How Memorial Sloan Kettering Cancer Center's Nurses Adopted and Adapted Relationship-Based Care

Relationship-Based Care was the right formula to 'come together and provide the best possible care to our patients,' CNO Elizabeth McCormick says.

When Memorial Sloan Kettering Cancer Center (MSK) embarked on its journey to earn Magnet Recognition®, which recognizes healthcare organizations that provide superior nursing care, Elizabeth McCormick, chief nursing officer (CNO), also began to consider new care models.

After extensive research, consideration, and a vote by hospital nurses, MSK chose Relationship-Based Care (RBC), a trademarked model developed by Creative Health Care Management (CHCM), a healthcare consulting firm.

RBC is an operational blueprint for improving safety, quality, the patient experience, employee engagement, and financial performance and advances the culture of healthcare organizations by focusing on three key relationships: relationship with self, with colleagues, and with patients/families, according to CHCM.

The outcomes appear to be beneficial. A study about RBC published in the Journal of Nursing Administration shows that caring behaviors increased substantially in 12 months.

Verbal behaviors, such as responding to an expressed concern or providing reassurance, increased from 52.17% to 87.5%, while nonverbal behaviors, such as sitting by the bedside or entering a patient room without being called, increased from 47.6% to 73.6%.

Nurse turnover rates also decreased from 9.4% to 1.9%.

RBC has had impact on MSK's outcomes, as well:

• Patient satisfaction scores increased from 87.5% to 95% year-over-year.
• Turnover among registered nurses dropped from 0.80% to 0.54% in less than 18 months.
• Family/caregiver wait times decreased from 20.11 minutes to 14.94 minutes in less than two years.

HealthLeaders talked with McCormick, who is retiring at the end of this year, about how RBC was adapted at the celebrated New York cancer center more than 15 years ago.

This transcript has been lightly edited for length and clarity.

HealthLeaders: Can you provide an overview of what Relationship-Based Care is and how Memorial Sloan Kettering came to adopt it?

Elizabeth McCormick: Relationship-Based Care is a philosophy that guides our practice, but it's also an operational blueprint on how to advance a caring culture within an organization.

The hardest part was getting started because it was so important to take something that seemed vague and intangible and break it down into concrete concepts and action-driven efforts to achieve. That was the biggest challenge for me: to get the momentum going.

I first learned about it through my association with the AONL [American Organization of Nurse Leaders]. I picked up a book about it and it really piqued my interest, so I shared my thoughts and the book with the other members of my executive nursing leadership team. It was [around the time] when we decided we wanted to seek Magnet designation, and one of the central requirements within any Magnet organization is that nursing needs a professional practice model.

For years, the nursing department had practiced primary nursing [when a single nurse is a patient's point of contact and primary caregiver during a hospital stay] as its care delivery model, so that really set me set me on this journey to understand the elements of a professional practice model, and then learning about RBC and whether it could assist us in getting to where we wanted to go. More importantly, putting Magnet aside, it's all about connecting better with our patients, improving the patient experience and elevating our practice, and the outcomes we achieve, so that's what got me really interested.

HL: What was it about this particular care model that made you embrace it so?

McCormick: What resonates with me about RBC is that it emphasizes the importance of therapeutic relationships or relational practices that are necessary in order to deliver the full package to our patients. So not only does it provide skilled and knowledgeable care, but it does it in a way that's really compassionate and caring and includes the patient's preferences. It really advocates for the engagement of our patients and their families.

We were already delivering that kind of care [but] we didn't have a standardized way of communicating it or embracing it. It helped us to identify where there were some gaps and potentials for improvement.

HL: How did you roll it out at Memorial Sloan Kettering?

McCormick: It was literally a journey and parallels our Magnet journey. It's a process that never ends.

After I had become exposed to it, read about it, and talked to my colleagues about it, I shared these ideas with my executive team that quite frankly didn't initially buy into it, so I actually did seek some outside help, some consultation, from Creative Health Care Management.

We held some workshops on site with nurses at all levels from across our care continuum, including nursing leadership, but we also included other interprofessional colleagues as well, to help us all gain a better understanding about relationship-based care as a philosophy and a framework of care. The workshops also helped guide us with very concrete steps to advance within the organization, because you can't improve the culture change or strengthen existing culture without having the associated organizational processes and structures in place that help reinforce it on a daily basis.

We held open sessions like town halls with our nurses and [that] helped us craft our professional practice model, which embraced a lot of the elements of RBC and individualized the approach to Memorial Sloan Kettering. We came up with a half dozen schematic designs and then we put it out to a vote to the entire nursing department. And that's how we selected our version of RBC.

HL: What were some of the concrete steps of MSK's version of RBC?

McCormick: We vetted our values as a professional department by coming up with the slogan "We CARE," with "CARE" standing for compassion, advocacy, relationships, and excellence, so we care every day, every way, and we came up with this really cool conceptual design with a heart and the iconic disease-specific ribbons around our heart.

Years later, we were able to change the dress code for the nursing staff and, again, they participated in decisions about a new standardized uniform, and now that schematic design for our version of RBC is on every single nurse's and nursing assistant's and nursing tech's uniform. So, it became a simple way of breaking down the elements of RBC so that they were understandable to staff at every level. And that staff at every level could reflect on everything they were doing every day as they went about in the delivery of care, and understand how that fit in with the fundamental core values or principles of RBC.

And then in terms of the processes and structures, we were also refining our shared governance structure to engage the staff decision making, to empower them to have a voice to help guide how we communicate with one another because you can't have a relationship without effective communication.

We broadened other elements like how to foster—within an organization that is quite frankly pretty much still physician-driven—the autonomous nursing practice, while also promoting effective interprofessional teamwork, and doing that in a way that also recognizes the need for promoting continuous learning and hardwiring the fact that we want it to be a learning organization, constantly elevating the bar.

HL: How did the nurses respond to it?

McCormick: The first time I started to notice that it was resonating was when the staff came up with their own sort of lingo, where when they saw their colleagues doing something right, they'd say, "That was very RBC-like," or if they saw something that displeased them, they'd say, "That's not very RBC of you." They started picking it up in their vernacular and pointing out the behavior or manifestations of the values we would try to embrace.

If one unit had experienced some things—either a huge impact, high volume, high acuity, or maybe the staff had experienced a tragedy (maybe a staff member became ill and passed away)—another team would reach out to them and would help to foster their resilience by buying pizza for lunch or offering a nice gesture of support. We would see more and more of those kinds of activities occurring throughout the departments.

Other ways that we can measure what's happening with RBC is we look at our strong outcomes. We look at our very consistently high levels of patient satisfaction, and our accolades that we've received because of our consistently high patient satisfaction ratings.

But it's not just about fostering self-care or promoting high-performing teams. There are many elements of it in which you have to break it down into its component parts and then weave it together so that you as a leader and the staff understand all of its components and how it formulates the basis to … come together and provide the best possible care to our patients.