Maintaining Positive Nursing
Practice Environments in a
Changing Labor Climate
Joan Shinkus Clark, DNP, RN, NEA-BC, CENP, FACHE, FAAN
Senior Vice President and System Chief Nurse Executive Texas Health Resources
Linda Burnes Bolton, DrPH, RN, FAAN
Vice President Nursing and Chief Nursing Officer Cedars-Sinai Medical Center
Objectives
1. Describe the role of nurse leaders in creating a culture of shared accountability for positive practice
environments
2. Identify key environmental factors that could influence positive employee relations and discuss proactive
approaches to hardwire excellence
3. Identify the key strategies from the AONE toolkit on the future of patient care delivery that facilitate staff
engagement, practice, and service excellence
4. Discuss the impact of shared accountability process and shared governance on unit and institutional
What are positive practice environments?
Positive practice environments (PPE) are cost-effective health care settings that support excellence and decent work, have the power to attract and retain staff and to improve patient satisfaction, safety and outcomes.
Characteristically such settings:
• ensure the health, safety and well-being of staff;
• support quality patient care;
• improve the motivation, productivity and performance of
individuals and organizations
Global Health Workforce Alliance:
(
Nurse Leader Role – Future Care Delivery
• The role of nurse leaders in future patient care delivery systems will continue to require a systems approach with all disciplines involved in the process and outcome models.
• Accountable Care Organizations will emerge and
expand as key to defining and differentiating healthcare reform provisions that will impact differing care delivery venues.
• Patient Safety, Experience Improvement and Quality Outcomes will remain a public, payer and regulatory focus driving work flow process and care delivery system changes as demanded by the increasingly
informed public.
Nurse Leader Role – Future Care Delivery
• Healthcare leaders will have knowledge of funding sources and will be able to strategically and
operationally deploy those funds to achieve desired outcomes of improved quality, efficiency and
transparency
• The joint education of nurses, physicians, and other
health professionals will become the norm in academia and practice promoting shared knowledge that enables safer patient care and enhancing the opportunity for
pass-through dollars to apply to APN residencies and/or related clinical education.
Communication Rich Culture The Presence of Adequate Numbers of Qualified Nurses The Presence of Expert, Competent, Credible, Visible Leadership Collaborative Practice Culture A Culture of Accountability Shared Decision Making at all Levels The Encouragement of Professional Practice and Continued Growth/ Development Recognition of the Value of Nursing’s Contributions Recognition by Nurses for their
Meaningful Contribution to Practice Elements of a Healthful Practice/Work Environment Nursing Organization Alliance, 2004
Elements of a Healthful Practice/Work Environment • Respectful collegial communication & behavior • Team orientation
• Presence of trust • Respect for diversity
Collaborative Practice Culture
• Clear and respectful • Open and trusting
Communication Rich Culture
• Role expectations are clearly defined • Everyone is accountable
A Culture of Accountability
• Role expectations are clearly defined • Everyone is accountable
The Presence of Adequate Numbers
of Qualified Nurses
• Serve as an advocate for nursing practice • Support shared decision making
• Allocate resources to support nursing
The Presence of Expert, Competent,
Credible, Visible Leadership
Nine Elements of a Healthful Practice/Work Environment • Nurses participate in system, organization,
and process decisions
• Formal structure exists to support shared decision-making
• Nurses have control over their practice
Shared Decision Making at all Levels
• Continuing education/certification is supported/encouraged
• Participation in professional association is encouraged
• An information rich environment is supported
The Encouragement of Professional Practice and
Continued Growth and Development
• Reward and pay for performance • Career mobility and expansion
Recognition of the Value of Nursing’s Contributions
Recognition by Nurses for Their Meaningful Contribution to Practice
Labor Environment is Changing
• Employee Free Choice Act - 2009
• National Labor Relations Board (NLRB) recess
appointments
• NLRB rule changing and legislative efforts
• NLRB case decisions
• Union consolidations and collaborations
• Targeted states
• Corporate campaigns and neutrality agreements
A tale of two organizations…..
•
Cedars-Sinai Medical Center
•
Los Angeles, California
•
Texas Health Resources
Cedars- Sinai Health System
•
Academic Medical Center plus Medical
Delivery Network
•
951 licensed beds
•
Mobile Medical Units
•
3,100 registered nurses, non union
•
750 union CPs, NCTs, STs, LVNs, Lift Team
•
12,000 employees 2,700 physicians
•
NICHE designation
Organizational Agility:
The New Imperative
• Clinical Quality
• Service Delivery
• Patient Safety
• Value
• Align organizational objectives with
employees values. Everyone rowing
together!
2002: A Look Back
• Three organizational earthquakes within three
(3) months
•
Nursing union organizing campaign loss
(later overturned)
•
Unforeseen operating loss
•
EMR installation halted
•
Most challenging: cultural tenor of the
organization
•
Divisive; bitter; lack of trust; failure to speak
up
Rethinking our Approach
•
Address key elements of employee
dissatisfaction
•
Address structure and Process
•
Employee Engagement
•
Employee Development
•
Leadership Development
Engaging Employees
•
Cultivate open dialogue
•
Leaders and staff “thinking together”
•
Move more problem solving to the point of
service
•
Help people gain greater sense of
ownership
A leader is best when people barely
know he exists, when his work is
done, his aim fulfilled, they will say
we did it ourselves.
Adopt Dialogue as an
Organization Norm
• Shared Governance/Shared Accountability
Teams
• MD/RN Collaborative
• Transforming Care at the Bedside
• Performance Improvement Teams
• AB394 – Patient Ratio Staffing
• Always Safe
Transforming Care at the Bedside
•
Engage first
•
Teach “one test of change at a time”. All ideas
welcome
•
Reward and Recognize
•
Listen to the voice of the staff
•
Listen to the voice of the patient
•
Outcomes- improved staff vitality, patient
centeredness, clinical outcomes and value
Shared Governance- Engagement
• Nursing Coordinating Council
• Divisional Clinical Practice Councils
• 42 Unit Practice Councils on nursing units
• Night Shift UPC’s
• 9 Shared Accountability Teams in other clinical areas • Small groups made up of staff and leaders thinking
together about unit/department specific issues
• Multi-disciplinary (RNs, nursing assistants, PT’s, etc.) • Infrastructure support.
• Trained facilitators, JIT education, and support for
• Employee Recognition cards & Employee of Quarter
• Transforming Care at the Bedside
• Involvement in Core Measures
• Visitor Policy
• Walking Executive Rounds
• Patient Safety Champions
• Sleeping Policy Enforcement
• English Only Policy
• Evidence Based Practice
Champions
• Electronic Medical Record
• ED Staff Role Assignments
• Peer Review
• ED RN Handoff to Imaging
• Toes Out - Toes In
• Charge Nurse Assignment
• Fall Prevention
• NICU Manager Selection
• Role Clarification of PT’s/OT’s
Unleashing the Power of Employee
Engagement: UPC Examples
Healthcare is a “Team Sport”:
Employees Engaged to Improve
Patient Safety
•
Thinking together to mitigate risk and
improve patient safety
•
A safe environment requires input from
those that deliver the care
•
“Always Safe” Initiative
•
“Safe Choices” unit based conversations
•
Assertive communication (crucial
Always Safe Initiative
•
Evolution of Thinking – How to Prevent
Medical Errors
• Early Thinking - “Blame and Train”; focus on
individuals
• Recent Thinking - “No Blame Culture”; focus on
systems
• Current Thinking - a balance of individual
responsibility and system design
•
This is the message we needed staff
members to embrace
Learning Culture Adverse Events Errors MD, Managerial and Staff Choices System Design
Always Safe – Staff Engagement
• Staff Engagement is Key
• To reduce errors and
improve safety, all staff are asked to focus on the
inputs:
• Designing safe systems that
catch errors or prevent them from harming the patient • Helping all staff and
colleagues make the optimal behavioral choices that
• Management Interventions
Guidelines- Leader development
• Updated management framework for working with staff involved in errors, or with performance/conduct issues
• Making Safe Choices
• Management and staff discussions to identify and correct where the unit has drifted from safe practice
• Crucial
Conversations/Confrontations
• Skill-building so leaders will coach and hold others accountable for safe practice
Learning Culture Adverse Events Errors MD, Managerial and Staff Choices System Design
Always Safe: Our Beliefs About
Managing Risk
•
To err is human
•
To drift is human
•
Risk is everywhere
•
We must manage and support our values
•
We are all responsible
•
200% Accountability is required.
•
Leaders as coaches
Choosing Your Culture: NICU CSI
• Creating a Safe Culture and Satisfying
Workplace in the NICU - 2008 to 2011
• The NICU CSI (
“
Clinical Safety Initiative
”
)
• “Safe Choices” conversation leads to CSI • Multi Disciplinary Staff Committee
• Group of NICU multidisciplinary staff
• Assembled for the purpose of creating a safe environment
• All staff have opportunity to participate
• Staff took the lead in identifying and acting on safety issues in their unit
NICU CSI
•
Realized that many issues related to
safety were embedded in their culture
•
Conducted honest assessment of current
unhealthy norms
•
Identified desirable healthy norms for
NICU
•
Aim: Replace unhealthy norms with ones
that reinforce safe practice
February 2005
March 2010
Day Shift
Engaging Employees in EMR
Implementation
•
November 2010 Phase 2 of EMR Install
• Clinical (non-MD) documentation - Very strong
apprehension about how staff would respond
•
Equipment/technology aspects of CS Link
were already being addressed by other
departments
•
Where help was needed was getting people to
successfully Accept and Adopt the new
Applying the Principle of Engagement
•
Ambassadors
• Champions • Super-users•
MD/RN collaborative
•
UPC’s/SAT’s
• 50+ councils were put to work planning and
preparing for change
• Facilitators were assigned to every group and
groups began meeting bi-weekly
UPC/SAT’s
•
Paint the vision
•
Discuss what the changes would mean on
their unit
•
Identify necessary preparation
•
Facilitators kept track of key concerns, best
practices, training needs, workflow changes,
staff morale, etc.
What did we Learn About Engaging
Employees in Change?
•
Generates enthusiasm and support
•
Never discount the challenge of change…even
if you think it’s simple
•
Involve people even if you don’t have a well
established employee engagement
infrastructure
•
Any size change is easier if you involve people
•
Move the conversation to the point of service
Change in Employee Survey 2002-2010
3.2 3.4 3.6 3.8 4 4.2 4.4Satisfied with the nature of the work
performed
Satisfied with my relations with
co-workers Cooperation and communication between nurses and physicians Documentation provides information I need to take care of patients Satisfied with my communication about patients with non-nursing members of care team 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011
What Did We Learn?
“…when the best leader’s work is done,
the people say we did it ourselves.”
24 acute-care and short-stay hospitals that are owned, operated, joint-ventured or affiliated with the system. 18 0utpatient Facilities
3,800 licensed hospital beds 21,500 employees
6700 Registered Nurses 5500 physicians
Texas Health Nursing Excellence
Magnet designation at
Texas Health Harris Methodist Fort Worth Texas Health Presbyterian Dallas
Texas Health Presbyterian Plano
Magnet applications scheduled for
Texas Health Arlington Memorial Hospital Texas Health Harris Methodist HEB
Pathways to Excellence at
Texas Health Presbyterian Allen
Texas Health Presbyterian Kaufman
Texas Health Harris Methodist Stephenville Texas Health Harris Methodist Azle
Texas Health Harris Methodist Cleburne
Texas Health Resources
•
First System Chief Nurse Executive
•
Started in 2008
•
Serve as the senior executive overseeing the
practice of nursing, and the standardization and
alignment of nursing care through the
implementation of evidence-based clinical and
managerial standards of practice
Nursing Practice Environment
•
Clinical Practice Model (CPM) model as
foundational to professional practice
• Unit based council structure of shared accountability
• Partnership council for interdisciplinary coordination
of activities
• System network of clinical operational improvement
councils (COPIC) across key specialties to address standardization and clinical integration
RN Focus Group Process
Primary Purpose
• Gain feedback from direct care nursing staff
• Identify opportunities for the nursing strategic plan
• Validate key drivers of nurse retention and relationship to current programs, policies or methods
• Identity ways to communicate best practices and expectations for THR RNs
• Identify potential enhancements to programs and policies for THR to improve retention
• Provide priorities or content for manager training and/or manager action plans
2008 Survey Results by Age Cohorts 1984 or later Millennial 1965 to 1983 GenX 1946 to 1964 Boomers 1945 or earlier Veterans EE Survey Results (4139 Total) 197 (4.8%) 2145 (51.8%) 1692 (40.9%) 105 (2.54%) Number of Questions Below Mean (Red)
13 (16%) 62 (76%) 48 (58%) 22 (27%)
Data/Question Analysis resulted in four Focus
Group Topic Areas
Unit Work Environment Involvement
Communication
Recognition
RN Focus Group Process
Focus Areas
• Four Age Groups • Millennial: • GenX: • Boomers: • Veterans: • Male RN’s • Single Parents RN’s • Ethnically Diverse RN’s
• RN’s with 2 to 3 years tenure with THR (high turnover)
44
RN Focus Group Process Cohort
Selection
RN Focus Group
Key Themes and THR Plan and Action Items
Themes THR Response A ll G roups
Peers and Teamwork Enhanced On-boarding, Clinical Leader Role
Unit Council Management Council Training
Management Support Leadership Training
Recognition Applause Program
Communication Nursing Town Halls, THR Nurse Publication
Staffing and Support Staffing Workforce Planning and Manager Education
U ni que G roups
Diverse – Emphasized Education Tuition Reimbursement, Specialized Training
Programs Gen X – Concerns about on-call,
preferred electronic communication
Enhanced Communication through Yammer, Facebook
Boomers, Veterans – Flexibility and time off, More reluctant to voice concerns
Regional Environmental Analysis
2008-2009
• Historical organized labor climate in Texas Hospitals
• Proposed Texas staffing ratio legislation
• Safe Staffing Act passed in 2009
• Amended 2006 Tenet neutrality agreement
• Implications for Texas
• Texas targeted by National Nursing Organizing
Committee - California Nurses Association (NNOC) and Service Employee International Union (SEIU)
• NNOC – organize nurses
Current Labor Environment
• Advance agendas through rule making over proposing legislation
• NLRB 2012 – recess appointments (2 Democrats and 1 Republican)
• Proposed changes (subject to litigation)
• Shortened election periods – from 38 to 15-20 days! (effective 4/30/12 if federal lawsuit filed by Chamber of Commerce and Coalition for a Democratic Workplace is unsuccessful)
• Elimination of pre-election litigation and resolution over voter-eligibility issues that need not be resolved prior to the election
• Names and addresses of employees to be provided to the
petitioner
Positive Practice Environment Through Systematic Performance Improvement Understand the Issues Build Effective Supervisors Address Employee Concerns Create a High-Performance Organization Diagnostic Programs • Employee Assessment Survey & Focus Groups • Customized Structured Interviews • Customized Opinion Surveys • Human Resources Practices Audit Skill Building • Employee Assessment Survey & Focus Groups • Recognizing Discontent • Supervisory Skill Training • Management Development • Organizational Development Practical Solutions • Employee Assessment Survey & Focus Groups • Issue Analysis • Issue Intervention • Do only those things
that make sense
• Process Improvement • Change Management • Performance Measurement • Performance Management • Recognition & Rewards Fact-Based Problem Identification
Fact-Based Leadership Preparation
Performance Improvement
Targeted Issue-Based Interventions
Positive Practice Environment Process
Satisfaction Index: Measurement of Progress Low Vulnerability to
Organization Performance Oriented Change High Vulnerability to Organization 48 Nursing Focus Groups, Surveys, & Interviews Supervisor & Manager Training, Internal Assessment Nursing Townhalls, Rounds. Website for Q&A System Career Advancement Program, Nursing Congress, COPICs, and Councils
RN Engagement Results 2011
Outcomes and Progress
2008 Survey Results by Age Cohorts 1984 or later Millennial 1965 to 1983 GenX 1946 to 1964 Boomers 1945 or earlier Veterans EE Survey Results (4139 Total) 197 (4.8%) 2145 (51.8%) 1692 (40.9%) 105 (2.54%) Percentage of
Questions Below Mean 16% 76% 58% 27%
2011 Survey Results by Age Cohorts 1984 or later Millennial 1965 to 1983 GenX 1946 to 1964 Boomers 1945 or earlier Veterans EE Survey Results (5360 Total) 423 (7.9%) 2672 (49.9%) 2064 (38.5%) 100 (1.9%) Percentage of
Questions Below Mean 72% 59% 21% 28%
Significantly Improved Opportunity for
Key System Initiatives
• System Wide Steering Committee
• Proactive Partnership with Human Resources and other key
stakeholders
• Extensive Management Training of Supervisors,
Managers, Directors and CNOs
• In-depth NLRB act and union campaigns • Web based yearly refresher training
• Board of Director Education Series
• Staff RN Communication and Awareness
• Town halls
• Employee web site
• Engagement survey results
• Development of Contingency Plans – Potential for
Contingency Planning
• Daily plan for rapid organizational
mobilization if petition occurs
• Use of central communication center and rapid response
team
• Conduct townhalls at regular intervals during a 15 day
campaign for centralized communication flow and to address issues arising through campaign
• Refresher training to entity leadership with fact sheets and
strategies
• Daily update to senior executive team, entity leadership, and
response team members, on activities and strategies
• Written weekly updates for all managers
Summary
• Positive Practice Environments are not built overnight!
• PPEs are foundational to an atmosphere of trust and cooperation between management and staff
• With the proposed NLRB ruling, it will be very difficult to
organizationally respond in a two week period.
• Build the foundation now
• Educate your leadership and Board of Directors about the unionization process
• Educate and engage your employees on the facts and implications of unionization to ensure that when or if
individual choice is exercised, it is grounded in a realistic and balanced point of view
Contact Information:
Joan Clark :
joanclark@texashealth,org
Linda Burnes Bolton: