The Interventional Cardiologist as Cath Lab Team Leader

Abstract: Interventional cardiologists act as leaders every time they step into a catheterization laboratory (cath lab), but leadership training is rarely included in cardiology training programs. Cath lab physicians should cultivate and practice effective leadership skills. Specifically, (1) before each procedure assess whether the cath lab team is prepared; (2) delegate authority to trainees and team members when appropriate; (3) use every procedure to improve the performance of team members through teaching, coaching, and mentorship; (4) debrief the team after adverse events; (5) develop the traits, styles, and skills associated with successful leadership; and (6) provide team training for the cath lab team.  

J INVASIVE CARDIOL 2015;27(6):E98-E105

Key words: leadership, catheterization laboratory, quality improvement, teamwork

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Invasive and interventional cardiologists act as leaders every time they step into a catheterization laboratory (cath lab) to perform a procedure. The physician selects and plans the appropriate procedure, leads the catheterization laboratory team to complete the procedure safely and effectively, and provides the best possible experience for the patient and the cath lab staff. The cardiologist is leader of the cath lab team due to his or her positional power¹ even if that role is unwelcome or unknown to the physician. Despite this, leadership training is rarely or never included in cardiology² training programs.

The quality of leadership in medical settings improves the success and safety of patient care.^3-7 This is particularly well documented for leadership of operating room (OR) teams^8-18 and resuscitation teams.^18-21 In contrast to the more robust literature on OR teams and leadership, the functioning of cath lab teams and their leadership by invasive cardiologists has not been described. This paper seeks to fill that void by briefly summarizing the extensive literature on leadership and teamwork,²² identifying findings relevant to cath lab leadership, and recommending behaviors and strategies that invasive cardiologists may use to successfully lead individual cath lab teams before, during, and after procedures. This subject is relevant for every invasive cardiologist who performs procedures in a cath lab. Cath lab directors can use the principles and skills described here in their own practice, as well as to instruct junior faculty, trainees, and other members of the cath lab team.

Cath Lab Teams and Operating Room Teams

Cath lab teams differ from OR teams in two important ways. Cath labs generally have fewer attending physicians and staff than do hospitals, so cath lab team members may work together more frequently than OR team members. Second, OR teams often include two physicians (a surgeon and an anesthesiologist) who may each serve in the role of team leader at different times during a case. In contrast, the cardiologist provides uncontested leadership of the cath lab team. 

Despite these differences, cath lab teams and OR teams are similar enough to warrant review of the literature on OR teams and their leadership. Both have patient-centered missions; need for communication, interaction, and collaboration to achieve safe and effective outcomes; change in team membership from one day to the next or even from one case to the next; and need to function well during both routine, predictable situations and chaotic, life-threatening ones. 

Catheterization Laboratory Teams

Cath lab teams. For the purposes of this paper, cath lab teams include the individuals present in the cath lab procedure room during a procedure. Other types of teams within a cath lab, including those that provide administration for the cath lab,²³ deal with quality issues,⁶ or initiate new interventional procedures are not discussed further here. However, the importance of cath lab teams, including all of those mentioned here, cannot be overemphasized. Evidence of this is the fact that patient outcomes correlate more closely with characteristics of the institution than with characteristics of individual physician operators.²⁴

Composition of cath lab teams. The background of cath lab team members varies from institution to institution. All cardiologists will have training in invasive procedures; many will be board certified in interventional cardiology. In cases where ad hoc coronary intervention is performed after diagnostic catheterization by a non-interventional cardiologist, leadership of the team may change during the procedure when an interventional cardiologist assumes responsibility. Interventional and/or general cardiology fellows will be present in teaching institutions. Technologists may be trained in cardiovascular technology (Registered Cardiovascular Invasive Specialists) or radiation technology (Registered Radiology Technologists). Nurses may have specialized training in critical care or cardiovascular technology. 

Functioning of cath lab teams. While the composition of teams will vary among and within hospitals, how they function can be described using structure, process, and output domains.²⁵

Structure. Cath labs typically demonstrate a traditional power hierarchy, with the physician – due to training, knowledge, and status – at the top, technologists and nurses below, and trainees occupying a variable position depending on their experience. For non-physician members of the cath team, different cath labs have different organizational structures. In one, all non-physician members of the team report to a cath lab operations manager or director. Alternatively, team members may have separate reporting hierarchies (eg, technicians reporting to cath lab managers, nurses reporting to senior nurses). The physician leader must work with this parallel reporting system to ensure optimal functioning of the team. Cath lab operators can work with either organization structure to successfully lead their cath lab team as long as non-physician leaders (ie, nursing director, chief cath lab tech, cath lab operations manager) ensure that their professional staff acknowledge and follow the leadership of the physician operator during a procedure. 

Process. Cath lab team members have specific skill sets, each necessary for successful completion of procedures. Experienced team members know their roles and perform efficiently. When members of the team are less skilled and competent (including physician trainees, or newly hired technicians or nurses), team functioning will be less efficient. Physician leaders must balance optimal patient safety and care with the need to train inexperienced team members.

Output. The product of the cath lab team is the completion of a safe and effective procedure. Secondary goals include creating a high-quality experience for the patient, and education and professional satisfaction of team members. The physician leader is responsible for prioritizing and guiding the team to accomplish these goals.

Training of cath lab teams. Each cath lab team member has received specialized professional training. However, that individual training should be supplemented with team training specific to the cath lab environment to reduce medical errors according to recommendations from the Institute of Medicine, Accreditation Commission for Graduate Medical Education, Association of American Medical Colleges, National Quality Forum, Agency for Health Research and Quality, and the Joint Commission.^26,27 Crew Resource Management has been advocated as a particularly effective method.²⁷ Table 1 lists components of a team training program for the cath lab. 

Leadership of Cath Lab Teams

While the Accreditation Council for Graduate Medical Education competencies include leadership, there is little or no formal leadership training in most physician graduate training programs.² The effects of this omission were apparent in a survey of surgical residents, who rated leadership skills as “important” while judging their own leadership skills to be deficient.¹⁰

Leadership should be added to the curriculum of teaching programs and taught by professional societies. Until then, physicians, if they are to become competent leaders, need to learn these skills “on the job.” For physicians who want to learn leadership, extensive literature has appeared in recent years and has been well summarized.²⁸ Leadership as a topic can be considered with respect to philosophies, styles, and leadership models.²⁹ 

Philosophies of physician leadership. Leadership philosophies describe the ideologies that inspire leaders and explain why leaders behave as they do. These philosophies, including servant-based, authentic-based, ethical-based, and value-based leadership, are summarized with references in Table 2, but are of little practical use for physician leaders in the cath lab.

Styles of physician leadership. Leadership styles describe the ways that leaders behave, including physician leaders in the cath lab (Table 3). Two major leadership styles have been recognized. 

Transactional leadership describes a two-way system of exchange between leaders and followers in which each satisfies the needs of the other.³⁰ Transactional leadership is the most common style manifested by physicians (eg, if the team performs well, the physician rewards the team with a rapid and efficient procedure and a “thanks” at the end). 

In contrast, transformational leadership seeks to empower and stimulate team members to improve.³¹ It is associated with greater team member satisfaction and participation in safety practices. Leaders who empower team members create greater psychological safety, foster relationships, and improve engagement in quality improvement programs. Transactional and transformational styles are not mutually exclusive, and leaders can transition between them as appropriate for a particular situation. However, the transformational style will lead to better long-term team dynamics and team satisfaction, and physician leaders should strive to use it.³⁰

Models of physician leadership. Leadership models fall into four broad categories: trait-based, behavioral, functional, and situational. 

Trait-based models of leadership postulate that: (1) leaders are born, not made; (2) specific fixed traits predict leadership success; and (3) lack of these traits predicts leadership failure.  In 1987, Kouzes and Posner identified ten ideal traits of leaders.³² Trait-based models remain attractive because of their simplicity and logic, but have generally been superseded by other models.^33,34

Behavioral models of leadership have gained popularity in recent years.^{17,18,24,33,35,36} Seven key leadership behaviors proposed by Parker are listed in Table 4.

Functional models focus not on leaders’ discrete behaviors or actions, but rather on the processes they must accomplish to make their teams successful (Table 5). These models identify both task accomplishment and team processes as important. For the invasive cardiologist, these models emphasize the importance of the leader taking responsibility for the professional satisfaction and welfare of the team, but otherwise are too theoretical to be of practical value.

Situational/contingency models suggest that different leadership styles are optimal for different situations and that leaders should adapt their leadership style based on the situation (Table 6).^31,33,35,37 In this context, “situation” includes both the type of task (characterized as simple or complex, structured or unstructured) and type of team (experienced or inexperienced, cohesive or non-cohesive). These models generally agree that directive or even authoritarian leadership is most appropriate with inexperienced teams and complex tasks, and that shared leadership with extensive group participation is most appropriate for experienced teams performing simple tasks. Situational leadership theories are particularly relevant to cath lab leaders because they provide specific guidance for cath lab procedures that vary from the most routine to the most complex, undertaken by cath lab teams that vary widely in experience. 

Invasive cardiologists most often lead experienced teams performing routine procedures. In these cases, the most effective leadership style is directive but not authoritarian. Specifically, physicians make key decisions throughout the procedure, but do not prescribe every action of every team member. For example, the physician must make a “directive” decision about whether to prepare the femoral or radial area for access, but the team does not need “authoritarian” orders regarding every detail and sequence of the site preparation process. The invasive cardiologist should delegate decisions where possible (eg, routine dose of sedation),⁴¹ empower the cath lab team to speak up (eg, if routine steps of a procedure are forgotten by the physician), add wisdom (eg, propose fresh ideas when the physician is faced with a difficult technical problem), and provide an extra pair of eyes (eg, noting the subtle catheter tip dissection when the physician is focusing on the distal stent) during every procedure. Over-controlling physicians who use an authoritarian style may inhibit valuable input and lose engagement from their teams.

When physician trainees are present and capable, more extensive delegation of leadership may be appropriate. This serves the purpose of allowing the physician trainee to gain experience while under direct supervision.  

Emergency or complex situations require a more authoritarian leadership style. In such situations (eg, acute myocardial infarction with cardiogenic shock), team members are less sure about their tasks and need more direction. The physician leader must make quick decisions and communicate them clearly. When experienced teams are dealing with emergency or complex situations, leaders should use both directive and participatory (ie, shared leadership) styles. For example, the leader must direct team members when necessary, but should also encourage team members to speak up regarding difficulties with their role in the procedure.

Inexperienced teams also require a more authoritarian style. Inexperienced teams usually consist of seasoned individuals lacking experience with a new task or procedure, such as transcutaneous aortic valve replacement. Cath lab physicians in such situations have a responsibility to prepare the team as much as possible by providing education and team training. Leadership in such situations requires directive or even authoritarian leadership when the cath lab physician is an expert at the task, but participative leadership is more effective when the physician is also inexperienced. 

A Practical Guide to Physician Leadership in the Catheterization Laboratory

Invasive cardiologists do not enter their profession anticipating a role as leader of a cath team. Most cardiologists don’t think about leadership until, or even after, they are thrust into that role at the end of their training. The invasive physician seeking to grow as a leader in the cath lab has limited resources upon which to draw. We offer here some practical advice.

Leadership regarding resources and environment. Check the team’s resources and the environment. 

Personal resources include: (1) personal experience and knowledge relevant to the particular situation; (2) leadership training (rarely); and (3) personality traits. Personality traits associated with successful leadership include openness to experience, conscientiousness, agreeableness, lack of neuroticism,³³ self-control when working under stressful conditions,³⁸ a strong sense of self that allows the leader to mentor other team members in leadership roles,³⁹ and a self-awareness of personal emotions and weaknesses that allows one to consciously compensate for them.⁴⁰ Work on cultivating these traits in oneself. In difficult or stressful situations, be aware of one’s ability to cope and if necessary defer a procedure or hand it off to a colleague

Team resources include experience and expertise of team members with respect to the task at hand (both individual and collective), leadership skills of team members, and prior experience of the team members working together as a team. The physician must also be aware of the team’s readiness. For example, a team that did emergency cases overnight may not be able to safely perform cases through the next day. Check with the team at the beginning of the day to assess problems that might affect team function (lack of sleep when on call, illness, understaffing, etc). 

Environmental factors include demands on the team placed by the patients and type of procedures undertaken. Very ill patients and unfamiliar tasks are more work intensive and stressful for the team and require the physician leader to adopt a more directive leadership style.⁴² In contrast, low-stress situations provide more opportunity for consultation and thus allow more empowering styles such as delegating decisions about sedative doses or involving technologists in procedural decisions.⁴³ Other environmental factors that stress the team include competing demands placed on the team by additional patients requiring procedures, or technical problems with facilities (such as cath lab breakdowns). Before each procedure, do a 360° scan of the environment to identify environmental problems.

Leadership behaviors for the catheterization laboratory. Cath lab operator behavior must promote: (1) effective and safe task completion; (2) development and support of team members; and (3) adaptation of the team to its specific situation.

Task-related behaviors include monitoring team functioning to be sure that all roles are performed correctly by team members. Physicians must provide direction as needed, prioritize tasks, and ensure that all team members are communicating clearly and adequately, ideally using closed-loop communications.⁴⁴ 

Team member-oriented leadership behaviors increase mutual trust, cooperation, and job satisfaction. These include leadership behaviors that: (1) support morale of team members, keeping emotions positive, using humor to relieve stress, modeling positive behavior, avoiding bad behavior such as shouting; (2) develop junior team members by delegating leadership when appropriate,³³ using debriefing to provide positive feedback, and helping the team with “sense-making” (ie, debriefing after difficult events such as an unexpected death in the catheterization laboratory);⁴⁵ and (3) empower team members to speak up, and “create psychological safety by reducing power-based barriers to speaking up, thereby minimizing power and status differences…”^46,47

 Situational leadership behavior identifies which behaviors are appropriate for different situations (eg, directive in critical situations; participatory in routine situations) and implements them.

Leadership success metrics in the cath lab. Metrics of success for cath lab leadership are not specified in guidelines for measuring quality in the cath lab,⁴⁸ but can be borrowed from the literature on OR teams. The first such metric is patient outcomes, measured in terms of successful procedures and patient safety. While physician skill plays a large role in successful outcomes, the quality of leadership and teamwork also correlates with patient outcomes.^2,3 

A second metric of successful leadership in the cath lab is professional satisfaction and growth of team members. The physician leader has a responsibility to the team to empower team members, improve morale, provide opportunities for growth and development, and protect team members’ mental health. 

A third metric of successful leadership is the cath lab’s overall successful operation as part of the institution in meeting the demands of other patients, physicians, technical staff, and hospital administration. These metrics include respecting and accommodating cath lab schedules (including schedules of other operators and teams) and fiduciary responsibilities (cost-effective practices).

Summary: Practical Steps for Cath Lab Operators

1. Assess one’s own leadership style and skills through discussions with supervisors and colleagues. 
2. Lead cath teams, recognizing that leadership style can result in success or disaster for the patient, the team, and self, measured in terms of patient outcome (effectiveness and safety), team welfare (professional satisfaction and emotional well-being), and personal reputation and liability.
3. Before every procedure, assess resources (team experience and status), environment (stressors faced by the team, team’s familiarity with the task, acuity of the patient), and self (fatigue, emotions, capacity for leadership). In rare cases this analysis might lead to postponement of a procedure, replacement of team members (including the physician operator), or modification of the procedure (eg, single-vessel instead of multi-vessel coronary intervention).
4. Before every procedure, and perhaps for every stage of a procedure, assess the need for directive leadership. Provide as much direction as needed but not more. Delegate authority to trainees and team members when appropriate.
5. Use every procedure to improve the performance of team members through teaching, coaching, and mentorship. The skills and experience gained during the current procedure may benefit the next patient.
6. Check with the cath lab team after every case to identify questions or problems. When an adverse event or even an unusual event occurs, take a few minutes at the end of the procedure to discuss what happened and determine whether further action is needed. After major adverse events, lead the team in a formal debriefing process. If not comfortable with this process, seek help.
7. Study this paper regarding the traits, styles, and skills associated with successful leadership. Improve leadership skills by reading relevant literature (including citations in this paper), training (eg, mock codes), practice, mentoring from colleagues, coaching, and soliciting feedback from team members. 
8. Discuss leadership techniques and mentor junior colleagues in leadership. Participate in team training with other members of the cath lab team. Hold the cath lab administration responsible for making team training a regular part of cath lab quality improvement activities.
9. Advocate for formal leadership training as part of the curriculum for cardiology and interventional cardiology fellowships. Develop and participate in formal training programs at one’s institution. Advocate for the Accreditation Council for Graduate Medical Education to formally include leadership as part of its “professionalism” competency.
10. Cath lab operators who are also cath lab directors should model and teach leadership skills. Create a cath lab culture that encourages colleagues to practice these skills and provides a structure for team training through policies that require team training (eg, mock codes), appropriate delegation of authority, and debriefing after cath lab mishaps. 

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From ¹Geisinger Medical Center, Danville, Pennsylvania; ²Palmetto Health System, Columbia, South Carolina; ³Mercy Regional Health Center, Manhattan, Kansas; ⁴the University of Virginia, Charlottesville, Virginia; ⁵Providence Health System, Portland, Oregon; ⁶Harvard University School of Public Health, Boston, Massachusetts.

Disclosure: The authors have completed and returned the ICMJE Form for Disclosure of Potential Conflicts of Interest. Dr Blankenship is the site PI for multi-center trials for Abbott Vascular, Abiomed, Astra-Zeneca, Boston Scientific, Regado Biosciences, Tryton Medical, and Volcano Corporation. The authors report no conflicts of interest regarding the content herein.

Manuscript submitted March 3, 2014, provisional acceptance given March 5, 2014, final version accepted March 11, 2014.

Address for correspondence: James C. Blankenship, MD, Geisinger Medical Center, Dept of Cardiology 27-75, 100 N Academy Dr, Danville, PA 17821. Email: jblankenship@geisinger.edu