Patient Care Delivery and Work Design

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					Healthy Work Environments: Striving for Excellence                                May 2003

1.       Patient Care Delivery and Work Design

         Excellence is not an accomplishment. It is a spirit, a never-ending process.
                                                    -- Lawrence M. Miller

Improved service delivery and work design are integral to the multifaceted strategies
hospitals are pursuing to strengthen the nursing work environment. Almost every hospital
in this study has indicated that the process used to achieve work redesign and improved
patient care is critical to its results. Unlike the aggressive cost-cutting re-engineering
efforts some have experienced in the past, the hallmark of recent efforts has been the
heavy involvement of frontline staff in team decision-making processes that focus on
what’s best for the patient, not just for the staff or the hospital’s bottom line. For such
processes to succeed, visibly supportive hospital and nursing leadership is also essential.

The examples below illustrate various methods different organizations have used in
developing care delivery improvement and work redesign processes, as well as some of
the results of those efforts. Common areas of focus have included delineation of nurse
manager and staff roles, unit staffing ratios and mix, incorporation of non-professionally
trained personnel into the care delivery team, reduction in staff nurse responsibility for
non-nursing functions, decentralization of clinical education support, interdisciplinary
decision-making on clinical issues, and enhanced coordination of continuums of care.

     •   York Hospital created a multidisciplinary design team that met with
         frontline staff on every unit to reach consensus on core principles to guide
         care delivery model changes and assist the application of the principles to
         each unit’s patient population. Nursing staff similarly participated in
         developing an entirely new process for admissions, which greatly
         alleviated the amount of paperwork and time required from nurses on
         each unit.
     •   Bayfront Medical Center reassessed traditional nursing roles on its
         Progressive Cardiac Unit for cardiac patients. This involved pilot testing
         alternative staffing patterns, including an innovative model that expanded
         the role of patient care technicians who participated in an incentive
         program for skill development training.
     •   Main Line Health System has carried out service redesign initiatives in
         all of its three hospitals to strengthen the application of patient-focused
         care principles. These efforts have resulted in improved benchmarking,
         clarification of care team member roles and relationships, enhanced
         organizational skills and leadership development for nurse managers, and
         greater physician understanding and involvement in care redesign efforts.
     •   North Mississippi Medical Center used a participatory planning process
         to engage managers and staff in revising nursing roles and scope of
         practice policies. Driven by a vision of patient-centered care, the redesign
         process built consensus on having the bedside nurse recognized as the

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       manager and coordinator of care, along with the adoption of a “plan of
       care” model that is much more interdisciplinary.
   •   Hartford Hospital has gone through two major care redesign processes
       over the past decade. The first established multidisciplinary
       “collaborative management” teams as the foundation of its patient-
       focused care model. The second further refined and modified manager
       roles and workforce relationships, with particular attention to delivering a
       better continuum of care to each patent treated in an acute inpatient or
       ambulatory care setting.
   •   Vanderbilt University Hospital initiated care redesign efforts in the
       mid-1990’s with a focus on patient centered care. Since then, it has used a
       disciplined approach to continuous quality and work process
       improvement as a means to make care delivery innovation a fundamental
       component of the hospital’s culture. In recent years this has entailed
       further refinement of performance measurement and feedback systems as
       well as other work environment improvement initiatives.
   •   Baptist Health in Miami found that changes made in an earlier re-
       engineering process had dysfunctional consequences for unit staff and
       managers. This led to a staff-driven work redesign initiative using fast-
       track process improvement teams that enabled each unit’s staffing model
       to reflect its patient population profile, workloads, case mix, and other
       patient characteristics.
   •   Sinai Hospital of Baltimore reassessed an earlier re-engineering decision
       that eliminated an entire layer of middle management by making clinical
       directors responsible for multiple units with the assistance of a number of
       clinical coordinators. With the hospital’s increasing dependency on
       agency and traveling nurses, a new redesign initiative led to a
       fundamentally revised approach that has addressed concerns about costs
       and the continuity of quality nursing care.
   •   Inova Fairfax Hospital used a well- supported multidisciplinary group of
       clinical directors to assess and redesign admission and discharge
       processes. The group also took the lead in managing and evaluating the
       implementation of the changes made. Another system- wide initiative
       similarly relied on empowered care delivery teams to establish an
       “outcomes-driven” case management system that better leverages Inova’s
       integrated health care resources to enhance patient care.
   •   Lowell General Hospital went through a major turnaround in which
       nursing leadership played a key role in successfully engaging nursing
       managers and staff in a process of operational and cultural change.
       Nursing leaders used a variety of methods to emphasize such values as
       productivity, customer focus, openness to change, and leadership
       accountability for performance through care redesign and operations
       improvement initiatives.

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Care Delivery Model Redesign

Several factors led York Hospital to undertake a major care delivery redesign initiative in
the late 1990’s. These included increasing patient acuity, pressure for shorter lengths of
stay, declining indicators of both patient and nurse satisfaction, and growing nursing staff
burnout and turnover. In response, a multidisciplinary care delivery design team led by
nursing was empowered by hospital leadership to (1) conduc t a situation assessment, (2)
identify alternative “best practice” patient care, (3) determine what changes to make in
York’s care delivery model focusing on what would be best for the patient, and (4) do
whatever was necessary to get these changes impleme nted.

Design team members went to every nursing unit and involved frontline staff in a shared
decision- making process. It took over a year to develop consensus on a set of core
principles to guide care delivery model changes and engage staff in determining how best
to apply them to each unit. The process was assisted by bringing in a consultant to work
with design team members and management to prepare educational programs for staff to
explain why change was needed, what options were considered, and how the proposed
principles and framework should be applied and adapted to specific patient population
needs. After conducting two educational sessions, the consultant coached several nurse
executives and managers to assume that role; the consultant then became an adviser who
was called upon on an as-needed basis as the process unfolded.

From the start, the hospital’s CEO was clearly invested in the care model redesign
process. According to nursing leaders, his commitment was a key factor in success of this
effort. He championed the importance of applying three “value screens” in the decision
process: “Focus on the patient first, employees second, and cost third.” The outcome was
significant staff participation and support in implementing a redesigned care delivery
model that entailed important changes in the roles and mix of nursing personnel. Overall,
there was virtually no reduction in RNs, some reduction of LPNs, and a substantial
increase in the use of nursing assistants, with variation among specific nursing units.

Patient Tower Facility Program Development

The hospital used another empowered design team-driven planning process with
substantial frontline staff participation to develop a forward- looking, patient-centered
program design for a new patient tower. Inspired by futurist Russell Ackoff’s admonition,
“Design the future you want now, and plan backwards,” this planning process involved
50 staff representatives in a visioning conference with senior management and nursing
executives. This was followed by regularly scheduled design team meetings and frequent
briefings and dialogue with frontline staff about future critical success factors for a
patient-centered care environment, along with their implications for facility design
options to be considered. According to one nurse executive, “We had night staff coming
in for these sessions after they had finished their shifts. People turned out for them

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because they knew their input would be heard and that their participation was

Express Admissions Unit

York Hospital’s Express Admission Unit is a relatively recent initiative that developed in
response to a concern repeatedly voiced by staff nurses. Staff members stressed that what
takes the most time away from their ability to provide direct patient care is the amount of
paperwork and time required for patient admission and discharge. These functions were
also among those most frequently mentioned in staff surveys and exit interviews as
factors contributing to increasing workload stress and staff burnout.

In response, a work process assessment and redesign team was charged with addressing
these concerns with the active participation of ER and unit staff nurses, physicians, and
hospital administration. The assessment entailed a comprehensive examination of bed
management and patient flow processes, with particular attention given to patients who
arrived at the ER without the knowledge or advice of a personal physician. In addition to
researching external models, team members used interviews and focus groups to gather
opinions and perspectives from all the caregivers involved. This process enabled
participants not only to define the problem and its causes, but also to provide ideas about
how improvements could be made.

According to one executive, the process led to a “total turnaround” in the way patient
admitting had traditionally been done at the hospital. The result was a redefinition of staff
roles in support of a new discrete unit within the ER that would handle the initial
admitting process fo r most patients so that they would arrive on the nursing unit as
transfer patients. Not only has the new process been greatly appreciated by staff nurses
on the units, it also been recognized for being a model of effective partnering by the
nurses, doctors, and administrators who tackled this important operations improvement
issue together.

Clinical Informatics and Performance Measurement

Nursing executives and frontline staff at York are now actively engaged in a planning
process with an IT vendor partnering with the hospital to determine how the future
applications of information technology can be done from a “clinically-driven and
informatics-supported practice perspective,” and not the other way around. Already this
process has led to the introduction of a new order entry system. Other projects are being
developed with significant input from staff nurses.

The nursing director for clinical and professional development has been conducting an
assessment of how the performance measurement and improvement process currently
used at York compares with the nursing quality indicators and benchmarking process
standards prescribed by the Magnet Recognition Program. To provide support for the
assessment, the hospital has recently hired a nursing performance improvement

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coordinator. The assessment is being done in part because the hospital is exploring the
possibility of developing an application for ANCC Magnet designation.

Internal advocates of York’s pursuing Magnet designation see the application process as
one way to “raise the bar” regarding how nursing quality, patient outcomes, and
performance improvement are approached by the hospital. York Hospital already uses
many national benchmarking indicators to measure patient quality and nursing
performance. However, some nurse managers emphasize there always are opportunities
for strengthening quality measurement and improvement processes.

According to one clinical director, Magnet Program standards require applicants to
demonstrate that their nursing program uses an evidence-based approach to assess
nursing excellence and support a professional nursing practice environment.
“Traditionally, nurses have been task-oriented, and have measured their practice by their
ability to do task X, Y and Z. By contrast, the professional nurse puts it all together and
sits with the physician to discuss the patient’s needs and the appropriate care plan.”

Physician Relations

For many years, York Hospital’s leaders have worked to foster collaborative working
relationships with physicians, and this remains a continuing agenda. During the mid-
1990s, the hospital undertook to improve the way its health care services were being
delivered by focusing on organized continuums of care for different patient populations.
Over time this led to the development of a comprehensive system of service line
organization and management that now embraces more than eighty percent of the clinical
programs and activities York provides.

A “triad” leadership team consisting of a physician, a nurse and an administrator was
established as the basic model for each of 6 to 8 major service lines. These leadership
teams have significant decision- making and budgetary authority, including the hiring and
firing of nursing personnel and other designated service line staff. This evolving
structure has enhanced the role nurses play in organizing and managing clinical program
planning and development. It has also helped to foster more effective working
relationships and communication among physicians and nurses. At the unit level, teams
of physicians and nurses also are used extensively to identify and resolve operational
issues and support ongoing quality management and performance improvement.


Work Redesign for the Progressive Care Unit

Work redesign has been one of the ways that Bayfront Medical Center has sought to
improve its nursing work environment. Two years ago the hospital decided to explore
different approaches to staffing its Progressive Cardiac Unit (PCU). The redesign process

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lasted over one year and entailed the pilot testing of alternative staffing patterns and new

Traditionally the PCU had been staffed exclusively by RNs (at a patient to staff ratio of 4
to 1) and one Certified Nursing Assistant (CNA) for 24 patients. As the acuity level and
nursing shortage increased, RNs were taking on more responsibilities including frequent
orientation of travelers and new employees, management of critical care situations while
waiting on Critical Care Unit beds, and rapid turnaround of patients. Stress levels reached
an all time high. The decision was made to take a fresh look at alternative staffing
patterns and revised roles and relationships. These changes included introducing an
ARNP, Patient Care Technicians (PCTs) and a Unit Service Coordinator (USC) to the

With the help of an outside consultant the work redesign process took place over the
course of a year. It entailed hours of discussion and planning among team members, re-
evaluation of the RN’s role, delineation and separation of essential nursing functions
from technical tasks, such as beds, baths, insertion of Foley catheters, blood glucose
monitoring, vital signs, etc., that could be delegated to trained and competent PCTs. The
education of new and existing staff, especially CNAs and PCTs, became a priority.
Many RNs had a “we must do everything ourselves” approach and were reluctant to
“trust” in the competency of the PCTs. Classes on delegation were a priority for nursing
staff members since they were familiar with the limited role of the existing CNAs and
had difficulty visualizing the role transformation from CNA to PCT.

Bayfront’s nursing division introduced a “Pay for Skills” initiative for PCTs during this
period. This program incentivized existing staff members to enhance their skills and it
attracted highly qualified applicants to the new role. Classes were held on the unit to
develop the PCTs competencies. In addition, a forum was established for PCTs
throughout the hospital to discuss their issues, concerns and learning needs, as well as
their contributions to customer satisfaction, compliance with point-of-care testing,
evaluation of products, fall prevention, skin breakdown prevention, etc.

The PCU is physically divided into North and South wings, and this facilitated exploring
two staffing models simultaneously. The more innovative model, tested on PCU North,
entailed additional PCTs, an ARNP and a USC, as well as revised staff roles and nurse-
to-patient ratios. A modified version of the existing staffing pattern was explored on the
South wing. Nurses who felt threatened by change had the option of remaining on the
South side, while those who felt more open to change staffed the North side. Key
features of the more innovative model included:
    • Nurse-to-patient ratio of 6 to 1
    • 3 PCTs per 24 patients
    • 1 ARNP
    • 1 Team Leader
    • 1 Unit Service Coordinator
    • Assigning a designated professional to handle certain medical needs or
        medication administration (including pushes, drips, etc.)

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   •   Assigning a designated professional to review results of lab tests, X-rays, etc.
   •   Utilizing the ARNP to facilitate complex issues such as pacemaker malfunctions,
       acute changes in conditions requiring immediate intervention, management and
       prevention of pre-code situations, and reduction in transfer of patients to a higher
       acuity level.
   • Utilizing the USC to coordinate and facilitate non-clinical unit management
Before launching the pilot model, and both during and after the year- long process, staff
nurses and physicians were surveyed and patient satisfaction was monitored to help
evaluate work design alternatives.

Prior to exploring change, existing CNAs viewed their role as a shared job with the RNs.
The CNA’s time was devoted to providing basic care often requiring the assistance of the
nurse. With the development and promotion of CNAs to the new role of PCT, and the
increased ratio from one CNA to three PCTs per 24 patients, they now had the ability to
form a team and work together to accomplish their tasks, i.e. the PCTs could now share
their workload among themselves. This allowed the nurse to focus on the nursing
process, assess and intervene in a timely manner, communicate findings to physicians and
spend more time educating patients and families, thereby finding greater professional
satisfaction in their role. According to the unit director, one lesson learned was the
importance of creating a work environment where technicians are highly trained and
where PCTs and nurses understand and value each other’s contribution to the care of the

Despite every effort to formulate a new, unique approach to providing care to PCU
patients and despite the commitment of the team members to its success, it became clear
over time that the limiting factor was the increased nurse-to-patient ratio. Very positive
outcomes however, include the development of the role of the PCT, the introduction of
the ARNP to the work environment, and having a USC to facilitate the non-clinical
management functions, thereby freeing up the clinical manager to address clinical issues.
Bayfront continues to explore new methods and means to provide excellence in patient
care while working with its nurses to ensure a work environment that is attractive and


Patient-Focused Care as a Focus for Work Environment Improvement

Over the past several years, Main Line Health (MLH) has used a variety of initiatives
aimed at forging a strong patient-focused care culture and work environment at each of
the system’s three hospitals: Paoli Memorial, Bryn Mawr, and Lankenau Hospitals.
These initiatives have included strategic planning for nursing; reassessing and improving
care delivery models in a hospital-specific and eve n unit-specific manner; and programs
addressing compensation incentives, flexible scheduling, professional development, and
staff recognition.

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Beginning in 1994 at Paoli Memorial Hospital, the smallest of the three MLH hospitals,
administration and nursing leaders initiated a comprehensive, multi- faceted effort to build
a patient- focused organizational culture and work environment. In the late 1990s, this
strategy was adopted as a system- wide effort, the implementation of which has been done
in a decentralized manner allowing the distinct culture and circumstances of each hospital
campus to shape the way patient-focused care concepts have been applied.

The initial patient-focus care model introduced at Paoli during the mid-1990s entailed
internal work flow assessments and consensus-building on revised nursing roles among
RNs, patient care technicians and patient care assistants. It also involved the physical
renovation of all nursing units, operational changes to support smaller 6 to 8 bed clusters,
and decentralization of many administrative and clinical functions. As the patient-
focused care approach was extended to the other two MLH hospitals, it has been applied
in a less comprehensive manner, with considerable variation by hospital campus and by
unit. One key aspect that often varies concerns the role of patient care assistants and how
they become a part of the care team.

Some of the original champions of the patient-focused care model at Paoli Hospital noted
that after they left for a few years to assume different positions within the larger regional
health system of which MLH is a member and then returned in the late 1990s, they found
that the initial model had become “fairly degraded.” Recently, this has led to a major care
delivery enhancement effort at Paoli to reinvigorate and further strengthen the original
patient-focused care concept, which is regarded as demonstrably beneficial not only for
patients but also for staff satisfaction and retention.

During the last few years, as the nursing shortage and competitive market have driven
home the importance of effective recruitment and retention, all MLH hospitals have paid
considerable attention to patient care redesign initiatives. At Bryn Mawr Hospital, for
example, these initiatives have included:
• Improved benchmarking, using nursing-related performance and patient outcome
• Clarifying roles and relationships of care team members;
• Translating patient- focused care concepts into revised job descriptions for nursing
• Providing enhanced organizational skills training and leadership development for
   nurse managers in addition to focusing on team building;
• Working to strengthen physician understanding and involvement in patient care
   redesign efforts via opinion surveys, committee participation, face-to- face contacts
   and other information sharing mechanisms.


CNO’s Organizational Assessment Process

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Soon after joining NMMC in January 2000, the CNO conducted an extensive
organizational assessment of nursing and the relationships between nursing and other
disciplines (e.g., pharmacy, respiratory therapy, physical therapy). While she introduced
herself to the organization through the assessment process, she also gained the
information and insights she needed to provide leadership for a series of initiatives
addressing frontline staff concerns. She also saw the wide array of practice patterns
evident among various nursing units.

During her assessment process, the CNO spent at least four hours on every shift (both day
and night) in each of the Medical Center’s 15 inpatient units and in additional outpatient
service areas. She made a point of “buddying up” with and shadowing different personnel
(an RN, a nurse assistant, and a unit secretary) during each of these visits. Throughout
the process, she listened and asked questions of all those she encountered: e.g., what do
you feel really good about, what are the hassle factors you face, how can things be

During her organizational assessment, she also met with many physicians, in addition to
those in the clinical section to which she, like other senior executives, had been formally
assigned as their administrative liaison. She also made rounds with physicians, and
attended medical section and medical executive committee meetings, always inviting
ideas about how patient care delivery could be improved. This “MBWA” (management-
by-walking-around) approach remains a key feature of her management style and is one
of the ways she strives to maintain face-to-face contact with nursing staff and people in
other disciplines.

Patient-Centered Care Delivery Model Development

Around 1996, the Medical Center began to face increasing financial concerns with the
expected impact of changes in Medicare payments and other market factors. A consulting
firm was brought in to provide financial performance improvement/re-engineering
assistance. That effort reportedly led to across-the-board staff reductions without any real
attention to the redesigning of work processes. The CNO maintains that the “cultural
fallout” of that experience fostered the attitude among the staff that, “We can’t do this or
that because we don’t have enough FTE’s.” NMMC is still working to change that
attitude by encouraging and supporting collective, interdisciplinary efforts to improve the
Medical Center’s care delivery model and work processes.

Working closely with the head of the Medical Center’s Operations Improvement
Department, the CNO has been a catalyst for numerous work redesign and process
improvement initiatives. In addition to the CNO’s initial organizational assessment when
she first joined NMMC, the nurse manger of each unit is expected to identify work design
improvement opportunities through ongoing dialogue with frontline staff. As just one
example, nurse managers are now reexamining whether nurses should continue to draw
blood or whether a phlebotomy team supplied by the lab handle that task. Any such
process change is assessed from both quality and clinical outcomes perspectives, as well
as from patient and staff satisfaction perspectives.

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The CNO’s organizational assessment underscored the extent to which every clinical unit
was doing its own thing, with minimal consistency or standardization in the absence of
any comprehensive care delivery model for reference. In effect, the evolution of
traditional unit-specific practices and “work-arounds” came to define, “That’s how we do
things here.” For example, on some units LPNs just gave medications and RNs felt they
were not getting the level of support they needed. On other units, however, LPNs were
much more integrated into health care delivery, working closely with RNs. On certain
units, nursing assistants were not allowed to take vital signs, whereas on other units
assistants could take the vital signs but were not allowed to enter them into the
computerized medical record.

To change this situation, the CNO led a planning process that engaged nurse managers
and frontline staff in focusing on the patient and asking fundamental questions about the
basic aspects of care, namely, what could or should be the respective roles of RNs, LPNs
and nursing assistants in care delivery. She initiated extensive discussion and
brainstorming with staff as well as several retreats, one of which was devoted to
developing a vision for nursing at NMMC. The outcome of that process was a Nursing
Vision that focuses on “becoming the provider of the best patient-centered care.”
Subsequently this was adopted as the vision for the Medical Center as a whole, and there
is now a strong leadership commitment to create an exceptionally attractive and
challenging work environment for all employees, not just nurses.

The new patient-centered care delivery model that emerged from the planning process
also clarified nursing roles and revised the scope of practice policies. In particular, the
process led to consensus on the role of the bedside nurse as the manager and coordinator
of the care to each assigned patient – a very different concept from the traditional view
which had long been in place. Another result was the adoption of a “plan of care” model
that is much more interdisciplinary, changing the way that patient information and notes
from different disciplines are organized and used in the medical record.


Patient-Focused Care Re-engineering and Work Redesign

Collaborative Multidisciplinary Teams for Patient-Focused Care

Hartford Hospital has gone through two major patient care redesign initiatives during the
past decade. Both are viewed as having significantly shaped and improved the hospital’s
overall approach to patient care as well as its nursing work environment. In the early
1990s the hospital launched what the CNO describes as “a very inclusive and well
thought out” initiative to strengthen nursing services. This was one of 50 demonstration
programs funded by a Robert Wood Johnson/Pew Memorial Trust grant. The
development of effective multi-disciplinary “collaborative management” teams involving
doctors, nurses and other professionals was a key feature of Hartford’s approach. Over

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time that initiative has evolved into an institution-wide effort to provide a truly “patient-
focused care” approach to the delivery of all hospital services.

In recent years, according to the CNO, the hospital’s approach has become more eclectic
with greater attention being given to targeted efforts to reduce costs, coupled with other
hospital- wide initiatives aimed at further strengthening its patient care model. In the late
1990s, as economic pressures on the hospital were rising, a second major multi- year
redesign initiative was launched. With the help of a re-engineering firm, the hospital
undertook a comprehensive reexamination of its patient- focused care model to identify
ways it could be made more efficient and more effective. Management actively engaged
staff in identifying ways to provide a better continuum of care to patients before, during,
and after their treatment in acute inpatient and ambulatory settings.

Doing Re-engineering the Right Way

One clinical director, who served as co- leader of a bedside care delivery team,
commented that the patient care delivery re-engineering process initiated two and a half
years ago was very helpful in establishing a structure for ongoing improvement efforts. It
also helped in building nurse manager skills and clarifying basic principles that have been
important to ongoing efforts to enhance patient- focused care delivery throughout the
hospital. This latest effort and the culture it reinforces play a key role in strengthening
nursing recruitment and retention.

The patient care re-engineering process was led by a multidisciplinary Steering
Committee. This committee coordinated and supported empowered multidisciplinary
teams dealing with particular clinical functions such as bedside care delivery or care
coordination, or defined clinical service clusters, such as women’s health, oncology, or
major ancillary services, e.g., pharmacy, radiology, respiratory therapy. Many of these
teams were further assisted by a Physician Advisory Group and a Patient Advisory Group
as they built consensus on key principles to guide patient-centered care improvements,
and then worked with frontline nursing staff and other caregivers to determine how these
principles could best be applied through revised staff roles and relationships, greater
standardization and consistency of practice, and other specific operational changes.

According to one clinical director, overall the re-engineering effort helped in many ways
because of several factors:
   • There were wonderful structures to support decentralized decision- making and
       innovation with heavy staff involvement.
   • The effort was hospital- wide and had the clear, sustained support of hospital
   • At virtually every level the process entailed multidisciplinary teams, all of which
       focused on “how can we make the delivery of care better for the patient” and not
       just how to save money.
   • The process made clear the importance of doing good research, benchmarking
       performance, learning from what other hospitals were doing, and “getting the

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       facts” so that nursing directors and managers could encourage innovation within
       the organization and overcome resistance to change.

Redesign of Nurse Manager Roles

According to the hospital’s CNO, “Work design must be a continuous process of
organizational learning and reassessment.” Indeed, Hartford has recently revisited and, in
some instances, reversed work design decisions that had previously been made. An
example frequently cited was the redefinition of the nurse manager’s role. As a result of
a re-engineering change in the mid-1990s that reportedly originated at the request of
frontline nursing staff, the nursing manager position was redefined to entail a 50/50 split
of each mana ger’s responsibility for direct bedside care on the one hand, and unit or
service management on the other.

However, after a period of time managers and staff began to raise concerns about this
approach, and turnover significantly increased among the individuals in these positions.
The reality was that it was very demanding for a person to be a “24/7” manager, work as
a bedside nurse half the time, and satisfy the expectations of line staff within the unit.
Earlier in 2002, after considerable reevaluation, the role of the nurse manager was once
again fundamentally redefined as a 100% management position. However, this has been
done with an explicit performance expectation that nursing managers will be a primary
resource to unit staff, focusing on helping to improve day-to-day care delivery and
operations at the unit level. In addition, another explicit expectation for nurse managers
is that as “chief retention officers,” they actively will encourage and support the
professional development of each staff member for whom they are responsible. To help
implement this concept, the hospital has intensified its educational and skill development
seminars and programs for nurse managers.

Care Coordination Team Initiative

Hartford’s recent re-engineering process has also addressed staff concerns about the
burdensome demands of the patient admitting and discharge process. In response, a “care
coordination team” has been established to support these unit staff. It consists of more
than 30 nurses and care coordinators who specialize in admission assessments, pre-
hospitalization patient preparation, care coordination and discharge planning. Reportedly
this initiative has greatly reduced the amount of time that frontline staff would otherwise
have to spend on non-direct patient care functions.

According to the CNO, the implementation of this initiative has also made clear the
importance of “learning shared work,” i.e., helping staff nurses become comfortable with
letting go of some things and clarifying the respective roles, responsibilities, and interface
between themselves and care coordination team members so that both patients and staff
will benefit from the new model.

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Work Redesign, Organizational Learning and Cultural Change

During the 1990’s Vanderbilt University Hospital (VUH) reorganized its clinical services
by clustering them into a large number of Patient Care Centers. However, like the
fragmented traditional structure of clinical departments that they were intended to
mitigate, if not replace, the Care Centers reportedly have tended to function in a “silo-
like” fashion. A few years ago this situation led to an extensive reexamination of the
hospital’s patient care delivery model, focusing in part on how well the hospital had
embodied and applied the principles of patient- focused care that were among its original
drivers. This reassessment was supported by outside consultants who assisted the
gathering of consistent information across clinical areas and the benchmarking of unit-
specific performance against national data. Frontline nurses were involved in collecting
real-time data proactively and they then examined the analyses for opportunities for

From the perspective of nursing leaders, subsequent efforts to improve patient care
delivery and the nursing work environment at VUH have entailed a major focus on work
redesign and cultural change. “We’re switching the paradigm from focusing on
recruitment to giving much greater emphasis on retention by investing in each person’s
professional development and creating an excellent work environment,” states a senior
nursing executive. Moreover, according to the CNO, “We also realize that we will be
constantly changing, and can’t assume we’ll find the permanent solution. Instead, as an
organization, we must embrace and support continuous learning and improvement…
Work redesign is the foundation of what we’re building on now.”

Work redesign is seen by some as more than patient- focused care, a concept that
Vanderbilt used to encourage care delivery innovation during the early and mid-1990s
when it received a Robert Wood Johnson Foundation/Pew Memorial Trust demonstration
program grant. That experience helped to forge an organizational culture at VUH that
supports continuous learning and reexamination of how well patient care is being
provided and how further improvements can be achieved. A related organizational and
work redesign initiative in the mid-1990s included the development of an internal
Learning Center that has since provided organization development assistance and
facilitation support for work environment enhancement efforts at the hospital and other
Medical Center components.

VUH has also invested in an Operations Improvement Department specifically to assist
work design and process improvement initiatives. This very disciplined approach to
continuous quality improvement entails frequent testing of new ways of doing things and
then carefully measuring and evaluating results. While considerable effort and expertise
have been applied to creating sophisticated performance measurement systems, the CNO
also noted that VUH is still working on how to develop effective metrics to assess desired
cultural changes, since these are much more difficult to define and use that more
commonly used recruitment, retention, and patient outcome measures.

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Staff-Driven Care Redesign

At Baptist Hospital of Miami, the dysfunctional consequences of an earlier re-
engineering process led to a recent staff-driven patient care redesign initiative, which
resulted in needed improvements that reflected the varying needs and requirements at the
unit level.

According to study participants, nursing staff found that jobs and functions frequently
overlapped as a result of staffing model design changes imposed as a result of the prior
re-engineering effort. As one example, one clinical director cited having housekeepers
also function as dietary aides delivering meals to patients. This meant that choices
sometimes had to be made between delivering cold food and preparing a room for an
emergency department patient. Additionally, nurse managers had to supervise non-
professional workers. Their time was being spread not only between nurse and patient
care supervision, but also to becoming knowledgeable about cleaning toilets and room
inspection guidelines. From the staff perspective, this approach decreased both the
efficiency and the quality of patient care.

Baptist has reassessed these and other consequences of the initial re-engineering initiative
by using “compressed process improvement teams.” They essentially undid the previous
patient care redesign and modeled fast-track processes that have improved efficiency.
These changes were staff driven in their design and implementation. Now, each unit
determines its own unique staffing model based on the unit’s patient population profile,
workloads, acuity, case mix index, and other patient characteristics.

For example, the orthopedic unit developed a model of care delivery based on a triad
approach. An RN, an assistant (either LPN or technician), and a “support partner” (an
aide who may provide dietary, housekeeping, and patient transport assistance) are teamed
together. This particular approach was adopted for orthopedics since so many patients on
this unit require complete physical care that often includes moving the patient, which can
require as many as three people.

By comparison, the pulmonary unit developed more of a partnership model. An RN is
paired with a technician, and they work as a team on 12-hour shifts. Many patients are
ventilator dependent on this unit and as such prone to rapidly emergent events. If the RN
becomes tied up due to an emergency, the technician helps care fo r other patients on the
unit so that emergencies do not leave patients unattended.


Re-engineering and Subsequent Redesign of Nurse Manager Roles

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During the mid-1990s, Sinai Hospital undertook a major re-engineering effort aimed at
flattening its overall management structure to help reduce costs and promote more patient
focused care. The entire layer of nursing unit managers was eliminated as part of this
restructuring process. Instead, a smaller number of clinical directors were made
responsible for multiple nursing units, and reporting to them were a number of “clinical
coordinators.” After several years, however, this arrangement was reassessed and
fundamentally altered by restoring nurse managers at the unit level. In addition, hospital
leaders gave increasing attention and support to the objective of developing unit
managers as the hospital’s “chief retention officers.”

Several factors led to these changes. First, as the clinical directors’ span of control
expanded, it became more and more difficult to get and keep people in these demanding
positions. Second, the hospital’s dependency on more costly traveling and agency nurses
steadily grew as patient acuity increased, pressure for shorter stays intens ified, and the
impact of the nursing shortage was increasingly felt throughout the hospital. These
trends raised internal concerns not only about staffing costs but also the consistency of
quality nursing care.

As a result, greater investment in the recruitment and retention of frontline nursing staff
along with further strengthening of the hospital’s work environment have become
important priorities for the Sinai’s administrative, medical and nursing leaders. For
example, every medical/surgical unit now has one manager who is responsible for day-to-
day running of the unit and 3 or 4 clinical leaders whose responsibilities are threefold:
direct patient care, staff education, and assisting staff hiring and performance evaluation.
In addition to patient care associates (i.e., technicians who support care coordination on a
given shift), Sinai has also introduced a “special assistant” role in some areas that gives
nursing students the opportunity to learn through one-on-one mentoring relationships
with staff nurses.

According to nursing leaders, other related work environment improvement initiatives
have included the following:
   • Reassessing nurse manager skills and core competencies and weeding out
       managers through retraining, redeployment, or release.
   • Creating a “manager assistant” position to free nurse managers to interface more
       with frontline staff and support them.
   • Promoting more decentralized decision- making at the unit level.
   • Encouraging ‘self-actualizing’ work teams involving nurses, other professionals
       and non-professionals.
   • Establishing a “SWOT” nursing team whose members can be readily deployed to
       assist any clinical area that may need immediate assistance or re-enforcement
       during high- load peak periods or help in transporting patients to ancillary
   • Providing traveling nurses with the same level of clinical and nursing orientation
       that permanent staff hires would receive as well as some unit-specific orientation
       - the aim being to narrow the gap between traveling nurses and permanent staff.
   • Developing more flexible staff scheduling options.

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   •   Developing a major foreign nurse recruitment initiative projected to bring to Sinai
       over 150 nurses from the Philippines.
   •   Engaging clinical chiefs and senior management in support of a new professional
       conduct policy and more collaborative nurse/physician relationships.
   •   Developing more effective coordination and communication on nurse retention
       and work environment initiatives among senior hospital executives.


“Be a Bed Ahead” – a Capacity Management Initiative

Operating virtually at full capacity, Inova Fairfax Hospital (IFH) had between 150 and
170 new patient admissions every day. The heavy volume of patient throughput placed
heavy demands on the time and energy of staff nurses and led to delays in getting a
patient into a bed in a timely manner. The aim of the “Be a Bed Ahead” (“BABA”)
initiative, according to the hospital’s COO, was to find a way to expedite and improve the
quality and efficiency of the flow of new patient admissions, starting in the MD’s office
or the patient’s home. It also addressed how to facilitate the patient discharges and the
preparations necessary to accommodate patient turnover in an optimal manner, from the
perspective of both the patient and the staff.

To accomplish this, a multidisciplinary group of clinical directors, supported by an
internal facilitator, was charged with redesigning the hospital’s admitting and discharging
processes. The process improvement team focused on assessing current practices,
creating new staff roles, and clarifying others. Group members then provided leadership
for introducing and managing the change process, which included tracking the measures
selected to assess implementation progress and impact.

The results of this initiative have been very positive. Its success is attributed in part to
giving this team all the resources they determined were needed. The hospital also
celebrated their success. There were also compensation benefits for the directors involved
since their bonus potential was tied to achieving targeted measures of improved
performance as a result of this initiative.

System-wide Outcomes-Driven Care and Case Management

Inova’s “Outcome Driven Care” initiative is designed to leverage the full range of the
System’s integrated care delivery resources to provide timely, quality care in the most
appropriate care setting. In addition to four acute care hospitals, these resources include
long-term care, home health, assisted living, urgent care and emergency services. At the
core of this initiative is the development of a more comprehensive and coordinated case
management care system using care delivery teams in various clinical settings both
within and beyond Inova Fairfax Hospital.

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This initiative is designed to improve the quality of Inova’s nursing work environment
along with the quality of the patient experience. According to the hospital’s CNO, “We
believe that quality patient care and the nursing work environment are both enhanced by
encouraging opportunities for specialization among nursing personnel. We believe a
nurse is not a nurse is not a nurse, as with a doctor. We have found that nurse retention at
the bedside is higher when individuals can specialize and are given opportunities for
career growth.”

One objective of the improved care management system is to reduce the proportion of
“non-service” patients on every nursing unit so that ninety percent will consist of a
specific clinical service’s patients. The greater ho mogeneity of each unit’s patient
population will contribute to more opportunities for specialization. Coupled with
enhanced training and professional development, this will allow nurses to build their
expertise in a particular area and pursue more rewarding career paths.

To carry out the this initiative, the IFH leaders have used all the classic CQI methods,
tools and techniques, starting with involved staff in reassessing current processes and
practices, reviewing pertinent data, and identifying opportunities for improvement. The
implementation of the initiative has entailed large group process facilitation and team
building activities supported by internal facilitators and trainers. Team building involves
using Myers Briggs and DISC to build awareness and appreciation of different learning,
decision- making and managerial styles.

Leadership development and innovative thinking are actively encouraged and supported
as well. Inova runs an internal management leadership academy, the “Lead or Shape”
Program. All clinical managers at IFH are also encouraged to be entrepreneurial and are
expected to include an innovation- focused project or research as part of their annual
performance objectives.


Hospital Turnaround Campaign

After many years of continued market and financial success, Lowell General Hospital
(LGH) found itself in serious financial difficulty several years ago. Hospital leadership
launched a major turnaround effort, which was assisted by a consulting firm providing
process improvement and financial performance support.

That effort has led to major organizational and cultural changes in the work environment
at LGH. The hospital hired a new CNO whose leadership has generated and energized
numerous initiatives to improve nursing recruitment, morale, and retention. A new Vice
President for Human Resources with experience outside of health care was also recruited
to the senior management team, who worked collaboratively with nursing leaders to bring
about significant improvements in the work environment for all employees.

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The outside firm focused on supporting the hospital-wide campaign to identify process
and productivity improvements and develop well- targeted interventions. Part of this
effort entailed encouraging all employees to pay increased attention to their internal and
external customers. According to one senior executive, the firm “helped us to work
smarter, become more productive, improve relations among departments, and make gains
on the revenue side and some on the expense side. They also helped us to focus on certain
indicators we didn’t use before, such as paid man hours per admission.”

Management recognized that happy employees have ideas about how to make things
better, so the hospital’s improve ment efforts encouraged them to identify and craft the
actions that needed to be taken. This meant that management’s role also had to evolve
away from a top-down, purely directive mindset. Consequently, attention was given to
empowering teams to work on different issues and then showcasing their successes. This
was done not only to express appreciation for work well done but also to encourage
mutual learning among hospital staff. Additional employee and nursing-specific staff
recognition programs also received increased support.

LGH leaders made it clear that the turnaround effort had to entail cultural change. They
place a new emphasis on values such as productivity, customer focus, openness to
change, and a philosophy of “leadership accountability for performance.” Deficiencies in
the quality of management at various levels led to organizational streamlining. This
involved some shedding of poor performing managers as well as some staff who could
not modify their attitudes and approach consistent with the new customer- focused culture
and the heightened emphasis on accountability and productivity.

The operations improvement and redesign effort has been very broad and focused in part
on enhancing revenue through improved coding and billing practices and cont ract
negotiations and other measures. It also entailed elevating compensation for nursing and
certain other employee categories, and revamping some benefits and HR policies relating
to training, professional development, and scheduling so as to offer more flexible and
creative solutions to increased employee satisfaction. According to the VP for Human
Resources, “We’ve learned from surveys that employees need to be treated as

The earlier high vacancy rate and a 20% turnover rate among LGH’s nursing staff have
been substantially reduced. The new leadership style of the new CNO has made a huge
difference. Respondents point out that the collaborative approach exhibited by nursing
and other administrative leaders has created a climate of change – one that invites
everyone to be engaged in reexamining traditional ways of doing business and focusing
on how to better serve the patient. One clinical director commented, “Our breaking out
of traditional silo thinking and behavior became the widely recognized challenge and
opportunity… For nursing this has meant that while before you just did what the doctor
told you to do, now you as a professional sit down with the physician, and sometimes
others, to share your ideas and make decisions more collaboratively. That’s the kind of
cultural and organizational change we are pursuing.”

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As for the methods that she and other clinical directors have been using to bring about
change, she underscored the following:
   • Challenging staff to reassess longstanding behavior and practices.
   • Helping staff to think “out of the box” about how improve things.
   • Helping people to “let go” and buy in to change.
   • Communicating the positive, not just the negative.
   • Saying thanks and paying attention to the small things, and not taking anything
       for granted.
   • Showing appreciation for what people are doing well.
   • Making it clear that as a manager you value each individual as a person.

2. Preparing for Magnet Hospital Recognition

                Magnet status is a journey, not an end state. It requires
                   constant organizational learning and growth.
                                           -- Study participant

About a third of the hospitals participating in this study had either attained or were in the
process of applying for ANCC designation as Magnet facilities. Respondents from several
of these hospitals underscored the galvanizing impact of the demanding application
process itself and the significant changes it generated in their organization’s work
environment. Some nursing leaders noted that it took persevering educational efforts by
a core group of champions to create the necessary readiness among both the nursing
staff and senior management for the quest for Magnet status to become a well-supported
strategy for change. Once a clear organizational commitment to this goal was made, it
triggered a process of rigorous self-assessment and staff empowerment that reportedly
has continued to drive efforts to achieve further improvement and nursing excellence.

   •   The Methodist Hospital, in launching a multi- year effort to attain Magnet
       designation, embraced the challenge of making significant changes to the
       hospital’s overall structure and culture along with changes in its nursing
       work environment. These included a new service line-focused structure,
       nursing staff empowerment through shared governance and decentralized
       decision- making, a higher standard of professional nursing practice and
       accountability, improved performance measurement and appraisal
       systems, and pay- for-performance compensation policies.
   •   Bayfront Medical Center used the Magnet program’s demanding
       standards to conduct a comprehensive nursing self-assessment and identify
       the improvements that would be needed to achieve Magnet status. The
       result was a series of staff-supported changes affecting unit- level nursing
       education, staff roles in decision- making, enhanced career ladder and
       reward system design, work redesign efforts, and attention given to
       nursing related research and performance measurement.

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   •   St. Luke’s Medical Center found that the process of preparing for
       Magnet recognition was valuable not only for developing a demanding
       improvement agenda for its nursing work environment, but also for
       building nurses’ awareness and pride in their history and
       accomplishments, including the improvements necessary for a successful
       application. The inventory of steps identified and addressed led to changes
       in nursing roles, elimination of many non-nursing duties, enha nced
       administrative support and decision- making responsibilities at the unit
       level, greater focus on the patient, and more effective multidisciplinary
       approaches for resolving clinical issues.


Multi-year Effort to Achieve Magnet Hospital Recognition

When the CNO of The Methodist Hospital (TMH) joined the organization in 1998, the
hospital had gone through an extensive period of job reduction and was still suffering
backlash effects. In the years that followed, she and other hospital leaders embraced a
strategy focused on achieving ANCC Magnet Program designation. This multi- year
effort, successfully completed during the course of this study, required nursing at
Methodist to develop the requisite attributes and infrastructure to support professional
nursing practice. According to the CNO, this process has entailed considerable cultural
change within Methodist and far more decentralization and sharing of authority than had
originally been anticipated, even by the leadership group within nursing that spearheaded
the effort.

From the hospital Administrator’s standpoint, especially during the last two and a half
years, Methodist has focused on achieving not just fundamental changes in the nursing
work environment, but on a major redesign of the hospital’s overall structure and its
culture. This has involved creating a service line- focused organization, which has
eliminated multiple layers of middle and upper administration, and altered the way
hospital staff works with physicians at every level. With a substantially flattened
organization, TMH has also taken steps to develop excellent managers for every
department and nursing unit, which the Administrator believes is the best way to have
happy employees, be they nurses or other employees.

Getting Started: Gap Analysis and Shared Governance

Four years ago, Methodist had a relatively underdeveloped nursing management
organization and infrastructure. There were few educational programs for nurse
managers, and very few managers had received master’s degree training. Outside
speakers had never been invited to address nurse manager meetings. Most nurse
managers were in their late 40’s and 50’s, and the structure of nursing authority and
decision- making was very centralized and tradition-bound.

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Once the new CNO came on board, a small number of nurse directors who had been
reading about new concepts in nursing organization and practice (many were members of
a journal club) became an informal group of champions for Methodist’s quest for Magnet
status. The CNO educated the hospital board, as well as senior administrators, about the
ANCC’s Magnet Recognition Program and shared the related research that had been done
about what distinguished Magnet hospitals. This helped to build support for pursuit of
Magnet recognition as a strategy to forge the best possible nursing program for

Gap Analysis and Shared Governance

In the very beginning, some TMH staff members and nurse managers conducted site
visits to Magnet hospit als. These site visits, one participant recalled, proved to be “a
powerful way to have people see the vision and better understand it, and get enthusiastic
about it.” The next step was to complete a gap analysis, comparing where TMH was in
relation to Magnet Program criteria and standards. It became immediately clear that
Methodist did not have anything like a shared governance model. After considering
alternatives, a “council model” approach to shared governance was adopted. Putting such
a structure in place became a major objective, and it has continued to evolve and be
refined ever since.

A 20-person Nursing Leadership Council (NLC) consisting of nurse managers and other
executives had been established to provide strategic planning for nursing. Reporting to
the NLC was a Research and Education Council, Clinical Information Council,
Professional Nurse Practice Council, and a Professional Nurse Advisory Council that had
representation from all nursing areas in the hospital. In addition, a Magnet Steering
Committee was created to coordinate the preparation of requisite documentation for the
Magnet application process. It was composed of both nursing directors and other
caregivers, and had support from a part-time staff person as well.

Revised Compensation Strategy

One specific initiative signaling a change in TMH’s nursing culture was the inauguration
of a “pay- for-performance” policy that replaced a system driven by seniority and across-
the-board pay adjustments unrelated to individual performance. The new CNO initiated
the development of the new policy by conducting an open and frank dialogue with staff
about what they thought nursing at Methodist should strive to become and how they
wanted to be rewarded and recognized. This was followed by comprehensive analysis of
every nurse’s performance and the prevailing correlation (or lack thereof) between pay,
performance, and tenure.

In light of this analysis, the new policy gave nursing unit directors the authority to decide
who would get annual raises (and by how much) on the basis of individual performance
evaluations. According to one respondent, the change in nursing staff attitudes, which the
new compensation policy helped to foster, was particularly noted by physicians.
Physicians gave their support to the strategy of striving for Magnet recognition because it

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would increase the quality of nursing and set a higher standard for professional nursing

New Performance Evaluation and Measurement Systems

Along with the new compensation policy, the performance assessment and management
model used by Nursing was also fundamentally changed. A 360-evaluation process was
introduced involving non-threatening, 45- minute small group reviews. As required for
Magnet Program recognition, the system of performance measurement used was
redesigned to focus on behaviors reflecting key institutional values, e.g., how an
individual practices ‘relationship-centered’ care, how individuals recognized the specific
contributions of others, etc., and not just the clinical or functional tasks prescribed by a
person’s job description.

Nursing also designed a creative board game to energize the new performance review
process. Performance attributes are categorized into three major areas: leadership, the art
of nursing, and the science of nursing. Three levels of performance – “novice,”
“professional,” and “expert” - for each attribute are described on color-coded cards,
trademarked as “Performance Power” cards. The participants in each review use the deck
of cards to react to an individual’s self assessment, with the aim of giving positive,
constructive feedback and building consensus on the person’s contributions and potential

The new performance appraisal and reward systems, along with the shared governance
model, have been very instrumental in fostering cultural change and an improved work
environment at TMH. The 360 evaluations involve staff, peers and directors in a
constructive, candid dialogue that is supportive of personal and professional
development. Vice Presidents are then expected to “force rank” people based on these
evaluations and distinguish among the stars, those doing a great job, those who need help
or redeployment, and those who are just not making it. For the last category, a six -
month improvement plan is worked out and at the end of that period a decision is make
about whether they stay on or are let go.

Other Related Work Environment Improvement Initiatives

Clinical directors also report that Methodist has been successful in making organizational
and cultural changes that have led to measurable improvements in nursing vacancy and
retention rates, employee, physician and nursing staff satisfaction, and the hospital’s
overall financial position. The nursing staff is now very dedicated, motivated, much
more involved in decision-making; and physicians have been very supportive of the
changes introduced as part of positioning the organization for Magnet recognition.

As one unit director put it, “More than ever, we are fostering a ‘relationship-centered
care’ environment in which the patient is at the center of every thing we do. It’s
everyone’s responsibility at all times to do whatever’s best for the patient and their
family, not the department or the caregiver.” She cites a number of additional initiatives

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and methods that have contributed to the changed work environment. For example,
communications within nursing have been improved by:
• Creating a dedicated website for nursing.
• Using of a common nursing score card among all units that allows comparative
   performance measures and recognition of excellence.
• Sending periodic letters from the CNO to nursing staff members at their home
• Holding open forums (nursing assemblies) to encourage discussion of any question or
   topic on people’s minds.

Others underscored the importance of the following:
• Expanding frontline staff involvement in unit- level benchmarking and more informed
   participation in nursing councils and hospital-wide committees.
• Incorporating non-nurse caregivers and directors in the annual retreat for nursing
   directors as part of efforts to encourage multidisciplinary team problem-solving.
• Having a medical director “partner” for nursing unit directors with whom they can
   discuss day-to-day issues and solutions.
• Offering fast-track management training and other educational opportunities,
   sometimes in partnership with a local university, along with schedule adjustments to
   make it easier for staff to take advantage of them.
• Providing improved benchmarking data, training, research skills development
• Promoting greater homogeneity of patients assigned to units as a result of the service
   line reorganization. This has helped nurses to cope with increasing patient acuity and
   provide greater continuity of care.
• Off-site training at Disney in customer focus and guest relations methods outside of
   the hospital industry.
• Expanded employee recognition programs and celebrations of outstanding individual
   and team performance.


Self Assessment and the Magnet Program Application Process

Bayfront attained ANCC designation as a Magnet hospital about two years ago.
According to some respondents, receiving Magnet designation makes the hospital more
attractive for many staff members, and not surprisingly it is used in the hospital’s
advertising and recruitment efforts. From one director’s perspective, the application
process itself was particularly valuable for nursing at Bayfront because it began with a
rigorous self-assessment using the Magnet program’s demanding standards. The self-
assessment process led to many important changes, especially with respect to:
• Increased nursing staff involvement in decision-making through a refined self-
    governance model;

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•   Decentralization of nursing education to the unit level so that it would be more
    responsive to frontline staff needs;
•   Enhancement of the Bayfront’s career ladder of nurses and its performance
    recognition system;
•   Greater attention to nursing-related research and performance measurement; and
•   Several important work redesign initiatives.

Another clinical director noted that there are real generational differences among nurses
with regard to the perceived importance of the Magnet program designation. This director
observed that the Magne t program application process certainly helped Bayfront to
provide a structure for staff input “that has been valuable for those who want to be
involved in it…Today, however, some younger nurses don’t care about Magnet status as
much as they care about how IT can make their work easier and more efficient.” Newer
nurses, she noted, come to work to be a nurse, rather than spend several hours a week
developing protocols or standards of care. “They want to be able to voice their opinion,
but not to have to spend extra time at work in order to do that…Younger nurses want to
have a job they can perform well and then go home and forget about it. This reflects a
very different ethic that the one that prevailed ten years ago.”


Magnet Program Application Process and Work Redesign

At the end of 2001 after going through a two-year application development and appraisal
process, St. Luke’s received Magnet Program designation from ANCC. According to one
clinical director, the lengthy process of preparing the Magnet Program application was
the most important thing St. Luke’s has done to enhance the hospital as a place for nurses
to work. Doing the application forced the hospital and nursing leaders and staff to
examine themselves, their history and past and current workforce relationships. The key
was the decision to complete the application and share the results with the entire staff.

Along with the Magnet application process, St.Luke’s also went through a major effort,
with outside help, to redesign the role of nurses. As well as contributing to the
application’s success, that initiative led to a number of important work environment
changes. These included:
    • Removing most non-nursing duties from nurses;
    • Creating improved administrative support for nurses;
    • Focusing on keeping each nursing unit strong and independent;
    • Forcing issue resolution decisions down to the unit level;
    • Keeping everyone’s focus on what’s best for the patient;
    • Creating a patient classification system; and
    • Developing a multi-disciplinary approach to clinical issue problem solving.

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These concurrent initiatives reinforced one another in a way that energized the entire staff
in focusing on continuing improvement initiatives and internal and external recognition
of the progress made in achieving an excellent nursing work environment.

3.       Shared Governance and Collaborative Decision-Making

 There is no contest between the company that buys the grudging compliance of its
 workforce and the company that enjoys the enterprising participation of its employees.
                                                            -- Ricardo Sempler

A number of hospitals in this study have established a link between nurse empowerment
and improved nurse morale, retention, and recruitment. Nurses are empowered through
shared governance – that is, through participating in management and clinical decisions
about how nursing services are organized and delivered – and through collaborating
with others in making broader management and clinical decisions. Empowered nurses
are treated like accountable professionals rather than, as one study respondent put it, in
the same way housekeeping employees are treated.

Hospitals in this study have approached nurse empowerment through a variety of
strategies and techniques.

     •   St. Mary’s Medical Center invested many years in creating a hospital-
         wide shared governance culture that has paid off in nurse turnover rates
         consistently less than half of the national average, high levels of staff
         empowerment and patient satisfaction, and Magnet hospital designation.
     •   St. Luke’s Regional Medical Center and Lowell General Hospital
         have established nursing self- governance through a variety of nursing
     •   St. Charles Medical Center adopted a comprehensive “nursing practice
         enhancement initiative” that included work analysis and redesign process
         based on a consistent philosophy and significant nurse autonomy in
         improving care delivery and nursing practice.
     •   Hartford Hospital has focused on work redesign in a manner that
         supports a collaborative decision-making culture, including
         multidisciplinary care teams for each major clinical service as well as a
         nurse manager and “clinical leader” for each nursing unit.
     •   The Methodist Hospital and York Hospital have empowered nurses
         through placing them in key roles in their service line organization
         structures, with more collegial nurse-physician relations as one result.
     •   At Lowell General Hospital, service lines have enhanced nursing staff
         participation in the planning and implementation of service delivery

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    •   Jewish Hospital has used nursing- led multidisciplinary work groups to
        ensure meaningful staff input in designing new applications of
        information technology to improve work processes and care delivery at
        the point of service.

Themes running through the experiences of the hospitals that have emphasized
empowerment through shared governance and collaborative decision-making:
   • Culture change takes time, training, top-level commitment, and
      continuous reinforcement.
   • Empowerment is a strategy that complements and is enhanced by many
      other strategies, from “staffing summits” (Baptist Hospital of Miami and
      Hartford Hospital) to clinical career ladders (St. Luke’s).


Building a Shared Governance Structure and Culture

Introducing the Concept

In the spring of 2002, St. Mary’s Hospital Medical Center was awarded Magnet
recognition by the ANCC. “Changing our culture into one driven by ‘shared governance’
has been the hallmark of our organization’s efforts, and its success, over the past ten
years,” a clinical director commented with considerable pride. Shared governance is
really a “shared accountability model” that gives responsibility and authority to “   the
governed” (staff nurses and managers) to make decisions collectively regarding nursing
practice and patient care. Implementation of this concept is expressed through structural
and cultural change that results in empowered decentralized decision- making,
collaborative management, and continuous improvement in providing excellent patient-
centered care.

The shared governance concept was elaborated many years ago by Timothy Porter
O’Grady, PhD, EdD, RN, FAAN. During the early 1990s St. Mary’s brought him in to
further educate a core group of interested nurses about shared governance and help them
understand where they were heading and the level of commitment and effort that would
be required to realize this concept. This group became the champions for change and
formed the core of a staff-driven steering group process. According to one participant,
“O’Grady warned that ‘ambiguity is the enemy,’ so we worked hard to define clearly
what we wanted to achieve, what a new structure would look like, how it would work,
what the clinical work to be done entailed, what sharing accountability implied, and what
were the most important things to focus on.”

As a result of that effort, St. Mary’s has changed its fundamental thinking about how to
organize relations with employees. This has entailed totally revamping the structure of
nursing, along with changes in nursing manager and staff roles and placing greater
emphasis on training for the management skills required.

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For the CNO, shared governance implies recognizing that nurses, like doctors, are
professionals who are licensed to practice as an independent group. As professionals,
they have accountability for defining the nature of their practice, managing its quality,
and making sure that practitioners have the requisite clinical competence. Historically,
how hospital management related to nurses, she noted, was the same way they related to
housekeeping employees. “What we have done at St. Mary’s over the past five years has
been to create a new work environment in which the role of managers, including the
CNO, is to provide the resources to support nursing practice. The biggest challenge for
hospital management, and especially senior management, in creating this new work
environment has been to relinquish control.”

Methods Used to Create Shared Governance Structure and Culture

Forging a new nursing environment infused with shared governance has taken years of
perseverance, but the payoffs for nursing morale, retention, and staff and patient
satisfaction have been huge. Study respondents emphasized that nursing is at the table at
every level of decision- making. A staff nurse chairs a committee on which the President
sits to deal with hospital-wide coordination issues. Nursing is directly involved in other
councils or committees dealing with human resources issues, information management,
patient care quality, and other hospital-wide concerns.

In addition, “Ninety percent of decisions affecting the role of nursing care delivery are
made at the unit level,” one nurse manager maintains. “St. Mary’s approach is not
participative management. It is the empowerment of people to make decisions in the
areas in which they are most competent and responsible… In a culture like ours, even
with the requirements of outside bodies that need to be satisfied, our nurses determine
how we will do our work.”

St. Mary’s has made a substantial investment in staff education. Special attention is given
to building the skills of managers to allow them to support the development of staff.
Organizational skills development includes learning such things as how better give
feedback to peer, how to receive it, and how to encourage learning from one another on
an ongoing basis. Even when the hospital has been under financial pressure, it reportedly
has continued to invest in, rather than cut back, staff education and manager development

Hospital leaders also recognize that nurses need to understand the business aspects of
what they do. This means getting appropriate information to them and ensuring that they
have the skills necessary to be effective participants in planning and decision- making
processes. One example cited was translating the hospital’s income statement in terms
that staff could understand and appreciate.

Other methods used to build a strong shared governance culture have included:

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•   Using a combined “self- and peer-based” performance evaluation system, in which a
    clinical director or manager is regarded as just another participant among many
    involved in the performance reviews of individual staff nurses.
•   Working with the hospital’s education department to “train the trainers,” i.e., to
    develop the educational interests of nursing staff members and enhance staff
    members’ competence and confidence in providing training for others.
•   Providing plenty of coaching, mentoring and reinforcement coming from peers, as
    well as from vice presidents, clinical directors and nurse managers.

Nurses at St. Mary’s clearly like the practice environment that has been developed. For
years, turnover rates have been consistently lower than half of the national average,
which recent studies put at about 20 percent. According to one clinical director,
“Physicians at St. Mary’s don’t necessarily understand the ‘shared governance’ model
within the nursing organization. But they see the outcome of it and work collaboratively
with nursing to address quality of care, patient satisfaction and service improvement

Even though it is situated in a very competitive environment, St. Mary’s has never had to
use agency nurses or mandated overtime, and it does not offer any signing bonuses to
attract nursing staff. The hospital wants people to come because they truly want to be
there. St. Mary’s wants only those nurses they believe are prepared to really be involved
and put in the extra time necessary for the empowered staff organization and
decentralized decision-making model in place.


Shared Governance and Multidisciplinary Care Teams

At St. Luke’s, the principle of empowering people to make decisions appropriate to their
knowledge and skills has been applied to nursing and to other professional disciplines as
well. During the early 1990s, St. Luke’s undertook a major initiative to redesign patient
care through interdisciplinary care teams. This effort was support by a Robert Wood
Johnson/Pew Memorial Trust grant program. The initiative focused on breaking down the
silos between professional disciplines and departments to improve service coordina tion
and collaborative working relationships.

The work redesign efforts entailed having staff from different disciplines (e.g., nursing
and respiratory therapy) participate in training programs together either in-house or
through courses at a local university. The initiative also promoted staff collaboration
across clinical and functional boundaries to develop more patient-focused policies and
procedures that would leverage combined skills and competencies.

This focus has also been incorporated in St. Luke’s approach to shared governance. The
hospital’s Clinical Leadership Council is multidisciplinary in composition and involves
individuals from nursing, pharmacy, lab, pastoral care, volunteers, nutrition, and other

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areas. The Council helps to bring the perspectives of different disciplines to bear on
common issues, such as patient safety, budgetary changes, quality care, etc. The Medical
Center is also initiating a joint staff appointment with a local university so that nurses
will be able to do more interdisciplinary research at the bedside.

As part of its shared governance model, St Luke’s has a Nursing Practice Council which
focuses on clinical issues and has final decision- making authority for all clinical practice
improvement issues, and a Nursing Leadership Council that deals with nursing
administrative issues. In addition, each clinical discipline has its own education council,
which makes recommendations to the Clinical Education Team regarding educational

Other Measures Enhancing the Nursing Work Environment

According to one study respondent, a key factor that induces nurses to stay at St. Luke’s
is its clinical career ladder, which encourages individual advancement in virtually all
clinical professions. The career ladder is designed to support and reward participation in
continuing education and professional development. Managed by a committee of five
senior nurse managers, the program is reviewed each year with staff to ensure that their
needs and input are addressed.

A related initiative has helped to speed the orientation of new nursing personnel and
allow for more individualized mentoring and training through the use of a performance-
based professional development system. The system software facilitates the assessment
of an individua l’s skills and competencies as part of his or her initial orientation. The
results are then used to develop a personalized professional development plan that places
the individual in an optimal career path and practice setting.

The improvement of clinical practice and work redesign, the CNO emphasized, is “an
ongoing process since we are constantly refining our models in light of changing needs
and circumstances.” Several related initiatives to foster an improved work environment
have included:
   • Decentralizing pharmacy to certain nursing units or defined geographic areas;
   • Introducing a new care management system to help improve care coordination
       and minimize non-care delivery activities assumed by nursing;
   • Creating a new “unit service associate” position to ensure the availability of
       supplies, pass dietary trays to patients, and provide support for a clean bedside
   • Revamping the medical record and incorporating a “charting by exception” model
       to facilitate improved patient information sharing across different disciplines; and
   • Communicating formally and informally with physicians to elicit their input and
       involvement in problem solving while recognizing that “physicians don’t have the
       time to be on committees.”

Clinical Service Lines

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About the same time that patient- focused care delivery redesign initiatives were being
launched under the Robert Wood Johnson/Pew Memorial Trust grant program, St. Luke’s
also began to restructure clinical programs under a matrix-oriented service line
management structure. Services lines were organized for heart care, cancer care,
women’s health, children’s health, medicine and surgery, each headed by an

According to the CNO, the interdisciplinary care team and service line restructuring
initiatives were partly aimed reducing “silo behavior” and the fragmentation of care. The
fact that both initiatives were pursued simultaneously probably made some the desired
changes in the nursing work environment more difficult to achieve, because the
organization “simply took on too much change all at the same time.” However, she
believes that over time the service line structure has been beneficial in developing more
effective working relationships between doctors and nurses and between nursing and
other professional disciplines.


Nursing Organization and Decision-Making

In the midst of a comprehensive turnaround campaign at LGH, 4 the hospital’s new CNO
reorganized and re-energized the nursing organization’s leadership structure and
decision- making style. This, she recalled, required some gutsy leadership on her part.
The newly revamped leadership Council’s meetings tended to lapse into unproductive,
negative complaining sessions focusing on labor relations issues only. In response, the
CNO disbanded it and started over with some changes in the Council’s composition to
help instill a more open- minded, problem-solving mindset. That proved to be an
important step in creating a new climate for constructive reassessment and change aimed
at improving the nursing work environment and focusing more on LGH’s internal and
external customers.

One nurse manager commented that, under the new CNO, Nursing Council has become a
significant component of LGH’s nursing organization. Through the 20- member Council,
all staff nurses are represented along with the clinical directors of every service line. The
Council gives staff the opportunity to make recommendations for improvement and has
input on decisions affecting patient care, staff development, operational policies and
procedures, and other issues affecting the work environment.

The Council has also established three ”sub-teams” respectively responsible for Nursing
Practice, Recruitment & Retention, and Professional Development. Each team meets
without the CNO, and they reportedly have assumed increasing responsibility for
identifying improvement initiatives and implementing them.

    See pp. 32-34 above.

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Service Line Model

In the last several years, LGH has also used a service line model in reorganizing many of
its clinical programs. Nursing has also adopted a somewhat service line-oriented structure
as well, with clinical directors designated for several core service areas (such as critical
care, oncology, maternal and child health, surgical services, emergency services, etc.)
Typically each service line has a physician as medical director and nurse as clinical
director, and some also have an administrative director. Organized service lines have
been established for cancer care, surgical services, medicine, emergency services, and
maternal and child health.

Study respondents indicate that service lines have helped to increase departmental
synergies and foster a spirit of cooperation and customer focus. This, some say, has
contributed to better communication and teamwork among and between nurses and other
caregivers and hospital staff. A nurse manager also observed, “The service line model
helped us to have a positive impact on patient outcomes. It has expanded the ways in
which nurses can have meaningful input, participate in discussing solutions and, most
important, help put these solutions into practice.”


Professional Nursing Practice Enhancement Initiative

In the spring of 2001, St. Charles Medical Center (SCMC) along with Central Oregon
Community Hospital (COCH) established a 12-person steering committee led by the
CNO to launch a major, multi- faceted nursing practice enhancement initiative, which was
expected to last until the fall of 2003. Steering committee members included top senior
executives, a number of nurse managers, an ancillary service manager, the staff nurse
chair of the professional nursing care committee, and a representative of the nurses’
union. This initiative was a response to intensifying wo rkplace pressures and tensions
stemming from the shortage of needed caregivers (nurses and other personnel) at a time
when SCMC was facing increasing market demand for services. Because SCMC and
COCH were in the process of merging to form a new health care system, their CNOs
decided the practice enhancement initiative created an opportunity to bring the two
cultures together while developing a consistent care model for the system. Utilizing
consultants to help guide them through the process, each facility dedicated a half-time
nurse to act as an onsite coordinator for the initiative.

Key components of this initiative included:
• Development of core principles to guide professional nursing practice and continuing
   care delivery improvement efforts;
• Formation of Unit Practice Committees (UPCs) to enhance nurses’ autonomy and
   control of their practice environment;
• Completion of a work complexity assessment by the major units as the basis for
   identifying key patient care and work environment improvement opportunities;

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•   Education and training programs to support refined work design and care delivery
    models; and
•   Enhancement of the resource management system including the integration of patient
    classification, scheduling and staffing processes.

Long before this initiative was launched, the Medical Center had put into place an
authority structure that decreased the number of management personnel, encouraged
cross-disciplinary problem solving and teamwork while decentralizing decision- making
through its council structure. The councils included an Executive Council consisting of
the CEO and vice presidents and a Leadership Council consisting of “leader/managers.”
(The title “leader/manager” was adopted for all managers to emphasize their leadership
role.) The Executive Council is responsible for the development and implementation of
the strategic plan as well as for the overall quality of care. The Leadership Council is
responsible for the operations of the organization. The leader/managers on the
Operations Council are responsible for the operations of their respective service clusters
as well as for the success of operations of the whole organization through their
participation on the Leadership Council. Key vice presidents, such as the COO, CNO,
VP of Education and VP of Human Resources, also serve as members of the Leadership

The CNO framed an initial vision statement: “To be the best place in the nation to
practice nursing and the best place to come for patient care.” She then brought
management and nurses together at a retreat to further define the vision and articulate its
implications. It became immediately apparent that nurses felt it was important that
management truly understand the current reality of their work environment. The CNO
commented, “We [management] spent the first part of our retreat just listening to the
nurses describe their experiences and then expressing our understanding through
drawings as well as words. Once the basis for genuine dialogue was established,
everyone joined together to further refine the vision.” Examples of this refinement
included adding to the vision that nurses will articulate their professional practice and
feel pride in their profession, and that every patient will have a primary nurse responsible
for a therapeutic relationship and plan of care throughout the patient’s stay on a given

The steering committee then spent almost three months developing a set of “practice
enhancement principles” (see Attachment C). Every unit of the two hospitals was
responsible for putting these principles into practice in a manner appropriate to the
patients served. The principles addressed the following five areas:
        • Healing health care philosophy
        • Responsibility for a therapeutic relationship and care plan for each patient
            (exercised by a primary nurse in collaboration with an interdisciplinary team
            that includes physicians and case managers)
        • Work allocation and assignments
        • Communication
        • Leadership

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Once consensus was reached on these principles, they provided the guiding framework
for Unit Practice Committees (UPCs) to use in designing their unit-based practice

Unit Practice Committees

A UPC was established for every unit, and each committee consisted of staff nurses and
some ancillary staff chosen by their peers, not by management. The UPCs used the
practice enhancement principles as guides and parameters for their improvement efforts.
The committees exercised significant autonomy in determining solutions for identified
operational improvement needs, and they decided how the core practice enhancement
principles would be applied in their respective area. If their improvement design met the
intent of the principles, it was accepted by the steering committee. The UPCs took their
work very seriously, and their unit improvement plans exceeded management’s
expectations. For example, many of the nursing units changed the way staff scheduling
was being done. A key reason was to ensure greater continuity and consistency of care
for the patient and improved staff hand-offs from one shift to the next.

Work Complexity Assessment

With the help of outside consultants, SCMC and COCH carried out a work complexity
assessment on four of their major units. This process entailed a two-day working session
for each unit. The units took a hard look at what they do and how they are doing it, and
identified improvement opportunities.

According to participants, the unit-based self-assessment process proved to be a very
valuable experience. In addition to introducing changes in staffing skill mix and shift
report methods, the process brought home the lack of standardized language or consistent
processes to describe and track the outcomes of nursing practice. This eventually led to a
decision to adopt the “nursing interventions classification” (NIC) and “nursing outcomes
classification” (NOC) language. Over time that decision has provided both hospitals with
a consistent way to benchmark and evaluate unit performance using nursing-relevant

Primary Nursing

A major principle guiding work design improvement was the introduction of a primary
nurse for each patient throughout his or her length of stay on a given service. For the
patient, having such an identified point person for their care is expected to help reduce
patient stress and uncertainty. From the staff’s perspective, the CNO noted, research has
shown that when a nurse has the same patient over two or more days, it alleviates
workload stress while increasing the nurse’s efficiency. The primary nurse is responsible
for a therapeutic relationship with the patient and developing a plan of care that is
respected and followed by the entire health care team. The primary nurse manages the
patient’s care with a team including a certified nursing assistant (CNA) or licensed

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practical nurse (LPN). He or she also works collaboratively with physicians as well as
other disciplines as needed.


Determining How to Apply New Technology

A common complaint among nurses is that they have to spend more time on documenting
what they do than on providing direct patient care. To address this issue, Jewish Hospital
has undertaken a major three-year initiative to design and implement a computerized
documentation system for nursing and to explore other possible applications of
information and communication technology to improve the nursing work environment.
This initiative began with a focus on the hospital’s intensive care units. It was then
extended to step-down units and is now focusing on medical/surgical units as well.

One immediate benefit of the new computerized documentation system is that it will
allow nurses at the bedside to do complete patient assessments directly online, rather than
having nursing notes prepared and then transcribed into an electronic record. For
frontline staff this means eliminating after-hours work to complete patient charts and
increasing the amount of time they will have with patients. Physicians reportedly like the
new system since they can log on and get the information they need about their patients
without having to track down individual nurses and question them.

A multidisciplinary working group led by nursing staff has played a key role in
determining the design of the new system and the reporting formats to be used. The roll-
out process will also involve a transitioning period during which paper charts will
continue to be used in response to physician preferences. The goal is to move to a fully
automated physician order entry system over a 3- to 5-year horizo n.

A new equipment management and tracking system represents another application of
technology, which the hospital has invested in response to staff concerns. Supported by a
team out of central supply, the system facilitates the location and redeployment of
specific equipment needed by individual units. In addition to improving response time in
getting needed equipment to the floors, the system has also enhanced proper maintenance
and updating of equipment and reduced the time it takes to have equipment cleaned
between its use by different patients. The importance of ensuring meaningful staff input,
not only in identifying work design improvement needs but also in the way technology
can be best applied in designing solutions, is underscored by hospital leaders and nurse
managers alike.


Nurse Managers and Clinical Leaders

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For many years decentralized, collaborative decision-making has been valued and
approached in different ways. One recent work design initiative ha s re- instituted having
one nurse manager for each nursing unit rather than having managers be responsible to
multiple units. The change is accompanied by assigning an RN “clinical leader” to assist
the nurse manager in providing nursing education, mentoring and forms of professional
development support for unit staff. These include helping to promote evidence-based
professional practice and assisting with data gathering and analysis within the unit.

The concept of the clinical leader role originated in one of the patient care redesign teams
in a recent process improvement effort. That team then took the lead in planning and
implementing this work model innovation. The hospital is now moving to develop more
standardization of the clinical leader role across nursing units as well as greater
consistency in the content and methods of nursing education activities. The underlying
objective is to provide enhanced flexibility for nurses as they pursue their professional
development and career paths throughout the hospital. It is also expected that these
changes will encourage more sharing of bedside care practices and mutual learning with
the nursing staff as a whole.

Multidisciplinary Care Management Teams

According the hospital’s medical director, Hartford has fostered a “collaborative
management culture” going back to the 1980s. For every major clinical service,
leadership teams exist in which a senior physician works closely with a senior nurse in a
dyad or, in some instances, a triad relationship involving a non-clinical administrator. At
the unit level as well, collaborative teams sometimes involve as many as eight to ten
people. Theses service management teams bring together physicians, nurses, residents,
social workers, case coordinators, and other professionals in planning and managing
clinical issues and processes. Typically these teams meet on a monthly basis. During the
last two years, the hospital has begun clustering many of theses care management teams
as part of moving toward a more organized service line structure.

Recruitment and Retention Summit on “Shortage Occupations”

Earlier in 2002, Hartford Hospital held a “Recruitment and Retention Summit” that
involved 75 to 100 people drawn from various “shortage occupation” areas, such as
pharmacy, lab, radiology, and varied therapies, as well as nursing. The session entailed
the exchange of ideas and the identification of specific initiatives through small
multidisciplinary group discussions that focused on a number of topics, including
recruitment practices and techniques, pay and benefits, work- life balance issues, etc.

The outcome of the daylong process was a number of task forces charged with pursuing
the development and implementation of specific actions cutting across different shortage
occupation groups. The summit generated many ideas and energy, and it confirmed that
that teaming up could help to address work environment needs and opportunities
throughout the organization.

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Nurse Council and Staffing Summit

Study respondents from Baptist Hospital are proud of their progressive approach to work
environment changes, which is designed to involve staff in a meaningful way. The
Nursing Council at Baptist has the final say on nursing policy and practice issues at the
hospital. Staff nurse representatives actively participate in the Council’s deliberations and
join nursing managers and directors in shaping the Council’s decisions.

One director emphasized that giving staff such opportunities for direct input on ways to
improve patient care delivery and work processes has made a tremendous difference.
Rather than imposing top-down solutions, as was sometimes the case in the past, nursing
leaders and managers have been able to show that they respect and heed staff nurses’
advice on how to do their job best. As a result, nurses at Baptist feel valued and respected
professionally due to solicitation and implementation of their ideas.

Collaborative decision- making also occurs between nursing leaders and leaders of other
clinical disciplines and administrative functions. One particularly successful initiative
that reflects this aspect of the Baptist’s organizational culture was a recent Nurse Staffing
Summit. The CNO and nursing directors gathered together with chief nurses and
managers of key support services including education, human resources, and recruitment
to brainstorm about how to improve retention, compensation and benefits, staff attitudes
and morale, the aging workforce, recruitment, and workforce planning. These and other
topics elicited a great deal of staff participation and many constructive suggestions.


Service Line Organization and Physician Relations

From past experiences at two other hospitals, Methodist’s new site administrator believed
that (a) if hospital caregivers and staff have responsibility for specific patient populations
and (b) if a team approach to organizing and delivering care is well established, then a
quality work environment can be created that will be more effective and more rewarding
for all those involved – patients, staff, and physicians.

Over the past few years, TMH has been putting a service line structure in place to achieve
these outcomes, with some very promising results to date. The new structure puts all
inpatient and outpatient departments for a differentiated patient population under one vice
president. Each service line also has a medical director and either an administrative or a
clinical director, many of whom have nursing backgrounds. Service lines have been
established for areas such as heart care, oncology, women’s health, neuroscience,
orthopedics, and general medical/surgical services.

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A parallel medical/administrative leadership team has been created at the level of each
department and each unit within every service line. Nurse managers (now called clinical
directors) work closely with a medical director “partner.” They are accountable for a
wider span of decision- making responsibilities, without having a multi- level
administrative hierarchy between them and the service line’s vice president. TMH now
has 75 unit and departmental directors, 45 of whom are nurses.

The hospital Administrator also instituted a Joint Operating Group (JOG) at the senior
management level that meets every week and brings together medical staff leaders and
key clinical chiefs. This was a major departure from the “arms length” posture that had
characterized TMH administration-physician relations for many years. The JOG was
created, according to the Administrator, in order to “model a new kind of open, frank
communication and collaborative discussion process” between hospital and physician
leaders, which was being encouraged at every level of the service line structure.

TMH’s quality management process has been restructured as well. Instead of the
traditional division of labor between a hospital operations- focused quality assurance
committee and a separate medical staff- focused committee, there are now
multidisciplinary “care management” committees for each service line.            These
committees have fostered a team decision- making approach for a wider range of
operational and performance improvement issues: patient outcomes, employee
satisfaction, staff recruitment and retention, operating costs, service development,
coordination of care, etc.

According to a senior executive, with this new service line structure, coupled with the
leadership brought by the new CNO, the old silos are gone. “Nurses, physicians, and
other caregivers are now working more collaboratively than ever before, with a
heightened focus on what’s best for the patient.” The new CNO reshaped her role to
provide leadership for:
    • Strategically defining what the practice of nursing at Methodist should be and
    • Promoting quality improvement, education and professional development
    • Coaching and mentoring at the unit level to model the kind of partnering
       relationships that nurses and physicians can achieve; and
    • Facilitating team building, improved communications, mutual learning, problem
       solving and skill development -- all of which are essential for the huge cultural
       change that is required to make the new organizational structure work.

The essential starting point for the Administrator was organizing and reorienting the
senior management group so that each vice president understood what his or her role was
to be. Adding, “I’m a believer that you get what you can measure,” she stressed that
performance in five key areas is evaluated, for each VP spearheading a service line:
    • Strategic planning – knowing where you’re headed and how you intend to get

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   •   Quality – how you motivate quality performance and what measures to use to
       track and evaluate it.
   •   Customer focus – who your internal and external customers are and how you will
       know their needs, preferences, and level of satisfaction.
   •   Leadership – how to hire the right people, force rank the people you have,
       determine who needs improvement and how to assist, redeploy, or release them.
   •   Budget – how to benchmark performance, manage costs and services.

With the flattening of the hospital organization and a heightened focus on the patient, a
conscious effort has been made to bring more nurses into administrative and executive
positions. TMH has also greatly enhanced training and educational opportunities for
nurses in unit manager and departmental or clinical director roles.


Service Line Organization and Physician Relations

For many years, York Hospital’s leadership has worked to forge effective, collaborative
relationships with physicians and other caregivers. Among other initiatives, York’s
comprehensive approach to service line organization and management has contributed
substantially to this continuing agenda.

During the mid-1990s, the hospital undertook improving the way its health care services
were being delivered by focusing on organized continuums of care for different patient
populations. This entailed developing a hospital- wide system of service line management
that now embraces more than eighty percent of the clinical programs and activities it
provides. A “triad” leadership team consisting of a physician, a nurse and an
administrator was established as the basic model for each of 7 or 8 major service lines.
These leadership teams have significant decision- making and budgetary authority,
including the hiring and firing of nursing personnel and other designated service line

The service line structure and the organizational culture supporting it have enhanced the
role nurse managers play in a broad range of clinical program planning, service
development, and operational improvement issues. Respondents maintain that York’s
service line model has similarly contributed to more effective working relationships and
communication among physicians and nurses. At the unit level, teams of physicians and
nurses are also extensively used to identify and resolve operational issues and support
ongoing quality management and performance improvement.

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   4.      Strategic Planning and Performance Measurement

               The significant problems we face cannot be solved at the
               same level of thinking we were at when we created them.
                                                   -- Albert Einstein

Several hospitals have emphasized the critical role that nurses play through the
development of formal strategic plans for nursing and through increased participation of
nursing leaders and staff in institutional strategic planning processes.

    •   Nursing leaders and staff at both Inova Fairfax Hospital and Main Line
        Health System collaborated in developing Nursing Strategic Plans.
        Inova’s plan grows out of a “nursing vision” that stresses “principle-
        centered” leadership, elevation of nursing practice, education and
    •   The plan developed by one Main Line Health hospital outlines strategies
        for six key dimensions of professional nursing practice and patient care:
        leadership, culture, recruitment and retention, professional growth,
        collaboration, and care delivery.
    •   Over several years, Vanderbilt University Hospital’s multi- faceted
        nursing work environment improvement strategy evolved out of a series
        of problem-solving task forces that involved other disciplines and
        significantly enha nced staff decision- making input and ownership.
    •   For over a decade, St. Charles Medical Center’s strategic plan has been
        built around creating a patient-centered culture and a work environment
        for all employees that emphasizes leadership development, teamwork,
        and decentralized accountability.

No matter how good the strategy, execution is the key. Hospitals that are successful in
recruiting and retaining nurses often stress the importance of establishing performance
measures for every aspect of their strategy, tracking performance frequently against
these measures, and acting quickly if performance does not meet expectations.

    •   Poudre Valley Hospital monitors monthly turnover and vacancy rates by
        unit along with other measures as part of a system- wide “balanced
        scorecard” focused largely on the organization’s employee culture.
    •   St. Charles Medical Center’s approach to performance measurement
        and accountability features dashboards with key measures for each
        performance area, annual caregiver surveys, monthly caregiver advisory
        council meetings, and weekly leadership forums to discuss performance
        and identify opportunities for improvement.

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Measuring and Strengthening the Organization’s Culture

Poudre Valley Hospital (PVH) focuses a great deal of effort on continuous improvement
of the organization’s employee culture and performance. As a Magnet facility, PVH
heavily engages its nursing staff in strategy development and decision- making processes.
Staff-driven committees play a major role in framing strategies and specific initiatives for
improving the work environment and strengthening the organization’s culture. There are
committees for Quality Improvement, Leadership Development, Professional Education,
and Evidence-Based Practice.

One nurse manager indicated that she and one of her directors are co-chairs of a
committee this year. Next year they will coach and mentor the co-chairs who assume
these roles, and in the third year they will withdraw from committee leadership. This
approach ensures that staff input through the committee process will continue to be
encouraged by effective leadership. It also frees up the nurse manager and her director to
become involved in other initiatives.

Strong staff participation in strategy development is coupled with significant attention to
performance measurement, particularly with regard to organizational values and culture.
Focus groups and employee surveys are extensively used to track performance and
evaluate success. Staff satisfaction surveys are carried out every six months. Every three
years an outside consultant performs an extensive staff satisfaction survey and compares
the results statewide and nationwide. Based on these benchmarking results, managers are
expected to implement action plans to address key issues and monitor improvements.

For example, the hospital closely monitors monthly turnover and vacancy rates by unit
and reports the results widely every quarter. These measures are part of a system- wide
balanced scorecard approach, which helps to communicate the organization’s business
goals, performance criteria, and accountability. The utilization of agency nurses, the
amount of overtime pay for nurses and patient outcome measures are also among the
performance indicators that are closely monitored.

Respondents underscore the serious way the hospital goes about tracking the internal
culture and measuring improvements relating to implemented changes. In recent years,
frequent internal employee surveys have been used to gauge what are referred to as key
indicators of “what makes you want to get out of bed and come to work.”
Multidisciplinary employee focus groups are conducted to evaluate such key workplace
attributes as teamwork, cooperation, responsibility, risk taking, resource availability, and
workplace safety. The hospital’s culture is aligned to these core values, and they are
included in employee performance appraisal criteria as well. Appropriate indicators for
these attributes are periodically updated, and performance and attitude scores are
correlated to staff turnover, a key balanced scorecard measure.

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Staff members are coached on how to implement caring behaviors consistent with core
organizational values. Such coaching is provided through in- house expertise. It addresses
such topics as: respectful behaviors, giving feedback to someone being disrespectful,
constructive criticism, and conflict resolution.

PVH also underwent three years of major construction and improved all patient care
areas. Nurses were significantly involved in the process to develop the facility plan for
this project. The new facility received state awards for its innovative design for meeting
patient needs as well as the work environment needs of the nursing staff. Nurses feel
involved and are recognized for their efforts.


Nursing Vision, Strategic Planning and Performance Measurement

About three years ago as part of an Inova Health System initiative, nurses at Inova
Fairfax H ospital (IFH) played a major role in developing for the first time a “Nursing
Vision” and Strategic Plan. This was done through a very participatory process that
engaged every component of the hospital’s nursing organization. According to the
hospital’s CNO, IFH is probably one of the few hospitals that have a strategic vision and
plan specifically for nursing. Both the planning process and its outcome have been
valuable in clarifying the focus and direction of nursing at both the hospital and the Inova
Health System as a whole. Inova’s Nursing Vision is as follows: “In an environment of
principle-centered leadership, elevation of nursing practice, education, and research to a
level of national distinction which differentiates Inova nurses from all others.”

Since being initially rolled out in the late 1990’s, the Nursing Strategic Plan has been
updated annually and continues to evolve. The plan contains goals and specific
initiatives that focus on six areas viewed as essential to recruiting and developing the next
generation of nurses for the IFH and Inova Health System. These are: Leadership,
Culture, Learning, Research, Practice, and Role Clarity. Each year the System
acknowledges and celebrates individual and collective contributions to these core goals
by nurses at IFH and all other Inova facilities.

Along with effective monitoring of plan implementation activities, disciplined
performance measurement has been a strategic priority for nursing and hospital leaders as
well. As a Magnet facility, IFH has used the American Nurse Association’s report card
and the extensive and disciplined metrics tied to the ANCC’s credentialing (and re-
credentialing) process. A great deal of attention is paid to customer satisfaction and
evaluation of the quality of care from the patient’s standpoint, as well as measures of staff
performance, satisfaction, and quality of care. Well articulated criteria and metrics are
used to assess hospital performance and improvement with regard to structure, process,
and outcomes in virtually every functional and clinical area – from Human Resources to
the ER. This process is also tied directly to annual performance appraisal and the
compensation of all managers.

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Nursing Strategic Plan

When a new CNO came on board at one of the three MLH hospitals, she initiated a
strategic planning process for nursing, with the involvement of staff and assistance from a
consultant. The planning process reportedly was very helpful not only in establishing her
new role, but in providing a clear framework for how every staff member can contribute
to a patient-centered vision for professional nursing practice.

The strategic plan targeted six critical dimensions of the patient care model that defines
the vision for nursing practice excellence: Leadership, Culture, Recruitment and
Retention, Professional Growth, Collaboration, and Care Delivery (see Attachment D      ).
For each area, the plan identified key activities and implementation steps, the person
responsible, required support, communication plan methods, and time frames. Because
of how well it was received by staff, nursing leaders at another MLH hospital are
considering using the plan as a model as they begin to launch a strategic planning process
of their own.


Leadership Training, Decentralized Teams, and Performance Accountability

Executive leaders at St. Charles Medical Center emphasize that for over a decade their
strategy has been to create an excellent work environment for all employees, not just
nurses, by “creating an environment based on making real and living every day our
patient-focused culture and values.” As one senior leader put it, “This translates into a
culture of healing and accountability.” Key me thods have included heavy emphasis on
leadership training and working in teams, coupled with substantial decentralization of
decision- making and performance accountability.

Hospital leaders believe that the organization’s culture and its approach to healthcare
differentiate St. Charles from its regional competitors. According to one respondent, the
Medical Center continues to nurture a holistic, wellness-oriented culture that empowers
people and focuses on the needs of both external and internal customers (i.e., patients,
family members, and employees). In addition to its distinctive wellness model, key
aspects of SCMC’s approach include:
    • “Relationship-centered” team building, training, and orientation provided to all
        hospital employees;
    • Strong support for staff development and education;
    • An administration that has always shown great respect for nurses’ practice and
        their professionalism, and that stands up for them with physicians; and
    • Good working relationships with bargaining unit associations representing RNs
        and LPNs respectively that have existed for many years.

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Critical Success Factors

SCMC leaders cite a number of critical factors that account for the organization’s success
in forging a strong culture which has enhanced its work environment. These include:

Strategic focus. One of the six strategies of SCMC’s Strategic Plan is to ensure an
exceptional work environment. As one senior executive put it, “From the Board and
senior management down, we make clear in what we say and do that this goal represents
a continuing top- level priority for SCMC.”

Perseverance. Champions of organizational and culture change are essential. At SCMC
champions have included everyone from top executives to unit and departmental

Augmented and constant communication. All caregivers and employees must repeatedly
hear and see modeled the people-centered team behavior and patient/family focus that are
the hallmarks of the organization’s culture and approach to health care.

Leadership development. Leadership training at SCMC does not mean just an occasional
class or seminar. Rather, training is done in an intensive and sustained way to enhance
leadership development, team building, conflict management, and collaborative
interpersonal relationships. All training programs are designed to reflect and reinforce the
organization’s vision, values and beliefs, and the commitment to make those value
statements real every day. Training programs also evolve to reflect the changing issues,
challenges and needs that everyone must deal with.

Starting in the early 1990s, SCMC inaugurated an evolving “cluster management”
initiative to change its traditional hierarchical hospital structure and culture by
introducing multidisciplinary teams for clustered clinical services and programs. Over
time, the cluster teams were empowered by increasing decentralization of decision-
making authority and responsibilities, and a new approach was adopted for selecting and
training team leaders (called “leader/managers”). One respondent noted, “Traditionally,
the best technologist or the best nurse would be the individuals selected to be department
or unit managers. However, with the development of service clusters, an increasing focus
was given to the team leadership skills and abilities of the individuals chosen for these

At SCMC, managers are called leader/managers to emphasize their leadership role. The
people (e.g., unit staff) who will be directly affected by a hiring decision are involved in
meeting and assessing all cand idates and they help make that decision. The Medical
Center looks for people who are attracted to it because of what the organization stands for
and its approach to health care. Leader/managers are expected to be individuals who
have real concern and respect for others, who work collaboratively as team members, and
who reflect SCMC’s values. “Just having excellent technical and clinical skills is not

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enough,” one respondent observes, adding, “We train our mangers to be master
facilitators because those are the tools and skills necessary to inspire people.”

Decentralized decision-making. Decentralized care teams are also essential to SCMC’s
new focus on what patients were looking for and needed. But it was recognized early on
that many caregivers really didn’t know how to establish effective teams and many were
simply not comfortable working in a team setting. Consequently, the Medical Center
organized a two and a half day training course on “people-centered teams” for every staff
member. This training deals with all aspects of team building and such practical
applications as problem solving, crisis management, how to raise and confront issues, etc.
Part of the program is done off-site by groups of approximately 30 people (either a whole
department, or different units or departments together).

Having hired a consultant to help design and launch the program, SCMC then took it
over, trained its own trainers, and built a strong Educational Department that continued to
grow and evolve into an expanded Center for Health and Learning. The Center now
sponsors a broad range of health awareness, prevention, health coaching, wellness, and
continuing educational programs for its internal and external customers, in addition to
supporting the training and professional development of SCMC’s caregiver’s
leader/managers. “In effect,” one senior executive remarked, “we have used training as a
change agent.”5

Performance Measurement is another key success factor that goes hand in hand with
leadership development and decent ralized decision- making at SCMC. According to the
CNO, “We continue to work to improve how we measure not just our clinical and
financial performance but also the way we collectively and individually live up to our
values and our expectations for leadership, teamwork, and people-centered relationships.”
The various methods used for measuring and monitoring performance include:
    • Using a set of dashboards with 20 or so key measures for major performance
    • Annual caregiver surveys to closely monitor internal customer satisfaction and
        feedback on issues that need attention, as well as Press Ganey surveys and focus
        groups to assess patient satisfaction. Each year the feedback gained from these
        surveys leads to several action plans to address identified issues and concerns.
    • Monthly caregiver advisory council meetings that give frontline staff
        representatives the opportunity to meet with the CEO with an open agenda that
        encourages frank, two-way discussion.
    • Weekly leadership forums that involve top senior executives and 50 other
        management representatives (leader/managers, team leaders and coordinators)
        responsible for units and departments throughout the hospital. These sessions
        involve open discussion of any issue and all issues and demonstrate the legitimacy
        of having all questions and concerns put on the table.

 For other examples of manager skills and leadership development initiatives, see Section 6 below, pp. 69-

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   •   Individual performance assessments that entail both self and peer/team
       evaluations. They emphasize leadership styles, relationships with others, staff
       turnover, and how SCMC’s institutional values and healing health care
       philosophy are reflected by each person’s behavior and performance.


Work Environment Improvement Strategy

Overall Approach and Strategy

For many years Vanderbilt University Hospital (VUH) has used a variety of initiatives to
improve nurse retention and job satisfaction. During the last few years, the impact of the
nursing shortage has become increasingly evident at the same time that patient demand
and acuity have intensified. In response, the hospital’s overall approach and strategy for
work environment improvement has become much more integrated and focused.

Starting in 1999, VUH initiated a comprehensive evaluation of nurse recruitment and
retention needs and the hospital’s performance in addressing those needs. This was
followed by an evolving series of task forces charged with examining specific areas of
improvement. Coordinated by a leadership steering group, the task forces have addressed
virtually all aspects of Vanderbilt’s nursing work environment, focusing on ways to
strengthen recruitment, retention, manager skills, and cultural change. Recently, a major
communications campaign targeted at internal hospital constituencies was launched to
more clearly articulate the multi- faceted strategy being pursued and the progress being

Work Environment Assessment Improvement Process

According to Vanderbilt’s CNO, a major underlying goal and strategy that emerged from
several years of work environment improvement activities is “to make ourselves
receptive and eager for going after Magnet status recognition…It’s been a ‘go slow to go
fast’ strategy.’” An important catalyst for many of these efforts was a presentation given
by Advisory Board Company representatives to nursing and hospital leaders about three
years ago. The presenters described the Advisory Board’s research findings regarding the
growing nursing shortage and the significant implications the findings would have for
hospitals nationwide. This perspective was further reinforced by other discussions of the
research being done by a recognized expert on the nursing profession based at
Vanderbilt’s School of Nursing.

At the time, VUH was already facing high vacancy and turnover rates. Moreover, a
Medical Center-wide employee survey - the first of its kind - showed that job satisfaction
and morale among staff nurses were lower than among all other employee and caregiver
groups, including residents, physicians, clinical directors, nursing assistants, technicians,
and housekeeping personnel. This led to the formation of a steering committee led by the

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CNO to carry out a comprehensive, in-depth assessment of all facets of nursing
recruitment and retention at the Medical Center. The assessment process took about 18
months to complete. The steering committee then established a series of task forces to
move forward with the implementation of numerous recommendations generated by the
assessment. Today, the steering committee consists of the co-chairs of six task forces, and
all interested task force members are invited to participate in steering committee meetings
as well (thereby involving up to an estimated 50 individuals).

Each task force established by the steering committee is co-chaired by an administrator
and a manager. In addition to staff nurses, task force members include other stakeholders,
such as individuals from human resources, finance, system improvement, pharmacy,
distribution and supplies, and environmental services. Task force co-chairs meet together
monthly to work, plan and communicate various program initiatives. Some key
performance improvement areas that have been addressed by task forces include the

•   Shared Governance/Decision-Making – In the early 1980s, VUH was one of the first
    hospitals in the United States to adopt the shared governance model for its nursing
    organization. Recognizing the importance of empowered, decentralized decision-
    making and staff participation to the overall culture of the hospital, this task force was
    established to update and re-energize the shared governance approach and methods
    being used at Vanderbilt and to ensure that the principles and practice of shared
    governance are understood and appreciated by all members of the hospital’s nursing

•   Staffing Effectiveness – This task force has dealt with improvements and innovations
    in nurse staffing ratios tailored to specific patient populations and nursing units; more
    flexible scheduling policies (including the idea of introducing a 10AM-2PM
    “mommy shift”); potentia l development of a web-based scheduling system; more
    consistency and flexibility in policies and procedures across nursing and clinical
    units; and new and better ways to share ideas and experiences within the nursing staff
    as a whole.

•   Nurse Wellness – This task force has used staff satisfaction surveys and focus groups
    to clarify staff needs, concerns, and existing knowledge about available services and
    resources. Such feedback has helped to galvanize information-sharing activities (e.g.,
    orientation materials, nursing- focused wellness fairs, a ”wellness planning” event)
    and task force attention to topics including safety issues, exercise and fitness, various
    counseling services, ergonomics, and stress management. One recent initiative has
    been a ”Take a Break” campaign that encourages managers and staff to support one
    another to take breaks to better manage day-to-day workload stress.

•   Manager Development – Leadership skills development and career advancement
    opportunities for current and potential nurse managers have been the focus of this
    task force. Working in partnership with VUH, the Advisory Board Company has
    recently provided support for the task force’s work by administering an electronic

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    “360 degree learning needs assessment” for all nursing managers at the hospital. Each
    manager’s supervisor and three other individuals they selected were asked to
    complete a learning needs assessment for that manager. (This was presented as
    something quite different from a performance assessment). Both individual manager
    and aggregated results were tabulated and summarized, and these included a
    quantitative ranking of professional development needs as well as qualitative
    suggestions. This process was followed by and two-day workshop facilitated by
    Advisory Board representatives to discuss staff development needs, current practices,
    and innovative alternatives to be considered. On the second day, the CNO and all
    clinical directors and supervisors left the workshop, and each manager received a
    summary profile of the f edback provided regarding individual learning needs and
    opportunities. This was followed by a facilitated discussion of next steps in
    developing and using individual professional development plans.

•   Staff Recruitment and First Year – This task force conducted many focus groups of
    staff nurses and managers, grouping participants in part by their number of years at
    Vanderbilt, as well as by nurses who left but later returned. An outside market
    research firm was hired to conduct focus groups involving nurses practicing at
    competitor hospitals. Data showed that 47 percent of nurses hired at the hospital came
    because of internal nurse referrals – a relatively high percentage according to outside
    experts. Moreover, those nurses who had left the hospital did so within two years of
    joining the staff, a finding that underscored the vulnerability of newly recruited
    nurses. In light of this research, the task force introduced a number of changes in
    recruitment and year-one retention practices at VUH. These included making sure
    that candidates experience peer interviews, see the units and meet doctors during the
    recruitment process, enhancing the orientation process provided to new staff,
    strengthening preceptor workshops and other first- year training and workload
    management processes. In addition, nursing leaders now conduct 30- month, 60-
    month and 90- month follow- up meetings with new staff members to hear and respond
    to any difficulties or concerns they may have.

Communications Campaign

Effective communication and Medical Center leadership support are two essential factors
for successful work environment change, according to the CNO. One challenge that
nursing leaders recognized early on was that it is important for frontline staff to
understand how all this task force activity will potentially benefit them. “Frankly, task
force reports can be pretty boring. Especially for busy staff nurses it can sound like, once
again, we’re back in committee- land.” This issue was one of the considerations that led
to a major communication campaign entitled, “Be the Best, Keep the Best,” which was
launched during the fall of 2002.

The aim of the communication strategy was to broadcast “in plain, instantly
understandable language” the progress of the work environment improvement process
underway. The CNO announced the communication campaign at her “state of nursing”
address during national Nursing Week early in 2002. She subsequently used this

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presentation to brief clinical chairmen and medical staff leaders and build their support
for the core goals and initiatives comprising the work environment improvement strategy.
A new newsletter has also been developed to keep the nursing staff updated about all
aspects of the “Be the Best, Keep the Best” campaign.

The four major themes of the communications campaign capture the key components of
Vanderbilt’s nursing work environment improvement strategy:
       • Select the right people
       • Foster personal and professional growth
       • Ensure quality of work life
       • Create the right culture

The campaign’s stated goals and desired outcomes are to:
      • Get the best and keep the best people
      • Be the employer of choice
      • Achieve Magnet hospital status

To achieve these goals, VUH currently has six major task forces designing and
implementing specific work environment i provement initiatives with the support of
internal facilitators. They focus on the following areas:
        • Recruitment and retention
        • Management development
        • Shared governance and decision-making
        • Quality of work life (including nurse wellness)
        • Staffing and scheduling (this task force consists of the co-chairs of the other
            task forces.)
        • Services improvement

Learning Center Support

Vanderbilt’s Learning Center grew out of a organizational and work redesign initiative in
the mid-1990s. The Center is now staffed largely by adult learning and organization
development specialists, who see themselves as supportive partners for clinical people
(e.g., department heads, nurse managers, clinical nurse specialists, unit educators and
other providers). According to its interim director, the Center has cultivated a creative,
engaging and upbeat style, which is one reason why it has been well received.

For nursing, the Center has helped to facilitate multi-disciplinary task forces, support
shared learning and improved communication initiatives, and provide various levels of
collaborative decision- making and process coordination assistance. One respondent noted
that the help of experienced facilitators is enormously beneficial to task force co-chairs
since it allows them to focus on content, rather than the process. The Learning Center has
also provided the nurse managers and staff nurses serving as co-chairs with a variety of
training and coaching services that address various topics such as meeting agenda

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planning, what to send out in advance, how to stimulate everyone’s participation, how to
bring closure to a work session and reach decisions, and other group facilitation skills.

5.       Senior Administration Support and Communication

                  Jingshen is the Mandarin word for spirit and vivacity.
      It is an important word for those who would lead, because above all things,
                 spirit and vivacity set effective organizations apart from
                               those that will decline and die.
                      -- James L. Hayes, Memos for Management: Leadership
Candid sharing of information and concerns, along with respectful, mutual listening –
especially between senior management and frontline staff -- are often casualties in the
typically high-paced, high-stress hospital work environment. The importance of
accessible, supportive leadership and open, two-way communication is a constant theme
heard from virtually every organization in this study. A number of the organizations cited
specific initiatives that have been helpful in fostering a positive, non-threatening, and
productive nursing work environment.

     •     Jewish Hospital instituted “Eye on the Patient” to enhance and
           expand communication between the nursing staff and senior
           management. Senior managers periodically share around-the-clock
           shifts on a given nursing unit, totally immersing themselves with the
           caregivers. Management team members then share what they learned,
           identify the major issues and, in concert with nursing leaders, reach
           consensus on actions to be taken.
     •     Hartford Hospital has adopted a modified management-by-walking-
           around technique in which individual senior administrators “adopt”
           one or more units to visit and spend time with frontline staff and
           patients. These scheduled visits facilitate a level of non-judgmental
           communication and familiarity that otherwise rarely occurs.
     •     The CNO at North Mississippi Medical Center has instituted regular
           focus group sessions for all nursing shifts, which she and one or two
           other senior executives attend. Quarterly town meetings for all
           employees are also held with senior management for open discussion
           of hospital-wide performance and employee questions and concerns.
     •     East Alabama Medical Center has been recognized for its success in
           achieving an exemplary employee- focused culture. Methods used
           include heavy emphasis on management’s accessibility, frequent
           formal and informal communication, staff empowerment and
           recognition, and a very employee-friendly benefit package.

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Senior Management/ Nursing Staff Interaction

Jewish Hospital has adopted an aggressive program (called “Eye on the Patient”) to foster
greater interaction and communication between staff nurses and the senior administrative
team. Initially, participating senior executives included the hospital’s President, COO,
CNO, and several of vice presidents, such as those responsible for Environmental
Services, Engineering, Information Services, and Materials Management. More recently,
all vice presidents as well as directors of key ancillary departments, such as lab and
pharmacy, have been asked to participate as well.

The program works as follows. Every two months a major clinical area is selected to have
senior executives and department heads take turns spending entire shifts on the units for
24 hours a day over a seven-day period. The program gives staff nurses the opportunity to
meet face-to- face with senior administrators to help them better appreciate the conditions
and challenges that nursing faces in the trenches. Each senior administrator and director
is expected to record his/her observations about day-to-day operations, especially the
issues, concerns, and opportunities for improvement that surfaced from their
conversations with frontline staff. The observers then meet to share what they learned,
identify the top twenty issues, and formulate proposed action plans to address them. The
results of that meeting are then discussed with nurse managers in order to build consensus
on a final, prioritized action agenda.

“The power of this process,” the CNO observed, “is that everyone brings a different
perspective.” According to nursing leaders, the program has clearly enriched the
frequency and quality of communication between senior administration and frontline
staff. It has also helped to prioritize and focus improvement efforts and bring varied areas
of expertise to bear on the development of solutions that are responsive to both staff and
patient needs.

A parallel initiative (called “Round with the Docs”) has been established at Jewish
Hospital to strengthen communication and mutual understanding between doctors and
hospital leaders. It entails assigning the CNO and each hospital administrator, responsible
for a clinical function, a certain number of physicians (ranging from 10 to 30) with whom
they periodically make patient rounds.


The “Adopt a Unit” Initiative

Hartford Hospital has recently launched a work environment improvement initiative,
“Adopt a Unit”, to promote enhanced face-to- face communication between senior
administrators and unit- level nursing personnel and other caregivers. Exemplifying the
“MBWA” (management-by-walking-around) approach, this program involves having

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hospital vice presidents “adopt” one or a couple of nursing units in addition to their
responsibility for designated clinical or support services.

On a scheduled basis a couple of times a month, the vice presidents spend time on
“their” units walking around with nursing managers and talking with patients, frontline
nurses and other personnel. They are there to listen and learn about issues, both small
and large, and look for things that they or their colleagues can do something about (e.g.,
brightening up a visitor’s lounge, fixing lighting fixtures, or other operational problems).
Moreover, as one respondent emphasized, these visits allow frontline staff a chance to see
and talk to a senior administrator on a face-to- face basis, something they rarely have an
opportunity or the time to do. This has meant, among other things, that “administrators
have become viewed as people you can talk to without having your head chewed off.”

The “Adopt a Unit” initiative is viewed as part of continuing efforts to foster effective
working relationships and communication across all levels of hospital staff and
administration. These efforts include giving increased attention to various staff
recognition and mutual learning programs, especially recognition of work at the point of


Enhanced Internal Communications

Monthly Staff Nurse Focus Groups

North Mississippi Medical Center (NMMC) leaders believe that effective two-way
communication is a critical component of a quality work environment. One strategy used
by the CNO to accomplish this is to conduct staff nurse focus groups on a monthly basis.
NMMC’s Administrator and the Vice President for Human Resources also attend these

The sessions are designed to encourage dialogue between senior management and line
staff on any and all issues as well as improvement opportunities. They also allow senior
management to report back on actions taken in response to ideas and concerns previously
raised by staff. Focus group sessions are held for both day shift and night shift personnel.
Once every quarter, the staff of every unit selects a representative to attend these monthly
sessions, which typically last one and a half hours and can involve up to 30 people.

Employee Town Meetings

Once every quarter, the Administrator of the Medical Center holds a series of ”town
meetings” open to all emplo yees. Attendance is voluntary. To make these sessions
accessible to all interested individuals, the meetings are held around the clock (at 6:00
AM, 10:00 AM, 1:00 PM and 7:00 PM) on Tuesday and Thursday. The meetings
typically review the status of progress being made in addressing a dashboard of

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performance indicators and include presentations of current topics of general interest. As
with the nursing focus groups, the town meeting sessions are also intended to encourage
two-way communication and dialogue between management and employees.

Physician Relations

Engaging physicians is always a challenge, if only because their time is an issue.
According to the CNO, it is important to recognize that physicians are data-driven
people, and they want to see evidence of why change will be good for their patients. For
that reason, the CNO strives to avoid nursing jargon, speaks in plain English when
presenting concepts to physicians, and explains how desired outcomes will be measured
whenever new initiatives or changes are proposed.

Building physician understanding and collaboration, moreover, is a relationship-driven
process, stressed the CNO. For that reason, it is important for nursing leaders to be
visible and credible by demonstrating that they have the pulse of what is going on in the
trenches, and not just sit in their offices thinking about what would be good for nursing.


Building an Employee-focused Culture

For the past 12 years, East Alabama Medical Center (EAMC) has focused on employees
as customers, with the goal of making itself the employer of choice in Eastern Alabama.
It has earned designation as one of Fortune’s 100 Best Companies to Work For (18th in
2002), the Alabama Quality Award, the Premier Health System Distinguished Performer
award, and many similar distinctions.

EAMC respondents stress that there is “nothing magical” in their approach, and not really
anything special for nurses – just listening to them and doing their best to meet their
needs. That attitude, plus an extremely stable and economically favorable competitive
environment, are the main reasons EAMC has achieved a steady 4-5 percent nursing
vacancy rate, turnover in nursing of about 8 percent (compared to a 13 percent overall
hospital turnover rate), and an average tenure in nursing of 12 years.

EAMC’s approach has four main components:
   • Unique employee benefits
   • Recognition for good work
   • Empowerment
   • Management accessibility and communication

Key work environment initiatives have included the following:

Unique benefits

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EAMC's salaries are competitive, but they are not pay leaders. The Medical Center has
put a lot of money into a benefits package designed with and by employees. EAMC has
typical benefits such as on-site day care, a flex benefits health program, EAP, maternity
leave, etc. But it also has unusual ones, such as:
    • Gain-sharing. EAMC establishes targets for overall patient satisfaction as well as
        department clinical outcomes and performance against targets (e.g., efficient linen
        usage). If the targets are exceeded, employees get part of the margin for the year.
    • Free mammograms and osteoporosis screening; adoption assistance; infertility
        coverage; paternity leave. Employees asked for these; they got them.
    • Scholarships. EAMC pays for many courses and degree programs; employees
        must agree to work for a specified number of months in return. If they leave,
        scholarships turn into a loan that must be repaid.
    • PACT Program Match. This is a State of Alabama program in which emp loyees
        can prepay college tuition. EAMC pays 25 percent of the prepay amount.
    • Cornerstone. An employee crisis fund with voluntary contributions by payroll
        deduction. An employee board administers it with no management involvement.
    • On-site dry cleaning, scrubs in Nursing Unit, 45,000 square foot fitness center,
        gift shop discounts and many more “little things” that employees asked for and

Recognition for Good Work

“We celebrate everything” is the way one staff member put it. There are celebrations
when anything good happens, plus several kinds of awards including an “instant award”
that managers can confer at will as well as a special award for people who make an
extraordinary effort to help patients or other employees. Gain-sharing counts under this
heading as well.


EAMC’s official statements do not mention this, and management has to be prompted to
do so, but EAMC involves employees in decisions about policies, procedures and
workflow to a greater extent than most hospitals. They use a typical CQI work team
approach to improve the work environment and the process of care – staff, physicians and
managers all participate -- but the results are hardly typical. For example, re-engineering
projects in nursing have resulted in:
    • A revamped nurse compensation system. A conscious effort was made to move
        toward a salaried model in applicative units (e.g., cardiac catheterization lab, peri-
        operative surgical services, etc.) and where there was staff interest. The nurses
        themselves decide how to allocate hours to cover shifts, how to allocate folks to
        travel. There is no overtime, and no traveling nurse differential.
    • A lower nurse/staffing ratio.
    • A point-of-care surgical facility.
    • Co-located cardiology and cardiac OR. Management gives this a lot of credit for
        EAMC’s designation as one of the “Top 100 Heart Hospitals.”

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Management Accessibility and Communication

Managers are quick to give the Medical Center’s President a lot of the credit for building
an organizational culture of open communication and trust, centered around:
    • Frequent formal employee satisfaction surveys plus follow-up reports. EAMC
       uses Press Ganey and conducts surveys at least once every 12-18 months. They
       share the results with employees and where improvement opportunities emerge,
       management follows up.
    • Open forums. The VP for HR and department heads hold frequent open meetings.
    • Daily rounds. EAMC’s President reportedly spends 4 hours each day “walking
       around.” He knows almost all of the 2,000 employees by name. The y talk about
       what’s going on, what problems there might be, how to improve things, etc.

In Press Ganey’s latest survey, 81 percent of employees agree with the statement that “I
can ask any reasonable question and get a straight answer,” and 78 percent agree,
“Management delivers on its promises.” EAMC’s performance on these and other survey
elements puts them in the 99th percentile of Press Ganey’s hospital clients.

6.         Leadership Development and Management Culture

                         If you pit a good performer against a bad system,
                             the bad system will win almost every time.
                                        -- Gary Rummler and Alan Brache

While many factors contribute to the issue of staff retention, the skill sets and leadership
style of managers have become a major focus of nursing work environment improvement
efforts. “People join good organizations but leave bad managers,” one study participant
observed. The role of the nurse manager as the hospital’s “chief retention officer” is now
widely appreciated, especially in face of growing generational and cultural diversity
within the nursing workforce and the highly demanding conditions under which it must
perform. The underlying culture of the organization also shapes how leaders, managers
and staff view their respective roles and behave. For some hospitals, this has meant
taking steps to ensure that leadership at every level is aligned with the mission, vision,
and values of the organization.6

      •    TriHealth hospitals have defined core competencies for every level of
           management and designed training and performance evaluation programs that
           address them in conjunction with organizational values and mission.
      •    St. Elizabeth Medical Center actively fosters a quality- focused management
           culture. Extensive manager training and continuing education is accompanied by

    For St. Charles Medical Center’s approach to manager leadership development, see pp. 58-60.

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       a decentralized approach to continuous quality improvement through empowered
       interdisciplinary teams.
   •   Inova Fairfax Hospital has made a conscious effort to change its management
       culture through leadership training, off-site planning and team building exercises,
       and the constant emphasis that hospital leaders give to such values as mutual
       respect, teamwork, evidence-based practice, and cross-disciplinary collaboration.
   •   At Lowell General Hospital, clinical directors and managers are involved in
       leadership development and mutual learning activities at quarterly leadership
       forums, as well as periodic meetings of service line directors, and training
       provided at departmental director meetings and Nursing Council sessions.


Management Training and Leadership Development

Centered around the partnership between Good Samaritan and Bethesda Hospitals,
TriHealth is the parent company of a regional health system serving greater Cincinnati,
Ohio. Drawing on exit interview data as well as current industry literature, TriHealth has
made a significant investment in upgrading and expanding management skills training
and leadership development programs for nurse managers. Hospital leaders recognized
that the qualities and skill sets that make an individual an excellent clinician do not
necessarily guarantee their success as a manager. Respondents expect that over time this
management development strategy will have a significant impact on work environment

To set the overall tone for manager development, a new initiative in this area was kicked
off with a meeting that focused on discussing the human aspects of caring and leadership.
The session emphasized how the purpose and desired outcome of the training initiative
were fundamentally aligned with TriHealth’s mission and values. In a related initiative,
TriHealth has taken steps to define more clearly the key competencies required for each
level of management. These competencies are now incorporated into job performance
criteria and appraisal measures used respectively for low, mid and senior- level managers.
An individual manager’s performance is assessed in light of these competencies and
related leadership behaviors and traits, as well as data-driven operational performance
measures such as vacancy rates, physician and patient satisfaction scores. The core
competencies developed by this initiative were based on the mission and values of the
organization and then aligned with specific performance measures so that results could be
evaluated effectively.


Quality-Focused Management Culture and Performance Evaluation

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St. Elizabeth Medical Center (SEMC) is a three- hospital system, which is part of Catholic
Health Partners (CHP), a large multi-state health system. At the annual CHP meeting in
2000, the Medical Center won all three of the system’s quality awards; in 2001 it won the
CHP’s “innovative practice” award; and in 2002 both a quality award and an innovative
practice award. Such recognition reflects the strong emphasis placed on continuous
quality imp rovement (CQI) at St. Elizabeth’s. According to respondents, key features of
their quality improvement program include top-down leadership support and direction,
interdisciplinary teamwork, constant use of data for decision- making, consistency in the
“plan-do-study-act” quality cycle, and a constant drive to improve processes and

Some methods used by the Medical Center to promote and support continuous quality
improvement include:
   • A “rapid redesign” methodology whereby multidisciplinary teams rely on
      quantitative data, intuitive judgment, collective experience, and workflow
      diagrams in order to change or streamline processes.
   • Unit-based design teams on nursing units that are empowered and expected to
      address quality and related operational improvement issues.
   • Multi-disciplinary teams created to deal with broader cross- functional and more
      complex issues.
   • Extensive management development training for current and potential nurse

“People join good organizations but leave bad managers,” emphasized one respondent.
St. Elizabeth’s approach to this issue has entailed the development of a quality- focused
management culture in nursing, as well as in other clinical areas. With the help of an
outside company, SEMC now has 23 trained in- house facilitators. All managers and
supervisors throughout the organization are required to attend a series of management
education programs based on their experience and needs. Satisfactory completion of this
series of continuing education programs is integrated into the performance evaluation
process for all managers and supervisors at the Medical Center. Nurse managers also are
enrolled in the Nursing Leadership Academy, a program designed by the Advisory Board
Company’s Nursing Executive Center and SEMC’s CNO and her management team.

In addition, a new survey tool called “Developing Managerial Competence” has been
introduced to enable the quality of leadership and performance of managers and
supervisors to be evaluated, without attribution, by the employees who report to them.
This is the first year of the program. Each manager directly receives his or her
evaluations, and the manager’s supervisor does not receive a copy. Based on the results
of their personal evaluation, each manager evaluated is required to write a work
improvement plan that specifically addresses the results and submit it to their immediate
supervisor. Next year the evaluations will be shared with the supervisors, and corrective
action plans will also be required. Hospital leaders believe that this approach will succeed
because of the high level of trust and the non-judgmental atmosphere that exits within
SEMC management.

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Respondents indicate that St. Elizabeth has always emphasized the importance of moving
decision- making to the most appropriate levels. Senior management spends considerable
time listening to staff member’s ideas and concerns. Focus groups are often held to gain
input from staff on specific issues or to encourage open-ended dialogue. One example of
staff input that has changed systems is illustrated by information gained from exit
interviews which showed some nurses were leaving SEMC in order to get a Monday-
through-Friday work schedule elsewhere. The Medical Center responded by introducing
an extensive range of nursing staff scheduling options (e.g., 12, 10, 8, 4- hour shifts and
increased pay for evening and night shifts, along with weekend programs).

In addition, there has long been a very autonomous Nursing Practice Council at SEMC.
The responsibility of the Council has been to identify nursing practice issues, develop
nursing procedures and recommend changes. Moreover, senior management has a culture
of requiring unit-specific issues to be resolved on the unit level as often as possible. Such
issues only come up to higher levels of the Medical Center when their nature or
resolution involves other parts of the organization.

Strong Emphasis on Core Values

The Medical Center has identified seven core organizational values: teamwork,
accountability, respect, giving, excellence, and timeliness. At each monthly managers’
meeting, one of the core values is selected for discussion. The specific value is discussed
by having half of the managers describe positive examples of expressing that value, while
the other half describe negative examples of what the lack of that value would entail.
Management believes that such open dialogue helps each participant to fully understand
the meaning of each core value. This method reportedly not only clarifies and reinforces
what each core value means and requires, but it also keeps the Medical Center’s mission
and values in the forefront of decision-making at every level.


Management Culture Change

For several years, Inova Fairfax Hospital (IFH) leaders have made a conscious effort to
change the hospital’s management style and culture, especially with regard to the nursing
work environment. As one clinical director put it, “Before if you (a staff nurse) did
something wrong, you were chastised by whomever you were accountable to. Now
things are different.” The reasons cited for why the situation at IFH has changed include
the following:
    • Leadership training programs for all directors and unit managers.
    • Enhanced frontline staff participation in decision- making and the improved flow
        of information about many more decisions that affect them.

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   •   Off-site planning sessions and retreats used for team building and bonding as well
       as for other training purposes among managers, unit staff members, and
       multidisciplinary teams.
   •   The ‘Take Care of Yourself’ educational program that has promoted stress
       reduction and other nursing-oriented wellness information and activities.
   •   A new health system-wide case management system in which staff nurses
       participate along with other caregivers in care decisions and patient/family
       education sessions.
   •   More staff nurse involvement in outreach activities outside the hospital where
       nurses have an opportunity to speak with primary care physicians in the
       community, groups such as Kiwanis, potential new staff members at nursing
       recruitment centers, etc.

Other respondents point to efforts by hospital leaders to emphasize such organizational
values as mutual respect, teamwork and cross-disciplinary collaboration. These and other
aspects of IFH’s culture are explicitly addressed in the hospital’s “Nursing Vision” and
its Nursing Strategic Plan.

In addition, since 1999, IFH has been emphasizing the importance of “evidence-based”
practice as opposed to “tradition-based” practice not only for nurses but also for all other
care providers. HR policies and practices regarding individual performance expectations,
incentives and rewards reflect this emphasis in nursing. One respondent notes that
clinical care directors are expected to take initiative and innovate, and “every nurse
manager is expected to do research that can help improve what we know and how we

Hospital leaders similarly give serious attention to securing, and keeping, high external
rankings for the quality of care at IFH and high patient experience ratings (e.g., from
Working Women Magazine and other outside sources). These also have been among the
reasons why, according one senior executive, the hospital has been able to “strengthen
the kind of culture and pride in our success we’re seeking to achieve.”


Nursing Leadership Development

Nursing leadership education has been important to the progress that Lowell General
Hospital (LGH) has been making in strengthening its nursing work environment. Nursing
at LGH sponsors a “leadership forum” which is held every quarter. Participants include
all nurse managers and clinical directors at the hospital. The forum focuses on the
educational needs and professional development opportunities for nurses at every level
and in every role at the hospital.

Another valuable forum for leadership development and mutual learning has been the
periodic off-site and on-site meetings held by all service line clinical directors. These

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sessions cover a broad range of topics and concerns, from sharing ideas about strategic
service line initiatives to how to deal with specific operational problems.

LGH has also invested a lot in team building exercises as well as training sessions
conducted at the quarterly Leadership Forum, the Nursing Council meetings and now
increasingly individual departmental directors meetings. Respondents underscore the
importance of the leadership that has been provided by the new CNO. It is widely
recognized as an essential factor not only in building morale and more effective working
relations within LGH, but also in promoting an enhanced professional image and identity
for Lowell General’s nursing staff in the community.

Given the intense regional and local competition for nurses, LGH has become more
aggressive than ever in forging and marketing a strong, professional image of nursing at
the hospital. The hiring of a full- time nurse recruiter was another key initiative, according
to respondents. The person chosen for this new position had been a staff nurse at LGH,
and she is involved in retention-related activities as well. With a new vice president on
board, nursing leaders are working collaboratively with HR to support the hospital’s
recruitment and retention efforts, which was not the case in the past.

7.       Nursing Education and Professional Development

              An empowered organization is one in which individuals have the
               knowledge, skill, desire, and opportunity to personally succeed
                  in a way that leads to collective organizational success.
                                                  Stephen R. Covey

Anyone in human resources can tell you that when economic times get tough, one of the
first things many organizations do is to cut back on their budget for staff training and
education. Among this study’s sample of hospitals, however, there is wide recognition
that a sustained investment in the professional development of nurses has become a
short- and long-term strategic imperative. It pays off in terms of staff recruitment,
retention, morale and productivity, as well as patient satisfaction and quality of care. The
examples cited below are indicative of the broad approach to nursing education and
professional development initiatives described by respondents from other hospitals as
well. These initiatives include enhanced orientation and mentoring for new staff hires,
individualized learning needs assessments at different career stages, and various forms of
hospital support for internally and externally provided professional training and degree-
granting educational opportunities.

     •   Baptist Hospital of Miami offers staff nurses full tuition scholarships for
         their next degree with a one- year work commitment, and it has partnered
         with a community college to provide an on-site campus for the college’s
         nursing program. Baptist Health System has also established a Center for

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       Nursing Excellence that provides philanthropic support for nursing
       scholarship programs.
   •   Lowell General Hospital has enhanced its tuition support benefits and
       developed collaborative arrangements with several educational institutions
       to make a continuum of nurse training programs much more accessible for
       LPNs and other employees.
   •   TriHealth has strengthened the training and mentoring of new staff from
       their initial orientation through the first year of their employment. It has
       increased repayment options for educational loans and has provided a
       student nurse “cultural awareness team” to ensure that students have
       excellent learning experiences at TriHealth hospitals.


Baptist Scholars Program

Baptist Hospital and other components of the Baptist Health System have developed a
comprehensive education program for staff nurses, dietitians, and certain other shortage
occupation groups.. The Student Scholar Program provides staff nurses with full tuition
scholarships in return for a commitment of one year of employment. Because the full
tuition program is very competitive, respondents believe that Baptist is also able to
choose the best available candidates.

In addition, Baptist has partnered with their local community college, Miami-Dade
Community College, which typically has a substantial waiting list for its nursing degree
programs. Through the collaboration, the College now offers a “campus” on-site at
Baptist Hospital. Twice a year, 40 students receive a full scholarship plus a stipend for
uniforms and books. The students are treated as “quasi-employees” and they have access
to staff benefits such as free parking, on-site childcare, newsletters, and giveaways.
Baptist also supplies faculty and clinical space and has built classrooms to accommodate
the program.

As a result of this program, the hospital reportedly receives about 80 new nurses
annually. Since each student has a one-year employment commitment, the hospital’s
pipeline for new nurses essentially stays full. By the time a nursing student has
completed his/her clinical experience for the degree program, he/she is completely
integrated into the hospital’s culture and feels comfortable beginning a career at Baptist.
As one respondent put it, “This approach seems to blend the best of both worlds: the old
hospital-based diploma program and the new college-based degree program.” In the long
run, hospital leaders believe that this approach will provide the student with an easier
transition into working as a nurse and increase long-term retention prospects as well as
short-term recruitment. Starting with the transition period for these students, Baptist has
begun to collect data that will allow the short- and long-term impact of the program to be
monitored and assessed.

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Center for Excellence in Nursing

Through its Center for Excellence in Nursing, Baptist Health System has received
generous philanthropic support for its internal and external nursing scholars programs. In
2001, the Baptist Health System Board provided $1 million to the Center for long-term
funding of the scholars program. The Board challenged System employees and the
community to match this level of funding. All four hospitals in the System now have a
mechanism in place for donations from nurses to nurses and for contributions from
outside sources to the Center for Excellence in Nursing. The Center has a three- fold
mission: research, technology, and education for the benefit of the nursing profession.
Nurses administer the Center’s funds. It also awards grants for programs that enhance
nursing. This has enabled the Baptist Scholars Program to not be dependent solely on
financing from operations.


Nursing Education and Training Continuum

One important initiative to strengthen nurse recruitment and retention at Lowell General
Hospital (LGH) has involved a substantial investment by the hospital to increasing its
tuition and training support benefits. LGH has also worked to develop collaborative
organizational relationships that would help to expand local nursing education and career
development opportunities and, in so doing, increase the attractiveness of LGH as a place
to work.

The result of these efforts has been a formal relationship between LGH and a nursing
school in Nashua, NH, and several community colleges in and around Lowell so that an
accessible continuum of nursing degree programs could become available for LPNs and
other employees working at LGH.


Multi-faceted Training and Work Environment Initiatives

TriHealth has approached the nursing workforce shortage from the perspective of
creating a healthy work environment for nurses, the System CNO emphasizes. This has
entailed a multi- faceted strategy focusing on staff recruitment, orientation and retention,
with particular emphasis on nurse education, manager training and leadership

As one respondent noted, beginning with the bottom of Maslow’s “hierarchy of needs,”
nursing work environment improvement began with upgrades to compensation and
benefits designed to be responsive to different employee group needs and preferences.
This was followed by promoting the philosophy that front- line managers are key to

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employee satisfaction and retention, along with organization-wide management training
and leadership development initiatives across all levels of supervisors and managers.

To strengthen nurse recruitment and orientation initiatives, TriHealth’s Good Samaritan
and Bethesda Hospitals each have a nurse recruiter and very active nursing recruitment
programs. In addition, nurse orientation procedures have been reassessed and cha nged to
ensure timely provision of information and support essential to the success of a new
nurse. Orientation was revised to include identifying and developing critical thinking
skills among new staff members. In addition, each individual nurse’s personal and
professional needs are now more explicitly considered and addressed as part of the
orientation period. Mentors are identified and assigned so that every new nurse has a
consistent contact available throughout the first year of employment. Nurse managers are
also now more visible in the nursing units. This ensures that they are in close touch with
operations, and improves their accessibility to new nurses and established staff members.

TriHealth works hard to gear its recruitment plans and retention initiatives to the
educational and professional development needs and preferences of different target
groups, such as nursing students, recent graduates, and senior nurses. TriHealth supports
the Good Samaritan Nursing College. If the College’s students work at either hospital as
a patient care assistant, they receive higher compensation than non-students. A graduate
from the Good Samaritan Nursing College can also begin at a higher level of
compensation than a graduate from a different school.

Other measures used to tailor educational support to meet different nurse segment needs
    • Loan Repayment Program. Varying years of employment can be used toward the
       repayment of educational loans.
    • Affiliations with Area Colleges and Nursing Schools. TriHealth works with area
       colleges and nursing schools to provide student- nursing rotations and actively
       seeks to maintain good relationships with these organizations to enhance
       recruitment as well as professional development opportunities for interested
    • Student Nurse Cultural Awareness Team. This team works to: (1) develop
       strategies to ensure that TriHealth become the most welcoming place possible for
       student nurses; (2) build rapport between existing staff and student nurses so that
       student nurses will want to return upon graduation; and (3) create excellent
       learning experiences for the student nurse at TriHealth hospitals.

Other related recruitment and retention initiatives include:

   •   Compensation and benefits. At TriHealth, staff nurse wages are now examined
       twice yearly, and compensation has been improved. A bonus program for straight
       nights, evenings, or weekends has resulted in more experienced nurses working
       these shifts. Nurses have the opportunity to increase their pay through shift work.

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     •   Staff recognition and physician relations. Other hospital-specific and system- wide
         staff recognition initiatives have also helped to reinforce the positive impact of
         improved orientation and compensation policies. Respondents note, for example,
         that the involvement of physicians in all aspects of planning and decision- making
         at TriHealth has improved communication and understanding between nurses and
         physicians, and this has contributed to a more respectful environment.
         Collaborative, mutually respectful relations between physicians and nurses remain
         a continuing agenda and an important goal at TriHealth.

     •   Customer-focused cultural change. Purposefully pursued cultural changes have
         been instrumental as well. The consistent emphasis that TriHealth leaders place
         on doing what’s best for the patient has significantly helped to improve the
         nursing working environment. For example, patient safety issues have been
         confronted, and new processes have been implemented which include safeguards
         and protocols. Respondents note that new processes are increasingly being
         developed using evidence-based research, which has reduced errors and yielded a
         more systematic approach to patient care. Moreover, the overall emphasis on
         improving customer service has resulted in a more pleasant work environment.
         Being pleasant and kind to customers has spilled over into workforce

8.       Staff Recognition Programs

                         …Now we don't expect lifetime employment,
                      but we do expect respect. And that's not happening.
                            -- Joanne Cleaver, The Annoyed Employed

In his book, 22 Keys to Creating a Meaningful Workplace, Tom Terez devotes an entire
chapter to stories illustrating the power that demonstrating genuine appreciation to one’s
internal customers can have in fostering a healthy, productive environment for external
customers. The participants in this study also underscore the importance in today’s
nursing work environment of recognizing and celebrating both individual and group
accomplishments, especially contributions to a truly customer-focused workplace. The
following examples are indicative of the conscious effort hospitals are making to
strengthen their staff recognition and reward systems, often through staff-initiated
activities. Some hospitals link these systems to performance feedback mechanisms
designed to reinforce the organization's mission, values and goals. These recognition and
reward processes can help to create what Terez refers to as a "culture of appreciation."

     •   St. Mary’s Medical Center has instituted a hospital- wide peer
         recognition program that encourages all employees to give “Kudos”
         appreciation cards to individuals they feel are cont ributing to a quality
         workplace. Prizes are awarded through drawings of the total pool of
         appreciation cards received on a quarterly and annual basis.

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   •   TriHealth relies on a Nursing Recognition and Reward Committee to
       spearhead the design and implementation of monthly staff appreciation
       activities. Individual units also receive a per enrollee allotment to fund a
       “tool kit” of staff recognition rewards, which are used at each unit’s
   •   Lowell General Hospital sponsors an annual awards event to recognize
       nurses nominated by their peers in each department for outstanding
       performance in patient care, educational programs, professional
       advancement, and other areas. Another initiative annually recognizes those
       employees selected each month for their suggestions regarding how to
       achieve outstanding customer service.


The “Kudos” Program

Staff recognition programs are another key element of a quality work environment. One
example is the “Kudos Program” at St. Mary’s Hospital Medical Center. It is a hospital-
wide peer recognition program that was introduced a number of years ago for all
employees, not just nurses. It encourages individual employees to express their
appreciation to anyone on staff for being helpful, creative, hard working, or otherwise
contributing to a quality workplace.

Personalized recognition cards are filled out by anyone who wants to recognize another
person. These cards are openly displayed on office walls, doors, bulletin boards, etc. On a
quarterly and annual basis, the hospital awards prizes to the winners of drawings from the
total pool of recognition cards collected.


Nursing Recognition and Retention Committee

As an outgrowth of TriHealth’s customer service excellence campaign, System and
hospital leaders realized that if nurses were not happy in their work, optimum patient
satisfaction would not be achieved. This led to the implementation of an extensive
reward and recognition program that has been spearheaded by a Recognition and
Retention Committee in Nursing. Each month the committee organizes different activities
aimed at recognizing both individual and collective nursing contributions to quality care
and a healthy work environment. For example, a recent activity was to compile a book
entitled Stories from the Heart, which contains nurses’ stories, ranging from humorous to
sad, that describe what it means to be a nurse and what issues are important to them. The
purpose of the book was not only to recognize the important contributions nurses make,
but also to instill pride among TriHealth nurses about what it means to be a nurse in the
TriHealth system.

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Recognition Tool Kit

In support of recognition activities and various awards, TriHealth distributes funds to the
individual nursing units based on a per employee allotment. As a result, each unit
receives a fixed dollar amount per staff member. Depending on unit size, this allotment
can reach several thousand dollars. These funds are used specifically for staff recognition
purposes, including maintaining and creatively using a “tool kit” of items that can reward
the accomplishments and contributions of individual staff members. Some units form a
staff committee to plan and manage a recognition and reward budget; in others, nursing
managers administer these funds in consultation with staff. Recognition tool kits can
include such items as candy bars, cards that one staff member could give to another staff
member to recognize worthy acts, giveaway items such as hand lotion, funds for a pizza
party on days when everyone is too busy for each nurse to take a lunch break, etc. A key
feature of this initiative is that each unit has total discretion about how the funds are to be
used. The program has become so popular that all departments now have a Recognition
Tool Kit, and TriHealth has recently increased by 25 percent the per employee allotment
used to fund these activities.


Activities Celebrating Nursing

During National Nursing Week, the Nursing Council at Lowell General Hospital
determines the criteria to be used by each department in making peer-based nominations
of nurses to be recognized for their exceptional performance in patient care, educational
programs, professional advancement, and other areas. Awards are given out at a major
evening event attended by staff and the family members of the nurses recognized. The
physicians’ organization affiliated with LGH has made additional monetary awards to
express its appreciation of nursing excellence. According to one respondent, the recent
nursing awards event was covered by the local newspaper, which was particularly
appreciated by many participants and their families.

Another example of ongoing efforts to find new ways to show pride in LGH’s nurses and
the nursing profession is the “Wall of Nursing” which was introduced by the CNO. Every
three months 10 or 12 photos of individual staff nurses are prominently displayed on a
wall near the nursing administration office. The photos are coupled with a brief statement
written by each person about why they entered the nursing profession and why they came
to LGH.

In addition to internally focused recognition activities for nurses, LGH has also pursued
an externally focused initiative. As part of its turnaround strategy, the hospital brought in
a nationally recognized public relations firm to upgrade the hospital’s approach to
employment advertising and assist with a branding campaign. One theme that was used
following September 11 was “Our Nurses are Heroes.”

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Customer Service Recognition

There also are other staff recognition programs at Lowell General that apply to nurses
and other employees as well. Outstanding customer service has become a major focus.
For example, a few years ago the hospital launched a customer focus initiative called
“ECHOS” (“Every Customer Has Our Support”). All hospital employees are actively
encouraged to suggest ways to improve customer service and patient care at the hospital.
Each month the suggestions received are widely showcased, and annual awards are given
for the best suggestions submitted.

Respondents also point out that for many years the hospital has also done things like
recognizing an “employee of the month,” each of who receives a VIP parking space and a
gift certificate. All candidates are nominated by their peers, often for their exceptional
service to internal customers. A committee representing all areas of the hospital staff, not
just Administration, makes the selectio n of award winners.

9.       Compensation, Benefits, and Incentives

         The challenge is to create pay practices that support the heart of stewardship,
           which is accountability and commitment to the well being of the whole.
                                                             -- Peter Block

Compensation, benefits, and incentives are important factors in the recruitment and
retention of well-qualified employees. However, ensuring that the pay policies, benefits
and incentives offered by an organization are the “right” ones can be a challenging task,
particularly for shortage occupations in highly competitive markets. Every benefit and
incentive will not entice every employee, especially for organizations like hospitals with
highly diverse workforces. Successful organizations are the ones that are able to narrow
benefit and incentive options to those that are most important to their employees as well
as those that reinforce the desired culture of the organization. As indicated by the
examples below, hospitals are using a variety of approaches in designing and adjusting
compensation, benefit and incentive policies to meet these objectives. However influential
these policies may be for staff recruitment and retention, many respondents in this study
seem to regard other categories of key initiatives to be of equal if not greater importance
for achieving nursing work environment excellence.

     •   Main Line Health System introduced a bold $25,000 bonus program for
         all nurses at its three hospitals who would commit to stay with the System
         for at least three years and support work redesign and process
         improvement efforts. Nurse managers also became eligible for
         performance-based bonuses relating to the achievement of improvement
     •   Poudre Valley Hospital has adopted compensation and benefit policies
         designed to maintain high nurse-to-patient ratios and attract committed

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       individuals who fit the organization’s culture. The hospital’s approach
       excludes signing bonuses; it includes recruitment assistance incentives and
       involving nurses in trade-off decisions affecting pay and benefits.
   •   Baptist Hospital of Miami, after a period of staff cutbacks, subsequently
       recognized the need to upgrade its nursing pay and benefit policies to
       remain competitive, aligning them with efforts focused on ensuring an
       outstanding work environment. This includes developing an internal pool
       of committed traveling nurses and excludes offering signing bonuses.
   •   St. Elizabeth Medical Center involves all employees in a health system-
       wide gain-sharing program, whereby every employee shares equally in 25
       percent of net income after expenses if patient satisfaction and financial
       goals are met.
   •   North Arundel Hospital has used targeted enhancements of pay and
       benefits for staff shortage areas and shifts that have experienced the
       highest vacancies and turnover rates. Other changes included coverage of
       state exam costs for new graduates and a “retention pay” program that
       allows for performance-based salary adjustments every six months.


Multi-Year Retention Bonus Program

By 1999, virtually all three Main Line Health hospitals were faced with growing inpatient
acuity, demanding staff workloads, mounting stress, and higher vacancy rates, especially
Lankenau Hospital, a large teaching hospital located closest to the highly competitive
urban Philadelphia market. These conditions led to several system- wide initiatives,
including an unusual retention bonus program announced in mid-2000.

The bonus program was introduced in order to ensure nursing staff stability over at least a
three-year period. During this time frame each hospital would engage its nursing staff in
a comprehensive reassessment of existing work models and processes. This would be
followed by the development and implementation of specific action plans to address work
intensity, staff retention and related issues.

The aim of the bonus program was to give MLH hospitals the time, staff continuity and
support needed to allow the concerted work redesign and improvement campaign to be
completed throughout the System and begin to demonstrate meaningful results. Existing
nursing staff members were offered a $23-25,000 bonus, which could be paid out over
three years in a number of ways, in exchange for their commitment to remain at MLH
hospitals for three years and support work redesign and improvement efforts. Ninety
three percent of MLH nurses reportedly signed up for the program. MLH hospitals have
also provided nurse managers with performance-based bonuses relating to the
achievement of targeted performance improvement objectives.

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New Scheduling Policies

Along with the multi- year bonus program, changes have been made in staff scheduling
policies to provide more flexible options that address different staff preferences and
needs. This has included reducing the frequency of obligatory weekend shifts for all staff
nurses by developing the System’s own cadre of traveling nurses. The members of this
resource team have been deployed, as needed, to cover weekend shifts or deal with other
needs. The pay rates for weekend shifts have been increased, and resource team members
are paid particularly well and receive attractive benefits. Nonetheless, because of market
competition, nurse executives indicate that it has been a challenge for MLH to recruit
enough personnel into the resource teams of each hospital to provide optimal weekend


Maintaining Low Patient- to-Nurse Ratios

 At Poudre Valley Hospital (PVH), nursing work environment improvement has focused
on maintaining high nurse-to-patient ratios, recognizing staff members for their efforts,
and ensuring staff involvement in management decisions through committee
participation. Compensation and benefits policies also play an important role.

PVH has worked very diligently to maintain on medical/surgical units a staff floor nurse-
to-patient ratio of 1 nurse for every 3 to 4 patients during the day, 4 to 5 patients during
the evening, and 5 to 6 patients at night. As a result, respondents indicate that mortality
rates are low and nursing satisfaction with their work environment is high. Nurses report
that they do not feel overwhelmed with unreasonable patient workloads. This strategy
costs money but pays off in increased retention and patient satisfaction.

The hospital also constantly monitors the local nursing pay environment in an attempt to
keep pace with the changing job market. Formal assessments are conducted every six
months, but informal investigation is continuous. PVH regularly scans competitors’ web
sites, and exit interviews are conducted with all nurses who decide to leave. If a nurse
reports that he/she is leaving for increased pay or for any other reason, the hospital
attempts to verify that information and to keep nursing managers and staff informed.
Respondents indicate that many of those who leave later return mainly because of the
satisfying work environment and low patient-to-nurse ratios at PVH.

Hospital leaders periodically review the entire picture of compensation and benefits, and
they involve nurses in trade-off decisions. When nurses have complained that other
hospitals pay more, and these claims are validated, nurses are involved in deciding
whether or not to increase short-term pay at the expense of benefits. The benefit package
is extensive and includes the following:
• Good health care benefits at low employee cost, which are quite comprehensive
    compared to those offered by other hospitals.

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•   Discounts fo r various area vendors and restaurants.
•   Incentives for recruitment assistance - PVH rewards employees for bringing new
    employees into the system. If a new employee stays for one year, the recruiting
    employee receives a bonus of up to $2000 depending on the area of employment.
    Since this initiative began, over 20-30 positions have reportedly been filled. This
    approach, one respondent noted, costs the hospital less in marketing and recruiting

No signing bonuses are provided by the hospital. PVH views this practice as unsuccessful
because it attracts a short-term workforce that has no commitment and longevity.
Instead, the organization concentrates on creating a quality work environment, which
enhances staff selection and retention and reduces the need for recruitment. There is a
strong preference to focus the hospital’s resources on its “own” people as opposed to
agency nurses and people attracted primarily by a signing bonus.


Role of Compensation and Benefits in Overall Retention Strategy

Baptist Hospital has approached the nursing workforce shortage from the perspective of
creating an image in the community that attracts nurses. Even as a Magnet facility,
Baptist, like many other hospitals, went through a period of nursing cutbacks in response
to fiscal pressures in the late 1990’s when re-engineering was in vogue. Hospital leaders
subsequently recognized the need to correct the impact of such cutbacks and improve the
pay scale of nurses. Primary areas of change have been compensation and benefits
policies. Increased attention has also been given to recognizing and rewarding nurses for
the importance of their work and the value they bring to the organization. According to
one respondent, Baptist’s marketing efforts have emphasized the organization’s “love of
nurses” and its appreciation of the essential role they play in providing quality patient

Baptist has been intent on remaining competitive in the market regarding nursing
compensation and benefits. Over the last year or so, the hospital has upgraded hourly
rates across the board, and staff benefits were also improved. Reportedly overall pay
scale increases were approximately 18 percent last year as a result of several incremental
changes. Nurses can also receive merit pay bonuses as part of their annual performance
appraisal. According to respondents, Baptist now leads the market for entry- level nursing
pay rates. Benefits were improved for long-term nurses. Paid time-off increases with
longevity of employment, as does pay. At the five-year mark, nurses receive a 2 percent
increase in pay; and vesting time was decreased from 5 to 3 years.

According to one respondent, moreover, Baptist Hospital has chosen not to participate in
“bidding wars” by offering signing bonuses. Such a policy has been rejected because it is
viewed as primarily attracting “the herd,” i.e., a group of employees who move from
place to place in order to get sign-on bonuses. Instead, Baptist’s leaders focus on

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maintaining such a terrific work environment that “nurses simply do not want to leave
when that is coupled with competitive pay and benefits.”

Baptist also views the use of per-diem agency nurses who work on a shift-by-shift basis
daily as detrimental to long-term retention, since these nurses typically earn a higher
hourly rate than existing full- time staff nurses. As an alternative, the hospital has
developed its own pool of “five-star” per diem staff nurses who have a continuous
relationship with Baptist, and it will only use certain traveling nurses who will make at
least a three- to six- month employment commitment. These temporary nurses are treated
the same as regular employees in the hope they can be converted to full-time staff nurses.

ST. ELIZABETH MEDICAL                           CENTER          (COVINGTON,   EDGEWOOD,

Performance Compensation Incentives

Nurses at St. Elizabeth Medical Center participate in a health system-wide gain-sharing
program. If patient satisfaction and financial goals are met, every employee receives an
equal share of 25 percent of the net income after expenses for the year. Respondents
indicate the amount shared in 2001 was nearly double the amount shared in 2000. This
program provides everyone with a common incentive to maintain and improve quality
care while also managing expenses. 7


Compensation and Benefits

According to Nursing and HR executives at North Arundel, the hospital went through a
re-engineering process in the mid-1990s that many felt was excessively driven by
outsiders who had short-term pat answers for long-term complex issues and failed to
involve staff in a meaningful way in framing solutions. After a few years, market demand
grew rather than declined (as had been forecasted), and competition for nurses and other
categories of personnel intensified. North Arundel found itself working hard to re-recruit
many of those who had left and to create a work environment that would attract and
retain both new and existing staff. In recent years, the hospital’s approach has centered
heavily on improving compensation, workload management, flexible staffing, career
development support, and management- nursing staff communication, and only minimally
on work redesign.

Two dedicated nurse recruiters were also brought into the HR team. Respondents stress
that the strong collaborative working relationship between Nursing and HR has been an

    Also see gain-sharing program at East Alabama Medical Center on p. 68.

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important factor in the hospital’s recent success in achieving an RN vacancy rate of three
percent. This rate is the lowest in the state, according to one hospital executive.

North Arundel also used a targeted strategy of enhancing compensation and benefits for
staff positions in those shortage areas and shifts (mainly evening and night shifts) that
had been experiencing the highest vacancies and turnover rates. This included offering
attractive salary differentials for these positions and shifts, coverage of state exam costs
for new graduates, and a “retention pay” program – not a signing bonus – that allows
each individual to earn salary adjustment every six months based on their performance.

Respondents also cite the following benefit programs and practices as contributing to
recent staff recruitment and retention success. These include:

      •   Education and Career Development - The hospital’s Education Department
          evaluates every person’s skills, professional development interests and training
          needs, be they patient care assistants, technicians or RNs. Professional
          development support is viewed as a long-term process. This involves providing
          many entry-level programs and in- house courses, as well as financial support for
          individuals who wish to go outside the hospital for more formal training. Tuition
          support comes with a service commitment.

      •   Flexible Scheduling Options - Through decentralized flexible scheduling policies,
          all unit managers try to accommodate individual professional development needs
          and personal circumstances. Most units use some form of self-scheduling; some
          have weekend options, and some do not.

      •   Accessible Management and Frequent Communication - Respondents emphasize
          how important it is for management to stay in touch with staff, listen to them, and
          keep them informed and involved in decisions that affect them. The culture of the
          hospital has always made it comfortable for people to walk in to the President’s
          office and the offices of other senior executives, as well. In addition to quarterly
          town meetings or council meetings attended by unit representatives, employee
          focus groups are used widely, and “nursing advisory teams” whose members are
          chosen by their peers periodically meet to discuss a broad range of issues.

10.       Flexible Scheduling Policies

             The person who arrives for work each day is not just an employee—
          he or she is also a spouse, a parent, a grandparent, a neighbor, and a friend.
                                                                 -- Tom Terez

Individuals seek different benefits from different jobs and employers. One benefit that has
become increasingly important to more and more people in many industries and
professions is flexibility in work scheduling. In a era when the nuclear family with one

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parent at home full-time is no longer the norm, many parents need to be able to work
their schedules around other commitments involving spouses, children, and aging
parents. Not surprising, many employers now offer flextime, compressed workweek, and
alternative work schedules to accommodate employees seeking alternatives to the
traditional 9-to-5 job. For the nursing workforce, flexible scheduling represents not so
much a “benefit” but an essential condition for an acceptable, viable work environment
that is responsive to generational and lifestyle differences. Study respondents also stress
the importance of recognizing the practice autonomy of professional nurses. This
includes having greater control over work schedules to be able to manage professional
responsibilities while also meeting personal demands. Some of the ways hospitals have
addressed these needs are illustrated by the following examples.

   •   TriHealth has introduced a bonus program linked to scheduling options in
       response to job satisfaction surveys that made clear that many nurses did
       not want night, weekend or holiday shifts. The new pay differentials for
       these shifts drew other nurses to fill them, and the result was a win-win for
       all those involved.
   •   Poudre Valley Hospital has created a full- time pay option for nurses who
       would work on weekends only, its own group of “r elief” or agency nurses
       who receive higher pay but not benefits, and a float pool of cross-trained
       nurses who could be scheduled in multiple units.
   •   Lowell General Hospital established bonuses for staff taking on extra
       shifts in response to staff suggestions regarding how the costs of using
       agency nurses could be reduced. The resulting cost savings have been


Bonus Program and Work Schedule Flexibility

In recent years, job satisfaction surveys conducted at TriHealth’s Good Samaritan and
Bethesda Hospitals showed that nurses were very unhappy about being called on so
frequently to pick up extra shifts, especially the least desirable shifts, in the face of
increased demand. The survey data indicated, moreover, the growing importance of
lifestyle considerations among nurses. Many wanted more time with their families or
simply did not want to work on nights, weekends, or holidays.

In response to these concerns, TriHealth implemented a bonus program tied to staff
scheduling options. The new policy offered extra pay for straight evenings or nights,
straight weekends, and extra holidays. Respondents indicated that this program became
so popular that it has eliminated the need for excessive rotations to cover evening, night,
weekend, or holiday shifts. Nurses must still work a required complement of holidays,
but after that each person may volunteer for additional holidays. Holidays are paid at 1.5
times regular pay. After working the required number of holidays, a nurse can volunteer
for additional holidays and receive 1.5 times pay plus a nine dollar per hour differential.

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According to respondents, the bonus pay program has turned out to be a total win-win for
all involved. Nurses that value flexibility now have a variety of scheduling options to
choose from to meet their lifestyle and personal needs. Moreover, those individuals who
wish to work undesired shifts and holidays can do so at a significant financial gain.


Flexible Staffing and Compensation Options

Poudre Valley Hospital (PVH) has instituted extra pay plans to meet evident demand
among nurses for greater scheduling flexibility. One such plan, known as the “Baylor
Shifts,” allows a nurse to be paid on a full- time basis for working weekends only every
week. Additionally, nurses are paid double time when working extra shifts and receive
extra weekend pay; and those that prefer to work evenings and nights exclusively receive
a bonus every six months.

The hospital has also established a float pool of cross-trained nurses who may be
scheduled in multiple nursing units. PVH has also established its own agency or “relief”
nurses. A nurse may work for the hospital as an “agency” or “per-diem” nurse by
picking up a minimum of four shifts per month. Agency nurses receive higher hourly pay
but no benefits. They can choose which clinical areas they want to work in, and are then
trained for those units. Shifts are scheduled one month in advance. Although agency
nurses are not guaranteed a specific number of hours, they can enjoy the maximum
amount of scheduling flexibility.

“Peak Census” Staffing Model

According to respondents, not long ago a common staff complaint was that PVH could
schedule a nurse for mandatory overtime, and then randomly send nurses home if they
were not busy. As a result, nurses’ weekly hours varied considerably and they had no
control over their schedules.

In response to this grievance, Poudre Valley Hospital has focused on obtaining baseline
census data for every nursing unit, and each unit is now allowed to hire to “peak census”
and schedule accordingly. If a unit is not busy, nurses are not sent home. Overtime is
voluntary and it entails increased hourly pay. This reversal of previous staffing policy
reportedly cost PVH between one and two million dollars. At the same time, staffing to
peak census has been very well received by PVH nurses, and it reportedly has reduced
expenditures for agency nurses and staff recruitment. In the view of one respondent, the
board of PVH has supported this staffing model because it has lowered overall costs
associated with nurse recruitment and retention.

Low Patient-to-Staff Ratios

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Most nursing units at PVH have a staff mix of approximately 80 to 85 percent registered
nurses; they also have comparatively low patient-to-nurse ratios. These ratios are 3
patients per nurse for the day shift, 4 to 5 per nurse for the evening shift, and 5 to 6 per
nurse for the night shift. Critical care units also maintain relatively low patient-to- nurse
ratios regardless of shift. Respondents maintain the high percentage of RN staffing and
the low patient-to-nurse ratios have improved patient outcomes at the hospital.
According to one respondent, evidence shows that this is reflected by reduced patient
falls, less frequent hospital-acquired infections, fewer pneumonia and urinary tract
infections, and lower complication rates.


Under a new CNO, the Nursing Council at Lowell General Hospital was reactivated. It
has now become a much more influential forum and has provided the nursing staff with
an important voice on a broad range of issues. For example, when the extensive and
costly use of agency nurses was discussed, staff nurses suggested that the hospital offer
existing staff bonuses for taking on extra shifts. This idea was adopted by the hospital,
and the new policy elicited a very favorable response from staff and generated substantial
cost savings, as well.

Another change in compensation and benefits policy that has been very well received has
been to create a consolidated “earned time” policy, instead of having employees
separately receive a designated number of sick days, vacation days, personal time, and
holidays. The new policy gives employees much more flexibility in using their earned
time off, and now seven of ten days have cash value. According to one senior executive,
the improvements made to nurse compensation and benefits substantially he lped the
hospital to rehire some former employees.

11.    Nursing Wellness

             Today's workplace is typically high energy and highly productive.
                 To play successfully within it, you and your employees
                must be well and fit, mentally, emotionally, and physically.
                        --Beverly Kaye and Sharon Jordan-Evens,
                          Love 'Em or Lose 'Em: Getting Good People to Stay

Productivity, efficiency, and profitability are typically the three top goals of worksite
wellness programs. In addition to demonstrating a commitment to their employees' well-
being, some of America's most successful companies have learned that prevention and
wellness programs can contribute to employee morale and performance, and as a result,
to the bottom line as well. A few hospitals involved in this study indicated that they have
addressed nursing wellness issues as part of multifaceted strategies for work environment

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improvement. In recent years, nurses have made it clear that the demanding pace of work
and the mounting workload intensity they face directly contribute to staff burnout and
related concerns about patient safety. Especially in the current shortage environment,
hospitals are recognizing that a healthy and happy employee is likely to be more
motivated and productive, use fewer sick days, and stay with the organization longer. The
examples highlighted below illustrate two very different approaches: one is a
programmatic approach focusing on nursing-specific wellness needs; the other is a
comprehensive organizational culture approach focusing on all hospital staff and
patients alike.

   •   Vanderbilt University Hospital used a Nursing Wellness Task Force to
       identify wellness needs through an extensive focus group process and
       spearhead the implementation of various initiatives including a “Take
       Your Break” campaign that targeted all components of the Medical
       Center. Other prevention-focused activities have addressed stress
       management, ergonomics, nutrition, fitness, and mental health.
   •   St. Charles Medical Center has long nurtured a distinctive holistic,
       wellness-oriented care delivery model that informs all relationships among
       caregivers, employees, patients and family members. For nurses, the
       wellness model has opened up new roles as “people-centered” team
       trainers and active participants in community health activities.


Nursing Wellness Task Force

Nursing Wellness was the focus of one of several task forces charged with developing
work environment improvement initiatives at Vanderbilt University Hospital (VUH).
The task force elicited a great deal of staff interest, and many individuals were involved
in its work, especially participants in a series of focus groups that helped to identify
specific wellness needs and possible responses. The focus groups were organized by age
group clusters as well as by different clinical areas (general inpatient care, critical care,
clinic services, etc.) Identified nursing wellness initiatives included developing child care
and concierge services, yoga classes, and other stress reduction activities, to enhancing
employee assistance programs.

Respondents emphasized that the task force’s overall approach was heavily oriented to
prevention and a proactive approach to nursing wellness needs. For example, one
educational program recommended by the task force focused on teaching new nurses how
to handle the night shift. Another addressed an issue that researchers have shown to be
widespread among nurses: namely, their reluctance to seek opportunities to take a break
from their typically demanding and stressful schedules. The Nursing Wellness Task
Force subsequently spearheaded the implementation of a Medical Center-wide ”Take
Your Break” campaign. One respondent observed, “We are promoting the importance of
nurses’ taking time to eat their lunch, rest, find a quiet place, and just have a break for

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themselves. We need to overcome the ethic of that being unacceptable behavior.” Other
areas of focus for nurse wellness activities have included mental health counseling,
education about ergonomics and body mechanics, and collaboration with a community-
based health center to make nutrition information and fitness programs more accessible to
interested staff members.


Applying a Healing Health Care Philosophy

Over the past ten years, the leaders of St. Charles Medical Center (SCMC) have been
working to develop a distinctive relationship-centered, holistic, wellness- focused
approach to health care based on an articulated “healing health care philosophy.”
Respondents emphasize that this holistic healing philosophy and the wellness-oriented
care delivery model it has fostered “drive everything we do.”8

According to Medical Center’s CNO, the origins of this philosophy go back to a
restructuring effort in 1992, which was aimed at making the Medical Center more
efficient and focused on patients. “We started out by asking, ‘What more can we do for
patients?’ Then our nurses asked, ‘But what about us?’ That led us collectively to
recognize that only by healing our relationships and ourselves and by investing in our
people would we really be able to provide the best care for our patients.” Faced with the
need to give greater attention to nurse recruitment and retention issues during the last few
years, SCMC has focused heavily on ensuring the personal growth and development of
our entire staff (nurses, other caregivers and employees) and creating an empowered
“principle-driven” hospital work environment.

In addition, efforts continue to provide a truly supportive physical environment in terms
of colors, lighting, and music along with access to exercise, wellness, and relaxation
facilities – all of which, the CNO emphasizes, “express our holistic healing health care
philosophy, which we apply to ourselves, our relationships, and our community.”

Another senior executive noted, “We believe that we must make people - patients, family
members, our caregivers and employees - understand that they are their primary care
providers. Many of the health awareness and wellness programs SCMC offers to the
community have been developed by first using our employees ‘as guinea pigs’ and then
continuing to offer them as an employee benefit.” One example is the New Directions
and health coaching program offered on a pay-as-you-go basis to the community. This is
a 10-week program, not just a half-day seminar. So far, based on participant outcomes
data showing the positive impact of this program on managing health risk factors and
health services utilization, SCMC has been able to interest major payers in their market to
offer financial incentives for subscriber participation as part of their benefit package.

    See also pp. 57-60.

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The Medical Center’s wellness model is credited with opening up new avenues of career
and role development for SCMC’s nurses. For example, most of the Medical Center’s
people-centered team trainers are nurses (some are directors and others are drawn from
frontline staff). One respondent maintains that the key to effective training is to be able to
draw on your personal experiences, and nurses are excellent at that. Nurses also play a
significant role in the SCMC’s community- focused activities on prevention, health
awareness, and holistic care. Following suggestions that originated within the nursing
staff, massage therapy is used by the Medical Center as well as and other alternative
treatment approaches. Though many doctors first scoffed when live music was introduced
(another innovation that came from nursing), the Center has collected data that shows a
decline in use of pain medication when live music is added to the patient’s care

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