[Revision and optimization of processes: a fundamental timing for adequate use of the resources and technological innovation. An example of intervention in the cardiology field and considerations on "total quality" in medicine]

The Cardiology Unit of the Este General Hospital began its activity in 1988. We soon identified a mismatch between a good, up-to-date diagnostic instrumentation with growing customers' demand and an inadequate utilization of the instruments. Waiting lists were getting longer, customers were not satisfied, no-shows at the appointments increased and we had a progressive loss in image. We therefore decided to intervene on our processes, starting the project "TOTAL QUALITY IN CARDIOLOGY". We focused our attention on two main fields, namely (1) electrocardiography, (2) other diagnostic techniques, separately analyzed because of important differences. Point (1) is basically worked out by paramedical personnel, in high numbers and with stable demand, while point (2) is determinantly linked to medical activity, although with concomitant need for paramedical support. The figures are lower for point (2) but are steadily growing. In the two operating fields we further identified two separate adverse effects: 1). ELECTROCARDIOGRAPHIC EXAMINATIONS (ECG) ARE TOO TIME CONSUMING, 2) THE NUMBER OF DIAGNOSTIC PROCEDURES IS TOO LOW FOR THE INSTRUMENTS AVAILABLE. We used preliminary analysis with process flow diagrams and our interventional methods were policy deployment and daily routine work. ELECTROCARDIOGRAPHIC EXAMINATIONS ARE TOO TIME CONSUMING. From cause-effect diagram for cause classification and subsequent Pareto analysis we identified two groups of main causes: 1. the paramedical-patient team is not able to optimise usage of the instrument; in particular, total time for undressing of the patient, lead attachment, dressing of the patient, change in ECG conductivity cream and, if necessary, repetition of ECG for mistakes in procedure is much longer than operative time of the instrument; 2. the necessary copy of the ECG done by the instrument was too time consuming (2') as compared to total procedure time. Implementation plans have been as follows: activity was concentrated in one single room at constant temperature (20 degrees); we augmented the number of dressing rooms and nurses (from 1 to 2 unit); we substituted the ECG conductivity cream with a water-alcoholic solution and the copy with a photocopy.

RESULTS

decrease in mean time for ECG from 6'52" to 3'25" (for example: total ECGs 1992: 14,827, total spared time: 852 working hours); reductions in dead times; capability to cope rapidly with high demand; consequent possibility to utilise paramedical personnel for other activities; reduction in copy costs from 156 to 50 Lit each (total reduction 1,571,662 Lit). EXPECTATIONS. further revision of the procedures to keep pace with new electrocardiographic instruments and to achieve shorter operative times.

[A case of double-chamber right ventricle operated on in adulthood]

A 49-year-old patient suffering from recurrent effort lipothymia and palpitation was referred for cardiac catheterization. A diagnosis of marked hypertrophy of right ventricular outflow tract and double chamber right ventricle with intraventricular gradient of 50 mm Hg was made. Operation was delayed until age 49 when an anomalous intraventricular hypertrophic band was resected. The first 2D and Doppler echocardiogram after operation disclosed a previously unrecognised intraventricular septal defect. Three years after operation the patient is asymptomatic.

[Congenital malformations of the mitral valve: clinical and morphological aspects]

The clinical, anatomic and functional features of 23 pts with congenital mitral valve malformation, seen at the University of Padua over a period of 10 years, are described. All pts underwent hemodynamic investigation and echo-Doppler evaluation. Diagnosis was confirmed at surgery in 17 cases, and at necropsy in six. In 9 pts mitral anomalies determined prevalent stenosis; the remaining 16 pts had moderate to severe mitral regurgitation. Associated cardiac malformations were present in 19 cases (82.6%). The clinical presentation occurred earlier in pts with mitral stenosis (16.9 months vs 6.55 years). The morphologic and echocardiographic features of each malformation are described. The term "valve dysplasia", as proposed by Becker et al to define the non-Ebstein malformations of the tricuspid valve, is herein applied to the congenital anomalies of the mitral valve in order to obtain a uniform and homogeneous approach to this vast spectrum of malformations.