JACC: CARDIOVASCULAR INTERVENTIONS VOL. 11, NO.

4, 2018

ª 2018 BY THE AMERICAN COLLEGE OF CARDIOLOGY FOUNDATION

PUBLISHED BY ELSEVIER

FOCUS ON CARE DELIVERY AND OUTCOMES

Operational Efficiency and Productivity

Improvement Initiatives in a
Large Cardiac Catheterization Laboratory
Grant W. Reed, MD, MSC, Scott Hantz, RN, MBA, Rebecca Cunningham, BSN, RN, Amar Krishnaswamy, MD,
Stephen G. Ellis, MD, Umesh Khot, MD, Joe Rak, MBA, Samir R. Kapadia, MD

ABSTRACT

OBJECTIVES This study sought to report outcomes from an efficiency improvement project in a large cardiac cath lab.

BACKGROUND Operational inefficiencies are common in the cath lab, yet solutions are challenging. A detailed report
describing and providing solutions for these inefficiencies may be valuable in guiding improvements in productivity.

METHODS In this observational study, the authors report metrics of efficiency before and after a cath lab quality
improvement program in June 2014. Main outcomes included lab room start times, room turnaround times, laboratory
use, and employee satisfaction. Time series analysis was used to assess trend over time. Chi-square testing and analysis of
variance were used to assess change before and after the initiative.

RESULTS The principal changes included implementation of a pyramidal nursing schedule, increased use of an electronic
scheduling system, and increased utilization of a preparation and recovery area. Comparing before with after the
program, start times improved an average of 17 min, and on-time starts improved from 61.8% to 81.7% (p ¼ 0.0024).
Turnaround times improved from 20.5 min to 16.4 min (trend p < 0.0001), and the proportion of days at full lab utilization
improved from 7.7% to 77.3% (p < 0.00001). There were no increases in overtime, night, or weekend cases. There was a
reduction in full time employees from 36.1 in 2013 to 29.6 in 2016, with an improvement in employee satisfaction.

CONCLUSIONS A systematic approach to reducing inefficiencies can improve cath lab start times, turnaround times, and
overall productivity. This knowledge may be helpful in assisting other cath labs in similar efficiency improvement initiatives.
(J Am Coll Cardiol Intv 2018;11:329–38) © 2018 by the American College of Cardiology Foundation.

P roviders are facing tremendous pressure to

maximize value by improving patient out-
comes while minimizing cost across all aspects
of health care in today’s economic climate. Key to
realizing these goals is identifying and eliminating
operational inefficiencies (1), which may be due to
redundancies or impediments in direct medical
service delivery, whereas others may be logistical or
administrative in nature (2). Identification of these
inefficiencies can fuel targeted operational improve-
ment initiatives (3), and is best achieved through
studying and making incremental changes to delivery
processes at a systems level.
The cardiac cath lab is particularly prone to
operational inefficiencies as it is typically a complex,
fast-paced, procedural environment. Identification
and elimination of inefficiencies may allow for
improved productivity (1), which could help offset

From the Heart and Vascular Institute, Department of Cardiovascular Medicine, Cleveland Clinic, Cleveland, Ohio. Dr. Khot is a
consultant for AstraZeneca. All other authors have reported that they have no relationships relevant to the contents of this paper
to disclose.

Manuscript received July 11, 2017; revised manuscript received September 5, 2017, accepted September 11, 2017.

ISSN 1936-8798/$36.00 https://doi.org/10.1016/j.jcin.2017.09.025

330 Reed et al.
Efficiency in the Catheterization Laboratory
ABBREVIATIONS recent declines in reimbursement for cardiac
AND ACRONYMS catheterization and percutaneous coronary
intervention (PCI) (4), and improve satisfac-
PCI = percutaneous coronary
intervention
tion for patients and health care providers.
However, there is heterogeneity in how
FTE = full-time employee
modern cath labs are operated across in-
stitutions, and metrics of efficiency in cath
lab operations are not standardized. Indeed, public
reports of successful quality improvement initiatives
in the cath lab setting have been scarce to date. Such a
report could serve as a valuable example to guide
meaningful changes and improve efficiency in cath
labs across various institutions. As most labs have
quality assessment processes in place, this would be
especially relevant and applicable to labs seeking
process improvement.
SEE PAGE 339
With this understanding, we conducted a quality
improvement program to identify the operational
inefficiencies in our large, quaternary care center cath
lab, with the intent of reporting our results broadly. We
report specific metrics of operational efficiency before
and after system-based changes that we describe in
detail, in an effort to demonstrate and quantify the
improvements in efficiency we have realized with
a systematic approach to quality improvement.
METHODS
STUDY POPULATION. The program start date was
June 1, 2014. All elective and urgent procedures were
analyzed for 1 year before and 2 years after the start
date (May 1, 2013 to April 31, 2016). Diagnostic coro-
nary angiograms, PCI procedures, right heart cathe-
terizations, myocardial biopsies, peripheral vascular
interventions, and structural heart interventions were
included. Emergent cases including primary PCI for
ST-segment myocardial infarction were excluded as
these cases follow a separate, unique workflow. The
cath lab at our institution is a closed lab with 10 cath
lab rooms, accommodating a single physician practice
of approximately 20 hospital employed physicians
(interventional or invasive, diagnostic, heart failure,
and electrophysiology cardiologists). The study was
approved by the institutional review board.
EFFICIENCY IMPROVEMENT PROGRAM. The first step
was to establish a program leadership team consisting
of the physician cath lab director, nursing manager,
nursing supervisors, department administrators, and
interested physicians that studied the workflow in the
cath lab by creating a process flowchart mapping
every step in the continuity of a typical patient’s care
(Figure 1). The goals were to completely understand
JACC: CARDIOVASCULAR INTERVENTIONS VOL. 11, NO. 4, 2018
FEBRUARY 26, 2018:329–38
the patient, technologist, nurse, and physician duties
in a usual case, document all material and informa-
tion flows, determine time elapsed at each step,
and identify potential bottlenecks and sources of
redundancy.
Nursing staff was required to time stamp each step
in the delivery process, fill out feedback forms if room
turn around time was >22 min or if there were issues
they felt were impeding care delivery, and comment
on improvements that could be made. Timestamps
for each component of the delivery process were then
collected via review of nursing records and the elec-
tronic cath lab documentation system. This, in com-
bination with the feedback forms allowed for
granularity in determining which steps in the care
delivery process could be targeted for reducing time
lapse and thus improving efficiency. The leadership
team then performed an exhaustive review of the
workflow process and identified several specific steps
where systematic inefficiencies existed using root
cause analysis and the feedback forms. Changes to
the cath lab delivery process were then implemented
via Plan Do Study Act cycles, and the team met
weekly to assess whether these changes were having
desirable effects on workflow with the use of She-
whart control charts, as these are commonly used
tools in quality improvement methodology (5,6).
Additional changes were made in an iterative, step-
wise fashion over time while evaluating the key
metrics of efficiency described below. Physicians,
nurses, and support staff were given feedback once a
month during this process improvement project.
STUDY ENDPOINTS. Study efficiency endpoints
included room start time, the duration of time be-
tween cases (room “turnaround time”), and lab room
utilization (Table 1). Study productivity endpoints
included the number of full-time employees (FTEs),
and the proportion of shifts that were after hours, on
weekends, or overtime. To determine the effect of
these changes on employee satisfaction, Press Ganey
surveys were conducted at time points before and 1
year after most changes had been made. These goals
were established based on what would constitute a
meaningful improvement based on historical trends
in our institution.
STATISTICAL ANALYSIS. All study endpoints were
assessed chronologically on a both monthly and
yearly basis to evaluate trends over time, as well as
before and after the program start date of June 1,
2014. Continuous outcomes are reported as mean 
SD, and categorical endpoints are presented as pro-
portions. Time series analyses utilizing regression
modeling were performed to assess trend in outcomes
JACC: CARDIOVASCULAR INTERVENTIONS VOL. 11, NO. 4, 2018 Reed et al. 331
FEBRUARY 26, 2018:329–38 Efficiency in the Catheterization Laboratory

F I G U R E 1 Process Diagram of Cath Lab Workflow in a Large Cardiac Cath Lab

Each step in the continuity of a typical cath lab case was mapped. The greatest opportunities to improve operational efficiency are those steps
in which the timing is average timing is highly “variable” and thus most modifiable with systems changes (denoted in red), compared with
those in which the timing is less variable and thus “fixed,” determined most by the nature of the case (denoted in green). IV ¼ intravenous;
PCI ¼ percutaneous coronary intervention.

over time. In addition, 2-way analysis of variance and
2-sample chi-square testing for equality of pro-
portions with continuity correction were used to
determine whether the differences were significantly
different before and after the program start date,
where appropriate. Statistical significance
determined as p < 0.05. All statistical analyses were
performed using R version 3.3.2 (R Project for Statis-
tical Computing, Vienna, Austria).
RESULTS
was CATH LAB WORKFLOW. The cath lab workflow pro-
cess is described in Figure 1. The major operational
332 Reed et al. JACC: CARDIOVASCULAR INTERVENTIONS VOL. 11, NO. 4, 2018

Efficiency in the Catheterization Laboratory FEBRUARY 26, 2018:329–38

17 min per room across 8 rooms allowed for 136 min

T A B L E 1 Definitions of Efficiency and Productivity Metrics and Goals for the Program
(2.3 h) of additional potential productivity per day.
Metric Definition Goal The main reasons for start time delays were dis-
On-time lab start Patient and physician arrival for Start time of 7:45 AM; cerned to be a lack of nursing resources early in the day
the first case of the day in any 85% of cases*
given lab room and communication issues between the preparation
Turnaround time Duration of time between the exit Goal <17 min area and the cath lab teams. Nursing staff bandwidth
of the prior patient and arrival
limitations were addressed by the pyramidal sched-
of the next patient to the cath
lab uling structure (described previously). Communica-
Lab utilization Percentage of open cath labs at Goal 100% tion issues were addressed by 2 major changes:
maximum capacity for any
given day Electronic cath “white board” system. Traditionally,
Lab productivity Number of FTE nurses and techs Stable or lower over time cases were scheduled on a physical board that served
compared with cath lab as a central terminal for all workers, located in the
volume, and proportion of
shifts that were overtime after cath lab hallway. This relied on physically viewing
hours or weekends this board or verbal communication to follow the
daily schedule. To address this, this physical board
*On occasion there were earlier or later pre-specified start times; these were excluded from analysis.
FTE ¼ full-time equivalent. was replaced with an electronic “white board”
(Siemens Healthcare, Erlangen, Germany). This web-
based interface allows for decentralized, real-time
inefficiencies identified and the changes made to notification of patient arrival, when prep is com-
address these issues are described in detail subse- plete, when cases are finished and transport is
quently, and summarized in Table 2. needed, and scheduling changes. It can be viewed on
any computer, and is displayed in each room, thus
INEFFICIENCIES IN CASE SCHEDULING. Case volume enhancing and speeding up communication for all
averaged 48.1  4.5 cases/day distributed across 8 workers. This not only contributed to improved start
possible rooms, totaling 731.0  50.4 cases/month times, but also reduced time spent transitioning be-
after accounting for lab closures (Figure 2). The trend tween several steps in the delivery process (further
of case volume did not significantly vary over the described subsequently).
years. Before any changes, the lab functioned on a Physician start time and case duration notification.
“block” schedule, whereby 4 to 5 rooms were open To improve knowledge of each operator’s schedule,
between 7:30 AM and 7:00 PM . By rearranging the every physician was asked of his or her start time the
nursing schedule, resources could be redirected to day before. An email was sent out to the entire
allow for more cases to be completed earlier and department and the electronic whiteboard updated
avoid late cases. The schedule was thus changed from the night before with the start times included. To
a “block” to a “pyramid” structure, in which 7 to 8 promote timely arrival of staff to their cases, the staff
rooms were opened at 7:30 AM and 3:30 PM , afterward cardiologist was paged within 5 min of patient arrival.
only 1 to 2 rooms remained open until 7:30 PM , and If the physician was unable to start the case within 15
between 7:30 PM and 7:30 AM a single nursing team min of the planned start time (or within 30 min if in
was available to finish late cases and for acute cases if an unavoidable meeting), it was his or her re-
needed. With this change, approximately 80% of sponsibility to find another physician to do the case
cases could be completed by 3:30 PM , allowing a or risk losing the preference to start early the next
greater number of urgent and add-on cases to be time they were in the lab. In addition, physicians
completed earlier in the day. were made aware of their average start times, delays,
and case duration per type of case to facilitate
ROOM STARTING TIMES. The average room start
avoiding scheduling several long cases in any given
time at the beginning of the program was 7:58 AM ,
day.
with only 63.9% of cases starting at the on time goal
of 7:45 AM (Table 3, Figure 3). Start times improved ROOM TURNAROUND TIMES. Room turnaround times
over the course of the study, with 89.1% of rooms were routinely above the goal of <17 min, however
starting on time in 2015, and 88.8% rooms on time in significantly improved over time (trend p < 0.0001)
2016 (trend p ¼ 0.190). Before start of the program (Table 3, Figure 4). Illustrating this, before the start of
(before June 2014), the average start time was 7:59 AM, the program in June 2014, the average room turn-
with only 61.8% on-time starts, whereas after the around time was 20.6  0.8 min, which improved to
changes the average start time was at goal of 7:42 AM , 17.1  1.8 min after the program (p ¼ 0.044). Turn-
with 81.7% on-time starts (p ¼ 0.0024). This gain of around time improved further to 16.4  1.0 min in
JACC: CARDIOVASCULAR INTERVENTIONS VOL. 11, NO. 4, 2018 Reed et al. 333
FEBRUARY 26, 2018:329–38 Efficiency in the Catheterization Laboratory

2016. This gain of 3.5 to 4.1 min per case, averaging 48

T A B L E 2 Summary of Major Changes, Key Results, and Timeline of Implementation
cases per day, amounted to a gain of 168 to 196.8 min
(2.8 to 3.3 h) of added potential productivity each Change Description Key Results Implemented

day. The key changes implemented to realize these Culture of Promoted a culture of 1. Employee “buy-in” June 2014
excellence excellence and to the changes
gains were as follows: collegiality among being made.
cath lab employees 2. Improved individual
“ P r o j e c t S c r u b B r o k e n ” . In cases of a turnaround and the prep/ employee satisfac-
recovery area tion and satisfaction
time >22 min, nurses were required to fill out a form
with management.
explaining why. The most common reasons were de- Electronic Decentralized internet 1. Allowed for rapid, June 2014
lays in the patient preparation and recovery area, scheduling based scheduling real-time notification
whiteboard system viewable of what step each
usually in obtaining consent, placing intravenous from any computer, patient was at in the
access, and patient use of the restroom. In addition, in any lab room case.
2. Improved start times,
there were often lags in communication from the cath turnaround times,
lab nurses that the room was clean, and from the and employee
satisfaction.
prep/recovery nurses that the next patient was ready.
Pyramidal nursing Changed from a block 1. Allowed for more July 2014
This process was automated in an initiative called schedule to a pyramidal cases and higher
“Project Scrub Broken” once the electronic white- nursing staffing productivity early
schedule in the day.
board was adopted. In this project, the moment 2. Improved lab start
the physician scrubbed out of the “current” case, the times to goal.
3. Increased nursing
charge nurse prompted the case to turn red on the satisfaction.
electronic whiteboard. This visually notified custodial “Project Scrub Immediately when 1. Reduced patient August 2014
Broken” physician scrub was transfer times.
staff to clean the room, the transport team to move
broken, electronic 2. Fewer manual sheath
the patient out of the room, and the preparation and whiteboard pulls in lab.
automatically 3. Patients moved to
recovery area to finish preparing the next patient.
notified nurses to prep/recovery area
This decreased the need for verbal communication, transport patient to wait if bed not
out/next patient in yet available.
and sped up overall communication between the cath
Physician start Physicians emailed night 1. Improved start times. August 2014
lab and preparation and recovery areas. time changes before their cases 2. Improved turnover
with start times, and times.
P a t i e n t t r a n s f e r p r o c e s s . Common reasons for expected to start
case within 15 min of
delays in patient transport were final destination
patient arrival
beds not being available on the floor, delays in nurse- Central supply Changed from stocking 1. Reduced need for September 2014
to-nurse verbal report, and nursing shift changes. To stocking catheter supplies in nurses to search
each room to room to room for
address this, nursing duties were clearly defined such stocking in a central supplies.
that among the 3 nurses (or 2 nurses and 1 tech) area, with certain 2. Reduced procedural
supplies on a mobile times.
assigned to a room, 1 would get the new patient, 1 cart
would transport the old patient, and the other would Streamlined Redundancy in nursing 1. Simplified September 2014
assist with room turnover. Manual sheath pulls in the nursing documentation was documentation.
documentation onerous and 2. Redefined nursing
cath lab were eliminated except in special circum- creating barriers to duties.
stances (reduced to 3% to 5% of cases/month). If the starting on time and 3. Reduced start times.
transitioning 4. Reduced turnaround
final destination room for the patient was not yet patients times.
available, the patient was transported to wait in the
preparation and recovery area rather than kept in the
cath lab room (except if going to an intensive care LAB ROOM UTILIZATION. Cath lab room utilization
unit). In addition, the implementation of the elec- was calculated as the ratio of the number of hours
tronic whiteboard allowed for patients’ locations to staffed to the number of hours utilized, excluding
be tracked, and if there were delays in the availability weekend cases and cases beginning after the lab’s end
of transport staff to bring a hospital inpatient to the time, after adjusting for room closures. A turnaround
lab, it became the responsibility of a lab nurse to time of 18 min was added for each case (25 min were
assist in physically transporting the patient. Further, added before January 2015 before we realized our
there were delays in nurses stocking rooms between gains). Room utilization improved from 2013 to 2016
cases, and at times needing to search between rooms (Table 3) (p for trend ¼ 0.177). Illustrating this, daily
for supplies during cases. This was addressed by room utilization was 91.1  9.1% before the start of the
utilizing a central supply room with a mobile cart in program in June 2014, and increased to 105.5  6.9%
each room with frequently used supplies to reduce afterward (p < 0.0001) (it was possible for utilization to
time spent looking for supplies. be >100% if the number of cases performed was more
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Efficiency in the Catheterization Laboratory FEBRUARY 26, 2018:329–38

F I G U R E 2 Monthly Case Volume, Weekend Cases, and After-Hours Cases

Over the 3-year study time frame (May 2013 to April 2016), case volume remained relatively constant, whereas the percentage of weekend and after-hours cases
remained low and were not appreciably changed by the initiative.

than the maximum expected given the staffing
hours available). Further, the proportion of days in
which the entire lab was operating at full utilization
capacity improved from 7.7% to 77.3% comparing
before to after the start of the program (p < 0.00001).
PRODUCTIVITY PER FTE. In 2013, the number of FTEs
was 36.1, which was reduced to 29.6 by 2016. There was
no significant change in case volume of the number of
physician operators in the lab over this time. No staff
were terminated; rather, a small number were not
replaced after turnover occurred. This lower nursing
FTE versus cath lab volume ratio indicated that despite
a reduction in 6.5 FTEs, productivity and efficiency
increased with the changes made over this time.
AFTER HOURS CASES, WEEKEND
OVERTIME HOURS. There was no discernable differ-
ence in the number of cases started after hours over
the years (p for trend ¼ 0.431), or before or after the
program (1.67% vs. 1.84% of shifts; p ¼ 0.927)
(Figure 2). There was also no change in our ability to
accommodate emergency cases. Similarly, there was
no difference in the number of cases worked on the
weekend over the years (trend p ¼ 0.148), or before or
after the program (1.81% vs. 2.00%; p ¼ 0.922)
(Figure 2). The proportion of hours that were overtime
did not increase as a result of the program (4.7% in
2013, 5.1% in 2015, 3.9% in 2015, and 3.8% in 2016;
trend p ¼ 0.341; p ¼ 0.812 before and after the
program).
EMPLOYEE EXPERIENCE. The effects on cath lab
nursing and support staff employee experience were
quantified by Press Ganey surveys before and after
program (Table 4). Employees were surveyed on their
level of engagement, perception of action planning
readiness, workplace safety, managerial effective-
CASES, AND ness, and overall satisfaction. Among managers at our
institution, a change of 0.20 is generally considered
meaningful in any category, or 10 points in action
planning readiness. Overall, the program had a
positive effect on each aspect of the employee expe-
rience, resulting in a meaningful improvement in
overall employee satisfaction.

T A B L E 3 Study Efficiency Outcomes Over the Course of the Program

Problem 2013 2014 2015 2016 p Value*

Start time 7:58 AM  45 min 7:49 AM  40 min 7:37 AM  42 min 7:46 AM  43 min —
% on-time start 63.9  7.6 68.0  12.6 89.1  3.4 88.8  2.7 0.190
Turnaround time, min 20.5  0.82 19.8  1.54 16.2  0.84 16.4  1.01 <0.0001
Lab utilization, % 85.1  2.3 106.7  7.6 104.9  6.4 97.9  4.3 0.177

Values are mean  SD unless otherwise indicated. *Trend across years.

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F I G U R E 3 Start Times and Percent On-Time Starts Over the Study Time Period

As a result of the initiative, there was a reduction in the average start time, with an increase in the proportion of cases starting on time over the study period.
The average start time was 7:59 AM through May 2014 (61.8% on-time starts), whereas after June 2014 the average start time was at goal of 7:42 AM (81.7% on-time
starts) (p ¼ 0.0024).

DISCUSSION reduce operational inefficiencies and streamline

workflow processes. Through targeted process
In this study, we demonstrate that a systematic improvement, we saw an increase in the proportion of
approach to quality improvement in the cath lab can cases starting on time, a reduction in room

F I G U R E 4 Turnaround Times Over the Course of the Study Time Period

As a result of the program, the turnaround time improved during the course of the study time period, from 20.5  0.82 min in 2013 to 16.4  1.01 min in 2016,
with most cases satisfying the goal turnaround time of <17 min (p for trend <0.0001).
336 Reed et al.
Efficiency in the Catheterization Laboratory
T A B L E 4 Press Ganey Employee Satisfaction Survey Results
2014 2015
Problem (Before Program) (After Program) Change
Engagement 3.78
Action planning readiness 70
Safety participation 4.16
Manager 3.58
Overall satisfaction 3.52
Results are on a scale of 1 (poor) to 5 (excellent), except for Action Planning
Readiness, which is on a scale of 1 to 100.
turnaround time, and an increase in lab utilization. In
addition, we were able to realign nursing resources
and reduce the number of FTEs while maintaining the
same case volume and without increasing the pro-
portion of weekend, after-hours, or overtime shifts.
In total, our changes lead to a gain of approximately
5.1 to 5.6 h/day in lab utilization due to improved
start times and reduced turnaround times. Further,
there were improvements in all measured aspects of
employee experience including employee satisfac-
tion. Our experience may serve as an example to
other institutions that process improvement initia-
tives such as ours can lead to significant efficiency
gains in the cath lab.
Operational efficiency is a core competency of a
successful business, yet a more challenging concept
to apply to the cath lab given the many components
involved in every episode of care. To minimize input
and maximize productivity in the most effective
means, we studied the variables that influence effi-
ciency of cath lab care (Figure 5). The changes with
the most impact on efficiency seemed to be switching
from a block to a pyramidal nurse staffing system to
address scheduling inefficiencies,
electronic whiteboard to decentralize communication
between caregivers, and reducing barriers to patient
transfer through increased utilization of a preparation
and recovery “holding” area. In our experience, hu-
man resource management by promoting a culture of
continual improvement and teamwork where each
caregiver is appreciated and constructive feedback
embraced was essential to realizing our goals and
fostering employee “buy-in” to the changes imple-
mented (7). We did not use incentives; however, this
may be another option to encourage provider partic-
ipation in quality initiatives. Further, although most
often applied to patient outcomes, internal peer re-
view may be a valuable tool in improving operator
efficiency (8).
To the best of our knowledge, this is one of the first
and most comprehensive reports
improvement initiative in a large cath lab made
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FEBRUARY 26, 2018:329–38
F I G U R E 5 Representative Diagram of the Various Factors
That Contribute to Cath Lab Efficiency
4.30 þ0.52
88 þ18
4.56 þ0.40
4.23 þ0.65
4.23 þ0.71
Cath lab efficiency is impacted by several factors, each of which
may be potential targets for process and quality improvement.
publically available to date. Although not a project
focused on quality of care, the term quality improve-
ment project is often used to describe projects such as
ours focused on improving efficiency and systems of
care. The only other report of a similar quality
improvement initiative in a cath lab was previously
published by our group, evaluating a narrower set of
metrics from 2009 to 2012 (2,9). Institutions should be
encouraged to study their own care delivery pro-
cesses, individualize specific productivity goals, and
be encouraged to share details on their cath lab op-
erations and efficiency improvement initiatives so
others can learn from them. This may also allow for
comparison and standardization of delivery metrics
instituting an in lab operations (such as turnaround time) across
hospitals and various care models. Although our
project focused on improving the efficiency of car-
diac, peripheral, and structural procedures, the
changes outlined in our study could be applied to
improve the delivery of any procedure provided in
the cath lab, including electrophysiology, aortic
endovascular, and interventional radiology proced-
ures. We plan to continue this initiative and find ways
to expand it to other service lines in the future.
A philosophy of problem solving, teamwork, and
leadership can lead to gains in efficiency and patient
satisfaction, which define operational excellence (10).
Although gains in efficiency are key to streamlining
care delivery processes, operational excellence in the
cath lab can only truly be realized after efficiency is
maximized, after which focused attention can be
of a quality placed on each patient’s overall experience, maxi-
mizing patient satisfaction, keeping employees
JACC: CARDIOVASCULAR INTERVENTIONS VOL. 11, NO. 4, 2018
FEBRUARY 26, 2018:329–38
empowered and attitudes positive, and embracing a
culture of continuous improvement. An efficient or-
ganization can better focus on the needs of each pa-
tient during each episode of care in the cath lab,
which in turn can help maximize each patient’s cath
lab experience and satisfaction.
The Affordable Care Act and Medicare Access and
CHIP Reauthorization Act are moving toward a reality
in which the majority of cardiovascular care will be
reimbursed through alternative payment models that
emphasize quality over quantity of care, such as
bundled payments (11,12). In a bundled payments
environment, the onus will be on the hospital and
provider to use a fixed amount of resources to com-
plete a given case, and thus reducing costs and uti-
lizing resources as effectively and efficiently as
possible will be paramount. It is with this realization
that quality improvement projects such as this one
are essential to maintaining the financial health of
providers and institutions.
STUDY LIMITATIONS. This project was conducted in
a large, quaternary care center cath lab and thus re-
sults may not be generalizable to smaller institutions.
That said, the outcomes we assessed (i.e., lab turn-
over time and start time) are common problems at
many institutions, and thus relatable to cath labs of
all sizes. Although the changes implemented had no
negative effect on patient care, patient outcomes
were not assessed as a part of this study. We
acknowledge that some of the changes we imple-
mented required capital investment, modest mone-
tary investment, and flexibility from our hospital
administration, which may not be available at all
centers. The pyramidal nursing schedule we intro-
duced did require several labs and availability of
more staff earlier in the day, however, could be
adopted to labs of smaller sizes as well. In addition,
we were unable to determine the effect of our project
on overall cost; however, this is less relevant, as cost
will vary from institution to institution, and we have
demonstrated improved productivity
changes we made, which should have a positive effect
on overall cost. Indeed, project cost may be counter-
balanced by the cost savings obtained by realizing
operational efficiencies. Further, it is difficult to fully
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Efficiency in the Catheterization Laboratory
discern which changes had what effect on efficiency
as several changes were made at once; we can only
say that all of these changes together allowed for the
gains in efficiency we have seen.
CONCLUSIONS
A systematic approach to process improvement can
reduce operational inefficiencies in the cath lab.
Through a stepwise implementation of specific
changes over a 3-year period, we have realized
improved cath lab start times, reduced turnaround
times, increased overall productivity, and an
improvement in employee satisfaction. Knowledge of
our experience may be helpful in guiding other cath
labs in similar quality improvement initiatives toward
realizing operational excellence.
ACKNOWLEDGMENTS The authors would like to
acknowledge the nurses, technologists, and support
staff of the Cleveland Clinic Sones Catheterization
Laboratories for their hard work and tremendous
commitment to excellent patient care every day.
ADDRESS FOR CORRESPONDENCE: Dr. Samir R.
Kapadia, Heart and Vascular Institute, Cleveland
Clinic, 9500 Euclid Avenue, Desk J2-3, Cleveland,
Ohio 44195. E-mail: kapadis@ccf.org.
PERSPECTIVES
WHAT IS KNOWN? Operational inefficiencies are common in the
cardiac cath lab, yet solutions for these issues are challenging.
WHAT IS NEW? We show that a systematic, team-based
approach to quality improvement can lead to improved room start
times, turnover times, and utilization with increased employee
satisfaction. The principle changes implemented included use of a
pyramidal nursing schedule, an electronic scheduling system, and a
preparation and recovery area to increase efficiency.
with the
WHAT IS NEXT? There is a need for cardiac cath labs to
publish results from quality improvement initiatives to guide
improvements in efficiency and productivity across institutions.
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KEY WORDS cath lab, catheterization
laboratory, efficiency, productivity, quality,
turn over time