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Redirecting the Workflow River

Operations and systems changes when a hospital joins the enterprise

Hospital integration

A healthcare organization’s culture includes everything from standards of medical care to brand colors, from safety policies and pay structures to the employee wellness program. In short, every health system has a long “how we do things and why” list, which must be incorporated by a newly acquired hospital.

That integration process is inherently gnarly, but with the right approach it can proceed smoothly. Introducing major systems quickly and establishing strong communication early on go a long way, says Matthew Slife, Executive Director of Cleveland Clinic Nursing Operations.

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Slife oversees resources and manages nursing-related integration of new hospitals into the Cleveland Clinic health system. That includes nursing policies and practice, equipment, staffing models, compensation structures, even uniforms – major change-management elements.

Communication

A smooth integration depends on clear, two-way communication and an open-minded approach.

“We come in to the new hospital and communicate about the Cleveland Clinic way, but it’s also important to listen,” Slife says. “If you don’t take the time to stop and listen, you won’t recognize leading practices that may be in place already.”

Sometimes those practices are worth incorporating throughout the system. Slife recently was part of a team of Cleveland Clinic leaders who visited hospitals in Florida that have been acquired over the last several years. “I have a dozen pictures on my phone and a notebook full of notes about ideas I want to bring back from [Cleveland Clinic] Martin Health and Indian River,” Slife says. “It’s important to walk around, talk to caregivers, and learn the culture of the new hospital: what they do well and where they think there is room for improvement.”

Although key systems still need to be integrated, nurse leaders almost immediately began the important work of integrating Cleveland Clinic nursing culture at the Florida hospitals, Slife says. “They did a lot of work to ensure that the practice of nursing was consistent – that even though the Florida hospitals have been on different information systems, the expectation is that everyone will deliver the same high-quality standard of care,” he says.

Systems integration

From a technological standpoint, three key systems need to be aligned from a Nursing perspective, Slife explains: electronic health records, policy systems, and payroll and timekeeping.

“Once those are implemented, you have 90% of your systems implemented that impact nursing,” he says.

Aligning these systems allows data and information to be accessed uniformly. “You can push a button to get the information you need for reports,” he says. “You don’t need to add footnotes to presentations that explain that you’re missing data from certain hospitals.”

Information technology integration requires far more than equipping the new hospital with computer terminals.

“Workflows are the biggest challenge to build,” Slife says. “A hospital new to the system has had an established way of checking in their patients, documenting, ordering medications and supplies, scheduling resources, and applying charges to patient accounts. Our Nursing Informatics teams partners work with our technology teams to build and test these workflows prior to go-live.”

From a human resources perspective, standardization must be applied to job codes, naming conventions (patient care technicians versus patient care nursing assistants, for example), pay grades and pay practices.

Barbara Yingling, MAed, BSN, RN, Chief Nursing Officer at Cleveland Clinic Mercy Hospital, which joined the system in 2021, says that a great deal of preparation goes into converting software and technology. The hospital recently converted its HR and timekeeping systems.

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“This was a big change, as both systems affected every employee in some way or another,” Yingling says. “The initial work of mapping the caregivers to the correct department, manager and director is very important. If it’s done incorrectly, there is a great deal of re-work.”

Management of information on incoming and outgoing caregivers and tracking open positions must be established, and managers have to be trained to use the new system.

Workforce management changes can be huge.

“Some hospitals are still using spreadsheets for filling shifts, or they’re using pencil and paper,” Slife says. “There is a great opportunity to leverage analytics to better inform your staffing needs.”

Cleveland Clinic relies on Epic medical record-keeping software and Kronos workforce management software to inform the scheduling process. “Patient loads are fed from Epic into Kronos,” Slife explains. “Based on the expected census on a given unit, we know we’ll need seven nurses and four technicians, for instance. That all needs to happen within the system, so we have to make sure that what we build per unit and that those census feeds makes sense.”

Every integration needs to introduce new technological workflows along with the operational workflows that support them. “We also try to infuse [operational] policy changes at the same time,” Slife adds. “Some of that policy will be electronically enabled in the system, so what may have been done manually will now be automated.”

Overall best practices

In addition to the challenges of introducing new technologies and workflows, hospital integrations require attention to a host of other details.

“Cleveland Clinic does a really good job with introducing our signage, culture, education and support programs for caregivers,” Slife says. “Our Caregiver Office and Nursing Education teams have a very effective playbook for infusing value to the caregivers of our newly acquired hospitals.”

Susan Clark, DNP, RN, CNL, is Chief Nursing Officer of Martin Health in Florida, which joined Cleveland Clinic in 2019. Her advice for other organizations facing the integration process is to introduce software systems as early as possible. “Without this happening up front, many of the requests for data and reporting have to be done manually, which adds a great deal to caregivers’ workloads,” she says.

“Also, consider time needed for training and how that affects teams, especially with existing workforce shortages,” Dr. Clark adds. “This transition presents an opportunity to change longstanding practices that will not work well moving forward. Creative strategies and flexibility in training options will be key.”

Finally, Dr. Clark says, it’s important to be mindful of how policies in different areas affect each other. “Even though there is a structured policy integration workflow, we are not often aware of changes to policies outside of nursing that can potentially affect our workflow,” she says.

Respecting the culture

Slife’s career experience includes system integrations both within and beyond healthcare. One of the biggest mistakes organizations make when they incorporate an existing entity into their system is “mowing down the culture of who they’re acquiring,” Slife says. “You can lose engagement from the new team and lose a lot of good ideas,” he says. “When Cleveland Clinic acquires a hospital, we paint the walls white, put gray on the floor, and the nurses will wear white scrubs. But we understand that there is also so much local flair worth preserving. That home ecosystem drives value for the caregivers, the community and, ultimately, the patients we serve.”

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Slife’s career experience includes system integrations both within and beyond healthcare. One of the biggest mistakes organizations make when they incorporate an existing entity into their system is “mowing down the culture of who they’re acquiring,” Slife says. “You can lose engagement from the new team and lose a lot of good ideas,” he says. “When Cleveland Clinic acquires a hospital, we paint the walls white, put gray on the floor, and the nurses will wear white scrubs. But we understand that there is also so much local flair worth preserving. That home ecosystem drives value for the caregivers, the community and, ultimately, the patients we serve.”

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