Process for Improving Efficiency: Experience From the EP Team at Lenox Hill Hospital

The electrophysiology laboratory at Lenox Hill Hospital-Northwell Health has experienced significant growth over the last two years. A physical move in April of this year divided our clinical services between multiple floors of the hospital, and presented an opportunity to examine our processes and seek areas of improvement. In this evolving environment, the EP lab committed to a comprehensive lean healthcare initiative with the intent of improving overall lab performance and increasing patient satisfaction. Our goal in committing to this ongoing project was to improve efficiency while maintaining the highest quality of care and best patient outcomes — vital components to our practice.

The first step was to proactively examine every aspect of our EP lab operations, looking at ways to streamline and reorganize. This decision was based on areas identified by our team that were in need of “fixing.” We focused on the following aspects: throughput, start times, patient arrival delays, communication, and patient satisfaction.

We created a multidisciplinary performance improvement team dedicated to analyzing EP procedure throughput. The members of the team were actively involved in the everyday operations of the EP lab procedures, and therefore, their input was critical. This helped guarantee that the solutions were driven by the staff who were closest to the process and had both the knowledge and expertise to execute the necessary changes. The team’s goal was to identify ways to leverage Lean Sigma and change management methods to optimize room usage.

Lean Sigma is a methodology used to restructure work processes and remove unnecessary or wasteful steps. This approach was first developed to improve manufacturing, but has been applied successfully to improve many work processes in hospitals and clinics. At Lenox Hill Hospital, we utilized consultants from the Medtronic PRO/CV service team, who facilitated a formal performance improvement project utilizing this methodology for identifying inefficiencies. The goal of Lean Sigma is to break down barriers, and identify and prioritize opportunities for continuous improvement. The PRO/CV approach emphasizes the use of data analysis for improving, optimizing, and stabilizing complex patient workflows.

Optimizing Throughput, Improving Start Times, Decreasing Patient Arrival Delays

After many hours of discussion with our team members reviewing initial data, we came up with several priorities on which to focus. Our first priority was to achieve on-time start times for first cases. We termed this as “Wheels In” and “Stick Times.” The target was to have the patient in the room (“Wheels In”) by 8:20 am, and start of procedure (“Stick Time”) by 9:00 am. With this as our motivator, we looked at practices and barriers that had a direct impact on achieving this goal.

The solutions we identified were:

• Improving signage. Our location had changed, so patients needed to be able to find us more easily in order to prevent delays in arrival.
• Changing the order of paperwork in the medical chart. Paperwork is now organized and easily accessible to all members of the team (RNs, anesthesiologists, NPs, PAs, and electrophysiologists).
• Identifying key team members to help prep/ready the patient for the procedure. This decreases duplication of work and ensures necessary documentation is concise and complete.
• Setting up the procedure rooms the evening before. This decreases room setup/pull times for first cases, and thereby eliminates it as a morning task. 
• Having consent signed by the patient and physician during their office visit. From a quality perspective, we felt that this allows more time for the patient to have questions asked and answered, and their concerns addressed. From an efficiency perspective, having this done on the day of the procedure allows the team to start the initial patient prep in a timelier manner, by not having to wait for a physician signature.
• Determining the absolute first case the day before — and adhering to it. Determining absolute first case for the following day was an issue for our lab. By determining the absolute first case the day before, we prevented the team from setting up the room for a procedure, only to have to change it as cases were switched. Room utilization improved, and team frustration decreased.
• Having all members of the team present earlier. This ensures procedural time out and in-room prep could be completed, ensuring timelier “Stick Time.”
• Looking at standardizing the individual roles of the staff within the procedure rooms. This helps improve efficiency and ensure effective team mobilization.

This has been an evolving process. When our “Wheels In” time did not go much above 18% in the first weeks, we had to revisit our process and determine what the team could do to improve. We instituted a communication board that is housed in a central location in the lab, visible to all members of the team, in our main holding area. The board documented our “Wheels In” and “Stick Time”, the team members assigned to each procedure room, and was a place to record delays in the patient throughput process. We also documented the time that each team member completed their part of the process. This allowed us to identify areas that needed improvement, and was a means of holding individuals accountable to the overall team effort. Our numbers improved dramatically in the first week to 43%, and then 80% for “Wheels In”. “Stick Time” went from 38% to 60%.

On-time case start times allowed our lab to be more efficient. With fewer delays, our days ended on time — benefiting both patient and staff satisfaction. 

Improving Communication

Another area of focus was communication. With the labs physically separated from the holding area by six floors, this became an area of major concern. We needed to ensure that communication with the entire team was timely, accurate, and complete. The charge/resource nurse role was vital to this process, as they are the point person and communication flows through them.

Some of the ways we improved communication were:

• Starting our day with team rounds or huddle at 7:30 am. Present at these rounds are a physician, charge/resource nurse, nurse practitioner or physician assistant, one or both managers, and any other team members present in the holding area. Discussion of the patients on the service, what their plan of care was for the day, and questions regarding the plan could be brought up by any team member. The timing and feasibility of potential add-on cases could also be addressed. These huddles/rounds have enhanced communication and promoted team building.
• Education of the schedulers and modifications to the booking sheet were also implemented. This ensured that patients were being added to the schedule in an accurate and timely manner.

Increasing Patient Satisfaction

Improving overall patient satisfaction is a goal of every performance improvement team. The feedback from our patients was usually above the benchmark, but if we did receive a complaint, it was generally about long wait times and different medical staff asking the same questions, a problem compounded by our different locations. Our team addressed these concerns by:

• Incorporating a primary nurse/team to complete the patient’s care from pre to post procedure. The aim is to eliminate the duplication of questions, which needlessly prolongs the evaluative process.
• A renewed commitment by staff to greet the patient with their name and title. In this manner, patients are aware of everyone’s role.
• Improving our “Wheels In” process allowed us to become more efficient at throughput. This effectively decreased patient wait times.

We are continually reviewing the results of our operational adjustments. Our lean healthcare overhaul had an added benefit of addressing some staff satisfaction issues. When cases do not start on time, it is difficult to end the day on time. This has an impact on staff satisfaction, and can increase the team’s stress and frustration levels. Improvement in this area was a huge benefit. Communication is vital to the smooth functioning of any unit, but by seeking solutions to our identified issues with communication, we were able to improve morale and team spirit. 

Final Thoughts

This project has been a rewarding experience that has become a positive team-building exercise in our EP department. We have already realized desirable changes in our organization. Going forward, we invite the challenge of extending the Lean Sigma principals to turnover times for the rest of our cases. This project has enabled the team to identify different processes that affect our turnover times, and this will be our next hurdle to address.

Disclosures: The authors have no conflicts of interest to report regarding the content herein.