BY: JEAN DOLS, PH.D., RN, NEA-BC, FACHE
It takes an entire organization's energy and a well-developed plan to facilitate nursing's drive to attain excellence. To be effective, nurse leaders must have:
- A clear vision
- A sense of urgency for change
- One set of collectively developed goals
- Participation from nurses
- Continual measurement of short-term results
- Ongoing reporting and recognition of positive results
Nurses need to envision what excellence looks like and recognize their role in attaining it. The organization's picture of the future therefore needs to include all nurses and all nursing across the entire system. In our organization, for example, nursing goes beyond acute hospital care to include outpatient services, home health, long-term acute care, hospice, skilled nursing and international nursing.
To create urgency for change, the vision must remain at the forefront of every plan. It should describe the picture of nursing's future in an inspiring, clear, brief and memorable way. At CHRISTUS Health, we express our vision in words reflective of the Prayer of St. Teresa; they embody our heritage and describe our future: The CHRISTUS Nurse, as the hands of Christ, creates excellence in professional practice and quality outcomes in a healing environment.
THE PATH TO EXCELLENCE: SHORT-TERM GOALS
To provide clear direction, nurse leaders must establish both short-term and long-term goals. Short-term goals establish basic infrastructure, address immediate needs for improved quality and patient safety, provide education and development of nurse leaders and assure a competent nursing staff. These priorities provide the foundation required for nursing excellence.
An important element of infrastructure is to position nurse leadership at the senior leadership level with appropriate titles. What's more, the infrastructure must include job descriptions and evaluations that define the roles and responsibilities of nurses and nurse leaders, including a delineation of their accountability for building excellence. A crucial component is establishing the method by which the competence of nurses is verified and developed.
Policies and standards should be developed to clarify for nursing staff what happens when new knowledge conflicts with what was previously known. Measures of quality and risk should be analyzed to determine the priority needs for addressing patient care and safety. Many organizations are likely to find opportunities to improve safety measures; they also may find a need to improve communication of adverse events. Short-term goals may focus on risk identification, performance improvement projects and improved methods of sharing best practices. One of our organization's nursing goals focuses on the automation of medication errors and adverse events so that they can be aggregated and analyzed more easily.
Educating and developing nurse leaders begins as a short-term goal to cultivate the skills needed to build an environment conducive to nursing excellence. This development and mentoring continues as a long-term activity, for it helps build the future state of nursing. Nursing competence is essential to the road map. Short-term goals should focus on recruiting and retaining exceptional nurses and providing the education and support for them to develop skills required in an environment of excellence. Among the necessary skills: leadership building and empowering nurses through participation.
HOW TO KEEP TRACK OF PROGRESS
Between short-term goals and long-term goals is the issue of monitoring progress. Among the most difficult things to achieve are determining and refining the metrics that will measure nursing excellence. The goals should be achievable but not an easy win. We should feel stretched to accomplish them.
Initially, the measures should be limited so focus will stay on what is possible to monitor. The measures should be meaningful so nurses will be able to relate to them. The metrics should be easy to collect so that they are readily available.
CHRISTUS Health monitors nursing throughout the entire organization by aligning goals and metrics to what we call "four directions to excellence" and to the nursing vision. The four directions keep us grounded and balanced. They are clinical quality, service excellence, business literacy and community value.
Nursing measures excellence with a one-page dashboard that includes metrics in each of the four directions. We determined up front to use an easy-to-read, one-page format with room for only 20 measures. It quickly became a struggle to determine which to include; limiting the size kept us focused. We agreed the measures had to be relevant to nursing excellence and reflect the four directions. Then we had to refine definitions and identify national/international benchmarks so we could make comparisons across our own facilities and in relation to national and international measures of excellence. We also had to clearly define the method of collection so that every metric reflected the same measure.
We find the measures help nurses and nurse leaders across the organization to quickly assess their progress toward attaining nursing excellence. The dashboards are unit/area-specific and roll up to facility/region-specific. Each nursing unit or area can check its color-coded score to see where it stands in relation to a goal.
For service excellence, we measure patient and physician satisfaction with nursing care, as well as staff and RN satisfaction. We also look at RN vacancies and RN turnover. For clinical quality, we monitor the incidence of four hospital-acquired conditions, in addition to falls and pain control. For business literacy, we monitor supply costs, staffing costs, productivity, staffing and skill mix. For community value, we monitor compassion.
Although it was difficult to accomplish, the one-page dashboard has become one of our most valuable tools. It gives us nursing metrics that are timely and accurate and can be used to improve operational performance.
THE PATH TO EXCELLENCE: LONG-TERM GOALS
Once the basic infrastructure is in place, nurse leaders need to keep a set of short-term goals, but also move toward completing long-term goals. A word of caution: Setting too many goals can become frustrating in environments that can't support multiple changes. It's a good idea to limit the number and complexity of long-term goals by assigning priorities. Then some items can move to a "pending" list and relieve the pressure of trying to meet too many goals within the period of an annual work plan.
In relation to nursing excellence, long-term goals include building a framework for nursing research and evidence-based practice, continued development of and mentoring for nurses and nurse leaders and improved operational performance across the four directions to excellence.
In order to move our organization quickly toward system-wide, evidence-based practice, we used an immersion technique. We established a goal of creating three protocols and forming an interdisciplinary evidence-based practice team in each region of our health care system. RNs from each region and from such specialties as rehabilitation, community health, risk management and informatics participated in an organization-specific, evidence-based practice workshop. We followed that with a national evidence-based practice workshop that included the opportunity to network with national experts.
At the workshops, the CHRISTUS nursing team identified three clinical problems. Afterward, the team developed three protocols focused on fall prevention, a system of color-coded alert wristbands and pressure-ulcer prevention and management. CHRISTUS has seen significant clinical success in relation to the new protocols and others, especially in the system-wide reduction of falls and medication-related injuries.
Nursing also established a research agenda, a defined set of priorities and focus areas with structures and boundaries in order to improve the quality of care provided, assure nursing competence, create a cost-efficient, nurse-friendly environment and advance the science of nursing practice. CHRISTUS has conducted system-wide studies on nursing incentives1, nursing leadership and nurse retention.
PILOTS AND PLAUDITS
One of our current goals in the area of business literacy is to design and implement programs with a positive impact on the organization's financial health while improving the quality of patient care. The plan is to implement nursing care delivery models that maximize the number of caregivers at the bedside while meeting the budgeted targets. We are conducting pilots at different hospitals to demonstrate the effectiveness of the models prior to moving them further throughout the organization. Pilot programs are one of the primary methods we use to demonstrate an innovation is effective. It enables inexperienced nurse leaders to learn from experienced nurse leaders, good hospitals to learn from great hospitals. It also permits isolated best practices to be refined before being spread system-wide.
We regularly share with the senior leadership and the board the work that nursing has completed, and we celebrate the achievements. Driving toward excellence takes the entire organization. It is essential to acknowledge the successes along the way and assure that the individuals who are responsible for the work receive the credit.
JEAN DOLS is the system director of nursing and quality at CHRISTUS Health. The system, headquartered in Dallas, includes more than 50 hospitals and facilities in eight states and Mexico.
NOTE
- L. Wieck, J. Dols and S. Northam, "What Nurses Want: The Nurse Incentives Project," Nursing Economics 27, no. 3 (May-June 2009): 169-177.