TL5 Nurse Leaders lead effectively through change.
Provide one example, with supporting evidence, of the strategies used by nurse leaders to successfully guide nurses through unplanned change.
AND
Provide one example, with supporting evidence, of the strategies used by nurse leaders to successfully guide nurses through planned change.
Example 1 – Unplanned Change
NAME OF INITIATIVE
Discontinuation of the Committed Weekend Premium Pay Plan and Revision to the Supplemental Weekend Premium Pay Plan
PURPOSE & BACKGROUND
In July 2012, Baptist Health System of South Florida (BHSF) President Brian Keeley wrote a letter to BHSF’s 15000 employees expressing his concerns about decreasing revenues brought about by decreased reimbursement, economic recession, high unemployment rate, increased numbers of uninsured and underinsured patients, and the uncertainties of the Affordable Care Act (ACA). (TL5 01 Message from the President, 7/2/12) He encouraged employees to improve efficiency, eliminate waste and look at cost-cutting measures in order for the system to weather the tough times in healthcare.
In response to Keeley’s appeal, system Chief Nursing Officers (CNOs) addressed the committed and supplemental weekend plan during the Patient Care Leadership Committee (PCLC) meeting in August 2012. PCLC consisted of CNOs across the system of which Homestead Hospital CNO and Vice-President, Gail Gordon, RN, was a standing member. Compensation Assistant Vice-President Margaret Marshall presented the CNOs an executive summary of the cost and potential savings opportunities after cost analyses for both plans were explored. BHSF had 2874 nurses participating in the supplemental weekend plan and 402 nurses in the committed weekend plan. Homestead Hospital (HH) had 302 nurses participating in the supplemental weekend plan and 111 nurses in the committed weekend plan.
The supplemental weekend plan was created in April 2000, to establish a weekend premium for Registered Nurses (RN) and Licensed Practical Nurses (LPN) who work additional weekend shifts. It afforded participating nurses an additional $3/hr, which translated to a 1.8 million annual cost to the system. The commitment to work weekends plan was established in December 2000 to ensure adequate nursing staff coverage for the weekends by providing a monetary incentive to RN/LPN’s who committed to work a regular weekend work schedule. It provided participating nurses an additional $7/hr, a 2.5 million dollars annual cost to BHSF.
Unplanned Change
In light of the urgent need to execute cost-saving measures, the CNOs reevaluated the business component of the above plans. They determined that by discontinuing the plans BHSF could save a substantial amount of funds without compromising patient care. At the time of its inception there were more than 400 direct care RN vacancies. In 2012, the majority of these positions had been filled and it was felt that there was sufficient man power to cover weekend care. The cost savings to HH with 28% of their nurses in the committed weekend plan was $700,000. Nurses highly favored these plans due to the attached monetary incentives. The Homestead Hospital nursing leadership team was concerned that phasing out these programs would result in RN dissatisfaction. The team recognized that a clear communication and implementation plan needed to be developed and carried out quickly in order to provide adequate time for the nurses to adjust to the income change.
Goal Statement
The Homestead Hospital nursing leadership’s goal was to successfully implement the unplanned changes to the committed weekend premium pay plan and supplemental weekend plan while maintaining nurse job enjoyment score in the highly satisfied level (T-score above 60) as measured by the NDNQI RN survey.
METHODS & APPROACH
Strategies Used by Nurse Leaders to Successfully Guide Nurses
After Marshall’s presentation, the CNOs reviewed the list of nursing pay plans provided by compensation. The CNOs decided to form a subgroup which included Vice-President, Gail Gordon, RN, to review/revise the committed weekend plan. Additionally, they made the following recommendations to Marshall: 1) Conduct a survey of the current industry standard for weekend differential and 2) Provide a cost benefit analysis between the committed weekend premium plan ($7) versus the supplemental weekend plan ($3).
In September 2012, the CNO subgroup recommended to PCLC to eliminate the committed weekend premium pay plan but keep the supplemental weekend plan. The subgroup also advised for non-nursing departments to re-evaluate their weekend plans. Thereafter, Gordon promptly informed Homestead Hospital nurse managers and directors during the weekly Nursing Operations meeting, that the committed weekend premium pay plan would be eliminated in January 2013 (TL5 02 Nursing Operations meeting minutes 9/7/12). She advised her leaders to meet immediately one-on-one with staff affected by the change and to inform them by December 2012. The Homestead Hospital nursing leadership team felt that individual meeting with affected RNs was the best approach. It allowed for dialogue and for questions to be answered factually.
In October 2012, PCLC officially approved the phase-out of the committed weekend premium pay plan by 2013 and the continuation of the supplemental weekend pay plan, beginning 7 pm Friday and ending at 7 am Monday. (TL5 03 BHSF-2240 Revised RN Supplemental Weekend Plan Policy). In January 2013, it was phased out in Homestead Hospital (TL5 04 Nursing Operations Meeting Minutes 1/4/13) and throughout BHSF by April 2013. Homestead Hospital nurses that were phased out in January 2013 received retroactive pay, up to April 2013, of $3/hour for hours worked from Friday 7 pm to Monday 7 am.
PARTICIPANTS
The Homestead Hospital nurse leaders involved in carrying out this unplanned change were:
Name/Credentials |
Years RN / |
Title |
Department |
Gail Gordon, MSN, RN, NEA-BC |
45 years / |
CNO and Vice-President of Nursing |
Nursing Administration |
Hector Aleman, MSN, RN, |
18 years / |
Patient Care Manager |
MS5 |
Maureen Allen, MHSA, RN |
21 years / |
Patient Care Manager |
MS4/Pediatrics |
Raul Botana, MSN, RN |
12 years / |
Patient Care Manager |
Nursing Administration - Clerical |
Sherine Craig, BSN, RN |
12 years / |
Emergency Services |
Emergency Department |
Leslie Everett, BSN, RN |
18 years / |
Patient Care Manager |
ICU/PCU |
Netonua Reyes, BSN, RN |
17 years / |
Patient Care Manager |
Pediatric Emergency |
Linda Simpson, BSN, RN |
37 years / |
Patient Care Manager |
MS3/Orthopedics |
Ana Cabrera, DNP, ARNP, NEA-BC |
28 years / |
Critical Care |
ICU/PCU |
Jan Weatherspoon, MSN, RN |
30 years / |
Perinatal |
Perinatal Services |
Leah Williams-Jones, MSN, RN, CMNL |
21 years / |
Patient Care Manager |
Perinatal Services |
Ann Marie Allen, MSN, RN |
26 years / |
Specialty Nursing Services Director |
Nursing Administration |
OUTCOMES
Outcomes were determined using the results of the RN Job enjoyment scale T-scores from NDNQI RN survey conducted in May 2013.
Exhibit TL5a: NDNQI RN Job Enjoyment Scale T-Score
Analysis: The results demonstrated that the unplanned change to the weekend supplemental contract did not adversely affect RN job enjoyment which was maintained above 60, at the highly satisfied level.
Summary Attachments/Hyperlinks/Evidences
TL5 01 Message from the President, 7/2/12
TL5 02 Nursing Operations meeting minutes 9/7/12
TL5 03 BHSF-2240 Revised RN Supplemental Weekend Plan Policy
TL5 04 Nursing Operations Meeting Minutes 1/4/13
Exhibit TL5a: NDNQI RN Job Enjoyment Scale T-Score
Example 2 – Planned Change
NAME OF INITIATIVE
Implementing Self-Scheduling in ICU
BACKGROUND AND PURPOSE
In the Intensive Care Unit (ICU) at Homestead Hospital, Web Scheduler had been in use for several years to help facilitate employee’s opportunity to request time off. Web Scheduler is a web-based workforce management software that supports the creation of an equitable schedule by granting all employees the same access to scheduling information through real-time communication. During this time, employees were only able to use the program to request time off. Scheduling of employees was completed at the discretion of the manager and according to policy. Nevertheless, scheduling for more than 70 employees posed a challenge to new ICU Patient Care Manager, Leslie Everett, RN, with special requests, leave of absences and vacations to consider. With the change in ICU leadership in May 2012 and the subsequent elimination of the weekend plan as described above, Everett noted a decrease in the 2012 NDNQI RN Survey “influence they have over their schedule” question. In 2012, the mean rating was 3.78 (benchmark mean=3.55 for bed size 100-199) compared to 3.90 in 2011.
During the January 2013 staff meetings, Everett, along with Chief Nursing Officer and Vice President Gail Gordon, RN announced the end of the weekend contract. With this news, nurses became upset with the number of weekends they would now have to work and perceived lack of control over their own schedules. Nurses who had set schedules as a result of being contracted to work weekends now faced instability of their schedules. Recognizing the impact of the schedule on RN satisfaction and engagement, Everett identified the need for a change in the scheduling process.
Planned Change
Over the next few months following the January 2013 staff meetings, Everett brainstormed methods that would allow staff more control over their schedules. She received communication from IT about enhancements coming to the Web Scheduler in the early part of fiscal year 2014 that would allow employees to schedule work days and time off through the program, as well as make changes to their requests and swap shifts with other employees. Everett was enthused with this planned update because it would address the limitations of the existing process and would allow nurses more access, flexibility and control over their schedule. She planned, with suggestions from staff, placing a paper schedule in the lounge allowing employees to practice self-scheduling over the next several months. She also developed a communication plan to prepare employees of the upcoming changes to the program and process and provide periodic updates through staff meetings and written communication. She collaborated with the Patient Care Supervisors, Kathie Trivett, RN, Liriola Harrison, RN and Eileen McMahon, RN in planning the education roll-out. Everett provided the staff with initial basic education on the changes to Web Scheduler during the February 2014 staff meetings. The education plan included education through staff meetings, computer based training self-study module, one-on-one assistance when needed and frequent reminders through huddles and emails. Then Everett planned to gradually incorporate Web Scheduler into the scheduling routine. Several of the staff verbalized that they did not mind being available to fill in the spots on the schedule and decided they would not self schedule. Given that information, Everett anticipated a 60% participation rate in the self-scheduling project.
Goal Statement
The goal of ICU nursing leadership team was to exceed NDNQI’s RN Survey question “Mean rating of influence over the schedule” score above 3.78 among ICU nurses.
METHODS & APPROACH
Strategies Used by Nurse Leaders to Successfully Guide Nurses
Early in January 2013, Everett placed a paper schedule in the lounge so staff could get accustomed to scheduling themselves. (TL5 05 Self-scheduling Paper Worksheet). She placed the self-scheduling form in the lounge and clearly labeled it for all staff to use. Nurses had an opportunity to self schedule using this method for about 4 months when the 2013 NDNQI RN Survey was released. Beginning in August 2013, Everett initiated planned communication on the changes coming in Web Scheduler that would open up many new capabilities with regard to scheduling of staff. She anticipated that in March 2014 Web Scheduler would go through an upgrade to be able to handle self scheduling, swaps, requests off and requests to work extra. Computer Based Training via Baptist Health University (BHU) was made available in December 2013 on the upgrades coming to web scheduler and all employees were encouraged to complete it. (TL5 06 Web Scheduler Training BHU Completion Report) Prior to the upgrade, Everett asked staff to check their access to web scheduler. Client Technology Technician, Robert Sisk provided access to anyone without log-in capabilities and assisted with troubleshooting any issues. Everett also gave instructions on how to access web scheduler from home during the August 2013 staff meetings (TL5 07 ICU/PCU Staff Meeting Minutes and Sign-in Sheet 8/26/13)
The Web Scheduler update went live 2/26/14, earlier than the previously anticipated date of March 2014. Everett notified the employees of this during the February 2014 staff meetings. Initially, staff expressed anxiety over accessibility to the program and time limits associated with this process. Those who were technologically savvy welcomed the change, where the others were more resistant. Everett, Trivett, McMahon and Harrison continued to guide and support them, as needed. The paper schedule was kept in place, and employees were reminded that this would act as a crutch during the transition. Everett continued encouraging employees to put their schedules on paper while simultaneously entering it into web scheduler to allow them time to work through the issues associated with the process change and new technology. Staff appreciated the dual process and felt more secure in knowing the paper would remain throughout the transition. Still many did not want to self schedule and wished to remain more flexible. Additionally, McMahon, Harrison and Trivett identified staff from each shift that was better at using the program and encouraged them to assist their coworkers. This worked well and Everett received several anecdotal accounts directly from the staff of one employee assisting the other with the process. (TL5 08 E-mail from Clinical Nurses and Web Scheduler Screenshot)
In working with the program, staff identified some program limitations. For example, it did not allow staff full access to the program’s capabilities as originally planned. In the April 2014 staff meetings, Everett discussed these issues and decided to leave the paper schedule in place solely for the purpose of making corrections. Staff who wanted to participate in self-scheduling were still encouraged to use Web Scheduler.
PARTICIPANTS
The ICU/PCU nurse leaders involved in carrying out this planned change were:
Name/Credentials |
Title |
Department |
Role |
Leslie Everett, BSN, RN, CCRN |
Patient Care Manager |
ICU/PCU |
Lead |
Kathie Trivett, BSN, RN, CCRN |
Patient Care Supervisor |
ICU/PCU |
Facilitator |
Eileen McMahon, BSN, RN |
Patient Care Supervisor |
ICU/PCU |
Facilitator |
Liriola Harrison, BSN, RN |
Patient Care Supervisor |
ICU/PCU |
Facilitator |
Robert Sisk |
Client Technology Technician |
Information Technology |
Assisted with access and log-in issues |
OUTCOMES
By May 2014, 58% of staff was using Web Scheduler to self schedule. Everett identified the remaining staff as those who chose not to self schedule.
Exhibit TL5b: ICU Mean Rating on “Influence Over the Schedule” Question in NDNQI RN Survey
Analysis: In May 2013, the NDNQI RN survey was sent out to the nurses. The goal of meeting or exceeding the 2012 score of 3.78 on the “Mean rating on influence over the schedule” was met with a score of 3.82. In May 2014, the score further increased to 3.88 demonstrating improved RN satisfaction on “influence over the schedule”.
As a follow up, in July of 2014, Everett queried staff through staff meetings, one-on-one’s and email about their feelings regarding Web Scheduler and self scheduling. The majority of the responses were positive, with some giving suggestions on how the process can be improved further.
Summary Attachments/Hyperlinks/Evidences
TL5 05 Self-scheduling Paper Worksheet
TL5 06 Web Scheduler Training BHU Completion Report
TL5 07 ICU/CU Staff Meeting Minutes and Sign-in Sheet 8/26/13
TL5 08 E-mail from Clinical Nurses and Web Scheduler Screenshot
Exhibit TL5b: ICU Mean Rating on “Influence Over the Schedule” Question in NDNQI RN Survey