We've just heard from some experts about why EP Labs should care about efficiency. It's about meeting our patients' needs, helping patients get better faster, and allowing them to live happier, healthier lives. It's about improving provider satisfaction and having better, more successful, more rested, and happier staff. It's about creating a healthier return on investment and helping everyone involved save money. But there's more, and we're going to learn about some of the more right now as we take a look at the model here in this beautiful hospital, Grandview Medical Center. In our next segment, we're going to be talking about the Grandview model of care specifically. It's my pleasure, along with Jose and Chris, to welcome Dr. Andrea Russo to the table. Andrea, were you as impressed as I was by watching the incredible work that this team does here? Yeah, absolutely. So this is, I was incredibly impressed the first time. This is my second visit here, and it's amazing how much more I even learned this time compared to last time. It's just an incredible, incredible team they have here. Wow. What kinds of things specifically do you think you can take away from your experiences here? So before I actually even came last time, and everyone would say, well, there's no way that he can get all that done in such an efficient manner in terms of procedure time and still do everything, and maybe there's things that aren't being done, or the veins aren't isolated, or there's pieces of the procedure that are missing. And so really, seeing is believing, and it's clearly, I mean, Jose is a very talented person. There's no doubt in my mind there, but it's more. It's the whole team approach. It's really the participation of all the different pieces in a standardized protocol. So there's protocols that are set up, they're discussed, not that you can't sway from it if the patient's not stable. You can certainly do whatever you need to do to take care of whatever you're doing, but there's some standard protocol set up ahead of time. So everyone, not even just in the room during the procedure, but before the procedure, everyone knows what they're supposed to do, what's expected, and everyone really works together as a team. So setting up that standardization ahead of time, creating something that makes sense, and then educating, and educating the staff, educating everyone who comes through and is watching Jose do these procedures, has really just opened up my eyes to that this is really the way to do this. And it's everyone from anesthesia, it's everyone from, you know, Chris, the nurse manager of the whole system. It was just really impressive, this partnership that's developed among all colleagues that are there, really, to take care of that patient and do it in the best way. The other thing that really struck me, and I think, you know, I don't want to say you're unique, but I think most centers don't have the level of support, you know, in terms of the higher ups, really the big hospital administrators that support what you're doing. And so there's that communication from every level. Everyone is just as important part of the team, but it's really the administration realizes that supporting you, to support your staff, to support the care of your patient is really better for everyone, better for the whole hospital. And so last time I took a bunch of things away, and this time I'm going to take some more things away, and actually really can make a difference, I think, in a lot of programs out there. So, Andrew, the last time you came, we talked about, you asked me a question about how did such a young hospital, we had been participating in so many clinical trials, and that was something that I took seriously, that question, because I had never thought about it, and it comes down to standardization of care. It's standardizing the entire process, and the flow, the communication, by standardizing and having these processes, that they become reproducible, but not just that, for an administrator to understand how much do I need to invest in this lab, in this team, to build this. So they can understand return on investment as well, because what we do has become very predictable for them. And it actually saves time. So even noticing today, the thing that struck me, too, is that the person assisting you had your ice catheter out, already had the bag wrapped around it. And so it doesn't take, maybe it takes a minute or two, but a minute or two here and there adds up in time. And they knew, without you even asking, I need the ice catheter, you know, put this, they had everything there ready to roll for you. And people were able to anticipate, because you did standardize protocols, they were able to anticipate what you needed next for that patient on the table, including your anesthesia person, right? They were able to anticipate what you needed to do next. So I think that's a lot to be said, and really just an incredible, you know, thing you've done here. It's very impressive. So when you're standardizing, as you said already, when you're standardizing processes, I mean, we need to create things that are going to work for two standard deviations, right, of the patients. And the outliers, you know, there's a small percentage of patients that we're going to have to deviate from the protocols we created. But for the vast majority of patients, there's not much innovation that we need to do in an AF ablation procedure today, particularly in a paroxysmal AF ablation, right? So there's very little that we're deviating. So by not having to decide if I'm going to use isoproterol or not, just using for everyone, by not having to decide if we're going to do something, and just having a protocol-based decision of how these patients are going to be handled, that facilitates the flow significantly, because there's planning now. Now we've been talking a lot about standardization, and the hundreds of visitors that you've been kind enough to host over the years have seen it. Andrew and I have both seen it. But for our viewers who haven't been in the room with you, can you just talk a little bit about what that actually looks like in your lab? So let's kind of start from, it starts from the day before, when Chris and our team, they will meet and understand what are the procedures we have the next day, how many physicians. Do we have cases that don't need sedation, don't need TEE? Do we have cases that, how are we going to sedate? And based on that, they'll decide the flow, the order of procedures, and they will call patients and make last-minute changes to when they're going to come. They will contact the anesthesiology department and say, this is the requirement, this is how many providers or physicians we have, this is how many patients, and we'll make a decision about how many labs we're going to run and the staff. Everyone comes at 5 to 5.30 a.m. and maps out the day, spends some time understanding. And at that point, you know, as the patients start coming, we have established, really, we have expectations for each part of the patient journey of what time and the time it will take for the patient to clear that step. So registration, we would like for the patients to, the first patients to arrive at 5.30 a.m. By 5.45 to 6, they need to be at prep and recovery. By 6 to 6.30, they need to be ready when the anesthesiologist will come and evaluate the patient. And as we've heard, we will hear from our anesthesiology colleagues, you know, that is very important, adds to patient care. At that point, we have an expectation that at 6.45, the patient is going to be taken to the EP lab, and 15 minutes, we'll be ready to start our first procedure. So I think what you got to start hearing, you know, the recurring theme for us has been for each step, we've mapped out this entire process, we have written down the entire patient journey, and we now have set expectations. For each one of these steps, we didn't just come up with these ideas and the expectations on our own. We met with the stakeholders in each one of those different parts of the hospital registration, prep and recovery, and we had their opinion and input into what's a reasonable expectation. Once they've agreed that this is a reasonable expectation for the time they need to do their job, we will make sure they stay within that practice parameter that they've agreed with us. At that point, if you have your first procedure of the day done at the right time, it sets the tone for the lab. The rest of the day just goes a lot easier. But we have, since Chris Cooper started this model, we've had this someone that doesn't have clinical responsibilities in the lab, which I think that's key, that is controlling the air traffic controller, so to speak, controlling the flow. So we have someone that, that person that comes in early, so you may call the manager or the coordinator, that comes in early and maps out, he or she is the person that's going to go to prep and recovery, pick up a patient, and bring that patient to the lab throughout the day. And because of that, he or she is going to set the pace for the lab that day. So our model has been to map out the process, to set the expectations, and then to continuously monitor if we are achieving, you know, for each one of those steps, those expectations we have set, and then on our QI meetings, talk about the outliers. So that's how we continue to, we have continued to maintain for now six years, the efficiency level we have achieved. I could just actually tag onto that too, because what also struck me, you know, even, you know, particularly even last time, when you have multiple procedures, you know, in a row that are going to need to, you know, to be able to finish them in a timely manner in the day, having Chris, having someone, and I think you said someone not responsible for, they're not a circulator in the other lab, they're not scrubbed in on another case, there's someone who is always looking over the whole picture. And that's what Chris was making sure that your next case, anticipating who you're going to need, you know, next, and what they need, when they get their TE, and when they need to be brought over to the next room. And so I think that's a really amazing part also, is that part of the team. We now have a prep and recovery, Chris manages that area as well, but we are very fortunate to have someone who has very good knowledge of the EP lab, because she worked there before, managing prep and recovery. It's amazing how that has improved the EP lab flow, because she has so much oversight into how we think, and what's going to come next, that that has improved our process. I think we have empowered the prep and recovery area, and trained them into post-anesthesia recovery, for example, so our patients don't have to go to other areas. So it has been a process of removing redundancies, so a process of, you know, a QI improvement in Lean Six Sigma, and anything that was redundant, we tried to remove, and continuously monitoring for outliers, to try to discuss with those that are causing it because what we have found is the vast majority of times when we have outliers, when we have things that didn't go well, it's not someone's fault. It's a system fault. The system failed. That person was not able to do the job properly because there was something else that happened. And it may be because we're not properly staffed, it may be for we don't have the right equipment. So understanding the outliers is a very good way to maintain the efficiency and understand the needs as your lab grows. Well, it clearly is impressive to see the way that you're doing things. How would you respond to some people in the audience who may think, oh, that sounds great, but I've heard Jose talk and I know that he's a gifted operator. How reproducible is this in other environments? I think it's absolutely reproducible. I think that the comments that it's, oh, it's because they do things different. They have supportive administration or it's because they do high volume. So he's become a gifted operator. I beg to, I would disagree with that. I think it has been a process of, I don't like when people say we're fast. We're not fast. We have removed redundancies. We have reduced the number of mistakes. The end result is, yes, we're doing things faster, but it wasn't with the intent of being fast. So we've had many physicians that have visited us and have replicated or improved upon the things we're doing. And one of the so important discussions we've had today is how sometimes very simple and free interventions you do, they can have an impact to the patient or to your efficiency. More than very complex or expensive interventions such as modulating how you're going to sedate your patients. You know, that's free, changing the ventilator. But it has such an impact on procedure time and the flow of the lab that I think this is a simple example that highlights that this is reproducible. But you have to have a champion and you have to have a desire from the entire lab to change. It doesn't work if it's a single physician. It doesn't work if it's just me and Chris trying to do this and no one else buys in. So for this to be reproducible, it needs to start somewhere, but you need to have all the other players and stakeholders buy in. And for that, we need to build something that they care about as well. Yeah, and I have to agree with that. Just an outsider coming in. I think it's reproducible. Maybe not every piece at the same time, but you're cutting out waste, wasted time. You're cutting that out and that's why it's fast. But there's certain limitations. So maybe, you know, for example, we may not have a lot of holding area beds that we share with. So it's a structural change. You're not going to change overnight at your center. If you need more recovery room area space, that may take some time, but you can clearly do things. You can have, you know, someone who is in Chris's type of position, you know, be coordinating things outside the lab and you can train and set up these protocols. So I think I've heard that too, that it's not, you know, it's not reproducible, but it is. You may not do it all at once. Well, Chris, you're living it. You're seeing this from the inside, working in a hospital with multiple different practicing groups with multiple different electrophysiologists. Have you seen evidence of that reproducibility here? Absolutely. Early on, we had a physician who came in with us from a different group who was doing possibly two AFibs and it took him all day to do those. And I'm not saying anything about that, but it's just that he watched our model. He watched our flow. He started adjusting his technique. He started adjusting what he did and he kind of let go and gave us the reins and let us run him as well, in a sense, as to show him, hey, I think we should bring this patient in this time and we'll start with this one. And then, you know, and then he started observing the other physicians because he could see like the volume they're doing and the volume he was doing. And he was like, well, hey, I'm just as good as those guys, you know. But let me let me be molded. Let me change. And he did. He, you know, we weren't pushy with him or anything. We made suggestions with him and such. And then one day he just bought in and he said, OK, run it for me. Tell me when to be here. Tell me what patient I'm going to start with, you know. And I'm not saying that that's something we have to do with everyone, but he saw what worked for us and was working for the other physicians and he wanted some of that. And so he allowed himself to be moldable, to be trainable, to be teachable. And now he can do four and five cases in one room in the same day. And I'm talking AFIBS and get time. And he just allowed us to just step in and just, you know, kind of nudge him along the way to the path that he needed to be on to get to where the other guys were. So yes, we have seen it and we can teach it. So if you're willing to learn, we can teach it. But this this HRS initiative, I think it's so important because think about it. These are not. These are not aspects of electrophysiology that we're typically focusing on training programs. Right. We have all seen things where you are trained in an institution. You start your practice, you're practicing very similarly to how you were trained, how your mentors and the attendings have trained you. And three years, four years later, you visit someone and you watch how they're doing and you have that aha moment and something clicks and you change something. But for most of us, these changes have always been around techniques and for the ablation and equipment that we use for the ablation, not really how to run a lab efficiently. So this is why this is so important, because many have not seen how a lab can be run. And if your expectation has always been two hours turnover time, that's a standard where I train was like this in my hospital is this way as well. You're going to have little drive to to change that once you see that it can be safely done. Absolutely. It can be safely done. And there's a reason why I want to do it that way, because it can improve patient safety and outcomes in the end. I think it's very important to highlight that to our electrophysiology community. Well, one of the reasons that I want to learn from you and bring some of the things, in fact, a lot of the things that you showed me today to my own practice is to have the opportunity to bring this to my trainees. So if they can learn these things as part of their training and not have to figure out after they leave training, that's where we're really going to be building the learning health care system that you've been so vocal in describing. Yeah, because that's so important. And so I'm actually curious to know, do you think some of the things you were doing today, I'm thinking, OK, so my fellow would be doing this. How do you translate or what parts do you think would be easily extracted to a training program and what parts might not be or is everything? Or how do you see this fitting in a center that's training AP fellows? So I see the efficiency of the lab and the efficiency of the procedure. I see both as the same way. Both are the same type of tasks you have to tackle. Which is, if you want to have your lab be efficient, you map out the process and you try to remove redundancies and you try to standardize. The same is true for the ablation itself, right? Write it out, each and every one of the steps you're going to undertake during your procedure. And that organization of saying how I will conduct this procedure will already decrease procedure time. And then once you standardize and you start to have extreme repetition on how you do it, and everybody that works around you understands, you're going to achieve even a higher level of efficiency. You saw how when we're doing procedures, the techs scrubbed with us. I mean, when I turn, a catheter is ready in my hand. And it's always like this, because every step is done the same way by every physician. That's an important aspect. It's not just one physician does one way. We all do things identical, the very same way. So because of that, you start the lab itself. Efficiency becomes our way of doing things, because we've set the expectation. So going back to your question, I think fellows need to understand that, yes, we need to use our academic prowess. And we need to try to innovate. And we need to think outside the box. But there are, particularly for paroxysmal AF ablation, there's also an importance in industrialization of this process. There's something to be said about standardizing every aspect of your AF ablation. And I will add to that also understanding and collecting data, outcomes data, or even just some key components of the procedure, so that as you make changes, you need to be able to understand how those changes will translate to outcomes. And so I think for the fellows, the focus perhaps needs to be less on the, let's make the lab efficient globally, but more about the quality improvement process and how quality improvement, if it permeates everything of your day, your entire EP operation, your procedure time will shrink, and your lab day will be also much more efficient. So these things should not be looked separately. They need to be looked at as just one for, you know, to obtain the best for our patients. That's important. Jose, thank you for painting it so clearly for us to see the great work that you're doing here at Grandview.

efficiency

EP Labs

standardization

protocols

teamwork

patient outcomes