Healthcare is constantly changing, constantly evolving and growing, and becoming more, becoming better. And our role in that improvement, the innovations that will continue to change and save lives, is to show up and do the best that we can. Maybe that's the why we've been looking for, to strive to go beyond what's expected, to go farther and push harder every single day. Because that matters. What we have learned together through this series matters. Thank you for watching. Thanks for doing what you do, how you do it, and why. Thank you. People may look at a program as high-functioning as the program here at Grandview and think, oh, we can't do that, or that can't be done in other places. In this segment, we're going to be addressing some of the questions around the reproducibility of the changes that the folks here at Grandview under Dr. Osorio's leadership have made. Let me turn first to you, Jen. I know you and I have been talking in the last couple days about being blown away by some of the things that we're seeing here. What are some of the things that you're looking at right now that you think you could take to your program this week? That's a great question. And so where do I start? How much time do we have in this segment? So I think looking at the low-hanging fruit going after that is important. So watching, seeing was believing. And so just watching the setup and the fact that even the table is completely set up by the time that you come in saves a lot of time. But I really think, ultimately, the next step, you know, so there's the low-hanging fruit part. That's just one example. But the next step is the communication step with your colleagues in other divisions and departments, and particularly your relationship that you have with anesthesia. And so we're fortunate, too, to have great colleagues in anesthesia. So I plan to meet with my colleague in anesthesia and talk about, you know, how we can best utilize anesthesia during the case to make the case more efficient and safe for the patient to minimize catheter movement. So that was just brilliant watching how the anesthesia protocol and your pacing protocol really resulted in increased catheter stability. So that was awesome, and that's going to be one of my priorities going back. And then also how quickly you were able to extubate the patient and to turn the room over, get them off the table and turn the room over. So those are my, you know, the first things that I would start with. Well, and I think it's so interesting, you know, listening to her comments that we're discussing over the past eight years of collecting outcomes on our patients. We've come to realize that the simplest of all interventions I've ever done, which is anesthesia management, ventilation management to increase stability, was the most impactful intervention for patient outcomes. So you do have, you should look at low-hanging fruits and things that are simple interventions, increasing communication, because the impact of those low-hanging fruit, you don't have to become too complex to make it all reproducible and achieve similar results. Excellent. Andrea, this is your second time here, unlike Jen and myself, who it's our first time to visit. You've seen this already before. What are you going to take away this time, having seen this twice now? Yeah, it took so many things home last time. It was really, you know, incredible to see the whole setup and some of the things you talked about here too. This time, actually, what struck me, and it wasn't as obvious the first time, was the standardized protocols that are not just you and your group, you know, not just for you, but something that really was more global for really everyone practicing here. It was really, it's quite impressive, actually, that even the other group, even people who were doing things one way for many, many years were able or really willing and really wanted to, not even willing, really saw what you do, what you created, and wanted to change their protocols to use what you did. So I think actually having standardized protocols clearly improves efficiency, but it, you know, improves patient care overall. So that was my big take home from this time, you know, the overall things, and actually some of the ventilator settings. And so, you know, although I heard a little bit about that last time, I think implementing and talking to anesthesia, we have a really good relationship also with our anesthesia department, talking to them more specifically about the specifics of the kind of things you do to help enhance catheter stability. So it was really impressive. It's one of those things, like, you know, sometimes you watch a movie and then you think, oh, the first time you kind of see all this, and then you come back and you watch it again and you learn so many more things. And probably those things were all there last time, but, you know, really impressive. And so lots of more take homes this time. Are there things that you did take home and implement the last time? Yeah. So I think some of, you know, so some of the things may have been protocol related. Some of the things we were trying to get is you have an overall manager that oversees, you know, Chris. I like to clone Chris is what I wanted to do when I got back, but we couldn't clone him. So we actually hired, you know, we hired someone else to take over, you know, that kind of role because you do need it can't be someone who's, you know, scrubbed in the other lab who's going to be the one who's also running the schedule, especially if you have three or four labs going at the same time. And they're even one of our labs is in a completely different building. You need someone who is dedicated to look and see where all the patients are, what stage they are, you know, where they're, you know, where their next piece needs to come in. So we did take that home and we did, we have a wonderful person we've hired, you know, and I said, this is how, you know, this is how they do it, how efficient they're doing all these things. And so we were able to, you know, get that supported. So that was a big change for us already. Josh, you've now been here several times. And I know you've probably done more than just about anybody else to try to bring these changes to your own program. What do you think now having been here four or five times? Yeah, reflecting on my time, this is my third trip here in about five years. And the first time I felt like all of you did completely in awe. And Renee, Jack was here with me. And honestly, our first reaction was we can't do this. And we thought it was just out of reach. And what we did, though, is we took notes that time. And we, we had sheets of paper, literally, we went back and we debriefed. And one of the things that we decided was we needed Chris Cooper in our lab, we need we need one of them. That's what Renee became for us. And a lot of what we did actually had nothing to do with the procedure itself. It was all the other stuff, the turnover time, the everybody has an assignment knows what they're doing. There was the air traffic controller who's making sure that, you know, everybody's getting their breaks. And we're not slowing down procedures by doing so. And then it's interesting, because this time, what's really struck me is your protocols. And we haven't done enough of, I think, standardizing the workflow during the procedure for everyone. And especially with anesthesia and improving patient outcomes. And we've made tremendous progress. So this time, instead of being completely blown away by it, I was like, oh, we do like 90% of this. And the last 10% that we don't do, I think, is the next step is how do we implement all these protocols? You know, we've done this stuff with the anesthesia, I started meeting with them on a regular basis after my first trip here. And we all got on the same page. And I learned so much from anesthesia. But now it's really getting to the next level where we're also improving quality, as well as efficiency. And I think what is so interesting to hear is that if you want to make your lab efficient, you have to be careful about the line you may cross in terms of, it's not about speed, we've talked about this, right? And in terms of what is a low-hanging fruit, if you want to just focus on efficiency or going home earlier is your goal, it's a lot easier to focus on the turnover than to try to shorten the procedure time. So starting there in addressing the turnover in an organized way, you're much less likely to cause a complication. There's no bad patient outcome because your turnover is quicker, right? But the end result of getting home earlier, it will be the same. So now what you hear from Josh is the same process that they've mapped and they did to address turnover and lab flow, the same principles are applied now to shorten your procedure time. Standardize and make the procedure itself more efficient. So you can work on both things at the same time or one and then focus on the other because the principles, I think, it's all the same. What did you think, Renee? Like you said, when we first came, I was blown out of the water. I didn't think that would happen. And coming back the second time, I don't feel that way and it's kind of cool just to see the similarities in how we did adapt the efficiency. We definitely started with just room turnover, what we could do to make that faster, getting an extra body in the room, just sharing what my experience was with the staff. And then we came a second time and brought different staff. And once they got to see what I was talking about, they were on board and engaging the staff and it was really important. But yeah, it's a whole different place now, I'd say. But yeah, it didn't take a while. It took a while. I think a lot of people think, oh, it's going to happen overnight. But it took us about two or three years to get, I think, where we're at now from when we first started. How would you characterize that result at this point? What changes have you seen in the outcomes? Well, we were able to do a lot more cases. And so I had a three-month wait time the first time I came down here and I was doing far less procedures. And now my wait time is typically two to three weeks. And so what I find is we're able to get patients in much quicker who may be sick. Or when there's an add-on inpatient case, it's much easier to accommodate that when we're efficient and we have more flexibility throughout the day. I think our workflows have improved. I've adopted a lot of what Jose does in his procedures, but not everything, including the anesthesia protocols. So that's, again, where I think the next step is to improve things even further. And you have talked about engaging the staff. I think that is so key, is every part of the team is a really important part of the team. So getting input, getting them involved, asking and having them be involved in the change is really important. It's basically creating a new culture. And it's wonderful now. And shortening the time from evaluation to the procedure for the patient, the wait time from three months to two, three weeks, this will have another added benefit, which is, I mean, you're going to strengthen your relationship with referring physicians and more patients will be taken care of properly. And so it helps build the program itself, grow the program. Renee, how's this been for the staff members of your team? It's been wonderful. There's been a very positive shift in the environment. The staff's happier. They enjoy getting out on time and going home. And like I said, they're very engaged and they're into the efficiency. And if there's a day that we were running behind, they want to talk about what we did or why there was a lag. They don't accept delays as a reason. They're out there trying to figure out what we can do to speed stuff up. So it's definitely been pretty awesome for them. Any other thoughts, Josh? I think what Renee said is really important. This did not happen overnight. And it's not done happening. It's going to keep happening. And it's a stepwise process. You have to get all stakeholders involved. Anesthesia is crucial, like Jen was saying, and you have to engage everybody throughout the whole process. And when we go back this time, we'll have to see what other changes we can make and engage everybody and see what their opinions are. Josh, that was a great idea about meeting with anesthesia regularly. Now I'm like, okay, this is what I'm going to do. It's like, oh, why didn't I think of that before? It just makes sense. And just having that open communication so that you can actually work on continuous process improvement. I think what's also really impressive that you've done is the communication also. You have the hospital administrators from each level. I don't know if you meet with them regularly or not, but it's clear that they very much know what you're doing and they're very much supportive of continuing to help you grow. They're completely engaged in the process. And they are partners and have helped us continue to grow. I think ultimately, to me, the more important message is that this is reproducible. If I suggest a book, we're talking, it's the Checklist Manifesto from Atul Gupta. A lot of this started from reading that book and understanding this process. When I moved to the U.S., I remember as I was starting residency, it was when the movement in the country was happening, led by him, to reduce central line infection rates. And it was all about a checklist. It was about having a nurse be empowered to ask doctors questions on a checklist format before doing a central access in the patient. And that had amazing results in reducing central line infections across the country in hospitals that did it. That was very impactful. It stroked me in a really positive way. And so after reading that book as well, I mean, it started permeating to everything we do, as you could see. So I think that could be a starting point for many. I think another thing that's really struck me, Jose, being here, is I was skeptical when I first came. Like, okay, is he going to be cutting corners? Like, how does he get so much done? And what I've found is you're actually more dedicated to quality improvement and safety. And so you're not compromising the safety of the patient. You're actually improving it by having this regimented and protocol-driven program. And I actually think that if we were to bring in any doctor, and you've shown this, actually, because physicians from other groups have come in, and they've kind of adopted to your program and molded and changed their practice. So I think it's more about the program. And you are a great operator. But I think if you put me in your same program, I'd be doing the same number of procedures and with similar outcomes. I agree completely. I agree completely. I think overall, as a group, for electrophysiologists, for AF ablation, procedure times are decreasing all over the country with the technology where we are. So we have catheters that are better. We have better understanding of the biophysics. I think we, as a group, are doing much better with AF ablation. So the areas that people can work on to shave procedure time right now, they're not necessarily in their skill level. They are really in their organization level, which that's why I think it makes all of this so reproducible. Yeah, I agree totally. And the standardization of the protocol, not just what you do. And it's the timing of things, right? So you have everyone knows their role, right? The staff is all ready. They're ready. They set up the room in a very team effort approach way. And they hand off things. And anesthesia, too, is that just people know what their job is. It's really well-defined. And that's, I think, key to some of that reducing wasted time. So a simple example, if you consider, I've talked to a few electrophysiologists to use isoproteinol post-procedure or not. And sometimes I do, sometimes I don't. This may seem like a simple question, but it really isn't. Because as someone, during the procedure, you're now going to make the decision. So, OK, now the team is going to have to prepare the isoproteinol. It may take 5, 10 minutes to get the pump ready. We use it for every patient. So this simple decision of having a protocol mandated care of our patients during the procedures will improve the time significantly. As a proud UCLA Bruin, I can say that I've heard it said by him that the eight laws of learning are explanation, demonstration, imitation, and then repetition, repetition, repetition, repetition, repetition. Does that resonate with you, Jose? Absolutely. I would add repetition a few more times. Because if you do that, what repetition will do is that now I'm not the only one engaged in the process of repetition. My entire staff is. That's where you will see that I don't have to ask the clinical to zero the contact force catheter. I don't have to ask the nurse practitioner or the nurse anesthetist to change the ventilation. I don't have to ask for the intracardiac echo catheter. I mean, things are just in my hands. But imagine if every procedure I was reinventing, every procedure I would do differently, the sequence of events were different. How can anyone in your team predict what you're going to do if you're not using repetition, repetition, repetition? So that process, I think, makes it very safe. We've discussed also how you obviously have to be willing to change if the clinical scenario requires it. But what I have found for AF ablations, and particularly paroxysmal, is that for the two standard deviations, for the vast majority of my patients, and I'll probably say for 90 to 95 percent, there's very little change. There's very little change that will happen during my AF ablations. Very, very little. So I like the idea to repeat repetition many times, as you've said. Excellent. Well, I'd love to thank you all for your insights. And it really seems to me that this can be done just about anywhere. Okay. I know I'm going to be taking a lot home. Me too. Thank you, Jesse, and your team. Thank you.

healthcare professionals

standardizing protocols

improving communication

efficiency

patient care

continuous improvement