patient safety quality healthcare

January/February 2013
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Nurse Leadership from Bedside to Boardroom

Nurse Leadership from Bedside to Boardroom

Nurses add something quite unique to the experience of safe and patient-centered care, particularly during hospital stays. They are the ones most able to connect, communicate, and coordinate across multiple departments, professional opinions and voices, and the hurried schedules of a patient’s day. Advocating and designing care WITH the patient and family is a true skill set and cultural attribute that adds tremendously to a culture of safety and patient-centeredness but requires the most able leadership to build these bridges across the many professionals engaged in care. Building this culture is a leadership challenge and there is no one, in my experience, better able to make these changes than nursing leaders.
— Maureen Bisognano


There is increasing recognition that nurses must be involved as leaders and decision-makers throughout healthcare, not just at the bedside or within the nursing community. Nurses are executive leaders in health systems and hospitals, of course, and also in professional associations, accrediting organizations, businesses, government, and universities. Within the nursing community, many feel that the skill set nurses need for modern-day practice also makes them valuable contributors throughout health systems, especially in leadership positions. As Maureen Bisognano points out, the best nurses are accomplished envoys among different players and interests involved in direct patient care, which is a skill needed throughout organizations and businesses, not just in hospitals or healthcare.
To develop a sense of how nurse executives view their work, Patient Safety & Quality Healthcare (PSQH) conducted a brief, informal survey of nurses who hold leadership positions in a range of organizations (see sidebar on page 34). We asked them to describe their roles; the challenges they face, especially regarding safety and quality; and accomplishments in which they take special pride. We also asked about their views of the relationship between patient safety and safety in the workplace and the usefulness of social media in their work lives.

Their responses are not presented here as “typical” or to represent a cross-section of nurse executives; in reality, they represent a “tip of the iceberg” view. In their responses, these nurses draw from deep wells of expertise, experience, and commitment to improving healthcare delivery. They deserve copious thanks for the thoughtfulness of their responses as well as for their contributions to the healthcare community. When I sent the initial surveys to a small group by email, I was thrilled to see immediate engagement—quick responses, willingness to participate, and fluid networking as my survey was shared and forwarded to colleagues. These busy executives were generous with their time and clearly interested in advancing opportunities for nurse leaders to make satisfying, lasting contributions.

All Nurses Are Leaders
Laura Caramanica, immediate past president of AONE (American Organization of Nurse Executives), points out that while some nurses hold executive positions, all nurses are leaders. This is an important point, especially in the context of U.S. healthcare reform and other developments that intensify our need to empower all executives, staff members, clinicians, patients, and families to advance their practice (whatever it may be), improve their institutions, and support one another to provide the best experiences and outcomes possible.

In Fostering Nurse-Led Care (2013), Ives Erickson, Jones, Ditomassi, and other contributors observe that leadership is an element of practice for all nurses, “from the bedside to the boardroom.” To successfully engage their “inner leaders,” bedside nurses need strong leadership from other nurses. According to Burke, Gallivan, Tenney, and Whitney,

For nurses to find that “leadership within,” they need to be provided with high-quality management; a workplace where they can be mentored and can develop good working relationships with others within and beyond their discipline; and opportunities for the development of communication, team-building, and problem-solving skills, along with clinical nursing knowledge (Ives Erickson, p. 242).

In her response to our survey, Jeanette Ives Erickson (lead editor of Fostering Nurse-Led Care) describes a new initiative at Massachusetts General Hospital called Innovation Units, which promote relationship-based care and offer a new opportunity for clinical leadership, a position called the “attending nurse.” This new position and the Innovation Units are featured in a sidebar.

Nurse Executives Supporting Patient Safety
Whether patient safety is explicit in their titles or not, all of the nurse executives I contacted play important roles in patient safety for their organizations. Among those who are working in hospitals, there is a broad range of responsibilities for assuring the quality and safety of patient care by providing a supportive work environment that includes effective systems, current technology, and a culture of safety:

The chief nurse is responsible for creating a practice environment that allows staff to do and be at their best in every moment. Beyond the operational aspects of quality and safety, as the chief nurse executive, I am ultimately responsible for two broad drivers of quality and safety: our organizational culture and the systems that support staff in their practice.
Culture conveys the accepted norms of the practice environment—our collective beliefs and values—that determine how we think about and respond to quality and safety issues and/or events of any type. It is my responsibility to cultivate a just culture of relentless caring that is vigilant about quality and safety. We know from the literature that organizations that value teamwork and are transparent, proactive, and patient- and family-centered, will be among the safest. Everyone plays a role in quality and safety—the people who clean the floors on a patient care unit, deliver meals, volunteer, administer medications, even patients and families, everyone—plays a role in quality and safety.

We also know that errors and safety issues are rarely the result of poorly performing individuals, but are typically the result of a system flaw. As chief nurse, I am responsible for ensuring we provide staff with the optimum tools and technology, policies, procedures, and guidelines available, and that these work together to support their practice.
– Jeanette Ives Erickson

When asked to identify the most persistent challenge they face in safety improvement, most respondents mention culture, accountability, and communication. Barb Olson finds that communication is a prime challenge:

The degree of communication—frequency, quality and specificity—required by highly specialized healthcare professionals to ensure an appropriate plan of care that addresses each patient’s individual goals is in place and is executed is mind-boggling. With this in mind, I would have to say that building an effective, multi-modal communication infrastructure—one that places the patient’s voice at the center—is the most challenging deliverable in taming the complexity beast.

Olson also puts “managing complexity” on her list of challenges. Saying that she has “learned a great deal by studying other high-consequence industries—commercial aviation, for instance—in which intended outcomes are delivered in a reliable fashion,” Olson goes on to examine what is different about complexity in healthcare:

Lucian Leape called out the differences in complexity in an article (in a urology journal, I think) that I read a long time ago that has helped me think about the usefulness of these comparisons. One hundred and fifty passengers on a commercial flight, for example, share just a few common goals, namely getting from Point X to Point Y safely and on time. A skilled flight crew of five, gate agents, and air traffic controllers routinely execute familiar, well-designed processes, including mission-critical safety checks, that allow passengers to attain their common goals (“on time” being the only outcome in which unwelcome variability occurs on a regular basis). But patients in a hospital lack the homogeneity of commercial airline passengers. Some people come to the hospital for healing, others to improve functional abilities, and others seeking palliative care that will promote better quality at the end of life.

Kerri Scanlon comments that it can be a challenge to maintain individual accountability in a non-punitive environment and adds that the current fiscal climate is difficult:

I think there are two main challenges. One is the creation of a non-punitive “just” environment. We have to balance accountability and a non-punitive approach. We have improved consistently in this, but it remains a challenge. Second is the cost. Given the current healthcare reimbursement environment, it is a fine balance to continually institute technological solutions to improve patient safety. We are fortunate as a health system that we are able to afford significant investments in this area.

Anne Challis’s list of responsibilities gives a sense of the varied agenda she and many other nurse executives oversee:

[My] role focuses on constituency satisfaction status, core measure compliance, expense management, and the role of the clinicians and providers in case management activities. Each of these areas is significantly impactful in patient safety. As Kooker (2011) describes, increased nurse satisfaction leads to nurse retention, which leads to improved patient outcomes. The role of the local CNO in these activities is inherent in improvement, and the supportive role of the DCNO [division chief nursing officer] has shown to drive advances in patient safety outcomes.

Laura Caramanica mentions accountability and the importance of establishing a culture where staff members feel secure enough to discuss near misses openly:

Becoming a high reliability organization requires persistence in holding staff accountable to ensure that all safety goals are taken very seriously. I agree with those that say checklists are not enough. Staff must feel safe in speaking up and sharing a near miss without fear of losing their job or license.

Maureen Bisognano observes that frontline nurses traditionally take pride in and are rewarded for solving problems in real time. The wrong tray is delivered, the infusion pump is missing, medications aren’t available—nurses do whatever is necessary to fix these problems for the benefit of their patients. This habit of developing “workarounds” is now recognized as a significant breach in safety. Bisognano points to this as an opportunity for nurse leaders to help frontline nurses develop skills and empower themselves to improve safety for all:
Nurses get promoted because they’re excellent fixers. In many hospitals, nurses are working around broken processes all day long, actions that are viewed as heroic and admirable. In many cases, a nurse who calls out an error or system problem is viewed as a complainer. We need to shift from that fix-it mentality to one where nurses feel comfortable calling out issues as system problems. Nursing leaders can help staff develop skills and build improvement capability at the frontline that empowers nurses to be equally effective at solving individual problems and making systemic improvements.

Workplace Safety
Everyone surveyed agrees that organizations should approach patient safety and workplace safety as closely related issues. Ann Scott Blouin’s comments about organizational safety culture at The Joint Commission represent a common theme in the responses:

[The Joint Commission] supports the belief that there is a relationship among factors influencing patient safety, organizational safety culture, and workplace safety, including the physical and psychological environment.

Jane Englebright succinctly describes the responsibility she and other executives feel for staff safety:

We cannot ask staff to be vigilant to patient safety issues without being equally vigilant to safety issues in the work environment.

Other comments from the survey about workplace safety reflect the complexity of issues included in a comprehensive commitment to staff safety:

It only makes sense, if an organization has achieved a “worker safe” environment, i.e. an environment where the worker feels protected and supported, along with established processes to achieve and maintain a safe working environment, then the potential for error will decrease, resulting in safer patient care delivery as well.
— Dana Alexander

There are many instances whereby it is only through worker safety that we can uphold safety for our patients. Some of these include providing “safe handling programs” to mobilize our patients and at the same time prevent harm to our caregivers; ensure safe staffing levels that when not present, may contribute to patient error; the use of protective mediums to prevent the transmission of infections to our staff and to our patients; and providing education and support to all staff so that they are equipped and better positioned to avoid an error that is preventable. All providers suffer when a patient suffers.
— Laura Caramanica

Our facility is extremely invested in improving worker safety, as evidenced by our CEO’s goal for 100% participation in the flu campaign and requirement of staff caring for high-risk patients to be immunized. Another example of our commitment to maintain a safe environment for our patients and employees was the implementation of a de-escalation education program for our staff caring for our behavioral health patient population, in order to reduce injury and maintain a more therapeutic milieu.
— Kerri Scanlon

The Lucian Leape Institute at the National Patient Safety Foundation (NPSF) has identified joy, the meaning of work, and workforce safety as a top leadership priority for the global advancement of patient safety. NPSF Interim President Patricia McGaffigan prefers the term “workplace health” and promotes a culture of safety that is all-inclusive. She also believes that a workplace that supports its staff members individually and collectively will promote success and allow the work itself to “thrive”:

To have a physically safe environment is critical, but perhaps even more critical is the sense of belonging, making a difference, respect, and being a valued employee that constitutes “workforce health.” I personally prefer this term over “workforce safety” because it could imply that we should just need to meet minimum standards for environments which are safe and free from harm. But we must do so much more. It is our job as leaders to understand both the obvious and hidden talents of our teams, and to do everything we can to bring out the best in our employees, both individually and collectively. “Goodness to people” is so much more than being transactionally kind to an employee. It is about investing in our staff, engagement of the team, valuing diverse contributions, and encouraging capable individuals and teams to make decisions and take responsibility for those decisions. In order for our workforce to feel truly safe, there must be direct “line of sight” at all levels of the organization, and a leadership philosophy that allows staff to learn from their experiences and feel supported by their leaders. When that becomes the essence of a culture, the work of an organization will thrive.



By Jeanette Ives Erickson, RN, DNP, FAAN
Senior Vice President for Patient Care and Chief Nurse
Massachusetts General Hospital (MGH)
Boston, Massachusetts

At a very critical time, staff members at MGH have taken a leadership role in redesigning care delivery, and our early evaluations point to some terrific results.

In March 2012, we designated 12 Innovation Units, where a philosophy of relationship-based care and 13 evidence-based interventions could be safely tested. Among the early results, we have seen a 5% decrease in length of stay; 3% drop in readmissions; and, patient satisfaction scores increasing at more than double the rate of other like units.

Central to the initiative is a new attending nurse (ARN). The ARNs function as clinical leaders, working with staff nurses, interdisciplinary team members, patients, and family members to manage the care of patients on a single unit from admission to discharge.

This role and the other interventions were designed around the Patient’s Journey—before, during and after hospitalization—looking at the areas where continuity of care and communication could be enhanced. Essentially, the ARN role is designed to manage between the spaces and coordinate the delivery of the care of patients on a single unit from admission to discharge, working with the entire healthcare team and the patient and family.

Upon admission, the ARN gives the patient and family a business card that establishes a ready and open line of communication. He or she then reviews a newly-developed “Welcome Packet” with patients and families. This includes a Patient & Family Notebook that includes a Patient Compact, overview of the care team, and space to jot down questions to review with caregivers. The ARN will consistently connect with the team of care providers reviewing each patient’s health plan, and post a “Goal for the Day” on an in-room whiteboard. And we’re also designing new ways to help prepare patients to make a smooth return home. For example, ARNs make post-discharge follow-up calls to patients to ensure they are following their plans of care and answer any questions. All of this ensures that the patient and family are viewed as part of the team.

The ARN is part navigator, advocate, educator, and discharge nurse, and gives patients and families a consistent presence throughout their hospitalization and after discharge. The ARNs’ five-day, eight-hour shifts, combined with an established relationship with the patient and family, provide both the care team and the patient and family with needed and reassuring continuity…and a familiar face, which can be invaluable during any hospitalization. Because the ARNs are staff nurses, they are better able to support the team in closing any gaps that may arise in this fast-paced world of health care.

The work of these Innovation Units can be replicated elsewhere, in whole or in part, and on a small or a larger scale. We are now spreading the tested and refined interventions to a second wave of 23 MGH patient care units. We are also beginning to share the “lessons learned” and best practices with outside organizations. More information is available at www.mghpcs.org/Innovation_Units.


Nurses as Business Executives
Some of the nurses who responded to our survey serve in executive positions in businesses. They each bring experience as bedside nurses, and often as hospital executives, to the commercial setting. Their identity as nurses shines through their comments, regardless of the work environment. They express feeling responsible for representing the interests and knowledge of nurses, as well as patients, in their business roles:

We realize that nurses are impacted by nearly every decision a hospital makes, and the only way to really ensure quality and safety in our products is for nursing to lead Capsule’s entire product strategy (the vision). Over the years, my role [as CNO] has evolved to a point where I’m now responsible early and throughout the entire product lifecycle: from design to implementation, to optimization (the voice). I can confidently say that our products are designed “with nurses for nurses.” Promoting the exchange of evidence-based safety practices is stressed continually in meetings, and I nurture a culture that embraces patient and caregiver safety on a daily basis.
— Susan Niemeier

By developing “smart” software that integrates the best of research and data-driven patient care, we can help prevent many patient safety issues such as nurse fatigue and understaffing. In my role as vice president of nursing for API Healthcare, I help the innovation team wrap clinical evidence into the development of smart workforce management systems that schedule caregivers based on evidence instead of the traditional opinion-based models.


• • •

In order to effectively use smart staffing systems, the user experience must be simple and easy to use for the frontline staff. Greater safety outcomes are achieved by integrating the voice of the clinician into the design of solutions, developing systems that are congruent with the science of human factors, and including how caregivers think and do their work.
— Karlene Kerfoot

Ann Scott Blouin observes that nurse leaders are filling many “non-traditional” roles in healthcare businesses, including medical suppliers and payers, and suggests that this is an area for future study. In addition to being responsible for customer relations for more than 20,000 organizations and programs The Joint Commission accredits and certifies, Blouin is also executive sponsor and senior staff member for the Joint Commission’s Nursing Advisory Council. Blouin reports,

The Council developed a seminal contribution to advancing the dialogue and dissemination around the Institute of Medicine’s (IOM) Improving the Future of Nursing, which was funded by Robert Wood Johnson Foundation. The 22 strategies developed by 28 “thought leaders” in nursing and healthcare were accepted by the Board of Commissioners in November 2011. Work continues at The Joint Commission to implement various aspects of those 22 strategies.

A Nurse is Always a Nurse
As much as it’s true that all nurses are leaders, it seems also to be true that nurses are centered on the needs of patients regardless of where they work. Reality, of course, is often more complicated than that idealized view, but this notion of nursing identity, which includes leadership qualities on display in corporate settings and in the daily life of the bedside nurse, was a strong theme among the nurses who contributed to this article.

Patricia McGaffigan expresses this is in personal terms:

I’m often asked why I left nursing…and I always respond that I have not. The diverse skills, including situational assessment, critical thinking, crucial conversations, and bridge building that I’ve cultivated as a nurse have served me exceptionally well in all of my jobs. Understanding how to transfer and translate core skills into future roles is so enabling for diverse career path growth and success. If we keep the patient and family at the center of everything that we do, which is the job of not only frontline nurses but nurses who have any presence in the healthcare system, we will stay on the right course and make wise decisions.

Susan Carr is editor and associate publisher of Patient Safety & Quality Healthcare (PSQH). She may be contacted at This email address is being protected from spambots. You need JavaScript enabled to view it. .

References
Committee on the Robert Wood Johnson Foundation Initiative on the Future of Nursing, at the Institute of Medicine. (2011). The future of nursing: Leading change, advancing health. Washington, DC: National Academies Press.

Ives Erickson, J., Jones, D. A., & Ditomassi, M. (Eds.). (2013). Fostering nurse-led care: Professional practice for the bedside leader from Massachusetts General Hospital. Indianapolis, IN: Sigma Theta Tau International.

Kooker, B., & Kamikawa, C. (2011). Successful strategies to improve RN retention and patient outcomes in a large medical centre in Hawaii. Journal Of Clinical Nursing, 20(1/2), 34-39. doi:10.1111/j.1365-2702.2010.03476.x

Olson, B. On your meds: Straight talk about medication safety. Available at http://blogs.medscape.com/onyourmeds

CONTRIBUTORS
To learn more about the role nurse executives play in patient safety, PSQH corresponded with nurses who currently hold executive positions and were willing to respond to a short list of questions, which were distributed by email. PSQH is grateful to these nurses for their time and the thoughtfulness of their answers.


PSQH CAREER CENTER

SPONSORS

ABQAURP American Society for Quality American Society for Quality Healthcare Division Consumers Advancing Patient Safety
EMPSF Institute for Safe Medical Practices
           
Medically Induced Trauma Support Services (MITSS) Medication Safety Officers Society NPSF Partnership for Patient Safety Society to Improve Diagnosis in Medicine