From Bedside to Boardroom: Nurse Leaders Drive Transformative Change

Added on Jul 22, 2016

From Bedside to Boardroom: Nurse Leaders Drive Transformative Change
By Diana Mahoney
From Industry Edge July 2016

Nurse leaders play a critical role in population health management and clinical integration, two essential core competencies for health system success, Dr. Kenneth Kizer, director of the Institute for Population Health Improvement, said in his keynote address to health care executives who gathered last month for the Press Ganey 2016 Nursing Leadership Summit in Denver.

“In the emerging value-based health care economy, it will be necessary for health systems to rigorously manage the health of populations, whether the population is defined by chronic condition, age, geography, gender or other characteristics,” Dr. Kizer explained. “And successful population health management will require that health systems integrate clinical services across providers, settings of care, conditions and time.”

The ability of an organization to deliver on clinical integration and population health objectives rests in large part on the readiness of its nursing workforce to meet the organizational and clinical challenges such care requires. Nurse leaders who are active participants in shaping organizational strategies around those objectives are in the best position to prepare front-line nurses to develop the skills they need to be successful, and by so doing, to help the organization realize its transformation vision, Dr. Kizer said.

“Nurse leaders must be prepared to take a lead role in designing care to address both clinical and nonclinical determinants of health and be the health system’s unrelenting conscience regarding provision of timely patient-centered and coordinated care,” according to Dr. Kizer.

Toward this end, Dr. Kizer stressed that it is incumbent upon nurse leaders to do the following.

  • Push for every patient to have a single, integrated care plan that is readily accessible to caregivers and patients.
  • Develop expertise in information and communication technologies used for virtual care, which will be central to population health management and clinical integration in the future.
  • Develop sufficient expertise with performance measurements, methods for outcomes assessment and data analytics in order to communicate to caregiver teams how and why these are being used.
  • Push caregivers to be up to date on and consistently utilize evidence-based practices and promote and nurture a collaborative culture and open communication with physicians and administrators.
  • Insist on being empowered and resourced to effect policy and operational changes to optimize care.

Recruiting and Retaining New Nurses

During the Summit, nurse executives from leading organizations across the country also shared insights and strategies for addressing some of the most pressing issues facing the nursing workforce today, including training, retention, performance and safety.

Ena Williams, vice president of Patient Services and associate chief nursing officer at Yale New Haven Hospital, described that organization’s nurse residency program, which was designed to give new-hire BSN graduates the tools they need to succeed professionally and, by so doing, to improve performance, engagement and retention.

“The yearlong program allows our new graduate nurses to participate in monthly sessions to help develop clinical and leadership skills during their transition from nursing student to acute care professional nurse,” Williams explained. “We assign each new nurse a preceptor to help steer them, and there are monthly meetings with other nurse residents.”

All the nurse residents take part in a comprehensive orientation program designed by the hospital’s nurse managers and nursing education specialists “to be competency-based, preceptor-based, criteria-based and individually suited to nurses’ needs and interests,” Williams said. “Each program is created so that, upon completion, the nurses will have the knowledge, expertise and competency to provide the exceptional care our patients deserve.” They also have the opportunity to take part in extended orientation programs in order to develop specific skills to work in specialty units, such as oncology, labor and delivery or intensive care.

To date, more than 1,600 nurses have completed the residency program, and the results are promising. The 2015 data for newly licensed nurse turnover shows a rate far below the national average (4.96% vs. 27%). “The program really helps with retention, because it provides new nurses with an opportunity to be socialized and to engage in practice changes and feel purposeful in a short time frame,” Williams said.

The hospital has also implemented a service-line recruitment strategy through which it brings in new graduates in groups based on their desired service line, “rather than hiring them ‘single file,’” according to Williams. “This allows us to use our resources better. We can build educators and preceptors around them; build orientation programs and simulation programs around them. It really streamlines processes and allows us to get the same outcome with the same resources by pulling together our existing infrastructure.”

The recruitment process is guided by an analytics-based strategy that allows the hospital to accurately anticipate staffing needs and “stay ahead of the curve,” Williams explained. “We use a predictive analytics process where we calculate, each year, how many vacancies we will likely need to fill to compensate for anticipated nurse turnover, service-line volume changes, and so forth.”

Optimizing Staffing Resources

In addition to services and support for new nurses, the care and management of existing staff is a hot-button topic in health care. Patrick Baker, vice president of Patient Care Services and chief nursing officer at West Chester Hospital in Ohio, discussed that organization’s adoption of a flexible staffing model to better meet the needs of front-line nursing staff and improve patient care.

The model (described in detail in an earlier issue of Industry Edge) empowers charge nurses to optimize nurse-to-patient ratio assignments depending on the situation, Baker explained. He compared the contingency model to the approach used in battlefield hospitals for directing resources “where they are needed, when they are needed.” (Baker worked as a health care administrator for the Ohio Air National Guard and the U.S. Air Force, which included deployments to Iraq, where he served as a flight commander for the 332nd Expeditionary Medical Group—the largest Air Force theater hospital in the country.)

The contingency model has resulted in significantly improved staffing ratios, better utilization of staffing resources, increased job satisfaction and decreased turnover.

“After implementation of the model, we surveyed inpatient nurses to evaluate the perceived benefit to staff and patients. The survey showed that greater than 80% of all inpatient nurses who responded to the survey strongly agreed or agreed that the model correlated with improved support of front-line RNs [and improved] leadership communication and that it positively influenced the inpatient units,” Baker said. Further, the improved staffing ratios increased RN satisfaction and decreased nursing turnover correlated with decreased falls per 1,000 patient days during the implementation, from an average of 3.2 per 1,000 patient days in 2012 to 2.5 per 1,000 patient days in 2014.

Building a Transparent Nursing Culture

Transparency of patient experience scores has received a lot of attention, particularly with the increase in the number of organizations that have adopted online reporting of physicians’ ratings to support improvement efforts and the move toward consumer-driven health care. Such transparency at the inpatient nurse level is difficult to achieve because patients are typically cared for by multiple nurses during their inpatient stay.

“We realized that not being able to communicate nurse performance at the individual nurse level was a missed improvement opportunity,” according to Carol Koeppel-Olsen, vice president of Patient Care Services and chief nursing officer at Florida-based Winter Haven Hospital/BayCare Health System. “Patient experience scores are a proxy for culture and for patient suffering, for how our patients heal when they’re in our institutions and how they carry that into their life when they go home. It’s intrinsic to quality and safety, and because nurses’ care and behaviors influence the overall patient experience, we knew it would be valuable to be able to tie data to individual nurses.”

Thanks to a visionary investment in a “huge enterprise data warehouse” more than five years ago and deep survey data, “we developed a nurse performance attribution model, using the patient ID that is attached to each encounter, which is the number that ties the encounter to the Press Ganey survey,” according to co-presenter Bianca Radney, director of patient experience at BayCare Health System. “That number also ties into Cerner [the EHR nursing patient assignment system]. That is the connection that allows us to identify which nurses cared for which patients.”

With the help of the health system’s data resources group and data visualization software, “we were able to translate the data into something meaningful, and we had valid, reliable data with a big enough N that we could tie an individual nurse to patient experience domain scores,” Radney said.

The leadership team developed a strategy for collecting and communicating this performance information to nurses, and established performance expectations.

“We printed score cards for each nurse to be reviewed in one-on-one meetings with their manager,” Radney said. “The goal is to use the meetings not for a disciplinary kind of conversation, but rather to show nurses where they are in the process and to offer resources and tactics as needed.”

With respect to performance expectations, the team established that the 60th percentile or greater in at least three of the six nursing-sensitive domains (nurse communication, communication about medications, responsiveness, discharge information, pain management and overall rating) is acceptable.

Team members not achieving acceptable performance are offered coaching on best practices to improve domain performance, but continued low performance may result in formal progressive discipline, Radney said.

Because patients are cared for by teams of nurses, managers make it clear that every member of the nursing care team is accountable for the performance of the team overall. “We remind the nurses that if everyone is accountable, scores are going to rise,” Radney said.

And rise they did. Since the program was launched in June 2015, “our nurse communication has started an upward trend and continues to climb well above the 60th percentile,” Radney said, noting that communication about medication specifically has skyrocketed to above the 95th percentile. Overall rating and pain management scores have also improved dramatically.

After giving nurses time to get used to the performance measurement system, and time to boost low performance, if necessary, “we have begun posting the scores in the breakroom,” Radney said. “There’s value in ownership, and we want team members to hold one another accountable for delivering patient-centered care.”

The Safety Imperative

Patient safety is a key attribute of care quality, and it is inextricably linked to workplace safety, Patricia McGaffigan, chief operating officer and senior vice president of programs at the National Patient Safety Foundation, told Summit attendees.

“Medical harm is the third leading cause of death in the United States after cancer and heart disease, according to new CDC data. This means that despite safety improvements, errors continue to put millions of patients at risk annually,” McGaffigan said. “Nurses are in a position to prevent many of these mistakes and to improve patient outcomes, and they need to be empowered to do so.”

Nurse staffing is an important target area for safety improvement. Nurse fatigue, burnout, dissatisfaction, depression and anxiety can contribute to patient and caregiver harm. Many of these outcomes are related to staffing and work environment factors and are often preventable, McGaffigan stressed.

Advancing patient safety in health care requires “an overarching shift from reactive, piecemeal interventions to a total systems approach with a key focus on teamwork, culture and patient engagement,” McGaffigan said. A total systems approach is one in which leadership constantly prioritizes a safety culture and in which safety is considered across the entire care continuum. “It also includes prioritization of workforce well-being and safety of workforce and avoids adding disjointed initiatives to a stressed delivery system and workforce.”

The first step in this direction is to make the boards of organizations accountable for patient and caregiver safety “through governance [and] goal setting, and [by] ensuring that executives and all levels of management value and prioritize safety,” McGaffigan said. “Leadership and governance bodies must also develop and implement robust processes that encourage honesty, foster learning, and balance individual and organizational accountability.”

To the degree that the success of providing patients with the safest and highest quality of care is dependent upon a strong cultural foundation at the unit level, nurse managers must establish and nurture a safety culture through leadership, evidence-based practice, teamwork and communication, according to McGaffigan. They should also have access to the necessary resources to assess their unit’s safety culture to identify specific behaviors and values that need to be strengthened in order to work with their staff in developing a plan for improvement.