Okay, we're still trying to better understand our why, and we've dug a little deeper into the what and the how, but what about who? All these wonderful, meaningful things we've been learning have to actually get done, right? So how does that happen? Well, it starts with people, me and you and him and her and us and them and all of us. It's about teamwork and partnerships. Let's take a look at the team approach. Well, thank you, Jose, for hosting us again. This is my third time coming to the Grand View. And if you remember, it's about five years ago, I think, the first time we came. And each time I learned something new. And I was talking to others earlier this morning about how talking about things, we talk often, but seeing it in person is different. And it's been invaluable to me and to our entire staff when we've come down here. So thank you again for hosting us. So the purpose of this session is to talk about the team in the EP lab and how we can improve team building. So the first thing I want to talk about is when you're forming the EP team, what are the key elements when thinking about the EP team? What do you need to start your electrophysiology program? I will say a few words about how I feel about it and how we've gotten here, but I think it's very important to hear from the rest of the team. I think it's very important to hear from Carlos, from Clay, from Julie, who have been with us for many years now. So the most important aspect for us has been to build a team of like-minded individuals. So all of us understand the importance of what we're doing, the patient care at heart. But we all feel like work-life balance is important, and we want to do things efficiently, and we want to do things well and be able to go home. So we have gravitated towards that. A lot of our staff members feel the same way. I do, and many of us here have young children or teenagers at home. So we want to be able to have a predictable life. So I think that was really one of the core aspects of the team we started to build, which has now allowed us to not just recruit, but to retain staff. So it doesn't matter necessarily, or the most important thing, I think, from what you're saying is you want people all to have the same vision and goals. And then, obviously, your value in that team is to be the leader. And who are the other people that you think are critical when developing your EP team? We're all, everybody's part of this core team, and it's critical to have good people for every aspect of what we do. We can't have a team that relies on just a few of us. But our team, the way it's built, the structure has been, you know, the champion, the EP physician champion that started the process. Chris Cooper initially had a coordinator role at the lab, and now Clay Rayburn has that coordinator role. Carlos is the EP lead tech. And I think as important having a nurse anesthetist or the anesthesiologist in facilities that use only anesthesiologists as part of that core team that will make decisions on how to carry on your day-to-day operation. Without these people, I don't think you can build a culture or the efficiency and the processes that you need to be successful. Right. Yeah, one thing Renee and I both noticed when we came here five years ago was the value that Chris was playing at that time, which it's interesting that you're now in a different role, and now Clay has that role. But we were amazed by you the first time we came here, Chris, and the way you kept the lab running. And it was like, you were really running the show. Jose was the captain, but you were running the show behind the scenes. And that really struck us. First of all, we were in awe when we came here. And we were, our first reaction was, we're never going to be able to develop our lab like you have it. And I contrast that with how I feel today. And so much of what we see, we've accomplished. And like I said, I'm still picking up a lot of different elements every time I come to your lab. But one of the key components was Chris's role, now Clay's role. And that's what Renee, she was with me on the first trip. And when we came back, that was one of our takeaways. We need to create that role. So Renee, do you want to talk about what that has meant for our lab? I mean, it's made a huge difference in our lab. Just following you around for the day and seeing what you do. And so now that's pretty much what I do from coordinating before the day starts, the assignments, what people are going to do, who's going to do what in what room, making sure patients are ready, making sure that inpatients are staged, everybody gets rotated out for lunch and that the lab just keeps moving without stopping. And that was a huge thing we took away. My lab doesn't stop. You can keep moving. And so now ours does too. And I just think it's a super important role that you have somebody that's available to kind of troubleshoot and be free and, you know, put out the fires before they start. I like the way you said it. I think putting out the fires. We frequently tell people, it's not that we don't make mistakes here. I mean, our lab, things happen every day, all the time. We just, because we plan more, we're more able to, you know, quickly find a solution and an alternative plan. And this couldn't be accomplished without significant planning. Clay, can you describe a little bit from the day before the process all the way to starting the lab day at 7 a.m. getting patients starting a procedure? What is it that you do every day? One of the key things, I think, is starting on time and getting that first table built and getting the patient, getting their TE done if they need that, getting all the pre-ready before his start time, and then starting on time. If you don't start on time, then everything else is for the day just doesn't go well. But getting the ablations together, devices together, having a flip room is huge. Can, doctor has a good stopping point, we can get that patient 15 minutes ready, and then he can just go straight into the other room. And a lot of it, as we discussed, is the planning, right? So you do planning phase the day before. You arrive here before everyone. So talk a little bit about the planning as well. So we have a meeting every day at 1 o'clock to discuss the next day's schedule and to discuss the patients if we need to change them. If we need to change up somebody, move somebody up, or if there's going to be using a different kind of system for this patient. We try to look at all those things in our office every day. And we bring everybody in that's involved, admitting, the charge nurse for the pre-post, the cath lab coordinator, Clay comes in there, TEE charge nurse comes in, everyone that's vested with what we're doing, invested with what we're doing, is in that meeting and we talk about the next day. And we go over, it's a five minute meeting, it doesn't take long, it's just, you want to touch base, look at the schedule, we'll make sure all the cases are on there, make sure we know what's going to be on for the next day and how we're going to be prepared for it. And then Clay comes in, and I'll let him tell you what, you can tell him what you do when you come in in the mornings, if you know what I mean. Getting the order and the board laid out, getting the CRNAs, the patients that they're going to get before they get them, so they have time to prep, and like you said, if we're going to use a different system, have that in order, instead of taking 20 minutes out of the day to turn a room over, everything can just flow back to back. And the things he takes away from that meeting in the afternoons as well is if it's going to be a different mapping system or if it's a study case, that way he can get in touch with those vendors as well and let them know, hey, we're looking at doing this case at noon tomorrow, so I need you to be here at 7 o'clock. But that's part of his responsibility, and he takes very good, he does very well with that responsibility, and just getting everybody going, it kind of hinges upon what this guy right here does every morning because he kind of is what gets the motor started, I guess you could say. He gets here at 5.30 in the morning, he goes out to the pre-op and he starts seeing which of his patients are here. Okay, so this one didn't show up first, but we had planned for this one, so they're here at the same time as well, so we're going to do them first now. So then he can go back and he can relay this message to the staff via the board or just talking to them and let them know, hey, this is what's going on, you're about to get this patient in 15 minutes, or Julie, we changed your patient up, there's a different one coming. But this guy, he's the director, that's exactly what he is. He's the director and he directs the flow, he directs the outcome of the day. These guys just do what we suggest of them. Luckily, they've entrusted us enough that they will, Clay can go to Dr. Ashoria and say, hey, I think we should do the PVC before the SVT or whatever, and unless he's had some other reason, then he's going to go with it because he can explain to him how this is going to help our flow if we can stay in this room and do this and not have to go over here. And it's those things that he keeps up with on a daily basis. It's those type of things. And there's a million others, of course, you couldn't think of them all to say right now, but it's a lot of things such as that. Yeah, we have a team that we trust so much that if they suggest something, we have to listen and we do listen. And the flow of the day, I have very little input. It's based on what's going to be the best for the overall lab, not just for a single physician, a single operator. It has to be what's best for all of us. To create a flow that it's going to get everyone to finish their day as early as possible together. Yeah. And since we've had the position of EP lab manager or EP lab lead that Rene has taken on, it's made a huge difference in our lab. And like you said, that five minutes of planning and Rene does the same thing the night before and make sure that the next day is planned out the way it should be, all the supplies are pulled and that the day is all set and ready to go. That makes a huge difference to the flow of the lab. Rene, anything else you want to add? I don't think so. I mean, you hit most of the points. Like I said, just having an extra, it's almost like an extra body just to oversee things. It's really great. Yeah. And I think the other thing it does, frequently we neglect to think about it this way, but it's a lot of responsibility that you're putting on the EP nurse and tech in the room that they're not just going to turn over a room, prep a room, be next for next another patient and also have to go pick up another patient as some labs do. I mean, by having someone dedicated to do that, they can focus on their tasks and keep doing it in an efficient way. And this just cemented the whole process, you know, I feel like. So Carlos, what are your thoughts? You've been working with this model with us for six years now. What are your thoughts regarding this? Yes. Having Claire as the coordinator, it does, it helps the flow when they plan a day before. The staff is ready for any type of change, you know what I mean? We do understand that it could be a possible change. So my job is to prepare the other techs and nurses to let them know that, hey, it can possibly be a change, but we change and we prepare ourselves for that. It's no task bigger for us to be able to accomplish. We work well as a team. So it sounds like you guys are able to roll with the punches. When something comes up, everybody knows how to handle it. Yes. You have somebody to lean to with Clay, who's going to help you understand what's going to happen. But then everybody has a role and can fulfill the role. Yes. And we do have a role, but also we don't mind picking up anyone else's role. We dare to get the job done. And if we have to step in to help someone to get their job done, we will. We work as a team very well and we do whatever, take care of the patient first and get the job done. That was another thing Renee and I noticed when we were here the first time, was how everybody could do each other's jobs and you picked each other up. And so when a patient comes in the room, everybody was doing something. They're all engaged in that task and they all knew what each other, like the other person's job and how they could do it. And so there was not, it was not relying on one person. It was the whole team working together. We kind of, we kind of, we can feel off of each other. We can, we see one person doing something, we go to the next thing. We don't just stand there and just look. We do, if, if someone need to get the mop and someone need to wipe the cables, we do what we have to do to get the job done. Another thing we noticed was how you work together with anesthesia and how anesthesia is working in parallel with the rest of the staff. It's not serious. It's not, the patient comes in the room, they get intubated, then the patient gets prepped. All that's happening at the same time. So Julie, do you want to weigh in on that? We had a patient one time tell us we were like a pit crew. And that hit me. It's like, you're right. We are. But if you wait till they've got all their stuff done and then I start doing my stuff, you're going to have a 10, 20 minute delay. So if you just get them in and like, they'll bring the patient in, I'm slapping on the blood pressure cuff and the pulse locks. They set them up, get all their stuff on, come back down, I put my stuff on. And if I'm busy with something, like you said, teamwork, if they see that I'm having to do something else, they'll put monitors on, whatever I need on. And that's the only way this thing will go fast. And it helps Clay when he's, the communication is probably the biggest key and probably the most frustrating thing for me in other departments is because I say, oh, you didn't know you were getting this patient? Clay will text me and say, hey, this is what's coming to you next. By that time I can get all my drugs, I can get everything set up in a drawer hidden away so that when the patient goes out, all I have to do is come back in, pull everything out of the drawer and ready for the next patient. That I think that is a lot of the teamwork and the communication is what makes this an efficient team. Yeah, I completely agree. And another thing I took away when I was watching Jose do the first case is he's communicating with you. Sometimes he doesn't have to because you've worked with him so much, but you can almost read his mind. But then when he's getting close to the end of the case, he's letting you know, right? There's a 15 minute warning, like, OK, you can start getting protamine, start getting lightening the patient up, where when the procedure ends, you can extubate. Yeah, that's the only way is if he tells me. Because otherwise, I mean, I can see what he's doing, but how do I know that he doesn't have more to do? Right, like today's case was a little bit more challenging than usual. Yeah, I mean, he's usually super fast. You know, we were talking about this morning, like within two or three minutes, each case is the same. But today's went a little bit longer. So he has to communicate that to you. Yeah, very clearly what you can see is the team approach means that if one person fails, we all fail. So that's why if someone is slowing down, if something is happening, if we don't all jump in and work together, we all fail. And the communication, it's not just about the efficiency of the lab, it's the safety for the patient. You know, it does that more than anything else. That's the more important part. As an example, a CRNNA, as we are sedating a patient, if there's changes in blood pressure, we want to be communicated that neosynephrine is being given. We don't want to see that the patient's blood pressure is dropping without us being aware and make sure there isn't an effusion. So simple things like that, Julie will not ever give vasoactive drugs without talking to us, without communicating. at the same token, by the simple fact of communicating that I'm on isoproteinol. Five, seven minutes of isoproteinol, I don't have any arrhythmias happening. Start lightening up the sedation. We have accomplished with this protocol that the average in this lab is from being done to extubation is seven minutes. That builds into the entire efficiency of everything we do. We have been able to do from being done to patient out of the room within 15 to 20 minutes. This is because when the procedure is over, we have a short time to extubation. And before the patient is extubated, the team already pretty much got all the patches are removed and the patient is ready to be transported. And growing care happens in the lab very quickly and efficiently as well. The team approach permeates to everything so that we're able to be efficient. But I think it's a positive feedback loop that makes everybody satisfied with the end result. Yeah, I like what you said about how communication improves quality and preventing complications. One thing I was also, and I continue to be very impressed by your program, is that the focus is not on doing it so fast that you compromise the quality of what's being done. The focus is actually quality and you happen to do it really fast. Do you want to talk about that? Yes, I would say more. I think the focus is quality and by doing fewer mistakes, you end up becoming more efficient and faster, right? By us prepping the patient well at first, we're faster. By us being able to achieve pulmonary vein isolation at first pass more frequently, we are a lot faster. So the focus needs to be on quality and protocols and standardization, and that will lead to the extreme efficiency. Yeah, that's great. Chris, I have a question for you. So you've been in every role, I think, in the EP lab, am I right? Somewhat, but not everyone. I've never done the tech's role. But now you're in a manager role, and so I think tying that in, what can you tell us about the importance of what management and administration plays in the team? So focus of management, okay, so my thoughts on it is management, for me, we can't do anything we do without these guys right here. So my focus being in management is, of course, I want to keep up the efficiency and everything else, but I want to make sure that this team is happy and they're getting what they need out of things, because they're going to give me their 100% if they're happy in what they're doing. And if I'm doing my part and administration's doing their part, it's to see what they need. They don't ask for extravagant things. They don't ask for things like that. But they just want a predictable work day. They want a fair and honest day, basically. They want enough staff to help them get through the day and the equipment they need to get through that day. My role now, I guess, would be to try to maintain some kind of happiness in the lab and to make sure they have all the equipment they have. And I'm their go-between between administration. I'm the one that keeps the pulse of the lab and lets them know that, hey, things are getting tough right now. We need some help here. We need some help there. And we're kind of going through some things like that right now. So we're growing, I guess you could say, and we're having some growing pains. But we're working through it in administration. It's my job to keep them posted as to what's going on in the lab. I think in summary, Chris and myself, we are advocates for the team. It has to be that way. We're big advocates for the team we have. And I couldn't be prouder of the team we have. I think in as much as we do everything to prevent complications, when we do have complications, I think that's when I'm the proudest of the team we work with. It's to see that everybody is there for the patient. And everybody will work the hardest to prevent a complication and to address a complication when it happens. So that cohesiveness shows not only the day-to-day operation, but when bad things happen, everybody's there to work together and address it. You learn the most about each other is when something bad happens, there's no doubt. Absolutely. One other thing that we've noticed is you guys have very little turnover. I know it's the same people every time I come here in the last five years. And so I want to talk a little bit about that, and maybe each of you could chime in to why you stay in this lab and what it makes for a program where you have low turnover. For me, it's enjoyment of what I do. I really enjoy what we do right now. And for a little while there, I was getting burned out on things. But when we came here and we had this opportunity to build this lab and actually have some say-so in how this is done and what we do here, the engagement, the level engagement they allowed us to have here is what I enjoy. These guys, well, I'm not going to speak for you guys, but the reason I stay is because I enjoy it, and I enjoy the people I work with, and I think we're like-minded individuals who feel the same way about it. We want to take good care of our patients, but we also want to do it in a timely fashion, and we also want to go home and see our families. So that's part of the reason why I really enjoy doing it. I think one of the main reasons why a lot of people, we stay together, we stick together because we have a leader that look over us and make sure that everything is taken care of. If we have problems, we can go to Dr. Osorio or Chris about anything. They're very open to us about any questions that we have, any concerns, anything like that. They know that we have families outside of here. We have another life, and they totally understand that. So we come in here, and we do our job from 6.30 to the last patient is on the table. And we don't mind staying over if we have to, if it's an emergency, but they understand that we have lives outside of here. And by us as a team being strong, me, Clay, others that have been here, we stick together no matter what. I mean, if Clay had to jump in a room, he does it. So by us just being together, helping each other, and just sticking and hanging in there, that's why this team is sticking together. Yeah, it sounds like you all have each other's backs. We make sure we have each other's backs. We don't like to see no one fall because once again, like Osorio said, when one fall, all fall, and we don't want to pick everybody up. I came to this team, basically when he started, the EP I had done was definitely different. It was longer, not where I would have enjoyed staying, but I came down and working with him, it was like, you know, I saw a team that worked well together, that helped each other. Everybody was pitching in. You didn't have to sit, put your patient to sleep, and then sit and wait for your doctor for 20, 30 minutes for him to show up. To me, that's wasted anesthesia. That's drugs a patient doesn't need. And it just, I have thoroughly enjoyed learning from Dr. Osorio, I have enjoyed everything new about it, and I still am not getting bored. And I want to, as long as I'm working, I'll be staying in the cath lab with this group. Yeah, that's one thing about electrophysiology, you always learn something. Yeah. It's always changing. Clay, anything else you would add? Just important to keep that work-life balance, and I think that's what we have here. And Renee, I know it's also a common thing between our programs that we have very low turnover in the lab. And Renee, do you want to share what you've taken from that? Yeah, I mean, pretty much what Dave said, the work-life balance is a huge thing outside of work. Everyone in the lab has a family and children, and they want to get out on time. And then back to what Chris said, just engaging your staff. Our staff really enjoys being educated, and learning things, and being appreciated in their role, and the fact that they get to learn to do new things that you wouldn't do outside the lab. I think that's super important to them. But we just truly enjoy our jobs, and learning every day, and always learning something new. I think that's really kept our staff pretty happy, and the staff's happy, we're all happy. Absolutely. Absolutely. The staff is the core of what we do. Those are the reasons why we do. So we have never lost any staff to competing labs in our region. This has not happened. We've lost two staff members recently. One went to industry, one went to Florida, and then he has the beach now, so we couldn't compete with that. But we have never needed travel nurses, travel techs here. We've had our core team. That also allowed for, they kept growing. The team kept learning more about electrophysiology, understanding the process you watch today. When I'm doing a procedure, I mean, literally, I do one step, I turn, Carlos is ready. There's no guesswork about what's next. That's the level of teamwork that we have been fortunate to accomplish. Yeah. Yeah, it's great. And I saw that, Carlos, and I thought, that's another thing we noticed when we were here the first time, was everybody always knew what was going to happen. And part of that is the reproducibility, you do the same thing every time, over and over again. And your partners probably have very similar workflows. That's key, Josh, because we talked about this before. For you to build an efficient lab, if you have, let's say you have five electrophysiologists, and just one chooses to be efficient, it's not going to work. Everybody has to. So we have, for example, standardized the basic things that are going to be in the EP tables. That's standardized. You know, we all use the same diagnostic catheters. We all use the same basic, the same tools, the same transeptal tools. By standardizing all of that, how much easier it is for the staff to prep that case. So by standardizing that, our EP lab runs as an OR with block schedule, and the start times are required when you're going to start. We also don't allow to have elective cases, you know, starting after 4 p.m. So all of this process is being standardizing and having all physicians agree to it. That should be the beginning of building that teamwork, because it builds a significant frustration. If one day, you as a staff in that lab practice one way, and the other day with a different physician, your workflows are completely different. It's like you're reinventing the wheel every day. That doesn't happen for our group. Yeah, so it sounds like standardization of workflows. I know, Julie, you mentioned waiting on a physician. I hear that often when I talk to people about efficiency. Do you want to elaborate a little more? It's very frustrating. I mean, if you happen to wait, then everything behind that is backing up. There's no way to speed back up. You've lost that time. And in our lab, you don't have that. If there's any wait, then something has happened bad somewhere else. And you know, that's excusable. So I often hear, when people visit my lab and talk to us about efficiency, when I get the staff alone, they often tell me that their biggest frustration is they're waiting for the doctors. They may be hustling and getting the patient ready, but then they're waiting. So I think whatever can be done to avoid that is critical. And one person we're missing from this conversation is an APP, or a nurse practitioner or physician assistant. And that's also been a key. One thing I took away from visiting you the first time is we needed our own EP, nurse practitioner or physician assistant. Because that way I can focus on being in the lab and not being in two places at once, going to see the consult in between cases. I can just stay in the lab and make sure that we're accomplishing everything we need to to make the lab efficient. Absolutely. You can also establish rotations, for example, where different physicians are doing consult weeks and not everybody, so that you allow people to be in the lab. And just one last thought on this, there have been multiple Lean Six Sigma projects done in large cath labs in this country that have shown that waiting for a physician was the number one reason for delay in many cath labs. Interesting. So another important concept I think that we need to address is any great team, it has to have, it has to come from somewhere. And usually there's a coach or a manager or a team captain that has a vision or an idea of what they want for their team. And then everybody has to buy into that vision to make it happen. So can any of you comment on what you think of that idea? I think it's very good. When we came here, starting with the anesthesiologist, they don't normally get here till 6.30 in the morning because the rest of us are here. But if when they're in the cath lab now, we get here at 6 o'clock so that they can see the patients and there's no delay. And if you, it's, all this came from Dr. Osorio telling us, teaching us that this is how we do it to get the things moving quicker. And I will be here on time. You're not wasting your time getting here early. Yeah, I mean, we need good players. And I think as a team captain, he was a lead by example. We all have to buy in, but you can't, you're not going to get buy in by telling people what you do. You're going to buy in by leading by example and then creating the culture that we were able to do. Exactly what we did. I know when you first brought us here, I mean, Dr. Solorzano's vision for our lab was to be like your lab. And by bringing us here and seeing it like that helped us buy into it, we're like, oh, we really want to do that too. So I mean, he was definitely the leader for ours. And then we really liked that concept and then he brought more people back and they got to experience and see what it was about and they're like, yeah, that's a really great idea. We want to do that too. So. I mean, I think we're so very proud, all of us, and I'll speak for everyone. I don't have any doubts. The team is proud of completing a day with looking, arriving here early in the morning, having a board with so many procedures to do, patients to take care of, and finishing a long day of work successfully so, and having done it with a perfect execution from the entire team. We're proud every day when the day ends. At the end of the day, it's, you know, you feel good because you've been a part of this, something that was so good and so beneficial. The reality is that it can't be done without any one of you. Exactly. Yeah. Thanks, everybody. I'm very proud of the fact that almost all of my patients, when they come back for follow-up, they will comment about the staff. They will comment about the staff. This doesn't fail. They will talk about the jokes they heard, they'll talk about how they were meant to feel well. Then even though you are in that uncomfortable environment, you know, people are putting patches all over your chest and back, and you have patients feel at ease with what's about to happen. You have, from the time when Clay picks up a patient and prepping recovery and is willing those patients, down the hall, the conversation is engaging, and it's to soothe people along the way. When the patient is put on the table, it continues with the CRNA, with the tech, and no one treats that as, you know, this is just someone here. No, it's a patient. Could have been my family member. The same way we have been fortunate and are grateful that our staff trusts us to do procedures on their family members, so this is, I think that to me, it highlights the level of pride that everybody has. If one of their family members need a procedure, they're going to be done by one of our team members. Yeah. And that's, that highlights it all. Yeah, there's no greater compliment that you can get than having someone refer a family member to you. I agree. Well, thank you all for participating in this roundtable. It's been great, and we look forward to the rest of this, the next couple days. Thank you.

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