"When I was in my 30s, both my parents, in short succession, went through really complex, multiple chronic disease conditions and, then ultimately, passed away," says the vice president/chief nursing officer of ambulatory at the newly merged Advocate Aurora Health. "So, I experienced the healthcare system from a lens that I had never experienced it before. I'll tell you the healthcare system didn't look very good to me through that lens."
Even as a healthcare professional, navigating the system was a challenge. And communication was subpar.
"The ways that clinicians and other caregivers communicated didn't respect the dignity of my parents or of my family. The healthcare system was helping us achieve our clinical outcomes but wasn't helping us with the burden of illness," says Quinlan, MSN, MBA, RN, NEA-BC. "It really changed the way I thought about my practice and my leadership."
As a result, she became a proponent of patient- and family-centered care. Over the years, she has worked to promote partnerships between patients and the organizations where she has worked. Here are some of her insights on enhancing patient experience.
Following are the highlights of Quinlan's recent interview with Health Leaders Media. The transcript has been lightly edited for brevity and clarity.
Expand your view of patient experience
"Patient experience is something we measure retrospectively. It can give us a narrow picture. We would do well to expand our view of what patient experience is, framing it broadly in patient-centered terms. For me, that means a holistic view of providing value for your consumer. I know that is not [traditional] nursing language. But, how do you translate this movement of value-based care and consumerism into what we've traditionally thought about as patient satisfaction and patient experience?"
"I think as nurse leaders we have to broaden our lens in terms of consumer value, patient- centered care and what that can lead to, as opposed to just focusing on patient satisfaction, patient experience, and HCAHPS or CGCAHPS scores."
Be an intentional listener
"The first avenue is engaging patients as our partners. One way to do this is forming patient advisory councils. The patient advisory council will help caregivers understand the [heart] of the patient's experience and how we might specifically design any program, particularly those where a robust discussion would shed light on the patients' wants and needs."
"Another way to engage patients is using consumer research. We are very lucky at Aurora to have an expert consumer research division that does ethnographic studies [research] that are very solid in terms of scale of measurement, data, and research. They analyze the data in a very evidence-based way."
"Typically, in the healthcare industry, we haven't done the kinds of consumer research that other industries, like Apple, do. Think about whether your organization is doing consumer research and listening to patients in a way that would really help you become more customer focused."
Drive improvement through data
"After our councils [give feedback] people will say, ‘That is one person's opinion.' So, when you have good consumer research, you get the power of the data and the benefit of rich dialogue in the advisory councils."
"For example, Anne Martino, who is vice president of consumer engagement at Aurora, and I partner on a patient advisory council. The discussions there inform thinking around her work and she often leverages issues of importance that come up at that council to inform her research."
"For example, billing was a huge issue for our patients and their families. Anne partnered with the billing department and her division to overhaul our online billing capabilities and the transparency of our charges. While the example isn't nursing-focused, it exemplifies how we [take] the council [input] and the consumer insights data and translate that into operations, whether that is a billing situation or a clinical program."
Connect back to the organization's culture
"As leaders, use your pulpit to connect that [patient-centered] work to the culture of the organization. Each person has a story. We are sensitive to what that person's story is—both those of our caregivers and our patients."
"I think there is messaging that leaders can use within an organization to both tell and show how listening to our patients is important—listening to our caregivers and understanding the perspectives of patients and families. This gives us a sense that we are all in it together."
Editor's note: Sharon Quinlan will be sharing more insights on patient experience during the panel presentation, "Leverage Nurse Impact to Innovate and Enhance the Patient Experience" on May 1 at the World Healthcare Congress in Washington, D.C.
The American Nurses Association president talks empowerment, advocacy, and how nurses can shape the future delivery of healthcare.
This article first appeared in the March/April 2018 issue of HealthLeaders magazine.
Over her 41-year nursing career, Pamela F. Cipriano, PhD, RN, NEA-BC, FAAN, president of the American Nurses Association in Silver Spring, Maryland, has held positions spanning the bedside, the boardroom, and beyond.
She has worked as a healthcare consultant, a nursing faculty member, a chief nursing officer, and a chief clinical officer. Now, as the ANA's 35th president, she uses her broad spectrum of experience to give voice to the nation's nurses.
In her words, Cipriano's career reflects how the nursing profession has changed over the years. In addition to nurses pursuing more education—Cipriano herself has a PhD in executive nursing administration—RNs are taking on more leadership roles at the point of care, in healthcare organizations, and in the community.
Gone are the days of submission and passivity where nurses waited for direction from physicians. Cipriano says nurses are now more empowered than in the past.
Today's nurses can be found leading care teams, driving care coordination, and working in advanced practice roles. They are also using their skills to move the healthcare delivery system from a hospital-centric environment to one that emphasizes care in outpatient and community settings.
Nurses bring more to the table than clinical skills, says Cipriano—their knowledge and experiences put them in prime positions to advocate for both patients and the profession.
As ANA president, her role could be described as the ultimate advocacy position, but nurses at all levels and in all settings can effect great change if they commit to making their voices heard, she says.
In fact, the ANA has declared 2018 the Year of Advocacy. The campaign's tagline, "Inspire, innovate, influence," sums up Cipriano's view of what nurses can do for patients, the nursing profession, the healthcare system, and society as a whole.
Cipriano recently spoke with HealthLeaders about the power and potential of nurses. Here are some highlights from that conversation.
On the value of nurses:
I think the message is nurses are really your secret weapon—whether it's in the home, whether it's in the community, whether it's in the hospital—and we are underutilizing their expertise. It's important to recognize this from a patient outcome [standpoint and an economic one].
The care that nurses provide is both what is obvious and a whole lot more that is not apparent.
For example, a nurse sources information about the patient and family, understanding what's holding them back, what's going to help them get better, what's important in terms of customizing the care for that patient.
And when the nurse intervenes because the nurse recognizes that the patient or the person or the family that they're caring for has bigger problems at home—they have opioid-addicted, suicidal siblings, or an aging parent who is unable to [be a caregiver]—the nurse is the one who puts the puzzle together.
We also need to be demonstrating the huge value that nurses have so that we can advance issues such as staffing, to make sure that organizations are taking it seriously, that they need to staff in a way that's good for patients and good for nurses.
On the new roles for nurses:
In the past, I think nurses were pigeonholed. You either work in a hospital, or you work in a clinic, and homecare was still relatively new. Now when I think about nursing in the United States, I think about our desire to move to preventive and community-based care, and we have nurses leading the way.
We have parish nurses. We have homecare that is high-tech—some of it is home monitoring, with remote monitoring. There are community-based organizations where nurses have a caseload of patients and families that they follow.
We have ways in which we're really engaging communities. We're using our advanced practice registered nurses along with staff nurses in primary care practice. We're using that expertise to make sure that people are following the requirements for immunization schedules, getting their preventive healthcare, and addressing their chronic conditions.
What we have done is really broadened the skill set requirements for nurses, and in doing so, it's given nurses more flexibility in terms of where they can provide care.
But, when I think about the future, I think about us still having a heavy concentration of nurses in a hospital, and at the same time, really tapping the expertise of nurses to be significant caregivers in the community.
The primary change that I would like to see is that nurses become leaders within their communities. We will have taken out the hierarchy that says nurses need to wait for orders.
On the importance of advocacy:
One of the conclusions that I've made in the last several years is—I don't say this in a negative way—but we often put forward the excuse that "I'm too busy to get involved in policy work or advocacy because I'm always busy taking care of patients."
Managers are always busy going to meetings. Executives are always busy in meetings or making visits to board members. There's always something that can keep you from the critical activities that you believe you should be doing.
To me, if we really believe it's important for nurses to influence the changes in healthcare, we need to find a way to support each other and to get the people on the front lines in front of the policymakers and in front of decision-makers in our organizations.
Healthcare executives are eager for solutions to the many challenges of running their business. But in their quest for answers, they may be overlooking a large and effective group of change agents already in their midst: nurses.
This article first appeared in the March/April 2018 issue of HealthLeaders magazine.
Nurses can improve quality and outcomes, enhance an organization's culture, and build relationships with patients, colleagues, and the community—yet to do so, healthcare leadership needs to see them as more than just a cost center.
Three nurse leaders share their thoughts on how nurses can influence change in healthcare and, if given the opportunity, be drivers of innovation.
Problem Solving
Profit margins, mergers and acquisitions, reimbursement: There's an enormous focus on these issues in the industry, but they are not the ultimate goals of healthcare.
"When all is said and done, our mission is caring for people, and the ones who care for people, primarily, are the nurses," Maggie Fowler, RN, BSN, MBA, NEA-BC, system vice president and chief nursing officer for St. Louis–based SSM Health. "It's not saying that our physicians, pharmacists, respiratory therapists, and all the other disciplines don't—in an acute hospital setting, it's definitely a team effort—but when most people go home, the nurses are still the ones there who are assessing the plan of care. They're the primary communicator in most situations."
Nurses also maintain near-constant contact with patients. Fowler says there are about 40,000 employees at SSM, with nurses making up one-third of the total workforce.
"When all is said and done, our mission is caring for people, and the ones who care for people, primarily, are the nurses."
Maggie Fowler, RN, BSN, MBA, NEA-BC, system vice president and chief nursing officer, St. Louis–based SSM Health
In SSM's hospital settings, 50%–60% of the workforce are nurses. This connection lets nurses understand the challenges patients face and develop solutions to promote optimal care.
"Nurses are problem-solvers. The cycle of change in healthcare over the last couple of years has been so rapid. We need [nurses'] eyes and ears to help us recognize how we can improve not only the care in a hospital setting, but in an ambulatory setting and all the places where care is going to be delivered going forward," Fowler says.
Solving the problem of falls
Fowler has seen firsthand how nurses can improve patient care and outcomes and, subsequently, an organization's bottom line.
"In a healthcare environment, falls can be devastating," she says. "They can lead to a negative perspective for patient morbidity if they're injured during the fall, and have a negative impact to the organization on a cost-of-care perspective."
Recognizing this, the organization's nursing practice councils, which facilitate evidence-based decisions regarding nursing practice standards, policies, and procedures, identified a fall risk assessment tool—the Hester Davis Scale—to help reduce falls at SSM.
SSM worked with Amy Hester, one of the creators of the tool, and its EMR vendor to launch a pilot project in spring 2016 at one of the organization's hospitals.
The pilot occurred on two units, and based on its results, SSM determined that the assessment tool had efficacy for the healthcare system. The pilot had validated the value of implementing the tool systemwide, with investment on the front end being recouped by savings on the back end.
"The outcome of that pilot clearly demonstrated that this assessment tool allowed us to more clearly recognize patients who were at risk for falls," says Fowler. "The Hester Davis
algorithm—once you make this assessment—identifies the steps you take to decrease falls."
The practice was then rolled out to the rest of the SSM system (although Fowler says one hospital still needs to be onboarded to the new procedure). Training was done via "waves" across the system, with three to four hospitals per wave, Fowler explains.
Each wave took three weeks and included webinar and online training. There was also coordination with the supply chain to ensure facilities had the correct equipment (including low beds and fall mats) to address fall risk.
The organization took a whole-hospital training approach that included RNs, physicians, physical therapists, environmental services, and others.
Results
Based on nearly a full year of data from the facilities where the fall risk assessment has been implemented, total falls have decreased by 30% per 1,000 patient days. That reduction should have a big payoff and save the organization an estimated $2.5 million annually, based on industry cost standards.
Additionally, there has been a 5% reduction in falls with injuries per 1,000 patient days, which equates to a savings of $500,000.
Fowler says SSM Health recognizes that healthcare delivery is changing and that nurses are integral to redesigning and transforming the industry.
The success of the fall risk assessment project has both empowered bedside clinicians to influence change and driven system leadership to increase its focus on the key priorities of safety, quality, and service.
"For you to be able to impact your nurses at the grassroots level, you need to be able to be at the table as a nurse leader and impact decisions, because in a lot of organizations nursing is the largest resource."
Katie Boston-Leary, RN, MBA, MHA, BSN, CNOR, NEA-BC, chief nursing officer at University of Maryland Prince George's Hospital Center in Cheverly, Maryland
"One of my priorities with nurses is that we have to translate the value [of nursing] and have the ability to translate the work into the bottom line. That is personally a passion of mine," she says. "It's translating it into dollars and cents. We're dealing in an environment with reduced reimbursement, so anything that we do, in turn, should have a positive outcome to lower the overall cost of care. We need to be advocates to help connect the dots for executives and other employees in the organization."
Innovation
The shift to value-based care, while necessary, is also posing a challenge for nurse leaders.
"The value-based approach to care, which is a much-needed change, has many challenges for leaders and organizations as we are making tough changes with declining reimbursement and the financial penalties that come with it while we continue to care for very sick patients," says Katie Boston-Leary, RN, MBA, MHA, BSN, CNOR, NEA-BC, former chief nursing officer and senior vice president of patient services at Union Hospital in Elkton, Maryland, and chief nursing officer at University of Maryland Prince George's Hospital Center in Cheverly, Maryland.
"And when we do meet our targets, in most cases, we never see rewards or they don't come in a very tangible way," she says.
Likewise, leaders are tasked with how to best utilize nurses in this updated care model.
"We are now recognizing that we are appropriately in the business of maintaining wellness, so how do or will our bedside nurses fit into that strategy? Strategies should not be constrained to providing care within the four walls, but well outside of that, and we should be able to measure impact on outcomes," she says.
Nurse leaders may feel like they have one foot in two boats as they try to manage a dual reality—the long-standing fee-for-service models still in use, plus the outcomes-based models that are increasingly being adopted.
"We have a lot of people in nurse leadership roles that are still using the approach of yesteryear where it is the top-down approach. It's a little bit of managing what was and what should be versus what is," observes Boston-Leary.
Instead, she says nurse leaders should be taking a proactive approach and creating solutions that will move nursing and healthcare into the future. "It's that adage of skating to where the puck is going."
CNOs: Advocates in the C-suite
The key to moving forward is having strong nurse leaders who are willing to advocate for nursing in the C-suite.
"It is really being able to have nurse leaders that can stand with their finance person, with their CEO, and work to get proper data analytics or IT resources to better utilize and manage nursing resources. When our frontline nurses are stretched with managing volume and high acuity, nurses barely have time to perform value-added care that is meaningful versus what we see today—less critical thinking and largely computer-driven protocols, which is 'color by numbers' nursing care," she explains.
In addition, she notes, "in many organizations, nursing productivity and [patient] acuity is not measured well. Yet in most cases, staffing decisions are being based on singular data points that are forcing nurse leaders to make decisions that will hurt their team and will cause them to lose top talent."
Boston-Leary points to the hospital census as an example of this. When one of Union Hospital's pediatric units had issues with patient volume and nurse retention, instead of relying on the traditional low-census day model of nurse staffing, Boston-Leary came up with an alternative solution.
"At Union Hospital, we had a small pediatric unit challenged with declining volumes and occasional spikes without having enough staff to care for patients. We also had high turnover and low retention with nursing," she says. "A quick phone call from me to the large reputable pediatric hospital, pitching an idea for that hospital to run our pediatric unit, resulted in a management service agreement with that hospital two years later. Nurse leaders need to take the lead with these types of collaborative strategies with the support of their peers in the C-suite."
Boston-Leary advises nurse leaders to look at data trends and put together a proposal for their C-suite peers on how they plan to manage workforce and labor expense.
"That innovation and taking that entrepreneurial approach and using analytics is what we need to do in a more proactive way," she says. "Otherwise, of course your CFO or CEO is going to need answers and implementation of changes that nurse leaders will not be comfortable with, and you're not going to be left with much choice. Then you're sunk. When you're in the red in terms of your variances, that doesn't leave enough lead time to try new innovative ideas without the financial pressures for an immediate turnaround."
Fostering bedside innovation
C-suite level support for nursing innovation is necessary to effect organizational change. "For you to be able to impact your nurses at the grassroots level, you need to be able to be at the table as a nurse leader and impact decisions," says Boston-Leary, "because in a lot of organizations nursing is the largest resource."
And nurses can come up with amazing solutions when they have support, she says.
"Empowerment reveals the goldmine of talent and innovation you have within your building that we typically don't take advantage of. I think taking that lid off and being less oppressive with our policies and empowering people breeds innovation," she says.
That is why Union Hospital stresses empowerment during its nurse residency program. "That's the one thing that we impress upon folks when they come in here new to practice—that you are a leader at the bedside. That is important for people to know early in practice," says Boston-Leary. "There's no submission here. You have a voice, these are your avenues, and we want you to be an innovator, too."
In fact, each nurse residency cohort at Union Hospital puts forth a research-based idea that the hospital can implement. "We have a major presentation at graduation that we also turn into actionable items for change in our organization," she says.
One example is the creation of a tranquility room where staff members can go when they need to de-stress during a shift. "We saw marked improvement with our RN satisfaction scores in almost every domain in comparison to two previous years, as nursing felt that they were being listened to," she says.
Another nurse resident found data that nurses who work nights don't eat healthfully during their shifts. On a SurveyMonkey questionnaire, nurses remarked that they were not eating healthfully and that they would like five-minute exercise routines to help boost their energy levels at night. As a result, the vending machines now have much healthier options, and the organization is in the process of distributing "fit kits" on every unit with quick and easy exercise routines.
A third nurse resident researched how to reduce chaos during codes and found evidence that labeling team members' roles using visible IDs would make code resolution more efficient and improve outcomes. The hospital is in the process of implementing that project
"These ideas were initiated by nurses who were relatively new to practice," Boston-Leary points out. "That speaks to empowerment at all levels because the incumbents may feel inspired by the fact that if a new entrant is implementing these great evidence-based ideas, I can certainly do something, too."
Organizational Culture
Jonathan B. Bartels, RN, BSN, CHPN, palliative care liaison nurse at the University of Virginia Health System in Charlottesville, may not be a nurse executive, but he's a prime example of how nurses can have a major effect on the culture of healthcare.
His concept of "The Pause," where care teams take about a minute after a patient's death to stop and honor the life that has left them, has garnered national and international interest.
The practice, Bartels says, gives healthcare providers permission to stop and honor loss, and it's a movement away from what he describes as "the industrialized / scientific / professional detachment" that healthcare practitioners have been trained in.
In short, it reconnects patients, family members, and providers with the essence of healthcare: humanity.
The ground for the "The Pause" was laid around 2010, after Bartels attended a retreat that focused on developing resilience. Participants were challenged to go back to their healthcare facilities and create changes. At the time, Bartels was working in the emergency department, and he noticed how staff handled an unsuccessful resuscitation.
"During one of our intense resuscitations, I had noted that when we were done, we kind of just walked away from the situation," he says. "I realized that we had lost a ritual of honoring, so I knew that's where I could possibly [have] influence."
"Leaders are not just the leaders who are identified by the institutions. These are leaders who are identified by their peers. Use them as change agents."
Jonathan B. Bartels, RN, BSN, CHPN, palliative care liaison nurse, University of Virginia Health System in Charlottesville
After losing a patient, Bartels took inspiration from the actions of a hospital chaplain who once requested the care team stop and pray after an unsuccessful resuscitation. "I emulated what a chaplain had done, but instead of offering a Judeo-Christian prayer, I asked that the room stop and honor the patient in humanistic language."
His example of such language: "Could we stop and honor this patient who was alive prior to coming in here, who was loved by others, who loved others, who had a life—and also take the moment to honor all the efforts we put into caring for the patient? I ask that we hold the space, to honor this patient in your own way and in silence." This allows staff to own the practice and honor a patient's last rite of passage when a chaplain is not available, he says.
The response to Bartels' action was positive. "People who were not necessarily religious per se came up to me and said, 'You gave me space to do this, and I thank you for that,' " he recalls. "It opened the door for others to imitate it, and others started to practice it. That's really how it took off—it was just people seeing it done once and then being empowered to do it themselves."
Thus, "The Pause" was born. It began to spread beyond the ED into UVA's other care areas. Trauma surgeons and anesthesiologists requested care teams to take part. It has spread to other healthcare facilities and settings, both nationally and internationally, as well.
"Other institutions have formalized it. Cleveland Clinic is now using it across the board," Bartels says. "It's being done for organ transplants in South Africa. When patients are donating, they do it for the donor and they do it for the recipients. In hospices, they're doing it, and they're also doing it out in the field for EMS care providers."
He adds that the University of Virginia's school of nursing is working on a preliminary national/international study to look at both the spread of The Pause and how different areas/cultures define it.
Anecdotally, those who take part in the ritual have had favorable experiences. "The results of that have been mostly qualitative reporting. 'This made me feel better; it felt right; it helped the family to see us do the practice,' " he says. "EMS [staff] and healthcare providers tell me [The Pause] shows that you really care. It's not just enough to try and save a life; it's that extra demonstrative of compassion."
As direct care providers, nurses are in a prime position to identify areas that need improving and, like Bartels, come up with solutions.
"Nurses are not only implementing the instructions and the guidance of the physicians; they are the eyes and ears of healthcare. They provide a huge portion of the direct hands-on care 24/7, and that affects outcomes," he says. "The way I see nursing really influencing is in helping to look at what outcomes are being worked [toward] for our patients. It's not just healing the disease, it's healing the whole patient. It's not just stating 'I'm offering compassionate care'; it's actually giving compassionate care."
Bartels encourages executives to look to those nurses who are "informal leaders" to facilitate change.
"Leaders are not just the leaders who are identified by the institutions," he says. "These are leaders who are identified by their peers. Use them as change agents."
Editor's note: This story has been updated to correct the name of the organization where Katie Boston-Leary, RN, MBA, MHA, BSN, CNOR, NEA-BC, currently works. Boston-Leary is chief nursing officer at University of Maryland Prince George's Hospital Center in Cheverly, Maryland.
After retooling its leadership team and committing to improving staff engagement, Appalachian Regional saw big improvements in its quality, safety, and patient satisfaction scores.
This article first appeared in the March/April 2018 issue of HealthLeaders magazine.
About four years ago, leaders at Appalachian Regional Healthcare System in Boone, North Carolina, realized they had a serious problem with employee engagement.
Staff engagement scores were in the basement—around the 19th percentile on the Bivarus employee engagement survey—and a nurse called The Joint Commission to complain that electronic medical records were affecting nursing workflows.
"I think [the nurses] felt like their only option was to report that externally," says Amy Crabbe, MBA, CHHR, senior vice president of people services at Appalachian Regional. "That really got our attention that we had some significant issues around engagement."
Additionally, the health system with two hospitals and more than a dozen medical practices was struggling with other metrics, such as HCAHPS scores.
"Our thought was that when we have engaged employees, everything else doesn't just automatically fall into place, but it obviously lays an infrastructure for the patient experience and for quality."
"Some questions had hit rock bottom. Some of the questions were as low as the 5th percentile; some were in the 30th percentile," Crabbe says. "On average, we were well below the 50th percentile, and that is not where we wanted to be."
A C rating by the Leapfrog Group added salt in the wound.
"We just went, ‘Holy cow! How can this be, that we're a C?' " says Kim Bianca, MSN, RN, senior vice president of hospitals and acute services and CNO at Appalachian Regional. "We don't consider ourselves C people or a C organization, but to have someone externally grade us that way … our CEO was quite concerned about it."
Today, however, the organization is leaps and bounds from where it was. Here's how it bolstered employee engagement and improved service and quality outcomes.
Step 1: Take a critical look at leadership
The Joint Commission complaint was a sign that nurses didn't think their concerns would be heard and acted upon by internal leaders.
"Our nurses were feeling like they didn't have a voice," Crabbe says.
So the first course of action to improve staff engagement was to take a hard look at the system's leadership team. This meant moving some leaders into new positions, both within the organization and outside of it, that better matched their skills and strengths.
"[Getting] the right people in the right leadership positions was our first decision and the impetus to some significant changes," says Crabbe.
"We took some key personnel and moved them to positions that would drive outcomes in a more specific way," explains Bianca, whose own position was changed from vice president of many ancillary services—including service lines, home health, and outpatient—to her current role, which includes responsibility for inpatient nursing.
"The very first thing we did was get the right people on the bus," she says.
"[Getting] the right people in the right leadership positions was our first decision and the impetus to some significant changes."
Two qualities were essential for members of the retooled leadership team—an ability to focus on data-driven and strategic outcomes, and a mastery of change management, says Crabbe.
Step 2: Increase visibility with employee rounding
Even before subpar metrics were staring them in the face, leaders at the health system had discussed working with the Studer Group to change the organization's culture. They have since signed on with the consulting firm and implemented many of its tactics, including employee rounding.
"The very first thing that I started immediately, which was a Studer tactic, was being as visible as I could possibly be," Bianca says. "I was rounding, rounding, rounding, rounding. I was in every nook and cranny of every unit—in the nighttime, the daytime, on the weekend, on the holidays. I think I pretty much lived here, probably for about a year, honestly. I wanted them to see that I cared about them … that we care, not just myself, but our leadership."
Today, leaders continue to round on their employees, and all employees get face-to-face time with their supervisor each month.
The meetings focus on a standard set of questions:
What's working well?
Who would you like to recognize?
What systems are working or broken?
What tools and equipment do you need?
"It's the kind of questions that will get at the heart of what's getting in the way of the employee doing meaningful, value-based work, and being recognized for it," Crabbe says.
Step 3: Make communication transparent
Leaders at Appalachian Regional have standardized communication boards in each department that articulate the organization's vision to employees, and that same information is covered during rounding.
The health system's CEO began hosting quarterly town hall meetings to which all employees were invited. Those meetings have evolved from canned questions to uncensored back-and-forth dialogue.
"When we first had town halls, we would ask people to send their questions in advance, and we would answer them in a scripted way," Crabbe says. "Now we're just to the point where we just open up the floor and ask, ‘What's on your mind? What do we need to do?' "
Crabbe says this is evidence that trust has formed between leadership and staff.
Step 4: Give recognition where it's due
To thank employees for their work to improve care outcomes, leaders have put their money where their mouths are.
In the first year after committing to revamp its vision and leadership team, Appalachian Regional found itself with a $2 million budget surplus due to a 2% increase over budget in operating margin.
Without hesitation, the CEO at the time said, "We're going to give it back to the employees that got us there," Crabbe recalls.
"It was a great day for Kim and I and our whole leadership team. We stood in our auditorium, and by surprise, we handed out $500 checks to every single employee."
However, recognition does not always have to come with money attached.
Thanks to her rounding, Bianca knows the names of the employees involved in patient care, and she takes the time to send them handwritten thank-you notes.
"People really do appreciate it, and they really feel very special when they get one of those notes at their house," Bianca says.
Step 5: Measure results
By rounding on patients and employees, providing sincere rewards and recognition, fostering leadership development, and creating transparent two-way communication, the hospital system achieved the following measurable results:
Improved employee engagement from the 19th to 86th percentile within 10 months
Moved quality from below the 50th to the 75th percentile in four of eight HCAHPS domains in 18 months
Achieved HCAHPS rankings at the 75th percentile in six of 10 patient experience domains
Achieved a $2 million budget surplus, due to a 2% increase over budget in operating margin
Judging by these numbers, it seems the old adage that happy employees equal happy patients is true.
"Our thought was that when we have engaged employees, everything else doesn't just automatically fall into place," Bianca says, "but it obviously lays an infrastructure for the patient experience and for quality."
Study finds physicians tend to practice in more affluent communities while NPs practice in areas of higher socioeconomic need.
In healthcare there’s a long-standing assumption that physicians go where the money is—affluent communities with already healthy populations.
Researchers at the University of Michigan wondered if this was, in fact, true, and sought to find out via the study,Supply of Healthcare Providers in Relation to County Socioeconomic and Health Status, published in the Journal of General Internal Medicine.
"The U.S. health workforce is now an eclectic mix of different providers. We thought it'd be interesting to see if other providers such as nurse practitioners and physician assistants established their practices in more affluent communities such as medical physicians," says Matthew Davis, PhD, assistant professor at the U-M School of Nursing, in a news release.
The researchers compared the number of physicians, physician assistants, NPs, and chiropractors available in counties at different levels of income and health status using life expectancy as an indicator of the need for healthcare.
They found that more physicians, PAs, and chiropractors are available in the most affluent areas with people who have a high life expectancy.
NPs, however, are different.
When the researchers examined where NPs work, they found the availability of NPs was about 50% higher in the least-healthy counties compared to the healthiest.
Additionally, more NPs practiced in lower-income areas with low life expectancy.
"That was nice to see," Davis says. "The nurse practitioner workforce appears to be having some positive effects. Our work shows that nurse practitioners are more likely to set up shop in areas of higher need and other studies have shown that they provide a substantial amount of care for individuals with chronic illness."
This, paired with the fact that in many states NPs can practice independently, is something that should be considered when setting policies aimed at improving access to care, the researchers write.
One hospital's multimodal approach has successfully lowered infections.
For Necia Kimber, RN, CIC, MHA, infection control practitioner at Stillwater (Oklahoma) Medical Center, "one infection is too many." Fortunately, when it comes to C. diff, Kimber has infection rates at the healthcare organization at just the right number: zero.
Thanks to a multifaceted approach, the 177-bed hospital with average daily census of 60 patients, has not seen a hospital-acquired case of C. diff since October 2017.
While the organization's rates were not above the national average, Kimber still wanted to reduce the bioburden—particularly of C. diff, MRSA, VRE, and CRE—within the hospital.
"We didn't have a high rate that made me say, ‘Oh, my goodness!' It was just wanting to do overall good and making sure we were doing the best we could," she says. "This is the hospital I'm going to bring my family to and I want to provide the best care for anybody who walks through that door."
Here are three ways Kimber achieved lower infection rates at Stillwater Medical Center:
1. Education
Kimber spearheaded an antimicrobial stewardship program at the facility in 2017. There was also assessment of and education regarding ordering of C. diff testing.
"[As healthcare professionals], when you have a patient and you can't find anything with normal testing, we tend to expound our testing," she says. "Sometimes it would end up hurting us with pay-for-performance—if [the patient] tested positive for [C. diff, it] didn't mean they were actually infected with it. They can just be colonized with it."
The infection control team provided education on national standards for ordering C. diff testing, including testing only when patients were symptomatic of the infection. The IC team provided nurses and physicians with education on when to implement C. diff precautions with the intent that earlier intervention would prevent transmission.
2. Hand hygiene and cleanliness
Hand hygiene was a focus area for preventing the spread of infections at Stillwater.
"We do a program that's a commitment to excellence," she says. "Last year we did a huge push on hand hygiene."
Each month, "secret shoppers" do direct observation on the units to assess issues regarding hand hygiene.
"What we check for is hand hygiene upon entering the room and upon leaving the room," Kimber says.
To increase patients' sense of safety, Kimber says she has reinforced hand hygiene practices with clinicians so that even if nurses or physicians have just cleaned their hands with alcohol foam or gel after exiting a room, they need to reapply it if they are going directly into a new room, even if they have not touched anything between rooms.
In addition, Stillwater Medical Center is using a bleach-based product to clean all rooms and equipment after a patient is discharged.
"We used to only [use bleach] on positive C. diff rooms," Kimber explains. "Now we use it on all rooms because there are so many people who are carriers and not showing signs [of infection] until after they've been discharged."
Kimber also educates environmental services staff on the "why" behind cleaning techniques.
"What we honed-in on is the actual cleaning of the area—friction and leaving the products on for the allotted time to disrupt the replication of cells and bacteria," she says. "We've done a ton of education on how to clean, when to clean, and why to clean."
3. Robots
While the campaign took place over a year, Kimber says it was the addition of pulsed xenon ultra-violet robots that drove C. diff rates down to zero.
"What we saw with our use of the UV robots, which we started in October 2017, was that for the last quarter of the year, our C. diff hospital onset cases have been zero," she says. "I've been an infection control nurse for almost 18 years and I'd never seen a drop as dramatically as I had in C. diff after implementation of the UV robots."
While the robots are not cheap, Kimber estimates that each machine costs about $100,000. Stillwater purchased six robots.
"You always worry about surgical-site infections, and you always worry about those infections that patients get in the hospital such as C. diff, MRSA, CRE, and VRE," she says. "By national standards one C. diff infection is about $30,000 when you look at morbidity and length of stay. For surgical-site infection, if it's a hip or a knee, you're getting into the hundreds of thousands. So, for example, with surgical-site infections if you could just save one surgical-site infection—say a hip or a knee—you've already saved $100,000, so your ROI will be pretty quick in knocking your infection rates down."
Kimber says she encourages infection control practitioners to talk with their colleagues about effective solutions for decreasing infections—whether it's using education, technology, or something else.
"I recommend people do their own research and find out what's best for their facility and what their actual needs are," she says. "Infection control nurses have a pretty tight network, so talk to your colleagues and see what they're doing in their hospitals. Talk to the ones that are the same size as you and bigger than you and see how you can glean information from that."
Kimber says, "There were tons of things that went into [reducing hospital onset infections]. Having that rate down to zero for three months has been a huge accomplishment."
One nurse leader is on a mission to see whether the concept of work-life balance exists.
Work-life balance is a hot concept in the nursing profession. We hear we need it. We want to achieve it. But does it really exist?
That question has piqued the interest of Adele A. Webb, PhD, RN, FNAP, FAAN, senior academic director of workforce solutions at Minneapolis-based Capella University.
"People think they need it," she says. "But, do they? Can you ever have it? Or are people chronically dissatisfied because it's like a unicorn … they're chasing something that doesn't exist."
Balance vs. satisfaction
Webb plans to study and delve into the concept of work-life balance and nurses. She says recent conversations with nurse executives, including those at HealthLeaders Media's 2017 CNO Exchange, left her realizing that the idea needs to be better defined.
"Years ago, I read an article called Balance is Bunk!," she recalls, "and [the point] was you never have 50% this and 50% that. Sometimes work takes more, sometimes family takes more."
For example, if a nurse must take off from work to stay home with a sick child, on that day, family needs more focus than work. And there are times, especially for those who work weekends or holidays, where work will eclipse family.
Still, Webb understands the desire behind the idea of work-life balance.
"What does work-life balance really mean? It means you're happy. Well, what does happy mean? Happy means you're satisfied with what you're doing," she says. "I think what people really want is life satisfaction. They can be satisfied at home and satisfied at work even if it's not balanced."
Generational differences
Another question Webb says she is pondering is: "How then do we address or encourage satisfaction and what does that mean?"
She has noticed, even among her own family, that different generations of nurses crave different things.
"I have a daughter and a granddaughter who are nurses. My granddaughter is definitely a millennial. She's 24, new in her career, and what she wants is opportunity," Webb says. "She's always reading, trying to better her skills, and to learn something new."
This drive to further their skills and their careers is a trait often tied to the millennial generation. However, it can also be a factor that contributes to their workplace turnover. According to the RN Work Project, almost 18% of newly licensed RNs leave their first employer within the first year.
"We have the job to educate these younger nurses on opportunities to find satisfaction in the job they're in. So, when you want more, you can sign up for a committee. You can look at policy in your community or state. There are opportunities outside of leaving your unit that can meet your needs," Webb says.
"How exciting it would be for a young nurse to have the opportunity to be on the quality committee at a hospital. Or to have the opportunity to contribute to care algorithms or standards or care or policies. They would learn [so much] from it [and] they could contribute so much."
While baby boomers are more likely to stay in their positions, they, too, have a need for life satisfaction and often value time and self-fulfillment, says Webb.
For example, offering tuition assistance to pursue a master's degree may give this generation a sense of satisfaction. Or, they may find fulfillment in sharing the knowledge they've garnered over their years of experience.
"[Give them] the opportunity to be involved and be on a budget committee at the hospital and understand the finances and the contributions they make," Webb suggests. "Train them to be preceptors. Let them share that knowledge with the younger generation."
What's next?
Webb is in the beginnings of reviewing the literature for existing information on work-life balance and satisfaction and plans to interview nurses about their insights. Once she has a working thesis, she plans to connect with nursing professionals through presentations and conferences to see whether her definition and evaluation of work-life balance or work-life satisfaction rings true.
From bundled payment models to uncompensated care, here are developments in the reimbursement realm to keep nurse leaders informed.
It's probably safe to say that nurse leaders' favorite subject is not finance. But in today's healthcare industry, financial incentives and reimbursement have become so entwined with patient care and outcomes, that you cannot have one without considering the other.
Below are recent HealthLeaders Media articles to help nurse leaders make sense out of the dollars and cents attached to patient care.
Last year the Centers for Medicare & Medicaid Services reined in its mandatory bundled payment models, leaving many healthcare providers concerned that investments they made to prepare for these models might for naught, writes HLM senior leadership editor Philip Betbeze.
Participants in the new model will be expected to keep Medicare expenditures within a defined budget while maintaining or improving performance on these seven specific quality measures:
All-cause hospital readmissions
Advanced care plan
Perioperative care: Selection of prophylactic antibiotic: First or second generation Cephalosporin
Hospital-level risk-standardized complication rate following elective primary total hip arthroplasty and/or total knee arthroplasty
Hospital 30-day, all-cause, risk-standardized mortality rate following coronary artery bypass graft surgery
Excess days in acute care after hospitalization for acute myocardial infarction
AHRQ patient safety indicators
The enrollment deadline in the model is nearing. The BPCI Advanced portal closes March 12.
CMS is changing its formula for calculating and allocating funds for uncompensated care for hospitals that qualify under its Disproportionate Share Hospital program. This new method presents both opportunities and challenges for organizations.
Thanks to the changes, hospitals may be able to identify care currently written off without a determination of financial need. Additionally, the new methodology for calculation of
Factor 3—a hospital-specific factor representing its share of the total uncompensated care provided—may allow hospitals to capture a larger portion of uncompensated care funds.
However, leaders should be aware that CMS is phasing in the use of cost report Worksheet S-10 data, including charity care and unreimbursed bad debt. This year, one-third of Factor 3 will be based on this data, but by fiscal year 2020, use of this data will be fully implemented.
To ensure they comply with reporting data on Worksheet S-10, leaders need to review new guidance from CMS as well as their own organizational policies for charity care determinations, uninsured patient discounts, and bad debt collections. Training for staff involved with submission of the cost report and handling charity care write-off is imperative.
One concern consistently raised about the implementation of pay-for-performance models is that healthcare providers and organizations serving more complex patients would not reap the same rewards as hospitals caring for less sick patients.
Now new research suggests that those fears may be warranted. A November 2017 study in the Annals of Internal Medicine found that Medicare's Value-based Payment Modifier program inadvertently shifted money away from physicians who treated sicker, poorer patients to pay for bonuses that rewarded practices treating richer, healthier populations, writes HLM senior editor John Commins.
In an interview with Commins, the study's lead author Eric Roberts, an assistant professor of health policy and management at the University of Pittsburgh Graduate School of Public Health, says that if changes aren't made, value-based payment models will continue to foster this inequity.
"Risk adjustment is usually inadequate in these programs, in part, because it is difficult to measure the differences in complexity of patients across providers. We need to take a careful look at how incentives in these programs are structured and how performance is assessed in order to create the right incentives to improve value and outcomes for the most vulnerable patients," Roberts says.
Changes to Cincinnati Children's Hospital's nursing management structure led to increased professional development opportunities and greater interest in nursing management positions.
This article first appeared in the January/February 2018 issue of HealthLeaders magazine.
Results
Hoying has sought feedback from targeted conversations with nursing directors and managers, and they have reported positive changes in their workload. Feedback was collected through email, interviews, and conversations.
In qualitative statements during these conversations, nurses reported increased managerial coverage on the off-shifts, and directors and managers said they fielded fewer calls in their off-hours, particularly during the evening.
Directors reported being able to delegate items to their managers for follow-up rather than staying to resolve issues themselves.
They also reported having the time for strategic planning, networking, process improvement, education, and mentoring. One-to-one time with direct reports has also increased, and onboarding and communication with new staff members has improved.
"The mentorship between directors and nurse managers has been wonderful," Hoying says. "When a director position came open recently, seven managers applied for it."
Indeed, applications for nurse manager and director positions have risen. In 2010, there were 19 overall applicant submissions for manager and director positions in the patient services department. In 2011, the numbers rose to 179 applicants for 16 positions. In 2016, there were 240 applicants for 31 positions.
"We have been able to fill these open positions internally rather than seeking these candidates from the outside," Hoying says.
"What we incorporate into our programs is the science and the art of nursing, because we feel it is a solid foundation professionally. So it's creating the leader within yourself and coaching others."
—Cheryl Hoying, RN, PhD, NEA-BC, FACHE, FANN, senior vice president of patient services, Cincinnati Children's Hospital Medical Center
The manager-to-FTE ratio has helped free up time for managers and directors to pursue internal and external professional development opportunities.
"We build in [time] for the director to help mentor and coach the nursing group that's coming up in the ranks," Hoying says.
Since 2008, the organization has had one participant in the Executive Fellowship in Innovation Health Leadership offered by AONE and Arizona State University; two participants in the AONE Nurse Director fellowship; 11 participants in the AONE Nurse Manager Fellowship, and two participants in the AONE Healthcare Finance for Nurse Executives Certificate Program.
"As the CNO, it is my responsibility to make sure the right resources are provided to enable the unit leadership to be successful and enjoy their role. If not, and that role turns over, it affects everybody on the unit," says Hoying.
Despite evidence that advanced practice registered nurses improve outcomes and access to care, the American Medical Association calls for strategic opposition to APRN independent practice.
In May 2015, the National Council of State Boards of Nursing introduced the licensure model called the APRN Compact. The model would allow advanced practice registered nurses to have one multistate license that provides the ability to practice in all compact states. The compact will go into effect when 10 states have enacted legislation.
So the American Medical Association's November 2017 resolution to create a strategic campaign to oppose legislation that includes the APRN Compact model and independent practice is perplexing.
Thus far, Idaho, North Dakota, and Wyoming have passed legislation in favor of the compact while Nebraska and West Virginia have legislation pending.
The idea of the APRN Compact makes sense. I am not an APRN, but when I worked in telehealth, I had to maintain multiple licenses—California and New York in addition to my Illinois license.
The process of applying for multiple licenses is time-consuming and cumbersome because each state has different requirements. Maintaining multiple licenses is a feat as well since each state has different continuing education requirements and different renewal time frames.
And, as I wrote about in the June HealthLeaders magazine, APRNs Improve Quality Outcomes, Cost of Care, decades of evidence shows that both APRNs and physician assistants produce quality outcomes similar to or better than physicians.
In this changing healthcare industry where technology has the potential to improve access to a healthcare provider, healthcare professionals need flexibility to efficiently work across state-lines. The APRN Compact would help APRNs provide high-quality care and improve patient outcomes in a larger geographic setting.
Nursing Groups Speak Out
The amendment to the AMA's resolution 214 occurred at the organization's Interim Meeting of the House of Delegates on November 11–13 in Honolulu.
According to its website, the American Society of Anesthesiologists, pushed for the resolution to engage "the entire house of medicine in a strategic initiative to oppose the efforts of non-physicians at the state and federal level to dismantle physician-led team-based models of care and, specifically, to oppose the harmful Advanced Practice Registered Nurses (APRN) Compact."
The ASA has typically opposed independent practice among certified registered nurse anesthetists. The group was vocal about this topic during last year's public comment period on extending full-scope of practice authority to APRNs working at the Department of Veterans Affairs. The result—a final rule that the VA granted full-practice authority to certified nurse midwives, clinical nurse specialists, and nurse practitioners, but not CRNAs.
Many nursing groups, including the American Association of Nurse Anesthetists, were not pleased with the AMA House of Delegate's recent move.
"Patients across the United States, especially those in medically underserved areas of the country and the military, rely on non-physician providers such as CRNAs for excellent, timely healthcare," says Bruce Weiner, DNP, MSNA, CRNA, AANA president in a news release. "Yet once again, here comes the AMA with its latest resolution seeking to prevent CRNAs and other highly qualified healthcare experts, who are not medical doctors or doctors of osteopathy, from caring for patients to the full scope of their education, training, and licensure."
Pamela F. Cipriano, PhD, RN, NEA-BC, FAAN, president of the American Nurses Association, calls for an end to the long-standing "turf war" between some physicians and APRNs.
"For AMA to imply that APRNs are incapable of providing excellent care or that their care puts the patient at risk is blatantly dishonest. The future of healthcare calls on all healthcare professionals to work together as a team to meet the growing demand for healthcare services. This dated way of thinking does a disservice to the public and is in direct conflict with the evidence-based recommendations advanced by the Institute of Medicine (now the National Academies of Sciences, Engineering, and Medicine). Research clearly shows that nurses consistently deliver exceptional care with high patient satisfaction," she says in an ANA statement.
"The AMA's resolution 214 aims to perpetuate longstanding turf wars between some physicians and nurses, which foster unnecessary impediments to patients receiving quality healthcare services. ANA invites leaders of the AMA to work with us on measures that will increase access to care," she says.