Quality and Safety: The Marshall Method

The hospital CEO and the CFO are meeting about critical concerns in their health system: quality and safety. The CEO says we need to train and educate our staff so they have the skills and knowledge to perform their services with quality and safety. The CFO counters that if we do that, well, not only is that going to cost a lot of money and time, but what if after we train them, they leave and go work for someone else? The CEO leans forward and with a little fear in her eyes, exclaims, “What if we don’t train them — and then they don’t leave?”

That is an old fable for which I can’t find the origin, but the conversation has been around for centuries. We read in history about how the Greek statesmen argued over costs while Greek warriors dedicated time to training and practiced their skills to the point that they were conquering the known world with Alexander the Great. Practice, rehearsal, training, and the cost thereof has been a constant factor for kings, pharaohs, maharajas, emperors, chiefs, and marshals. All World Series, Super Bowl, and Stanley Cup teams have invested a lot of time and money in training, and in developing skills and knowledge.

How much should be invested in training? Each hospital is different and each department is unique in its own staffing and technologies. Therefore, you need to analyze your own situation carefully before plotting your course for improving quality and safety. Training is an investment. Training does cost time and money. We all want a good return on our investment. No one wants to waste time and money on bad investments. If you spend money on programs, but don’t provide the time to institute them, or to reinforce and refresh them, usually your investment will wither and die. So quality and safety are not a one-time requirement of money and time.

Too often, we go to outside experts to make quality and safety happen, and then next year, we go to another outside expert, and so on. We make the investment, but lose on the return. We may use computer competency tests and online videos that have little impact, and sometimes weak verification of competency, because it is less expensive, it does document, and it takes less time. But are we really getting the quality and safety training and skills that we want and need?

Perhaps your program is doing well. If so, end of discussion. Go read another article and use your time in areas that need your attention. If you are interested in learning about a proven method of increasing quality and safety while building a team, then read on, and consider the possibilities of change.

I have worked in the cardiac cath lab since 1972, in labs all over Pennsylvania, and in West Virginia, South Carolina, Texas, and California. I have seen many different healthcare systems, and the changes in one healthcare system over three decades, and now work as a cardiology consultant. The biggest concern, across the board, is turnover of staff. Quality and safety come high on the list as well. The revolving door of staff definitely has a major negative effect on quality and safety with a further, major impact on productivity and stability.

The cause of this loss of staff? Many different things contribute:

• Below-market pay;
• Industry or travel opportunities;
• On-call duties;
• Long hours;
• Inequity;
• Lack of communication;
• Stress;
• Lack of support;
• Lack of respect and appreciation;
• Exposure to radiation, blood, and clutter.

What I have often seen is that leadership doesn’t recognize those factors and/or claims inability to change those factors. So, yes, I am putting the responsibility of team loss on the leadership. The leadership fails to make the necessary remediation, with the result being a drop in quality and safety.

Last year, I was consulting with the staff of a cath lab whose major complaint was a pay scale below market and state level. When I debriefed with upper management, the response to this observation was that if they upped the cath lab wages, then the whole hospital would want a higher wage. I told them that was a great idea! Ironically, this hospital continues to pay more for travelers than for their own staff. Granted, the situation was not clear cut, as the hospital had many problems. However, stability and engagement of staff is necessary for improved quality and safety. The bonus is that the reputation and customer base of the hospital also will improve.

When you lose a cath lab technologist of five years who is then replaced by a fresh graduate, there is definitely a learning curve, and this upheaval in team members would have me question quality and safety. There is no substitute for experience.

Recruitment, interviewing, on-boarding, and getting new staff up to speed with the loss of productivity of other staff and leadership in order to accommodate new hires costs anywhere between $3,000 to $5,000 in the first month. Bringing in travelers to fill the gaps can be even more expensive. Recruitment and retention are two of the goals of quality and safety.

Based on my own experience and mistakes, I can pass on some knowledge and wisdom. Therefore, I would like to present my method of improving quality and safety, under the name of the Marshall Method.

The Marshall Method

There is a new “marshal” in town. Now is the time to marshal your healthcare team. The Cambridge Dictionary reminds us that the verb “marshal” means to bring together or organize people or things in order to achieve a particular aim. Our aim is to develop and improve quality and safety. This is more than a plan. This is a method that becomes a daily part of providing health care. In fact, we make it a lifestyle.

First, take one day of the week, usually not a Monday or a Friday due to weekend overload. Let us, for this example, use Wednesday. Block 30-40 minutes for training from the usual start time. Try to coordinate with other meetings to avoid conflict or to take advantage of a slow morning due to other meetings or office hours.

First Wednesday of the month. We assign the first Wednesday to the cardiologists to provide a presentation on their favorite subjects or areas they think need to be addressed for quality and safety. Cardiologists are doctors. Doctor is the Latin word for “teacher.” Most cardiologists are excellent teachers! This interaction between doctors and staff, outside the cath lab procedure flow, develops better interaction in the cath lab, with a closer collegial association for the physicians and staff. Fellowship and friendship makes working together smoother in most cases.

Second Wednesday. Assign the second Wednesday of the month for instrumentation or technology training. Have a vendor, physician, staff, or biomedical representative come in to go over the operation of equipment. Focus on the lesser-used, high-risk equipment such as the intra-aortic balloon pump (IABP), Impella (Abiomed), Rotoblator (Boston Scientific), etc., but do include the more commonly used equipment as well in that 30-40 minutes. Do this to reinforce your policies and procedures. What you do and how you do it in the cath lab must be reflected in your policies and procedures. This is an excellent opportunity to review and revise your policies and procedures, which will also help with accreditation.

Third Wednesday. The third Wednesday of the month is for journal club and case review. Staff members present their own critique on the introduction, research, sample size, conclusions, and even the relevance of a journal article. They are required to present their takeaway and the importance of this article, followed by questions. This is tight for a 5-minute presentation, but it keeps your team up to date and aware of what is going on in other areas.

Usually there are two journal articles and two case studies presented. The case studies may be from the lab or from journals. We don’t all experience the case and even being in that case offers a different vantage point. (I have personally only seen four single coronary artery systems in my career.) Case reviews provide background, reason for procedure, findings, options, and treatment. Most importantly, outcome, for what was or wasn’t done. The presentation is followed by discussion and thoughts on the case presented. Invite your cardiologists to attend, but take care that they don’t overshadow or intimidate the education.

Fourth Wednesday. The staff meeting takes place on the fourth Wednesday of the month. This requires an agenda and minutes. If you don’t document it, it never happened. Agendas make sure information and issues are not missed while inside a 40-minute timeframe. I recommend that you note the accomplishments of the month and year in the meeting. Quality and safety data is presented and discussed. Quality and safety plans for the future are discussed, including expectations going forward. This discussion provides transparency, a forum to hear staff concerns and thoughts, and a platform for engagement and improvement. Avoid complaints and excuses. When necessary, refer such to a private or committee meeting at a later date. Being aware of what the future holds and being able to be a part of it encourages engagement. None of us knows as much as all of us together know. Tap into the knowledge base to improve quality and safety. Keep your cardiologists informed as well.

Fifth Wednesday. There are three or four months with a fifth Wednesday, time that can be used for a mock code, competency tests, electronic learning, committee meetings, and catching up on email. This keeps the rhythm going and provides stability. The staff knows that every Wednesday from 6:00 am to 6:40 am there is time set aside to educate and improve, also known as a wise investment.

There are inevitably some bumps in the road. We have ST-elevation myocardial infarction (STEMI) patients, a higher priority than training. Time is muscle. Other problems with presenters and even meeting rooms may call for adjustments to your plans. I suggest that in October, the template is made for the upcoming year, and speakers arranged so there is a plan to follow. Always have an option B available; don’t lose that precious time and opportunity. Alternatives should also be planned in October for the coming year.

Make a further investment by videorecording presentations, allowing those unable to attend to see what transpired. Certainly, it is not the same quality or as interactive as being there in person, but much better than not knowing or worse, getting misinformation. This also helps with meeting minutes. Some of the presentations will be classics that you will want to retain for future recruits to view.

The most important part of the method is to have a daily huddle.¹ Having daily huddle before starting the day is essential to improving quality and safety. Staff can’t wait until next month’s staff meeting to learn about problems, let alone address them. Huddles are short and to the point. Everyone stands. That keeps it short. No one likes standing more than 10 minutes. First we address what happened since the last huddle. What did we accomplish? What quality and safety concerns are present? What patient, physician, and staff concerns exist? What problems happened with equipment, supplies, or other departments? After addressing the past, look at the present. What is our schedule like? What is our battle plan to meet the demands? Who will be doing what and where? What are the plans for the rest of the week? (For more details, refer to the article referenced above). The huddle is where we inject the quality and safety concept daily. You must have that on your huddle agenda. Under “quality”: what physician wasn’t happy with a long turnaround time in the electrophysiology department? Under “safety”: what time-out went askew and how do we prevent it in the future? Keep the huddle short, but keep quality and safety as an integral piece.

The Marshall Method is not martial law. This is not an oppressive program that forces quality and safety down the throat of our team. The goal is to improve quality and safety as a buy-in for the team. This is an opportunity to engage cath lab staff to improve their knowledge and skills. Working in the cath lab is not a job; it is a lifestyle. We are one of the few teams that gets paged at 3:00 in the morning to save a life. If you save one life you are a hero, if you save many lives, you work in the cardiac cath lab. So we want our team engaged. We want them to be excited about the good work they do. Moreover, we want them to be enthusiastic team members as we seek to improve the quality of lives in our communities. Encourage them to join the American Heart Association, Society for Cardiovascular Angiography and Interventions (SCAI), the Alliance of Cardiovascular Professionals (ACVP), or other professional organizations. Have copies of Cath Lab Digest, EP Lab Digest, and the Journal of invasive Cardiology, and any other publications you find valuable in the break room and available for staff. Provide opportunities for them to subscribe at home.

Work on a four-step ladder program to recognize and financially reward the merits of your staff for their skill, knowledge, and experience. Support your staff with reimbursement for attained certification and a stepwise raise system. I don’t want to have nurses and technologists; I want to have certified cath lab nurses and cath lab technologists.

Cardiovascular Credentialing International (CCI) provides credentialing tests for nurses and technologists as a Registered Cardiovascular Invasive Specialists (RCIS) and/or Registered Cardiac Electrophysiology Specialist (RCES). The American Registry of Radiologic Technologists (ARRT) has a Cardiac Interventional Radiography certification program. Promote credentialing to your staff. Provide educational material, seminars, and practice exams to ensure credentialing. That investment alone will improve your quality and safety.

Make sure your team is large enough in number to sufficiently and safely handle the on-call schedule. You don’t allow people with sleep deprivation to handle large and heavy equipment. You don’t want them overstressed while trying to save lives. Provide scheduled staffing large enough to provide a day off after on-call. Remember, with PTO of over a month for each team member, that results in one less team member available with every twelve teammates. Stated another way, out of twelve members, there are, in fact, only eleven available. The tightrope you inevitably walk is that of having adequate staffing without the need to flex off team members on a regular basis.   

To add more to the quality, consider having nursing and technology students rotate through the cardiac cath lab. Many nurses are unaware of the cath lab as a career. The great thing about students is they ask questions. This keeps our staff members on their toes answering those questions. Our staff should also be putting on their best faces. Yes, there are a lot of type-A personalities in the cardiac cath lab. This means that we have to make the extra effort to be hospitable to our visitors, as well as the rest of the team. What excuse is acceptable for rude or crude behavior, especially in front of patients and visitors? Keeping the rotation going provides insight as to which promising stars of the future would be a good match for the cardiac cath lab. Invite back those bright stars and encourage their interest in cardiology. Perhaps they will be a future teammate. This in itself will improve your quality and safety. Yet handle such student rotations carefully, since there is the possibility that these interactions may cause distractions and thus lower your quality and safety.

Every medication, no matter how good, does have side effect or negative qualities. Likewise, recognize the pros and cons of all your programs. Re-evaluate and note what is and is not working. What worked once does not always work now. Be objective with regards to quality and safety. Don’t fool yourself into complacency. Nothing lasts forever. Change is always a constant. Look in the mirror. It is a different face from years ago. Look at your technology, also much different from years ago. Keep up to date with your quality and safety training.

Similarly, your team will change! When you are playing a game of draw poker and you look at your hand, you know what cards you were dealt. Sometimes you try to improve your hand by replacing one, two, or three cards with new ones from the dealer. It’s a gamble, because you don’t know what you will get. Sometimes better, sometimes worse: it’s a big chance you are taking, but therein lies the excitement of the game. You know the team you have. Rather than gambling on getting newer and better team members, the wiser plan is to train and educate the team you currently have, making them the all-star team. Provide them with the tools and training, removing doubt that they are the best. You want to train your team so they could work anywhere, but you want to treat them so well that they wouldn’t go anywhere, no matter the competing money or promises.

Most staff leave a team because of the way management did or didn’t treat them. It is management that pushes them over the edge, not the competitor pulling them. Treat your team so well that they are loyal friends, happy to work with you. Become that “Servant Leader”², giving your team the training and tools to do the best work. Make the work environment hospitable to your staff. Happy staff stay. Stressed, scared, or sad staff depart your cardiac cath lab in search of a better life. Recruitment is always more expensive than retention in time and money.

Spiritual health is important. Depending on your situation, I would suggest that you also allow for spiritual growth with your team. Allow a 2-minute meditation, poem, prayer or inspirational reading to aid in the recovery from the ‘fight or flight’ mode. That moment of deep reflection and a quiet calm can be beneficial for a team while dealing with stress. Devotionals not only inspire, but can help us keep emotional balance, improve harmony, and be more positive about the day and life in general.

Take annual or more frequent photos of your team and show that you are proud of their good work. Provide birthday cakes, pizza parties, and other celebrations to thank them for their quality and safety. Recognize and reward work well done. Annual evaluations should describe what staff have accomplished, but should emphasize future goals and accomplishments. If you have the best team, their evaluations should document it. Make the cardiac cath lab lifestyle a good life, and offer respect and a purpose: that of providing quality healthcare, safely.

Conclusion

The method described herein will improve quality and safety, but only if you put in the time and effort. That means planning, organizing, and supporting the program. Coaches may be good at planning and organizing, but if they don’t show enthusiasm — that extra support — their teams can falter. Excitement is external, enthusiasm comes from within. Leaders have enthusiasm. Bureaucrats only do their duties. The question you need to stop and ask yourself is, do you care? Does it matter if you are not the best? Does it make a difference if you know all the cardiologists and only half the staff, and no one in housekeeping? Numbers alone don’t tell you about quality and safety. Your cardiologists, your staff, and your patients do!

The Marshall Method combines many points to keep us focused on quality and safety. As with any other prescription (Rx — Latin for “recipe”), you may alter the ingredients to make this fit your situation. Do not let quality and safety drift off your radar until the Joint Commission is due to visit. Let’s make quality and safety training and education a lifestyle that benefits all. 

Marshall W. Ritchey, MS, MBA, RCIS, CPFT, CET is an independent contracted cardiology consultant. He has over thirty years of chief technologist, manager, director, and executive director experience in over seven healthcare systems. Marshall can be contacted at marshallritchey@hotmail.com.

1. Ritchey MW. They call it a “huddle” or leitungsbesprechung! Cath Lab Digest. 2015 Sept; 23(9): 52-54. Available online at https://www.cathlabdigest.com/article/They-Call-It-%E2%80%9CHuddle%E2%80%9D-or-Leitungsbesprechung. Accessed April 12, 2019.
2. Dittrich LA. “Servant leadership” in healthcare: a natural fit. Cath Lab Digest. 2019 Apr; 27(4): 32-33. Available online at https://www.cathlabdigest.com/content/servant-leadership-healthcare-natural-fit. Accessed April 12, 2019.