Of all the current financial, compliance, and operational issues facing cardiovascular administrators today, cath lab staffing continues to top the list of common conundrums. As we witness at client sites across the country, fine-tuning adequate daily staffing and covering 24/7 emergency operations requires much creativity and flexibility. But, Corazon believes that optimal cath lab staffing strategies can do much to ensure best practice care, while putting a program on the path to success.
In general, management of a cardiac catheterization laboratory environment presents a particular challenge because of the magnitude of resources utilized, the timeliness of intervention required, the sophisticated technological and clinical procedures used, the depth of data necessary for decision-making, and the degree of collaboration among varied disciplines. When considering that staffing is an umbrella covering all these program elements, ensuring that the right team is in the right place (at the right time!) is crucial to both quality and efficiency.
The right team
Clinicians in the cardiac cath lab must possess highly specialized critical care and technical skill sets. Blended staff, often comprised of registered nurses and radiologic technologists, each bring unique and necessary strengths to the procedural area. Depending on the particular market and state practice guidelines, managers should seek to hire and retain experienced clinicians who can fluidly manage changing case types and fluctuations in severity of illness and condition…which can be a difficult combination to find in many areas of the country. Experienced cath lab staffs are difficult to find, and most programs seeking to fill vacant positions must rely on training internal candidates. Nurses with previous critical care and specifically, hemodynamic monitoring experience, are a good start. Technical/scrub competencies evolve over time and dedicated orientation hours must support a six-month learning curve.
Cath lab staff are not accustomed to providing care outside their individual departments. Teams are developed internally and rely on each other’s knowledge and historical strengths when facing emergency situations. When exploring cross-coverage scenarios, it becomes even more important to ensure consistent competencies of the group. The most successful system coverage patterns have developed in markets where the staff is in support of the process and sees value in a work-life balance that results in fewer call shifts per individual lab.
…In the right place
Cath lab staff can often function as a “closed unit,” able to handle all procedural surges, call-offs, and leaves of absence without staffing support from other areas in the hospital. As such, the department maintains flexibility on a daily basis to attempt to offset workload. Conversely, when volumes decline, it becomes extremely difficult to “right-size” staffing while continuing to cover emergency call.
Creative managers are able to find essential operational responsibilities for staff to perform in times of low volume as a means to ensure minimum hours. These roles include managing inventory, radiation safety, case review, education of staff, and the completion of American College of Cardiology National Cardiovascular Data Registry (ACC-NCDR) or other registry data sets. In fact, most facilities struggle with the sheer amount of data collection required for cardiac cath, electrophysiology, and peripheral vascular patients; thus, the importance of training staff to perform this essential task becomes a requirement to smooth operation of the lab(s).
Ensuring staff are knowledgeable of the registry definitions is an ongoing responsibility of the cath lab administrator. Selecting a core group as “super users” promotes accountability and trust that reported outcomes are representative of cases performed. Data collection and reporting is a continually evolving responsibility of the direct providers in the cath lab. Understanding the “why” and indications for procedures performed is fast becoming a mandatory competency for staff.
Corazon believes a creative staffing approach is the best way to succeed in today’s highly variable interventional environment. We regularly work with clients to find reasonable solutions to maximize efficiency, ensuring that staff are working at their highest capacity, whatever the role. For instance, we have had a great deal of recent experience consolidating call schedules to meet system needs for ST-elevation myocardial infarction (STEMI) coverage. Physicians typically guide geographic consolidation of services and we work to match the staff coverage in those instances, ensuring staff is placed appropriately in a needed role for the program. Electrophysiology and vascular procedures are amenable to a streamlined system approach as a way to maximize staff expertise, niche equipment, inventory, and patient throughput. Our experience increasingly sees hospitals aligning as “health systems” with more emphasis placed on comprehensive system offerings, rather than one-stop shopping at each campus.
…At the right time
Scheduling staff for the cardiac cath lab can cause headaches for administrators, especially for time-sensitive, off-hour emergencies. As daily case volumes fluctuate based on physician schedules, a focus on appropriateness, along with the flattening growth in procedures, have caused managers to struggle with creatively staffing rooms while maintaining a sufficient call schedule rotation.
Corazon advocates a three-person call team that includes at least one registered nurse. Daily staffing patterns may include a fourth staff member who serves in a “float capacity” to relieve for lunches/breaks and seek out necessary equipment needed during cases. The charge role continues to be an essential one in busy labs. This person must be able to adjust to the varying daily case loads and direct staff appropriately in order to keep room turnover and time between cases at a minimum.
Physicians play a key role in operationalizing change, and can make or break the success of implementation. Reducing door-to-balloon time variation and time-to-staff arrival is an added benefit of a move towards consolidation for STEMI call coverage. Some labs have increased call pay since there are fewer shifts required and mandate in-house coverage for those shifts. Each market and lab differs, and decisions to require in-house coverage are dependent on the commute time of the responding staff.
Large centers have found additional creative strategies to manage volume and acuity fluctuations that maximize part-time and per diem staff. Allocating ancillary resources for room cleaning, transport, and sheath removals frees time for procedural staff to efficiently complete cases and maximize the scope of work of each care provider. Top-performing best practice centers complete face-to-face hand-offs post procedure while the remaining staff prepare for the next case. This is just one example of ensuring efficient room turnover, decreasing physician wait time between cases, and maintaining maximum staff productivity.
Since cardiac cath lab scheduling continues to have day-to-day add-on variability, labs must approach even light days with the same speed and efficiency as the busiest in preparation for the unknown. Corazon does not recommend relying on the call teams to support after-hours cases or consistent volume surges, especially in light of increasing cross-coverage situations for STEMI. Reasonable attempts should be made to match staffing patterns to historic physician practice patterns and call teams should be treated as the last resort – not a guaranteed resource for surge volume management.
The role of the manager
Managers must be constantly one step ahead of the hiring curve. Any one unexpected vacancy can cripple day-to-day operations and the ability to cover STEMI call. Due to the highly specialized training requirements for cath lab nurses and radiologic technologists, there tends to be at least a six-month learning curve to acclimate inexperienced staff. Succession planning is crucial and administrative support to onboard new employees in advance of vacant positions is equally important. Managers must balance the financial performance of the cath lab while ensuring adequate experience within the core group.
Planning for the “what-if” scenarios have become a luxury; today, very little wiggle room exists in most cath lab operational budgets to manage this aspect of delivery. For that reason, the strength and foresight of the cath lab manager is invaluable. One of the most sought-after positions we currently recruit for is that of an experienced cath lab manager. In fact, 25-30% of our searches are for this position, which serves as the foundation for program performance at every organization in which a cath lab exists.
The behind-the-scenes planning and ability to respond nimbly to ever-changing conditions is a coveted skill set. Moreover, the ability to enforce accountability while maintaining a supportive team atmosphere is the crucial skill for leaders in the cardiac cath lab. The work of both the staff and manager is becoming more and more complex, and the right fit for this position is essential. While team members need to be accountable to their role, a strong manager is key to overseeing the entire program.
Organizations that are open to flexibility in the manager’s credentials and background are the most successful and most quickly placed, which is important to note, as often we are recruiting for a position that has been vacant for six months or more.
In some instances, promoting from within is the answer, though success with internal candidates is usually determined by the ability of the person to be viewed in a new light and not as simply “one of the staff.” That transition is most effective when supported by an administrative mentor, and typically not in labs where the manager position has been vacant for extended periods of time. Still, a staff member who excels in the procedural area may face challenges moving into a managerial role. Staff naturally challenges the transition from peer to authoritative figure, and support of a managerial mentor can make the difference in a new leader’s success.
Adequate staffing, opportunities for educational advancement, and participation in role development rank at the top of the priority list for staff in this area. Leaders need to be agile in order to best match opportunities for top performers.
Positions in the cardiac cath lab continue to be among the most sought after in an organization because of the cath lab’s reputation to be one of the most sought after open positions in an organization, because of its reputation for excellence along with the professional opportunities that come from being part of such a cohesive and high-performing team. As such, the logistic work required to keep this area functioning at the highest level will continue to be a top concern and priority for many years to come.
Kelly is an Account Manager at Corazon, Inc., offering consulting, recruitment, interim management, and IT solutions for hospitals and practices in the heart, vascular, neuro, and orthopedics specialties.
To learn more, call (412) 364-8200 or visit www.corazoninc.com. To reach the author, email: firstname.lastname@example.org