise.
For years, providers have experienced growth in cath lab volumes. And, although heightened scrutiny relative to Appropriate Use Criteria (AUC) has tempered these increases more recently, we continue to see demand for cardiovascular (CV) services in our work across the country. This may be due to several factors, including an aging population, continued migration of patient care to less-invasive modalities, and advancements in technologies and skillsets, all of which lead to continued service expansions by providers as a result of this steady or increasing need.
At the same time, financial constraints are challenging healthcare managers to effectively provide care for a growing patient population in existing space. If capital constraints weren’t as prevalent as they are today, a number of these providers may have found the means to simply add more capacity through additional lab space. Indeed, even amid any downturn, cath labs have continued to function as profit centers for hospitals, and therefore play a crucial role in the contribution margins of the CV service line in particular. Whether it’s funding limitations or a lack of available space to expand, management of these areas can confront major difficulties with finding means to accommodate a growing number of procedures in the same amount of space.
In such cases, Corazon often recommends that providers identify additional lab capacity by working to understand current patient throughput “bottlenecks” and their impact on capacity. This is a relatively low-cost solution to addressing capacity issues, whereas an expansion plan or implementation can result in extreme output of financial, time, and human resources. Being proactive and first completing an efficiency analysis related to capacity can save time and money in the long term. Changes implemented to address issues resulting from the analysis are often inexpensive and easy to enact — a preferred scenario in today’s healthcare environment!
When evaluating the capacity and utilization of a lab, a number of methodologies have been employed for various reasons. Some are driven by regulation, while the impetus for others may be rooted in continuous quality improvement efforts.
Most often, providers use a simple evaluation of scheduling to determine their current capacity. For example, providers will simply review the average number of cases completed per time increment (day, week, month) and associate that to the total number of available slots on the schedule. This approach provides an idea of how lab space and staff are (or are not) being utilized, but does not provide enough useful information in order to identify gaps, gain efficiency, and enhance operations.
In a state requiring certificate of need (CON) for the development of or expansion to add a cath lab, such regulation may provide cause for taking a different approach to evaluating capacity. In these markets, a methodology that utilizes procedure equivalents to determine lab use serves as the approach. In a number of CON states, a hospital is required to apply weighted procedure equivalents to the procedures performed in a lab, such as those found in Table 1.
To determine the utilization or capacity of a current lab, the provider will simply add the total procedure weights for procedures performed (or projected) and compare that to the total capacity for a cath lab. For a number of these regulated states, the capacity for a cath lab is equal to 2,000 weighted cases per year. As an example, if Hospital ABC performed 700 diagnostic caths, 300 therapeutic cardiac caths, and 200 peripheral angiograms in a lab last year, the lab would have been operating at 80% capacity using this methodology. This approach provides a very simple understanding of the lab’s capacity for regional planning purposes, but is not useful when attempting to understand whether specific opportunities for improvement exist in a provider’s current lab(s).
When evaluating capacity of lab space, we recommend that organizations apply a more detailed approach that can be as complex as is required by the situation. Although the level of complexity may vary, there are some common tenants involved in the equation that should be incorporated in all situations, including:
- Availability of the lab. Incorporate the actual lab availability into the equation based upon the standard hours of operation.
- Actual average procedure times. If possible, it is preferred to derive this at an operator level to better understand the particular physician’s impact upon capacity.
- Approach to scheduling. Apply the methodology used for case scheduling (e.g., open, block, etc.)
- Room turnover time. Incorporate the actual room turnover time (time from when the previous patient leaves the lab until it is ready for the next case) into the analysis.
- Inefficiency factor. Account for the common inefficiencies that impact case scheduling.
Some providers have a better handle than others on the impact that inefficiency has on current capacity. These factors may include any number of things, such as delays to scheduled start times due to patient readiness, physician delays, and the like; impact of emergent/urgent cases on scheduled cases; and challenges associated with current approaches to case scheduling. Working to limit the amount of such variances will not only improve efficiency and patient throughput, but also increase an existing lab’s capacity. In instances when providers do not have a good understanding of specific inefficiencies involved, we recommend applying a general inefficiency factor to account for unknowns.
Using this more detailed approach, the same lab at ABC Hospital would be calculated to function at 57% of capacity. This approach provides ABC Hospital with a better understanding of the actual capacity of the lab when compared to the previous regulatory example, and will aid in determining whether capacity exists for continued growth prior to requiring additional lab space.
In addition, this approach allows for understanding the impact individual operators have on capacity and effective lab utilization. Based on the method described above, the capacity impact by operator is is explained in Table 3.
If ABC Hospital were to generate accurate data that quantifies physician-related inefficiencies in the care process, the hospital would have a clearer understanding of the physician impact on capacity and lab utilization. Likewise, it will provide management with a mechanism to make adjustments aimed at improving lab utilization. When projecting growth in procedural volume by physician, management will be in a better position to understand the impact new patient volumes will have on existing infrastructure. This type of analysis can reveal potentially simple solutions (i.e., scheduling adjustments) that may be the difference between expanding capacity and improving lab utilization in existing space vs. adding new lab space unnecessarily.
With continued growth in the volumes of the varied procedure types provided in a cath lab setting, the ability to effectively manage scheduling and capacity will become even more complex. This is particularly true of sites that have introduced hybrid rooms to manage some of the procedural volumes that were once scheduled in a traditional cath lab space. In addition, as programs continue to diversify their service offerings and expand capabilities to offer new services, the need to understand capacity implications will become even more important. For example, as more providers develop advanced electrophysiology programs, the impact on lab need/capacity may be significant, especially given the relatively long average times for the more complex procedures.
At present, providers are challenged to tighten operations and do more in the same space. The ability to conduct more detailed evaluations of lab utilization and capacity will allow organizations to affect change where necessary to function more efficiently, and effectively increase capacity in current labs without the need for immediate investments in new space.
David is a Senior Vice President at Corazon, Inc., offering consulting, recruitment, interim management, and IT solutions for hospitals and practices in the heart, vascular, neuro, and orthopedics specialties. To learn more, call (412) 364-8200 or visit www.corazoninc.com. To reach the author, email firstname.lastname@example.org.