Health care’s rapid changes and growing complexity necessitate that all care providers collaborate and maximize their efficiency as never before, and few health care professionals understand that better than nurses. As their leaders on the front lines of patient care, system chief nurse executives and hospital chief nursing officers bring a unique — and increasingly valuable — perspective from which to champion these efforts, from the bedside to the top of the leadership ladder.
“We are the most trusted profession, responsible for the total care of the patient; we are the conveners,” says Maureen Swick, R.N., CEO of the American Organization of Nurse Executives and senior vice president and CNO of the American Hospital Association (pictured). “The system CNE must look at all required competencies across the care continuum, particularly in ambulatory settings, to manage population health.”
Swick points out that the AONE has organized a task force on the emerging competencies needed to be successful as a chief nurse executive. For example, AONE is further defining the CNE’s role in systemwide data integration, as well as pursuing a partnership with the Healthcare Financial Management Association to help nurse executives better understand new payment models and the financial implications of clinical outcomes.
“We need to seek more nationwide intraprofessional education, building programs as a team,” Swick says. To that end, AONE, along with the American College of Healthcare Executives, the American Association for Physician Leadership, the Healthcare Information and Management Systems Society, the Medical Group Management Association and HFMA have formed the Healthcare Leadership Alliance, whose goal is to identify common ground in advancing the health care management profession. Among its achievements, the alliance has created a competency directory highlighting best practices, integrated across its related professions.
“When you realize that three-quarters of all employees in the [health] system are nurses or on the nursing team, that their voice affects so many people, it’s important to have the CNE voice at the executive table,” says Maggie Hansen, R.N., South Florida-based Memorial Healthcare System’s first CNE. Three of the system’s current hospital CEOs are nurses. “Nurses touch patients at every level of care and we need them at every change point [in care],” Hansen says. “Our goal is to address every risk proactively, and nurses know where those risks are. They have a vantage point that health care leadership needs.”
5 key competencies
Bonnie Clipper, R.N., chief clinical officer of Cornerstone Hospital Austin (Texas), and a Robert Wood Johnson Foundation executive nurse fellow, sees five crucial evolving competencies for nurse leaders: influencing innovation, spanning boundaries, collaboration, expanding the accessibility and use of technology and, perhaps particularly important, courage.
For the first competency, Clipper says, “Nurse executives have to build a culture of innovation within their organizations, piloting new ideas and educating their staff, physicians and patients on what [innovation] means.” She cites the growing trend among nurse supervisors to carry wireless tablets that allow them to track patient census and complete other daily tasks. This enables them to interact with staff on the floor with the information they need right in front of them, rather than staying at their desks. Such a practice also exemplifies boundary spanning, she says.
“Nurses have to understand how to lead across the continuum of care, including in both pre- and post-hospitalization roles,” Clipper says. “We are no longer siloed; we’ve been forced to learn how to expand our boundaries.”
Innovation links directly to the competency of courage, she adds. “Health care leaders will need to take more calculated risks. Innovation fails in health care because we have zero tolerance for failure. We need to be more open to pilot [new ideas], iterate and pilot again.” Such testing will not endanger patients, she says, and it doesn’t have to be expensive. “We all want to be perfect before we roll anything out,” Clipper says. “But we have to speed up our processes if we’re going to transform care.”
With those goals in mind, Clipper participated on a team of RWJF executive nurse fellows who just completed a five-year project on sustainable innovation. The group studied what nurse leaders know about innovation, how it works and how it can be used to meet the goals of the Triple Aim — or, as it is increasingly defined, the Quadruple Aim. It has developed an innovation road map to help nurse leaders bring more innovation into their organizations.
However, innovation requires collaboration, and Clipper says a “dyad leadership model” will become increasingly necessary, through which nurse executives and chief medical officers work together to achieve organizational goals. “As they respectively manage their nurses and doctors, they will need to be in lockstep with each other, asking their disciplines to do the same things at the same time,” she says. “The more we partner up front, the more successful we will be.”
“The CMO and CNE have to be partners to address the clinical agenda — and they need to be role models for how physicians and nurses should work together,” agrees Jane Englebright, R.N., senior vice president and chief nursing executive at HCA in Nashville, Tenn. “Finding the right people to put in these roles is key to establishing that mutual respect and teamwork.
Moving forward with big data
Englebright, who started at HCA as a critical care nurse, coordinated the development and installation of nursing and order-entry modules for the system’s first electronic health record. She has continued to pursue her passion for using health information technology to drive organizational change, including writing her dissertation on big data, and guiding multiple technology initiatives for the system. She moved to HCA’s corporate quality department in 1999, where she also started its patient safety program.
“CNEs need to be able to use data in comparative ways,” Englebright says. “A good portion of the data that go into EHRs comes from nurses, and, traditionally, those data have not been consumed, sometimes because information is entered in nonstructured ways that the computer can’t assimilate. We need to codify data so they can be presented more usefully for patient care, for hospital operations and for research.” It is the CNE’s responsibility to understand how to derive value from the data about nurses and nursing care in the EHR and in other information systems.
Fortunately, the incoming generation of millennial health care leaders is more technologically nimble, comfortable with a much wider range of apps and web-based solutions, Clipper says. “Many [high-tech] tasks will become very mainstream and we’ll have to speed up our adoption rate of technologies like telehealth and 3-D printing,” she says. “And many tasks, such as scheduling, will become automated.”
In such an environment, CNEs and CNOs must develop what Englebright calls “change hardiness” and model it to their staff. “Nursing has never been more of a team sport than it is today, and nurse executives need to expand their sphere of influence beyond the hospital walls,” she says. “Because of value-based care, nurses bear more responsibility for readmissions, from post-discharge phone calls to post-acute care to outreach in the community. There is a blurring of the lines between roles, and that requires more teamwork.”
Nurse practitioner Heather O’Sullivan is chief clinical officer for Cardinal Health’s affiliate naviHealth, a post-acute care liaison between health systems and plans. She has firsthand knowledge of the need for that teamwork. “Nurse leaders are optimally positioned to ensure that we look at the entire episode of care and all parts of the care continuum,” she says. “There couldn’t be a more exciting time to be a CNE. They are the most trusted advisers, and now they are being spotlighted at the executive table. And as we transform from fee-for-service to value-based care, their insight is invaluable.”
Advice for future nurse leaders
For those who want to become nurse executives, O’Sullivan advises pursuing advanced degrees in economics, health care administration or an MBA. “I look for that key talent; these will be critical roles going forward,” she says. “There is a shortage of clinicians with a business or economics background. Nurses with MBAs or other analytical experience will be sure to find positions in the coming years.” Similarly, O’Sullivan recommends that nurses who want to pursue the business side of health care should let their C-suites know. “Nurses should go to the chief operating officer or the chief financial officer and ask them about their perspective, maybe even what keeps them up at night,” she says. “They will be surprised and delighted to have nurses ask for that.”
AONE’s Swick agrees. “We have to take time to develop face-to-face relationships with our key colleagues,” she says. “The best patient outcomes happen when we work together as a team.”
Englebright says that it is the hospital's or system CEO’s responsibility to establish an organizational culture that values clinical perspectives. “The CEO champions the culture and the mission of the organization. As such, he or she must be highly visible in valuing and respecting the clinical leadership that is critical to achieving that mission,” she says. “Teaching people how to be visible in their work is what creates alignment — and that’s as much an art as it is a science.”
Technology can support nurse executives in gaining and maintaining that visibility, Englebright says. “I use an internal Facebook page to tell people where I am and what I’m doing. Some CNOs use Snapchat on rounds or send weekly e-messages. You can’t hold staff meetings as easily when nurses work three 12-hour shifts a week. The creative use of social media can provide a way to make sure we all connect — technology is one of the ways to touch direct care nurses in the middle of their workflow.” For those reasons, she also sees the chief nurse information officer as an important emerging role.
Hansen predicts that “CNEs will be key executives to align multidisciplinary care teams around mission and vision and the cost effectiveness of care — and their role will grow. Health care systems that are successful realize that the nurse executive is a necessary role.”
Clipper underscores that point. “CNEs are critical to achieving standardization, best practices and patient-centered value across the full continuum of care; our financial stability depends on it,” she says. “We are well-versed in being problem-solvers, assimilating improvements and always advocating for the patient. As nurse leaders, we are dedicated, lifelong learners and we have an obligation to remain that way.”
Executive Corner: An 'idea book' for nurse leaders
"The Innovation Road Map: A Guide for Nurse Leaders," was drafted by a team of five Robert Wood Johnson Foundation executive nurse fellows tasked with exploring how sustainable innovation works, nurse leaders’ knowledge of the concept and how it can be used to achieve the Institute for Healthcare Improvement’s Triple Aim. Published in June 2016, this “idea book,” as its authors describe it, was created to help nurse leaders introduce “the spirit and practice of innovation to their organizations” or, in other words, help to create and support an organizational culture of innovation. To do so, health care leaders must foster, model and reward the following key behaviors, the authors state.
- Divergent thinking. Such thinking allows a specific problem to be addressed by considering and connecting seemingly unrelated matters and ideas to its solution.
- Failure tolerance. Understanding that the road to success is often paved with many failures along the way, health care leaders must tolerate failure as the only way to encourage and support innovative risk-taking behaviors among their staff.
- Agility and flexibility. The ability to adjust swiftly to global market changes defines agility. Flexibility is its natural partner in achieving those rapid adjustments.
- Risk-taking. This means engaging in behaviors that involve risk in order to achieve a goal. Divergent thinking often may create ideas or projects that seem risky to undertake.
- Autonomy and freedom. When employees are given the autonomy to do their work as they see fit, this trust and freedom give them more confidence in their abilities and decisions, which may give them more willingness to continue to pursue innovative solutions for the organization.