Maintaining Positive Nursing Practice Environments in a Changing Labor Climate

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2 Maintaining Positive Nursing Practice Environments in a Changing Labor Climate Joan Shinkus Clark, DNP, RN, NEA-BC, CENP, FACHE, FAAN Senior Vice President and System Chief Nurse Executive Texas Health Resources Linda Burnes Bolton, DrPH, RN, FAAN Vice President Nursing and Chief Nursing Officer Cedars-Sinai Medical Center

3 Objectives 1. Describe the role of nurse leaders in creating a culture of shared accountability for positive practice environments 2. Identify key environmental factors that could influence positive employee relations and discuss proactive approaches to hardwire excellence 3. Identify the key strategies from the AONE toolkit on the future of patient care delivery that facilitate staff engagement, practice, and service excellence 4. Discuss the impact of shared accountability process and shared governance on unit and institutional operational goals

4 What are positive practice environments? Positive practice environments (PPE) are cost-effective health care settings that support excellence and decent work, have the power to attract and retain staff and to improve patient satisfaction, safety and outcomes. Characteristically such settings: ensure the health, safety and well-being of staff; support quality patient care; improve the motivation, productivity and performance of individuals and organizations Global Health Workforce Alliance: (

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6 Nurse Leader Role Future Care Delivery The role of nurse leaders in future patient care delivery systems will continue to require a systems approach with all disciplines involved in the process and outcome models. Accountable Care Organizations will emerge and expand as key to defining and differentiating healthcare reform provisions that will impact differing care delivery venues. Patient Safety, Experience Improvement and Quality Outcomes will remain a public, payer and regulatory focus driving work flow process and care delivery system changes as demanded by the increasingly informed public. AONE Guiding Principles for the Future Of Patient Delivery

7 Nurse Leader Role Future Care Delivery Healthcare leaders will have knowledge of funding sources and will be able to strategically and operationally deploy those funds to achieve desired outcomes of improved quality, efficiency and transparency The joint education of nurses, physicians, and other health professionals will become the norm in academia and practice promoting shared knowledge that enables safer patient care and enhancing the opportunity for pass-through dollars to apply to APN residencies and/or related clinical education. AONE Guiding Principles for the Future Of Patient Delivery

8 Recognition by Nurses for their Meaningful Contribution to Practice Communication Rich Culture The Presence of Adequate Numbers of Qualified Nurses Recognition of the Value of Nursing s Contributions The Encouragement of Professional Practice and Continued Growth/ Development Elements of a Healthful Practice/Work Environment Shared Decision Making at all Levels A Culture of Accountability The Presence of Expert, Competent, Credible, Visible Leadership Collaborative Practice Culture Nursing Organization Alliance, 2004

9 Elements of a Healthful Practice/Work Environment Collaborative Practice Culture Respectful collegial communication & behavior Team orientation Presence of trust Respect for diversity Communication Rich Culture A Culture of Accountability The Presence of Adequate Numbers of Qualified Nurses Clear and respectful Open and trusting Role expectations are clearly defined Everyone is accountable Role expectations are clearly defined Everyone is accountable The Presence of Expert, Competent, Credible, Visible Leadership Serve as an advocate for nursing practice Support shared decision making Allocate resources to support nursing

10 Nine Elements of a Healthful Practice/Work Environment Shared Decision Making at all Levels Nurses participate in system, organization, and process decisions Formal structure exists to support shared decision-making Nurses have control over their practice The Encouragement of Professional Practice and Continued Growth and Development Continuing education/certification is supported/encouraged Participation in professional association is encouraged An information rich environment is supported Recognition of the Value of Nursing s Contributions Reward and pay for performance Career mobility and expansion Recognition by Nurses for Their Meaningful Contribution to Practice

11 Labor Environment is Changing Employee Free Choice Act National Labor Relations Board (NLRB) recess appointments NLRB rule changing and legislative efforts NLRB case decisions Union consolidations and collaborations Targeted states Corporate campaigns and neutrality agreements Mandated staffing legislation

12 A tale of two organizations.. Cedars-Sinai Medical Center Los Angeles, California Texas Health Resources Dallas Fort Worth, Texas

13 Cedars- Sinai Health System Academic Medical Center plus Medical Delivery Network 951 licensed beds Mobile Medical Units 3,100 registered nurses, non union 750 union CPs, NCTs, STs, LVNs, Lift Team 12,000 employees 2,700 physicians NICHE designation Magnet designation- going for 4 th in 2012!

14 Organizational Agility: The New Imperative Clinical Quality Service Delivery Patient Safety Value Align organizational objectives with employees values. Everyone rowing together!

15 2002: A Look Back Three organizational earthquakes within three (3) months Nursing union organizing campaign loss (later overturned) Unforeseen operating loss EMR installation halted Most challenging: cultural tenor of the organization Divisive; bitter; lack of trust; failure to speak up

16 Rethinking our Approach Address key elements of employee dissatisfaction Address structure and Process Employee Engagement Employee Development Leadership Development

17 Engaging Employees Cultivate open dialogue Leaders and staff thinking together Move more problem solving to the point of service Help people gain greater sense of ownership Multiple avenues for engagement

18 A leader is best when people barely know he exists, when his work is done, his aim fulfilled, they will say we did it ourselves. Lao-Tzu

19 Adopt Dialogue as an Organization Norm Shared Governance/Shared Accountability Teams MD/RN Collaborative Transforming Care at the Bedside Performance Improvement Teams AB394 Patient Ratio Staffing Always Safe Leader Rounding

20 Transforming Care at the Bedside Engage first Teach one test of change at a time. All ideas welcome Reward and Recognize Listen to the voice of the staff Listen to the voice of the patient Outcomes- improved staff vitality, patient centeredness, clinical outcomes and value

21 Shared Governance- Engagement Nursing Coordinating Council Divisional Clinical Practice Councils 42 Unit Practice Councils on nursing units Night Shift UPC s 9 Shared Accountability Teams in other clinical areas Small groups made up of staff and leaders thinking together about unit/department specific issues Multi-disciplinary (RNs, nursing assistants, PT s, etc.) Infrastructure support. Trained facilitators, JIT education, and support for managers and chairs

22 Unleashing the Power of Employee Engagement: UPC Examples Employee Recognition cards & Employee of Quarter Transforming Care at the Bedside Involvement in Core Measures Visitor Policy Walking Executive Rounds Patient Safety Champions Sleeping Policy Enforcement English Only Policy Evidence Based Practice Champions Electronic Medical Record ED Staff Role Assignments Peer Review ED RN Handoff to Imaging Toes Out - Toes In Charge Nurse Assignment Fall Prevention NICU Manager Selection Role Clarification of PT s/ot s

23 Healthcare is a Team Sport : Employees Engaged to Improve Patient Safety Thinking together to mitigate risk and improve patient safety A safe environment requires input from those that deliver the care Always Safe Initiative Safe Choices unit based conversations Assertive communication (crucial conversations)

24 Always Safe Initiative Evolution of Thinking How to Prevent Medical Errors Early Thinking - Blame and Train ; focus on individuals Recent Thinking - No Blame Culture ; focus on systems Current Thinking - a balance of individual responsibility and system design This is the message we needed staff members to embrace

25 Always Safe Staff Engagement Staff Engagement is Key To reduce errors and improve safety, all staff are asked to focus on the inputs: Designing safe systems that catch errors or prevent them from harming the patient Helping all staff and colleagues make the optimal behavioral choices that minimize risk System Design Adverse Events Errors Learning Culture MD, Managerial and Staff Choices

26 Always Safe Key Components Management Interventions Guidelines- Leader development Updated management framework for working with staff involved in errors, or with performance/conduct issues Making Safe Choices Management and staff discussions to identify and correct where the unit has drifted from safe practice Crucial Conversations/Confrontations Skill-building so leaders will coach and hold others accountable for safe practice System Design Adverse Events Errors MD, Managerial and Staff Choices Learning Culture

27 Always Safe: Our Beliefs About Managing Risk To err is human To drift is human Risk is everywhere We must manage and support our values We are all responsible 200% Accountability is required. Leaders as coaches

28 Choosing Your Culture: NICU CSI Creating a Safe Culture and Satisfying Workplace in the NICU to 2011 The NICU CSI ( Clinical Safety Initiative ) Safe Choices conversation leads to CSI Multi Disciplinary Staff Committee Group of NICU multidisciplinary staff Assembled for the purpose of creating a safe environment All staff have opportunity to participate Staff took the lead in identifying and acting on safety issues in their unit

29 NICU CSI Realized that many issues related to safety were embedded in their culture Conducted honest assessment of current unhealthy norms Identified desirable healthy norms for NICU Aim: Replace unhealthy norms with ones that reinforce safe practice

30 February 2005 Day Shift March 2010

31 Engaging Employees in EMR Implementation November 2010 Phase 2 of EMR Install Clinical (non-md) documentation - Very strong apprehension about how staff would respond Equipment/technology aspects of CS Link were already being addressed by other departments Where help was needed was getting people to successfully Accept and Adopt the new technology

32 Applying the Principle of Engagement Ambassadors Champions Super-users MD/RN collaborative UPC s/sat s 50+ councils were put to work planning and preparing for change Facilitators were assigned to every group and groups began meeting bi-weekly Work closely with ambassadors

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34 UPC/SAT s Paint the vision Discuss what the changes would mean on their unit Identify necessary preparation Facilitators kept track of key concerns, best practices, training needs, workflow changes, staff morale, etc. Weekly report to CSMC executives

35 What did we Learn About Engaging Employees in Change? Generates enthusiasm and support Never discount the challenge of change even if you think it s simple Involve people even if you don t have a well established employee engagement infrastructure Any size change is easier if you involve people Move the conversation to the point of service

36 4.4 Change in Employee Survey Satisfied with the Satisfied with my nature of the work relations with coworkers performed Cooperation and communication between nurses and physicians Documentation provides information I need to take care of patients Satisfied with my communication about patients with non-nursing members of care team

37 What Did We Learn? when the best leader s work is done, the people say we did it ourselves.

38 24 acute-care and short-stay hospitals that are owned, operated, joint-ventured or affiliated with the system. 18 0utpatient Facilities 3,800 licensed hospital beds 21,500 employees 6700 Registered Nurses 5500 physicians

39 Texas Health Nursing Excellence Magnet designation at Texas Health Harris Methodist Fort Worth Texas Health Presbyterian Dallas Texas Health Presbyterian Plano Magnet applications scheduled for Texas Health Arlington Memorial Hospital Texas Health Harris Methodist HEB Pathways to Excellence at Texas Health Presbyterian Allen Texas Health Presbyterian Kaufman Texas Health Harris Methodist Stephenville Texas Health Harris Methodist Azle Texas Health Harris Methodist Cleburne Texas Health Specialty Hospital 39

40 Texas Health Resources First System Chief Nurse Executive Started in 2008 Serve as the senior executive overseeing the practice of nursing, and the standardization and alignment of nursing care through the implementation of evidence-based clinical and managerial standards of practice

41 Nursing Practice Environment Clinical Practice Model (CPM) model as foundational to professional practice Unit based council structure of shared accountability Partnership council for interdisciplinary coordination of activities System network of clinical operational improvement councils (COPIC) across key specialties to address standardization and clinical integration Fully integrated electronic health record

42 RN Focus Group Process Primary Purpose Gain feedback from direct care nursing staff Identify opportunities for the nursing strategic plan Validate key drivers of nurse retention and relationship to current programs, policies or methods Identity ways to communicate best practices and expectations for THR RNs Identify potential enhancements to programs and policies for THR to improve retention Provide priorities or content for manager training and/or manager action plans

43 RN Focus Group Process Focus Areas 2008 Survey Results by Age Cohorts EE Survey Results (4139 Total) Number of Questions Below Mean (Red) 1984 or later Millennial 197 (4.8%) 13 (16%) 1965 to 1983 GenX 2145 (51.8%) 62 (76%) 1946 to 1964 Boomers 1692 (40.9%) 48 (58%) 1945 or earlier Veterans 105 (2.54%) 22 (27%) Data/Question Analysis resulted in four Focus Group Topic Areas Unit Work Environment Involvement Communication Recognition

44 RN Focus Group Process Cohort Selection Four Age Groups Millennial: GenX: Boomers: Veterans: Male RN s Single Parents RN s Ethnically Diverse RN s RN s with 2 to 3 years tenure with THR (high turnover) 44

45 RN Focus Group Key Themes and THR Plan and Action Items Themes Peers and Teamwork THR Response Enhanced On-boarding, Clinical Leader Role All Groups Unique Groups Unit Council Management Management Support Recognition Communication Staffing and Support Staffing Diverse Emphasized Education Gen X Concerns about on-call, preferred electronic communication Boomers, Veterans Flexibility and time off, More reluctant to voice concerns Council Training Leadership Training Applause Program Nursing Town Halls, THR Nurse Publication Workforce Planning and Manager Education Tuition Reimbursement, Specialized Training Programs Enhanced Communication through Yammer, Facebook Scheduling, Workforce Planning

46 Regional Environmental Analysis Historical organized labor climate in Texas Hospitals Proposed Texas staffing ratio legislation Safe Staffing Act passed in 2009 Amended 2006 Tenet neutrality agreement Implications for Texas Texas targeted by National Nursing Organizing Committee - California Nurses Association (NNOC) and Service Employee International Union (SEIU) NNOC organize nurses SEIU organize everyone else

47 Current Labor Environment Advance agendas through rule making over proposing legislation NLRB 2012 recess appointments (2 Democrats and 1 Republican) Proposed changes (subject to litigation) Shortened election periods from 38 to days! (effective 4/30/12 if federal lawsuit filed by Chamber of Commerce and Coalition for a Democratic Workplace is unsuccessful) Elimination of pre-election litigation and resolution over votereligibility issues that need not be resolved prior to the election Names and addresses of employees to be provided to the petitioner NLRB could deny review and rulings post-election

48 Nursing Focus Groups, Positive Practice Environment Process Surveys, & Website for Interviews Nursing Townhalls, Rounds. Q&A Understand the Issues Diagnostic Programs Employee Assessment Survey & Focus Groups Customized Structured Interviews Customized Opinion Surveys Human Resources Practices Audit Fact-Based Problem Identification High Vulnerability to Organization Build Effective Supervisors Skill Building Employee Assessment Survey & Focus Groups Recognizing Discontent Supervisory Skill Training Management Development Organizational Development Fact-Based Leadership Preparation Supervisor & Manager Training, Internal Assessment Address Employee Concerns Practical Solutions Employee Assessment Survey & Focus Groups Issue Analysis Issue Intervention Do only those things that make sense Targeted Issue-Based Interventions Satisfaction Index: Measurement of Progress Performance Improvement Create a High- Performance Organization Performance Oriented Change Process Improvement Change Management Performance Measurement Performance Management Recognition & Rewards System Career Advancement Program, Nursing Congress, COPICs, and Councils Low Vulnerability to Organization Positive Practice Environment Through Systematic Performance Improvement 48

49 RN Engagement Results 2011 Outcomes and Progress 2008 Survey Results by Age Cohorts EE Survey Results (4139 Total) 1984 or later Millennial 197 (4.8%) 1965 to 1983 GenX 2145 (51.8%) 1946 to 1964 Boomers 1692 (40.9%) 1945 or earlier Veterans 105 (2.54%) Percentage of Questions Below Mean 16% 76% 58% 27% 2011 Survey Results by Age Cohorts EE Survey Results (5360 Total) 1984 or later Millennial 423 (7.9%) 1965 to 1983 GenX 2672 (49.9%) 1946 to 1964 Boomers 2064 (38.5%) 1945 or earlier Veterans 100 (1.9%) Percentage of Questions Below Mean 72% 59% 21% 28% Opportunity for Further Analysis Significantly Improved

50 Key System Initiatives System Wide Steering Committee Proactive Partnership with Human Resources and other key stakeholders Extensive Management Training of Supervisors, Managers, Directors and CNOs In-depth NLRB act and union campaigns Web based yearly refresher training Board of Director Education Series Staff RN Communication and Awareness Town halls Employee web site Engagement survey results Development of Contingency Plans Potential for shortened election period

51 Contingency Planning Daily plan for rapid organizational mobilization if petition occurs Use of central communication center and rapid response team Conduct townhalls at regular intervals during a 15 day campaign for centralized communication flow and to address issues arising through campaign Refresher training to entity leadership with fact sheets and strategies Daily update to senior executive team, entity leadership, and response team members, on activities and strategies Written weekly updates for all managers System CEO broadcast to all employees prior to election day

52 Summary Positive Practice Environments are not built overnight! PPEs are foundational to an atmosphere of trust and cooperation between management and staff With the proposed NLRB ruling, it will be very difficult to organizationally respond in a two week period. Build the foundation now Educate your leadership and Board of Directors about the unionization process Educate and engage your employees on the facts and implications of unionization to ensure that when or if individual choice is exercised, it is grounded in a realistic and balanced point of view

53 Contact Information: Joan Clark : joanclark@texashealth,org Linda Burnes Bolton: linda.burnesbolton@cshs.org