The elective pathway for cardiology encompasses a wide range of patient transactions and, as with any multi-component patient journey, opportunities for human error, inefficiency and system failure can arise at any point. But lean principles and a clear IMPaCT programme can achieve and sustain cardiology pathway improvements, say Anne Mawson and Lucy Reynolds.
University Hospitals of Coventry and Warwickshire Trust introduced a programme of work to improve patient flow through the cardiology department, whose catheterisation labs undertake a high volume of percutaneous coronary interventions and primary PCIs for treating coronary artery blockages each year.
From January to December 2009, 621 PCIs and 442 primary PCIs were undertaken; from January to December 2010, this rose to 756 PCIs and 379 primary PCIs.
The programme aims to improve the overall patient experience, reduce on-the-day waiting times for patients, and reduce catheter suite overruns.
Changes to the cardiology pathway were also designed to deliver significant improvements for staff by creating a more efficient, functional, less frustrating and therefore more fulfilling workplace.
Serving a population of more than a million people, the trust created an IMPaCT programme - improve, motivate, participate and create transformation - to raise quality and efficiency across its services.
The programme uses lean techniques and members of the IMPaCT team have been coached in lean and change management methodologies, which are now being cascaded through the trust.
To achieve and sustain real pathway improvements, a 13-week rapid improvement event cycle was followed between June and August 2009. It has three stages: preparation, event, action.
A six-week preparation phase ensured engagement events were well planned; clinical and managerial leads were identified; and performance measures, baselines and targets were set. During this phase, clinical director Peter Glennon was identified as the clinical lead for the programme, with responsibility for leading on efficiency improvements.
The aim of the event stage was for stakeholders to collectively review cardiology processes - from the point at which a decision is made to perform an elective cardiac catheter procedure, through to the moment when the cardiologist’s report reaches the patient’s GP - and then to co-create improvements to the process.
The events had strong participation from consultants, registrars, administrators, physiologists, radiographers and nurses. Activity broadly followed a five stage model.
During day one, stakeholders mapped out the existing cardiology pathway and identified issues that were impeding patient flow. Issues included multiple patients being booked to arrive at the same time, lack of preadmission tests causing delays, frequent changes to the lab running order creating confusion among staff, poor organisation of the physical work and stores area creating wasted time and repeated delays in discharge.
Between day one and two, the event team roadshowed the current state map around the department at different team briefs, to ensure that everybody in the wider cardiology team had a chance to contribute to the “current state” map findings.
Day two was used to review the current state map and feedback from other team members, and to begin identifying and prioritising improvements that would enable these issues to be addressed, and the desired “future state”.
Solutions were prioritised and selected based on ease of implementation versus potential benefit. Implementation of the “easiest” solutions began during the workshop, to generate initial quick wins and create a sense of momentum. Solutions that required more time and planning were collated into an action plan by the team the following day, for implementation after the event.
During day three the team received basic change management training, to ensure that selected solutions and changes would be implemented in a managed and sustainable way. The team carried on with implementing some of the quick wins and were coached on how to develop action plans, communication plans and control plans for each selected solution.
Elective lists finishing before 5pm following the improvement process
On day four, action, communication and control plans were completed, followed by a presentation of all mapping work, outcomes and implementation plans to a wide group of trust staff on day five. Attendance was excellent, with representation from the trust’s executive team including the chief executive, chief operating officer, finance director and medical director.
Making change happen
During the action stage, weekly progress meetings were held. These sessions were led by Dr Glennon.
The following solutions were selected and have now been implemented:
Pre-operation preps provided in-clinic: To reduce patient waiting time and standardise patient’s preparation for the catheter lab, all patients now have their blood samples and ECGs taken in-clinic. This has now become nurse led, with staff also being trained to do patient consenting. Around 30 per cent of patients now receive in-clinic pre-operative preps, with an aim to extend this to 100 per cent.
Staggered appointments: Rather than four patients arriving at the same time, patients are now given specific appointment times throughout the day.
Patient list reorganisation: A points-based system was developed to ensure the right balance between routine and complex procedures on surgery lists. This was intended to reduce overruns within the catheter lab. While list reorganisation is an ongoing initiative, the team have found that the pressure of the four week target sometimes overrides the points system, meaning that application can be inconsistent. Ongoing work is being undertaken in this area to try and overcome this issue.
Elective and emergency list split: The catheter lab list has also been split into separate elective and emergency lists, to enable the catheter lab team to plan the day more efficiently. This is a marked improvement.
Catheter lab co-ordinator: A dedicated work station and phone line have been installed for the catheter lab coordinator. Previously the physiologist had to answer calls throughout the day, and the coordinator could not view the list while on the phone.
Standardised start time: Delays to the first procedure were frequent due to different interpretations of what a 9am start time actually meant. “Start time” has now been re-defined as “when the patient is on the table”. This enables teams to understand the specific tasks that must be completed before this time.
Reporting by registrars: Errors in the method of exporting reports to the CRRS system resulted in the inability of staff to commence the discharge process as the reports were not visible on the system. A guide has been completed and placed at each PC to ensure consistency in the method used to export reports.
Visual management: Whiteboards have been introduced, to improve clarity around staff movements and enable communication of catheter lab issues. A plasma screen has also been set up, to display the patient list schedule. The screen is in place, and it will have new software to enable patient lists to be displayed. Improvements have also been made to the large storeroom area, using a specific lean tool for improving workplace organisation and safety - the 5S tool - sort, set, shine, standardise, sustain.
Medications: Pre-meds are now given in the catheter lab, to address the previous issue that patients’ medications either wore off before they were transferred to the catheter lab, or were repeated at the lab, resulting in double dosage. Changes have also been made to ensure registrars and consultants document medication changes in the same area of their report to a patient’s GP. In cases where it is not critical for patients to receive medication immediately, this enables patients to bypass delays caused by waiting for prescriptions for take-out drugs while they are still admitted, by receiving a prescription directly from their GP instead.
Consultant availability: With the aim of improving their availability in the catheter lab, a new workspace has been created for consultants to complete their administration work between patients. This also enables better supervision of junior registrars and contributes to a faster turnaround of patients.
Patient registration: To reduce waiting times in reception, patient registration was introduced in the cardiology day unit, with staff receiving training about how to admit a patient and create an ID wrist band. Despite a strong start for six months, this initiative was dropped, due to staffing issues and inconsistencies within the registration process.
The above changes have brought significant improvements to the whole departmental approach.
As well as identifying significant opportunities for cost neutral improvements, benefits of the rapid improvement event approach include:
- Reduced patient waiting from arrival on the ward through the entire pathway, and a more seamless process from start to finish;
- More effective use of staff time and skills;
- Improvement in trust reputation through a better patient experience.
After six months of implementation, the following improvements have been identified:
- Reduced patient waiting time for elective procedures (from an average patient wait time of 4.5 hours prior to intervention, to an average of just 1.5 hours following improvement work);
- Reduced late starts (from an average of 50 per cent to 5 per cent). For instance, representative data captured for the week commencing 31 January 2011 shows that over 80 per cent of elective lists were commenced before 9am;
- Reduced late finishes (75 per cent of elective lists were finishing before 5pm previously, whereas 95 per cent finished before 5pm following the improvement process);
- The team has experienced some slippage in this area, due to staffing shortages and a high number of complex cases. However, work is underway to address these;
- Improved consultant availability;
- £250 per week reduction in clinical stock held in storage;
- Widespread engagement of staff across cardiology was high throughout the improvement process, with the cardiology event team taking every opportunity to brief colleagues and keep them aware of planned changes and their impacts. This whole team approach to communicating change has ensured the improvements are embedded and will be sustainable.
The issues - and proposed benefits
- Four patients booked to arrive at the same time
- Lack of pre-admission tests caused delays
- Frequent changes to the lab running order
- Poor organisation of the physical work and stores area
- Delays in discharge
- Staggered patient arrival times
- Clinical ‘one-stop’ pre-assessment in clinic
- Development of ‘points’ system of list scheduling
- Elective and emergency lists split
- Patients register directly in cardiology day unit
- Designated co-ordinator work area
- Visual management in lab area and stores
- Consistent “start” times
- Enhanced medication schedule
- Improved availability of consultant
- Specific appointment ensures patient waits the minimum time in the day unit
- All have bloods and ECGs in clinic resulting in fewer delays before attending the lab
- Procedure less likely to be delayed
- No waiting at main reception to book in
- Improved pre-med - when necessary
- Reduced number of tests necessary on the morning of admission
- More even work load
- Improved planning -fewer complaints
- Improved support from colleagues
- Able to offer improved service
- Reduced costs
- Improved revenue