When it comes to quality assurance, there are always areas for improvement. In the following article, we look at how current EP staff successfully manage quality control and quality assurance practices in their electrophysiology lab. These accounts were taken from “Spotlight Interviews” published in EP Lab Digest over a four-year period. The labs mentioned are located all across the United States, and were interviewed between September 2001 to September 2005. In this article, comments were edited slightly so as to focus solely on the quality control/quality assurance aspects of their labs.

John Muir/Mt. Diablo Health System, September 2005:
At John Muir/Mt. Diablo Health System in Concord and Walnut Creek, California, quality control checks on the equipment in the procedure rooms are performed on a daily basis by the staff, while the Biomed department tracks and performs the preventative maintenance. Daily checks include the imaging equipment, defibrillators, emergency equipment and the ACT machines.

Rockford Memorial Hospital, August 2005:
Rockford Memorial Hospital in Rockford, Illinois, recently received the 2005 Health Grades Distinguished Hospital Clinical Excellence Award in eight areas, including Cardiology. Their hospital is ranked among the top 5% of hospitals in the nation. In order to determine how well they care for their patients, Press Ganey scores are used to identify their strengths and weaknesses, ranking regularly in the 90th percentile. This is a national program that reflects customer satisfaction. Their cardiology program also subscribes to The National Registry of Myocardial Infarction (NRMI), which assesses their ability to effectively care for patients who are having a myocardial infarction. Their response times have been well below the national median, with their last quarter results reflecting an 83-minute door to dilatation time, 90–120 minutes being the recommended range. They also participate in the American College of Cardiology database. Their department performs its own hospital point of care quality assurance testing for hemoximetry, glucose, and activated clotting times.

Sinai-Grace Hospital, July 2005:
At Sinai-Grace Hospital in Detroit, Michigan, the patient undergoes a physical exam immediately post procedure in the holding area, and the CXR is performed if the subclavian vein access was performed. The patient is then transferred to the hospital room. The following day, the pertinent physical exam is performed during which vascular access sites are carefully addressed and any hematoma/bleeding is documented. The patient receives a phone call by an EP lab nurse after one week to re-address if any procedural complications were noted. The EP team also gets together monthly to discuss any procedural complications. Their complication rates are lower than the national average.

Baptist Health, June 2005:
At Baptist Health in Little Rock, Arkansas, their equipment is inspected periodically and their inventory is checked monthly for expiration dates. Dr. Neuhauser informs us of any complications such as hematomas or infections. Each case that is done in the EP lab is entered into their Witt system, and any complications during the procedure are documented there.

McConnell Heart Hospital at Riverside Methodist Hospital, May 2005:
At McConnell Heart Hospital at Riverside Methodist Hospital, their Arrhythmia Services clinical outcomes manager tracks key metrics for their department. Her findings are analyzed and shared on a monthly basis to each of their eight physicians. Monthly reporting of Quality Outcome Indicators include device infection within 90 days of implant, pneumothorax requiring chest tube, tamponade, respiratory compromise requiring intervention, bleeding, and in-lab mortality. Data is presented by case and in a control chart format that shows rolling 12-month data to the physicians, unit managers, and the Quality Specialist for peer review. Aggregate data is shared with the EP lab staff and the Heart Services Line Continuous Process Improvement Council. Compared to the outcomes noted in the literature, Riverside EP lab outcomes are at or below benchmark. Their data is utilized to identify opportunities for improvement and to develop action plans.

St. Mary’s Hospital Medical Center, April 2005:
At St. Mary’s Hospital Medical Center in Madison, Wisconsin, they track vascular complications, and were in the process of setting up a system for tracking implant complications.

Marion General Hospital, March 2005:
At Marion General Hospital in Marion, Indiana, they do QA monitors for infection, hematoma formation, conscious sedation and patient satisfaction.

Medical University of South Carolina, February 2005:
Prior to every case at the Medical University of South Carolina in Charleston, South Carolina, a checklist is performed, confirming the presence of consent, history, physical and that the correct procedure is being done on the correct patient. As required by JCAHO, they always use a minimum of two patient identifiers. Their nurses perform an independent double check on all meds before administration. Staff must demonstrate working knowledge of all equipment through annual competencies.

Central Baptist Hospital, January 2005:
At Central Baptist Hospital in Lexington, Kentucky, their QA/QC measures include conscious sedation, complications and documentation review. Any medication given for sedation reversal is reported to patient safety. They also do equipment checks and monitor history and physical assessment, which is a JCAHO requirement.

United’s John Nasseff Heart Hospital, December 2004:
At United’s John Nasseff Heart Hospital in St. Paul, Minnesota, the BioMed department performs routine preventive maintenance. All lab test devices are QA’ed according to CAP regulations.

Lancaster General Hospital, November 2004:
At Lancaster General Hospital in Lancaster, Pennsylvania, their QA/QC measures include conscious sedation, equipment, complications and documentation review. The conscious sedation QA examines the documentation of their sedation personnel. This looks at everything from vital signs to appropriate medication administration. Also, any time a reversal medication is given, the sedation flow sheet is reviewed to figure out the cause of over-sedation and how to prevent it in the future. The equipment QC involves making sure their day-to-day equipment, such as X-ray, ACT machines, refrigerators, and contrast warmers, is functioning appropriately. Their complications, as previously mentioned, are tracked and any common denominators are noted and a root-cause-analysis is determined. Their documentation QA examines the procedural recordings to be sure that all mandatory fields are completed and accurate. This QA also includes looking at all equipment used throughout the case and making sure the usage of the equipment is contained in the procedural notes.

Massachusetts General Hospital, October 2004:
The EP lab staff at Massachusetts General Hospital in Boston, Massachusetts, is a highly skilled and dedicated team. With larger staff-to-patient ratios, they ensure the highest quality and safest patient care. They follow their patients closely, from initial pre-procedure phone calls to follow-up calls after discharge. This service helps monitor patients’ progress after complex procedures, alleviates anxiety and concerns of patients and families, and maintains continuity while increasing patient satisfaction.

University of Florida, August 2004:
At the University of Florida, they review select cases for evaluation in their quarterly Cardiology QA meetings. They also audit patient and medication safety compliance as well as all JCAHO regulations.

Lenox Hill Hospital, July 2004:
At Lenox Hill Hospital in New York, a nurse practitioner who works part-time collects all of the quality control data and reviews cases with complications. The entire EP staff meets once every two months to discuss these issues/cases.

Porter Adventist Hospital, June 2004:
At Porter Adventist Hospital in Littleton, Colorado, the physicians and staff work with the hospital-wide Quality Improvement Department to maintain the high standards the hospital requires. They have ongoing QI processes for groin sites, post-device implant infections, lead dislodgements, and post-implant pneumothorax. Their complication rates are extremely low.

St. Peter's Hospital, May 2004:
At St. Peter's Hospital in Albany, New York, they have a nurse who collects and maintains outcome data on all of their high-volume procedures and as needed. There are quarterly quality assurance meetings attended by staff, and quarterly reports are distributed to staff and physicians for review as well. These reports are analyzed and carefully reviewed by their program director. They monitor outcomes, length of stay (LOS), and complications. They participate in National Patient Safety Goal enforcement and are implementing new Fire Safety Protocols.

Medical City Heart, April 2004:
Medical City Heart in Dallas, Texas, has a Cardiology Performance Improvement Committee that meets once a month. This is a multidisciplinary team of physicians, managers, and directors.

Tufts-New England Medical Center’s Cardiac Arrhythmia Center, March 2004:
At Tufts-New England Medical Center’s Cardiac Arrhythmia Center in Boston, Massachusetts, all machines are QA’d per JCAHO guidelines.

St. Luke’s-Roosevelt Hospital Center, February 2004:
At St. Luke’s-Roosevelt Hospital Center in New York, the EP laboratory has a weekly clinical conference. At this conference, when appropriate, they present cases for review by the entire team, including nursing staff. They find this extremely helpful to review their policies and procedures, and make changes as appropriate. Everyone gains from this process, and it is not considered harsh or punitive. Of course, they make appropriate reports to the institutional authorities.

Emory Crawford Long Hospital, November/December 2003:
At Emory Crawford Long Hospital in Atlanta, Georgia, they track all outcomes. A nurse compiles quarterly outcomes reports, and they attend a regularly scheduled morbidity and mortality conference. Conscious sedation variances are reported and analyzed.

St. John Hospital and Medical Center, October 2003:
At St. John Hospital and Medical Center in Detroit, Michigan, they regularly evaluate the functioning of their equipment and closely monitor complications in their laboratory. Furthermore, to assure an efficient flow of cases in/out of the laboratory, they pay close attention to procedure lengths and turnover between cases.

UCLA Cardiac Arrhythmia Center, September 2003:
At the UCLA Cardiac Arrhythmia Center in Los Angeles, they have bi-monthly QA and QI meetings. They discuss minor and major complications in-depth for lab improvement.

University of Massachusetts Medical Center, July/August 2003:
At the University of Massachusetts Medical Center in Worcester, Massachusetts, they always have quality control projects going on. In their lab, they have a large database that contains all of the information and statistics on the patients and cases that they have done in the past. Periodically they doublecheck this information and determine if there is something going on that they haven’t looked at yet, or if there is something that they can improve upon. This is generally taken care of by the nursing staff.

University of Iowa Hospitals, June 2003:
At the University of Iowa Hospitals in Iowa City, Iowa, they routinely evaluate the complications in their laboratory and the functioning of their equipment. Further, they assess the length of time of the cases and the problems with select cases. If there is a substantial issue, this is raised for all faculty members, fellows and staff.

University of California – San Diego, May 2003:
At the University of California – San Diego, they have a standard quality assurance committee, which has regular meetings to review all cases in which complications might have occurred. They have periodic meetings to review lab efficiency and performance characteristics (e.g., case volumes, turn-around times, procedure times, start times, etc.). They conduct periodic patient satisfaction surveys. They periodically assess competencies of staff in various duties by direct observation or written examination. They provide regular training and meeting attendance to staff in order to maintain and update credentials.

University of Rochester Medical Center at Strong Memorial Hospital, April 2003:
At the University of Rochester Medical Center at Strong Memorial Hospital in New York, quality control is a managed program that is unit- and hospital-wide. There are specific accountability guidelines for incident reporting, and there are regularly scheduled quality assurance meetings.

Advocate Illinois Masonic Medical Center, March 2003:
At Illinois Masonic Medical Center in Chicago, Illinois, they keep very specific documentation of all their procedures both for research and quality assurance/control purposes. Their medical director reviews their QA statistics each month and any cases where there were complications.

Carle Heart Center, January/February 2003:
At Carle Heart Center in Urbana, Illinois, most equipment is maintained by the BioMed department of the hospital, who respond promptly when needed. They have maintenance contracts with vendors as well (e.g., GE for fluoro equipment). The EP staff check items such as external defibrillators, emergency drugs, stimulator, and radiofrequency generators on a regular basis.

Mercy Heart Institute, November/December 2002:
At Mercy Heart Institute in Sacramento, California, quality control and quality assurance is measured by: 1) Quarterly procedural sedation audits; 2) Tracking of case volume, case length, turnover time; and 3) Implementation of audit process for billing accuracy.

Einstein Heart Institute, September/October 2002:
At Einstein Heart Institute in Philadelphia, Pennsylvania, the lab measures quality control, quality assurance, patient safety and patient satisfaction.

Riverside Methodist Hospital, May/June 2002:
The medical director of the EP lab at Riverside Methodist Hospital in Columbus, Ohio attends a monthly meeting with their outcomes manager to review cases in which there were complications. Dr. John Hummel, one of the electrophysiologists, is the co-chair of the hospital’s Continuous Process Improvement Team for Heart Services. There is also an EP work team composed of an EP physician, EP lab management, EP outcomes manager, representatives from the physicians’ office and from the nursing units in the hospital who frequently care for pre- and post-EP patients.

Saint Vincent Heart Center, March/April 2002:
Saint Vincent Heart Center in Erie, Pennsylvania, has a cardiology database to track all outcomes. Areas such as length of stay, turnover time, physician response time and complications are trended and a quarterly report is generated. This report card is posted for everyone to identify areas of improvement.

Walter Reed Army Medical Center, November 2001:
At Walter Reed Army Medical Center in Washington, D.C., all physicians who perform procedures at the WRAMC cath lab participate in quarterly multi-disciplinary quality improvement meetings. Daily quality control checks are performed in the cath lab on the Avoximeter, HRACT machine, IABP, and crash carts.

Morristown Memorial Hospital, September 2001:
At Morristown Memorial Hospital Morristown, New Jersey, quality assurance is measured on several levels. First, there is a monthly cardiology conference at which both cardiac catheterization laboratory as well as electrophysiology laboratory complications are presented. Fortunately, though, complications have been extremely uncommon. Another conference held with the greater cardiology staff is devoted to the presentation of interesting lectures or cases pertinent to cardiac rhythm management. One of the electrophysiologists serves on the department's formal Performance Improvement Committee. Any problems that may occur as system errors are carefully explored, leading to the development of mechanisms to prevent recurrences. In addition, formal reporting to the state is required, both with respect to procedure numbers as well as complication rates. The electrophysiology laboratory has been inspected by various parties including JCAHO, and has exceeded expectations both for efficiency and cleanliness.