Catheterisation Lab

Executive sponsor: Dori Lombardi

Clinical team lead: Jamie Rankin

Project team leader: Katherine Birkett

Aims

• To improve the flow of

elective patients through Cath Lab

• To review the booking process

• To comply with accepted

KPI’s of waitlist times irrespective of category

• To reduce the number of deferrals/cancellations

• To optimise the utilisation of the Cath Lab

• To improve the patient experience

DMAIC Methodology

Customer focused

Current process

Data driven

Involves clinicians

The Business of Cardiology

• The Cath Lab undertakes over 4000 procedures per year and are

increasing

• The Cath Lab accepts direct admissions from other hospitals,

emergency and elective admissions

• There is increasing competition between

electives and non electives

What we do

• The main procedures are:

• Angiograms/plasties

• Pacemakers/ICD’s

• Transoesophageal echo

• Cardioversions

• Electrophysiological

studies

• Rt/Lt heart catheters

• Cutting Edge procedures are:

• Trans Aortic Valve Implant

• Left Atrial Appendage

Occlusion

• Pulmonary vein ablations

• Renal Artery Dennervation

• Valvuloplasty

• Electrophysiological studies

What staff told us

• There is variability in all stages of the booking and admission

process

• The booking process is very complex especially GA’s

• There is no transparent procedure list, and the order changes

frequently

• There are competing demands for lab access from non elective

patients

• Patients arrive in the Lab with no consent and no cannula

• Cath Lab lists run overtime

• On call arrangements impacts on staff available next day

• Lists starting late because staff not ready

• Cardiobase data not always complete

Mapping We engaged over 30 stakeholders from across the

hospital through participation in:

3 Process Mapping sessions

Numerous 1:1 discussions

3 Root-Cause-Analysis sessions

We logged 178 issues,

numerous root causes and delay reasons

We also asked our patients what they

thought of the booking and

admission process

Define: Process Mapping 1

Booking Process

Define: Process Mapping 2

Elective Patient Pathway through the Lab

Measure: What we needed to find out

• Booking slips

• Cancellations

• Where our patients came from

• Mode of admissions elective/non elective

split

• Waitlist – number/length

• Cath Lab utilisation

• What our patients think

Measure: Bookings • Booking slips – often incomplete and variation as to who

entered it – Consultant, Registrar, RMO, secretary

• Incomplete clinical information

• Complex booking system with much variation

• Specific patient needs can be forgotten and patient is

subsequently cancelled as needs not met

• Patient can be forgotten on the list

• Critical Care bed not always requested when needed

• Only 57% in one survey had a completed consent

• Variation in the content of letters and in the sending of

procedure information

Measure: Cancellations

• Patients being

cancelled on the

day for a variety of

reasons – EP more

likely than

interventional ?due

to complexity of

procedure. No of

cancellations in

2011 = 77

Measure: Cancellations • All cancellations in 2011

• Top reason – procedure

subsequently not

deemed necessary

• Other findings included

three different reasons

for cancellation,

secretary rebooking

procedure did not know

that the pt had been

cancelled and bookings

not completed in EBS –

inaccurate pt list

0%

20%

40%

60%

80%

100%

120%

0

5

10

15

20

25

30

35

40

EBS Top 10 Cancellation reasons 2011 N = 194

Measure: Patient mix

0

500

1000

1500

2000

2500

2008 2009 2010 2011

Changes to Cardiology Admissions 2008-2011ELECTIVE WAITLIST ELECTIVE DIRECT

NON ELECTIVE DIRECT NON ELECTIVE EMERGENCIES

8%

47%

30%

-35%

47% increase

in electives

Measure: Waitlist • Audit of Booking Slips

• Procedure date allocated –

75% of pts in one survey of

120 bookings

• Urgency – 80% classified as

category 1’s of which 69%

given date within time

• Compared mean time of

procedure by Consultant to

allotted Cath Lab session

time

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

0

5

10

15

20

25

30

35

Procedure booked - Top 11

Reasons for no consentRadiological

Procedure,

7, 10%

Country

Patient, 59,

86%

Consent not

required for

this

procedure,

3, 4%

Measure: What is the problem?

Staff told us patients arrived in Cath Lab

with no consent

• Of the 69 patients not having signed a consent, 59 (86%) allegedly lived in the country

• Only 22/59 (37%) actually lived in the country Source: EBS Audit, Dec 2011

In a snapshot study of 122 EBS booking slips in December 2011 there were 53/122 (43%) patients with a consent at time of booking:

Consent completed at Time of EBS, Dec 2011

43%

57%

0%

10%

20%

30%

40%

50%

60%

YES NO

Source: EBS Audit, Dec 2011

A more recent audit in DSU revealed that only 4% of Cardiology patients booked in for a procedure had a consent at time of hospital admission:

Measure: What is the problem?

You told us that the labs were working “flat out”

WORKING DAY 0800-1200, 1300-1700

30% loss in utilisation

= 160mins which equates to

on average two extra

angiograms per day per Lab.

Source: Cardiobase

31/10/11-22/12/11 Data sourced from Cardiobase Oct 31-Dec 22 2011

Mean Utilisation per Room

• Angio 1 70%

• Angio 2 66%

• EP Lab 63%

• Treatment Room 27% (not graphed)

Angio 1 Mean on table time 08:44 Mean needle to skin 09:08 Mean end time 17:00

Angio 2 Mean on table time 09:02 Mean needle to skin 09:37 Mean end time 16:49

Measure: What is the problem? Lists start late and end late

Source: Cardiobase Oct 31-Dec 22 2011

Angio Lab 1 First Cases Starting Time/Last case end time

08:00

09:00

10:00

11:00

12:00

13:00

14:00

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M T W T F M T W T F M T W T F M T W F M T W T F M T W T F M T W T F M T W T

Start On Table End

Mean start 09:08

Median 09:10Mean End 17:00

Median 17:12Angio Lab 2 First Cases Starting Time/Last case end time

08:0009:0010:0011:0012:0013:0014:0015:0016:0017:0018:0019:0020:00

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M T W T F M T W T T W T F M T W T F M T W T F M T W T F M T W T F M T W T

Start On Table End

Mean start 09:37

Median 09:40

Mean end 16:49

Median 16:55

EP Lab

Mean on table 08:38

Mean needle to skin 09:22

Mean end time 16:27

On table – pt has been

moved into the room

Needle to skin – start

End – when procedure

finishes

Measure: What is the problem?

In a study on Cardiobase data from Oct 31 – Dec 2011, there were 94 Angiograms carried out. Of these, 13 patients (13.8%) got the subsequent angioplasty on the same visit to the Lab. There were 9 (9.6%) patients who had to be rebooked either because they could not get a bed or it was a medical decision to stage the procedure

Staff indicated that patients needing an Angioplasty on the same day as an

Angiogram were often cancelled as there was no bed available

Patients indicated that

the one thing they

were frustrated about

was that

they waited for their

procedure in DSU not

knowing what time

they would go Cardiology Elective Cancellations to DSU 2011 by Time of

Arrival/Cancellation

06:0007:0008:0009:0010:0011:0012:00

13:0014:0015:0016:0017:0018:0019:00

0 10 20 30 40 50 60 70 80

Patients cancelled (time order)

Tim

e o

f A

dm

issio

n

0:00

1:00

2:00

3:00

4:00

5:00

6:00

7:00

8:00

9:00

10:00

Wait

ing

Tim

e

Arrival time Cancel time Wait time

Source: DSU with thanks

Affinity Diagram

Measure: Root Cause - Patient not

prepared

Root Causes

• Variation to Practice

• Lack of business rules, no agreed start time or definition of start time

• No agreed standards for data entry, not validation and data entered

retrospectively

• Variation to booking processes decentralised and by Consultant – no one

person responsible

• Rostering did not meet demand, Consultant on for lab did not see pt in

clinic, Consultant not in clinic

• Patient not prepared as had not received information

• No visible procedure list on wards

• Struggling with leadership both medical and cath lab

• Scheduling – no quarantined time for electives, no one responsible,

mismatch of forecasted procedure time to time allocated

Solutions

Set

business

rules

Set

definition

of start

time

(needle to

skin) Set the

time

Establish

KPI’s on

turnaround

time

Review

cleaning

arrangements

Roster

review

for all

staff Review

oncall

and

overtime

First pt of the

day to be a

golden

patient

Consultant to

be in the Lab

when

rostered

Introduce a

transparent

procedure

list

Staff suggestions on how to improve the patient journey

Improve: Solution generation RPH:ELECTIVE CARDIOLOGY PATIENT JOURNEY

Request for Waitlist

Procedure Preadmission Journey Admission Procedure

Post Procedure care

and disposition

ROOT CAUSES ROOT CAUSES ROOT CAUSES ROOT CAUSES ROOT CAUSES Booking relies on secretary’s

knowledge (if one step missed pt

can get cancelled)

Systems do not always talk with

each other

Consultant not in Clinic (decision

on procedure can't be made and

consent not obtained as a result)

No standardisation in the booking

system

No one responsible for

overseeing the schedule

No standard practice for patients

referred from private rooms

Senior decision maker not

available at time of procedure

booking

Lack of knowledge re business

Variation in completion of EBS

Variation in amount of

information available at time of

booking

Registrar not trained in EBS

No access to EBS off site

Consultant not in clinic as

rostered elsewhere

Rostering practices –

Doctor in clinic not same one as

performing procedure

Policy on consent not being

followed

Lack of monitoring/audit of

completion of consent

Access to scanners

Clinician variation in obtaining

consent

No standardisation in obtaining/

managing consent

No standardised procedure for

checking contact details of pts

referred from private rooms

Secretary not having access to all

the relevant information (having

to do EBS

No one person follows

through (mixture of medical

and secretarial staff )

No one person responsible

for managing waitlist

Lack of consistency in giving

patient written information

regarding the procedure

Patient not understanding

instructions

Registrars delegate

responsibilities to secretaries

to inform patients of

preparation prior to the

procedure

Proceduralist changing list

order (pt not yet arrived and

is next on list as the list has

changed)

Results not checked prior to

admission (mainly bloods)

External clinic does not send

results or tell patients the

results

DSU not accessing EBS for

presence of consents

Delays in accessing results

because the coordinator is

multitasking

After hours clerk not

completing task (getting old

notes for DSU) (supposed to

get remaining files ready for

DSU)

RMO/Intern have conflicting

priorities (not getting

consent)

Variation of practice

amongst Registrars, RMO’s

and Interns (some say its OK

to consent and so cannula in

CTLB)

Policy on consent not being

followed

No quarantined time for

electives

No transparent guidelines on

when staff can do on call

Lack of flexibility re sick leave

relief few relieving staff have

been trained)

Staff mostly starting at the same

time

Lack of flexibility in Oncall

practices

Consultant rostering (can be

elsewhere and not on the floor)

External clinical commitments

Rostered Staff allocation not

meeting dept needs

No one responsible for

monitoring times

Difficulties in predicting

emergency demand

No agreed start/end time

No agreed business rules eg KPI’s

Business rules not monitored

No transparent procedure list

Procedure list frequently

changing

No KPI’s for turnaround

No one EP Consultant covers

entire day

Less flexibility with EP

scheduling should AM list finish

early

No one person responsible for

scheduling

Not enough known re the

business

No policy/process re

cancellations

No agreed minimum data set for

Cardiobase

No business rules for consistency

of Cardiobase data

No business rules re timeline

Numerous systems needing same

information on procedural time

No one person responsible for

checking EBS booking is

completed post procedure

Delayed discharges in 4F/ CCU

thus there are delays in T/F

pts and they stay in recovery

DSU unable to take pts back

early if radial approach

Improve: Solution generation RPH:ELECTIVE CARDIOLOGY PATIENT JOURNEY

Request for Waitlist

Procedure Preadmission Journey Admission Procedure

Post Procedure care and

disposition

SOLUTIONS SOLUTIONS SOLUTIONS SOLUTIONS SOLUTIONS Explore having access to EBS from

the private rooms

Standard procedures for entering

EBS

System in place for prioritising

category 1’s

Have consultant available at Clinic

to discuss 1-2 pts who need a

procedure

Identify on person to be

responsible for the waitlist

Review what information

patient needs pre procedure

Standardise letters sent to

patients and the information

within in.

Standardise procedure

information given to pt

Provide pt with pre admission

form and health questionnaire

to be completed in clinic

Have pt consumer group review

skeleton pt letter and

instructions for ease of

understanding

Have skeleton letter sent to

Consultants/Registrars for

review

Review role of coordinator in

CTLB

Identify one person with overall

responsibility for scheduling

Have a system in place where

“fit for procedure” is

determined eg check INR is

therapeutic

Pts for cardioversion who go to

PAAS – have a system to have

their ecg checked prior to going

back to PAAS

System to contact pt a day

before the procedure to check

details/confirm pt is coming

Arrange PAAS clinic a day earlier

than present for cardioversion

pts – bloods can then be ready

?Extra clinic to review pt just

prior to procedure

Look at staggering admission

times in relation to patient list

Review pre procedure

preparations and associated

policies eg groin shaves

Allocate an intern/RMO to go

over to DSU to get cannula

inserted/ prehydration

prescribed

Review heart failure admission

process

Review role of CTLB clerk in

admitting patients

Implement a flagging process

whereby pts who have had the

procedure as an emergency can

be cancelled from the elective

admission list

Set up business rules

Set start time and set changeover

time

Set against approved standards (set

KPI)

Operational policies

Consequence if not on time – set

some rules

Leadership – developing policies

around leading the team rules

Consultant on the floor when

rostered

Roster Consultant/Team based

rostering for the day so that

rostered in the lab no other duties

Rostering review – nursing/Cath

staff

Review start/end/shift length

System for sick leave cover

Review overtime and on call

Review cleaning requirements inc

nos

Review IT resources

First patient on the day to be set as

the “golden patient” and is locked in

night before

Determine needle to skin as 0830

Education sessions must enable one

theatre to proceed as per usual

Implement a transparent patient

list

Quarantine time on the schedule for

elective pts

Review clerical processes for

completing EBS

DSU to take back pts with radial

approaches earlier

Review recovery staff allocation

and nursing care

Review care practice

standards/operational

Post Cardioversion have the ecg

completed and reviewed in CTLB

before going back to DSU

Solutions • Booking Process - centralise

• Business Rules

• Agreed start time

• Turnaround time

• Rostering review

• A scheduling review to examine use of session by

Consultant and to match allocated sessions to

Consultants with greater numbers of electives booked

• Introduce golden patient

• Introduce transparent list

• Local cancellation policy that meets hospital standard

Improve: Solutions

• Ranking based upon

• Importance

• Quick, medium or long term fix

• Action required

• By whom and when

• Evidence to ensure achieved

• Sub groups formed to develop and implement

solutions

• Early solutions to implement were improving start

times, improve utilisation and introduce golden pt

Kotter’s Theory

• Complacency

• Creating the Vision

• Guiding Coalition but then did we……..

• Removing obstacles

• Communication

• Quick wins ?

• Don’t celebrate success too quickly

• Embed the change

Reflections: Challenges

• Competing demands between emergency and

elective sources of admission

• The need for beds and more beds

• Validity and reliability of data in a background of

impending activity based funding

• No baseline measures of utilisation available prior to

commencement

• Staff recognised that the system was broken and had

been for a while but not having the ability to fix the

problem as they were “very busy”

Reflections: Lessons Learnt

• Not all Consultants respond in the same way – the

challenges of getting them all onside and committed

to change

• It’s not always about the bed

• Staff on the floor were engaged and indicated they

wanted change but they were looking to the

leadership to drive the change

• Implementation harder than the journey to get to

that point – need a good governance structure

In god we trust…….

Reflection: Key Changes • Recognition that the service required good clinical

leadership

• Importance of Cardiobase: good data = better

reporting measures

• Feeding back to staff how they are doing

• Earlier Lab finish times yet increased activity

• Improved starting times

• Recent changes to the governance structure

• Sometimes key changes require escalation - voice of

the organisation is important to ensure the voice of

the patient is heard and understood

• External review