Q&A: Nurse Leaders on Affecting Outcomes Through Leadership

Three nurse leaders from the Premier CNO Network, an organization made up of 235 CNOs from across the country that aims to promote networking, collaboration, advocacy, and peer-based learning share their views in an open-ended, roundtable discussion:

• Kathleen D. Davis, RN, MBA, Senior Vice President and CNO of Presbyterian Healthcare Services in Albuquerque, NM;
• Judy Watland, R.N., MSN, Senior Vice President and Chief Clinical Officer/Nurse Executive at O'Connor Hospital in San Jose, CA (part of Daughters of Charity Health System); and
• Carolyn C. Scott, RN, M.Ed, MHA, vice president of performance improvement/quality for the Premier Healthcare Alliance

This is the first of two parts; look for part two next week.

HLM: What should nurse leaders really be concentrating on now when it comes to healthcare reform?

Davis: I really think it's critical for nurse leaders to understand the changing reimbursement landscape and specifically how that relates to programs that are tied to the quality of care, and the experience of care.

And to understand that trajectory over time and how more and more of the work we're doing is subject to incentives or disincentives related to our performance.

HLM: What is coming up next? What are leaders worried about now?

Scott: What we're hearing a lot at Premier [that] in the first year of value-based purchasing calculations, it was core evidence-based, care-based metrics as well as patient experience.

In the next calculation, mortality comes into play. Last year you heard a lot of uproar or angst about the impact about patient experience, and as a country we haven't done really well across the board and it's really hard to hit the mark.

And we're hearing this year about the same kind of issues and the same kind of angst [from nurse leaders that] our mortality rates aren't what we hoped they would be, we really need some help in hitting the mark and understanding the impact of that.

Watland: I think [healthcare reform] is a great opportunity for nursing to step up and get involved in shaping what this is going to look like, both in acute care settings and also in a community-based environment.

I read somewhere that 32 million newly insured people are going to be in the system with healthcare reform, and if we don't think that's going to change healthcare, we've got to really take that seriously. How [are] we in nursing going help shape [that and] take care of those additional people that are going to be covered and coming forward for healthcare?

I think there's a big opportunity for to have an impact on outcomes. I think about all the new nursing roles that have evolved, with monitoring outcomes, and making sure we've gathered all the data, and doing all of the documentations pieces right.

But the nurse at the bedside, the nurse that's taking care of the patient absolutely needs to be educated beyond their clinical expertise. They need to be educated about this whole process and be familiar with how to retrieve data, how to analyze data, how to use evidence-based practice in nursing care to shape those outcomes and to really at the bedside, understand that.

Because we can't afford to keep just putting more and more layers of people into the healthcare system, monitoring, and tracking data and then having the caregivers be totally separate. I think really expanding the role of the caregiver, the nurse at the bedside, to be able to embrace all of this and be engaged in all of this can really help strengthen their practice and shape the outcome that we're going to get. I think we have a big opportunity to improve care and also optimize our resources.

Davis: One of the critical ways that nurse leadership can really take an important role in this is through what I would consider a redesign of the care at the point of delivery. Really understanding how to utilize our quality, lean, process improvement tools to be very focused on the processes that produce value for patients [and] eliminating unnecessary steps to create a better experience, not only for the patient but also for the care team, and to leverage those tools to build not only new models, but to enhance the teamwork on a particular unit.

I know we have done a lot of work in both our ambulatory settings and our hospitals settings where we have looked at the care model on particular units and really worked to create more effectiveness and efficiency and at the same time, generate better clinical staff focus and patient experience outcomes.

So I see the nurse leaders, the CNOs, taking a really important role. We've done quite a few projects that we are now spreading to really help us diffuse those improvements and sustain those improvements over time. As Judy was saying, it's difficult in these complex environments to sustain improvement. How do we continue to build on the good work and create more value for patients?

Watland: [The term] "nurse leader" takes on a whole new meaning. And I don't mean the formal leader, the chief nurse or even the director level...we have to cultivate nurse leaders at all levels of the organization.

I think at the bedside, there are many nurses that can be taught leadership tools, and how to do peer coaching, to make sure that we're holding each other accountable for complying with good standards, good practices.

I think we have to incorporate the whole meaning of nursing leadership at all levels within the organization, and have them really take an active role. Taking more of a leadership role at the bedside, in addition to what we traditionally think about as formalized management type of leadership roles. I think we really need to cultivate the clinical leadership as well with nurses that are at the bedside.

HLM: Can you share some real-world examples of how you've done that successfully?

Watland: Over about 18 months we identified nurses in each unit who wanted to be involved and had the ability to kind of take on more of this [leadership] role, and we taught them tools on how to apply research, how to do tests of change, how to gather data/analyze data, how to apply these evidence based standards, and we focused it around sepsis morality with a goal of reducing sepsis based mortality.

So with this model, nurses were able to learn how to use these tools, they learned how to coach their peers. They learned how to hold each other accountable in a very professional and respectful way, and we were able to then infuse that kind of model into all the different units.

And that it's not just the manager of that unit that holds each other accountable to complying with those practices and those standards...the staff became engaged in that practice. That was very successful, and now we're expanding that to other goals that we've established for other quality indicators and also customer service, or patient experience indicators and outcomes.

We're going through that same process, using those same tools, and [asking ourselves] how do we apply that, then, to other goals we have for improving outcomes in the unit. The staff have really stepped up to be involved at the level. They get education on how to do those kinds of things...it's really using evidence-based practice and then the tools that are generated through that to hold each other accountable, and then they measure outcomes.

And if something's not working, they change it, and then they test [to find out if] this is working better, and they've learned how to do that process. It's really quite exciting.

HLM: That's an interesting way of making the healthcare reform principles part of their practice.

Davis: We have trained a number of our staff in quality improvement tools. We also have a department in our quality institute that is focused on performance improvement. We are a part of TCAB (Transforming Care at the Bedside).

So we've used a more of a project-based approach where we're taking principles of just-in-time training on how to utilize data and tools; and how to look at the work on a particular unit and decide what where there's value, what might we improve; what's creating difficulties for patients and for staff and how can we improve those outcomes.

We call our model our "unit-based care model" where we have used the tools to really define the standard work for the nurse, the support staff on the unit, the physicians that predominately work on those patient care units. [We] have brought that together in a number of ways.

One of the more notable is our integrated team rounds on our general medicine and general surgery units where we evaluate the patient scheme as a team, and it's enabled us to reduce complications, reduce length of stay, and improve overall satisfaction for our patients and our staff that work on those units.

So in many ways it's a lot of the similar principles that Judy mentioned, but different approaches to how can we create lower costs, take out waste and improve our clinical outcomes.

HLM: Is it easy or hard to get individual bedside nurses involved? To get all of them involved and all of them engaged?

Watland: Getting all of them engaged, I think is hard because there are some people who willingly and proactively want to be engaged and want to be involved and then you have those who honestly probably don't want to be involved as much.

But I guess to go back to what I was talking about before with some kind of peer coaching. If you're actively involved, taking a leadership role on your unit, versus those that aren't taking a leadership role, still I think everybody's commitment and compliance to the standards can be elevated through that model.

Whether or not they want to be actively involved, I think peers holding each other accountable just raises the bar for everyone. So from that perspective, maybe they're not proactively involved, but they're involved. Everybody has a different role that they play throughout their career and experiences that they're going through in life; sometimes they can take an active role and other times they don't.

I think we have to respect where that person is at that time, but still hold each other accountable to what the standards are, what the practices are, and what the outcomes we're going after, and helping everybody be onboard with that. I think that is very possible. But for everybody to take a leadership role in that, it isn't [possible], not at the same time at least.

Davis: There's so many different areas that we can focus on. One of the principles that we use [is] when folks have energy for a particular topic, let's go there, and let's really leverage their willingness to be involved and their engagement and to the extent that we can alter the priorities on a particular agenda, and get engagement we do that.

Because I think we need the nursing staff to focus on things that are important to them. And I think that helps you grow your early adopters, and when people start to see improvement they're much more apt to get involved.

Watland: Agreed. And I think it's really important to be transparent; no secrets. Be transparent and open and honest with each other. I think that's very important. Trust and respect for relationships between management and staff, staff and staff, physicians and staff.

Because I think [when you do] that, everybody knows the vision and understands that, and there's open communication between senior leadership, middle leadership, and all staff.  Whether or not you agree with it or not, people are less insecure.

They're more secure in what's going on, they understand it; they have a better understanding of where they're going and why. I think the "why" is absolutely essential for people to know in the nursing profession and healthcare; why things are changing and why we're doing what we're doing and then having a voice in that. I think that's extremely important.

Davis: These changes take time, and you have to work at things and [do] multiple cycles of improvement and measurement. We have been implementing a process around failure to rescue and making sure that we're escalating subtle changes in the patient's condition quickly for action.

We've been working on this for many years, and just this past year we've been able to add technology to that to assist a nursing staff. So I think those [are] payoffs: When you can really install a strong process that improves care and then help to automate it, to actually make the work easier for the nursing staff who are responsible for it.

So I think this is more of a journey; this is the endurance run.

These are not sprints in the sense that so much of what we do [will be] one result building on another, strengthening our capacity; [that's] really the generative nature of work like this.

Look for part two of our conversation next week.