The Importance of Process Management in Cardiovascular Outpatient Flow

Thomas James Jankowski, RN, Supervisor Cardiovascular Special Procedures Area ThedaCare Health System, Appleton, Wisconsin
Thomas James Jankowski, RN, Supervisor Cardiovascular Special Procedures Area ThedaCare Health System, Appleton, Wisconsin
With increasing health care costs, decreasing reimbursement and an increasing baby boomer population, the healthcare industry will soon realize the necessity of looking at process flow improvement in order to achieve cost savings. With information and quality measures steering consumer decisions, it is imperative that the healthcare industry not only meet these measures, but exceed them. This must be achieved while improving consumer satisfaction and providing safe and financially responsible healthcare. With this vision on the horizon, the proposal is not to work harder, but to work smarter, a goal that can be achieved with the implementation of standardized work, proactive and organized change, and the use of advancing technology. Financial Gains The growing cost of health care resources continues to place enormous pressure upon all aspects of the world market. Designing a healthcare system that is customer-focused and financially accountable will make healthcare organizations part of the solution rather than part of the problem. The continued survival of healthcare while finding permanent solutions to rising healthcare costs is attainable by using process flow redesign and lean principles. Organizations with a forward-thinking vision can use these savings to their advantage with a solid reinvestment strategy and through capital avoidance. Capital avoidance is the process of using process redesign, flow and throughput to avoid new construction, multi-million dollar additions, and freestanding clinics. These savings are then reinvested into areas with increased growth potential. The use of existing assets to provide savings, growth and financial stability, can be achieved without the associated costs of using borrowed money. At Appleton Medical Center (ThedaCare Health System), we have delayed the building of an additional cardiac catheterization lab by redesigning process flow, creative case scheduling, and building a collaborative partnership with our partners at the Appleton Heart Institute. The redesign of flow created capacity within current schedules and increased production capability. This capital avoidance savings, estimated to be approximately 1.6 million dollars, will allow for resources to be used to expand other services. This level of collaboration could not be achieved without the clear communication of goals, a collaborative effort between partners, and the flexibility of physicians and staff. To date, ThedaCare Rapid Improvement Events (R.I.E.), have achieved a projected savings of over ten million dollars. Organizations successful in achieving budget-neutral status and reinvesting their savings may ultimately pass on lower costs to the consumer. This business practice can increase market share, provide business stability, and position organizations to be leaders in the industry. Discussing the bottom line is always a hot topic. At some point it is important to bridge the gap between financial gain and providing world-class healthcare. The gains that can be realized by increasing flow through an area are many. For some facilities, it may mean saving millions of dollars by deferring or eliminating projected building projects. For others, it may mean changes to create capacity within an area, by improving the flow and reducing waste. Waste can come in several different forms, including wasted resources and wasted human talent. Many hospitals have been faced with patient bed census problems. By creating standard work, flow and throughput, a large patient volume may be moved through an area in a shorter time period. This reduces inpatient bed space needs, staffing, and the potential for errors, meaning less risk for patient incidents or infection, less overtime on nursing units and improved satisfaction of staff. Providing a standardized workflow and developing the ability to care for patients in a safe, timely and patient-centered manner results in a win-win concept. It can also be seen as a marketing win, as a pleasant patient experience can drive some financial markets. The exact dollar figures are variable, as each institution will need to evaluate their own overall cost savings. A Focus on Length of Stay In the Cardiac Special Procedures Area (CSPA) at Appleton Medical Center, flow and throughput have successfully been redesigned to directly improve the care delivered to patients. The continuous movement towards providing best practice standards of care and continuous improvement are based on the lean principles of automotive manufacturing, specifically, the Toyota Production System. At ThedaCare, these principles have been mentored by Simpler Consulting Inc.1 As a result, Appleton Medical Center has been able to safely decrease the length of stay for most PCI patients to less than 5 1/2 hours. The CSPA at Appleton Medical Center was originally designed as a four-bed overflow unit to support the cardiac inpatient floor. In times of high inpatient census, the unit was opened to accommodate patients that would be short stay (between eight to twelve hours). This was staffed with one RN and a clinical technician. As the daily volume increased, it was not uncommon to care for six patients per day in this four-bay area. With this growth in mind, a twelve-bed unit was created and built. The current CSPA cares for short-stay patients who have received percutaneous coronary interventions (PCI), electrophysiology procedures (EP), ablation, peripheral vascular interventional radiology procedures, CT biopsy and bronchoscopy. It also serves as an outpatient and inpatient procedure area for tilt table, transesophogeal echocardiogram, electrocardioversion, and stress echocardiogram patients. With twelve beds, it is not uncommon to care for eighteen to twenty patients per day. Creative scheduling, flexible staff and a clear goal of focused patient care make it possible to deliver the highest quality and cost-effective care. The current staffing in CSPA is as follows: One administrative assistant, one LPN/clinical technician, and three RNs. We have recently hired two additional RNs, who will be used to support our additional deployed sedation at ThedaCare, as well as our newest initiatives. A new design will incorporate CSPA and PACU as a one-stop teaching, admit, recovery and discharge area for both inpatient and outpatients. This design eliminates the blocking of inpatient beds awaiting procedures or surgery, and we plan for it to serve all scheduled cath lab, radiology, internal procedures, and scheduled inpatient surgery patients. The combination of staff from both CSPA and PACU will provide high-level expertise, cost effectiveness, and team collaboration between staff. The Importance of Standardized Workflow PCI technology of today and tomorrow lends itself to some significant opportunities for process flow redesign. The implementation of standard work drives continuity of care standards, as well as providing measurable goals for documenting success. Tracking of standard work that falls outside of the guidelines provides an opportunity for reevaluation and improvement, replacing previous management styles of mass punishment and putting out multiple small fires. Two major clinical challenges with outpatient PCI throughput include: Timing and effectiveness of renal protection Anticoagulation safety Both of these issues, with their associated complications, can impact patient length of stay and ultimately, hospitalization costs. Post percutaneous coronary intervention complications result in enormous revenue loss each year. Reduction of these unexpected costs would save hundreds of thousands of dollars each year. Bleeding complications and transfusions are also among the most costly complications in PCI, accounting for an incremental cost of hospitalization after PCI that may exceed $10,000, due to increased length of stay and the use of additional resources such as ultrasound evaluation and surgical repair of the vascular site. 2 ThedaCare process changes that have impacted patient flow include a new protocol for renal protection, the use of bivalirudin (Angiomax, The Medicines Company, Parsippany, NJ) and vascular closure devices. Renal Protection. As of September 2005, ThedaCare instituted the use of a new protocol to provide proactive renal protection. This included changes to ensure proper pre-procedure oral hydration. In most scenarios, fluids can be encouraged for several days prior to the dye exposure. By encouraging oral fluids up to 2 hours prior to the procedure and providing specialized intravenous hydration, the renal system is not unnecessarily challenged with contrast. The hydration helps to provide a natural protection to the kidneys. The use of acetylcystine (Mucomyst), and the use of sodium bicarbonate intravenous fluid also provide some degree of protection for some subgroups of patients. 3 Intravenous fluid rates are weight-based and adjusted for left ventricular failure. The decision to implement the renal protocol is based on the calculation of individual patient Glomural Filtration Rates (a GFR Anticoagulation/Closure Devices. Cardiovascular lab (CVL) patients were previously cared for in an inpatient unit with sheath pulling done by nurses or technologists. There were frequent challenges with site bleeding, patient discomfort with flat bedrest, and staff dissatisfaction with the physical demands of holding manual site pressure. To address the challenges with anticoagulation complications, process changes have included the use of bivalirudin and access puncture site closure devices. Bivalirudin’ short half-life, used in conjunction with a closure device, has allowed the removal of introducer sheaths in the catheterization lab immediately following PCI. This successful flow change decreases the need for sheath-pulling units, manual pressure, and 1:1 staffing patterns. Patients now recover in the same outpatient area in which they were admitted. This continuity of care has been satisfying for both staff and patients. The process also affords the opportunity to decrease the number of hand-offs and transfers of patients, thus ultimately increasing safety and quality. The outpatient area has also seen a significant decrease in post-procedure bleeding complications (data collection is ongoing). Our current length of stay is less than 5.1 hours for a PCI patient, placing us in the number ten ranking in the ACC-NCDR database. The use of bivalirudin is suspected to have been a key factor in these successes and this thinking is supported by the recent results from the REPLACE 2 Trial, which looked at bivalirudin in comparison to heparin and GP IIb/IIIa inhibitors: In the past decade, significant reductions in heparin dose and warfarin use were associated with reduced bleeding complications, but glycoprotein IIb/IIIa inhibitors have been shown to increase the clinical and economic costs of bleeding complications. The replacement of heparin with bivalirudin is associated with significant reductions in the costs of antithrombotic therapy and in complications. Reductions in bleeding complications have become a primary target for further improvements in both clinical and economic outcomes. 2 The Importance of Planning & Inclusion Criteria for More Complex Patients There are other variables to be considered for evaluation of a patient’s appropriate placement into an outpatient setting. Patients with more complicated medical conditions can also follow the same outpatient flow by incorporating their special medical needs into that patient’s plan of care. For example, a patient that has impaired renal function and is dialysis-dependent can use the outpatient flow by planning for same-day dialysis. Patients at higher risk because of diabetes or iodine allergies are started on the renal protocol or dye allergy protocol prior to their hospitalization. Of the patient age groups treated through the Cardiovascular Special Procedures Area (CSPA) in 2006, 39.1 % were over 61 years of age. The age group over 75 years old was 24.7%. Results: Throughput Improvement Through our initial flow design, willingness to change, and search for continuous improvement, Appleton Medical Center’s CSPA has been able to safely decrease outpatient length of stay, in most cases to significantly less than a 7-hour total length of hospital stay (LOS). The average patient per day census of CSPA is currently 15 patients. The maximum capacity of the fourteen bed unit, open 16 hours, would be 42 patients per day (the major constraint to this being physician preference for hours of practice). The following scenario depicts a leisurely seven-hour stay within a fourteen-hour day. This capacity would allow a potential for 28 patients per day with fourteen beds, double the capacity of one inpatient bed. As efficiency for decreasing length of stay and creative scheduling evolve, the potential to increase the revenue per square foot increases. Table 1 demonstrates the simplified mathematics. In our old world, it was not uncommon to run short of inpatient beds. Frequently, we would block up to fourteen inpatient beds for a full day with PCI patients. The opportunity to use open bed space creatively provides new opportunities. Plans are currently underway to use under-utilized room space for the teaching and intake of surgical patients, thus eliminates the building of new teaching and intake areas. By creating flexible spaces that can be used for multiple disciplines, organizations can maximize the use of current space. This capital avoidance has the potential to save millions of dollars. The Importance of Geographical Impact There are some areas of the country that do not rely on patient choice for provider and health care systems. Patients go to the regional center that provides the cardiac service. There are, however, geographical areas where health care choices are still made by the patients. ThedaCare is in an area where there are at least 10 hospitals performing percutaneous coronary intervention in a 50-mile radius. Competition for the patient's hospital of choice is a reality. As a number of corporations and their employees manage their own healthcare, it is imperative to provide world-class healthcare to be competitive. It ThedaCare’s philosophy that this loyal patient base is an earned benefit of giving the patient what they want, when and where they want it. This is achieved by truly becoming customer-focused without sacrificing safety or quality. By collecting quality data using the ACC-NCDR database, the Wisconsin Collaborative and the Institute for Health Improvement as a benchmark for comparison, organizations can set best practice standards and compare themselves to other high-quality hospital systems. As consumers of healthcare become more aware of data and outcome comparisons, institutions must become increasingly transparent and work to become the best. Conclusion As technology continues to advance, healthcare providers are challenged with providing care for a more informed and technology aware patient. Patient satisfaction with their care and respecting their time has quickly become the new benchmark for quality care. Safety and quality are expected as part of the procedure. It will become increasingly difficult to rely on the clich©, That is the way we have always done it. The realization that the industry needs to focus on achieving health care efficiency is more than on the horizon, it is on the doorstep. It is imperative to maximize time saving measures, while also improving the safety and quality of care that is delivered to patients. Appleton Medical Center and Theda Clark Regional Medical Center are among only five hospitals in Wisconsin and 206 hospitals in 180 markets nationwide to be named Consumer Choice Award winners out of more than 3,000 eligible hospitals. The complete list of hospitals and sponsoring health systems was published in Modern Healthcare Magazine 2005/2006.4 This article or any information in this article is not to be published or used in any format without the written consent of the author. Thomas James Jankowski can be contacted at tom.jankowski @ thedacare.org
1. CMS proposes policy, payment changes for physicians’ services in 2007. Medicare News. Accessed Sept. 18, 2006, at http://www.cms. hhs.gov/apps/media/press/release.asp?Counter=1939

2. Simpler. What is strategic lean enterprise transformation? Building Strategic Advantage Through Enterprise-Wide Improvements. Accessed Jan. 23, 2006 at http://www.simpler.com

3. Milkovich G, Gibson G. Economic impact of bleeding complications and the role of antithrombotic therapies in percutaneous coronary intervention. American Journal of Health-System Pharmacy 2003;60:suppl 3, S15-S21. Accessed Jan. 23, 2006, at http://www.ajhp.org/cgi/content/abstract/60/suppl_3/S15.

4. Merten G, Burgess W. Prevention of contrast-induced nephropathy with sodium bicarbonate: a randomized controlled trial. JAMA 2004;291(19):2376.

5. The NRC Consumer Choice Award. Healthcare Market Guide: 2005/06 winners. National Research Corporation Modern Healthcare Magazine, Jan 2006. Accessed Sept. 20, 2006 at: http://hcmg.nationalresearch.com/Default.aspx?DN=52,7,1,Documents