Abstract
The successful development of a structural heart program necessitates more than clinical expertise; it requires cohesive leadership, strategic planning, and a foundational commitment to multidisciplinary collaboration. We developed the TEAMS (Teamwork, Efficiency, Assets, Messaging, Scalability) framework as a practical roadmap for institutions looking to build or grow their program. Teamwork lays the foundation by uniting interdisciplinary staff around a shared mission. Efficient workflows are streamlined and patient pathways are standardized to improve outcomes and resource utilization. Asset management highlights the importance of financial planning and investing in the team to provide long-term sustainability and growth. Messaging emphasizes the need for clear, consistent communication across all stakeholders. Scalability refers to the progression from one procedure to an entire program offering various therapies.
Key words: cardiovascular disease, valve repair, valve replacement
Graphical Abstract
Teams
To guide the complex and multifaceted process of developing a structural heart program, we propose the TEAMS framework—a strategic model grounded in core principles essential for program success (Figure 1). TEAMS stands for Teamwork, Efficient workflows, Asset management, Messaging, and Scalability. Each element addresses a critical domain of the program and collectively provides an organized, actionable approach for institutions aiming to build, expand, or optimize their structural heart services.
Figure 1.
TEAMS Framework
APP = advanced practice provider (nurse practitioner or physician associate); CT = computed tomography; CTS = cardiothoracic surgeon; CV = cardiovascular; IC = interventional cardiologist; IP = inpatient; OP = outpatient; RN = registered nurse; RT = radiology technologist; VPC = valve program clinician.
Teamwork
The foundation of a structural heart program at our institution involved the full engagement of a multidisciplinary team (members of the team Figure 2).1,2 The valve program clinicians were essential members of the team and the central coordinators of care for the multifaceted areas involved in the procedure.1,2 Our interventional and surgical physicians established collaboration through granular sharing of both the technical and decisional aspects of the procedure. The surgeons were also able to apply newly acquired skills in their operating rooms—for example, placing a catheter-based left ventricular assist device and gaining proficiency with interventional wires. This cross-training was necessary for safe procedures, but it also created buy-in and a sense of contribution during the procedure. The extended team included members who might not have provided direct patient care, such as coding specialists and data abstractors, who helped ensure accurate revenue capture and quality care.
Figure 2.
Huntsville Hospital Structural Heart Team
Efficiency
Before the procedure, tracking patients' testing, procedure dates, and clinical status via electronic spreadsheets and embedded patient lists in the electronic health record helped maintain timely treatment. To accommodate growing volume, we established dedicated imaging slots for echocardiograms and computed tomography scans, along with a weekly valve clinic day with the interventional cardiologists. Our institution refined the patient pathway by not requiring preadmission testing and establishing standardized order sets throughout the care process.
The transition from a surgical to an interventional procedural approach was a significant and challenging cultural shift, but consistently positive outcomes and low complication rates confirmed that this decision was best for our patients.3 Initially, transcatheter aortic valve replacement was performed in an operating room under general anesthesia; it is now performed in a dedicated hybrid cardiac catheterization room with monitored anesthesia care.
The cardiac short stay unit provides the same nurse pre- and postprocedure, which has been beneficial in recognizing subtle changes in patient conditions. The unit also uses structural nurse practitioners for recovery and to facilitate discharge. All follow-up appointments are arranged before the patient is discharged.
Asset Management
Gaining support and commitment from the institution leaders in the various departments through strategic team planning was essential for resource utilization. Most patient referrals initially came from within our institution, but we strategically expanded our referral base through a grassroots outreach initiative. Physicians and valve program clinicians engaged with outlying cardiology teams to raise awareness about available therapies. This approach has been especially important, as the program serves many rural communities with limited access to specialized care. Notably, approximately half of our patients travel more than 60 miles to receive care at our institution. Developing an interventional-based procedure created a cost savings that was significant for the institution and patient while also improving patient satisfaction, reducing length of stay, and providing favorable clinical outcomes.3
Messaging
Clear and consistent communication has been essential to fostering a collaborative and transparent team environment.2, 3, 4 Monthly operational meetings with clinical and administrative team members are held to review ongoing challenges and to implement solutions to support program efficiency, growth, and quality care.5 A weekly virtual valve conference brings together the core team to review imaging for procedural planning, focusing on factors such as frailty, comorbidities, social support, and goals of care.1,4 We developed a shared electronic document that provides the entire team access to the specific procedural details. To ensure an optimal procedure day, a secure group text among all departments was implemented to enhance timely communication of schedule or procedural changes. After the procedure, consistent communication with referring clinicians through procedure notes and personal calls/texts from our physicians has sustained our robust referral process. Additionally, new and emerging therapy options are communicated face-to-face and through emailed memos. Finally, a quarterly quality meeting includes review of transcatheter valve therapy registry data to ensure we are providing high-quality care and assessing program outcomes.
Scalability
Program growth required strategic investment in financial resources, personnel, and advanced technology.2 Expansion of the program included increasing dedicated time in our catheterization laboratory for structural procedures, adding an additional computed tomography scanner for preprocedural testing, optimizing required follow-up visits by employing a nurse practitioner, and ensuring awareness of therapy with educational outreach. Providing educational updates for all staff who participate in the care of these patients and highlighting excellent care has been an important aspect of team building and camaraderie. This has been accomplished through quarterly staff educational dinners, 10-minute “knowledge bites,” a partnership with the marketing department to highlight milestones, and a service-line device day fair to learn about the variety of therapies. Sharing a mission to provide high-quality and efficient care to our patients has fostered trust and collaboration among the team members.
Declaration of Generative AI and AI-Assisted Technologies in the Writing Process
During the preparation of this work the, author(s) used OpenAI model ChatGPT in order to edit for grammar and clarity. After using this tool/service, the authors reviewed and edited the content as needed and take full responsibility for the content of the publication.
Take-Home Message
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A successful structural heart program is built on strong leadership, strategic planning, and a foundation of multidisciplinary collaboration. The TEAMS (Teamwork, Efficiency, Assets, Messaging, Scalability) framework offers a practical guide to aligning people, processes, and resources.
Funding Support and Author Disclosures
Drs Vasquez and van Wagenberg have been consultants for Edwards Lifesciences. Dr Christina Cantey has been a consultant and speaker for Edwards Lifesciences. All other authors have reported that they have no relationships relevant to the contents of this paper to disclose.
Footnotes
The authors attest they are in compliance with human studies committees and animal welfare regulations of the authors’ institutions and Food and Drug Administration guidelines, including patient consent where appropriate. For more information, visit the Author Center.
References
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