University of Michigan Health System
Program and Operations Analysis
Analysis of Room Turnover Process for EP and Cath Labs
Final Report
Submitted to:
Janice Norville, MSN, MSBA, RN, Director of Clinical Operations
Sheryl Wagner, Nursing Supervisor
Jim Bloom, Allied Health Senior Supervisor
Colleen Lucier, Allied Health Senior Supervisor
Katie Schwalm, Industrial Engineer
Andrei Duma, Industrial Engineer
Mary Duck, UMHS IOE 481 Liaison
Mark Van Oyen, IOE 481 Faculty Instructor
Submitted by:
IOE 481 Project Team #1
Scott Agnew
Kimberly Cusmano
Brandon Duba
Holly Johnston
Date submitted: December 13, 2016
Table of Contents
Executive Summary3
Introduction6
Background6
Key Issues6
Goals and Objectives7
Project Scope7
Methods & Findings7
Literature Search7
Historical Data Analysis8
Time Study of Current Processes10
Process Maps11
Staff Interviews11
Conclusions12
Task Inside Labs Consistently Completed Before Next Patient Arrives12
Current Turnover Times Longer than Goal12
Variation in Turnover Processes12
Lack of Parallel Workflow13
Tasks Completed Before Wheels Out13
Valuable MiChart Fields Not Consistently Entered13
Techs Leave Lab to Retrieve Equipment13
Recommendations13
Further Investigation14
Time between Room Ready and Wheels In14
EP Technologist Equipment Retrieval14
Temporary Colored Badges for CPU Staff Identification14
New Turnover Process14
Cath15
EP15
Future Tracking16
Expected Impact16
References17
Appendices
Appendix A: Data Analysis18
Appendix B: Log of Observation Hours20
Appendix C: Data Collection Sheet21
Appendix D: Current State Cath Process Map22
Appendix E: Current State EP Process Map23
Appendix F: Staff Interview Questions24
List of Figures
Figure 1. Historical data breakdown showing relative size of relevant and
excluded data types8
Figure 2. Turnover start time, organized by lab type9
Figure 3. Turnover time, organized by lab type10
Figure 4. Future State Cath Turnover Process15
Figure 5. Future State EP Turnover Process16
Figure A-1. Cath lab turnover organized by patient class transition between cases18
Figure A-2. EP lab turnover organized by patient class transition18
Figure A-3. Turnover time organized by lab type and anesthesia type19
Figure A-4. “Room Start-Room Ready” Room Ready values only existed for EP records19
Figure B-1. Number of hours observed on each day of the week20
Executive Summary
The Cardiac Procedures Unit (CPU) at the University of Michigan Hospital System (UMHS) performs Electrophysiology (EP) and Heart Catheterization (Cath) procedures. The CPU has noted abnormally long turnover times that often lead to patient, physician, and staff dissatisfaction. The CPU Director of Clinical Operations asked a team of industrial and operations engineering students to evaluate the current EP and Cath turnover processes, identify key wastes within these processes, and establish means to facilitate future EP/Cath turnover evaluation. For the purposes of this project, turnover is defined as the process between the last patient being wheeled out of the lab room and the next patient being wheeled into the same lab room. This report summarizes the findings, conclusions, and final recommendations for this project.
Background
The Cardiac Procedures Unit (CPU) at the University of Michigan Hospital is a procedural unit within the Division of Cardiovascular Medicine, located in the Cardiovascular Center (CVC). Specifically, the CPU performs Electrophysiology (EP) and Heart Catheterization (Cath) procedures. The CPU noted abnormally long turnover times that often lead to patient, physician, and staff dissatisfaction. However, staff within the CPU have differing perceptions of what the turnover process entails. The CPU Director of Clinical Operations requested that the team explore the turnover process and the potential causes of extended turnover times.
The CPU Director’s main concerns included understanding the current processes, identifying process waste, and establishing the means to evaluate future turnovers. The team addressed these concerns through five methods: literature search, analysis of historical data, time studies, development of process maps, and interviews with CPU staff. Based on initial observations, the team developed process maps to display and record the current state of EP and Cath turnover processes. The process maps were further refined after data was collected through time studies and staff interviews. This information helped identify probable causes of delays and get a comprehensive understanding of the processes. Additionally, to gain further background information and ideas for potential solutions, the team analyzed historical CPU turnover data and performed a literature search.
Methods & Findings
The team employed five methods to evaluate the current turnover processes. This section outlines these methods and associated findings.
Literature Search
The team performed a literature search on past IOE 481 projects and relevant research. The reports were beneficial to understanding the background of the Cardiac Procedure Unit [1, 2], parallel workflow, staffing level increases, and definition of work roles that limit downtime and balance workloads [3]. The articles detailed the process researchers took to standardize definitions and collect turnover time data for baseline management [4]; strategies to reduce turnover times in an operating room, and using lean tools, such as a variability analysis; and the single minute exchange of dies method to improve operating room turnover times [6]. The articles helped guide the team with analysis methods.
Historical Data Analysis
The project coordinators provided the team a set of historical data capturing CPU operations from January to August 2016 taken from MiChart, an electronic medical record used by UMHS staff to log data. The data included parameters such as room start/stop times, anesthesia used, lab room, patient class, and procedure type for both Cath and EP labs. The team processed and analyzed the data to gain insight about the turnover processes. The team found the median turnover values for Cath and EP labs, which helped inform current state evaluation. It was also found that certain metrics critical to turnover are not consistently documented.
Time Study of Current Processes
To gain a better understanding of the tasks and staff coordination involved in the turnover process, the team observed the turnover processes for approximately 53 hours in the EP and Cath labs, witnessing 30 turnovers collectively. The team used stopwatches to track the start and end times of each step in the process. These times were used to determine the length of the current processes, act as a baseline number for future comparisons and create the process maps. The team found that there was no standard procedure; some tasks occurred before the turnover began and EP lab rooms were not consistently stocked. Numerical data from the time study were used to develop the process maps described below.
Process Maps
Based on results from observations and interviews, the team developed process maps of the current EP and Cath turnover processes. The process maps were developed with a “swim lane” approach, showing each staff member involved in the processes and their specific tasks during turnover. The maps allowed the team to capture data of sequential and simultaneous tasks. Furthermore, the team determined there was an uneven workload balance between the staff.
Staff Interviews
The team interviewed key staff in the CPU to obtain different perspectives on the turnover processes. The team collected data from different staff members and used their responses to inform recommendations and develop process maps. The nurses reported that the process of locating and securing patients can be confusing and time consuming. For EP, the staff reported there are communication difficulties between the nurses and CRNAs. Staff also reported that physician preference for procedure intricacies could elongate turnovers.
Conclusions
Findings obtained from the literature search, time study, historical data analysis, turnover process maps development, and CPU staff interviews led to determine seven conclusions that provide critical insight into the current state of turnovers within the CPU, which are as follows:
- Tasks performed inside the EP and Cath labs are not the cause of long turnovers. Through findings from the time study, process map development, and staff interviews, the team determined that tasks completed inside the EP/Cath labs are performed efficiently and without waste; they therefore are not the cause of long turnover times.
- Current turnover times are longer than goal turnover times, in both EP and Cath labs.
Through findings from the historical data analysis and time study, the team has substantial evidence that the current median turnover time for both EP and Cath labs do not meet the goal turnover times set by the client. - Variation exists within the turnover process for both EP and Cath.
Through findings from the literature search, time study, and staff interviews, the team found that turnover tasks in EP/Cath labs are not always executed in a consistent order. - A lack of parallel workflow exists between technician roles during turnovers.
Through findings from the literature search and process map development, the team determined there is an unbalanced workload between Scrub and Monitor Techs for EP turnover, and Circulator and Monitor Techs in Cath turnover. - Some turnover tasks are performed before a patient is wheeled out of the lab.
Through findings from the literature search, time study, and process map development, the team concluded some turnover tasks, such as removing trash bags or cleaning lab equipment, is completed before “wheels out” occurs. - Valuable MiChart fields are not consistently entered.
Through findings from the historical data analysis and time study, the team found that electronic documentation of lab turnover is not always consistent, which limits how the process can be evaluated. - EP techs leave the lab to retrieve equipment during turnovers.
Through findings from the time study and process map development, the team concluded a primary factor in EP turnover is EP technologists leaving the lab to retrieve equipment.
Recommendations
From the conclusions described above, the team developed three recommendations to reach the project’s goals. The team recommends the following to improve the turnover processes in the EP and Cath Labs.
Further Investigation
The team recommends that the CPU perform additional investigation of several key metrics related to turnover, including tasks that occur outside the lab during turnover, and the root cause for EP Techs leaving the lab during turnover. Additionally, if a student group or other external team is brought in for this investigation, providing staff with color-coded badges will help the team identify staff roles.
Recommended Turnover Process
The team has developed recommended turnover processes for EP and Cath turnover. The processes balance workload between technologists, and maximize the amount of work completed before a patient is wheeled out of the lab.
Future Tracking
The team recommends the CPU perform thorough tracking of future turnovers. Technologists and nurses will have additional avenues of communication to ensure critical turnover metrics are always entered in turnover documentation. Additionally, statistical analysis and quarterly reports will provide managerial staff the information needed to access future turnover.
Introduction
The Cardiac Procedures Unit (CPU) at the University of Michigan Hospital System (UMHS) performs Electrophysiology (EP) and Heart Catheterization (Cath) procedures. The CPU has noted abnormally long turnover times that often lead to patient, physician, and staff dissatisfaction. Turnover is defined as the process between the last patient being wheeled out of the lab room and the next patient being wheeled into the same lab room. In addition, staff within the CPU have differing perceptions of what the turnover process entails. The CPU Director of Clinical Operations has expressed concern that coordination issues within the unit could be causing long turnover times. The CPU is looking to explore the current turnover process and identify the potential causes and improvement opportunities.
The Director asked a team of industrial engineering students to observe the operations involved in EP and Cath turnovers and identify wastes within the processes. The Director would like to understand the current turnover processes and determine improvements that will reduce waste and coordination problems. Furthermore, the Director wanted a baseline indicator of turnover time and a method to evaluate future turnover performance.
The team observed, evaluated, and analyzed the current turnover processes. Based on initial observations, process maps were created to display and record the current EP and Cath turnover process. These were updated throughout the duration of the project as the team collected more data. During further observations, team members recorded the length of various tasks and other data within the turnover processes to determine causes of delays. Additionally, the team interviewed staff to gain insight into potential problem areas. This final report summarizes the findings, conclusions, and recommendations for this project.
Background
Two procedure types occur within the CPU: EP and Cath. These procedures have unique scheduling, staff, and processes. In addition to EP labs and Cath labs, the CPU has 36 preparatory and recovery rooms, including beds for overnight observation. The CPU schedules procedures from 8am-4pm with a bulk of the procedure turnovers occurring between 11am-3pm.
Currently, no written standard procedure exists for EP and Cath lab turnover.
The CPU Director had concerns regarding the current turnover processes. Physicians and staff are dissatisfied when procedures do not start on time as it often lengthens the work day. The lengthy turnover times can increase patient wait times, leading to unnecessary stress. Additionally, the Director worried that the various roles involved in the turnover process foster miscommunication and coordination problems between the staff. Miscommunication exacerbates the issues of differing staff perceptions of the turnover processes. The CPU does not have a system to evaluate and analyze turnover processes and times.
Key Issues
The following key issues are driving the need for this project:
●Long turnover times lead to patient, physician, and staff dissatisfaction.
●Physicians and staff have different perceptions of the turnover processes.
●There is no documented process for EP and Cath turnover.
●There is no system to assess turnover effectiveness, both in terms of overall time required, and time required for each step of the turnover process.
Goals and Objectives
To determine the primary factors of long turnover times, the team achieved the following
goals:
●Evaluate the current turnover process for both EP and Cath.
●Identify waste and coordination problems within the current turnover processes.
●Establish means to evaluate future turnover effectiveness.
From this information, the team achieved the following objectives:
●Develop process maps for the current turnover processes.
●Perform time studies and conduct interviews with EP and Cath laboratory staff to measure key performance metrics of current turnover procedures.
●Establish a standard procedure for performing and coordinating turnover tasks efficiently.
●Develop a method CPU managerial staff can use to track and assess performance metrics of turnover procedures.
●Make recommendations to CPU managerial staff regarding implementation of the above objectives; recommendations may differ between EP and Cath procedures.
Project Scope
Any activity or task to prepare the room for the following procedure was considered in the scope of this project. The turnover process includes transporting the current patient to recovery and the
next patient into the lab room; therefore, these activities were also within the project scope. The team only analyzed the turnover process for EP labs 1-5 and the Interventional Cath labs. The Heart-Failure Cath Lab and EP Lab 6 were excluded from this project. Patient processes prior to the procedure were not investigated; however, delays and late arrivals were noted.
Methods & Findings
The team used five primary research and evaluation methods to complete this project: literature search, analysis of historical CPU data, time study of the current process, process maps, and interviews with key staff. Each method yielded several findings used to generate the team’s conclusions. This section details each of the methods and the corresponding findings.
Literature Search
The team performed a literature search and found reports for similar projects conducted by past student groups. Along with the past student report, the team also found articles on Google Scholar.