Setting the Scene: Inova Heart and Vascular Institute Inova Heart and Vascular Institute is part of Inova Health System, a not-for-profit health care system based in Northern Virginia that consists of six hospitals and other health services including emergency, urgent care centers, home care, nursing homes, mental health, blood donor services, and wellness classes. Inova is governed by a voluntary board of community members. Our mission is to improve the health of the diverse community we serve through excellence in patient care, education and research. Established in 1961, Inova Fairfax Hospital is an 833-bed regional medical center serving the Washington, D.C., metropolitan area. Included on the campus is the 186-bed Inova Fairfax Hospital for Children, the only children's hospital serving critically ill children in Northern Virginia and 156-bed Inova Heart and Vascular Institute, the region's only facility dedicated exclusively to heart and vascular care. The campus also includes Northern Virginia's only Level 1 trauma center for treating the most critically injured patients, the nation's fifth busiest obstetrics program, a subspecialty level Neonatal Intensive Care Unit and the region's only hospital to offer the full spectrum of organ transplant. Problem: Retaining Experienced Staff Over five years ago, the staff and management group of the cardiac catheterization and arrhythmia services at Inova Fairfax Hospital were reviewing options which could help retain personnel and stimulate a professional desire to improve clinical and leadership skill sets. At the time, the cardiac catheterization and arrhythmia departments employed about 36 full-time equivalents. All employees were either classified as level 2 cardiovascular specialists or clinical supervisors. For over twenty years, the hospital had operated an accredited allied health cardiovascular training program in conjunction with Geneva College in Beaver Falls, Pennsylvania. The allied health school had been a primary source of personnel. Inova would train and educate new personnel, but then the experienced personnel would eventually be lost to other healthcare employers or to industry. This was acceptable as long as the cardiovascular program growth at Inova remained flat. However, future plans included a new heart and vascular institute, which would require more dedicated and experienced personnel. Additionally, there was a desire on management's part to break this cycle of loss and retain the experienced personnel. A Clinical Ladder Development of the clinical ladder allowed for a collaborative partnership with our employees and empowered them to make decisions about future processes and desired outcomes. At the time of inception, there were three career pathways for cardiovascular professionals at Inova Fairfax Hospital. These pathways were: 1. Career advancement into management positions (limited by the number of opportunities). 2. Remain as a clinical professional with no substantial recognition for service other than annual increases. 3. Leave the organization for other opportunities. It was the opinion of management that something was needed to elevate performance to higher levels and provide more meaningful job satisfaction to this technical care group. A committee was formed, consisting of senior clinical personnel and some managers. The task of the group was to develop a clinical ladder which would provide economic reward while recognizing clinical accomplishments. The committee wrestled with eligibility requirements, expected professional behaviors and economic incentives. The program was modeled after an existing nursing clinical ladder already operational at the organization. Why reinvent the wheel if you do not have to? The committee developed a name for the clinical ladder program: Advancement in Cardiovascular Healthcare Interventional Excellence with Versatile Experience (ACHIEVE). After about one year of researching nursing clinical ladders, mechanisms for evaluating job performance, and invasive cardiovascular skills outlined by Registered Cardiovascular Invasive Specialist (RCIS) scope of practice, the committee presented the ACHIEVE program to the Human Resources Department. The program was approved and implemented in August 2002. Until the implementation of the ACHIEVE clinical ladder, all the employees were in the same economic bracket. Only years of experience separated these experienced personnel. We have a mix of cardiovascular technologists, nurses, and radiology technologists making up the department personnel. We grandfathered no one; if the person does not want to pursue the clinical ladder, they remain at CIS level 1 or CIS level 2. The ACHIEVE program allows our cardiovascular professionals to excel clinically, offering another avenue for professional advancement. The clinical ladder allows the employee to develop or recognize their highly technical skills and provide the organization with continual quality improvement through professional development. We emphasize the RCIS credential because it is the recognized professional credential for invasive cardiovascular professionals. We try to encourage personnel to pursue the RCIS credential because the credential helps improve their skills and knowledge base. The clinical ladder provides four levels of economic reward. Each economic level represents a six percent salary increase. All personnel have been classified as cardiovascular invasive specialists (CIS). A brief outline of criteria for the ACHIEVE program is listed in the Table 1. The ACHIEVE committee oversees the application process and recommends advancement if written documentation and criteria demonstrate that the candidate meets all requirements. Key to Advancement: Long-Term Projects The goal of each level is to develop personnel's leadership skills and raise the expectations for personnel to be expert resources. Each applicant must formally apply and complete all of the documentation prior to being awarded the advancement. With each level, the person is assigned a long-term task which is an ongoing project. Each project is developed collaboratively with management to achieve further organizational improvement. For example, one candidate's project involved developing continuing medical education programs for cardiovascular care professionals once a quarter. In 2004, this individual developed four continuing education programs; however, in 2005, this individual organized 17 continuing education programs for the clinical staff, exceeding the original project design goals. Another project example involves continuously educating personnel on topics related to medication changes or policy changes related to drug administration. The candidate designed the education method and then presented The Drug of the Month at departmental meetings. As an extension of the scope of the project, this person became the liaison to the pharmacy department, and now deals with all pharmacy-related issues. The effectiveness of the ACHIEVE program is a result of the ability to empower the employee to seek higher ground and excel. Each long-term project has factors that affect implementation and follow-through. Often the scope of a project evolves, as with the continuing education and pharmacy liaison examples. Each applicant's project is presented to the staff and this candidate then becomes a resource related to that specific skill or task for the department. Accountability is driven by the potential loss of economic incentive, which has not been withdrawn from any candidate who successfully participates. The benefits to the organization have been numerous. Employee retention, job satisfaction, quality improvement, empowerment and development of the participant's professional demeanor are exceptional. Inova's cardiac catheterization and electrophysiology laboratories employ 52 full-time equivalents. Thirteen of these employees are clinical supervisors, twenty-four employees are currently Level 2 CIS, twelve employees are Level 3 CIS, and four are Level 4 CIS. Sixteen candidates participate at the ACHIEVE CIS Level 3 and 4, which represents 30.7% of personnel. Conclusion What have we learned along the way? Initially, the projects were too shallow in scope and accountability was missing. As the program evolved, further attention was needed to develop never-ending, long-range projects which produce substantial operational improvement outcomes. This is not an easy task and the pathway of least resistance is an easy choice for participants. If a project is too narrow in scope, the project has no long-lasting outcomes. Projects that are too narrow in scope allow the candidate to feel they have met the expectations, but we do not just want the candidates to meet expectations. We want job ownership, commitment and follow-through. Project scope is outlined by management. Project effectiveness is also measured by management. If the project goals are not met, the project scope can be readjusted to meet projected expectations. Management encourages the candidates to define the scope of a project within certain limits, for example, developing a departmental telephone list. This could be a one-time event, or it could become a continuously evolving project, by expecting the candidate to maintain the database and oversee the additions and deletions. The scope of the project sets the tone of expectation. The success of a project is dependent on the candidate. Peer recognition is the cornerstone of this clinical ladder and improvement is only derived when empowerment becomes real for the employee. As we fine-tune this program, we are finding the benefits definitely outweigh the risks. The goal of the ACHIEVE clinical ladder program was to increase job satisfaction, improve performance, and retain qualified personnel. While we are very satisfied with our clinical ladder, we are currently evaluating the effectiveness of the ACHIEVE program in-depth, in the areas of retention, job satisfaction, and performance. Acknowledgements The author wishes to thank the members of the ACHIEVE committee Martha Breads, RRT, RCIS IV, Dominique Bradford, RN, RCIS IV, Nichole Robison, RCIS III, and Caroline Morgan, RN Clinical Supervisor, for their assistance in compiling information for this article. This article was reprinted with permission from Cath Lab Digest 2006;14:1,12,15.