How to Structure Nursing within a Health System: Part II

By Kelly Hancock, MSN, RN, NE-BC

Earlier this year, I posted part one of a two-part article series on how to structure nursing within a health system based on ‘Lessons Learned’ in our Cleveland Clinic Nursing Institute journey. The first article highlighted three of five key lessons:

• Lesson 1: Take the temperature of your current health system landscape.
• Lesson 2: Align infrastructure with operations and designate accountable leaders.
• Lesson 3: Include all appropriate audiences in the integration process.

In this second article, I will discuss lessons four and five: confirm that good process and accountability measures are in place; and set strategic direction and continually evaluate progress.

Cleveland Clinic Nursing lessons learned

Lesson 4: Confirm that good process and accountability measures are in place.

Success must be measurable. In order to analyze how well or not-so-well the overall structure of an organization is working, you must confirm that detailed, specific processes are in place.

In part one of this series, I outlined how the Cleveland Clinic Nursing organization is structured in terms of people and key areas of organizational focus – including systemwide focal areas like advanced practice nursing, care management, education and professional development, quality and practice, research and innovation, patient experience and staffing, as well as nursing at each of our regional hospitals, main campus, family health and surgery centers, and express clinics.

We thrive on process and accountability, and we do so at both micro and macro levels within each key area of focus, within our nursing organization, and within our health system.

Process training is key. When structuring a nursing organization, make sure your nurse leaders are properly trained on how to implement good processes that will lead to measureable results – and outline the various ways in which they will be held accountable. It is suggested that each leader clearly define associated goals and timeframes, conduct research and create benchmarks, ensure they have the right team members in place, and consider challenges, opportunities and best practices to successfully execute initiatives and analyze progress. Nurse leaders should do this both on a tactical level and on a program level.

It should also be clearly defined when and how leaders will be required to report results or projections, with the caveat that at any point in time, information may be needed. This means keeping up-to-date records is highly advantageous. Each week, our nurse leaders report tactical-specific and program-specific updates to the ECNO, and each month, they present progress to the systemwide nursing leadership team in an in-person leadership meeting. As the ECNO, I also report weekly updates and monthly presentations to the health system leadership team. Additional, notable progress reports are also communicated quarterly and annually.

Using various tools and resources, our nurse leaders electronically record statistics and findings for continual monitoring and evaluation, which is not only smart, but often necessary per federal regulations. For example, our chief nursing officers and their teams track metrics such as core measures, HCAHPS, CLABSI, falls prevention, staffing, finances, and more.

Through Cleveland Clinic’s web-based performance management system, we can view a general executive summary of our efforts, take a close look at our current productivity and trends in productivity, monitor documentation compliance, analyze patient experience and satisfaction scores, evaluate quality and safety initiatives and scores, customize and review monthly and annual financials, and more. We also have the ability to look at every performance metric, the associated target compared to actual reporting and the resulting variance. And we can compare month-over-month, year-over-year and so on, in an easy-to-view scorecard format.

As you think about implementing process and ensuring accountability, one of the biggest things to remember is that change is inevitable. Leaders who successfully manage change for performance improvement, or to meet industry challenges or standards, for example, are likely to experience heightened success. If change is integrated into all relevant processes, its effectiveness can be sustained, accessed and measured.

Lesson 5: Set strategic direction and continually evaluate progress.

The final of our ‘Lessons Learned’ in achieving successful nursing structure within a health system is the importance of setting strategic direction and continually evaluating strategic progress.

It’s imperative that all members of your nurse executive leadership team are closely involved in all phases of strategic planning – beginning with defining your mission, vision and values. An important part of organizational structure is making sure that the key decision-makers on the team truly believe in the foundational principles of the organization and have a hand in shaping them.

To effectively produce measurable results and grow and strengthen the organization, those at the top need to support these principles in order to transmit them throughout their teams. This means all members of the organization have the opportunity to see and understand the bigger picture, beyond their daily responsibilities.

After a series of collaborative sessions and discussions, Cleveland Clinic Nursing first launched its vision statement, our promise as nursing professionals, and our values statement – what we stand for as Cleveland Clinic nurses – in 2009. In the fall of 2011, we launched our mission statement to accompany our vision and values statements, while also slightly altering our values to ensure better alignment with the values of the Cleveland Clinic health system.

Our statements are as follows:

Mission: To be the global leader in the professional practice of nursing through education, research, innovation, collaboration and quality care where compassionate caregivers excel and patients are first.

Vision: Cleveland Clinic Nurses: Delivering on the Promise of World Class Care

Values: Quality, Innovation, Teamwork, Service, Integrity, Compassion

The support and collaboration from the entire team should continue as you outline your initial phases of strategic planning and beyond. Through forums and discussions, team members should review and consider strengths, weaknesses, opportunities and threats and collectively determine specific strategic themes. In our case, we defined four themes that we would focus on as strategic priorities for two years, but with the notion that we would need to continually evaluate these as our profession is one that is fast-paced and ever-changing.

It can require many days, weeks, months and sometimes years, to see specific strategies and tactics come to fruition, and there can certainly be roadblocks along the way. Strategic planning needs to be part of everyday existence and discussed in weekly and monthly executive meetings.

It also needs to include dedicated and ongoing involvement from other nurse leaders within your organization, such as nurse directors and nurse managers, so that it successfully reaches frontline nurses. This can be achieved through committees, councils, affinity groups, shared governance and more.

When we formed our Nursing Institute, one of the more significant ways we included our comprehensive nursing leadership team in strategic planning was through an annual Nursing Leadership Summit. The Summit, which continues to be held every July, is an interactive, strategic planning forum designed for our 450 nurse leaders, from executive leaders to hospital leaders and nursing floor/unit leaders.

It is intended to set or regenerate strategic planning and organizational direction and often includes guest presenters, open discussions and updates, brainstorming and idea generation, table work, break-out sessions, video highlights and more. The 2015 Summit theme was: “Creating excellence at the intersection of leadership and care management.”

The day followed the ‘appreciative inquiry’ model for creating leadership change by valuing the best of what is and envisioning what will be, and should be. In the morning, our nurse leaders reviewed our identified strategic themes and shared a selection of notable best practices that align with each. In the afternoon, we turned our focus to the future, delving into areas such as care coordination, advanced practice nursing, and nursing research and innovation.

Throughout the entire day, our nurse leaders were charged with thinking creatively about our strategic direction – considering what’s been working as well as what hasn’t, and how our current organizational strategy is or is not positioning us for success as we move forward.

Best practices and other lessons learned

I hope you enjoyed this two-part series on the lessons our Cleveland Clinic Nursing organization learned as we officially created our nursing structure within the Cleveland Clinic health system. I’m sure many of you reading this have additional tips, advice, best practices and lessons learned throughout your organizational journey. Please feel free to comment and share!

Kelly Hancock is the Executive Chief Nursing Officer of the Cleveland Clinic Health System, and Chief Nursing Officer of Cleveland Clinic Main Campus.