https://orcid.org/0000-0002-2224-7448
This editorial refers to ‘Process optimization for atrial fibrillation ablation’, by A. A. Boehmer et al., on pages 1763–1768.
In recent years, pulmonary vein isolation (PVI) has been established as the cornerstone of the treatment of atrial fibrillation (AF), together with guideline-directed anticoagulant treatment.1 Indications for PVI are growing: patients with heart failure even have higher benefit and some are even considering PVI in asymptomatic AF.2,3 Owing to improved safety, also elderly patients are nowadays increasingly referred. Age remains the number one risk factor to develop AF. Owing to an aging population, an epidemic rise in patients with AF is expected across all continents.
Quality of healthcare should be focused on the timely (short waiting times), equitable (‘smart waiting lists’ based on which patient benefits most and not exclusively ‘first-come-first-serve’), safe (low fluoroscopy use and few complications), effective (first-pass isolation >90%), and personalized (patient-related outcome measures) treatment of as many patients as possible.4 Since resources are limited, this should be translated into a (cost)effective, safe, efficient standardized PVI with minimized standard deviation of cathlab occupation to optimize cathlab planning and consequently reduce waiting lists and healthcare costs. Multiple studies have demonstrated that the diagnosis-to-ablation time clearly correlates with PVI success, suggesting that ablation should be performed as early as possible.5–8 In the treatment of persistent AF, a steep decline is seen if ablation is performed >6 months after onset.9
Boehmer and colleagues integrated a Lean and Six Sigma approach in their cryo- ablation PVI workflow to cope with this increased demand and limited resources in their high-volume electrophysiology (EP) centre. We have tried to incorporate a similar approach in our standardized CLOSE protocol using the high power short duration, whereas other authors focused on same-day discharge PVI or venous occlusion devices.10–13
Lean and Six Sigma are both efficiency improvement strategies, goal oriented and focused on productivity, waste elimination, simplification and standardization, using a Kaisen mindset of continuous improvement. Boehmer et al defined reduced cathlab occupation <120 min as their goal for future PVIs. As for all improvement, they started measuring their own data, to see which reasons for time delay were encountered. This is a crucial step: to obtain reliable, detailed process and structure data. As described in our experience, there is no magic in a lean approach. Small steps using a standardized ACT workflow, abandoning routine transoesopageal echocardiography, adding an extra nurse etc., let to their favourable final results. The authors should be congratulated for their lean approach since they are now able to routinely perform six cryo-PVI procedures a day in a high-volume EP centre. From a patients’ perspective, one could question if the first and last patient are equally satisfied with the hospital stay.
A clear limitation of this study by Boehmer et al is the entire lack of effectiveness data and the sole focus on the process. From a patient’s perspective safety and effectiveness (and not efficiency) are crucial. This highlights a clear shortcoming of lean management by putting its focus on cost reduction, speed and the PVI procedure itself, in addition on the removal of waste, simplification and the patient as a pure health care consumer. Hospital managements can misuse lean management as a way to cancel new investments and solely focuse on cost: therefore, process optimization should clearly never be an argument in favour of reduction of quality or efficacy. Therefore, we used routine vascular ultrasound, PVI validation, a temperature probe and lower AI targets on the posterior wall in our standardized lean PVI experience (for typesetters, please insert the reference to the original article by Boehmer et al and renumber the references as appropriate; the details will be provided by the Publisher).
The COVID pandemic has been disruptive for healthcare and taught us that we live in a volatile vncertain vomplex, and vmbiguous (VUCA) world. Although the benefit of a standardized lean PVI procedure is clear, it seemed somewhat inefficient in times of lockdowns.14 Health care systems adapted only little after every new wave, due to several bottlenecks and an inflexible not-agile healthcare mindset. Therefore, a lean approach should be incorporated within a broader, more flexible and more vision oriented agile mindset (Figure 1).
Lean management within an agile mindset.
In summary, future studies on efficiency should always incorporate outcome data In our opinion, it is time to disruptively change our healthcare attitude and encompass telemedicine, big data, cloud computing, wearables and automation in a responsive agile healthcare system.
References
Author notes
Conflict of interest: B.B. received research and travel grants from Biotronik, Abbott, Biosense Webster, and received honoraria and consulting fees from Biosense Webster. H.P. received honoraria and consulting fees from Abbott, Biosense Webster, Boston Scientific, and Medtronic.
