PDCA (Plan, Do, Check, Act) “ One Facility`s Optimization of Patient Experience in Community Hospital East Cath Lab

Cath Lab Opportunity Statement An opportunity exists with the outpatient cath lab process, beginning with the registration of the patient and ending with the patient’s arrival in the cath lab. The current process causes patient, physician and staff dissatisfaction due to lack of space available for holding/processing patients. There have been pre and post procedure decreases in the number of cases that are able to be managed due to length of time spent transporting patients between the observation unit and the cath lab. Improvement in the process should result in increased patient, staff and physician satisfaction, increase in the number of cases and less time spent transporting patients. It is important to tackle this problem now because increased patient volumes are expected in 2006, due to an increased number of physicians and improved equipment.

Step 1.

Some of our patient satisfaction information was skewed due to small patient volume size, but nonetheless, one could easily see there were problems. All of the following parameters were low: Cath Lab Overall Quality of Care Key driver #1: Dignity & Respect Shown Key driver #3: Trust & Confidence Felt Registration Process Staff’s Instructions/ Explanations of Tests Staff’s Understanding and Caring Overall Teamwork b/t Nurses and Staff Respect for Privacy Ease of finding way around facility Discharge Instructions Likelihood of Recommending Friends/Family

Step 2.

We studied the basic logistics of our patient transport process. This was a clumsy process due to physical distance and navigation of various elevators. Waiting for elderly families exacerbated this problem. Patient Distance & Travel Time Study Distance for Cardiac Cath Process Distance from Emergency Room Aviary to waiting area, to Cardiac Cath Lab Distance: Approximately 120 feet using elevator V9. Time: Approximately 2 minutes for staff Distance from Outpatient. Registration (main entrance of hospital) to 5 OBS Distance: Approximately 570 feet using elevator #3 Time: Time for patients and family to walk is about 18 minutes Time: Time for staff is about 7 minutes Distance from 5th floor room 3553 to the waiting area to Cardiac Cath Lab Distance: Approximately 490 feet using elevators 4, 5, 6. Time: Time for patients and family walking from 5 OBS is 15 mins. Time: Time for staff walking is 5 minutes Turnover time (48 min average) for Cardiac Cath Lab Case Ends. MD finishes case and drops from scrub. MD dictates and speaks to family (10 min) Staff does closure device and removes patient from table (20 min) Patient and family are taken to 5 OBS (30 min) Cath Lab staff re-arranges furniture; Obtains transfer board; Assists in making patient comfortable; Find a nurse to let her know of arrival of patient. Staff to obtain another patient on 5 OBS or other unit (13 min). Back to Cath Lab Preps patient Procedure starts Documented Events April 13, 2005: Patient and family complaint of service. Patient would not return to 5 OBS and arrangements had to be made to transfer to another floor after the cardiac cath. June 29, 2005: Order for lab work upon arrival to 5 OBS not done. Delayed case 30 minutes while patient was on the table. Staff, Patient and Patient Family Concerns Distance from 5 OBS to Cath lab No private bathroom for patients to use before procedure Families complain about walking the whole hospital to get to the lab Transporting delays turn-over and takes away from preparation of lab 5 OBS not following MD’s written orders Patients confused about process and their questions not answered to their satisfaction from 5 OBS Transporting to 5 OBS takes away from preparation time for lab

Step 3.

We brainstormed various strategies and flowcharted them, looking for issues.

Step 4.

We created an Ishakawa (fishbone) diagram. This is a problem-solving tool where a team places process elements onto a skeleton under the appropriate categories. The specific categories can change depending on your needs. This was useful in helping us define the causative issues.

Step 5.

We also described, listed and ranked our perceived barriers to implementation. This helped us determine how best to expend our resources.

Step 6.

We brainstormed and flowcharted eight possible patient flow strategies which might address our issues. Eight Possible Flow Charts of CL Patient & Process Flows

Step 7.

We then selected the strategy that we felt best addressed our problem.

Step 8.

We considered our solution strategy and listed practical working guidelines, which we felt would facilitate the actual implementation of our strategy. The fact that we considered the operational issues seemed to make us look more credible to administration when we presented our summary. Operational Issues of Implementation Holding area will be jointly staffed by the cath lab (CL) and interventional radiology (IR) during procedure hours of 7:30 to 4:00 pm. Staffing will consist of 2 RNs that work as a team and oversee care of patients holding for the CL and IR procedures Before & after normal hours of operation, each area (CL & IR) will provide care for their own pts The plan is to convert open RT position of CL into an RN position in order to better support this venture; Radiology will provide support and expertise regarding radiology and radiology safety issues for the CL. Radiology techs are not expected to staff CL procedures Individuals will provide call and holiday support to their home department Holding rooms will be stocked with supplies from both par levels Linen and point-of-care testing supplies will be shared This will have a positive impact on OBS, because beds no longer used for pre-cath patients can be used for other outpatients. Existing clerical staff (2) will be cross-trained to register non-preregistered patients.

Step 9.

In an effort to further streamline our patient turnover process, we listed inter-procedure activities. (Those tasks with an asterisk are activities not done between every case.) Cath Lab Inter-procedure Task List End of Case Tear down sterile field Tie up and take trash bag & water bowl to utility room *Restock room We xcide x-ray table slide board, arm rests & back table, wipe down floor as needed, wipe down cables as needed Secure sheath, attach & flush art line and apply dressing Wash hands b/t pts and after removing dirty gloves Waste & return prev pt’s meds Complete MacLab documentation Complete RN documentation Insure ASA form is complete Insure sedation audit form complete *Insure stent paperwork complete D/C all intraprocedure orders & verify d/c orders Return/waste meds *Give post-procedure meds Complete orders Complete report sheet & call Rpt *Staff bathroom break Document contrast amt, sedation complications, pulses, site assessment, fluoro & RN goals met. Beginning of Case Research & enter ACC-NCDR data Pull up next pt in MacLab, C/V & Innova *Load power injector with contrast Throw on sterile items for next procedure Put linen on table Place clean trash bag on frame Pull meds (std meds pulled from Pyxis) RN assessment of pt Check and document pt’s labs Enter pt’s orders into Centricity Pick up pt from DBs or floor Verify consent, H&P, 2 pt IDs and correct procedure Check & document pt’s pulses Obtain next pt’s name from CL Coordinator

Step 10.

In response to the presentation of our quality improvement project, we were invited to participate in a hospital-wide Patient Placement Redesign Summit, where one of only six summit objectives included: Provide pre-procedure care services for IR and cath lab patients in the procedural department. The purpose of the summit was to maximize the quality and efficiency of care at Community Hospital East while decreasing cost, increasing revenue capture and improving the flow of patients by achieving: 1. Appropriate assessment and placement of patients 2. Efficient flow of patients 3. Productivity improvements Many great ideas were voiced at the summit and we are now awaiting communication of our specific implementation strategy. Author Jim Wade can be contacted at: jwade@ecommunity.com

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