To manage growing volumes, structural heart programs often jump to staffing as the primary challenge and solution. But given financial and resource constraints, programs must take a holistic view of efficiency to manage capacity and support long-term growth. Here are lessons from the market.
Strive to be a program that doesn’t require additional staff
At a baseline, efficiency starts with streamlining the TAVR procedure and care pathway itself. Below is a list of operational efficiencies to consider
- Optimize use of procedural areas—e.g., perform procedures in cath labs instead of ORs to decrease staff and overhead costs or refigure space and staffing for procedures, like TEER, that don’t require a surgeon.
- Streamline TAVR or other structural heart procedure days by stacking cases and cross-training staff—e.g., conduct procedures in one day by flipping between the OR and cath lab and leveraging cross-trained teams of OR, EP, and cath lab staff who can alternate conducting procedures as necessary.
- Prioritize certain procedural areas for structural heart—e.g., one program assessed what procedures should be done at what sites and now prioritizes TAVR, ablations, etc. for the cath lab and moved procedures like peripheral vascular elsewhere.
- Build in additional evaluation steps—e.g., protocols to proactively identify complications with the goal of streamlining recovery and ensuring efficiency gains are not lost.
- Adjust post-procedure recovery workflows—e.g., move patients away from surgical workflows and identify patients who can bypass the ICU, moving straight to telemetry unit or progressive care unit.
- Divide patient support between care settings—e.g., an advanced practice provider (APP) manages the patient in the outpatient setting and the nurse manages the patient in the inpatient setting, or valve clinic coordinator (VCC) handles pre-op and nurse navigator manages post-op.
- Expand outpatient operations—e.g., where possible, shift staff from inpatient hospital to conduct consults or other services in the outpatient setting to free up inpatient space, expand ambulatory footprint, and increase access.
The next step after addressing procedural and operational efficiency is becoming a lean and agile operation, especially for stand-alone and community hospitals. Programs should act on the imperatives detailed below.
Cross-train staff across structural heart procedures
Both structural heart coordinators and clinical teams should be able to manage different types of structural heart cases as needed. Programs early in the process of growing their structural heart program might have their staff specialize by procedure. But cross-training staff is critical to managing capacity as programs grow and evolve, especially given current challenges with staff turnover. For example, many programs have trained their cath lab team to do open cases and trained their OR team to handle catheters, wires, etc. Cross-trained staff can switch between procedures and rooms depending on need. For example, they can alternate between the OR and cath lab to complete more procedures in one day and minimize the need for physicians to come for an additional procedure day. An unforeseen benefit is that offering cross-training opportunities to staff has become an engagement driver and has helped to attract and retain staff.
Enable staff to work at top-of-license
Before making the next staffing investment, programs should assess whether existing staff capabilities properly align with tasks and workflows. By first investing in care team redesign to achieve top-of license care, programs or service lines might uncover FTEs that have additional capacity. For example, some programs have identified nonclinical staff who can support their program. Other programs have identified the need to off-load data registry at the program or organization level or outsource it to a vendor. Care team redesign not only improves efficiency and patient throughput but also increases patient satisfaction and access, improves revenue, and betters communication across the care team.
When approaching care team redesign, consider the specific needs of your program and how to appropriately allocate staff to ensure each team member is working top-of-license. First, work to upskill clinical practice across the team, making nursing staff responsible for practice operations and APPs responsible for appropriate aspects of CV patient care. Second, ensure nonclinical staff have full responsibility for non-clinical tasks. While each role has its own spectrum of responsibilities, remember that the structural heart care team functions holistically and will rely on inter-role collaboration to provide comprehensive care.
Develop scalable workflows to accommodate growth
Organizations are reconfiguring their workflows to reduce the burden on coordinators while also improving patient experience. For example, once patients are referred, they are triaged into standard clinical pathways based on their diagnosis. The pathways specify designated clinic days and imaging slots so patients can receive diagnostic services in a one-stop shop. Coordinators, providers, and the organization benefit from knowing what to expect when, and the institution as a whole benefits from the subsequent inter-department communication and efficiencies that result.
Decentralize ancillary equipment based on disease state
As structural heart volumes grow, ancillary services that feed multiple programs can act as a bottleneck, constraining capacity. To alleviate this problem, some programs invest in their own ancillary services. For example, programs can run dedicated imaging services that give priority to structural heart patients and then serve other patients as time allows. If such investments are not feasible, programs work with ancillary departments to create dedicated slots and days for structural heart.
Justify investment across the structural heart enterprise
To successfully secure funding for structural heart program investments, leaders and physicians work hand-in-hand to justify the program to both hospital/system administrators and philanthropy leaders. Here’s how:
- Illustrate growth outlook: Leaders continuously educate the enterprise about the value and necessity of structural heart (SH) and emphasize the distinctions of what makes SH unique compared to the rest of the cardiovascular service line.
- Demonstrate current performance: Leaders tell the story of where their program is, where they need to go, and how to get there. Data includes growth projections, referral volumes, halo effect volumes, quality outcomes, current and projected staff workloads, staff time study data, patient wait times, and patient stories.
- Articulate the need: Leaders proactively make the business case for the next investment a year or two in advance of program need and emphasize the projected benefits to patients, the program, and the institution at large. Most importantly, they paint the picture of what will be lost without investment.
