Johnson City Medical Center: Center for Cardiovascular Health

What is the size of your cath lab staff and facility? Johnson City Medical Center’s Center for Cardiovascular Health has a total of six cath labs, with one dedicated to electrophysiology (EP) procedures. There is a 32-bed holding room and the 34-member staff includes 25 registered nurses (RNs), with the remaining bulk of the staff being cath lab technologists. Each lab is staffed with one RN and two technologists. The RNs are specialty-trained for the cath lab and the technologists are certified as registered cardiac invasive specialists (RCISs). Located in the heart of the southern Appalachia Mountains near the Tennessee/North Carolina/Virginia borders, Johnson City Medical Center (JCMC) is a teaching hospital and serves as tertiary center for 29 counties throughout four states. JCMC is the flagship facility for Mountain States Health Alliance (MSHA), a 15-hospital healthcare system with locations in Tennessee and Virginia. JCMC’s Center for Cardiovascular Health was listed in the Data Advantage Hospital Value Index™ 2008 report (Louisville, KY) as the 67th largest heart program in the nation per volume. Located in the heart of the southern Appalachia Mountains near the Tennessee/North Carolina/Virginia borders, Johnson City Medical Center (JCMC) is a teaching hospital and serves as tertiary center for 29 counties throughout four states. JCMC is the flagship facility for Mountain States Health Alliance (MSHA), a 15-hospital healthcare system with locations in Tennessee and Virginia. JCMC’s Center for Cardiovascular Health was listed in the Data Advantage Hospital Value Index™ 2008 report (Louisville, KY) as the 67th largest heart program in the nation per volume. What types of procedures are performed in your cath lab? The cath lab performs left and right heart catheterizations, combo catheterizations, peripheral angiograms, pacemakers and implantable cardiac defibrillators. With the growth of the MSHA healthcare system and recent physical expansion of the cath lab at JCMC, volumes have continued to rise. Four years ago, the cath lab performed just over 5,000 procedures. That number has dramatically increased. Approximately 7,200 procedures were performed in the last year, equating to an average of around 135 cases performed each week. How does your cath lab employ surgical backup? JCMC is a large, 541-bed tertiary medical center and home to a Level 1 trauma center offering a large variety of medical services around the clock, each day of the week. Inside the cath lab, primary angioplasty is performed with surgical backup on a regularly scheduled basis. Surgical teams are also placed on standby with high-risk notification. What procedures do you perform on an outpatient basis? Diagnostics are performed on an outpatient basis. What percentage of your patients is female? Fifty-five percent of our patients are female. What percentage of your diagnostic cath patients go on to have an interventional procedure? What percentage of your diagnostic caths are normal? Approximately 40 percent of diagnostic cath patients go on to interventional procedures and the remainder are normal. Who manages your cath lab? 1. Ed Stump, director of interventional cardiology, AAS, BA, MBA, member HFMA, ACHE. Ed has been with MSHA since October 2001, having worked in cardiology since April 2004. He assumed directorship in July 2007. Ed received his undergraduate degree from Virginia Intermont College in 1992, with a concentration in business administration, and received his MBA from King College (Bristol, TN) in May 2007. Ed has worked in a mentoring capacity with Cindy Salyer, RN, vice president of cardio-pulmonary, since 2004. He was program speaker at Premier Inc.’s annual meeting in 2006 on cost reduction strategies and effectively partnering with clinicians, and will be a program speaker along with Cindy Salyer at the 2009 Premier Annual Meeting in Anaheim, California. 2. Kathy Jordan, RN, BSN, clinical leader – nurse manager. Kathy assumed the clinical leader – nurse manager’s position in September 2007. Prior to that, she had previously worked in a supervisory position in the cath lab. She has extensive cardiac experience in invasive cardiology. Kathy has been an RN since 1993, and has worked in the cath lab environment since 1997. She received her BSN from East Tennessee State University in 2004, having been an RN-AD prior to that time. In 2008, Kathy completed a cardiovascular fellowship with the Corazon Academy in Pittsburgh, Pennsylvania. Other management staff include Cindy Salyer, vice president, cardiovascular pulmonary services; Allyson Haga, RN, CV educator; Brenda Baines, RT, inventory supply manager; Judy Heaton, RN, nurse manager interventional holding. Do you have cross-training? Who scrubs, who circulates and who monitors? Our cath lab teams are cross-trained, including RNs in the interventional holding areas. RNs do not scrub. Does an RT have to be present in the room for all fluoroscopic procedures in your cath lab? A radiologic technologist does not have to be present for all fluoroscopic procedures, but is available upon request. Two of our working technologists are RTs and our inventory manager is also an RT. How does your cath lab handle radiation protection for the physicians and staff that are in the lab day after day? There are radiation monitoring services and a radiation monitoring committee that meets for regular updates. How is coding handled in your lab? Dedicated case managers work one-on-one with physicians for billing. How does your lab handle hemostasis? Physicians handle both manual and vascular closure devices for hemostasis. All patients are then taken to the 32-bed holding area. The majority of hemostasis is handled by vascular closure devices, although manual compression is also utilized. This is a physician-patient preference area. Vascular closure has been a focus in the lab over the past year and there is a current process improvement team in place examining the clinical and financial impact of the current system. The facility has a policy in place that requires competency signoff. We have experienced success with the new Mynx closure device (Access Closure, Mountain View, CA). Can you describe the systems you utilize to organize staff and communicate necessary information? Communication has proven to be key to success in the cath lab at JCMC. We begin each day with what we call the “MSHA Moment.” This is a time for the system to communicate messages, news and other events. In the cath lab, we also utilize this time for a small, daily staff meeting with our team members. It’s a positive way to start the day. Once a week, the director is available during the meeting to speak with staff one-on-one and convey senior support. On a quarterly basis, there is a staff meeting held to cover all relevant policy and procedure changes, and update the team on performance and quality initiatives. These measures are also conveyed on a board format with charts that clearly demonstrate achievements. We try to keep the emphasis on building teamwork with the staff of the interventional holding unit (IVH) as well. This unit is critical to successful transition of patient care. We currently have cross-training between the RNs in the cath lab and IVH, which allows for vacancies and paid leave time to be accommodated more readily. Each RN must be oriented and signed off competently by the CV educator before taking independent assignment. This also enables cath lab RNs to take breaks from the cath lab environment. There is an incentive differential for all RNs that work in the cath lab area. A shift leader in the 32-bed IVH unit works daily with the cath lab shift leader to ascertain and plan patient flow. This enables the labs to be efficient and maintain physician schedules. We also block the labs for two hours each month to hold a monthly education/staff review, held in conjunction with the department of cardiology. In working with our physicians, we hold a quarterly scheduling meeting, open to staff, to discuss scheduling. We currently operate on a block scheduling format. Cath lab leadership works to maintain a very open communication pattern with the cardiology practice administrators, with a quarterly practice meeting held in conjunction with our business development department. We hold a monthly invasive committee meeting with our physicians to address inventory, operations and financial performance of the lab. There is also a monthly leadership meeting, where each member of management presents their key indicators, which include financial driver, quality drivers, and operational drivers, to the director. A quarterly management retreat includes the entire CV service line to discuss retention, patient-centered care and strategic planning. This format has allowed us to keep our commitment to our patients while also achieving our goals. What is your lab’s hematoma management policy? The cath lab has a “hematoma hot line” and patients may be triaged if they develop a hematoma. How is inventory managed at your cath lab? A dedicated inventory manager and inventory technologist handle purchases and inventory maintenance. What are some of the new equipment, devices and products introduced at your lab lately? A recent $22 million expansion to the Center for Cardiovascular Health created four new labs (for a total of five labs less than 18 months old) and brought us new equipment, including intravascular ultrasound, AngioJet (Possis Medical, Inc., Minneapolis, MN) and a new hemodynamic system, as well as converting to a new picture archiving and communication system (PACS) from Siemens (Malvern, PA). The cath lab suites at JCMC have two Philips (Bothell, WA) bi-plane rooms, as well as one Philips coronary-peripheral room. In early 2009, each cath lab suite was also fitted with the latest Omnicell (Mountain View, CA) pharmacy dispensing system. What type of quality control/quality assurance measures are practiced in your cath lab? All MSHA facilities follow the Malcolm Baldrige Quality Model (www.quality.nist.gov) and the system has a large, dedicated quality department staffed with clinical and non-clinical team members to examine all aspects of the system’s operations and evaluate for potential quality improvements. The cath lab also has a dedicated performance improvement team that regularly meets to evaluate outcomes and to initiate additional quality improvement projects on an ongoing basis. National patient safety goals are also reviewed monthly inside the lab and appropriate changes are made as needed. Over the past two years, the lab at JCMC has been involved in process improvement with regards to a number of quality initiatives, the most significant being door-to-balloon time. The facility currently meets the 90-minute window 90%+ of the time as a result of performance improvement measures. Being a major regional tertiary referral center required that the lab implement a cross-functional team that consisted of physicians, administration, as well as cath lab and emergency department (ED) staff. The team recommended various improvements in the process, including the addition of a second call team, the implementation of a ST-elevation myocardial infarction (STEMI) database system to monitor outcomes and times, and having the acute MI abstractor’s office located in the cath lab area. This has led to a greater emphasis on the measure and opened up communication on a daily basis. There is also an administrator on STEMI call weekly. The lab maintains a STEMI board in the cath lab hallway where results are posted and shared. This information is also shared with the ED department. The ED has partnered successfully with the cath team on this initiative. Without their assistance, the results would not have been possible. The staff’s annual incentive payout was also directly correlated to this measure. In 2007 and in 2008, door-to-balloon time improvement was recognized at MSHA’s annual quality awards presentation and the measure was nominated the top award in clinical effectiveness. The lab has also had a consistent focus on infection control measures for cardiac rhythm management (CRM) implants and groin complications. Focus in these areas has brought about a less than one percent infection rate for CRM implants and has significantly reduced groin complications through education and new product evaluations. In 2007, the center also hired a full-time CV educator, Allyson Haga, RN, who works closely with the staff on education, spending the majority of her time working on cath lab issues. What measures has your cath lab implemented in order to cut or contain costs? Over the last year, all departments inside MSHA have been directed to reevaluate processes for financial savings. The cath lab has been engaged in that effort, as well as continuing to participate with the national healthcare organization, Premier, for group purchasing. The cath lab has managed to save $2.5 million in working with Premier. How does your lab compete for patients? MSHA covers a 29-county region and has one major competitor for cardiovascular services. It has a large, in-house communications and marketing department that develops ongoing campaigns for identified services. MSHA has labeled cardiovascular services one if its five Centers of Excellence, which affords the service more internal resources for marketing its services. Regular marketing campaigns promote the services via television, billboards, radio and newspapers. Press releases are frequently distributed to the media to highlight patient success stories — a recent example includes a patient who had a pacemaker replacement procedure 27 years after his initial pacemaker procedure. The original pacemaker was still working. Another marketing tool includes an online heart health evaluation tool that has been heavily marketed to the region. The HeartAware Program — marketed under the tagline of “7 minutes that could save your life” — encourages visitors to the MSHA website to answer a series of questions gauging their heart health. The program has a “call to action” for those identified as high risk and a follow-up phone call from a registered nurse advising them of their options. A free medical health screening is then offered to anyone falling into the high-risk category. The health system also has dedicated cardiac outreach managers who work closely with referring physicians to keep them educated on services while building professional relationships. The outreach managers also attend community events to educate the public on heart health issues and to explain local services. How are new employees oriented and trained at your facility? Approximately 30 percent of the team members in the cath lab have less than a year’s experience. There is a multi-day orientation for clinical personnel at MSHA that educates new team members on general clinical systems. A cardiac educator is then assigned to work with new team members in the cath lab. These new team members are also engaged in a preceptor program. To be considered as a new team member inside the cath lab, it is required the person have a background of working either in an emergency department or in an intensive care unit. What type of continuing education opportunities are provided to staff members? At least two team members are sent each year to national conferences and encouraged to share their new knowledge with the rest of the team. Inside the MSHA system, there are regular opportunities for expanded knowledge, including computer-based learning programs as well as in-services and organizational development classes. JCMC is located next to the College of Nursing at East Tennessee State University, which offers additional opportunities for expanded medical training. MSHA has a tuition reimbursement program for those team members involved in an approved degree program, whether it be for a nursing degree or an approved advanced degree program. How do you handle vendor visits to your lab? Vendor visits are strictly controlled inside all MSHA facilities, with visits only allowed at prearranged, pre-approved times. There is a single vendor entrance at the hospital that is only accessible via a computer sign-in. To be eligible for the sign-in, each individual vendor representative is required to attend a one-day vender training seminar and wear a name badge whenever on MSHA property. Once the vendor has signed into the computer for a visit, an electronic message is then send to the cath lab alerting team members to the vendor’s presence. There is a scrubbed-in vendor rotation one day a month. How is staff competency evaluated? The CV educator, as well as the clinical leader, signs off on a list of competencies for each team member. Does your lab have a clinical ladder? The lab has a BEST Program (Bedside Excellence Shining Through) as part of its clinical ladder. RCISs became part of the ladder in January 2009. How does your lab handle call time for staff members? Each four-member call team is made up of the same mix of personnel needed for the lab, and call is self-scheduled, with four days of primary call and four days of secondary call each month. Within what time period are call team members expected to arrive to the lab after being paged? The call team is expected to arrive within 30 minutes. The attending cardiologist must call back within five minutes and arrive within 30. Do you have flex time or multiple shifts? The cath lab has multiple shifts of 8, 10 and 12 hours. Where is the cath lab located in relation to the OR and ED? While JCMC is a large facility, service areas are concentrated and movement paths between different departments are identified to provide the more efficient use of time. The cath lab is located adjacent to the OR and a few hundred feet from the ED. Next to the cath lab is the hospital’s chest pain center. This service has been created to expedite a emergency patient’s treatment once they present in the ED with a complaint of chest pain. Once triaged, the patient bypasses the traditional ED and is taken directly to the chest pain center for continued care. How do you see your cardiac cath lab changing over the next decade? The largest change expected in the coming years is in terms of volumes. There is an expected increase in peripherals and EP procedures in the coming years. What’s special about your city or general area in comparison to the rest of the U.S.? JCMC is situated in the center of the southern Appalachian mountains. As a Level 1 trauma center as well as home to the region’s largest air ambulance service, JCMC sees an unusually unhealthy population. Tobacco use and obesity are well above the national average, creating a larger than average pool of patients for the cath lab. Ed Stump can be contacted at watsonjw@msha.com

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