At a community hospital board meeting a few years back, Connie Curran, R.N., faced a challenge that as a nurse and former CNO she was unusually qualified to address. Facing declining revenues, the CEO proposed closing the hospital pharmacy on weekends. The board was ready to go along when Curran, the only board member with front-line clinical experience, asked: If we close the pharmacy, who will prepare medications for new patients?

Nursing, the CEO responded. But he hadn't asked the chief nurse if it was feasible — or advisable.

"I explained I had to vote against it unless the chief nurse said she didn't have a problem with it," Curran says. Based on the potential patient care and safety issues she raised, the board reversed itself and voted unanimously to keep the pharmacy staffed on weekends.

This shows the value of involving nurse executives in the highest levels of management and governance. "Well-meaning people can make decisions without any understanding of how they might affect care," says Curran, who formerly headed the American Organization of Nurse Executives and is now CEO of Best On Board, a governance consultancy.

With health system reform putting a premium on coordinating evidence-based care inside and outside the hospital, making the most of nursing resources is imperative, says Terri Gaffney, R.N., senior director at the American Nurses Association. "Nurses have been coordinating care since the beginning of the profession. As such, nurses are in a unique position to lead the practice innovation needed to succeed clinically and financially under health care reform."

But nurse leaders need negotiation, communication, financial, organizational behavior, workflow design and change management skills to be full partners in improving the effectiveness and efficiency of health care systems, Gaffney says. To that end, ANA is establishing a nursing leadership academy.

Integrating nursing with other hospital disciplines has proven a powerful tool for improving quality, says Julie Kliger, R.N., director of the Integrated Nurse Leadership Program, which works with several hospitals in the San Francisco Bay area. By developing peer relationships with other disciplines, they've been able to make significant changes in work processes. One project reduced sepsis mortality rates by 54.5 percent over three years at nine hospitals. Empowering nurses to respond immediately and autonomously to clinical emergencies was a critical success factor.

The chief nurse plays a key role in marshaling upper management support, resources and cooperation with other disciplines and hospital departments needed to improve care processes on the front line, Kliger says. "I call it the vertical team between senior management and front-line leadership. It is a process of common goal setting, support and resource allocation enabling positive change to occur in a free and transparent manner."

Better care through mentoring & empowering

Karen S. Hill, R.N. | vice president, nurse executive and chief operating officer, Central Baptist Hospital, Lexington, Ky. | Hill, a CNO for 16 years, added the COO role in November, and now oversees operations and patient care services at 383-bed Central Baptist Hospital. She has been honored by the AONE Institute for Nursing Leadership Research and Education and is a Robert Wood Johnson Nurse Executive Fellow. She is currently editor of the Journal of Nursing Administration and a commissioner of the National League for Nursing Accrediting Commission.

Because of concerns about retirement income and investments, nurses are staying longer and reinventing their vision for retirement. They don't want to go from 100 mph to zero, they want transition jobs. The challenge as a nurse executive is to use that experienced talent pool to meet both the nurses' and the organization's needs.

At the same time, public transparency of outcomes in care quality, safety and patient experience that soon will affect financial outcomes is changing the nature of nursing. It has shifted from getting a separate order for everything to following evidence-based standardized care plans and bundles, and anticipating patient needs based on population research.

Addressing care across the continuum expands the nursing role. At the bedside, nurses are taking more responsibility for what will happen when patients leave the hospital. This is a real shift in thinking. We assign more-seasoned nurses to help educate patients and help out with discharges. It allows more nurses to work regular hours and shorter shifts, and helps nurses on the floor to focus on patient care. We have reduced heart failure readmissions by 5 percent by connecting with patients after they leave the hospital, using multiple methods of communication.

I think it will take the talents, energy and innovation from all disciplines including nursing to significantly accomplish reform within our health care system. To maximize our opportunity to contribute, nurses need a seat at the table on boards, committees, medical staff meetings, the executive team, and outside the hospital on school boards and the chamber of commerce and other civic organizations.

We also need to encourage creativity throughout the organization by mentoring others, supporting evidence-based pilot projects and engaging staff in improving daily performance.

Translating policy to practice

Linda Burnes Bolton, R.N. | vice president for nursing, chief nursing officer and director of nursing research, Cedars-Sinai Health System and Research Institute, Los Angeles | In addition to serving as CNO at 1,000-bed Cedars-Sinai for 16 years, Burnes Bolton is an associate clinical professor at the University of California branches in Los Angeles and San Francisco. She is a board member of the Robert Wood Johnson Foundation, and was vice chair of the study committee for the Initiative on the Future of Nursing in America, launched by the Institute of Medicine and RWJF.

Changes in state and federal financing of the delivery system require that CNOs develop a much broader financial acumen. While anyone may be able to manage a daily operating budget, it takes much more to understand the impact of changing finances on resources and how they can be deployed, and equipment and supply decisions. The CNO must be much more knowledgeable in finance and adept in working with other members of the C-suite to ensure the organization's financial health while maintaining clinical excellence.

CMS and private industry are demanding as close to defect-free health care as possible, so there is a burgeoning of performance measures. The challenge is they are not all the same. The CNO must understand the evidence-based processes and measures developed by others and translate them into the daily work that they lead. This requires participation in not only performance improvement but also in the design of PI systems that engage nurses on the floor.

At a minimum, nurse executives should be master's-prepared. More and more it will be difficult to succeed without a doctorate, but not necessarily in nursing; what's really needed is the ability to translate knowledge into practice and that requires another level of competency. You must have knowledge of the health care environment and policy, as well as system design, economics and technologies. We need technical knowledge to work with clinical engineering teams and enterprise information teams to ensure patient safety as we put in more and more technology.

The role of the CNO on the executive team is not only to represent nursing as a discipline, but more importantly the patients. Because of our proximity to the patient we truly understand how the allocation of resources and the services the institution provides affect the community. Nurses need to be full partners in designing and improving care.

Improving outcomes through collabortation

Tonny DeMent, R.N. | director of nurses and clinical services, Piggott (Ark.) Community Hospital | Dement has been CNO at 25-bed Piggott Community Hospital, a critical access facility, for 13 years and also directs some ancillary departments. This year, the hospital is being recognized by the Arkansas Foundation for Medical Care for achieving 100 percent compliance with congestive heart failure and pneumonia process measures over several quarters.

When I started as nurse manager, mainly what I had to know about was nursing and nurse management. Now CNOs need to know about quality measures, CMS rules, coding, RAC audits, government reviews, state regulations and finances. And you need to collaborate to improve performance.

When CMS and the Arkansas Foundation for Medical Care began requiring us to meet quality standards, we had to communicate more among departments. Making sure blood cultures are drawn and processed requires communication and cooperation between nursing and the lab. Getting the right antibiotic means getting pharmacy involved, and getting X-ray information means getting radiology involved.

Now we have an interdisciplinary patient care committee that meets on a weekly basis to discuss quality measures. We have integrated our data collection so we can keep track of the measures and continue to improve. We spend a lot more time entering and analyzing data. All of the requirements of a successful, high-quality program do require more of our time, but it has helped us do what we needed to do to improve, and now we have hit 100 percent on several measures.

I work closely with our CEO James Magee and speak with him almost daily. He has been supportive in helping improve my skills. I sit in on meetings with consultants on accounting and regulatory issues. I also meet quarterly with the CEO, the nurse quality manager, the information system manager and a board member to keep the board up-to date. We have had discussions on joining a tertiary care center in an ACO, and we plan to evaluate this in the future.

Above everything, you need to be open to do this job — open to new ideas and willing to collaborate with everyone in the facility, managing all the way down.

Managing care across the continuum

Cynthia C. Barginere, R.N. | vice president, chief nursing officer and associate dean for practice, Rush University Medical Center, Chicago | Barginere joined 664-bed Rush last year after five years as CNO and COO at Baptist Medical Center South, Montgomery, Ala., and 12 years as CNO and associate executive director at the University of Alabama Birmingham Hospital. She has been a Robert Wood Johnson Foundation Executive Nurse Fellow and a Johnson & Johnson executive nurse fellow.

I came to the chief nurse role via case management and performance improvement for CRM. Charged with achieving specific clinical and financial outcomes and reducing costs per case, I became immersed in the processes of hospital payments, cost allocation and billing. This not only increased my financial acumen, but also gave me insight into the psyche of the finance team, enabling me to speak the same language. So, I've been making a financial case for clinical care right from the start. Also, my master's in nursing administration combined health administration with MBA courses in financial accounting, cost accounting and marketing and gave me a great foundation for the role of CNO and hospital leader.

In the early 1990s, I worked with an organization that had 2,000 capitated Medicare managed care lives, so I also joined the world of management across the continuum of care. We built partnerships with home care agencies for pathways for congestive heart failure and reducing readmissions by focusing on clinical indicators of care and making sure patients got what they needed. When capitation went away, it was not because the financial incentives didn't work; the whole [Medicare] program kind of fell apart.

Where money flows, attention goes, so with health reform, case management is back. This transformation concentrates on the health of the community and how we manage the health of a community. For someone who has done case management as long as I have, it is wonderful to see that the incentives are there to do what is best for the patient clinically.

The role of the nurse, particularly the advanced practice nurse, is expanding. In medical homes, nurse practitioners do a great job of managing chronic disease and understanding the psychology of the patient and what fits their lifestyle. No one knows what new payment structures will look like, but advanced practice nursing will play a big part. Nurse leadership will be needed to create the tools, infrastructure and context to make it work.

Designing better care

Peggy Gricus, R.N. | chief nursing officer and vice president, patient care services, Silver Cross Hospital, New Lenox, Ill. | Before her appointment as CNO seven years ago, Gricus served for eight years as director of maternal child care and other hospital departments, including behavioral health, rehab, lab and pharmacy at 304-bed Silver Cross, and previously was head of maternal child services at Ingalls Memorial Hospital in Chicago's south suburbs.

This is an exciting time for nursing. We used to be seen as a cost center. With the start of the value-based purchasing program, nurses have the opportunity to positively impact reimbursement. Nurses are the face of the hospital. We have the privilege of being with the patient and their family most, so who better to influence the patient care experience? This experience is becoming more important in the light of publicly reported HCAHPS patient satisfaction data.

Our new hospital is one more way to influence the total experience for our patients and their families. Prior to completing the design, we conducted a time and motion study and found that, on average, nurses spent 118 minutes per day tracking down medications and supplies and double-documenting. We shared these results with other departments; they were appalled at the waste of nursing time and worked with us to give those hours back to our patients. My mantra is that staff have the wisdom. The more you involve the users, the better the outcome. We decided to stock supplies between every two rooms. We equipped every patient room with a computer so that not only the nursing staff but also the physicians can record and readily access information. We just moved in, so we don't know exactly how much it is saving us yet, but it is considerable.

As we adjust to the changes imposed by health care reform, collaboration between disciplines and health care providers is imperative. Ten years ago we were focused mostly on what happens within our walls. Now we've expanded our influence into the community to meet the ongoing needs of our patients post-discharge. One example is our work with heart failure patients. Our case managers, in collaboration with physicians, staff at nursing homes, and home health nurses, developed an aggressive plan to keep our congestive heart patients healthy and prevent readmission to the hospital. By educating the staff and implementing a follow-up plan, we have been able to reduce heart failure readmissions by 50 percent.

Howard Larkin is a contributing editor for H&HN.


• The CNO skill set

  • Nurse leadership skills for transforming health care delivery
  • Advanced clinical training to facilitate interdisciplinary collaboration
  • Administrative experience and training
  • Design and implementation of care coordination across delivery sites
  • Clinical quality and safety measurement and improvement
  • Workflow and system design skills
  • Ability to create and apply accountability mechanisms
  • Financial skills for setting and measuring performance goals
  • IT applications knowledge
  • Understanding of health care economics, regulation and ethics
  • Team leadership and collaborative leadership experience and training
  • Governance experience in health care and the community

• CNO responsibilities for accountable care

  • Collaborate with other clinical disciplines and administrative areas to set organizational goals and optimize performance.
  • Implement and manage evidence-based care processes on the front lines.
  • Participate in system and facility design and operational decisions to make full use of nursing resources.
  • Collect and analyze performance data.
  • Manage based on real-time data.
  • Develop and implement coordination across the care continuum to optimize patient outcomes and improve community health status.

• What CEOs need from CNOs

  • Trusted partner for developing and executing strategy
  • Reality check of how executive decisions affect care on the front lines
  • Expertise in making the best use of nurse resources to achieve organizational goals
  • Collaboration with other C-suite executives
  • Ability to operationalize policies and strategies
  • Coordination of care beyond hospital walls