Developing and Implementing a Medical Railroad Map in the Cardiology Department

The authors can be contacted via Dr. Pieter Stepaniak at pieter.stepaniak@gmail.com.

Figure 1. A portion of the Medical Railroad Map created by the Cardiology Department at Catharina Hospital Eindhoven.     

The Catharina Hospital Eindhoven has a large cardiology department. Every year, over 6,000 patients are treated in one of the five catheterization laboratories (cath labs). All the professionals in our department work together enthusiastically, under the vision that healthcare should be efficient, effective, and safe. Every member of the team has a responsibility to contribute towards this goal. 

From 2013-2015, we improved the efficiency of the cath labs dramatically, reducing turnover times by 50% and increasing utilization rates by 7%, up to 94%. Overall the forecast errors of procedures were reduced.^1,2

One of the things we noticed when analyzing the cancelled cases was that patients were regularly scheduled for a treatment pending examinations. Sometimes the results were not available in time; hence, scheduled patients were cancelled and re-scheduled to another day. This resulted in frustrated patients, and because of the short time between cancellation and day of treatment, there were often no patients available to fill the hole in the schedule. As a result we faced idle cath lab capacity.

In general, we noticed that activities prior to scheduling a patient could be improved. Not every decision maker within the cardiology pathways had the right medical information to push the patient to the next phase. This resulted in planning delays or cancellation of a scheduled patient on the day of or some days before treatment. 

Because a lot of information is collected and needed prior to scheduling a patient, scheduling can be quite a complex challenge. The main question was, when do we have all the information needed to schedule the patient in a safe way and reduce the chance that the procedure will be canceled?

To answer this question, we first performed a structured search to find examples. We searched on the Internet and contacted other cath labs in Europe. To the best of our knowledge, no concept answering our question existed. Therefore, we decided to develop it ourselves. To start, we performed a meticulous analysis of patient flow from first visit to discharge. This was done by a multidisciplinary team consisting of cardiologists, cath lab nurses, and team leaders, coordinated by  the Dutch Foundation for hospital safety (VVCZ³). We also used the feedback we were given by patients. The common goal was to increase awareness for patient safety within the department, improve effective communication among all professionals, and reduce the number of (avoidable) procedure cancellations. Simply put, to increase team cohesion and the safety climate. 

To perform the analyses, we designed a “Medical Railroad Map”. In this railroad map, we defined all the steps taken by the patient in the cardiology pathway. For every step, we described which information is needed, who should provide this information, who should get the information, and the staff member responsible for this step. We also defined STOP moments. A STOP moment is a point in time where it is decided if a patient can be pushed to the next station. In other words, is it safe to hand over the patient to another care provider?

To help care providers in this decision, we developed a checklist. This checklist contains all critical steps and information. Each step has to be signed off on by the responsible care provider.

After the development period, we started the implementation phase in May 2014. During the first few months, everybody had to get used to the new way of working. We also received a lot of valuable information from nurses and cardiologists resulting in some adjustments to the railroad map. At the beginning of 2015, we noticed that the number of cancelled cases on the day of treatment decreased by over 50%. The overall experience of working as a team within the department improved, resulting in even more dedicated and happy staff members working in an efficient and safe workflow. 

References

1. Stepaniak P, Soliman Hamad MA, Dekker LR, Koolen JJ. Improving the efficiency of the cardiac catheterization laboratories through understanding the stochastic behavior of the scheduled procedures. Cardiol J. 2014; 21(4): 343-349.
2. Stepaniak PS. Understanding the stochastic behavior of procedures helps to improve efficiency within the cath lab. Cath Lab Digest. 2014 Apr; 22(4).
3. Available online at https://www.vvcz.nl. Accessed June 22, 2015.