Competency is “an expected level of performance that integrates knowledge, skills, abilities, and judgment” (American Nurses Association, 2015, p. 86). Competency must be assessed and confirmed at the outset (during recruitment and onboarding) before placing the employee in the role of service delivery. Experts agree that competency should be re-assessed periodically by a multiple of methods (CE, peer review, skills workshops, etc) in order to keep pace with medical discovery, changes in technology and advancing techniques.
In the following pages we will address the issue of Competency in Electrophysiology from several angles.
The Problem...
What we need to know...
Stakeholders...
Hallmarks of Legacy Electrophysiology Programs...
Solutions...
Resources and things you can do...
THE PROBLEM:
More than once, during an Electrophysiology procedure, someone has asked me "what's going on"? Were they distracted, disinterested for lack of procedural familiarity? Were they so focused on their own "silo" that they were unaware of what was happening during the procedure?
Who is responsible for maintaining the standards of care during an Electrophysiology procedure? Should the physician be the only one with responsibility for recognizing errors in study protocol or data collection? More importantly, shouldn't the staff in the procedure room and control room be trained to mitigate risks and respond to emergent complications associated with every procedure?
Here are some examples:
What are the risks of mistakenly pacing the ventricle at high rates when the intention was to induce an atrial arrhythmia?
What are the potential complications seen during transseptal procedures and what are the clinical signs of tamponade?
Where is your pericardiocentesis tray and is the sterilization date expired?
What pacing rate is required to terminate tachycardia and whose responsibility is it to recognize and measure the tachycardia rate?
On the monitor screen, what is the order of intracardiac electrograms that demonstrate conduction from the sinus node through the ventricles?
How do electrical impulses travel from the right atria to the left atria?
What can happen during a routine AVNRT procedure if the ablation catheter slips from 4 o'clock to 1 o'clock on the tricuspid valve while energy is being delivered?
Whose job is it to ensure that catheters are in proper position and recorded electrograms are accurate?
What tools on the recording system are used to confirm signal identification, size and fidelity?
What are the mechanisms of tachycardia?
How can you tell where you're pacing from?
What are the endpoints of a successful procedure?
What are your complications rates and outcomes?
Compare the next two examples of employee perspectives.
Employee X:
Employee X sees only their little piece of the action. Their primary focus is on their specific role and the tasks associated with it. "Just need to get through this case, clear the board and get outa here".
"I know there's a lot going on in the Lab, but the doctor calls the shots. All they need me for, is to get the patient set up. I'm not trained to pace or burn. Sure, I'd like to understand what's going on but knowledge is power around here and there's no opportunity to learn.
"...no opportunity to learn"
How can I possibly learn EP when every doctor does it a different way. They don't like to take time to teach. Besides, there's no path to promotion. As soon as I find something better, I'm outa here".
Employee Y:
Employee Y sees their work environment as a "system". They see every activity and recognize how their role and each process or component comes together to fulfill the intended outcome. "Did you see that rhythm change?, the tachycardia just terminated!"
"I go to work every day excited to check the schedule to see cases and assignments. I am eager for any opportunity to record electrograms and operate the stimulator. It's an important set of tasks that make good use of my training. I can anticipate procedural protocols, recognize electrograms, conduction changes and test for arrhythmia induction and ablation effectiveness. I know that monitoring rhythm changes and recording accurate clinical data is vital to diagnosis and intervention. I'm like a second pair of eyes and hands for the doctor in the room"
"...good use of my training..."
I learn something new every day and feel like an important member of the patients' care team. My employee evaluations are good, and they tell me I will soon meet the next threshold that will lead to more responsibility and opportunity."
There is little doubt about our responsibility to respect patient rights and comply with the legal and moral imperatives that guide our accountability for quality patient management. The universal protocol "time out" in a procedure lab is recognized as a critical step in preventing wrong site, wrong procedure and wrong person surgery as described in the Joint Commission Standards. This is a team exercise that is foundational to fulfilling competency. But there's more that can be done to positively and safely influence the patient outcomes.
As in the Time Out example, it makes sense to expect all health professionals to be educated to deliver patient-centered care as members of an interdisciplinary team, emphasizing evidence-based practice, quality improvement approaches, and informatics (1). This is primary patient-centric behavior based on what we know from our training and care standards.
WHAT WE NEED TO KNOW...REALLY MATTERS:
A classic study by Elstein et al (2) demonstrated that experts have more knowledge than novices. It is this increased knowledge that enables them to achieve a higher rate of diagnostic accuracy, rather than just general problem solving skills. The common consensus among employers is that enabling and empowering employees in the workplace contributes to job satisfaction, career fulfillment and mission achievement. In this case, knowledge is power.
"Knowing is not enough; we must apply.
Willing is not enough; we must do" - Goethe
It is not only the amount of knowledge, but also the manner in which this knowledge is arranged in clinicians' memories that facilitates accurate diagnostic reasoning (3). This is important in areas like the Electrophysiology Lab where clinical data is collected, measured and analyzed in order to determine the course of therapy and continuation of care.
It is becoming increasingly clear that improved outcomes and compliance to treatment can be achieved with attention to patients, their families and communities (4-7). The Institute of Medicine’s 2003 report, Health Professions Education: Bridge to Quality, recommended that “all licensed health care professionals periodically demonstrate the ability to safely deliver patient care” (p. 9). Practically speaking in Electrophysiology, both licensed and non-licensed professionals must also be expected to demonstrate their competencies.
This ongoing assessment should be based on the core competencies of the profession and include direct measurement. Measurement methods include “technical competence, patient assessment, evaluation of patient outcomes, and other evidence-based assessment methods” (Institute of Medicine, 2003, p.9). Peer review programs are common in these institutions where multidisciplinary participation contributes to the formality and success of these processes
STAKEHOLDERS INCLUDE YOU, AND YOU, ARE RESPONSIBLE:
In this business, everyone's a Stakeholder. At the front-line of these health care processes are clinicians, health managers and other health professionals who are intimately familiar with the needs of patients and the realities of the system’s operations (8-12). Their ability to decode these demands and appropriately respond is fundamental to their competent performance.
Employee management, recruitment, retention, staff development and reliable service delivery are important elements determined by depth of training, experience and mature judgement. This supports the maintenance of service standards, and anticipates the disruptive conditions and behaviors that can weaken an otherwise successful program.
HR Managers, Service line Directors and Risk Managers are important stakeholders as they must consider the negative and positive influences of competency at the point of service delivery, and the far-ranging impact on mission achievement and financial success.
There are many stakeholders who benefit from internal programs and processes that bring distinction and recognition to their programs. These are the stakeholders of "Legacy" programs whose leaders recognize the value of gap analysis, benchmarking, problem solving and employee development. These stakeholders manage a delicate balance between revenue, investment and ROI (return on investment).
HALLMARKS OF LEGACY ELECTROPHYSIOLOGY PROGRAMS:
The challenges faced by healthcare organizations are myriad and require attention to the largest and smallest details necessary for success and sometimes survival. These institutions are committed to, and embrace compliance with, the medical, legal and moral imperatives that guide behaviors and subsequently successful patient outcomes.
Here are just a few of the key characteristics of the best Electrophysiology Programs:
At the center of every mission is the - Patient.
At the core of every mission are the - Employees.
Quality of Care is "top of mind" every day and in every procedure.
Processes, policies and competencies are established and reviewed routinely by multi-level and multi-disciplinary teams using innovative quality management techniques like case review, gap analysis and peer-to-peer evaluations.
Procedures, techniques and the technology employed, are optimized for clinical efficiency, accuracy and safety.
Staff training and competency assessments are performed routinely to maintain standards of safety and patient outcomes.
Staffing models and case scheduling focus on efficient work flow, staff competencies and teamwork.
Staff management training and personnel development provide for personal growth, performance recognition, compensation equity and retention.
Problem solving and critical decision-making are skills that are sharpened by enlightened leadership who take pride in successes achieved by employees.
"Accreditation"
The most highly regarded programs promote their quality-of-service attitude in the form of Accreditation. As described in Accreditation, Quality and Making Hospital Care Better, JAMA. 2018;320(23):2410-2411. doi:10.1001/jama.2018.18810, ensuring quality is a critical component of high-performing health systems...patients who enter the health care system—whether a clinic, a hospital, or another venue—need to be confident that they will receive care that is safe, effective, and consistent with the latest clinical evidence.
SOLUTIONS:
Setting Expectations
Developing Abilities
Providing Resources
Inspiring with Confidence
Set expectations for performance and behavioral expectations with recognizable and achievable standards and then establish an environment for them to succeed. People will rise or fall to your level of expectation. Gary Winters, coach, facilitator and author of Managing Friends & Former Peers, writes, "How well your employees perform has as much to do with your expectations of them as it has to do with their own abilities. If you think they will do well, they probably will do better than if you think they won’t do well. If you want the best from your people, you have to expect the best. That doesn’t mean simply raising the bar and hoping for the best – it means truly believing in your people and their incredible capacity for outstanding performance".
Develop Abilities to fit the requirements of the job description. It may be the single most important way to fulfill the mission. If the job description is not clear then perform a job task analysis that clearly defines tasks, responsibilities, accountability, requisite education, performance skills, and experience. Do this with all stakeholders and review it frequently to keep up with our rapidly changing work environment.
Providing Resources is not just like giving your kid gas money. Employees need a range of resources that secure the opportunity for them to succeed. Employee resourcing (Oxford Reference), is that element of human resource management concerned with obtaining and retaining a workforce with the necessary skills, competencies, values, attitudes, and other attributes. As such, it is akin to other generic HR activities, such as employee development, reward management, and employee relations.
Inspiring with Confidence rests squarely on the shoulders of direct leadership and supervision. Role models who represent the desired characteristics for employees are more likely to manifest behaviors in others. To inspire is to produce or arouse the motivation to excel and to succeed, to encourage self-belief. To affirm skills through any means (pat on the back, thank you, reward/recognition) is to empower the employee to trust their own judgement and to act with Confidence.
RESOURCES AND THINGS YOU CAN DO:
“Standards and Job Descriptions”
Please forward this article to practitioners and administrators in your network.
Know the standards. Follow this link to the IAC Standards and Guidelines for Cardiac Electrophysiology (EP) Accreditation (2019)
Establish an open dialogue with staff, doctors and hospital administrators about education, credentialing, advancement and compensation.
Don't reinvent the wheel, look at models.
"Get trained, get certified, get to work"
Everybody works for somebody so get over yourself, you will never get hired just because you need a job. There is plenty of opportunity in Electrophysiology, but you have to work at it. You need to be educated, trained, practiced, tested, committed, and dedicated.
“Lives depend on the decisions you make and the actions you take, so don't be a sloppy learner.”
Electrophysiology Schools and Programs: cardiac electrophysiology schools - Bing
Follow these links to credentialing resources: https://ibhre.org ; Cardiovascular Credentialing International | Apply for Exams
If this isn't enough, contact me.
I will help you:
Harlie Ferguson, Founding Director, G&G Consulting, LLC
Email: foundingdirector@ggconsultingllc.com
Phone: 1+402.306.4835
References:
Ann C. Greiner, Elisa Knebel, Health Professions Education: A Bridge to Quality Editors, Committee on the Health Professions Education Summit; ISBN: 0-309-51678-1, 192 pages, 8 1/2 x 11, (2003)
Elstein AS, Shulman LS, Sprafka SA. Medical Problem Solving: An Analysis of Clinical Reasoning Cambridge, MA: Harvard University Press, 1978.
Eva KW, Hatala RM, Leblanc VR, Brooks LR. Teaching from the clinical reasoning literature: combined reasoning strategies help novice diagnosticians overcome misleading information. Med Educ. 2007
WHO Regional Office for Europe. (2012). Health 2020: A European policy framework and strategy for the 21st century. Copenhagen: WHO Regional Office for Europe.
WHO. (2015). WHO global strategy on people-centred and integrated health services. Interim report. Geneva: World Health Organization.
WHO Regional Office for Europe. (2015). Priorities for health system strengthening in the European Region 2015-2020: walking the talk on people centredness. Copenhagen: WHO Regional Office for Europe.
WHO Regional Office for Europe. (2013). Strengthening people-centred health systems in the WHO European Region: a roadmap. Copenhagen: WHO Regional Office for Europe.
WHO. (2006). The World Health Report 2006: working together for health. Geneva: World Health Organization.
Mikkelsen-Lopez, I., Wyss, K., & de Savingy, D. (2011). An approach to addressing governance from a health system framework perspective. BMC International Health and Human Rights,11(13).
WHO. (2005). Preparing a health care workforce for the 21st century: The challenge of chronic conditions. Geneva: World Health Organization. (http://www.who.int/chp/knowledge/publications/workforce_report/en/, accessed January 15, 2014).
WHO PAHO. (2013). Core competencies for public health: A regional framework for the Americas. Washington: World Health Organization.
Frenk, J. Chen, L., Bhutta, Z., Cohen, J., Crisp, N., Evans, T., Fineberg, H., Garcia, P., Ke, Y., Kelley, P., Kistnasamy, B., Meleis, A., Naylor, D., Pablos-Mendez, A., Reddy, S., Scrimsah, S., Sepulveda, J., Serwadda, D, Zurayk, H. (2010). Health professionals for a new century: transforming education to strengthen health systems in an interdependent world. The Lancet. Vol. 376: 1923-1958.
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