- Email: [email protected]
RETRACTED: Toward a greater understanding of health system nursing organizations and the role of the CNO
Toward a Greater Understanding of Health System Nursing Organizations
D
and the Role of the CNO
R
ET R AC TE
Lauren Arnold, PhD, RN, Wilhelmina Manzano, MA, RN, Sherrie L. Jones, Gerald E. Bisbee, Nancy E. Holecek, BSN, RN, and Karlene Kerfoot, PhD, RN
The formation of the multi hospital health system as a prevalent model for organizing the structure, financing, and delivery of health care has stimulated the development of large-scale nursing management structures. Arguably, the trend toward systematization has driven nursing to become more corporate in nature. This trend has created many opportunities for nursing leaders to adopt business discipline, advancing the profession and its position in the industry. These opportunities also pose tremendous tensions. Chief among them is the quality/cost chasm in which many health system nursing executives find themselves. 30 Nurse Leader
They must bridge the corporate incentives for effectiveness with the realities of patient care delivery. The corporatization of nursing amplifies traditional tensions and introduces new ones. It also creates many opportunities for nursing leadership within each health system and for the profession at large. Many health systems have established large-scale nursing management structures that have dynamically evolved over time. These nursing organizations serve an expanding scope of nursing leadership and management requirements. Health systems have taken various approaches in modeling their nursing organizations. Many health systems August 2006
D
tions about the health system CNOs’ roles and leadership priorities in the areas of quality, patient safety, and compliance; financial performance and nursing resource management; patient care delivery; leadership development; and nursing practice and professionalism. The sample of CNOs consists of members of the Health Management Academy (HMA), which convenes large health system executives as a forum to discuss issues. The CNO Forum meets regularly to discuss issues of shared concern and has leveraged the knowledge embedded in this network of colleagues to learn from each other and enhance their individual performance in their positions as the top nursing executive in their health systems. Believing that the knowledge embedded in the forum is worth sharing, these CNOs established the goal of synthesizing and reporting on that knowledge. Sampled were 35 CNO members of the HMA, 22 of whom responded (63% response rate). Collectively the 22 CNOs lead nursing care in 433 hospitals, covering 106,695 licensed beds, 2,162,153 inpatient admissions, 34,888,568 outpatient visits, and 7,985,252 ER visits. Total net patient revenue represented by health systems in this sample is $53.422 billion. CNOs responding lead nursing in health systems ranging from 2 to 74 hospitals, from 1200 to 16,000 beds. They cover the full spectrum of academic and community-based models and represent single market to national spans. Both not-for-profit and investor-owned health systems are included in this sample. Study findings provide insights into how CNOs are using different strategies to organize nursing responsibilities and choosing to prioritize them. A brief review of the findings is included in this article and a report of the full study is available.1
ET R AC TE
have chosen to place responsibility for nursing leadership at the hospital level, while other health systems have created system-wide nursing executive positions. These positions have large spans of control, often covering many hospitals, sometimes in multiple states with tremendous variations in regulatory and practice environments. Such a scale of responsibility requires the health system nursing executive to balance a wide range of responsibilities with ultimate accountability for financial, quality, service, and compliance outcomes. As such, the health system nursing executive is responsible for providing high-quality, service-oriented nursing care; delivering such care with disciplined cost management; leading and developing a group of nursing executives and managers at the facility level; establishing nursing professional development programs; building and maintaining an effective supply of nurses; and advocating for nurses and patients. The corporate environment in which many health system nursing executives operate establishes a new operating environment and, therefore, new behavioral and performance expectations. This article provides insight into the strategies and priorities of large health system nursing executives in balancing their obligations to the health system and the nurses they lead. It also outlines a program of inquiry that has been launched aimed at providing a greater understanding of health system nursing.
BACKGROUND
R
Chief nurse executives of health systems face significant leadership responsibilities, requiring them to balance multiple imperatives and strike a balance in the cost/quality equation. As such, they are required to establish a nursing agenda that delivers value to the corporate entity, member hospitals, hospital-based nursing leaders, practicing nurses, physician colleagues, and, most importantly, patients, and their families. These responsibilities cascade throughout the entire nursing organization as nursing leaders at all levels recognize and balance their own obligations to these various imperatives. Large health system leaders are also cognizant of their responsibilities to the profession at large, hoping to create solutions in their organization that might be transferable to others. As such, many health system nursing leaders are working collaboratively to understand the nuances of nursing’s challenges and to find new, break through solutions. Health system nursing leaders approach these challenges in different ways, influenced by a number of factors, including the organizational structure, environment, goals, and strategies of the health system and their positions within that structure, as well as the professional, political, regulatory, and economic conditions of the markets in which their hospitals operate. This article provides information about how health system chief nursing officers (CNOs) organize their roles and prioritize their activities. It is based on information derived from a descriptive study designed to answer critical ques-
August 2006
STRATEGIC PRIORITIES OF HEALTH SYSTEM CNOs Chief nursing executives face an endless number of challenges requiring them to have a balanced and deep understanding of the health system’s priorities, which are not always explicitly communicated, and detailed knowledge about the markets in which the health system operates. In addition, the health system CNO is required to have firsthand knowledge of nursing and patient care issues in member hospitals. Using this knowledge set as a foundation, CNOs are challenged to draft the nursing agenda, gain executive support, and market the strategies and tactics to relevant stakeholders.
Quality, Patient Safety, and Compliance Health system executives are placing increasing emphasis on enterprise-wide patient safety and quality programs, and they are turning to nursing leaders to drive these programs. Driven in part by the emerging trends toward public reporting and increased scrutiny, health system executives are increasingly positioning quality at the top of their agenda. Chief nursing officers report that they spend most of their time on quality, compliance, and patient safety
Nurse Leader 31
R
ET R AC TE
D
requirements. The communities nursing care team, to achieve financial Nursing organizations are within which the health systems operand quality balance. Complicating this establishing systems to ate are increasingly calling for better picture is the demand to establish performance. HMA recently coneffective workforce planning and optimize nursing ducted a survey of its member health recruitment and retention programs. financial performance systems, and patient safety was the Nurse leaders continue to be chalclear top priority for all members of lenged by the workforce shortage; with business intelligence the executive team. In some health they are attempting to address the capabilities. systems CNOs are key leaders in serious issues created by the shortfall designing the approach of the health in the number of nurses and the comsystem to improving its patient safety culture and outpetence and skills of current and new nurses. comes, including the creation of new nursing quality strucStrong financial performance is considered by most to be a tures. They are focused on implementing programs to core element of their role; without strong financial permeet national patient safety goals and are organizing their formance, the perception of nursing in their organizations is vulnerable. New tools and systems are required to nursing enterprise for successful performance in publicly ensure strong performance. reported nurse-sensitive indicators, and for participation in pay-for-performance programs. CNOs see patient safety and quality as important organizing priorities for their Patient Care Delivery nursing organizations and one which nurses at all levels of Health system integration is often organized around the organization support. They also view it as an indisclinical integration strategies. Health systems focused on putable area of domain responsibility and a rallying point clinical integration are creating clinical programs that leverfor cross-departmental support. age the power of the system’s brand and distribute highquality services across multiple campuses, coordinating access, intervention, recovery, and health maintenance at Financial Performance and Nursing appropriate sites. By virtue of position and authority, Resource Management health system nursing leaders are responsible for establishHealth system nursing leaders are concerned with proing a common standard of nursing practice and patient viding efficient, effective care and are feeling the tension care delivery that supports such programs. inherent in balancing costs with quality. Hospitals are At the same time, CNOs are focused on improving the increasingly expected to do more with less, to provide outworkplace environment to support practice. Delivering standing patient care on an ever tighter budget. The juxtaexcellent care is the gold standard, but it is difficult to position of the rising cost of care and slower growth in achieve in our current hospital environments. Many are public spending on care has further strained the financial now intensely focused on changing the workplace and well-being of health systems. The downstream effect for practice environments to support the delivery of highhospitals is significant. Health systems face the daily reality quality care, driving for solid performance in health system of revenue-related cost pressures and attempt to respond performance and nursing outcome measures. Evidencewith cost management solutions. Margin pressures are top based approaches to practice and the workplace environconcerns for the entire executive suite. ment lead discussions at all levels. Given this challenging financial picture, CNOs noted that they are strengthening financial performance across their systems. Executive teams are sharpening their focus on Leadership Development financial performance, and nursing organizations are designHealth system CNOs are focused on improving leadering methods to improve efficiency by establishing systems to ship competencies and skills among their hospital based optimize nursing financial performance with business intelliCNOs and their frontline managers. Some have outsourced gence capabilities. They are also focused on improving finanleadership development, while others are building incial management performance of nurse leaders at the house capabilities. Either way, health system nursing leadhospital level through skill-building and accountability strucers are concerned about leadership competencies and tures. And, as has been true traditionally, nurse leaders skills. They are also concerned about succession planning, spend a large amount of their time advocating for budgets given the advancing ages of many nurse mangers. A top that balance the cost/quality equation and address complipriority among CNOs is developing leadership capabilities ance, accreditation, and regulatory requirements. among charge nurses and nurse managers, as well as estabOngoing tensions exist between CNOs and those lishing leadership capabilities among nurses who serve as responsible for tightly managing costs. Many are focused team leaders. CNOs expressed concerns that team-based on addressing the complex question of nursing resource models require team leaders with competencies that do management through nursing care model design. CNOs not uniformly exist in the current nursing workforce. They are addressing this deficit in a number of ways, including continuously design new approaches to staffing clinical education and coaching programs in-house and in partnerunits, attempting to find the precise solution for staffing ship with nursing schools. and deploying APNs, RNs, and other members of the
32 Nurse Leader
August 2006
team is recognizing that nursing represents not only the largest expense in the operating budget but an important key to patient safety and community support for the hospital and its parent health system. Further research into the benefits of health system CNO positions is warranted to understand the costs and benefits and value associated with such structures. Another success variable is the degree to which the CNO has real authority to design and lead a nursing agenda. In some cases, health system CNOs are considered to be the ultimate authority for nursing in that organization and are given strong support with accountability for performance. In other cases, CNOs are afforded little authority. A CNO’s team members also influence the success of the role and the individual in that role. Selecting the right team is critical. Intraprofessional and interprofessional collaboration is perceived by these CNOs to be an important success factor. Hospital-based CNOs have their own agendas to pursue, while attempting to serve the health system’s goals. Successful CNOs recognize and address conflicting priorities. CNOs are challenged to lead an agenda with a complex matrix accountability structure. Their ability to influence and build relationships across departments is perceived to be a strong determinant of success. Likewise, building relationships across departments is critical. Further research is needed in this area. Various models define health system nursing organizations; nursing organizations range from centralization to loose affiliations and CNO roles develop accordingly. Various options must exist for health systems as they define the right approach for that particular system. It is important for all members of the executive team, including the CNO, to better understand how these organizational models influence the nursing performance. This information will provide a framework for decision making by health system executives. Other questions remain. With patient safety and quality as the dominant area of focus for this cohort of CNOs, what health system–level quality structure yields the greatest return? How do we manage the myriad of nursing and nursing-related measures without being overwhelmed? How do we engage staff across a health system in our quality agenda? Cost and efficiency are implied in all priorities. What approaches to nursing resource management will yield the greatest performance in balancing the quality/cost/efficiency equation? Designing the right patient care delivery model is an important challenge. There is no clear-cut evidence to drive decisions about which model or model components to pursue. How do we design the optimal patient care model that is high performing and high impact? Professional practice is of great concern to the surveyed CNOs. Questions persist about how best to collaborate with nursing schools to improve workplace readiness of new graduates. Entry level into practice and Continued on page 49
ET R AC TE
Establishing a supportive practice environment is of paramount importance to health system nursing leaders. They approach this challenge by establishing a foundation and structure for practice that meets professional requirements and keeps pace with peers. Chief among their strategies is pursuing evidence-based practice organizations and built-in collaboration with interdisciplinary team members and with extramural partners, including information technology partners, schools, and the like. They are also organizing their efforts around improving practice and professionalism through awarding organizations such as ANCC and the Magnet program. Their sense of readiness for the Magnet journey determines the extent to which this is an immediate or long-term priority. The CNO must address the issue of perceived variability in quality within the system if only one or two hospitals are eligible for this esteemed recognition. Achieving Magnet status requires a corporate culture that unequivocally supports nursing and patient care quality. Such cultures must permeate the entire organization, and CNOs are faced with the task of establishing support for the Magnet process, garnering cross-departmental buy-in, and creating a foundation to advance nursing to a level of excellence.2,3 In organizations that may not be supportive of the Magnet journey, CNOs are adopting other frameworks to guide their work, referencing recommendations and standards recently published by other professional and membership organizations. Those leading health systems with Magnet status are focused on keeping the spirit alive, meeting the increasingly rigorous standards, and acculturating and enfranchising new staff in the Magnet environment.
D
Nursing Practice and Professionalism
CNO ROLE POSITIONING STRATEGY AND SUCCESS FACTORS
R
Building on this early work, a team of health system CNOs, members of HMA, are investigating important issues surrounding the structure and organization of health system nursing and the relative perceived influence on performance. The group aims to understand: • How is nursing organized within the health system? • What variables influenced the design of the nursing structure? • What is the perceived impact of the structure on performance? Health system CNO positions are challenging. CNOs interviewed in this study identified several factors they believe are essential to success in these roles. First, executive sponsorship is critical. This may seem obvious; however, the trend toward a corporate-level CNO is relatively recent. Without authentic executive support by the executive team for the CNO position, the officer and nursing’s strategic agenda are vulnerable. The relative value of health system nursing organizations has been debated, but no systematic study of the role and contribution of a corporatelevel CNO has been undertaken. Increasingly, the executive August 2006
Nurse Leader 33
Toward a Greater Understanding of Health System Nursing Organizations and the Role of the CNO Continued from page 33
ET R AC TE
D
workplace implications of differentiation cause persisting confusion. The workforce shortage has opened, though, new dialogues for CNOs and nursing school deans, leading to innovations. Succession planning for these very complex corporatelevel CNO roles is emerging as an important priority. The CNO role is being defined along with the evolution of the health system and nonnursing executive roles. With the role evolving and highly variable, concrete thought needs to be given to learning experiences, mentoring opportunities, and advanced education to prepare people who are considering directing their career in this effort. This is a serious question that systems and the nursing profession need to consider for the future of these roles. References 1.
2. 3.
Arnold L, Drenkard K, Ela S, Goedken J, Hamilton C, Harris C, et al. Strategic positioning for nursing excellence in health systems. Nurs Admin Q 2006;30:11-20. McClure M. Magnet Hospitals insights and issues. Nurs Admin Q 2005;29:198-201. Goode C, Krugman M, Smith K, et al. The pull of Magnetism: a look at the standards and the experience of a western academic medial center hospital in achieving and sustaining Magnet status. Nurs Admin Q 2005;29:202-13.
Lauren Arnold, PhD, RN, is the CEO of Alliance Healthcare Consulting in Huntingdon Valley, PA. She can be reached at [email protected]. Wilhelmina Manzano, MA, RN, is senior vice president and chief nursing officer of New York-Presbyterian Hospital and Healthcare System in New York, NY. Sherrie L. Jones is president of the Health Management Academy in Alexandria, VA. Gerald E. Bisbee, PhD, is chairman and CEO of the Health Management Academy in Alexandria, VA. Karlene Kerfoot, PhD, RN, is principal of Kerfoot & Associates, Inc, in Indianapolis, Indiana. Nancy E. Holecek, BSN, RN, is senior vice president of Patient Care Services at Saint Barnabas Health Care System in West Orange, NJ.
R
Acknowledgments
The authors wish to acknowledge the chief nursing executives who shared their perspectives and insights. Constance Cronin, Henry Ford Health System; Heidi Crooks, UCLA Medical Center; Karen Drenkard, Inova Health System; Sue Ela, Aurora Health Care; Goedken, Sisters of Mercy Health System; Karen Haller, The Johns Hopkins Hospital; Connie Hamilton, Florida Hospital; Carla Harris, Legacy Health System; Eileen Sampanes, Christus Health; Chris Seitz, Allina Healthcare; Paulette Seymour Route, UMass Memorial Medical Center; Carolyn Webster, Carilion Health; Maureen White, North Shore–Long Island Jewish Health System; and Martha Whitecotton, Carolinas Health System; Ann Campbell, MSN, RN, vice president for nursing, Virtua Health; Marilyn Dubree, MSN, RN, vice president for nursing, Vanderbilt University Medical Center; Mary Ann Fuchs, vice president for nursing, Duke University Health System; Nancy Davis, MN, vice president for nursing, Ochsner Clinic Foundation; Barbara Hertzler, MS, COO, Trinity Health; Diane Talarek, MA, vice president for nursing, Christiana Care Health System; and Joan Wessman, MS, vice president for nursing, Moses Cone Health System. 1541-4612/2006/ $ See front matter Copyright 2006 by Mosby Inc. All rights reserved. doi:10.1016/j.mnl.2006.05.004
August 2006
Nurse Leader 49
D
and the Role of the CNO
R
ET R AC TE
Lauren Arnold, PhD, RN, Wilhelmina Manzano, MA, RN, Sherrie L. Jones, Gerald E. Bisbee, Nancy E. Holecek, BSN, RN, and Karlene Kerfoot, PhD, RN
The formation of the multi hospital health system as a prevalent model for organizing the structure, financing, and delivery of health care has stimulated the development of large-scale nursing management structures. Arguably, the trend toward systematization has driven nursing to become more corporate in nature. This trend has created many opportunities for nursing leaders to adopt business discipline, advancing the profession and its position in the industry. These opportunities also pose tremendous tensions. Chief among them is the quality/cost chasm in which many health system nursing executives find themselves. 30 Nurse Leader
They must bridge the corporate incentives for effectiveness with the realities of patient care delivery. The corporatization of nursing amplifies traditional tensions and introduces new ones. It also creates many opportunities for nursing leadership within each health system and for the profession at large. Many health systems have established large-scale nursing management structures that have dynamically evolved over time. These nursing organizations serve an expanding scope of nursing leadership and management requirements. Health systems have taken various approaches in modeling their nursing organizations. Many health systems August 2006
D
tions about the health system CNOs’ roles and leadership priorities in the areas of quality, patient safety, and compliance; financial performance and nursing resource management; patient care delivery; leadership development; and nursing practice and professionalism. The sample of CNOs consists of members of the Health Management Academy (HMA), which convenes large health system executives as a forum to discuss issues. The CNO Forum meets regularly to discuss issues of shared concern and has leveraged the knowledge embedded in this network of colleagues to learn from each other and enhance their individual performance in their positions as the top nursing executive in their health systems. Believing that the knowledge embedded in the forum is worth sharing, these CNOs established the goal of synthesizing and reporting on that knowledge. Sampled were 35 CNO members of the HMA, 22 of whom responded (63% response rate). Collectively the 22 CNOs lead nursing care in 433 hospitals, covering 106,695 licensed beds, 2,162,153 inpatient admissions, 34,888,568 outpatient visits, and 7,985,252 ER visits. Total net patient revenue represented by health systems in this sample is $53.422 billion. CNOs responding lead nursing in health systems ranging from 2 to 74 hospitals, from 1200 to 16,000 beds. They cover the full spectrum of academic and community-based models and represent single market to national spans. Both not-for-profit and investor-owned health systems are included in this sample. Study findings provide insights into how CNOs are using different strategies to organize nursing responsibilities and choosing to prioritize them. A brief review of the findings is included in this article and a report of the full study is available.1
ET R AC TE
have chosen to place responsibility for nursing leadership at the hospital level, while other health systems have created system-wide nursing executive positions. These positions have large spans of control, often covering many hospitals, sometimes in multiple states with tremendous variations in regulatory and practice environments. Such a scale of responsibility requires the health system nursing executive to balance a wide range of responsibilities with ultimate accountability for financial, quality, service, and compliance outcomes. As such, the health system nursing executive is responsible for providing high-quality, service-oriented nursing care; delivering such care with disciplined cost management; leading and developing a group of nursing executives and managers at the facility level; establishing nursing professional development programs; building and maintaining an effective supply of nurses; and advocating for nurses and patients. The corporate environment in which many health system nursing executives operate establishes a new operating environment and, therefore, new behavioral and performance expectations. This article provides insight into the strategies and priorities of large health system nursing executives in balancing their obligations to the health system and the nurses they lead. It also outlines a program of inquiry that has been launched aimed at providing a greater understanding of health system nursing.
BACKGROUND
R
Chief nurse executives of health systems face significant leadership responsibilities, requiring them to balance multiple imperatives and strike a balance in the cost/quality equation. As such, they are required to establish a nursing agenda that delivers value to the corporate entity, member hospitals, hospital-based nursing leaders, practicing nurses, physician colleagues, and, most importantly, patients, and their families. These responsibilities cascade throughout the entire nursing organization as nursing leaders at all levels recognize and balance their own obligations to these various imperatives. Large health system leaders are also cognizant of their responsibilities to the profession at large, hoping to create solutions in their organization that might be transferable to others. As such, many health system nursing leaders are working collaboratively to understand the nuances of nursing’s challenges and to find new, break through solutions. Health system nursing leaders approach these challenges in different ways, influenced by a number of factors, including the organizational structure, environment, goals, and strategies of the health system and their positions within that structure, as well as the professional, political, regulatory, and economic conditions of the markets in which their hospitals operate. This article provides information about how health system chief nursing officers (CNOs) organize their roles and prioritize their activities. It is based on information derived from a descriptive study designed to answer critical ques-
August 2006
STRATEGIC PRIORITIES OF HEALTH SYSTEM CNOs Chief nursing executives face an endless number of challenges requiring them to have a balanced and deep understanding of the health system’s priorities, which are not always explicitly communicated, and detailed knowledge about the markets in which the health system operates. In addition, the health system CNO is required to have firsthand knowledge of nursing and patient care issues in member hospitals. Using this knowledge set as a foundation, CNOs are challenged to draft the nursing agenda, gain executive support, and market the strategies and tactics to relevant stakeholders.
Quality, Patient Safety, and Compliance Health system executives are placing increasing emphasis on enterprise-wide patient safety and quality programs, and they are turning to nursing leaders to drive these programs. Driven in part by the emerging trends toward public reporting and increased scrutiny, health system executives are increasingly positioning quality at the top of their agenda. Chief nursing officers report that they spend most of their time on quality, compliance, and patient safety
Nurse Leader 31
R
ET R AC TE
D
requirements. The communities nursing care team, to achieve financial Nursing organizations are within which the health systems operand quality balance. Complicating this establishing systems to ate are increasingly calling for better picture is the demand to establish performance. HMA recently coneffective workforce planning and optimize nursing ducted a survey of its member health recruitment and retention programs. financial performance systems, and patient safety was the Nurse leaders continue to be chalclear top priority for all members of lenged by the workforce shortage; with business intelligence the executive team. In some health they are attempting to address the capabilities. systems CNOs are key leaders in serious issues created by the shortfall designing the approach of the health in the number of nurses and the comsystem to improving its patient safety culture and outpetence and skills of current and new nurses. comes, including the creation of new nursing quality strucStrong financial performance is considered by most to be a tures. They are focused on implementing programs to core element of their role; without strong financial permeet national patient safety goals and are organizing their formance, the perception of nursing in their organizations is vulnerable. New tools and systems are required to nursing enterprise for successful performance in publicly ensure strong performance. reported nurse-sensitive indicators, and for participation in pay-for-performance programs. CNOs see patient safety and quality as important organizing priorities for their Patient Care Delivery nursing organizations and one which nurses at all levels of Health system integration is often organized around the organization support. They also view it as an indisclinical integration strategies. Health systems focused on putable area of domain responsibility and a rallying point clinical integration are creating clinical programs that leverfor cross-departmental support. age the power of the system’s brand and distribute highquality services across multiple campuses, coordinating access, intervention, recovery, and health maintenance at Financial Performance and Nursing appropriate sites. By virtue of position and authority, Resource Management health system nursing leaders are responsible for establishHealth system nursing leaders are concerned with proing a common standard of nursing practice and patient viding efficient, effective care and are feeling the tension care delivery that supports such programs. inherent in balancing costs with quality. Hospitals are At the same time, CNOs are focused on improving the increasingly expected to do more with less, to provide outworkplace environment to support practice. Delivering standing patient care on an ever tighter budget. The juxtaexcellent care is the gold standard, but it is difficult to position of the rising cost of care and slower growth in achieve in our current hospital environments. Many are public spending on care has further strained the financial now intensely focused on changing the workplace and well-being of health systems. The downstream effect for practice environments to support the delivery of highhospitals is significant. Health systems face the daily reality quality care, driving for solid performance in health system of revenue-related cost pressures and attempt to respond performance and nursing outcome measures. Evidencewith cost management solutions. Margin pressures are top based approaches to practice and the workplace environconcerns for the entire executive suite. ment lead discussions at all levels. Given this challenging financial picture, CNOs noted that they are strengthening financial performance across their systems. Executive teams are sharpening their focus on Leadership Development financial performance, and nursing organizations are designHealth system CNOs are focused on improving leadering methods to improve efficiency by establishing systems to ship competencies and skills among their hospital based optimize nursing financial performance with business intelliCNOs and their frontline managers. Some have outsourced gence capabilities. They are also focused on improving finanleadership development, while others are building incial management performance of nurse leaders at the house capabilities. Either way, health system nursing leadhospital level through skill-building and accountability strucers are concerned about leadership competencies and tures. And, as has been true traditionally, nurse leaders skills. They are also concerned about succession planning, spend a large amount of their time advocating for budgets given the advancing ages of many nurse mangers. A top that balance the cost/quality equation and address complipriority among CNOs is developing leadership capabilities ance, accreditation, and regulatory requirements. among charge nurses and nurse managers, as well as estabOngoing tensions exist between CNOs and those lishing leadership capabilities among nurses who serve as responsible for tightly managing costs. Many are focused team leaders. CNOs expressed concerns that team-based on addressing the complex question of nursing resource models require team leaders with competencies that do management through nursing care model design. CNOs not uniformly exist in the current nursing workforce. They are addressing this deficit in a number of ways, including continuously design new approaches to staffing clinical education and coaching programs in-house and in partnerunits, attempting to find the precise solution for staffing ship with nursing schools. and deploying APNs, RNs, and other members of the
32 Nurse Leader
August 2006
team is recognizing that nursing represents not only the largest expense in the operating budget but an important key to patient safety and community support for the hospital and its parent health system. Further research into the benefits of health system CNO positions is warranted to understand the costs and benefits and value associated with such structures. Another success variable is the degree to which the CNO has real authority to design and lead a nursing agenda. In some cases, health system CNOs are considered to be the ultimate authority for nursing in that organization and are given strong support with accountability for performance. In other cases, CNOs are afforded little authority. A CNO’s team members also influence the success of the role and the individual in that role. Selecting the right team is critical. Intraprofessional and interprofessional collaboration is perceived by these CNOs to be an important success factor. Hospital-based CNOs have their own agendas to pursue, while attempting to serve the health system’s goals. Successful CNOs recognize and address conflicting priorities. CNOs are challenged to lead an agenda with a complex matrix accountability structure. Their ability to influence and build relationships across departments is perceived to be a strong determinant of success. Likewise, building relationships across departments is critical. Further research is needed in this area. Various models define health system nursing organizations; nursing organizations range from centralization to loose affiliations and CNO roles develop accordingly. Various options must exist for health systems as they define the right approach for that particular system. It is important for all members of the executive team, including the CNO, to better understand how these organizational models influence the nursing performance. This information will provide a framework for decision making by health system executives. Other questions remain. With patient safety and quality as the dominant area of focus for this cohort of CNOs, what health system–level quality structure yields the greatest return? How do we manage the myriad of nursing and nursing-related measures without being overwhelmed? How do we engage staff across a health system in our quality agenda? Cost and efficiency are implied in all priorities. What approaches to nursing resource management will yield the greatest performance in balancing the quality/cost/efficiency equation? Designing the right patient care delivery model is an important challenge. There is no clear-cut evidence to drive decisions about which model or model components to pursue. How do we design the optimal patient care model that is high performing and high impact? Professional practice is of great concern to the surveyed CNOs. Questions persist about how best to collaborate with nursing schools to improve workplace readiness of new graduates. Entry level into practice and Continued on page 49
ET R AC TE
Establishing a supportive practice environment is of paramount importance to health system nursing leaders. They approach this challenge by establishing a foundation and structure for practice that meets professional requirements and keeps pace with peers. Chief among their strategies is pursuing evidence-based practice organizations and built-in collaboration with interdisciplinary team members and with extramural partners, including information technology partners, schools, and the like. They are also organizing their efforts around improving practice and professionalism through awarding organizations such as ANCC and the Magnet program. Their sense of readiness for the Magnet journey determines the extent to which this is an immediate or long-term priority. The CNO must address the issue of perceived variability in quality within the system if only one or two hospitals are eligible for this esteemed recognition. Achieving Magnet status requires a corporate culture that unequivocally supports nursing and patient care quality. Such cultures must permeate the entire organization, and CNOs are faced with the task of establishing support for the Magnet process, garnering cross-departmental buy-in, and creating a foundation to advance nursing to a level of excellence.2,3 In organizations that may not be supportive of the Magnet journey, CNOs are adopting other frameworks to guide their work, referencing recommendations and standards recently published by other professional and membership organizations. Those leading health systems with Magnet status are focused on keeping the spirit alive, meeting the increasingly rigorous standards, and acculturating and enfranchising new staff in the Magnet environment.
D
Nursing Practice and Professionalism
CNO ROLE POSITIONING STRATEGY AND SUCCESS FACTORS
R
Building on this early work, a team of health system CNOs, members of HMA, are investigating important issues surrounding the structure and organization of health system nursing and the relative perceived influence on performance. The group aims to understand: • How is nursing organized within the health system? • What variables influenced the design of the nursing structure? • What is the perceived impact of the structure on performance? Health system CNO positions are challenging. CNOs interviewed in this study identified several factors they believe are essential to success in these roles. First, executive sponsorship is critical. This may seem obvious; however, the trend toward a corporate-level CNO is relatively recent. Without authentic executive support by the executive team for the CNO position, the officer and nursing’s strategic agenda are vulnerable. The relative value of health system nursing organizations has been debated, but no systematic study of the role and contribution of a corporatelevel CNO has been undertaken. Increasingly, the executive August 2006
Nurse Leader 33
Toward a Greater Understanding of Health System Nursing Organizations and the Role of the CNO Continued from page 33
ET R AC TE
D
workplace implications of differentiation cause persisting confusion. The workforce shortage has opened, though, new dialogues for CNOs and nursing school deans, leading to innovations. Succession planning for these very complex corporatelevel CNO roles is emerging as an important priority. The CNO role is being defined along with the evolution of the health system and nonnursing executive roles. With the role evolving and highly variable, concrete thought needs to be given to learning experiences, mentoring opportunities, and advanced education to prepare people who are considering directing their career in this effort. This is a serious question that systems and the nursing profession need to consider for the future of these roles. References 1.
2. 3.
Arnold L, Drenkard K, Ela S, Goedken J, Hamilton C, Harris C, et al. Strategic positioning for nursing excellence in health systems. Nurs Admin Q 2006;30:11-20. McClure M. Magnet Hospitals insights and issues. Nurs Admin Q 2005;29:198-201. Goode C, Krugman M, Smith K, et al. The pull of Magnetism: a look at the standards and the experience of a western academic medial center hospital in achieving and sustaining Magnet status. Nurs Admin Q 2005;29:202-13.
Lauren Arnold, PhD, RN, is the CEO of Alliance Healthcare Consulting in Huntingdon Valley, PA. She can be reached at [email protected]. Wilhelmina Manzano, MA, RN, is senior vice president and chief nursing officer of New York-Presbyterian Hospital and Healthcare System in New York, NY. Sherrie L. Jones is president of the Health Management Academy in Alexandria, VA. Gerald E. Bisbee, PhD, is chairman and CEO of the Health Management Academy in Alexandria, VA. Karlene Kerfoot, PhD, RN, is principal of Kerfoot & Associates, Inc, in Indianapolis, Indiana. Nancy E. Holecek, BSN, RN, is senior vice president of Patient Care Services at Saint Barnabas Health Care System in West Orange, NJ.
R
Acknowledgments
The authors wish to acknowledge the chief nursing executives who shared their perspectives and insights. Constance Cronin, Henry Ford Health System; Heidi Crooks, UCLA Medical Center; Karen Drenkard, Inova Health System; Sue Ela, Aurora Health Care; Goedken, Sisters of Mercy Health System; Karen Haller, The Johns Hopkins Hospital; Connie Hamilton, Florida Hospital; Carla Harris, Legacy Health System; Eileen Sampanes, Christus Health; Chris Seitz, Allina Healthcare; Paulette Seymour Route, UMass Memorial Medical Center; Carolyn Webster, Carilion Health; Maureen White, North Shore–Long Island Jewish Health System; and Martha Whitecotton, Carolinas Health System; Ann Campbell, MSN, RN, vice president for nursing, Virtua Health; Marilyn Dubree, MSN, RN, vice president for nursing, Vanderbilt University Medical Center; Mary Ann Fuchs, vice president for nursing, Duke University Health System; Nancy Davis, MN, vice president for nursing, Ochsner Clinic Foundation; Barbara Hertzler, MS, COO, Trinity Health; Diane Talarek, MA, vice president for nursing, Christiana Care Health System; and Joan Wessman, MS, vice president for nursing, Moses Cone Health System. 1541-4612/2006/ $ See front matter Copyright 2006 by Mosby Inc. All rights reserved. doi:10.1016/j.mnl.2006.05.004
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