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Transforming Oncology Care: Developing a Strategy and Measuring Success
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Seminars in Oncology Nursing, Vol 32, No 2 (May), 2016: pp 110-121
TRANSFORMING ONCOLOGY CARE: DEVELOPING A STRATEGY AND MEASURING SUCCESS PATRICIA REID PONTE, DONNA BERRY, LORI BUSWELL, ANNE GROSS, CAROLYN HAYES, JUDY KOSTKA, MARY POYNER-REED, AND COLLEEN WEST OBJECTIVES: To examine accountability and performance measurement in health care and present a case study that illustrates the link between goal setting and measurement and how a strategic plan can provide a framework for metric selection.
DATA SOURCES: National reports, literature review and institutional experience. CONCLUSION: Nurse leaders and clinicians in oncology settings are challenged to anticipate future trends in oncology care and create a culture, infrastructure, and practice environment that supports innovation, advancement of oncology nursing practice and excellence in patient- and family-centered care. Performance metrics assessing key processes and outcomes of care are essential to meet this challenge.
IMPLICATIONS FOR NURSING PRACTICE: With an increasing number of national organizations offering their version of key quality standards and metrics, it is critical for nurses to have a formal process in place to determine and implement the measures most useful in guiding change for a particular clinical setting.
Patricia Reid Ponte, RN, DNSc, FAAN, NEA-BC: Chief Nursing Officer, Senior Vice President, Patient Care Services, Dana-Farber Cancer Institute, Boston, MA; and Executive Director, Oncology Nursing & Clinical Services, Brigham and Women’s Hospital, Boston, MA. Colleen West, RN, BSN, MBA, CPHQ: Director, Clinical and Professional Development, Dana-Farber Cancer Institute, Boston, MA. Anne Gross, PhD, RN, FAAN: Vice President, Adult Ambulatory Oncology Nursing and, Clinical Services, Dana-Farber Cancer Institute, Boston, MA. Judy Kostka, RN, MS, MBA, OCN®: Senior Director, Nursing and Clinical Services, Satellites and Network Affiliates, Dana-Farber Cancer Institute, Boston, MA. Lori Buswell, MSN, ANP, OCN®: Vice President, Epic System, Operations and Global Cancer Medicine, DanaFarber Cancer Institute, Boston, MA. Carolyn Hayes, PhD, RN, NEA-BC: Associate Chief Nurse, Adult Inpatient
Oncology, Medicine and Integrative Nursing, DanaFarber Cancer Institute, Boston, MA; and Brigham and Women’s Hospital, Boston, MA. Mary PoynerReed, PhD, CNRN, ANP, NEA-BC: Vice President, Associate Chief Nurse, Medicine Patient Services, Boston Children’s Hospital and Pediatric Oncology Patient Services, Dana-Farber Cancer Institute, Boston, MA. Donna Berry, PhD, RN, AOCN®, FAAN: Director, Phyllis F. Cantor Center, Dana-Farber Cancer Institute, Boston, MA; and Associate Professor, Harvard Medical School, Boston, MA. Address correspondence to Pat Reid Ponte, RN, DNSc, FAAN, NEA-BC, Brookline Ave (D1632), Boston, MA 02215. e-mail: [email protected] © 2016 Elsevier Inc. All rights reserved. 0749-2081 http://dx.doi.org/10.1016/j.soncn.2016.02.005
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KEY WORDS: oncology, nursing, leadership, strategic planning, quality measures, performance.
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eaders of every industry are often asked to predict what the future holds, and to speculate on which factors will drive growth, how organizations can develop new knowledge while responding to change, and how they should leverage access to “Big Data” and define and measure success. Such questions are increasingly debated in health care. With the ongoing shift from fee-for-service reimbursement to value-based care, healthcare organizations are pressed to achieve the triple aim of simultaneously improving population health, reducing costs per capita, and improving the patient experience of care,1 and the more recently defined quadruple aim, which expands the triple aim to include improving the work life of health care providers.2 The challenges posed by the quadruple aim are especially acute in oncology care, where the pressure to rein in costs is complicated by the aging patient population and growing demand for services, and by research advances that are yielding promising, individualized but costly treatment options.3 Ongoing efforts to achieve the quadruple aim are greatly aided by advances in measurement science and the ability of organizations to harness technology and capture clinical and administrative data reflecting the process and outcomes of care. However, when seeking to implement change and improve care, measurement alone is not enough. As noted by Berwick and colleagues4 (p. I-31) “Clear purpose, focused goals, and valid and reliable performance metrics set the stage for the use of measurement to pursue changes that are improvements.” This article examines the role of measurement in oncology nurses’ efforts to implement care improvements and ensure excellence in oncology nursing practice today and in the future. An overview of accountability and performance measurement in health care is presented, as well as a case study that features the strategic planning process implemented by the Department of Nursing at Dana-Farber Cancer Institute (DFCI; Boston, MA). The case study illustrates how carefully selected performance metrics are essential tools that can help nurse leaders and clinicians guide change and assure the success of improvement efforts.
PERFORMANCE MEASUREMENT IN HEALTHCARE Measuring the quality of health care and using those measurements to improve care have been a major focus of health services researchers, clinicians, educators, and policy makers for the past two decades.5-7 Previously, efforts to evaluate health care quality generally followed a quality assurance model and were guided by Donabedian’s conceptualization of quality, which identified the contributions of structure, process, and outcome elements.8-10 In relation to clinical quality, structure refers to human and material resources and other aspects of infrastructure that influence an organization’s or clinician’s capacity to provide care. Process refers to activities through which an organization or clinician provides care and services to patients; and outcomes refer to the health of patients impacted by or resulting from health care.11 In the early 1990s, few hospitals routinely collected and monitored quality measures. Similarly, at the national level there was no ability to systematically evaluate the quality of the health care system and little to no consensus about the types of measures on which data should be gathered.6,12 Appreciation for the importance of quality measurement and monitoring among hospitals and clinicians grew with the publication of landmark reports by the Institute of Medicine13,14 that highlighted the prevalence of errors in healthcare and the need to define, and measure adherence to, performance standards. Recognition of measurement’s importance was also fueled by the adoption by many healthcare organizations of the performance improvement model, which links measurement to the process of improvement and attaining clearly defined goals.4 In response to the growing demand for greater accountability, a presidential advisory commission recommended the creation of the National Forum for Health Care Quality Measurement and Reporting (now called the National Quality Forum or NQF).12 NQF was charged with aiding efforts to improve health care quality by standardizing the means by which health care quality is measured and reported. Since its inception, NQF has used a consensus development process to identify and endorse more than 600 evidence-based quality measures.15 Today, NQF-endorsed measures are
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considered the “goal standard” for health care measurement and are widely used in payment and public reporting programs. In the past two decades, public reporting of quality measures by hospitals and other health care organizations has become routine. A limited set of quality reporting requirements was first implemented by the Joint Commission in the late 1990s through its ORYX initiative.6 Reporting requirements quickly expanded, and today hospitals must provide data to the Joint Commission on a minimum of six measure sets based on the services they provide and the populations served.16 Many of the measures are also publicly reported to Centers for Medicare and Medicaid Services (CMS), which shares hospital-level data with the public through the CMS website.17 Within oncology, the American Society of Clinical Oncology’s Quality Oncology Practice Initiative (QOPI) has identified a set of measures specific to oncology care and developed a voluntary process through which oncology practices can monitor their performance and compare it with that of other practices.18 Research indicates that participation in QOPI over time is correlated with improvement in measured performance.19 Measurement in Nursing Nurses have long been in the forefront of using data to improve the quality and safety of health care delivery across the continuum, beginning with Florence Nightingale who used statistical methods to correlate patient outcomes to environmental conditions.20 More recently, nurses have sought to identify nursing-sensitive measures and use them to evaluate nurses’ contributions to health care quality. This work began in the 1990s when the American Nurses Association funded pilot studies that examined linkages between nurse staffing and quality of care.10 The studies led to the identification of an initial set of nurse-sensitive quality indicators that formed the basis of the National Database of Nursing Quality Indicators (NDNQI). Today, the NDNQI program tracks up to 19 nursesensitive quality measures, including many measures that are endorsed by NQF.10,21 The NDNQI measures include patient-centered outcome measures (eg, failure to rescue, pressure ulcer prevalence, patient falls); nursing-centered intervention measures (eg, smoking cessation counseling for patients diagnosed with an acute MI), and system-centered measures (eg, skill mix, nursing care hours per patient day).22 More than 2,000
hospitals participate in the NDNQI program and use the database to monitor their performance and compare it with that of other institutions.23 Nursing quality efforts have also focused on educating nurses about essential quality and safety practices. In a prominent example, the Quality and Safety Education for Nurses (QSEN) initiative identified six core quality and safety competencies for nurses in 2007.24 The competencies include quality improvement and the ability to use data to monitor, evaluate, and improve care processes and outcomes. Since their release, the QSEN competencies have become part of national nursing education curricula standards.5 Using Data to Drive Improvement With an increasing number of national organizations offering their version of key quality standards and metrics, nurse leaders and clinicians are challenged to clarify which issues and questions are of greatest importance to them and what measures will be most useful in guiding improvement and assessing performance. The challenge is compounded by the emergence of Big Data, or the availability in real time of large quantities of data from multiple sources. While Big Data offers leaders an unprecedented opportunity to develop actionable predictive models,25 tapping its potential requires having a clear sense of priorities and formulating meaningful questions that can be answered with the data at hand. As suggested by Berwick and colleagues,4 determining what is important to an organization and specifying goals and a plan to accomplish them are important precursors to the measurement process. The strategic planning process, in particular, offers organizational and nursing leaders a unique opportunity to assess an organization’s or department’s strengths, identify gaps and opportunities for improvement, and develop a plan to address the gaps and weaknesses.26 Attaching metrics to goals and specific initiatives allows nurse leaders and clinicians to monitor progress and determine when a different approach might be needed. Several examples illustrate how strategic planning and metric selection go hand-in-hand. One example is from Shoemaker and Fischer27 who described how their organization used its balanced scorecard to guide strategic planning, facilitate alignment of strategically important activities across departments and the continuum of care, and monitor progress on key initiatives at the organizational, division, and department level. In another example,
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the University of Illinois at Urbana-Champaign28 linked its strategic goals to specific initiatives and metrics. For example, for the goal, “Make a significant and visible societal impact,” the university identified six initiatives and eight metrics, including a count of faculty that attain national academies membership, the percent of sponsored research expenditures from foundations and corporations, media “hits” or stories in which the university is featured, and results from an alumni feedback survey. A third example specific to oncology nursing is provided in the following section. The example describes a multi-step strategic planning process through which the nursing leadership team at DFCI defined goals and priorities for the future, identified processes to achieve those goals, and specified metrics that they use to monitor the progress of implementation and measure success. The case study illustrates the vital role of metrics in strategic planning and improvement.
LINKING PLANNING AND MEASUREMENT: A CASE STUDY DFCI provides cancer care and treatment to children and adults while maintaining an expansive program of cancer research and training the next generation of oncology care providers and clinicians. DFCI is located in Boston, MA, and is a teaching affiliate of Harvard Medical School and a preferred training site for nursing and nurse practitioner students from several universities. In 1999, DFCI joined with Harvard Medical School, the Harvard School of Public Health, and four other Harvard-affiliated teaching hospitals to form the Dana-Farber/Harvard Cancer Center, which was designated a comprehensive cancer center by the National Cancer Institute and coordinates cancer research efforts across the participating organizations. Relationships with other health care organizations allow DFCI to offer a full complement of cancer services to patients throughout New England. Through collaborations with nearby Brigham and Women’s Hospital and Boston Children’s Hospital, DFCI provides adult and pediatric inpatient and ambulatory care and a full array of diagnostic and specialty services. DFCI also has partnered with community hospitals and physician practices to establish satellite practices that offer patients and families in outlying areas easier access to DFCI providers and cancer services and
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clinical trials. DFCI was first recognized as a Magnet organization29 by the American Nurses Credentialing Center in 2005, and has maintained Magnet designation ever since. Work to expand DFCI’s Magnet status to include recently acquired satellite and physician practices in the next Magnet redesignation process (scheduled for 2018) is currently underway. Factors that Led to the Strategic Planning Process DFCI board members have long been active in the Institute’s quality and safety programs, a practice that is supported by research linking board involvement to better quality performance by managers.30 As a result, board discernment and input is frequently sought by Institute leaders. The board’s discernment was apparent following a presentation about the organization’s clinical pathways program, when one board member posed a question asking how DFCI leaders assure that quality patient care and the patient care experience beyond the clinical pathway (which focuses on the diagnostic and treatment plan) is standardized and continually monitored and improved across all sites of care. Improving the quality of care and the patient experience is a central focus of the Department of Nursing’s ongoing planning efforts. However, the board member’s question, coupled with the challenge of incorporating the satellite programs and physician practices into the Institute’s Magnet designation, prompted senior nursing leaders to recognize they needed to more fully evaluate how the Department of Nursing would ensure nursing excellence, quality and safety in patient care, and a means for measuring and monitoring critical structures, processes, and outcomes across the continuum in the years to come. The need for a full evaluation was further strengthened by the ongoing implementation of health information technology that promised interoperability and ready access to data. The nursing leaders realized that leveraging the vast amount of data that would soon be available to them required clarifying goals for the Department of Nursing and oncology nursing practice. Given the scope and importance of these multiple challenges, the leaders decided to embark on a comprehensive strategic planning process to establish the direction for the Department of Nursing for the next 4 years and a means for measuring success. The strategic planning process involved a series of steps that took place over several months. The
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process was led by the chief nurse with the participation of each member of the Nurse Executive Committee (NEC), and was assisted by an outside consultant with expertise in health care and strategic planning. NEC is the executive governing committee for the Department of Nursing and is composed of nursing vice presidents and senior nurse leaders responsible for clinical nursing operations, nursing practice, professional development, and research. The committee is united by the nursing department’s vision and values, which underscore nursing’s commitments to patients and families and the importance of collaboration and partnership. Because so much of oncology nursing practice is steeped in interdisciplinary and interdepartmental relationships and collaborations, the nurse leaders knew that successful strategic planning would require examining nursing practice at
DFCI through the context of organizational goals and priorities as well as a professional nursing lens. Step One: Defining “Must-Have” Elements. As a basis for the strategic planning process, the nurse leaders first spent time specifying structure, process, and outcome elements that were already in place at DFCI and that the nurse leaders recognize as essential for assuring excellence, quality, and safety in patient care and clinical trial delivery in any location. As noted in the schematic presented in Figure 1, key structural elements include a nursing leadership and governance structure that engages nurses at every level in decision making, and structures that support and ensure competency, performance management, professional development, workforce diversity, and professional affiliations. Key process elements include practices
Dana-Farber Cancer Ins tute Oncology Nursing Organiza Structure (People)
Process
Outcomes
Characteristics of an organization including leadership, availability of resources , the professio nal practice mode l, roles, respo nsibilities and performance management.
Standardize procedures to compl y with regulatory measurements and ensure consistency across the continuum of care including activities and resources that support innovation and knowled ge development.
Quantitative and qualitative evidencerelated to imp act of structure & process on patients, families, the workforce and the organization.
Roles & responsibil s: managers , clinicians , researchers, staff, execs. ons management Governance structure – p /unit, nursing council, nursing department, p on hospital-based p Affil ons: academic, community, industry Competency: licensure, c on, privileges, edu onal prepa on, orienta on, professional development Performance management and peer review Preceptorship/residency/mentorship Assuring a diverse workforce Succession planning, career planning
Policies and procedures Pathways, treatment plans and evidencebased standards of care Regu ons/audits Clinical trial compliance model/theory Professional p guided p /integra e nursing/Synergy Model Primary nursing/ onship-based care/p - and family-centered edu on/informa on P Care coordin on/pa nt navig on Con nuous quality improvement Nurse scien led research teams Interdisciplinary team training Mindfulness-based nursing p
Technology Epic Electronic Medical Record – adop on, training, support and op miza on. Reports to advance innov on and knowledge g on Employee safety technology – li , needle safety P safety technology – IV pumps, monitors, -centered technology – remote self-care & symptom P Management & decision making, medi on adherence tools, p gateway, psychosocial screening
P on reported outcomes P Symptom management Oral chemotherapy adherence Central line infec on Extravasa ons rates Falls with injury Medi on error rate on Nurse & clinic assistant Nurse cer fi on rates BSN prepa on rate Vacancy/turnover rates Employee injury Safety culture – teamwork Financial – budget development, monitoring, variance repo ng
External Benchmarks QOPI Magnet Joint Commission DPH/CMS BORN NACQ IV Nursing Society Standards
FIGURE 1. DFCI Oncology Nursing Services: organizational framework.
NICHE ANA CEU Provider OSHA ONS/ASCO Guidelines NCCN Guidelines ELNEC Guidelines
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that ensure safety and consistency across the continuum of care; a professional practice model and care delivery practices that support professional nursing practice and holistic, patient- and familycentered care; and programs that promote innovation and nursing knowledge development. Nursing impact and effectiveness are assessed through outcome metrics measuring clinical quality and safety, workforce strength, and the patient and family experience of care. Underpinning all of these elements are technologies that facilitate safe and effective care delivery, and external benchmarks and standards that allow nurse leaders and clinicians to compare the nursing department’s performance with other institutions and identify best practices. The elements listed in the structure, process, and outcomes domains reflect clinical, workforce, and organizational elements that form the basis of the American Nurses Credentialing Center Magnet Model31 and are consistent with evidenced-based approaches to measuring and delivering quality care. Collectively, the elements reflected the Department
FIGURE 2. Proposed priorities for nursing.
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of Nursing’s baseline state, as well as a foundation upon which nurse leaders and clinicians would build when implementing changes and innovations needed to meet future challenges.
Step Two: Identifying Priority Areas. To launch the next phase of the strategic planning process, the chief nurse drafted a list of priorities to be vetted with NEC and other nursing and organizational leaders (Fig. 2). The priorities were familiar to NEC members as they represented issues and projects that NEC had discussed or worked on for months, or in some cases years, and that the group had put on hold while it helped implement the new health information technology and other initiatives. The list also was informed by organizational goals as well as best practices related to the nursing work environment and oncology nursing practice reported in the literature. In identifying the priorities, the chief nurse focused on important, large-scale issues or “big rocks” rather than day-to-day or operational
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concerns and assigned each priority to one of the following categories: •
•
•
Foundational: Priorities assigned to this category related to new systems, structures, and supports that were needed to achieve the department and organizational vision. The priorities addressed the following four areas: quality, safety and care; financial and operational; technology; and accreditation. Differentiator: Priorities assigned to this category included new programs and changes that would further highlight areas of innovation and leadership that are beyond the traditional functions of a department of nursing. The priorities addressed the following four areas: growth, patient engagement, innovation, and research. Levers: Priorities assigned to this category related to structures and processes that would enhance the effectiveness of Foundational and Differentiator elements. The priorities addressed the following six areas: work environment, interdisciplinary/ interdepartmental relationships, governance, structure & roles, talent, and learning and development.
The chief nurse shared the draft priorities with NEC and asked the group to identify any additions, deletions, or edits. The chief nurse also shared the draft list with the broader nursing leadership team that includes nurse directors and clinical specialists, and with the Nursing Council. The Nursing Council is the central component of the Department of Nursing’s shared governance structure and is primarily composed of direct care nurses representing each role group and practice setting. Both of the groups readily endorsed the draft list and highlighted priorities that were of special importance to them, including priorities that offered opportunities for addressing ethical aspects of patient care and research, and priorities that focused on strengthening governance and communication structures. Having gained agreement on a draft list of priorities, NEC was ready to move on to the next step, that of ranking the priorities. The group realized this was a greater and arguably more important challenge because it would determine which priorities would in fact be implemented and how department resources would be allocated. Step Three: Ranking Nursing Priorities and Creating a Strategic Action Plan. The nurse leaders agreed the ranking process merited an indepth discussion through which they could consider
internal and external factors that should inform their thinking and the importance of each priority to nursing and the organization. To allow sufficient time for discussion, the group planned an off-site, 1.5-day retreat. The chief nurse proposed to facilitate the retreat with the assistance of the external consultant and developed an agenda to achieve the following objectives: 1. Identify and review key external advances in oncology nursing care and how they will impact nursing practice at DFCI. 2. Review the current state of DFCI nursing care, including successes and opportunities for improvement. 3. Create a forward-looking strategic action plan, with structure, process and outcome measures that would serve as guideposts for continuous improvement. As background for the retreat, the chief nurse asked the members of NEC and administrative and physician leaders who participated in the earlier interview process to complete an online survey in which they described their vision for DFCI nursing; identified external advances in oncology that should inform the strategic planning process; ranked the areas specified in the strategic plan in order of importance; and described gaps to converting the strategy into action. The agenda for the first day included presentations and activities that provided a context for identifying top priorities for nursing, including a discussion of the online survey results. Survey comments regarding the vision for the Department of Nursing were of particular interest to the group. The comments yielded an expanded vision for nursing (Fig. 3) that emphasized the department’s leadership role in multiple areas, from advancing DFCI’s contribution to the healing and health of patients and communities, to achieving “systemness” across all DFCI locations and accomplishing the quadruple aim. (Systemness is a multifaceted concept that focuses health care systems to operate with a high degree of coordination, integration, and productivity across the health enterprise, to provide the best possible patient care, experience, and outcomes while carefully considering the cost of care.32,33) Physician and administrative respondents to the survey also encouraged nursing to consider expanding nurse leader role descriptions to include an expectation for participating in direct patient care, similar to the physician leadership model. In discussing advances in cancer treatment, the survey respondents
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FIGURE 3. Expanded Dana Farber Cancer Institute nursing vision.
highlighted progress and the need for innovative approaches in care delivery related to oral chemotherapy, immunotherapy, cell therapies, symptom science, and personalized medicine and genetic profiling. Survey respondents noted that all of these advances have implications for the nursing role, interdisciplinary collaboration, and care coordination across settings and should inform the strategic plan. The presentations and survey data served as a backdrop to the next task, which involved identifying top priorities for action. This was accomplished through a multi-voting exercise, in which each NEC member was asked to consider the Foundational, Differentiator, and Lever priorities and identify the top six priorities in each category. Through this process the group narrowed the list of nursing priorities to 13 areas. The second day of the retreat was dedicated to developing an overall plan and timeline for addressing the priority areas. The plan was developed through an intensive work session that focused on defining goals for each priority area and translating the goals into specific initiatives with identified owners, timelines, milestones and deliverables. The group also identified an initial set of metrics for each initiative (see examples, Table 1). By design, the work plan developed for the initiatives was highlevel, as NEC expected the designated owner of each
priority area to convene a work team to develop and implement a more detailed project plan, including additional project-specific metrics if needed. In conjunction with the metrics specified in Figure 1, the new metrics would allow nurse leaders and clinicians to evaluate the overall quality of nursing practice, assess the effectiveness of the strategic initiatives, and guide ongoing improvement efforts. Over the next weeks, the senior nurse leaders refined the list of nursing priorities to indicate how they related to organizational priorities, and to reflect the interdisciplinary nature of clinically focused initiatives (see Fig. 4). The chief nurse then shared the list with the nursing leadership team, Nursing Council, interdepartmental leaders, and the Patient and Family Advisory Council. In doing so, she obtained further input on the priorities and also ensured that leaders throughout the organization had a shared understanding of the Nursing Department’s direction for the next 4 years.
DISCUSSION AND LESSONS LEARNED The past two decades have been marked by noteworthy advances in measurement science and the development of valid and robust measures of healthcare quality. Data capture and reporting
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TABLE 1. Sample Objectives and Metrics Initiative New Care Modalities
Nursing Talent
Implementation Objectives Cellular Therapies 1. Design and implement ambulatory/inpatient nursing checklist to assure all steps in the process of implementing new trials (new care modalities) are taken prior to activation. 2. Educate RNs on each trial prior to activation and at the time of amendments as needed. 3. Develop an approach to assure adequate resources for each trial. Oral Chemotherapy 1. Assure all patients on oral agents receive adequate medication teaching. Implement a diverse talent pipeline and a leadership model that includes a patient care component with clear leadership structures and accountability.
Metrics Outcome measures: Cellular Therapies ■ Percent of nursing staff who completed protocol inservice prior to caring for patient, measured through Healthstream or unit-based log documentation (target: 100%) Oral Chemotherapy ■ Percent of oral chemotherapy patients who receive RN teaching call
Outcome measures: Percent of DFCI RN workforce composed of racially diverse RNs ■ Percent RN certification rate ■ Number of career advancement transitions completed by DFCI RNs/NPs and nurse leaders ■ Percent of RNs (at all sites) with BSN ■
FIGURE 4. Nursing priorities and their relationship to organizational priorities and initiatives.
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systems used by healthcare organizations have also improved, giving healthcare leaders and clinicians access to a constant flow of data from numerous sources. As a result, leaders and clinicians seeking to improve the quality of care face a new kind of challenge, that of determining which of the numerous data elements and metrics they are able to track will be most useful in assessing organizational and department performance and improvement efforts. The strategic planning process implemented by DFCI nurse leaders offers a model for basing metric selection on clearly defined goals. As Berwick and colleagues note,4 this type of approach is critical in “set[ting] the stage” for using measurement to guide improvements. DFCI nurse leaders believe the strategic plan they developed has positioned the Department of Nursing to meet future patient and family needs and advance the science and practice of oncology nursing. However, in many ways the benefits obtained from the strategic planning process exceed the final product. For example, by obtaining input from internal experts and external sources, nurse leaders gained a heightened awareness of ongoing changes in cancer treatment, health care policy, and care delivery that will inform numerous aspects of their practice in the years to come. Additionally, by engaging physician and administrative leaders in the initial planning stages, and obtaining their input on the final list of nursing priorities, the nurse leaders prompted a dialogue through which organizational leaders recognized the need for more communication and interdisciplinary collaboration on clinical issues at the executive level. Such collaboration is of growing importance, given the size and complexity of the organization’s adult ambulatory and inpatient practices and the need to better integrate services across sites and disciplines. Steps to ensure interdisciplinary collaboration among executives are currently underway and are embedded within the enterprise-wide “systemness initiative.” One of the key advantages of a strategic plan is its usefulness as a leadership performance measure. As noted in Figure 1, the Department of Nursing at DFCI already had in place a robust set of nursing metrics going into the strategic planning process. However, with the exception of measures evaluating workforce strength and work environment, most of the metrics assess some aspect of clinical nursing practice and thus are an indirect reflection of nurse leader practice. With its timeline and specified process and outcome measures, the strategic plan
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allows DFCI nurse leaders to better gauge their productiveness and efficiency. The approach to strategic planning used by DFCI nursing leaders offers a number of lessons related to visioning, planning, and measurement that may be useful to other leadership teams considering their own strategic planning process. The lessons include: •
•
•
Reach out to stakeholders and content experts: By definition, strategic plans must reflect changes and trends in the health care environment as well as internal goals and concerns. Although the senior nurse leaders at DFCI were aware of many of the changes impacting health care and oncology, they found that speaking with internal and external experts, and supplementing conversations with a review of the literature, yielded critical context for the strategic planning effort. Similarly, by obtaining input on strategic priorities from a broad range of internal stakeholders – including nurses in directcare and formal leadership roles, interdisciplinary colleagues, and members of the DFCI executive leadership team – the leaders ensured that the nursing strategic plan was aligned with organizational goals and garnered critical support for strategic nursing initiatives. Expect (and seek) the unexpected: Going into the strategic planning process, the senior nurse leaders believed they had a firm grasp on the top priorities for nursing. While this was largely true, they found they obtained new and crucial insights through the interviews with nurse and interdisciplinary leaders, the leadership survey, and the off-site work session. For example, the nurse leaders had not anticipated the interest, expressed by physician survey respondents, for adding a clinical practice component to the nursing leadership model, a change they are currently exploring in internal dialogues with nurse directors. Information obtained through the survey also helped them more fully appreciate the implications of emerging care modalities and the importance of enhancing the department’s capacity to quickly ramp up and respond to treatment advances with appropriate practice changes and nursing resources. Building such capacity was ultimately identified as a top priority. Consensus is good, endorsement is critical: Given the range of perspectives represented within nursing leadership teams, there will inevitably be some disagreement about priorities
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•
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and priority rankings among team members. The DFCI nurse leaders found that respectful disagreement was a good thing because it forced them to evaluate different points of view and a broader range of issues than they might have otherwise considered. Rather than striving for consensus, they sought to obtain the endorsement of the entire leadership team, and to have each team member demonstrate a commitment to ensuring the successful implementation of each priority. Multi-voting can be effective in obtaining such endorsement because it gives each person an equal voice and opportunity to weigh in on the priorities,34 and assures the final list reflects the full range of perspectives. Moving from ideas to action: While defining priorities is an important step in any strategic planning process, translating the priorities into actionable initiatives with identified owners and initiative-specific metrics is essential for ensuring the strategic plan moves off the page and drives action and continuous improvement. At DFCI, engaging all of NEC in the translation process was beneficial as it ensured a more informed consideration of time requirements, facilitated the identification of competing initiatives and synergies, and promoted a sense of shared responsibility for the overall plan. External support: A good strategic planning consultant brings skills, tools, and knowledge that can streamline the strategic planning process and provides a perspective informed by region-
al and national trends. Nurse leaders at DFCI found that the external consultant also offered a level of objectivity that was especially useful in keeping the group on track and open to new ideas. A skilled strategic planning consultant can thus benefit most any group, including leadership teams that have a great deal of strategic planning experience.
CONCLUSION In light of the accelerating pace of change in health care and oncology practice, it is imperative that oncology nurse leaders take time to assess the environment, establish priorities for the future, and develop a plan to achieve them. A well-crafted strategic plan inclusive of a clear and compelling vision and backed by carefully selected metrics can serve as an important blueprint for action. By identifying priority initiatives, timelines, and performance measures, the plan provides guidance for decision making, helps nurse leaders stay on track toward achieving desired goals, and provides them with an overall metric for evaluating their performance as a leadership team. Even more important, it helps ensure that nurse leaders continue to fulfill their mandate to guide and advance the art and science of nursing practice and to work with nurse clinicians in defining patient- and family-centered care environments for the future.
REFERENCES 1. Berwick DM, Nolan TW, Whittington J. The triple aim: care, health and cost. Health Aff 2008;27:759-769. 2. Sikka R, Morath JM, Leape L. The Quadruple Aim: care, health, cost and meaning in work. BMJ Qual Saf 2015;24:608610. 3. American Society of Clinical Oncology. The state of cancer care in America, 2015: a report by the American Society of Clinical Oncology. J Oncol Pract 2015;11:79-113. 4. Berwick DM, James B, Coye MJ. Connections between quality measurement and improvement. Med Care 2003;41(Suppl 1):I-30-I-38. 5. Sherwood G, Zomorodi M. A new mindset for quality and safety: the QSEN Competencies redefine nurses’ roles in practice. Nephrol Nurs J 2014;41:15-22, 72. 6. Chassin MR, Loeb JM, Schmaltz SP, Wachter RM. Accountability measures – using measurement to promote quality imporovement. N Engl J Med 2010;363:683-688. 7. Savitz LA, Jones CB, Bernard S. Quality indicators sensitive to nurse staffing in acute care settings. In: Henriksen K, Battles JB, Marks ES, et al., eds. Advances in patient safety: from
research to implementation, Vol. 4. Programs, tools, and products. Rockville, MD: Agency for Healthcare Research and Quality; 2005. 8. Donabedian A. The quality of care: how can it be assessed? JAMA 1988;260:1743-1748. 9. Donabedian A. The role of outcomes in quality assessment and assurance. QRB Qual Rev Bull 1992;11:356360. 10. Montalvo I. The national database of nursing quality indicators (NDNQI). Online J Issues Nurs 2007;12:doi:10.3912/ OJIN.Vol12No03Man02. 11. Agency for Healthcare Research and Quality (AHRQ). Selecting quality measures. Available at: https://www .qualitymeasures.ahrq.gov/tutorial/selecting.aspx. Updated June 2015. Accessed January 14, 2016. 12. Kizer K. The National Quality Forum seeks to improve health care. Acad Med 2000;76:320-321. 13. Institute of Medicine (IOM). Kohn LT, Corrigan JM, Donaldson MS, eds. To err is human: building a safer health system. Washington, DC: National Academy Press; 2000.
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14. Institute of Medicine (IOM). Crossing the quality chasm: a new health system for the 21st century. Washington, DC: National Academies Press; 2001. 15. National Quality Forum (NQF). About us. Available at: http://www.qualityforum.org/story/Aboutus.aspx. Accessed January 14, 2016. 16. Joint Commission. Facts about ORYX for hospitals. Available at: http://www.jointcommission.org/facts_about_oryx _for_hospitals/. Accessed January 14, 2016. 17. Centers for Medicare and Medicaid Services (CMS). Hospital inpatient quality reporting program. Available at: https:// www.cms.gov/medicare/quality-initiatives-patient-assessment -instruments/hospitalqualityinits/hospitalrhqdapu.html. 18. Neuss MN, Desch CE, McNiff KK, et al. A process for measuring the quality of cancer care: the Quality Oncology Practice Initiative. J Clin Oncol 2005;23:6233-6239. 19. Neuss MN, Malin J, Chan S, et al. Measuring the improving quality of outpatient care in medical oncology practices in the United States. J Clin Oncol 2013;31:1471-1477. 20. McDonald L. Florence Nightingale and the early origins of evidence-based nursing. Evid Based Nurs 2001;4:6869. 21. The American Nurse. NDNQI changes hands. The American Nurse. Available at: http://www.theamericannurse.org/ index.php/2014/09/02/ndnqi-changes-hands/. Accessed January 14, 2016. 22. Kurtzman ET, Corrigan JM. Measuring the contribution of nursing to quality, patient safety, and health care outcomes. Policy Polit Nurs Pract 2007;8:20-36. 23. Press Ganey. Nursing quality (NDNQI). Available at: http:// www.pressganey.com/solutions/clinical-quality/nursing -quality. Accessed January 14, 2016. 24. Cronenwett L, Sherwood G, Barnsteiner J, et al. Quality and safety education for nurses. Nurs Outlook 2007;55:122131. 25. Westra BL, Clancy TR, Sensmeier J, Warren JJ, Weaver C, Delaney CW. Nursing knowledge: big data science – impli-
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cations for nurse leaders. Nurs Admin Q 2015;39:304310. 26. Drenkard K. Strategy as solution: developing a nursing strategic plan. J Nurs Adm 2012;42:242-243. 27. Shoemaker LK, Fischer B. Creating a nursing strategic planning framework based on evidence. Nurs Clin North Am 2011;46:11-25. 28. University of Illinois at Urbana Champaign Strategic Planning Working Group. University of Illinois at Urbana-Champaign strategic plan 2013–2016. Available at: http://strategicplan .illinois.edu/documents/2013-2016_Campus_Strategic_Plan .pdf. Accessed January 14, 2016. 29. American Nurses Credentialing Center. ANCC magnet recognition program. Available at: http://www.nursecredentialing.org/ Magnet. Accessed January 14, 2016. 30. Tsai TC, Jha AK, Gawande AA, Huckman RS, Bloom N, Sadun R. Hospital board and management practices are strongly related to hospital performance on clinical quality metrics. Health Aff 2015;34:1304-1311. 31. Wolf G, Triolo P, Ponte PR. Magnet Recognition Program: the next generation. J Nurs Adm 2008;38:200-204. 32. Zuckerman AM. Systemness: the next frontier for integrated health delivery. Becker’s Hospital Review. Available at: http://www.beckershospitalreview.com/hospital-management -administration/systemness-the-next-frontier-for-integrated -health-delivery.html. Accessed December 17, 2015. 33. Kazemak E, Bader B, Witalis R, Lockee C. Pursuing systemness: the evolution of large health systems. The Governance Institute. Available at: http://static1.squarespace.com/ static/5487509fe4b0672ae6c16f81/t/54a4267fe4b0d132f64b1b64/ 1420043903525/05_WP_Bonus_LgSystem.pdf. Accessed December 17, 2015. 34. Institute for Healthcare Improvement. Idea generation tools: brainstorming, affinity grouping, and multivoting. Available at: http://www.ihi.org/resources/Pages/Tools/Brainstorming AffinityGroupingandMultivoting.aspx. Accessed December 16, 2015, 2015.
Seminars in Oncology Nursing, Vol 32, No 2 (May), 2016: pp 110-121
TRANSFORMING ONCOLOGY CARE: DEVELOPING A STRATEGY AND MEASURING SUCCESS PATRICIA REID PONTE, DONNA BERRY, LORI BUSWELL, ANNE GROSS, CAROLYN HAYES, JUDY KOSTKA, MARY POYNER-REED, AND COLLEEN WEST OBJECTIVES: To examine accountability and performance measurement in health care and present a case study that illustrates the link between goal setting and measurement and how a strategic plan can provide a framework for metric selection.
DATA SOURCES: National reports, literature review and institutional experience. CONCLUSION: Nurse leaders and clinicians in oncology settings are challenged to anticipate future trends in oncology care and create a culture, infrastructure, and practice environment that supports innovation, advancement of oncology nursing practice and excellence in patient- and family-centered care. Performance metrics assessing key processes and outcomes of care are essential to meet this challenge.
IMPLICATIONS FOR NURSING PRACTICE: With an increasing number of national organizations offering their version of key quality standards and metrics, it is critical for nurses to have a formal process in place to determine and implement the measures most useful in guiding change for a particular clinical setting.
Patricia Reid Ponte, RN, DNSc, FAAN, NEA-BC: Chief Nursing Officer, Senior Vice President, Patient Care Services, Dana-Farber Cancer Institute, Boston, MA; and Executive Director, Oncology Nursing & Clinical Services, Brigham and Women’s Hospital, Boston, MA. Colleen West, RN, BSN, MBA, CPHQ: Director, Clinical and Professional Development, Dana-Farber Cancer Institute, Boston, MA. Anne Gross, PhD, RN, FAAN: Vice President, Adult Ambulatory Oncology Nursing and, Clinical Services, Dana-Farber Cancer Institute, Boston, MA. Judy Kostka, RN, MS, MBA, OCN®: Senior Director, Nursing and Clinical Services, Satellites and Network Affiliates, Dana-Farber Cancer Institute, Boston, MA. Lori Buswell, MSN, ANP, OCN®: Vice President, Epic System, Operations and Global Cancer Medicine, DanaFarber Cancer Institute, Boston, MA. Carolyn Hayes, PhD, RN, NEA-BC: Associate Chief Nurse, Adult Inpatient
Oncology, Medicine and Integrative Nursing, DanaFarber Cancer Institute, Boston, MA; and Brigham and Women’s Hospital, Boston, MA. Mary PoynerReed, PhD, CNRN, ANP, NEA-BC: Vice President, Associate Chief Nurse, Medicine Patient Services, Boston Children’s Hospital and Pediatric Oncology Patient Services, Dana-Farber Cancer Institute, Boston, MA. Donna Berry, PhD, RN, AOCN®, FAAN: Director, Phyllis F. Cantor Center, Dana-Farber Cancer Institute, Boston, MA; and Associate Professor, Harvard Medical School, Boston, MA. Address correspondence to Pat Reid Ponte, RN, DNSc, FAAN, NEA-BC, Brookline Ave (D1632), Boston, MA 02215. e-mail: [email protected] © 2016 Elsevier Inc. All rights reserved. 0749-2081 http://dx.doi.org/10.1016/j.soncn.2016.02.005
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KEY WORDS: oncology, nursing, leadership, strategic planning, quality measures, performance.
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eaders of every industry are often asked to predict what the future holds, and to speculate on which factors will drive growth, how organizations can develop new knowledge while responding to change, and how they should leverage access to “Big Data” and define and measure success. Such questions are increasingly debated in health care. With the ongoing shift from fee-for-service reimbursement to value-based care, healthcare organizations are pressed to achieve the triple aim of simultaneously improving population health, reducing costs per capita, and improving the patient experience of care,1 and the more recently defined quadruple aim, which expands the triple aim to include improving the work life of health care providers.2 The challenges posed by the quadruple aim are especially acute in oncology care, where the pressure to rein in costs is complicated by the aging patient population and growing demand for services, and by research advances that are yielding promising, individualized but costly treatment options.3 Ongoing efforts to achieve the quadruple aim are greatly aided by advances in measurement science and the ability of organizations to harness technology and capture clinical and administrative data reflecting the process and outcomes of care. However, when seeking to implement change and improve care, measurement alone is not enough. As noted by Berwick and colleagues4 (p. I-31) “Clear purpose, focused goals, and valid and reliable performance metrics set the stage for the use of measurement to pursue changes that are improvements.” This article examines the role of measurement in oncology nurses’ efforts to implement care improvements and ensure excellence in oncology nursing practice today and in the future. An overview of accountability and performance measurement in health care is presented, as well as a case study that features the strategic planning process implemented by the Department of Nursing at Dana-Farber Cancer Institute (DFCI; Boston, MA). The case study illustrates how carefully selected performance metrics are essential tools that can help nurse leaders and clinicians guide change and assure the success of improvement efforts.
PERFORMANCE MEASUREMENT IN HEALTHCARE Measuring the quality of health care and using those measurements to improve care have been a major focus of health services researchers, clinicians, educators, and policy makers for the past two decades.5-7 Previously, efforts to evaluate health care quality generally followed a quality assurance model and were guided by Donabedian’s conceptualization of quality, which identified the contributions of structure, process, and outcome elements.8-10 In relation to clinical quality, structure refers to human and material resources and other aspects of infrastructure that influence an organization’s or clinician’s capacity to provide care. Process refers to activities through which an organization or clinician provides care and services to patients; and outcomes refer to the health of patients impacted by or resulting from health care.11 In the early 1990s, few hospitals routinely collected and monitored quality measures. Similarly, at the national level there was no ability to systematically evaluate the quality of the health care system and little to no consensus about the types of measures on which data should be gathered.6,12 Appreciation for the importance of quality measurement and monitoring among hospitals and clinicians grew with the publication of landmark reports by the Institute of Medicine13,14 that highlighted the prevalence of errors in healthcare and the need to define, and measure adherence to, performance standards. Recognition of measurement’s importance was also fueled by the adoption by many healthcare organizations of the performance improvement model, which links measurement to the process of improvement and attaining clearly defined goals.4 In response to the growing demand for greater accountability, a presidential advisory commission recommended the creation of the National Forum for Health Care Quality Measurement and Reporting (now called the National Quality Forum or NQF).12 NQF was charged with aiding efforts to improve health care quality by standardizing the means by which health care quality is measured and reported. Since its inception, NQF has used a consensus development process to identify and endorse more than 600 evidence-based quality measures.15 Today, NQF-endorsed measures are
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considered the “goal standard” for health care measurement and are widely used in payment and public reporting programs. In the past two decades, public reporting of quality measures by hospitals and other health care organizations has become routine. A limited set of quality reporting requirements was first implemented by the Joint Commission in the late 1990s through its ORYX initiative.6 Reporting requirements quickly expanded, and today hospitals must provide data to the Joint Commission on a minimum of six measure sets based on the services they provide and the populations served.16 Many of the measures are also publicly reported to Centers for Medicare and Medicaid Services (CMS), which shares hospital-level data with the public through the CMS website.17 Within oncology, the American Society of Clinical Oncology’s Quality Oncology Practice Initiative (QOPI) has identified a set of measures specific to oncology care and developed a voluntary process through which oncology practices can monitor their performance and compare it with that of other practices.18 Research indicates that participation in QOPI over time is correlated with improvement in measured performance.19 Measurement in Nursing Nurses have long been in the forefront of using data to improve the quality and safety of health care delivery across the continuum, beginning with Florence Nightingale who used statistical methods to correlate patient outcomes to environmental conditions.20 More recently, nurses have sought to identify nursing-sensitive measures and use them to evaluate nurses’ contributions to health care quality. This work began in the 1990s when the American Nurses Association funded pilot studies that examined linkages between nurse staffing and quality of care.10 The studies led to the identification of an initial set of nurse-sensitive quality indicators that formed the basis of the National Database of Nursing Quality Indicators (NDNQI). Today, the NDNQI program tracks up to 19 nursesensitive quality measures, including many measures that are endorsed by NQF.10,21 The NDNQI measures include patient-centered outcome measures (eg, failure to rescue, pressure ulcer prevalence, patient falls); nursing-centered intervention measures (eg, smoking cessation counseling for patients diagnosed with an acute MI), and system-centered measures (eg, skill mix, nursing care hours per patient day).22 More than 2,000
hospitals participate in the NDNQI program and use the database to monitor their performance and compare it with that of other institutions.23 Nursing quality efforts have also focused on educating nurses about essential quality and safety practices. In a prominent example, the Quality and Safety Education for Nurses (QSEN) initiative identified six core quality and safety competencies for nurses in 2007.24 The competencies include quality improvement and the ability to use data to monitor, evaluate, and improve care processes and outcomes. Since their release, the QSEN competencies have become part of national nursing education curricula standards.5 Using Data to Drive Improvement With an increasing number of national organizations offering their version of key quality standards and metrics, nurse leaders and clinicians are challenged to clarify which issues and questions are of greatest importance to them and what measures will be most useful in guiding improvement and assessing performance. The challenge is compounded by the emergence of Big Data, or the availability in real time of large quantities of data from multiple sources. While Big Data offers leaders an unprecedented opportunity to develop actionable predictive models,25 tapping its potential requires having a clear sense of priorities and formulating meaningful questions that can be answered with the data at hand. As suggested by Berwick and colleagues,4 determining what is important to an organization and specifying goals and a plan to accomplish them are important precursors to the measurement process. The strategic planning process, in particular, offers organizational and nursing leaders a unique opportunity to assess an organization’s or department’s strengths, identify gaps and opportunities for improvement, and develop a plan to address the gaps and weaknesses.26 Attaching metrics to goals and specific initiatives allows nurse leaders and clinicians to monitor progress and determine when a different approach might be needed. Several examples illustrate how strategic planning and metric selection go hand-in-hand. One example is from Shoemaker and Fischer27 who described how their organization used its balanced scorecard to guide strategic planning, facilitate alignment of strategically important activities across departments and the continuum of care, and monitor progress on key initiatives at the organizational, division, and department level. In another example,
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the University of Illinois at Urbana-Champaign28 linked its strategic goals to specific initiatives and metrics. For example, for the goal, “Make a significant and visible societal impact,” the university identified six initiatives and eight metrics, including a count of faculty that attain national academies membership, the percent of sponsored research expenditures from foundations and corporations, media “hits” or stories in which the university is featured, and results from an alumni feedback survey. A third example specific to oncology nursing is provided in the following section. The example describes a multi-step strategic planning process through which the nursing leadership team at DFCI defined goals and priorities for the future, identified processes to achieve those goals, and specified metrics that they use to monitor the progress of implementation and measure success. The case study illustrates the vital role of metrics in strategic planning and improvement.
LINKING PLANNING AND MEASUREMENT: A CASE STUDY DFCI provides cancer care and treatment to children and adults while maintaining an expansive program of cancer research and training the next generation of oncology care providers and clinicians. DFCI is located in Boston, MA, and is a teaching affiliate of Harvard Medical School and a preferred training site for nursing and nurse practitioner students from several universities. In 1999, DFCI joined with Harvard Medical School, the Harvard School of Public Health, and four other Harvard-affiliated teaching hospitals to form the Dana-Farber/Harvard Cancer Center, which was designated a comprehensive cancer center by the National Cancer Institute and coordinates cancer research efforts across the participating organizations. Relationships with other health care organizations allow DFCI to offer a full complement of cancer services to patients throughout New England. Through collaborations with nearby Brigham and Women’s Hospital and Boston Children’s Hospital, DFCI provides adult and pediatric inpatient and ambulatory care and a full array of diagnostic and specialty services. DFCI also has partnered with community hospitals and physician practices to establish satellite practices that offer patients and families in outlying areas easier access to DFCI providers and cancer services and
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clinical trials. DFCI was first recognized as a Magnet organization29 by the American Nurses Credentialing Center in 2005, and has maintained Magnet designation ever since. Work to expand DFCI’s Magnet status to include recently acquired satellite and physician practices in the next Magnet redesignation process (scheduled for 2018) is currently underway. Factors that Led to the Strategic Planning Process DFCI board members have long been active in the Institute’s quality and safety programs, a practice that is supported by research linking board involvement to better quality performance by managers.30 As a result, board discernment and input is frequently sought by Institute leaders. The board’s discernment was apparent following a presentation about the organization’s clinical pathways program, when one board member posed a question asking how DFCI leaders assure that quality patient care and the patient care experience beyond the clinical pathway (which focuses on the diagnostic and treatment plan) is standardized and continually monitored and improved across all sites of care. Improving the quality of care and the patient experience is a central focus of the Department of Nursing’s ongoing planning efforts. However, the board member’s question, coupled with the challenge of incorporating the satellite programs and physician practices into the Institute’s Magnet designation, prompted senior nursing leaders to recognize they needed to more fully evaluate how the Department of Nursing would ensure nursing excellence, quality and safety in patient care, and a means for measuring and monitoring critical structures, processes, and outcomes across the continuum in the years to come. The need for a full evaluation was further strengthened by the ongoing implementation of health information technology that promised interoperability and ready access to data. The nursing leaders realized that leveraging the vast amount of data that would soon be available to them required clarifying goals for the Department of Nursing and oncology nursing practice. Given the scope and importance of these multiple challenges, the leaders decided to embark on a comprehensive strategic planning process to establish the direction for the Department of Nursing for the next 4 years and a means for measuring success. The strategic planning process involved a series of steps that took place over several months. The
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process was led by the chief nurse with the participation of each member of the Nurse Executive Committee (NEC), and was assisted by an outside consultant with expertise in health care and strategic planning. NEC is the executive governing committee for the Department of Nursing and is composed of nursing vice presidents and senior nurse leaders responsible for clinical nursing operations, nursing practice, professional development, and research. The committee is united by the nursing department’s vision and values, which underscore nursing’s commitments to patients and families and the importance of collaboration and partnership. Because so much of oncology nursing practice is steeped in interdisciplinary and interdepartmental relationships and collaborations, the nurse leaders knew that successful strategic planning would require examining nursing practice at
DFCI through the context of organizational goals and priorities as well as a professional nursing lens. Step One: Defining “Must-Have” Elements. As a basis for the strategic planning process, the nurse leaders first spent time specifying structure, process, and outcome elements that were already in place at DFCI and that the nurse leaders recognize as essential for assuring excellence, quality, and safety in patient care and clinical trial delivery in any location. As noted in the schematic presented in Figure 1, key structural elements include a nursing leadership and governance structure that engages nurses at every level in decision making, and structures that support and ensure competency, performance management, professional development, workforce diversity, and professional affiliations. Key process elements include practices
Dana-Farber Cancer Ins tute Oncology Nursing Organiza Structure (People)
Process
Outcomes
Characteristics of an organization including leadership, availability of resources , the professio nal practice mode l, roles, respo nsibilities and performance management.
Standardize procedures to compl y with regulatory measurements and ensure consistency across the continuum of care including activities and resources that support innovation and knowled ge development.
Quantitative and qualitative evidencerelated to imp act of structure & process on patients, families, the workforce and the organization.
Roles & responsibil s: managers , clinicians , researchers, staff, execs. ons management Governance structure – p /unit, nursing council, nursing department, p on hospital-based p Affil ons: academic, community, industry Competency: licensure, c on, privileges, edu onal prepa on, orienta on, professional development Performance management and peer review Preceptorship/residency/mentorship Assuring a diverse workforce Succession planning, career planning
Policies and procedures Pathways, treatment plans and evidencebased standards of care Regu ons/audits Clinical trial compliance model/theory Professional p guided p /integra e nursing/Synergy Model Primary nursing/ onship-based care/p - and family-centered edu on/informa on P Care coordin on/pa nt navig on Con nuous quality improvement Nurse scien led research teams Interdisciplinary team training Mindfulness-based nursing p
Technology Epic Electronic Medical Record – adop on, training, support and op miza on. Reports to advance innov on and knowledge g on Employee safety technology – li , needle safety P safety technology – IV pumps, monitors, -centered technology – remote self-care & symptom P Management & decision making, medi on adherence tools, p gateway, psychosocial screening
P on reported outcomes P Symptom management Oral chemotherapy adherence Central line infec on Extravasa ons rates Falls with injury Medi on error rate on Nurse & clinic assistant Nurse cer fi on rates BSN prepa on rate Vacancy/turnover rates Employee injury Safety culture – teamwork Financial – budget development, monitoring, variance repo ng
External Benchmarks QOPI Magnet Joint Commission DPH/CMS BORN NACQ IV Nursing Society Standards
FIGURE 1. DFCI Oncology Nursing Services: organizational framework.
NICHE ANA CEU Provider OSHA ONS/ASCO Guidelines NCCN Guidelines ELNEC Guidelines
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that ensure safety and consistency across the continuum of care; a professional practice model and care delivery practices that support professional nursing practice and holistic, patient- and familycentered care; and programs that promote innovation and nursing knowledge development. Nursing impact and effectiveness are assessed through outcome metrics measuring clinical quality and safety, workforce strength, and the patient and family experience of care. Underpinning all of these elements are technologies that facilitate safe and effective care delivery, and external benchmarks and standards that allow nurse leaders and clinicians to compare the nursing department’s performance with other institutions and identify best practices. The elements listed in the structure, process, and outcomes domains reflect clinical, workforce, and organizational elements that form the basis of the American Nurses Credentialing Center Magnet Model31 and are consistent with evidenced-based approaches to measuring and delivering quality care. Collectively, the elements reflected the Department
FIGURE 2. Proposed priorities for nursing.
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of Nursing’s baseline state, as well as a foundation upon which nurse leaders and clinicians would build when implementing changes and innovations needed to meet future challenges.
Step Two: Identifying Priority Areas. To launch the next phase of the strategic planning process, the chief nurse drafted a list of priorities to be vetted with NEC and other nursing and organizational leaders (Fig. 2). The priorities were familiar to NEC members as they represented issues and projects that NEC had discussed or worked on for months, or in some cases years, and that the group had put on hold while it helped implement the new health information technology and other initiatives. The list also was informed by organizational goals as well as best practices related to the nursing work environment and oncology nursing practice reported in the literature. In identifying the priorities, the chief nurse focused on important, large-scale issues or “big rocks” rather than day-to-day or operational
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concerns and assigned each priority to one of the following categories: •
•
•
Foundational: Priorities assigned to this category related to new systems, structures, and supports that were needed to achieve the department and organizational vision. The priorities addressed the following four areas: quality, safety and care; financial and operational; technology; and accreditation. Differentiator: Priorities assigned to this category included new programs and changes that would further highlight areas of innovation and leadership that are beyond the traditional functions of a department of nursing. The priorities addressed the following four areas: growth, patient engagement, innovation, and research. Levers: Priorities assigned to this category related to structures and processes that would enhance the effectiveness of Foundational and Differentiator elements. The priorities addressed the following six areas: work environment, interdisciplinary/ interdepartmental relationships, governance, structure & roles, talent, and learning and development.
The chief nurse shared the draft priorities with NEC and asked the group to identify any additions, deletions, or edits. The chief nurse also shared the draft list with the broader nursing leadership team that includes nurse directors and clinical specialists, and with the Nursing Council. The Nursing Council is the central component of the Department of Nursing’s shared governance structure and is primarily composed of direct care nurses representing each role group and practice setting. Both of the groups readily endorsed the draft list and highlighted priorities that were of special importance to them, including priorities that offered opportunities for addressing ethical aspects of patient care and research, and priorities that focused on strengthening governance and communication structures. Having gained agreement on a draft list of priorities, NEC was ready to move on to the next step, that of ranking the priorities. The group realized this was a greater and arguably more important challenge because it would determine which priorities would in fact be implemented and how department resources would be allocated. Step Three: Ranking Nursing Priorities and Creating a Strategic Action Plan. The nurse leaders agreed the ranking process merited an indepth discussion through which they could consider
internal and external factors that should inform their thinking and the importance of each priority to nursing and the organization. To allow sufficient time for discussion, the group planned an off-site, 1.5-day retreat. The chief nurse proposed to facilitate the retreat with the assistance of the external consultant and developed an agenda to achieve the following objectives: 1. Identify and review key external advances in oncology nursing care and how they will impact nursing practice at DFCI. 2. Review the current state of DFCI nursing care, including successes and opportunities for improvement. 3. Create a forward-looking strategic action plan, with structure, process and outcome measures that would serve as guideposts for continuous improvement. As background for the retreat, the chief nurse asked the members of NEC and administrative and physician leaders who participated in the earlier interview process to complete an online survey in which they described their vision for DFCI nursing; identified external advances in oncology that should inform the strategic planning process; ranked the areas specified in the strategic plan in order of importance; and described gaps to converting the strategy into action. The agenda for the first day included presentations and activities that provided a context for identifying top priorities for nursing, including a discussion of the online survey results. Survey comments regarding the vision for the Department of Nursing were of particular interest to the group. The comments yielded an expanded vision for nursing (Fig. 3) that emphasized the department’s leadership role in multiple areas, from advancing DFCI’s contribution to the healing and health of patients and communities, to achieving “systemness” across all DFCI locations and accomplishing the quadruple aim. (Systemness is a multifaceted concept that focuses health care systems to operate with a high degree of coordination, integration, and productivity across the health enterprise, to provide the best possible patient care, experience, and outcomes while carefully considering the cost of care.32,33) Physician and administrative respondents to the survey also encouraged nursing to consider expanding nurse leader role descriptions to include an expectation for participating in direct patient care, similar to the physician leadership model. In discussing advances in cancer treatment, the survey respondents
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FIGURE 3. Expanded Dana Farber Cancer Institute nursing vision.
highlighted progress and the need for innovative approaches in care delivery related to oral chemotherapy, immunotherapy, cell therapies, symptom science, and personalized medicine and genetic profiling. Survey respondents noted that all of these advances have implications for the nursing role, interdisciplinary collaboration, and care coordination across settings and should inform the strategic plan. The presentations and survey data served as a backdrop to the next task, which involved identifying top priorities for action. This was accomplished through a multi-voting exercise, in which each NEC member was asked to consider the Foundational, Differentiator, and Lever priorities and identify the top six priorities in each category. Through this process the group narrowed the list of nursing priorities to 13 areas. The second day of the retreat was dedicated to developing an overall plan and timeline for addressing the priority areas. The plan was developed through an intensive work session that focused on defining goals for each priority area and translating the goals into specific initiatives with identified owners, timelines, milestones and deliverables. The group also identified an initial set of metrics for each initiative (see examples, Table 1). By design, the work plan developed for the initiatives was highlevel, as NEC expected the designated owner of each
priority area to convene a work team to develop and implement a more detailed project plan, including additional project-specific metrics if needed. In conjunction with the metrics specified in Figure 1, the new metrics would allow nurse leaders and clinicians to evaluate the overall quality of nursing practice, assess the effectiveness of the strategic initiatives, and guide ongoing improvement efforts. Over the next weeks, the senior nurse leaders refined the list of nursing priorities to indicate how they related to organizational priorities, and to reflect the interdisciplinary nature of clinically focused initiatives (see Fig. 4). The chief nurse then shared the list with the nursing leadership team, Nursing Council, interdepartmental leaders, and the Patient and Family Advisory Council. In doing so, she obtained further input on the priorities and also ensured that leaders throughout the organization had a shared understanding of the Nursing Department’s direction for the next 4 years.
DISCUSSION AND LESSONS LEARNED The past two decades have been marked by noteworthy advances in measurement science and the development of valid and robust measures of healthcare quality. Data capture and reporting
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TABLE 1. Sample Objectives and Metrics Initiative New Care Modalities
Nursing Talent
Implementation Objectives Cellular Therapies 1. Design and implement ambulatory/inpatient nursing checklist to assure all steps in the process of implementing new trials (new care modalities) are taken prior to activation. 2. Educate RNs on each trial prior to activation and at the time of amendments as needed. 3. Develop an approach to assure adequate resources for each trial. Oral Chemotherapy 1. Assure all patients on oral agents receive adequate medication teaching. Implement a diverse talent pipeline and a leadership model that includes a patient care component with clear leadership structures and accountability.
Metrics Outcome measures: Cellular Therapies ■ Percent of nursing staff who completed protocol inservice prior to caring for patient, measured through Healthstream or unit-based log documentation (target: 100%) Oral Chemotherapy ■ Percent of oral chemotherapy patients who receive RN teaching call
Outcome measures: Percent of DFCI RN workforce composed of racially diverse RNs ■ Percent RN certification rate ■ Number of career advancement transitions completed by DFCI RNs/NPs and nurse leaders ■ Percent of RNs (at all sites) with BSN ■
FIGURE 4. Nursing priorities and their relationship to organizational priorities and initiatives.
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systems used by healthcare organizations have also improved, giving healthcare leaders and clinicians access to a constant flow of data from numerous sources. As a result, leaders and clinicians seeking to improve the quality of care face a new kind of challenge, that of determining which of the numerous data elements and metrics they are able to track will be most useful in assessing organizational and department performance and improvement efforts. The strategic planning process implemented by DFCI nurse leaders offers a model for basing metric selection on clearly defined goals. As Berwick and colleagues note,4 this type of approach is critical in “set[ting] the stage” for using measurement to guide improvements. DFCI nurse leaders believe the strategic plan they developed has positioned the Department of Nursing to meet future patient and family needs and advance the science and practice of oncology nursing. However, in many ways the benefits obtained from the strategic planning process exceed the final product. For example, by obtaining input from internal experts and external sources, nurse leaders gained a heightened awareness of ongoing changes in cancer treatment, health care policy, and care delivery that will inform numerous aspects of their practice in the years to come. Additionally, by engaging physician and administrative leaders in the initial planning stages, and obtaining their input on the final list of nursing priorities, the nurse leaders prompted a dialogue through which organizational leaders recognized the need for more communication and interdisciplinary collaboration on clinical issues at the executive level. Such collaboration is of growing importance, given the size and complexity of the organization’s adult ambulatory and inpatient practices and the need to better integrate services across sites and disciplines. Steps to ensure interdisciplinary collaboration among executives are currently underway and are embedded within the enterprise-wide “systemness initiative.” One of the key advantages of a strategic plan is its usefulness as a leadership performance measure. As noted in Figure 1, the Department of Nursing at DFCI already had in place a robust set of nursing metrics going into the strategic planning process. However, with the exception of measures evaluating workforce strength and work environment, most of the metrics assess some aspect of clinical nursing practice and thus are an indirect reflection of nurse leader practice. With its timeline and specified process and outcome measures, the strategic plan
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allows DFCI nurse leaders to better gauge their productiveness and efficiency. The approach to strategic planning used by DFCI nursing leaders offers a number of lessons related to visioning, planning, and measurement that may be useful to other leadership teams considering their own strategic planning process. The lessons include: •
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Reach out to stakeholders and content experts: By definition, strategic plans must reflect changes and trends in the health care environment as well as internal goals and concerns. Although the senior nurse leaders at DFCI were aware of many of the changes impacting health care and oncology, they found that speaking with internal and external experts, and supplementing conversations with a review of the literature, yielded critical context for the strategic planning effort. Similarly, by obtaining input on strategic priorities from a broad range of internal stakeholders – including nurses in directcare and formal leadership roles, interdisciplinary colleagues, and members of the DFCI executive leadership team – the leaders ensured that the nursing strategic plan was aligned with organizational goals and garnered critical support for strategic nursing initiatives. Expect (and seek) the unexpected: Going into the strategic planning process, the senior nurse leaders believed they had a firm grasp on the top priorities for nursing. While this was largely true, they found they obtained new and crucial insights through the interviews with nurse and interdisciplinary leaders, the leadership survey, and the off-site work session. For example, the nurse leaders had not anticipated the interest, expressed by physician survey respondents, for adding a clinical practice component to the nursing leadership model, a change they are currently exploring in internal dialogues with nurse directors. Information obtained through the survey also helped them more fully appreciate the implications of emerging care modalities and the importance of enhancing the department’s capacity to quickly ramp up and respond to treatment advances with appropriate practice changes and nursing resources. Building such capacity was ultimately identified as a top priority. Consensus is good, endorsement is critical: Given the range of perspectives represented within nursing leadership teams, there will inevitably be some disagreement about priorities
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and priority rankings among team members. The DFCI nurse leaders found that respectful disagreement was a good thing because it forced them to evaluate different points of view and a broader range of issues than they might have otherwise considered. Rather than striving for consensus, they sought to obtain the endorsement of the entire leadership team, and to have each team member demonstrate a commitment to ensuring the successful implementation of each priority. Multi-voting can be effective in obtaining such endorsement because it gives each person an equal voice and opportunity to weigh in on the priorities,34 and assures the final list reflects the full range of perspectives. Moving from ideas to action: While defining priorities is an important step in any strategic planning process, translating the priorities into actionable initiatives with identified owners and initiative-specific metrics is essential for ensuring the strategic plan moves off the page and drives action and continuous improvement. At DFCI, engaging all of NEC in the translation process was beneficial as it ensured a more informed consideration of time requirements, facilitated the identification of competing initiatives and synergies, and promoted a sense of shared responsibility for the overall plan. External support: A good strategic planning consultant brings skills, tools, and knowledge that can streamline the strategic planning process and provides a perspective informed by region-
al and national trends. Nurse leaders at DFCI found that the external consultant also offered a level of objectivity that was especially useful in keeping the group on track and open to new ideas. A skilled strategic planning consultant can thus benefit most any group, including leadership teams that have a great deal of strategic planning experience.
CONCLUSION In light of the accelerating pace of change in health care and oncology practice, it is imperative that oncology nurse leaders take time to assess the environment, establish priorities for the future, and develop a plan to achieve them. A well-crafted strategic plan inclusive of a clear and compelling vision and backed by carefully selected metrics can serve as an important blueprint for action. By identifying priority initiatives, timelines, and performance measures, the plan provides guidance for decision making, helps nurse leaders stay on track toward achieving desired goals, and provides them with an overall metric for evaluating their performance as a leadership team. Even more important, it helps ensure that nurse leaders continue to fulfill their mandate to guide and advance the art and science of nursing practice and to work with nurse clinicians in defining patient- and family-centered care environments for the future.
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