Developing Successful Structural Heart Programs

Role Definition

Without role clarity, workflows tend to be inefficient, with the focus shifting to the request or the immediate need demanding the staff member’s attention. Often, this results in frequent distractions, forgotten details, and high levels of staff frustration. In addition, undefined responsibilities may lead to duplication of work thus reducing productivity. It is critical to the success of any program to take time to identify essential tasks and assign them to the appropriate job role.

Primary planning to assess skill task alignment and establish position responsibilities and functions begin with the entire team mapping out workflows. It is critical to have a concrete understanding of what is presently being performed before making changes that will ultimately impact patient care. Accordingly, frontline staff are critical to this discussion as they have first-hand knowledge of the workday roadmap. Engaging the team to outline future states will provide authentication of new workflows, elicit concordance, improve the likelihood of adherence, and consequently increase efficiency.

The process should start with categorizing tasks into buckets: preprocedural, peri-procedural, and post-procedure care. Scribing the patient throughput on a whiteboard or a visual display where all team members can see and contribute will accelerate and enhance the exercise. Decision points should be identified and tied into defined workflows. Once completed, a thorough review of the current state should be discussed, eliminating redundant and unnecessary steps.

The next phase includes a comprehensive review of job categories that may consist of the following roles: administrative support, APP, registered nurses (RN), certified medical assistants (CMA), and physicians. Other positions to consider depending on the size and scope of the program include research coordinators and analysts responsible for data abstraction and quality.

Although staffing models and job titles vary from institution to institution there are basic functions that are required for programs to run efficiently and successfully. One foundational role usually established at the onset is the valve coordinator (VC). This role is typically filled by an APP—either a physician assistant (PA) or a nurse practitioner (NP)—as clinical insights are essential to establishing appropriate patient pathways. Navigation through the pre-screening process to post-procedural care is complex and multifaceted so patients and their families rely heavily on the VC for support.

Depending on program volume, additional APPs may be required to support the valve clinic as well as assist with the educational and clinical needs of patients and their families. Program leadership may struggle with the decision to utilize an APN versus RN in this role. Factors contributing to the decision should include whether the hire is functioning to the top of his or her license. In addition, economic value should be considered when staffing valve clinics and assigning tasks, as having a licensed provider answering phones and scheduling testing may not be the most cost-effective use of personnel. Adequate administrative support is advised to facilitate timely referral to treatment times, support the clinical team, and increase patient and referring provider satisfaction. An alternative staffing model presents efficiencies through having an APN oversee RN team members, assisting in answering clinical questions, entering orders, and facilitating patient throughput. This blended example provides the advanced capabilities of having APN coverage while offering a less costly choice for organizations.

CMAs play an integral role in valve clinic triaging patients, scheduling any additional testing, and helping patients to navigate through their evaluation. The CMA also obtains historical medical records and test results prior to the first appointment. Additionally, CMAs room the patient, take vital signs, and enter pertinent information into the patient’s record.

Another essential support role is that of the administrative coordinator who schedules clinical appointments and all associated testing and performs front-end duties including triaging phone calls. While some programs have APPs serve in this function, most programs find a clinical background is not necessary and that an administrative hire is less costly. Perhaps one of the most essential tasks for the administrative role is the interactions with the patients and families. The patient experience begins with the first phone call, which underscores the importance of hiring staff members who are professional and demonstrate both patience and compassion. Structural heart patients tend to be older and are likely to have a multigenerational family involved in their care requiring several points of contact that can be time-consuming and labor intensive, which should be factored into staffing ratios.

Time studies are an effective way to determine appropriate staffing ratios. These studies can validate daily responsibilities by tracking the number of minutes required to perform each task. Fig. 26.1 is an example of a time study for an APP. Although only a time study can definitively reveal how long it takes to complete each task, on average, structural heart programs have found that new team members should be added when the patient volume increases by a maximum of 100 procedures.

After all staff roles have been clearly defined by the planning team, attention should be directed to maintaining efficiency and ensuring accountability. A daily huddle, at a defined time each day, allows for the sharing of any pertinent patient information or concerns, allowing the team to remain focused and act upon issues in real time.

Structural heart remains a dynamic field with a continual pipeline of new innovations, medical devices, research, and best practices that need to be reviewed on a routine basis. It is therefore essential for the team to remain flexible when making decisions that are based on the current needs and latest reported evidence-based practice guidelines. Program leadership should meet regularly to examine and consider any necessary changes to the definition of roles and assigned workflows and make revisions accordingly.

Program Logistics

A thorough capacity assessment should be completed prior to adding a new procedure to a structural heart program. This can be accomplished internally or through an outside consultant but should be an initiative the program administrative director has the capability of completing.

Space in the valve clinic is a good starting point for a capacity assessment. The following questions should be explored: Is there adequate space for the additional volume generated by adding mitral valve patients? How many exam rooms are available? How often does the clinic take place? Do clinic hours need to expand? What volumes do you envision over the next 5 years? What realistic options are available to the program?

Consideration must be also given to departments outside of the valve clinic as the decision to add mitral valve therapy will add volume to their programs as well and have ramifications on patient access. Resources in radiology, the cardiac catheterization lab (Cath Lab), the operating room (OR), non-invasive cardiology, anesthesia, and recovery units are among some of the areas that will be impacted. Considering resources are finite, it is important to remember that for every one mitral valve patient there will be multiple echocardiograms required over the course of care and treatment. Non-invasive cardiology will need to plan for the equipment and personnel necessary to deliver the required testing. The radiology department will be asked to make time for additional computed tomography (CT) scans and will be faced with increased staffing needs and growth in addition to cardiac procedures such as coronary computed tomography angiography (CCTA). These demands should not be the rate-limiting factor inhibiting growth and providing treatment for this patient population. Partnering with other services early on is critical to understanding their needs and the barriers they face providing care for the mitral valve patient.

Some programs are limited by case time availability in either the Cath Lab or the Operating Room, as they have been given assigned days and hours to perform their structural heart procedures. Meeting with the administrative leadership with a proposed new procedure and projected volumes is critical to growing the program. Being armed with an understanding of the impact the additional patients will bring to these departments will help facilitate better decision making and ensure a more collaborative approach to expanding programmatic services.

Improving interdepartmental cooperation begins with partnering with each department’s decision maker. Developing sub-committees that meet monthly can be effective in promoting improved patient throughput and data-driven decision making. Routine meetings lead to the identification of potential barriers of care, improved communication, and ultimately decreased frustration. Additionally, as departments discuss shared challenges and develop solutions together, a more positive working relationship is fostered, allowing for increased efficiencies and patient throughput.

Planning not only for the present but prospectively looking 5 years out is an exercise that should be conducted at a minimum on an annual basis. Many programs have faced staffing shortages as burgeoning volumes have impacted patient throughput and delayed referral to treatment times, resulting in staff, physician, patient, and family frustrations. Program leadership should be aware of the tipping point by proactively adding new staff instead of waiting until team resentment builds, resulting in resignations, turnover, or burnout.