Leadership at Forefront of Cath Lab Operations

While knowledge and technical capabilities are important for any interventionalist, solid leadership skills are a must when managing a cath lab. As part of the Society for Cardiac Angiography and Interventions (SCAI) Cath Lab Boot Camp, several cath lab leaders shared their thoughts on how to best manage staff, maintain morale and handle conflict resolution.

Responsibilities of a director

Charles E. Chambers, MD, of Penn State Milton S. Hershey Medical Center, Hershey, Pa., summed up the responsibilities of a cath lab director, a role he has held for more than 20 years. It is important, he said, to understand the commitments of the position — managing personnel, ensuring adequate health care resources, maintaining high radiation safety standards and fostering communication and teamwork.

An arsenal of resources is necessary to do this correctly, Chambers said. “You must recognize what you need to be successful and then ask for it,” he said. Protected time, financial support, assurance and administrative assistance are necessities for any new cath lab director.

Running a cath lab is a team effort, he noted. Maintaining positive working relationships with physicians, laboratory staff, the quality assurance team, information technology support, physicists, hospital administration and full-time staff is in the best interest of the director.

Morale a key ingredient

Managing morale in the cath lab is vital, said Bernadette Speiser, MSN, CCRN, RCIS, of the Palo Alto Veteran Administration Health Care System, Palo Alto, Calif. She defined morale as “the confidence, enthusiasm and discipline of a person or group at a particular time.” Yet building morale is easier said than done, she said.

The reality of the nursing shortage in the United States is that “there’s way more demand than supply, and it’s widening as the years go by,” Speiser said. The turnover rate among registered nurses (RNs) is 8% to 44% per year, and costs associated with nurse turnover approached $10 billion in 2010. The estimated cost of replacing a single RN is up to $48,000.

“Management style has been found to be the key variable in predicting nurse retention,” she said. It is important for managers to build trust, foster empowerment and be flexible. Ideas for boosting morale include staff members swapping places for a day in order to appreciate the various roles of their colleagues, transparent communication, active listening and public recognition of “star performers.” Speiser said it is important for staff “to feel appreciated for the work they do and … know the job they’re doing is positively affecting the mission of the organization.”

The heart team approach

James C. Blankenship, MD, of Geisinger Medical Center, Danville, Pa., said cath lab leaders play a role in the success of a heart team, which in coronary cases is used when “the optimal revascularization strategy is not straightforward.” Team members include the interventional cardiologist, a cardiac surgeon and, often, a general cardiologist.

The valve heart team is more complicated, Blankenship said, and should be used in high-risk patients who might benefit from surgical valve repair or TAVR. Its main members are a cardiologist, surgeon and structural valve interventionalist but it can also include CV imaging specialists, anesthesiologists, advanced practitioners, nurse coordinators, geriatricians and intensive-care specialists. The team should discuss options with the patient and family and be involved in each step, from planning and performing to postprocedural care.

A collaborative approach can also be used for patients in cardiogenic shock, Blankenship said. The cardiac intensivist, interventional cardiologist and extracorporeal membrane oxygenation surgeon should have a bedside conversation with the patient and family to ensure optimal outcomes.

Blankenship recommended that valve teams should meet weekly in the clinic, coronary teams should meet daily or weekly in the hospital depending on urgency and LV support teams should meet on an ad hoc basis. Benefits of the heart team range from professional satisfaction and camaraderie to better patient outcomes. 

Ultimately, institutional support is required, Blankenship said. Not only does the hospital administration need to buy into a system-wide commitment, but heart team members need geographic proximity to foster random encounters. Also, an “excellent hospital-wide image viewing” platform and a process for reviewing and archiving outside images will better enable success, he said.

Conflict resolution

Speiser also discussed conflict resolution for cath lab managers. When dealing with low performers, “you can’t ignore the problem,” she said. The rest of the team may feel slighted if a cath lab manager does not adequately address the issue.

The first step is to understand whether the employee is the problem or if improper training is actually responsible. A cath lab manager should determine whether a proper environment has been created and if the right amount of support and clear expectations have been provided, Speiser said. Then, it is up to the manager to arrange a sit-down meeting to discuss goals, assess root causes of underperformance and establish consequences with a well-defined timeline for improvement. If the situation escalates, she noted, it is important to stick to institutional human resources guidelines and keep careful written records.

Keys to efficient teamwork

Herbert D. Aronow, MD, of the Michigan Heart and Vascular Institute, Ann Arbor, Mich., asked the presenters about the best strategies to train cath lab technicians to be “fully-functioning scrub techs.”

Speiser suggested letting technicians scrub in with fellows to learn the basics before advancing. “Go easy; don’t start with a STEMI,” she said. Utilizing medical device representatives to explain devices and technologies can also be beneficial during training.

Another attendee asked how to handle a particularly difficult staff member who also happens to be vital to cath lab’s performance. “The key is to encourage a team approach,” Chambers said. Speiser proposed giving such an employee a valuable role “so they understand that you need them.”

Disclosures:

• Chambers and Blankenship report no relevant conflicts of interest.
• Speiser reports serving as a speaker for Academy Medical Corporation, Ali Medical Company, Arrow, HMP Communications and St.
• Jude Medical, and consulting for Abiomed and Terumo Corporation.