New and Emerging Advanced Vascular & Interventional Radiology Procedures
Secrets of a High-Performing Vascular Interventional ......Secrets of a High-Performing Vascular...
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18 CATH LAB OPERATIONAL EFFICIENCIES: EXPERT ADVICE AUGUST 2019 Can you tell us about your division at MUSC? We work in Vascular Interventional Radiology (VIR), focusing primarily in oncology, liver, and in peripheral arterial and venous diseases. Our Division per- forms around 7,000 cases per year. We have a group of 6 attendings and 4 fel- lows, and have a busy practice. When did Terumo Business Edge first begin to work with your lab? Six years ago, I became involved in some performance improvement proj- ects as a VIR attending. Years after hav- ing some initial projects with positive outcomes, I had the opportunity to meet Terumo leaders, who suggested a visit by Terumo Business Edge (TBE) to evaluate and report on our workflow and our op- erations overall. At the end of their visit in 2015, they generated a report that was very helpful in learning about things we needed to work on — and we worked on every single opportunity to improve that was pointed out by TBE’s report. I invited Terumo Business Edge to come back four years later, which was in June of this year. They found us to be a totally different division, one with greater effi- ciency, a shorter turnover of rooms, much lower turnover of staff, increased patient satisfaction, and increased staff satisfaction and engagement. These are all a result of our daily efforts after the 2015 visit. During our journey, we reset our mission, vision and values, and let people go who were not aligned with our vision and values. Team members who were aligned stayed with us and we went on to hire some excellent people. We revamped the whole division just by getting the right people in place under the right mission, vision, and values, and of course, going on to initiate several performance improve- ment projects that included minimizing wastes of time, reducing workflow re- dundancies, and having efficient patient- centric operations. Ultimately, we were able to increase our capacity and do more cases per day. We also completed a proj- ect to decrease the room turnover time. Before, our time averaged 45 minutes and today, it is 20-25 minutes or less to turn over a room.We also created a VIR hand- book, our manual of operations, with standardized operations and processes, including our procedures, what supplies to use, what antibiotics to use, planned bloodwork before a procedure, and post procedure orientation for the patients, among other things. The VIR handbook has been edited and improved every year since 2014. It resulted in better internal communication among the divisional members, reduction of operational vari- ability, reduction of resources and time waste, and increased predictability and consistency of positive outcomes. How did everyone participate in this process? First, it is important to emphasize that we started with the fundamentals: vision and mission values that were defined for the staff, by the staff. A leadership team was built carefully, and includes a nurse su- pervisor, a radiologic technologist super- visor, and a manager, and this team started to meet weekly. We also put together a shared governance team to work on per- formance improvement projects. We had a representation of the physicians, the nurses, the fellows, and the technologists, and put our heads together to first under- stand the problems, and then brainstorm and come up with solutions. It was not a top-down decision-making but bottom- up, and that was critical to make sure we had buy-in from the staff. I don’t think you can make so many cultural changes as we’ve been through without getting deeply involved in the operation yourself, so I wasn’t only delegating things, but I was fully engaged, making sure people were held accountable, and that they had action items and due dates. The team was not used to that type of leadership style. Things had been very loose. We basically transformed the way we were leading, because before, people could do anything — there was no accountability, no clear expectations and no one was checking to make sure things were getting done in a timely fashion. The idea was to influence the division leadership to understand that being a leader is not about working less and going home earlier, or not being fully engaged. We ended up having to make personnel changes at the beginning of the process, but the team we have now is phenomenal. They understand that being a leader means you need to work more, not less. You can’t go home at 3 o’clock and expect everyone to work hard. That is a tough proposition to sell. We are here to serve our people — to serve our pa- tients and serve our staff. It is not about ourselves. It’s about providing world-class, outstanding patient care, without losing focus on simultaneously taking care of our staff well-being. In addition, we need to work cohesively; it is not about one in- dividual making a decision, but is a team approach. It was essential to build up that team approach mentality, and make sure everyone understood their roles and expectations. Once the team had a real understanding, then there was a trickling down of accountability and what expec- tations were. It sounds like the evaluation by Terumo Business Edge began a period of sustained change for your lab. We were already working on sev- eral projects. I realized that we needed to work on improving our operations overall. That was my general assumption. TBE analysis was able to provide detailed, specific information and tell me, for ex- ample, your room turnover is 45 minutes and it should be 20 minutes. After their analysis, they were able to tell us, “If you do x, y, and z, you are going to increase your capacity at the end of the day.” TBE brought the necessary granularity and the details, allowing for a better visual- ization of the problems. It was an excel- lent experience. There were things that we needed to work on that were new to us as well, no question about that. I am grateful for that work. The evaluation by Terumo Business Edge empowered us to succeed by making the necessary changes. That is the most important thing to em- phasize. You might understand that you have several issues to work on, but what’s a priority? What is going to have a ripple effect by being addressed first? It was an enlightening and humbling experience. One of our projects involved out- reach to referring physicians, with the goal of increasing our referral base. There are small things you can do to increase your patient pool and physician refer- ral satisfaction. For example, we are now sending a text message to the referring physician after the procedure so that they can be immediately aware that the pro- cedure is done and what happened. As a result, patient care can be expedited, i.e., the patient can be sent home faster and the provider can plan what is the next step in patient care, basically all through improved communication. Very simple things can bring a huge benefit to patient care. Great communication is powerful. After their first assessment of our lab in 2015, we recently asked Terumo Business Edge to return and their sec- ond assessment occurred about a month ago. They spent two days interviewing our key stakeholders, such as the nurse supervisor, managers, business manager, and prep and recovery area supervisors. They also walked around and watched our operations, with some observation periods — similar to what the Japanese call “gemba,” basically a way to analyze workflow through observation. The latest TBE report showed that there were ma- jor improvements in our operations since 2015, but it also pointed out residual de- ficiencies and opportunities for further refinement on improved operations. This external analysis was extremely insightful, because it helped us to recognize simple Marcelo Guimaraes, MD, FSIR Secrets of a High-Performing Vascular Interventional Program: Leadership and Culture Cath Lab Digest talks with Marcelo Guimaraes, MD, FSIR, Director, Division Vascular Interventional Radiology, Professor of Radiology and Surgery, Medical University of South Carolina, Charleston, South Carolina. Definitely, the Terumo Business Edge (TBE) team has empowered us to improve our productivity and quality of patient care. With the ongoing changes in healthcare, with the economic pressures around performance and improving efficiencies, decreasing waste, decreasing cost, and making healthcare more affordable, a project like this is critical. This article is supported by Terumo Business Edge. Dr. Marcelo Guimaraes can be contacted at [email protected]. PM-02218
Transcript of Secrets of a High-Performing Vascular Interventional ......Secrets of a High-Performing Vascular...
18 C A T H L A B O P E R A T I O N A L E F F I C I E N C I E S : E X P E R T A D V I C E A U G U S T 2 0 1 9
Can you tell us about your division at MUSC?
We work in Vascular Interventional Radiology (VIR), focusing primarily in oncology, liver, and in peripheral arterial and venous diseases. Our Division per-forms around 7,000 cases per year. We have a group of 6 attendings and 4 fel-lows, and have a busy practice.
When did Terumo Business Edge first begin to work with your lab?
Six years ago, I became involved in some performance improvement proj-ects as a VIR attending. Years after hav-ing some initial projects with positive outcomes, I had the opportunity to meet Terumo leaders, who suggested a visit by Terumo Business Edge (TBE) to evaluate and report on our workflow and our op-erations overall. At the end of their visit in 2015, they generated a report that was very helpful in learning about things we needed to work on — and we worked on every single opportunity to improve that was pointed out by TBE’s report. I invited Terumo Business Edge to come back four years later, which was in June of this year. They found us to be a totally different division, one with greater effi-ciency, a shorter turnover of rooms, much lower turnover of staff, increased patient
satisfaction, and increased staff satisfaction and engagement. These are all a result of our daily efforts after the 2015 visit. During our journey, we reset our mission, vision and values, and let people go who were not aligned with our vision and values. Team members who were aligned stayed with us and we went on to hire some excellent people. We revamped the whole division just by getting the right people in place under the right mission, vision, and values, and of course, going on to initiate several performance improve-ment projects that included minimizing wastes of time, reducing workflow re-dundancies, and having efficient patient-centric operations. Ultimately, we were able to increase our capacity and do more cases per day. We also completed a proj-ect to decrease the room turnover time. Before, our time averaged 45 minutes and today, it is 20-25 minutes or less to turn over a room. We also created a VIR hand-book, our manual of operations, with standardized operations and processes, including our procedures, what supplies to use, what antibiotics to use, planned bloodwork before a procedure, and post procedure orientation for the patients, among other things. The VIR handbook has been edited and improved every year since 2014. It resulted in better internal communication among the divisional members, reduction of operational vari-ability, reduction of resources and time waste, and increased predictability and consistency of positive outcomes.
How did everyone participate in this process?
First, it is important to emphasize that we started with the fundamentals: vision and mission values that were defined for the staff, by the staff. A leadership team was built carefully, and includes a nurse su-pervisor, a radiologic technologist super-visor, and a manager, and this team started to meet weekly. We also put together a shared governance team to work on per-formance improvement projects. We had a representation of the physicians, the nurses, the fellows, and the technologists, and put our heads together to first under-stand the problems, and then brainstorm and come up with solutions. It was not a top-down decision-making but bottom-up, and that was critical to make sure we had buy-in from the staff. I don’t think you can make so many cultural changes as we’ve been through without getting
deeply involved in the operation yourself, so I wasn’t only delegating things, but I was fully engaged, making sure people were held accountable, and that they had action items and due dates. The team was not used to that type of leadership style. Things had been very loose. We basically transformed the way we were leading, because before, people could do anything — there was no accountability, no clear expectations and no one was checking to make sure things were getting done in a timely fashion. The idea was to influence the division leadership to understand that being a leader is not about working less and going home earlier, or not being fully engaged. We ended up having to make personnel changes at the beginning of the process, but the team we have now is phenomenal. They understand that being a leader means you need to work more, not less. You can’t go home at 3 o’clock and expect everyone to work hard. That is a tough proposition to sell. We are here to serve our people — to serve our pa-tients and serve our staff. It is not about ourselves. It’s about providing world-class, outstanding patient care, without losing focus on simultaneously taking care of
our staff well-being. In addition, we need to work cohesively; it is not about one in-dividual making a decision, but is a team approach. It was essential to build up that team approach mentality, and make sure everyone understood their roles and expectations. Once the team had a real understanding, then there was a trickling down of accountability and what expec-tations were.
It sounds like the evaluation by Terumo Business Edge began a period of sustained change for your lab.
We were already working on sev-eral projects. I realized that we needed to work on improving our operations overall. That was my general assumption. TBE analysis was able to provide detailed, specific information and tell me, for ex-ample, your room turnover is 45 minutes and it should be 20 minutes. After their analysis, they were able to tell us, “If you do x, y, and z, you are going to increase
your capacity at the end of the day.” TBE brought the necessary granularity and the details, allowing for a better visual-ization of the problems. It was an excel-lent experience. There were things that we needed to work on that were new to us as well, no question about that. I am grateful for that work. The evaluation by Terumo Business Edge empowered us to succeed by making the necessary changes. That is the most important thing to em-phasize. You might understand that you have several issues to work on, but what’s a priority? What is going to have a ripple effect by being addressed first? It was an enlightening and humbling experience.
One of our projects involved out-reach to referring physicians, with the goal of increasing our referral base. There are small things you can do to increase your patient pool and physician refer-ral satisfaction. For example, we are now sending a text message to the referring physician after the procedure so that they can be immediately aware that the pro-cedure is done and what happened. As a result, patient care can be expedited, i.e., the patient can be sent home faster and the provider can plan what is the next
step in patient care, basically all through improved communication. Very simple things can bring a huge benefit to patient care. Great communication is powerful.
After their first assessment of our lab in 2015, we recently asked Terumo Business Edge to return and their sec-ond assessment occurred about a month ago. They spent two days interviewing our key stakeholders, such as the nurse supervisor, managers, business manager, and prep and recovery area supervisors. They also walked around and watched our operations, with some observation periods — similar to what the Japanese call “gemba,” basically a way to analyze workflow through observation. The latest TBE report showed that there were ma-jor improvements in our operations since 2015, but it also pointed out residual de-ficiencies and opportunities for further refinement on improved operations. This external analysis was extremely insightful, because it helped us to recognize simple
Marcelo Guimaraes, MD, FSIR
Secrets of a High-Performing Vascular Interventional Program: Leadership and Culture
Cath Lab Digest talks with Marcelo Guimaraes, MD, FSIR, Director, Division Vascular Interventional Radiology, Professor of Radiology and Surgery, Medical University of South Carolina, Charleston, South Carolina.
Definitely, the Terumo Business Edge (TBE) team has empowered us to improve our productivity and quality of patient care. With the ongoing changes in healthcare, with the economic pressures around performance and improving efficiencies, decreasing waste, decreasing cost, and making healthcare more affordable, a project like this is critical.
This article is supported by Terumo Business Edge.
Dr. Marcelo Guimaraes can be contacted at [email protected].
PM-02218
19C A T H L A B O P E R A T I O N A L E F F I C I E N C I E S : E X P E R T A D V I C EA U G U S T 2 0 1 9
A perceived inability to act on symptoms could signify a life-threatening situation, according to
research published in the European Journal of Cardiovascular Nursing, a journal of the European Society of Cardiology (ESC).1 The time it takes for patients to interpret and respond to symptoms is the main rea-son for delays in getting to a hospital and the care they need.
The study enrolled 326 patients under-going acute treatment for a first or sec-ond heart attack. Participants completed the validated questionnaire “Patients’ ap-praisal, emotions and action tendencies preceding care-seeking in acute myocar-dial infarction” (PA-AMI).
Patients in the study waited a median of three hours before seeking medical help.
Some delayed for more than 24 hours. So what went through their minds during that period? This study, for the first time, identified two general reactions.
A perceived inability to act had a signifi-cant impact on patients who waited more than 12 hours. These patients said: “I lost all power to act when my symptoms be-gan”; “I did not know what to do when I got my symptoms”; “my symptoms para-lyzed me”; and “I felt I had lost control of myself when I got my symptoms”.
“This immobilization during ongo-ing heart attack symptoms has not been shown or studied before,” said study au-thor Dr Carolin Nymark, of Karolinska University Hospital, Stockholm, Sweden. “At the moment we don’t know why some patients react in this way. It is
possibly linked to fear or anxiety. This should be a novel element in educating people about what to do when they have heart attack symptoms.”
Inaccurate symptom appraisal also affect-ed those who delayed for more than twelve hours. These patients said it took a long time to understand their symptoms; they thought the symptoms would pass; they thought the symptoms were not serious enough to seek medical care; and they thought it would be difficult to seek medical care.
Conversely, patients who accurately identified their heart attack symptoms and sought medical help quickly had a wish to seek care, knew the symptoms were serious and where they should go to get help, and did not try to divert their thoughts away from the symptoms.
“Our previous research has shown that some patients believe their symptoms aren’t serious enough to call an ambu-lance,” said Dr. Nymark. “Others think the intensive care unit is closed in the middle of the night, perhaps because they do not think clearly during the event.”
Warning signs of a heart attack include moderate to severe discomfort such as pain in the chest, throat, neck, back, stomach or shoulders that lasts for more than 15 minutes. It often comes with nausea, cold sweat, weakness, shortness of breath, or fear.
“Another red flag is feeling you have no power to act on your symptoms,” said Dr. Nymark. “This may indicate a real health threat and the need to call an ambulance.”
Dr. Nymark said this new signal could be discussed in outpatient appointments for those with cardiovascular risk factors and in cardiac rehabilitation programs for heart attack survivors. The study ques-tionnaire could be used to identify pa-tients who previously experienced an in-ability to act or poor symptom appraisal.
“Our findings are worrying because even a small reduction in delay would save heart muscle and lives,” said Dr. Nymark. “Reducing patient delays ap-pears to be a complex task and we need to find innovative ways to inform and educate patients and the public.”
Dr. Nymark concluded: “If you have symptoms that may be caused by a heart attack, don’t ignore them. Call for help immediately. It is better to be wrong about the symptoms than dead.” n
References1. Nymark C, Henriksson P, Mattiasson
AC, Saboonchi F, Kiessling A. Inabilityto act was associated with an extend-ed delay prior to care-seeking, in pa-tients with an acute myocardial in-farction. Eur J Cardiovasc Nurs. 2019.doi:10.1177/1474515119844654.
issues that became obvious after discuss-ing the report with the TBE team. Our Division is committed to innovation and constant process improvements, but we quickly learned that we need to keep harnessing the pillars of our foundation (our mission, vision, values, and culture) if we want to have an excellent, efficient, and long-lasting work environment.
What did you think about the Terumo Business Edge team and what their people brought to the table?
TBE has a team of experts with de-cades of experience in healthcare opera-tions and management. The group is led by Gary Clifton, who has worked col-laboratively with numerous healthcare systems throughout the world during his 14-year tenure with Terumo. His team ishighly experienced and well versed in theendovascular procedural space. Some ofthe TBE goals have been to improve theoperational performance of inpatient andoutpatient procedural areas, and to rede-fine best practices and clinical pathways.Definitely, the TBE team has empoweredus to improve our productivity and qual-ity of patient care.
What did you tell your key stakeholders about why the evaluation by Terumo Business Edge was important for your division?
It provides granular data necessary for improving performance operations,
which can lead to cost reduction, optimi-zation of human and space resources, in-creased capacity, and a chance to work on branding. With the ongoing changes in healthcare, with the economic pressures around performance and improving effi-ciencies, decreasing waste, decreasing cost, and making healthcare more affordable, a project like this is critical. Healthcare is 15 to 20 years behind other industries in terms of technology in general manage-ment, cost analysis, and operational effi-ciencies. Remember the value equation is outcomes divided by cost. Most of us want to have good outcomes with a low-er cost, but in many healthcare systems, there is a lot of waste, and an illogical and blurry analysis of cost. It is critical to have an analysis and a snapshot of what is hap-pening in your program.
Can you talk about the value in partnering with Terumo Business Edge over the long term to help achieve your strategic goals? What would you say to a divisional or department director who might have reservations about letting a company do such a detailed analysis?
Honestly, initially I was a little hesitant about working on performance improve-ment with a device company. My main concern was about having an obliga-tion to buy Terumo devices, something that turned out not to be the case. Our partnership and work with TBE allowed
us to diagnose issues and waste, identify remedies, and set priorities and an action plan that resulted in the creation of best practices from clinical and managerial standpoints that have lasted several years.
At the end of their evaluation and analysis, Terumo Business Edge provided a confidential report. After the report, it is important to have brainstorm sessions with the key stakeholders and discuss your action plan. For example, what are the minimal resources needed and what are the potential tools you need in or-der to get where you want? It is impor-tant to emphasize the short-term and the long-term parts of a project, because sus-tainable changes require a major shift in culture. The long-term project is to make sure that people understand the culture shift, become aligned with the vision and values, and are committed to change. Everybody can change for a month or two, but there is a tendency as human be-ings to go back to a default position a few weeks after an initial engagement in
productivity. It is important to discuss the plan, and share why and what’s next in every step of the way. During the action plan execution, the MUSC Performance Improvement office was also supportive of the implementation of the TBE rec-ommendations, resulting in major im-provements in a timely fashion. You may have a vision, you might have the drive and desire to make improvements, but it takes an efficient team to make effective changes without delays. Without this col-laborative work, I sincerely believe that we would be still stuck in the past and in our inefficiencies. As we can’t predict the future, our Division decided to be proac-tive and to be prepared for the ongoing and upcoming changes in healthcare. The recent TBE evaluation confirmed that our cohesive team has been efficient and very effective on managing challenging scenarios. In summary, I would encour-age department and divisional directors to tap on TBE expertise and support. You won’t regret it. n
N E W S
You’re Having a Heart Attack. Why Not Ask for Help?
Ultimately, we were able to increase our capacity and do more cases per day. We also completed a project to decrease the room turnover time.
“At the moment we don’t know why some patients react in this way. It is possibly linked to fear or anxiety. This should be a novel element in educating people about what to do when they have heart attack symptoms.”
PM-02218
