- Email: [email protected]
Great Expectations: Linking Vision to Everyday Work
Great Expectations: Linking Vision to Everyday Work Karen Richards, DNP, RN, NE-BC, and Jean Mellott, MSN, RN-BC
I
n a Magnet® organization, leaders must continu-
duced several evidence-based initiatives designed to
ally seek out opportunities to improve patient out-
provide staff with the tools needed to deliver an excep-
comes and processes associated with the delivery of
tional experience. Service communication, relation-
high-quality, safe patient care. Using the Magnet
ship-based care, TeamSTEPPS™, and lean thinking
model as a framework helps to guide leaders to link an
concepts were all introduced sequentially over a 4-year
organization’s vision to the everyday work. Outstanding
period. Grounded by nursing’s professional practice
patient care experiences are at the heart of Exeter
model, the tools became critical components of every-
Hospital’s mission, vision, and values. In an effort to
day clinical practice and guided the work of the unit-
enhance the patient care experience, Exeter intro-
based practice councils.
www.nurseleader.com
Nurse Leader
67
O
ver time, however, it became clear that leaders, providers, and staff from across the organization were uncertain as to how the initiatives were interconnected and how each supported the other. Managers often expressed frustration that some departments had received significant training, whereas others had only received the basics. As a result, employees had variable levels of exposure, training, and utilization of these evidence-based resources and tools. In response, senior leaders chartered a group of system educators and content experts to uncover opportunities to enhance the level of integration and application of the key concepts and tools into standard daily work. The group was tasked with creating an integrated curriculum for all employees, providing education for current employees and managers, and identifying key behaviors and job skills to effectively integrate the concepts into employee performance.
STRUCTURE A cross-affiliate team of educators and content experts was chartered to take on the challenge of integration and application of the 4 initiatives and to determine competency outcomes.Team structure was changed from ad hoc to a formal project team, with the work of the team becoming known as the “integrated curriculum.” As the process began, it became evident that the concepts of service communication, relationship-based care, TeamSTEPPS, and lean thinking, all shared common threads, as identified in Figure 1. Over the course of the next 18 months, 4 priorities surfaced and focused the team’s work: 1. Involving managers more in the everyday application of the concepts 2. Refining the structure of the curriculum and production of competencies, materials for new and existing staff, managers, and providers 3. Identifying how to use exisiting data sources to guide future education needs assessments 4. Establishing milestones and outcome metrics for the project Project team meetings were held monthly, and progress was reported out quarterly to the members of the health systems operating group (HSOG). The group, chaired by the chief executive officer, and composed of various system vice presidents, became the sponsors of the project.
employees. This was a critical finding for the team, which ultimately led to the development of the integrated curriculum, a program designed to educate all current and future employees on the cultural expectations of: • Putting patients’ needs first • Effective interpersonal communication • Effective teamwork while integrating the concepts of service communication, TeamSTEPPS, relationship-based care, and lean thinking. Figure 2 presents the visual tool designed to compliment the curriculum. In late fall, the team conducted a survey of mangers and directors that validated that leaders, providers, and staff across all Exeter affiliates had variable levels of exposure and training, and variable opportunities to actually implement these evidence-based initiatives, resources, and tools. The team created an integrated curriculum to provide all employees with an understanding of the basic performance expectations. In an effort to brand the program and more clearly express the content, the integrated curriculum was renamed Expectations for Excellence at Exeter, or Ex3. Objectives were to examine the patient care experience, create awareness of foundational evidence-based practice tools, and begin to help participants appreciate their unique role in Exeter’s continuous quest for excellence. The program was first presented to senior leaders, managers, and directors, and the feedback was generally positive. Some of the content was revised based on specific suggestions from the group, such as paring down the slides, offering concrete examples of excellent communication and handoffs, and keeping the conversation broad and applicable to all staff, rather than focusing primarily on clinical staff. Feedback from the program evaluations included statements such as: • “Linking the concepts will be very helpful in solidifying the patient care experience.” • “Improving professional conduct and team work is key to a positive work environment.” • “Common vision… alignment (of) our work” • “Shared mental model” • “Will help to focus on sustaining business” • “Stronger, more effective team”
SUSTAINABILITY PROCESS Initial phases of the project included compiling descriptions of key aspects of each initiative. Time was spent discussing the descriptions and developing shared understanding and assumptions. Finally, comparisons and considerations were made regarding the following: • How do the initiatives complement one another? • How do they duplicate or overlap? • Is there a logical order to the introduction of each of the 4 initiatives? Following the team’s in-depth exploration of the 4 initiatives, common elements quickly began to emerge. These elements, deemed fundamental to each of the programs, were identified as “basic performance expectations” for all Exeter
68
Nurse Leader
The vice president for human resources expressed the need to create a model that would include the ability to measure the effectiveness of corporate orientation. He suggested that Ex3 should have a follow-up component. To meet that expectation, new employees now receive an additional 4-hour follow-up course approximately 90 days post-hire. Ex3, Part 2, delves deeper into each of the evidence-based tools and offers participants the opportunity to discuss application of the basic performance expectations in their unique work setting. Ex3, Part 2 objectives are to identify strategies to sustain and create relationships, discuss examples of effective teamwork, demonstrate various techniques to optimize the patient care experience, and identify opportunities for improving departmental efficiency using lean principles. The
June 2014
Figure 1. Text
Figure 2. Text
teaching strategies include a combination of lecture and group exercises specifically designed to engage participants in the learning process. One such teaching strategy is the World Café,1 a creative format for encouraging collaborative dialogue. World Café evolved out of the work of Juanita Brown and David Isaacs, stimulates meaningful conversations, and helps create common purpose. Participants share and apply the learning that has taken place as they move from conversation to conversation. Participants sit 4 to a table and discuss a question for about 20 minutes; 1 person becomes the table leader and remains to welcome a new group while the other 3 go to 3 different tables and essentially “cross pollinate” ideas. Examples of the group exercises include: role playing with a focus on empathy, relationship building, and customer service; creating a problem statement from an actual workplace
situation; analyzing a situation from past experience, where subtle behaviors undermined team performance and recommending tools and strategies to address those behaviors; and openly sharing examples of Ex3 concepts/tools in action (or opportunities for better utilization). After the rotations are complete, the group reconvenes, and each table leader reports on discussion highlights, observations, and any suggested recommendations. World Café is consistently mentioned as a strength of the program. Sample comments include: • “Clearly presented with continuous examples and ability for group participation” • “Material was presented effectively in an environment open for communication.” Evaluations from the first Ex3, Part 2 demonstrated exceptional scores as seen in Table 1. Using a Likert scale of 1 to 5
Table 1. Ex3, Part2 Evaluation Results
Objectives: As a result of this educational activity, I am able to: Identify strategies to create and sustain effective relationships with patients, colleagues, and self
4.6
Discuss examples of effective teamwork in the language of TeamSTEPPS
4.7
Demonstrate techniques to enhance relationships, effective teamwork, and communication to optimize the patient care experience
4.7
Identify opportunities for improving departmental efficiency using lean principles
4.8
I am satisfied with this program
4.8
This program enhanced my knowledge
4.7
Because of this program, I will change my practice, skill, attitude, or performance
4.5
This program met my personal objectives.
4.7
Teaching effectiveness
4.9
www.nurseleader.com
Nurse Leader
69
Figure 3. Text
patient care experience, become critical components of everyday clinical practice and ultimately be deeply imbedded into the corporate culture. NL References 1. The World Café Community Foundation. World Café Method. http://www.theworldcafe.com/method.html. Accessed August 15, 2013.
Karen Richards, DNP, RN, NE-BC, is executive director professional practice at Elliot Health System, Manchester, New Hampshire. She can be reached at [email protected]. Jean Mellott, MSN, RN-BC, is a professional development specialist at Exeter Hospital in Exeter, New Hampshire.
(5 ⫽ strongly agree, 1 ⫽ strongly disagree), participants were asked to rate how well the content met the objectives. Overall scores ranged from 4.5 to 4.9, signifying participants strongly agreed that content objectives were met.
ENCULTURATION
Acknowledgments The authors would like to recognize their colleagues Lianne Tonry, MSN, RN-BC, NE-BC, Mary Beth Jermyn, CQE, CMQ/OE, Jenn Delvechio, Diane White, BSN, MSHA, RN, LNC, Sue Demarco, MPA, Sherry Ovens-Burleigh, DPT, and Laurie Berube, MSOL, RN-BC, as having contributed to the development of the Ex3 curriculum. 1541-4612/2014 Copyright 2014 by Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.mnl.2013.09.015
The final phase of the integrated curriculum project was to incorporate the principles of EX3 (Figure 3) into employee performance evaluations and position profiles for employees at all levels. A group, including members of the integrated curriculum team, representatives from human resources (HR), and the vice president of HR, began the process of revamping the annual appraisal tool by discussing the personal behaviors that would demonstrate knowledge of the EX3 concepts. Lengthy discussions aimed at identifying how managers could measure whether individuals were putting patient’s needs first, demonstrating effective teamwork, and using effective interpersonal communication led to changes in content and weighting within the existing performance evaluations. Enculturation of service communication, relationshipbased care, TeamSTEPPS, and lean thinking into the annual evaluation process required the group to identify key constructs within each of the concepts that would be measurable, yet not lead employees to view them as standalone models. Other agreed-upon principles that became part of the revision process included: the changes made would be applicable to employees at all levels; the appraisal tool needed to have clear, concrete, easily measurable language; and education needed to be provided to both managers and staff on the appraisal tool changes. The work to align the corporate strategy, the employment structure, and the every day work is an ongoing process. Like any journey to excellence, a strong foundation is the key to success and requires time and commitment to develop. The goal is that these evidence-based initiatives and tools (service communication, relationship-based care, TeamSTEPPS, and lean thinking concepts), which will deliver an exceptional
70
Nurse Leader
June 2014
I
n a Magnet® organization, leaders must continu-
duced several evidence-based initiatives designed to
ally seek out opportunities to improve patient out-
provide staff with the tools needed to deliver an excep-
comes and processes associated with the delivery of
tional experience. Service communication, relation-
high-quality, safe patient care. Using the Magnet
ship-based care, TeamSTEPPS™, and lean thinking
model as a framework helps to guide leaders to link an
concepts were all introduced sequentially over a 4-year
organization’s vision to the everyday work. Outstanding
period. Grounded by nursing’s professional practice
patient care experiences are at the heart of Exeter
model, the tools became critical components of every-
Hospital’s mission, vision, and values. In an effort to
day clinical practice and guided the work of the unit-
enhance the patient care experience, Exeter intro-
based practice councils.
www.nurseleader.com
Nurse Leader
67
O
ver time, however, it became clear that leaders, providers, and staff from across the organization were uncertain as to how the initiatives were interconnected and how each supported the other. Managers often expressed frustration that some departments had received significant training, whereas others had only received the basics. As a result, employees had variable levels of exposure, training, and utilization of these evidence-based resources and tools. In response, senior leaders chartered a group of system educators and content experts to uncover opportunities to enhance the level of integration and application of the key concepts and tools into standard daily work. The group was tasked with creating an integrated curriculum for all employees, providing education for current employees and managers, and identifying key behaviors and job skills to effectively integrate the concepts into employee performance.
STRUCTURE A cross-affiliate team of educators and content experts was chartered to take on the challenge of integration and application of the 4 initiatives and to determine competency outcomes.Team structure was changed from ad hoc to a formal project team, with the work of the team becoming known as the “integrated curriculum.” As the process began, it became evident that the concepts of service communication, relationship-based care, TeamSTEPPS, and lean thinking, all shared common threads, as identified in Figure 1. Over the course of the next 18 months, 4 priorities surfaced and focused the team’s work: 1. Involving managers more in the everyday application of the concepts 2. Refining the structure of the curriculum and production of competencies, materials for new and existing staff, managers, and providers 3. Identifying how to use exisiting data sources to guide future education needs assessments 4. Establishing milestones and outcome metrics for the project Project team meetings were held monthly, and progress was reported out quarterly to the members of the health systems operating group (HSOG). The group, chaired by the chief executive officer, and composed of various system vice presidents, became the sponsors of the project.
employees. This was a critical finding for the team, which ultimately led to the development of the integrated curriculum, a program designed to educate all current and future employees on the cultural expectations of: • Putting patients’ needs first • Effective interpersonal communication • Effective teamwork while integrating the concepts of service communication, TeamSTEPPS, relationship-based care, and lean thinking. Figure 2 presents the visual tool designed to compliment the curriculum. In late fall, the team conducted a survey of mangers and directors that validated that leaders, providers, and staff across all Exeter affiliates had variable levels of exposure and training, and variable opportunities to actually implement these evidence-based initiatives, resources, and tools. The team created an integrated curriculum to provide all employees with an understanding of the basic performance expectations. In an effort to brand the program and more clearly express the content, the integrated curriculum was renamed Expectations for Excellence at Exeter, or Ex3. Objectives were to examine the patient care experience, create awareness of foundational evidence-based practice tools, and begin to help participants appreciate their unique role in Exeter’s continuous quest for excellence. The program was first presented to senior leaders, managers, and directors, and the feedback was generally positive. Some of the content was revised based on specific suggestions from the group, such as paring down the slides, offering concrete examples of excellent communication and handoffs, and keeping the conversation broad and applicable to all staff, rather than focusing primarily on clinical staff. Feedback from the program evaluations included statements such as: • “Linking the concepts will be very helpful in solidifying the patient care experience.” • “Improving professional conduct and team work is key to a positive work environment.” • “Common vision… alignment (of) our work” • “Shared mental model” • “Will help to focus on sustaining business” • “Stronger, more effective team”
SUSTAINABILITY PROCESS Initial phases of the project included compiling descriptions of key aspects of each initiative. Time was spent discussing the descriptions and developing shared understanding and assumptions. Finally, comparisons and considerations were made regarding the following: • How do the initiatives complement one another? • How do they duplicate or overlap? • Is there a logical order to the introduction of each of the 4 initiatives? Following the team’s in-depth exploration of the 4 initiatives, common elements quickly began to emerge. These elements, deemed fundamental to each of the programs, were identified as “basic performance expectations” for all Exeter
68
Nurse Leader
The vice president for human resources expressed the need to create a model that would include the ability to measure the effectiveness of corporate orientation. He suggested that Ex3 should have a follow-up component. To meet that expectation, new employees now receive an additional 4-hour follow-up course approximately 90 days post-hire. Ex3, Part 2, delves deeper into each of the evidence-based tools and offers participants the opportunity to discuss application of the basic performance expectations in their unique work setting. Ex3, Part 2 objectives are to identify strategies to sustain and create relationships, discuss examples of effective teamwork, demonstrate various techniques to optimize the patient care experience, and identify opportunities for improving departmental efficiency using lean principles. The
June 2014
Figure 1. Text
Figure 2. Text
teaching strategies include a combination of lecture and group exercises specifically designed to engage participants in the learning process. One such teaching strategy is the World Café,1 a creative format for encouraging collaborative dialogue. World Café evolved out of the work of Juanita Brown and David Isaacs, stimulates meaningful conversations, and helps create common purpose. Participants share and apply the learning that has taken place as they move from conversation to conversation. Participants sit 4 to a table and discuss a question for about 20 minutes; 1 person becomes the table leader and remains to welcome a new group while the other 3 go to 3 different tables and essentially “cross pollinate” ideas. Examples of the group exercises include: role playing with a focus on empathy, relationship building, and customer service; creating a problem statement from an actual workplace
situation; analyzing a situation from past experience, where subtle behaviors undermined team performance and recommending tools and strategies to address those behaviors; and openly sharing examples of Ex3 concepts/tools in action (or opportunities for better utilization). After the rotations are complete, the group reconvenes, and each table leader reports on discussion highlights, observations, and any suggested recommendations. World Café is consistently mentioned as a strength of the program. Sample comments include: • “Clearly presented with continuous examples and ability for group participation” • “Material was presented effectively in an environment open for communication.” Evaluations from the first Ex3, Part 2 demonstrated exceptional scores as seen in Table 1. Using a Likert scale of 1 to 5
Table 1. Ex3, Part2 Evaluation Results
Objectives: As a result of this educational activity, I am able to: Identify strategies to create and sustain effective relationships with patients, colleagues, and self
4.6
Discuss examples of effective teamwork in the language of TeamSTEPPS
4.7
Demonstrate techniques to enhance relationships, effective teamwork, and communication to optimize the patient care experience
4.7
Identify opportunities for improving departmental efficiency using lean principles
4.8
I am satisfied with this program
4.8
This program enhanced my knowledge
4.7
Because of this program, I will change my practice, skill, attitude, or performance
4.5
This program met my personal objectives.
4.7
Teaching effectiveness
4.9
www.nurseleader.com
Nurse Leader
69
Figure 3. Text
patient care experience, become critical components of everyday clinical practice and ultimately be deeply imbedded into the corporate culture. NL References 1. The World Café Community Foundation. World Café Method. http://www.theworldcafe.com/method.html. Accessed August 15, 2013.
Karen Richards, DNP, RN, NE-BC, is executive director professional practice at Elliot Health System, Manchester, New Hampshire. She can be reached at [email protected]. Jean Mellott, MSN, RN-BC, is a professional development specialist at Exeter Hospital in Exeter, New Hampshire.
(5 ⫽ strongly agree, 1 ⫽ strongly disagree), participants were asked to rate how well the content met the objectives. Overall scores ranged from 4.5 to 4.9, signifying participants strongly agreed that content objectives were met.
ENCULTURATION
Acknowledgments The authors would like to recognize their colleagues Lianne Tonry, MSN, RN-BC, NE-BC, Mary Beth Jermyn, CQE, CMQ/OE, Jenn Delvechio, Diane White, BSN, MSHA, RN, LNC, Sue Demarco, MPA, Sherry Ovens-Burleigh, DPT, and Laurie Berube, MSOL, RN-BC, as having contributed to the development of the Ex3 curriculum. 1541-4612/2014 Copyright 2014 by Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.mnl.2013.09.015
The final phase of the integrated curriculum project was to incorporate the principles of EX3 (Figure 3) into employee performance evaluations and position profiles for employees at all levels. A group, including members of the integrated curriculum team, representatives from human resources (HR), and the vice president of HR, began the process of revamping the annual appraisal tool by discussing the personal behaviors that would demonstrate knowledge of the EX3 concepts. Lengthy discussions aimed at identifying how managers could measure whether individuals were putting patient’s needs first, demonstrating effective teamwork, and using effective interpersonal communication led to changes in content and weighting within the existing performance evaluations. Enculturation of service communication, relationshipbased care, TeamSTEPPS, and lean thinking into the annual evaluation process required the group to identify key constructs within each of the concepts that would be measurable, yet not lead employees to view them as standalone models. Other agreed-upon principles that became part of the revision process included: the changes made would be applicable to employees at all levels; the appraisal tool needed to have clear, concrete, easily measurable language; and education needed to be provided to both managers and staff on the appraisal tool changes. The work to align the corporate strategy, the employment structure, and the every day work is an ongoing process. Like any journey to excellence, a strong foundation is the key to success and requires time and commitment to develop. The goal is that these evidence-based initiatives and tools (service communication, relationship-based care, TeamSTEPPS, and lean thinking concepts), which will deliver an exceptional
70
Nurse Leader
June 2014