Editor’s note: Linda Burnes Bolton, Dr.P.H., R.N., F.A.A.N., chief nursing executive and vice president for nursing at Cedars-Sinai in Los Angeles, discusses the link between nursing and quality improvement, diversity in the nursing workforce and her own work as a nurse leader in this interview with Kenneth Anderson, D.O., chief operating officer and acting president of the Health Research & Educational Trust, an affiliate of the American Hospital Association. Burnes Bolton is the 2016 recipient of the HRET TRUST Award.
Kenneth Anderson: How has being a nurse and a nurse leader influenced your life and career path?
Linda Burnes Bolton: I wanted to be a nurse since I was about 7 years old. I had severe asthma and was in and out of hospitals. Passion for human caring was instilled in me from the individuals who cared for me — not just my mom and family but also the nurses at St. Mary’s Hospital in Tucson, Arizona. I saw how the nurses influenced their patients and families and thought that would be a good career for me.
Being a nurse was a fulfillment of my lifelong dream. Being a nurse leader has enabled me to help others — not only nurses but other members of the health care profession — get on the path toward wholeness. We’re in this business because we want to remove the barriers and provide education, guidance and support to enable individuals to achieve and sustain health and wellness.
Anderson: How do you view the link between nursing and quality improvement at a hospital or health system?
Burnes Bolton: Nursing is part of the team of professionals — not only clinicians but also performance improvement facilitators and other individuals — who design and implement change that leads to improvement. It’s innate in relationship to nursing because nurses are always seeking to find better ways to do things that will enable all members of the team to achieve the care outcomes designed. So nursing and quality improvement are intricately paired — it’s not a separate thing. Performance improvement, safety and quality — these are the No. 1 job of every member of the health professional team and certainly the No. 1 job of nursing.
At my organization, I’m a member of the executive safety group, which comprises the chief operating officer, chief medical officer, chief quality safety officer and other operational and clinical leaders. We are examining the systems of care, identifying opportunities for improvement, launching those improvements and working to achieve systems of care that result in positive patient care processes and outcomes.
The next very important step is to design the system so there’s no drift. That is, to be confident that the system is designed to meet the six-level sigma and that every human who’s responsible for part of that system will perform their role consistently. Identifying and addressing drift performance improves the likelihood that desired outcomes will be achieved for every patient, at all times. Nursing is part of a larger quality improvement in the health care system. We’re intricately involved both at the leadership and staff levels.
Anderson: As hospitals and health systems improve quality and patient safety, we know that some health systems are reaching into their communities to more closely mirror their composition. What is your advice to those trying to address health care disparities?
Burnes Bolton: As a member of the AHA’s Equity of Care Committee, I’ve been immersed in the program that HRET has led to reduce health care disparities. The first thing that hospitals need to ask and know is, what are our numbers? What are the health disparities in our community? Make sure the hospital has a rich system for gathering the evidence — not just gathering evidence and putting it in a report but making that evidence part of what the hospital speaks about and acts upon with community partners. It’s important for hospitals to do a community needs assessment, determine vulnerable populations and then work with community partners to establish and implement programs that begin to close the gap.
At Cedars-Sinai, one of our community’s most vulnerable populations is the frail elderly. Most patients in this population have limited access to social support services and other programs. Patients might have a Medicaid card, but they also are having issues with housing or transportation or getting sufficient food. We implemented a program that deployed nurse practitioners into skilled nursing facilities to assess the frailty risk of those residents. Then, working with families and the SNFs, we began to implement programs to decrease these patients’ risk and, as a result, reduce readmissions.
We also worked with community aging centers to look at why low-income patients, particularly Hispanic and African-American patients, had higher readmission rates. These patients had a low medication literacy score. We worked with nursing students and some pharmacy residents at [Charles R. Drew University of Medicine and Science] in Los Angeles to improve the literacy of patients and families about medications. Now patients can take medications appropriately and break the cycle of being discharged and then being readmitted within 14 to 30 days because of not understanding their medications.
Anderson: If hospitals and health systems reflect the composition of their communities, will that help to generate a more diverse nursing workforce? If we are successful in promoting a more diverse workforce, what impact might we see in the health of our communities?
Burnes Bolton: From numerous Institute of Medicine studies and other published studies, we know it does matter in providing health care that we have as diverse and inclusive a professional population as we do in society. For all of my professional life, I’ve worked with ethnic nursing organizations and schools of nursing. We’ve worked with community partners to increase not only the numbers of nurses from diverse backgrounds but also to make sure they’re graduating from bachelor’s, master’s and doctoral nursing programs and assuming leadership roles.
Part of our work is not just waiting for people to come to our door, whether they come in for elective procedures or through the [emergency department]. We actually go out in the community and say, “You, too, can be a health professional.” We’ve worked with youth education development departments in high schools and colleges. One of my educators is talking not just about nursing but about other health professions to seventh- and eighth-graders. We let students know that being in a family with an income of less than $40,000 a year doesn’t mean they cannot go to college. And we talk about how we’re going to help them do that. I’m proud of our work and the engagement of students — of individuals we’ve connected with who have become nurses, doctors and pharmacists. We’re in partnership with these students to improve and help sustain health in our community.
Anderson: As you reflect on your career, particularly the opportunities you created to lay the foundation for those who follow, what are you most proud of?
Burnes Bolton: One of my proudest moments was working with the Area Health Education Center program in California to get the University of California to open its doors wider to Native Americans, Hispanics and African-Americans seeking to get into professional schools — nursing, dentistry, public health and medicine. During six years of very hard work, we doubled the number of individuals who were accepted into those professional schools throughout the health campuses of the University of California.
I’m also proud of our work on health literacy and getting nurses to do assessments in clinics throughout the United Sates. We reached out and taught over 400 clinics in the United States, teaching nurses how to do a health literacy screen before they started educating patients about their medicine or self-care processes.
At [the American Organization of Nurse Executives], I worked to promote leadership and diversity leadership, chairing a task force we launched three years ago. We demonstrated the importance of reaching out and tapping into academicians who may not have thought about being on the board of AONE, but who are helping to produce the next round of health professionals. They’re going to bring diversity of thought and expertise to the table. Other organizations took on leadership diversity work and did the same thing — the American Nurses Association, American Association of Colleges of Nursing, National League for Nursing, American Academy of Nursing and National Black Nurses Association. It’s about paving the way by providing examples so others can help scale the work of promoting the next round of nurse leaders.
AONE reached 10,000 members this year. Each of those 10,000 is capable of reaching another 100,000. It’s an opportunity to influence individuals who will go and help wave the banner about why we believe it is important to be inclusive in health care. Being inclusive is more than just counting how many of “x” you have. It means developing a broad group of individuals who will help lead the cause.
Anderson: What is on the horizon for health care over the next 10 years?
Burnes Bolton: I think it’s already been launched — the need to reshape the health care delivery system to do more outside the walls of hospitals. The AHA’s “redefining the H” is absolutely right on. But it’s going to take some effort. We will still need America’s hospitals — they will always be needed. But we will need hospitals to be more engaged in population health management. That’s something that was not in the core curriculum of many health professions.
How do hospitals retool the workforce? As organizations move in the direction of being more than a hospital, what can they do to make sure they’re a cornerstone of a health care system, not just a health delivery system?
It will take leadership to prepare the health care workforce to be engaged in population health management. And it will take being engaged with new partners that are addressing the social determinants of health. I think it is exciting and will help hospitals to reduce health disparities, because we will be looking at it from a broader lens.
Kenneth Anderson, D.O., is the chief operating officer and acting president of the Health Research & Educational Trust, an affiliate of the American Hospital Association.