Cath Lab Operational Efficiencies: Expert Advice

Secrets of a High-Performing Vascular Interventional Program: Leadership and Culture

Cath Lab Digest talks with Marcelo Guimaraes, MD, FSIR, Director, Division Vascular Interventional Radiology, Professor of Radiology and Surgery, Medical University of South Carolina, Charleston, South Carolina.

Cath Lab Digest talks with Marcelo Guimaraes, MD, FSIR, Director, Division Vascular Interventional Radiology, Professor of Radiology and Surgery, Medical University of South Carolina, Charleston, South Carolina.

Can you tell us about your division at MUSC?

We work in Vascular Interventional Radiology (VIR), focusing primarily in oncology, liver, and in peripheral arterial and venous diseases. Our Division performs around 7,000 cases per year. We have a group of 6 attendings and 4 fellows, and have a busy practice.

When did Terumo Business Edge first begin to work with your lab?

Six years ago, I became involved in some performance improvement projects as a VIR attending. Years after having some initial projects with positive outcomes, I had the opportunity to meet Terumo leaders, who suggested a visit by Terumo Business Edge (TBE) to evaluate and report on our workflow and our operations overall. At the end of their visit in 2015, they generated a report that was very helpful in learning about things we needed to work on — and we worked on every single opportunity to improve that was pointed out by TBE’s report. I invited Terumo Business Edge to come back four years later, which was in June of this year. They found us to be a totally different division, one with greater efficiency, a shorter turnover of rooms, much lower turnover of staff, increased patient satisfaction, and increased staff satisfaction and engagement. These are all a result of our daily efforts after the 2015 visit. During our journey, we reset our mission, vision and values, and let people go who were not aligned with our vision and values. Team members who were aligned stayed with us and we went on to hire some excellent people. We revamped the whole division just by getting the right people in place under the right mission, vision, and values, and of course, going on to initiate several performance improvement projects that included minimizing wastes of time, reducing workflow redundancies, and having efficient patient-centric operations. Ultimately, we were able to increase our capacity and do more cases per day. We also completed a project to decrease the room turnover time. Before, our time averaged 45 minutes and today, it is 20-25 minutes or less to turn over a room. We also created a VIR handbook, our manual of operations, with standardized operations and processes, including our procedures, what supplies to use, what antibiotics to use, planned bloodwork before a procedure, and post procedure orientation for the patients, among other things. The VIR handbook has been edited and improved every year since 2014. It resulted in better internal communication among the divisional members, reduction of operational variability, reduction of resources and time waste, and increased predictability and consistency of positive outcomes.

How did everyone participate in this process?

First, it is important to emphasize that we started with the fundamentals: vision and mission values that were defined for the staff, by the staff. A leadership team was built carefully, and includes a nurse supervisor, a radiologic technologist supervisor, and a manager, and this team started to meet weekly. We also put together a shared governance team to work on performance improvement projects. We had a representation of the physicians, the nurses, the fellows, and the technologists, and put our heads together to first understand the problems, and then brainstorm and come up with solutions. It was not a top-down decision-making but bottom-up, and that was critical to make sure we had buy-in from the staff. I don’t think you can make so many cultural changes as we’ve been through without getting deeply involved in the operation yourself, so I wasn’t only delegating things, but I was fully engaged, making sure people were held accountable, and that they had action items and due dates. The team was not used to that type of leadership style. Things had been very loose. We basically transformed the way we were leading, because before, people could do anything — there was no accountability, no clear expectations and no one was checking to make sure things were getting done in a timely fashion. The idea was to influence the division leadership to understand that being a leader is not about working less and going home earlier, or not being fully engaged. We ended up having to make personnel changes at the beginning of the process, but the team we have now is phenomenal. They understand that being a leader means you need to work more, not less. You can’t go home at 3 o’clock and expect everyone to work hard. That is a tough proposition to sell. We are here to serve our people — to serve our patients and serve our staff. It is not about ourselves. It’s about providing world-class, outstanding patient care, without losing focus on simultaneously taking care of our staff well-being. In addition, we need to work cohesively; it is not about one individual making a decision, but is a team approach. It was essential to build up that team approach mentality, and make sure everyone understood their roles and expectations. Once the team had a real understanding, then there was a trickling down of accountability and what expectations were.

It sounds like the evaluation by Terumo Business Edge began a period of sustained change for your lab.

We were already working on several projects. I realized that we needed to work on improving our operations overall. That was my general assumption. TBE analysis was able to provide detailed, specific information and tell me, for example, your room turnover is 45 minutes and it should be 20 minutes. After their analysis, they were able to tell us, “If you do x, y, and z, you are going to increase your capacity at the end of the day.” TBE brought the necessary granularity and the details, allowing for a better visualization of the problems. It was an excellent experience. There were things that we needed to work on that were new to us as well, no question about that. I am grateful for that work. The evaluation by Terumo Business Edge empowered us to succeed by making the necessary changes. That is the most important thing to emphasize. You might understand that you have several issues to work on, but what’s a priority? What is going to have a ripple effect by being addressed first? It was an enlightening and humbling experience.

One of our projects involved outreach to referring physicians, with the goal of increasing our referral base. There are small things you can do to increase your patient pool and physician referral satisfaction. For example, we are now sending a text message to the referring physician after the procedure so that they can be immediately aware that the procedure is done and what happened. As a result, patient care can be expedited, i.e., the patient can be sent home faster and the provider can plan what is the next step in patient care, basically all through improved communication. Very simple things can bring a huge benefit to patient care. Great communication is powerful.

After their first assessment of our lab in 2015, we recently asked Terumo Business Edge to return and their second assessment occurred about a month ago. They spent two days interviewing our key stakeholders, such as the nurse supervisor, managers, business manager, and prep and recovery area supervisors. They also walked around and watched our operations, with some observation periods — similar to what the Japanese call “gemba,” basically a way to analyze workflow through observation. The latest TBE report showed that there were major improvements in our operations since 2015, but it also pointed out residual deficiencies and opportunities for further refinement on improved operations. This external analysis was extremely insightful, because it helped us to recognize simple issues that became obvious after discussing the report with the TBE team. Our Division is committed to innovation and constant process improvements, but we quickly learned that we need to keep harnessing the pillars of our foundation (our mission, vision, values, and culture) if we want to have an excellent, efficient, and long-lasting work environment.

What did you think about the Terumo Business Edge team and what their people brought to the table?

TBE has a team of experts with decades of experience in healthcare operations and management. The group is led by Gary Clifton, who has worked collaboratively with numerous healthcare systems throughout the world during his 14-year tenure with Terumo. His team is highly experienced and well versed in the endovascular procedural space. Some of the TBE goals have been to improve the operational performance of inpatient and outpatient procedural areas, and to redefine best practices and clinical pathways. Definitely, the TBE team has empowered us to improve our productivity and quality of patient care.

What did you tell your key stakeholders about why the evaluation by Terumo Business Edge was important for your division?

It provides granular data necessary for improving performance operations, which can lead to cost reduction, optimization of human and space resources, increased capacity, and a chance to work on branding. With the ongoing changes in healthcare, with the economic pressures around performance and improving efficiencies, decreasing waste, decreasing cost, and making healthcare more affordable, a project like this is critical. Healthcare is 15 to 20 years behind other industries in terms of technology in general management, cost analysis, and operational efficiencies. Remember the value equation is outcomes divided by cost. Most of us want to have good outcomes with a lower cost, but in many healthcare systems, there is a lot of waste, and an illogical and blurry analysis of cost. It is critical to have an analysis and a snapshot of what is happening in your program.

Can you talk about the value in partnering with Terumo Business Edge over the long term to help achieve your strategic goals? What would you say to a divisional or department director who might have reservations about letting a company do such a detailed analysis?

Honestly, initially I was a little hesitant about working on performance improvement with a device company. My main concern was about having an obligation to buy Terumo devices, something that turned out not to be the case. Our partnership and work with TBE allowed us to diagnose issues and waste, identify remedies, and set priorities and an action plan that resulted in the creation of best practices from clinical and managerial standpoints that have lasted several years.

At the end of their evaluation and analysis, Terumo Business Edge provided a confidential report. After the report, it is important to have brainstorm sessions with the key stakeholders and discuss your action plan. For example, what are the minimal resources needed and what are the potential tools you need in order to get where you want? It is important to emphasize the short-term and the long-term parts of a project, because sustainable changes require a major shift in culture. The long-term project is to make sure that people understand the culture shift, become aligned with the vision and values, and are committed to change. Everybody can change for a month or two, but there is a tendency as human beings to go back to a default position a few weeks after an initial engagement in productivity. It is important to discuss the plan, and share why and what’s next in every step of the way. During the action plan execution, the MUSC Performance Improvement office was also supportive of the implementation of the TBE recommendations, resulting in major improvements in a timely fashion. You may have a vision, you might have the drive and desire to make improvements, but it takes an efficient team to make effective changes without delays. Without this collaborative work, I sincerely believe that we would be still stuck in the past and in our inefficiencies. As we can’t predict the future, our Division decided to be proactive and to be prepared for the ongoing and upcoming changes in healthcare. The recent TBE evaluation confirmed that our cohesive team has been efficient and very effective on managing challenging scenarios. In summary, I would encourage department and divisional directors to tap on TBE expertise and support. You won’t regret it. 

This article is supported by Terumo Business Edge.

Dr. Marcelo Guimaraes can be contacted at