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EP Lab Efficiencies
3: FOCUS ON QUALITY IMPROVEMENT
3: FOCUS ON QUALITY IMPROVEMENT
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I really hope you're enjoying the conversations and experiences we've had together so far. As you've just seen, daily routines are a huge part of what Dr. Osorio and his teams are accomplishing here. Let's talk about the process. Over the next 30 minutes or so, we're going to dive deep together. We're going to dive deep into how these things actually get done. Let's learn about the process together. Let's talk more specifically about the Quality Improvement, or QI, process. Although Jose and Chris have done amazing things, we in healthcare have really a lot to learn from other industries. Take for example the airline industry, where the analysis of near misses, instituting pre-flight briefings, post-flight debriefings, and other sorts of things have led to continuous processes for improving the ways that our airline and aviation industry work in ways that we could really envy in healthcare. Other industries, such as the nuclear power industry, submarine fleets in the Navy, have really brought in incredible processes. There are several frameworks for doing these kinds of things, including things you may have heard of, such as LEAN and Six Sigma, and other sorts of frameworks for addressing things in a systematic kind of way for improving processes. It's my pleasure now, in addition to Jose and Chris, to be joined by Dr. Jennifer Wright. Jen, can you tell us about why you, like I, came here to learn from Jose and the things that you're doing in your institution? Absolutely. Thanks, Paul. I want to thank Jose and Chris for having us today. The reason that I wanted to be here, in addition to, I think, everybody else wanting to be here, is because we have a problem at our institution, and our problem was that we were the opposite of efficient. Because of that, there were very much so some negative downstream consequences of that, not only for our faculty, but for our staff members and our patients. We want to change that narrative, flip it over to make it a more positive experience by becoming more efficient. That's why I'm here today, to learn from you, and I've already been super impressed. I have so many questions, but just want to hear back from you. Well, you and me both, and I think we are probably more like the rest of our community than Jose and Chris are. But Jose, tell me about the process that you've been using, specifically, to tackle these things. So, Jen talked about efficiency, and efficiency being what one aspires in their lab. And I think, as we started these conversations, we want to achieve efficiency, we all do, and we want to achieve it along with quality. And quality improvement processes can be used to do this. What we have modeled after is what I would call a Lean Six Sigma Lite approach. And why a Lean Six Sigma Lite? Because Lean Six Sigma, which is the combination of the Lean processes and Six Sigma developed by Motorola, it's a process that can cause paralysis by analysis. You can spend just too much time analyzing processes, trying to discuss how the process and quality improvement is going to go, and in the end, you may not really accomplish much. So, the way we wanted to do this is to use the concepts and the premises that Lean Six Sigma uses to achieve these results. And by using these premises, created what has worked for us, particularly in healthcare. Things are not as predictable as other industries, as engineering processes, but there's a lot that we can do to make things as predictable as possible. And I think the Lean Six Sigma Lite approach that we have started here has allowed us to keep focused on how to always keep getting better, or an ongoing and continuous quality improvement approach without spending too much time analyzing, really focusing more on getting things done, on the end result. So the end result was the goal. And so, Jose, can you describe that Lean Six Sigma Lite in a little bit more detail on how it actually applies to the EP lab and efficiency? Absolutely. So let me describe the so-called Lean Six Sigma Lite approach. Using the same premises of Lean Six Sigma, I would say the most important thing is focus on the customer. Let's focus on the patient. So everything has to be with the patient as our really most important aspect of what we do. We're going to manage things and try to improve things by analyzing them first and understanding what we're trying to change. So you can't conduct a quality improvement process without measuring. So you need to measure. And when I say measure, for example, in the EP lab setting, measure your turnover time and break it down. Understand what are the components of the turnover time and which components you need to work at. Map the process. That's perhaps the most important aspect of this that I feel like many haven't quite done. You understand that your patients are getting to the table late, and you would like to start earlier in the day, and you have to understand why. It may not be because of your staff. It may not be because of the prep and recovery area. It may be because the registration process is taking too long. It may be because they have one person in the registration desk and too many patients. So mapping the process, I think, is where it all starts. And once you map the process and we establish how we want the process to be done, we created our standard. We created our benchmarks and expectations for everybody. And from that point on, we manage by always measuring and trying to do root cause analysis to understand and reduce the variation. So reducing the variation is the goal here. You want to have a low standard deviation. You want to have that your processes, they all look very similar, that the time from registration to prep and recovery, from prep and recovery to the EP lab. We want to shorten that process, and we want to make it consistent. And you can only do that by establishing benchmarks and understanding what's going on and focusing on improving each one of these components of the process you've mapped first. So that's why I think it starts there, starts with mapping the process and then measuring. And after you measure, you choose the areas you're going to act on and always try to make small improvements. And if there are areas that are failing, you need to understand why they're failing. Oftentimes, it's not staff to be blamed. It's because the logistics of the hospital have not given them, the staff, a chance to be successful. So I think that's why mapping out the process is so important. I've heard it said in quality improvement work that you can't improve what you can't measure. How have you gone about measuring all of these various aspects of things to try to improve them? So different ways. I think there's many things to discuss. I'll let Chris describe how we started our lab and this process of mapping, how it was done, bringing all stakeholders when we got started at Grandview. So when we first came to Grandview, we met with every stakeholder involved, went from administration to the registration to the laboratory to anesthesiology. But we all met at the same time in the area for which we would be working. And we went around and said, we want to do this this way, we want to do this this way. And everybody was able to talk about if they would have any problems with being able to do those things that way. So with everybody together, that's when we made all these decisions on what we were going to be doing and what we had planned to do. So it's important to get all those people together and get them all on the same page and say, if you give us this, we can do this with that. And we can provide quality patient care in a timely fashion. Every aspect of what we do is timed. From the time the patient signs into the registration area, if they're not in the pre-op bay within 30 minutes, then it's going to throw up a flag and we're going to have to go back and do some root cause analysis on that. And it could be because of registration was short that day and a lot of people showed up at once. If the patient's not pre-opped, in the pre-op within 30 minutes, it's mapped. We know that it takes about 30 minutes to get that patient ready. I mean, barring there's not a bad IV or difficult IV stick or some other family issue or something, but we know how long it takes. We know how long it takes once we get that patient into the EP lab, how long it should take us to get that patient ready because we've put times on it. In our charting systems, we have had a template built that it automatically drops these times to these templates. And it tells us, well, it took you 35 minutes to get this patient ready this time. So then we need to go back and look at what caused that to do that, to take 35 minutes to be ready once we got in the room. And then we just time everything we do. And in the beginning, we were able to just whittle away at some of those times and change some of our techniques and what we do or how we bring people in. We slowly whittled away at that. And I guess what I would say to people is put a time on everything. It's easy. Just put a time on it. And then you go back and you look at that time and you figure out what I can do to shave off a little bit of that time. And five minutes here or there adds to another case that day. So that's how we monitor things, and that's how we got started with it. So when it comes to a QI process, mandating the process is difficult because you don't typically get buy-in from the stakeholders. So how did you approach everyone to get buy-in? A very practical approach to this, similar to what we did, is get all the stakeholders, meet with them in front of the registration, and walk through the same steps that a patient would. So you start a registration, and at that point, let the director of that area, the person in charge, to say, I'm not able to register five patients from 5.30 to 5.45. I need more staff. And that was the process. We then walked to the prep and recovery, and we asked a nurse, how long does it take to prep a patient? Well, I can get a patient entire process in 30 minutes, and that became our benchmark. At that point, if not done in 30 minutes, we want to understand why. We discussed with the director of the lab, if we draw a lab at 6.15, how much time do you need to have that lab back so that we're going to load the patient at 6.45? So each and every one of those steps, I mean, this exercise, it is simple to do. It will take a few hours, but I think my suggestions would be, decide when you want to start. Decide, what is the time you want to have the patient ready and starting a procedure walk backwards? And understand for each one of those areas, each one of those components, what are the requirements of the personnel, the staff that are going to be doing that? You may be surprised to see that oftentimes the delays are not that someone isn't working well. It's that we didn't give them the opportunity to work well. So that's why this exercise, I think, not just will be great for you to understand the process and start making changes, but makes everybody feel included, that they are now part of this. They understand now that for that patient to have a successful procedure, I'm in the lab, I never see that patient, but they understand that they're part of this. And I think it really brought a lot more cohesiveness to what we're doing. And that makes total sense, bringing all the stakeholders in, for ultimately for the patient. So did you have automatic buy-in when you did that process? Or did that also take time and further consultations with administration? I think at first they were rather hesitant about it because they didn't know if we could produce what we were telling them that we could do, or we could do what we said. So basically once we got started and they saw that, okay, this is working like they said it was going to. So then you had, they were just drinking the Kool-Aid at that point, I guess, they were just getting in with it and they were like giving us what we needed. So you show them the data? Yeah, we showed them the data. We showed them the proof and what we could do on a daily basis. It was, this hospital opened in October of 2015. So in a way, we were lucky that we came here with a blank canvas and we could paint the way we wanted. So that allow us to do that. But when we asked so many resources from the hospital, so many, and we are now not just asking for resources in terms of building an EP lab, but the personnel, the involvement from multiple areas for us to be successful. Yes, it took a little while for people to believe that we could deliver, but very quickly you saw different areas looking at us and trying to understand what was done that worked well. You saw the anesthesia department, the anesthesiologists and CRNAs understanding that we established this benchmark that we're going to start our procedures at 7 a.m. And indeed we are. And if the lab understood. So it took a little while, but I will say that by being, by making everybody's lives predictable, it wasn't long. It wasn't long from when we went from one lab to two EP labs and three or four. We've had discussions here about the economical aspects of this. I think we all have to be cognizant that the EP lab is the most expensive area of a hospital when you look at the cost to run an EP lab per minute, not just in the number of staff members inside a room to deliver a successful EP procedure, but our equipment is very expensive. So making good use of that is being a good stewardess of the whole process for the hospital, for the patients. And so it was once the hospital saw that we were making good use of what they delivered to us, the buy-in was immediate. And at that point, it allowed us to continue that process. And so what was the initial or what were the initial steps that you took? Like the low hanging fruit that you could go after without the complete buy-in of the administration, that was easy to do, easy to change. And then you could say, here, this is what we did. So what were your first steps? I think that's a very good question, Jen, because I'll say as we engage this discussions about quality improvement, you can go, I think that's a very good way to frame it, to go from low hanging fruit all the way to much more complex ways to automate this process. But I would say that the first was absolutely mapping out the process. And it may sound too simplistic, but it was not. Mapping out the process gave everybody a voice. Mapping out the process was essentially a handshake agreement with all stakeholders that we will do these things at this time with this expectation. So setting the expectations, I would say is the low hanging fruit. Let me give you some examples. We expect our first patient to arrive at 5.30 to clear registration at 5.45 to 6 a.m. By 6 a.m., prep and recovery. By 6.30, the patient should be ready. The anesthesiologist will evaluate the patient at 6.30. At 6.45, we take the patient to the EP lab. So mapping out the process, establishing our expectations to each one of these stakeholders, having the handshake agreement, and after that, doing, as Chris said, a root cause analysis and understanding why we failed, that was the beginning of it. That was absolutely the beginning. Jen, does this give you some ideas of where to start? It does, and, you know, because we're at the beginning of the process already. So it's first of all reassuring to hear that it does take some time and that it is natural to go after the things that we can change within our own section, for example. To go to your point, minimizing uncertainty is such a valuable tool in that it makes people just happier, everybody involved in the process. So that's what we started with. And we started with the things that we could change within our lab. And now we're at the point that we need to, you know, go to those areas where we need, you know, a stepping stool or a ladder to reach. So more of a system-wide change, because we need more support from a staffing situation, so more. So how now do we go and say to our administrators, okay, how about more pay for our nurses? How about more anesthesiologists? How about our own anesthesiologists? I was just so impressed with your anesthesia, your CRNA today, and how you guys worked together. You've clearly worked together multiple times. You have your rhythm. And to have that is invaluable. So how did you get to that spot? And, I mean, was it always like that? So I think continuing on what just mentioned about the process, you have to get all of the electrophysiologists on the same page to do this because you will not be successful if you arrive there at 6.45 and you are ready to start your procedure at seven, and you have a colleague, for example, that the patient was loaded and is on the table at seven, and the colleague arrives at 7.30 or eight o'clock. That will lead to extreme frustration of the staff, and this process will not continue that way. So I say this because if you want to achieve the process of standardization, when you're gonna get all the stakeholders, the physicians need to agree on this, and they need to agree on all the premises of how you're gonna conduct business and the operation of your laboratory. We start that process. We need to be champions of this and own this because after you do that, and then everyone around you understand the expectations, it became a lot easier. So with a good example about this is I've seen, I've discussed with some electrophysiologists that are frustrated about the flow in their lab, and I think you need to wear the hat of the anesthesiologist or the CRNA and think about how do they think about our operation because if for them, they're only gonna be used, for example, as the fourth case in the day, and they don't know if they're gonna start at nine, 10, three o'clock or 5 p.m., you made their day inefficient. You can't do that. For you to be successful, everybody's days need to be efficient. So that's how we have done this. For example, you mentioned the way we work with the CRNAs. They know what to expect, and it's gotten to the point that we don't have to say anything, right? Throughout the procedure, you saw multiple changes in the ventilation. We've done not just to improve patient care, but also the efficiency, and these are led by the CRNAs now. The protocols we've written about sedation and of patients for AF ablation, those were written with them, so everybody is a part of the process. So the important aspect for this is we electrophysiologists need to start it. We need to agree on how we're gonna do things, and we need to stick to it. We need to do it every day the same way. So I think before you go too far with the QI process, get all your colleagues, all the electrophysiologists in the room, and you all need to have a very good agreement on to what extent you're willing to go, how far you're willing to go to improve the process, because just one person is not gonna change everything. We need to do it together. Jose or Chris, can you get a little bit more granular and tell me specifically how you went about collecting that data that you utilize then to present to the administration? So our recording system up there is Philips. So when we figured out our goal as to what we were trying to do is to figure out how much time it took to do everything that we do in the lab, and then we wanna start looking at that time to see how we could change it, we got with Philips, who is in our recording systems in our labs, and we had them build a template into our charting that gave us the times that we needed from wheels in to patient prepped and ready, physician arrived, physician paged. We go all the way down through there and we can monitor those times and look at those and see if like, why was the doctor not here at this time or what took so long to get the patient ready? If there's something in there, if it's just out of ordinary, we can look at it and see, well, maybe there's a special case with this patient, but that's how we monitor all these data points as to how we keep our efficiency up is just by monitoring those. If things start getting longer, like it looks like it took somebody 30 minutes to prep a room, then we gotta figure out what happened with that. Was it a staffing issue? Was it an equipment issue? What was it? So we look at those things. If it becomes a problem, I mean, once you can let that one go, but if it just becomes routine, then we've gotta look back and see what are we doing here or what has changed that's causing this. So with those monitorings or the data that we've had built into our charting, we're able to tell that and we can run reports off of it and we can see our average start times or how long it takes for the patient once they got in the room to be ready before we stick the groin or when the patient comes off the table, we can look at, or at the end of the case, how long it took us to get the patient off the table as far as the extubation and all and so on and such forth. Monitoring those times is key. I'll add a few things in terms of the next steps, right? You talked about low-hanging fruit. I think we made very good use of the EP Lab accreditation processes that exist today to develop our core team for the QI process. And as we were going through the EP Lab accreditation process, we revised all of our protocols. We grabbed, we decided who were gonna be the leaders for EP Lab tech, nurse from the EP Lab. And we were initially meeting once a month. We now meet once every three months. In our meetings today, using the data that Chris described, we discuss the outliers. So today, we're no longer discussing about processes that we wanna improve, but it's more understanding outliers. If 15 minutes is the benchmark, why did we take 45 minutes? And by understanding this, we have been able to maintain the efficiency. Great, yeah, that's very important because you gotta establish it and then you have to maintain it as well. Yes, and I think the accreditation processes can help you. It's a good exercise. It's a good exercise for us to do as a team. You built the team, the culture, and that allowed us to revise everything in this context. And so for an existing lab that has been doing this for years and now there's a call for a change, I think the accreditation processes can really be a good catalyst for it. Thank you. I think you've really helped us to understand more specifics about the QI process that you guys have introduced here. Thank you, Jen. I agree. Thank you so much. This has been great. Thank you.
Video Summary
Dr. Jose Osorio and his team are implementing a Quality Improvement (QI) process in their healthcare institution. They have drawn inspiration from other industries, such as the airline and nuclear power industries, to improve their processes. They have adopted a Lean Six Sigma Lite approach, which focuses on efficiency and quality improvement. The first step in their process was to map out the entire patient journey, involving all stakeholders in the discussion. They then established benchmarks and expectations for each step of the process. By measuring and analyzing data, they were able to identify areas for improvement and reduce variation. The team emphasizes the importance of getting buy-in from all electrophysiologists and stakeholders to achieve successful process standardization. They utilize data collected from their recording system to monitor and identify opportunities for improvement. The team also emphasizes the importance of maintaining the efficiency gained through the QI process. The implementation of the QI process has led to positive outcomes and increased buy-in from the administration. Accreditation processes have also played a significant role in driving the change.
Keywords
Quality Improvement
Lean Six Sigma Lite
Efficiency
Patient Journey
Data Analysis
Process Standardization
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