Operational Efficiency in the Cardiac Cath Lab: The Time for Metrics Is at Hand

Review paper lays out a blueprint and call to action


More than a few guideline and consensus statements have been developed to define quality of care in the cardiac catheterization laboratory, but the same is not true for operational efficiency of the cath lab. A new review paper by Cleveland Clinic interventional cardiologists and a Harvard Business School professor aims to change that by laying out the first proposed standardized metrics of cath lab efficiency.


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“Many institutions are desperate for guidance on how to efficiently provide high-quality cath lab care,” explains Samir Kapadia, MD, Director of the Sones Cardiac Catheterization Laboratories in Cleveland Clinic’s Miller Family Heart & Vascular Institute and senior author of the review, published in the Journal of the American College of Cardiology (JACC) (2018;72:2507-2517). “We developed this paper to demonstrate the importance of operational efficiency to cath labs’ sustainability by approaching the topic from a business perspective and proposing standardized metrics of efficiency that could be used in future public reporting around the value of cath lab care.”

Introducing congruence modeling

The paper focuses on operational efficiency, or the ability to deliver a service in a cost-effective manner while maintaining high quality standards. “With continuing shifts in reimbursement away from fee-for-service models toward quality-based models, it is paramount for hospitals and health systems to control costs,” notes Dr. Kapadia. “Those that embrace operational efficiency in the cath lab will benefit in this environment.”

To make the case for such action, Dr. Kapadia and his Cleveland Clinic colleague Grant Reed, MD, partnered with Michael L. Tushman, PhD, of Harvard Business School on the paper, which provides a framework for improving efficiency based on the Nadler-Tushman congruence model, a commonly used tool for designing and aligning organizational management.

A congruence model helps assess the performance and efficiency of an organization by examining several interconnected elements: executive leadership, strategy, critical tasks, formal organization, people and culture. “The greater the alignment, or congruence, among these elements, the better a cath lab’s performance and efficiency will be,” observes co-author Dr. Reed.

Well-functioning cath labs can benefit too

The authors note that congruence modeling can help cath labs address performance gaps — i.e., inefficiency-related differences between actual and optimal performance — as well as opportunity gaps — i.e., areas of potential growth if the lab were to embrace novel procedures, technologies or innovations. “Pinpointing opportunity gaps can be an important growth strategy for a cath lab that’s already functioning well,” Dr. Kapadia says.

The paper reviews how each of the elements examined within the congruence model figures into cath lab operational efficiency, with an emphasis on the particular importance of effective leadership by the physician cath lab director, whom the authors dub the “cath lab chief executive officer.”

The authors then share a detailed example of how Cleveland Clinic used a congruence model to address a performance gap — i.e., how to increase the cath lab’s ability to perform elective cardiac catheterizations for inpatients within 24 hours of a request. The steps taken led to a rise in the number of completed same-day or next-day cases from 71.1 percent to 80.9 percent, which resulted in more same-day discharges and related cost efficiencies.

Nine proposed efficiency metrics

The paper’s centerpiece is the authors’ proposal for standardized metrics of cath lab efficiency, which are laid out and defined as follows:

  • Case volume: Number of cases in a specified time period
  • Room utilization: Ratio of the number of hours each cath lab room is staffed to the number of hours the room is utilized
  • Percentage of days at full capacity: Proportion of days the whole lab is at full operating capacity
  • Percentage of on-time starts: Proportion of times the patient and physician arrive on time for the first case of the day in a given lab room
  • Turnaround time: Time between exit of the prior patient and arrival of the next patient in a lab room
  • Percentage of sheath pulls in room: Proportion of nonradial cases in which the vascular access sheath is pulled in the lab room
  • Productivity per FTE: Ratio of case volume per nonphysician full-time employee (FTE)
  • Percentage of after-hours cases: Proportion of scheduled cases that occur after normal operating hours
  • Percentage of overtime hours: Proportion of hours paid to FTEs that are classified as overtime


The authors note that they longitudinally assessed these metrics in a recent study of a cath lab quality improvement (QI) initiative that Drs. Kapadia and Reed published (with other Cleveland Clinic colleagues) in JACC Cardiovascular Interventions (2018;11:329-338). Their latest paper also shares goals for each efficiency metric from that QI study, noting that they obtained improvements in virtually all the metrics by addressing performance gaps identified from a congruence model they ran for the initiative.

The net result was a gain of 5.1 to 5.6 hours per day of additional cath lab time, which arose from improved utilization and reduced room turnaround times, the authors note. This was achieved without negative effects on case volume and with improvements in employee satisfaction and productivity, as detailed in this earlier Consult QD post.

“A systematic approach to operational efficiency using a congruence model can be a valuable tool for improving cath lab management,” Dr. Kapadia concludes. “We encourage cath labs to report results from their QI initiatives using metrics similar to those we’ve defined in this review paper.”

The full paper, which also addresses reducing supply costs and strategies for supply savings, is available here.


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