TL4 - The CNO is a strategic partner in the organization’s decision-making.
Provide one example, with supporting evidence, of the CNO’s involvement in the organization’s decision-making (not involving technology).
AND
Provide one example, with supporting evidence, of the CNO’s involvement in the organization’s technology decision-making.
Example 1 – Decision-making Not Involving Technology
NAME OF INITIATIVE
Homestead Hospital Strategic Plan
BACKGROUND & PURPOSE
The Chief Nursing Officer (CNO) and Vice President, Gail Gordon, MSN, RN, NEA-BC is responsible for the development and implementation of the organization’s plan for providing nursing and other clinical care to patients. This involves developing the organization-wide patient care programs, policies, and procedures that describe how nursing and other clinical/patient care is assessed, interventions planned and provided, and outcomes are evaluated. The primary responsibility is for the quality of patient care thus, ensuring safe, efficient, quality and effective coordination and delivery of patient care services. The CNO plans, directs, and coordinates activities of multiple clinical departments in the organization to maintain standards of patient care, and advises the Chief Executive Officer (CEO) in matters related to clinical operations. Gordon is responsible for all matters affecting the day-to-day operations of the hospital, as well as in planning for the future, and in establishing community linkages for health improvement. As such, the CNO reports directly to the CEO and participates with leaders of the Board of Directors, Senior Leadership team, management team, and medical staff in planning, promoting, and conducting hospital-wide quality assessment and performance improvement activities. The CNO is a key member of the Senior Leadership team and is an integral part in the strategic planning and organization-wide decision-making.
It is essential that the CNO have the full support, respect, and confidence of Board of Directors, executive leadership, physicians, interdisciplinary teams, and the nursing department. Gordon accomplishes this through her ability to establish and sustain healthy relationships and open lines of communication. For example, Gordon is invited to attend all meetings of the Board of Directors and Medical Executive Committee. Gordon also presents an annual report of the Department of Nursing. (TL4 01 Board of Directors Agenda) A substantial amount of thought and planning goes into the design, message, and content of this report. It is a strategic opportunity for the CNO to inform the members of the accomplishments, challenges, and opportunities so that they can support nursing’s agenda. More importantly Gordon is actively involved in the strategic planning of the organization.
METHOD AND APPROACH
CNO as Strategic Partner
In April of 2013, the Board of Directors, Medical Executive Committee, senior executives, and other key members such as the Foundation and Marketing held a retreat to establish a strategic plan. The retreat, hosted on-site at Homestead Hospital, led by Chief Executive Officer Bill Duquette began with an overview of where the organization was based on the six pillars (People, Service, Quality, Finance, Growth, and Community). Various presenters gave synopses of the current healthcare environment as well as forecasts of the future environment which to date continues to be unknown. The focus was on developing a plan to meet the needs of the community, meanwhile meeting the mission and vision of the organization. Each pillar was discussed and throughout the retreat, attendees were given opportunities to conduct a SWOT analysis (strength, weaknesses, opportunities, and threats) to determine future goals and plans for the organization. As CNO, Gordon was able to provide valuable input into the strategic goals and provided information and updates about capacity management. (TL4 02 Strategic Planning Retreat Agenda)
Knowing that efficiencies stemming from the ED were still of concern, Gordon had coordinated efforts to address throughput, resulting in the formation of several subcommittees and taskforces. To address the key indicator for efficient and timely care in the ED, at our biannual Leadership Development Institute (LDI), held in April of 2013, with about 100 leaders in attendance from all levels, from senior executives to front line supervisors, Gordon asked the LDI team to focus on capacity management and throughput initiatives. This strategic initiative tied in well to the many changes the organization was experiencing. As a result, the topic of discussion focused on leading change and developing an engaged team. During the presentation, members of the Throughput Team consisting of Patient Care Manager Raul Botana, RN and Patient Care/House Supervisors Candace McLaughlin, RN and Laurie Cogar, RN presented data and updates on this strategy. During this session, the LDI team divided the leaders into groups to discuss how they could impact this initiative. The LDI team also asked them to take a look at their individual departments on how they could be more efficient in supporting this goal in order to meet the intended target. (TL4 03 LDI Newsletter May 2013)
As a follow up to the retreat, in July 2013, the senior executive team met again to review the SWOT analysis and the topics addressed during the retreat and to finalize the strategic plans. By the conclusion of the meeting, key strategies had been identified with key targets and champions. Duquette delegated several strategic goals to Gordon. In addition to her duties and responsibility to achieve the highest standard for nursing preparation and performance through Magnet designation, Gordon was assigned to be the champion on providing efficient, timely service in the Emergency Department (ED), achieving and maintaining superior patient satisfaction, improving operational efficiency using Action OI (Operational Intelligence) as a benchmark, reducing overtime and maintaining sitter usage below $1 million. This is a huge undertaking as it involves and impacts the entire organization. (TL4 04 Strategic Plan FY 2014-2016)
ORGANIZATIONAL OUTCOMES DUE TO CNO INVOLVEMENT IN DECISION-MAKING
Capacity Management
Cogar from the Throughput Team led the Discharge Taskforce which looked at the processes and barriers to patient discharge. The taskforce piloted an admission/discharge unit. This resulted in a decrease of the median time for “Request to Occupy”, that is time when bed is requested by the ED to the time the patient occupies a bed in an inpatient unit, from 87.74 minutes to 70 minutes.
Magnet recognition process
Gordon continues to move forward and support efforts to obtain Magnet designation. She provides ongoing updates to the board members, senior executive team and leaders within the organization through communication at leadership meetings, retreats, staff meetings, one-on ones and/ or the weekly newsletter. The Magnet Designation Department reports directly to Gordon and actively supports the ongoing activities and functions to establish and maintain the Magnet culture.
Patient Satisfaction
Gordon chairs the Studer Steering Council (TL4 05 Studer Steering Council Meeting Minutes) which is responsible for oversight on patients’ satisfaction. The council meets monthly and is comprised of six team leaders: Nuclear Medicine Supervisor Janet Herrera, representing Standards/ Rewards & Recognition Team; Imaging Director Raul Lorie representing Communications Team; Patient Care Supervisor Maria Carrillo, BSN, RN, CMSRN representing the Inpatient Communication Team; CT Supervisor David Sardinas representing Service Recovery Team; Assistant Vice President Ann Marie Allen, PhD(c),MSN, RN as LDI Team leader; and Executive Assistant to CNO Gina Alvarez representing the Measurement Team. Each team leader provides an update on their respective teams and provides recommendations for improvement and/ or maintenance of patient satisfaction scores. Gordon ensures that communication about the organization’s performance is reported weekly through weekly report card updates. She also spearheads the quarterly patient satisfaction celebration in collaboration with Human Resources and the Standards/ Rewards & Recognition Team. This event is an opportunity to recognize departments who have shown consistency or highest improvements in their scores.
Operational efficiency & Overtime
Financial responsibility is always of concern in the healthcare environment. Overtime is tracked and reported biweekly by finance. During the monthly meetings with nurse leaders, Gordon reviews departmental responsibility reports to justify overtime, included in these conversations is the review of open positions, staff on leave and other circumstances that may lead to incurring overtime and additional costs. To avoid hiring of additional FTE’s, nurse leaders are asked to evaluate closely the need to fill vacancies. Justifications are submitted and reviewed by Gordon and then by the senior executives before final approval.
Gordon also meets quarterly with the corporate Performance Analyst Coreatha Toomer and each nurse leader to discuss how the organization stands with the benchmarking data from Action OI, the largest healthcare operational and financial database in the country. This comparative list includes over 750 organizations’ labor and supply costs at the department level. It is a self-reported data-sharing process among healthcare organizations. It allows Homestead Hospital to compare its internal metrics with departments of similar size and patient mix at other organizations. Currently all patient care nursing departments participate in Action OI. As of March 2014, about half of these departments have been able to achieve the BHSF expectation of being at 75th percentile ranking for cost ratio.
Summary Attachments/Hyperlinks/Evidences
TL4 01 Board of Directors Agenda
TL4 02 Strategic Planning Retreat Agenda
TL4 03 LDI Newsletter May 2013
TL4 04 Strategic Plan FY 2014-2016
TL4 05 Studer Steering Council Meeting Minutes
Example 2 – Technology Decision-Making
NAME OF INITIATIVE
Patient Acuity System
BACKGROUND AND PURPOSE
CNO Involvement in Organizational Technology Decision-Making
Dating back to October 2010, the Chief Nursing Officer (CNO) of all Baptist Health South Florida (BHSF) hospitals during their Patient Care Leadership Council (PCLC) meeting identified the need for an acuity system that was objective, user friendly and precise in predicting nurse staffing needs. The process at that time had a lot of limitations such as the inability to adequately capture nurse’s workload and effectively manage staffing, tedious to complete, double documentation and inconsistencies in rating the acuity because the criteria lent itself to subjective interpretation. To make staffing assignments, patient care supervisors and relief charge nurses initially assigned patients by blocks of rooms and took into consideration the complexity of patient’s diagnosis and nursing procedures required. This process was done manually and involved a lot of subjectivity. The intent was to integrate innovative technology that would alleviate the burden on staff and transform the subjectivity factor of staffing predictions to a more objective measure focused on patient outcomes instead of tasks. As such, the implementation of an acuity system was placed as a tactic to meet the system nursing strategic goal of implementing a standardized evidence-based patient care staffing system. Due to unforeseen delays, such as a change in the electronic documentation and financial platform, this initiative continued into the following years and became a focus in the 2014-2016 BSHF nursing strategic goals. (TL4 06 PCLC Strategic Plan 2014-2016) Gail Gordon, MSN, RN, NEA-BC, CNO for Homestead Hospital, along with her CNO counterparts, would approve the necessary resources to bring the project to fruition (e.g., human/material) and would facilitate organizational change of processes.
METHODS AND APPROACH
The CNOs’ requested to establish a system-wide council, BHSF Collaborative Staffing Council, to define the project’s goals and select a software program that was evidence-based, outcome driven and most importantly, seamless to the bedside nurse. Consequently, Suarez and Vasserman started a system-wide council comprised of nurse leaders, clinical nurses, clinical nursing informatics and information technology (IT). Gordon specifically requested Homestead Hospital nurse leaders and clinical nurses to be represented on the BHSF Collaborative Staffing Council. The initial members consisted of Clinical Nurse Kathleen Miller, RN, Patient Care Manager Maureen Allen, RN, Directors Ann Marie Allen, RN, and Ana Cabrera, ARNP. The council embarked on a search for the correct software/ vendor that would meet their needs.
While BHSF’s IT team was comprehensive as there were representatives in many lines of business, the BHSF Collaborative Staffing Council recognized the need to contract with an established technology organization to help implement a patient acuity system that was compatible with the existing electronic medical record (EMR) system. In accordance with BHSF policy, the council drafted and issued a request for proposal (RFP) for an IT system with the capabilities of using clinical documentation values in assigning patient acuity levels. The successful candidate’s electronic system would need to capture the complexity of patient and family care needs; effectiveness of nursing interventions through patient outcomes; track progress of patient problems; and assign an acuity level that would be used to manage patient flow and staffing assignments. As such, a very complex algorithm linked to outcome sets is an essential component that would drive this team’s decision-making process.
Once again due to several postponements and to unexpected circumstances, it took a while to discern the right vendor who had the right product. Gordon, together with the rest of the CNOs, held true to the initial vision of finding an objective, evidence-based product that would interface with the current EMR system. During this time, the BHSF Collaborative Staffing Council asked several vendors to present their product. Gordon and the other CNOs were present to provide input and hear feedback from the council. In September 2012, Gordon and the rest of the CNOs approved Cerner Clairvia based on BHSF Collaborative Staffing Council’s recommendation. (TL4 07 PCLC Meeting Minutes 9/27/12) In late 2012, a RFP was submitted and a final vendor and contract was signed with Cerner Clairvia by December 2012. The CNOs primary reasons for choosing Cerner Clairvia were:
- Patient focused, objective, evidence-based elements
- Real-time byproduct of clinical documentation
- Established reliability and validity
- Increased CNO and CFO confidence in data for decision support in productivity analyses
- Incorporates intra-shift workload
- Automated trending of patient progress toward desired outcomes and expected length of stay (LOS)
In May of 2013, the team from Cerner Clairvia along with the Chairs of the BHSF Collaborative Staffing Council, namely, Assistant Vice President Advanced Practice Maria Suarez, ARNP and Clinical Informatics Director Alex Vasserman, RN, made a presentation the PCLC. They provided project overview, objective, timeline and a demonstration of the acuity system. They scheduled a tentative go-live date for October 2013. They requested the CNOs to provide feedback and complete a questionnaire.
Due to several problems with interfaces needed between Cerner Clairvia and the existing electronic platforms, go-live date was postponed. During this time, additional training was provided to other areas, Critical Care, Women’s Services and Pediatrics and data was requested regarding budget, length of stay and staffing. In September of 2013, the controllers were invited to PCLC to sit with the CNOs. During which, they were given an overview of the functionality and methodology used to calculate workload, hours per patient day and length of stay within the acuity system in order to gain their confidence on the system’s utility in budgeting for staff for the coming years. Homestead Hospital Controller Erik Long was present. (TL4 08 PCLC Minutes 5/16/13 & 9/19/13, highlighted) Over the next several months, patient outcome experts (POE) continued to audit clinical documentation and mapping of outcomes.
As part of the configuring of the acuity system, it was needed to identify Patient Outcome Experts (POEs) or super users. These nurses would be responsible for the review of appropriate clinical outcomes by reviewing the Nursing Outcomes Classification (NOC) book and become familiar with how the outcomes are organized. They would also serve as experts to staff regarding the use of NOC. The POEs would participate in the review of how clinical documentation is mapped to nursing outcomes and become familiar with how clinical documentation values drive rating at the indicator and outcome level. Gordon advocated and supported the use of clinical nurses, patient care supervisors, and clinical nurse educators as support personnel. (TL4 09 Homestead Hospital Senior Leadership Meeting Minutes 4/8/14) In one of her weekly Operations meetings, Gordon requested her nurse leaders to identify clinical educators and clinical nurses to become POEs. She supported flexible scheduling and any necessary overtime that would be incurred to allow staff to attend training and complete the necessary audits over the coming months. (TL4 10 Operations Minutes 4/11/14)
After overcoming several obstacle and barriers with interfaces between the electronic systems, the BHSF Collaborative Staffing Council scheduled a go-live date of June 2014. The clinical informatics/ IT teams provided a list of nurses that were available during the go-live week for each hospital in the system. In order to effectively maximize the use of the acuity system and provide a consistent message to all staff, each hospital was asked to identify an Operational Champion who acted as liaison between the hospital and the BHSF Collaborative Staffing Council Member in troubleshooting issues during and post-implementation. Cabrera was selected to Homestead hospital’s representative. Each week, she participated in a conference call with all entity operational champions, Suarez, Vasserman and IT and discussed current issues and outstanding items pending resolution. She then brought information back such as potential solutions, best practices and future goals to Homestead Hospital nursing team.
On June 5, 2014, the Cerner Clairvia Nursing Acuity went live at all medical surgical units, progressive care units, and critical care units in Homestead Hospital and across BHSF. Though the system is still not perfect, as glitches between the staffing and scheduling system and the nursing documentation system still exists, it serves as a tool to begin capturing nurse workload, acuity and length of stay that is based on object data and patient outcomes obtained from the electronic medical record.
PARTICIPANTS
Name/Credentials |
Title |
Department |
Role in the Team |
Kathleen Miller, RN |
Clinical Nurse |
MS4 |
BHSF Collaborative Staffing Council Member |
Raul Botana, MSN, RN |
Patient Care Manager |
Nursing Administration Clerical |
BHSF Collaborative Staffing Council |
Maureen Allen, BSN, RN, CMSRN |
Patient Care Manager |
MS4 |
BHSF Collaborative Staffing Council |
Ana Cabrera, ARNP, DNP, NEA-BC, CCRN |
Director |
Critical Care Services |
BHSF Collaborative Staffing Council and Operational Champion |
Flor Amaya, BSN, RN, CMSRN |
Patient Care Supervisor |
MS4 |
Super user |
Charmaine Richards, BSN, RN, CMSRN |
Patient Care Supervisor |
MS4 |
Super user |
Claudette Nelson, BSN, RN, CMSRN |
Clinical Nurse |
MS4 |
Super user |
Alejandro Rodriguez, RN |
Clinical Nurse |
3 South |
Super user |
Maikel Luis, BSN, RN, CMSRN |
Patient Care Supervisor |
3 South |
Super user |
Karen Anding, BSN, RN |
Patient Care Supervisor |
MS3 |
Super user |
Monica Roca, BSN, RN |
Patient Care Supervisor |
MS3 |
Super user |
Sandy Jones, BSN, RN, CMSRN |
Clinical Nurse Educator |
3 South |
Super user |
Kathie Trivett, BSN, RN, CCRN |
Patient Care Supervisor |
Critical Care Services |
Super user |
Kati Biddy, BSN, RN |
Clinical Nurse |
Critical Care Services |
Super user |
Tashi Benjamin, RN |
Clinical Nurse |
Critical Care Services |
Super user |
Eileen McMahon, BSN, RN |
Patient Care Supervisor |
Critical Care Services |
Super user |
Miguel Gonzalez, RN |
Clinical Nurse |
Critical Care Services |
Super user |
Charles Juste, RN |
Clinical Nurse |
3 South |
Super user |
Mery Fernandez |
Supervisor |
Nursing Administration Clerical |
Super user |
Kimberly Mitchel |
Room Control Coordinator |
Nursing Administration Clerical |
Super user |
OUTCOMES
The BHSF Collaborative Staffing Council is in the process of measuring the software’s organizational impact through discussions with Cerner Clairvia and all stakeholders involved. Cerner Clairvia shares their best practices, workflow recommendations and the impact to our organization’s workflows, policies and procedures. Based upon best assumptions, the council is proactively determining who in the organization will be accountable for key functions including, but not limited to the standardization of workflows, awareness campaigns, end-user trainings, and program evaluation. The council chairs provide regular feedback to Gordon and the rest of the CNOs in the PCLC meetings and through the operational champion and hospital representatives. Homestead Hospital also established an entity staffing committee comprising of clinical nurses, patient care supervisors and nursing leaders.
Summary Attachments/Hyperlinks
TL4 06 PCLC Strategic Plan 2014-2016
TL4 07 PCLC Meeting Minutes 9/27/12
TL4 08 PCLC Minutes 5/16/13 & 9/19/13, highlighted
TL4 09 Homestead Hospital Senior Leadership Meeting Minutes 4/8/14
TL4 10 Operations Minutes 4/11/14 and Acuity System Screenshot