Cath Lab Management

Focus on Results: A Culture of High-Performance Ownership

Doug Langager, RCIS

Doug Langager, RCIS

In a previous article, I wrote about my philosophy on the orientation of new employees.1 It is a basic guide for the management of onboarding new employees, and promotes an outcome of knowledge, quality, and safety as new staff learn to perform the tasks they were hired to do and fit in. Today, we will discuss what comes after the orientation, because our job is not complete.

Once the orientation process is finished, we assume new employees will “pick things up”. They will! But who knows what they’ll pick up and from whom? Now that they have learned appropriate tasks, what is the objective? Free from a preceptor, where does your new employee go from here? Do you just want them to show up for work, wait for a work assignment, and then go do cases? Goals are needed to map employee success after orientation. Without a destination, you have no way of measuring success.

What we don’t take into account after orientation is that our staff will seek positions that strike a balance between fitting in and standing out. At work, we subconsciously want to fit in; most of us evaluate ourselves by our ability to throw ourselves in with the huddled masses.2 Culture is the behavior that results when a group arrives at a set of unspoken and unwritten rules for working together.3 If leadership relies on others to set these “unspoken and unwritten rules”, it becomes a formula for failure. Management must set measurable goals for the new employee in order to help them become a high performer. Such goals might include the following: performing a right heart cath with speed and efficiency, mastery of the hemodynamic monitor icon prompts, achieving the intellectual deftness to measure and edit pressures and validate calculations, setting up a sterile table and draping a patient at ST-elevation myocardial infarction (STEMI) speed, and the ability to operate and troubleshoot x-ray equipment.

Every organization has a culture, though in many cases it is a culture that developed out of a negotiation of social values rather than by conscious design.3 Culture is the only sustainable source of competitive advantage, and thus cultural “blueprinting” is crucial.2 Our culture should be about high performance: using superior knowledge and techniques to perform tasks and handle emergencies. As educators, supervisors, managers, and directors, our goal needs to be communicating a culture where value is placed on effort.4 We do a great disservice (and become ill-prepared for success) if we train staff members to value abilities OVER effort. Our effort sets us apart; our ability is the byproduct. Competence in most areas (ability) is directly related to “time on task” (effort).3

Years ago, when I worked as a supervisor at University Hospital in Augusta, Georgia, the cath lab moved to a skilled-based pay system. The financial reward for employees was linked to their contribution. With the direction of my manager, Theresa Waters, and human resources, we created an exciting work environment. Unwittingly, we changed the culture! In the past, individuals had been asked simply to use their scrub, circulating, or monitoring skills during cases. Now we wanted, needed, and expected more from staff, and leadership created an improved compensation system for employees involved in quality, cost reduction, and mentoring. A great working environment ensued and high-level performance became the norm.

This change also affected our patient care techs, who learned to perform electrocardiograms (ECGs), draw lab work, and pull sheaths, and these techs became an invaluable asset. Patient care techs were also given a career pathway — an opportunity to train as cath lab technologists. Our nurses, technologists, and physicians provided support for this training because we were all vested. Workload was taken off the holding area nurses and it became extra time they spent with our patients. Our patient experience became second to none.

Another milestone that occurred during this transition was that management provided registry review classes for both nurses and technologists. The information gained was significant and became solid preparation for staff to obtain their CCRN, CVRN, RCIS, or ARRT-CIR if they chose. There was a new natural order. Newfound knowledge and accomplishment brought more opportunities. When asked to become super users and be involved in quality measures (to be, in other words, working at a high performance level), the staff were more than capable to take on these tasks.

Some of the most influential employees in an organization don’t have a management title. They are leaders because they see what needs to be done and are willing to get involved. Windows of opportunity were created, and staff became willing to make suggestions and influence others to work with them.3 Motivated employees (high performers) tend to be creative and productive, and go the extra mile, which distinguish their work from others.

On the other side of the coin, there were some individuals who chose not to participate. Unmotivated employees (low performers) are likely to spend the minimum effort to do the job and produce low-quality work. They lack initiative, they feel entitled, they produce disruptive behavior, and they sabotage the effort of others. One toxically negative person can drag down the morale and productivity of everyone. It is a core leadership responsibility to create a workplace environment where toxic emotional negativity is not tolerated.3 From a salary point of view, employees who chose not to join in this undertaking fell into a pay range reciprocating their contribution (a pay cut). A timeframe was set for goals to be achieved. Staff had deadlines and we were the better for it. We lost a couple of individuals as they searched for other opportunities, but as you can surmise, the workplace culture shifted to high performance, quality, and stability.

When teams see their mission is to become superior nurses or technologists, they own it. This also helps the organization address customer challenges. After all, our performance-oriented work ethic5 should be about patient care. You can hold people accountable for showing up on time and for fulfilling the terms of their job descriptions, but can you hold them accountable for being committed and engaged? Yes! Why not raise your expectations and lower your tolerance level for deviation from those expectations?  Then efficiently and effectively communicate that to your staff. They can’t read minds and they are very poor at reading facial expressions.

If you want to have HIGH performers, it requires effort on the part of leadership! We need to institute an orientation and annual competencies that do not only focus on the prerequisites of performing the job. Organizationally, the orientation of the new employee is about learning to perform tasks. The best people (high performers) in any field are those who devote time to deliberate practice explicitly intended to improve performance. This concept has to become part of our culture. Our mindset should be about best practice and high performance. Anything we put down on paper, any information taught, and how the work force is supervised all must originate from these values in order to change the culture.

After my retirement from the Army in 1988, I moved to the Pacific Northwest, where I hired on to be the cath lab supervisor at Providence Hospital in Portland, Oregon. They had a very interesting culture/process going. The critical care unit responded to all STEMIs. The patient’s cardiac care unit (CCU) nurse became the patient’s first experience and last experience during their hospital stay. CCU nurses received the patient in the emergency department, came with them to the cath lab, and were a key member to facilitate care in both departments. Upon completion of the cardiac cath, we assisted the patient to the CCU where post care was given. If open heart surgery was planned, believe it or not, our CCU nurse followed the patient through this pathway. Talk about high performance and patient satisfaction!

Leaders are often frustrated because they believe they spend 80 percent of their time on 5 percent of staff who are not meeting expectations.6 Leadership effort should be put on the high and middle performers. Cut the low performers loose.

The backbone to Providence Hospital leadership training was Zenger-Miller’s “The Basic Principles: How to be a Trustworthy Leader” program7:

The Zenger-Miller Basic Principles:

  1. Focus on the situation, issue, or behavior, not on the person.
  2. Maintain the self-confidence and self-esteem of others.
  3. Maintain constructive relationships.
  4. Take initiative to make things better.
  5. Lead by example.
  6. Think beyond the moment.

Let’s take a closer look at these six basic principles.

1. Focus on the situation, issue, or behavior, not on the person.

Employees trust objective, clear-headed leaders who look at the big picture, focus on facts, and keep an open mind. Basic principle 1 helps everyone solve problems more efficiently, make better decisions, and avoid emotional outbursts.

2. Maintain the self-confidence and self-esteem of others.

Contributing fully is easier in a climate of trust and acceptance. When people can express themselves without fear of attack, they are more willing to take risks and stretch their abilities. Self-confidence helps others respond to the constant change inherent in today’s workplace.

3. Maintain constructive relationships.

Getting things done depends on a network of trusting colleagues. Today’s workplace has never been more diverse in age, background, education, geography, and perspective. Leaders who leverage these differences help generate innovative thinking required to solve today’s problems.

4. Take initiative to make things better.

Playing the victim or dwelling on what can’t be done only saps energy and amplifies stress. To gain credibility and trust, leaders must demonstrate their readiness to risk failure for a larger purpose — which often begins by owning up to past mistakes.

5. Lead by example.

In the normal course of setbacks, stress, and pressure to deliver, leaders have a lot to gain in modeling the needed actions and attitudes. Leaders who set a high standard for others earn the trust and credibility critical in today’s demanding work environment.

6. Think beyond the moment.

Effective leaders consider the impact of their decisions and avoid decisions that benefit themselves at the expense of others. When leaders set compelling goals, make thoughtful plans, and behave ethically, they promote business success and inspire trust in everyone around them.

What I like about “The Basic Principles” is its directness. Leaders being soft on problems will only allow these problems to escalate into greater difficulties. If leaders are spending 80 percent of their time on 5 percent of staff who are not meeting expectations, by being swift and firm in action, imagine the hours saved as a result. There is no room for nonsense (excuses). We are promised “life, liberty and the pursuit of happiness.” But don’t forget about that word “pursuit”: to follow, to chase, to inquire, to hunt, to seek. To track in order to overtake and capture. That’s what I want to see in my co-workers.

People who seek reasons and logic as to why they can’t, shouldn’t, or didn’t do the right thing are stopped in their tracks. Personnel who think they are entitled take the desire out of people to work hard and accomplish goals because they think, “Why should I work hard for something if I can just coast by and get the same acceptance from leadership with no or little work on my part?” I restate that our efforts shouldn’t be about low performers. It must be made clear that low performance is not acceptable; here are what the expectations are and this is what you need to do to meet our standards. Failure to do so will lead to further action by human resources.

“If you hire for one skill and one skill alone, please let it be this: personal accountability.”8

Personal accountability can be defined as taking ownership of one’s thoughts, behaviors, actions, and performance. Someone who has developed a high level of personal accountability is resilient, resourceful, and honest. Importantly, you can count on them to follow through on the things they say they will do. They also tend to keep and maintain a positive attitude over time.

Accountability is Cultivated

Creating a great culture is about cohesion, alignment, and sustainable standards. Encouraging longer-standing employees to coach new ones gives momentum to a cycle of engagement and team accountability. While a responsible employee does the work, an accountable employee finds meaning in the work. Some associate the term “accountability” with someone assigning you a task — and holding you to it. But this kind of thinking is limiting to the pursuit of employee engagement. For an engaged employee, accountability is a matter of personal investment and ownership. A culture of accountability fosters self-reliance and confidence. Employees don’t need to be micromanaged when accountability permeates an organization at every level. Rather than managers bestowing tasks where employees are simply labor, an accountable employee sees responsibilities as challenges to meet and problems to solve.9

An important element in empowering employees is assisting them. First, they need to look into the mirror and perform a self-assessment. A reality check, I call it. Patty Azzarello’s blog on “Making Sense of Employee Performance Ranking” has wonderful elements for self-reflection10:

Level 1. Performance Problem (hopefully very few employees)

One or more is present.

  • Does not meet commitments, does not do what they say
  • Does not show up, does not participate
  • Work of poor quality, late, incorrect, frequently needs rework
  • Consistently below expectations
  • Negative impact on people and team performance

Level 2. Low Performer (few)

  • Meets expectations, but only just
  • Needs direction or explanation about the work required
  • Does not generally contribute extra effort or energy
  • Does not generally share knowledge
  • Neutral impact on people and team performance

Level 3. Solid Performer (most people will be level 3)

  • Always meet expectations, can be counted on
  • Sometimes exceeds expectations
  • Sometimes contributes additional value
  • Does an excellent job, as the job is defined
  • Will go above and beyond expectations when asked
  • Generally positive impact on people and team performance

Level 4: Excellent Performer (few)

  • Consistently exceeds expectations
  • Strategic thinker — contributes new ideas, improvements, suggestions
  • Takes on additional work to add more value without being asked
  • Can take on big problems or opportunities with minimal direction
  • Regularly shares knowledge
  • Consistently has positive people and team impact
  • Does some of the level 5 behaviors, but not all of them, and not all the time

Level 5: Exceptional Performer (the stars, very few)

Does almost all of the following consistently.

  • Very strategic thinker — redefines the job to meet evolving business needs
  • Consistently raises and exceeds expectations, does more than asked
  • Finds efficiencies, reduces costs, improves processes without being asked
  • Solves big problems, or finds new opportunities without needing direction
  • Is known as an expert by other employees
  • Shares knowledge as a process, mentors others regularly
  • Helps others be more productive by improving the work environment
  • Communicates effectively across and outside the organization
  • Attracts additional support and resources
  • Personally, invested in helping the whole team perform better

In my initial article on orientation for the new employee, I reflected on Berry & Kohn’s discussion of the personal attributes displayed by individuals performing duties.1,11 These attributes are used to evaluate an employee’s progress, since they provide proper descriptors that complement individual skill performance. Personal attributes are reflected in the manner in which an individual performs his or her duties. Let’s revisit these attributes to understand the outcome of performance of our employees.

Work Ethics: Carries out job responsibilities in a timely and efficient manner, communicating a positive attitude about these responsibilities to patient, customers, and coworkers.

Performance Improvement:

Constantly strives to meet or exceed the expectations of the persons we serve.

Collaboration & Cooperation:

Coordinating efforts toward a common goal while demonstrating responsibility to the system, the persons we serve, and to each other.

Honesty & Integrity: Exemplifying conscientiousness, reliability, and trustworthiness.

Ethical Conduct: Actions that maintain the highest principles and values for our patients, customers, and coworkers.

Accountability: Uses the authority one has been delegated to make decisions consistent with the system’s missions and values.

Innovation & Flexibility: Has an understanding of the principles of one’s work. With the resources available, is creative and efficient at solving problems without sacrificing quality.

Job Knowledge: Knowledge of instrumentation, equipment, procedures, and the care required for many diverse patients. Approaches each procedure as unique and individualized, while maintaining acceptable performance standards.

Efficiency & Good Organization: Develops organized work habits, anticipates the needs of patients and team members to save time and energy. Prepared for the unexpected.

Initiative: Aptitude displayed in the initiation of action.

Ability to Take Instruction: Pays attention, listens to details of instruction and reacts appropriately.

Manual & Intellectual Dexterity: Has quick hands, a sharp mind, and keen eyes. Manual dexterity is perfected with experience.

Intellectual Eagerness & Curiosity: The team has a legal responsibility to remain current in their knowledge.

Managers are looking for leaders within their team. Leadership is often a key element for advancement up a clinical ladder. Whether or not someone has the capacity to be a great leader, they still need to be molded and nurtured. That means EVERYONE, even if their job doesn’t have a leadership component right now, should consider developing leadership traits.12

In contrast to accountability, a responsibility is something that is given to someone: a job title, a list of duties, and even something as simple as showing up to work on time are all considered responsibilities. A mere job description is simply not going to engage and energize anyone. Successful leaders understand that real motivation comes from within. They then have to promote, encourage, coach, mentor, and grow that motivation within their team.

Ownership and high performance are a mindset. Employees choose whether to take ownership or not. We as leaders can grow or mark down the importance of this mindset or culture. The work, sweat, passion, tears, planning, time management, and structure are all in the hands of our employees, if they so choose. This doesn’t mean it is easy — in fact, it is incredibly difficult. This hard work is what separates those reaping rewards from those wishing on the sidelines. The owners go all in, own their fear, define it, and accept the possibility of failure.13 You are getting paid to be there, so do it right. Life has this universal law of giving you what you put in. It’s a matter of maturity, wisdom, and pride to pursue excellence.

In the movie “Moneyball”, Stephen Schott, owner of the Oakland A’s baseball team, asked two questions: “What’s going to prevent you from accomplishing the goal?” and “What are you most afraid of?”14 My answer to “what are you most afraid of?” would be leaving employees to fend for themselves within this workplace culture. If you don’t set a goal, then you have no destination. If you don’t have a destination, then you have no way of measuring success. If you have no way of measuring success, then your team has no hope. Establishing high performance standards provides a destination, measurable outcomes, and hope for growing your team to their full potential.

“When the storm breaks, each man acts in accordance with his own nature. Some are numb with terror, some flee, some hide, and some spread their wings like eagles and soar on the wind.”

— “Elizabeth: The Golden Age”

Acknowledgements. I would like to thank Lynnette Dalton, RN, BSN, MHA, MBA, Marshall W. Ritchey, MS, MBA, RCIS, and my loving wife Betty, my son Daniel, and my daughter Ashley Murray, RCIS, for their support, knowledge, and proofreading.

Doug Langager, RCIS, LPN, is currently a cardiovascular technologist at Berkeley Medical Center in Martinsburg, West Virginia. Since 1976, he has worked as an assistant technical director, program coordinator of a cardiovascular technologist course, supervisor, and staff educator.

Doug Langager can be contacted at

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