Category: Leadership Strategy, Clinical Transformation
Rebuilding Nurse Staff Structure and Satisfaction
In 2016, Kaleida Health, a Buffalo, New York health network with four hospitals and 1 million annual patient visits, faced a serious challenge. Problems were surfacing across its nurse workforce, including high turnover among CNOs at three acute care hospitals for several years running. This came just as Kaleida Health was starting to turn the corner and experience growth after two years of intense changes, including hiring a new leadership team and addressing financial challenges.
Now, there was significant dissatisfaction, distrust, and turnover at the director and nurse manager levels, as well as unrest and low engagement among the nursing staff. Nurses were unhappy with staffing levels and more than 600 had signed cards stating they believed staffing was unsafe. RN staff engagement scores were the lowest of any hospital in the area and well below national averages.
HCAHPS scores were significantly below target and many nursing related scores were below the 20th percentile, particularly in the areas of nurse communication and staff responsiveness. Additionally, all patient experience and safety outcomes domains were below the CMS threshold and several safety outcomes fell below the hospital baseline.
(Cheryl Klass, MBA, BSN, RN, executive vice president and chief nursing executive of Kaleida Health. Photo courtesy of Kaleida Health.)
Senior leadership knew the future success of Kaleida Health depended on leading from the bedside and ensuring high-quality patient care. This meant having a well-trained, high-performing, and engaged nurse workforce. Strong nursing leadership was essential. Most importantly, Kaleida Health needed a nurse leader who could successfully oversee a complete transformation.
Cheryl Klass, MBA, BSN, RN, was this person.
Jody Lomeo, CEO, appointed Klass as executive vice president and chief nursing executive. Not only did her appointment confirm the organization's commitment to lead from the bedside, it also laid the foundation and provided the leadership required for the transformation. It was a big move for Klass, who stepped away from her role as president of Kaleida Health's flagship Buffalo General Medical Center. It required the vision and perspective that the chief nursing executive role could do more for the system as a whole, rather than one hospital.
Klass oversaw a deliberate and methodical change strategy over the course of two years to improve nursing operations, nurse engagement, and care quality. The plan included appointing new nursing leaders across the organization, including CNOs at each Kaleida Health hospital. Klass also appointed a systemwide director of nursing education and professional practice, and a director of women and children's services. In addition, 35 full-time nurse managers and assistant nurse managers came on board, several of whom were promoted from within. Klass also implemented a nurse manager council.
Today, nurse managers across the system meet monthly for information sharing, team building, project work, and continuing education. This was one of the most important aspects of transformation, according to Klass. Other changes included a 10% increase in nursing hours per patient day; 24/7 staffing support; and the appointment of dedicated charge nurses on many nursing units.
As a result, nurse engagement and satisfaction, as well as care quality improved. In 2017, a survey showed overall engagement scores hit a high of 3.90 from 3.77 (on a scale of 1 to 5). The climate of trust jumped from 33% to 59% and RN voluntary turnover improved by 68%. HCAHPS scores improved in several areas between 2015 and the first quarter of 2018, with dramatic improvements in quality of care scores:
▪ 69% improvement in MRSA
▪ 68% improvement in CLABSI
▪ 66% improvement in Colon SSI
▪ 42% improvement in CAUTI
▪ 33% improvement in falls with injury
▪ 27% improvement in C. Difficile
▪ 21% improvement in Sepsis
"These scores clearly point to the success of this nursing transformation," says Karen Kirby, MSN, RN, NEA-BC, FACHE, FAAN, president and CEO of Kirby Bates Associates, LLC, which conducted a nursing assessment on patient care quality and developed a transformation plan for Kaleida Health in 2016. "The difference in the enthusiasm among nursing leaders, particularly the nurse manager group, was dramatic and palpable," she says. "Several of the nurse managers who had been promoted from within had said just one year prior that they would never consider a nursing leadership role at Kaleida Health, despite holding a master's degree. In a year they were transformed and excited to share all the new programs that were being implemented to increase both quality of care and staff engagement."