Perspectives on the Acute Care Continuum

The Acute Care Continuum is the integration of urgent, emergent, inpatient and post-discharge care of patients with acute medical conditions. 

Transforming Hospital Culture Through Staff Empowerment

3/31/2016 12:10:54 PM | 0 comments

When we asked CEP America leaders for examples of great hospital cultures, they enthusiastically pointed us toward John Muir Medical Center – Concord (Calif.). In today's post Donna Brackley, RN, Senior Vice President, Patient Care Services and CNO, talks about her hospital's journey toward staff empowerment and care excellence.

Welcome, Donna. Can you tell us a little about your hospital?
Sure. We're a non-profit, 245-bed community hospital located about 30 miles east of San Francisco. Our ED, which is staffed by CEP America, sees over 60,000 visits a year.
I understand you joined the hospital during a time of transition.
Yes, you could say that. I was recruited as CNO in 2000. The hospital had undergone a major reorganization in 1993 and a merger in 1997.
When I arrived, I thought the frontline staff had a great spirit. In particular, there was a strong sense of collegiality between the nurses and physicians. But people also seemed demoralized. After a merger, there's often a sense of loss as the organization's identity changes. Many people also felt that they hadn't been heard during the change process.
How did you start taking the hospital in a new direction?
In my first year-and-a-half as CNO, I focused on getting to know the nurses and their vision. We didn't really use the term "culture" at the time, but we had a lot of discussions about what they wanted their work environment to look like.
Over time, it became clear that our nurses really wanted to influence their practice and to be respected for their knowledge. I began to consider the Magnet Recognition Program as a vehicle to engage the staff and organization.
What is Magnet?
It's the highest level of recognition offered by the American Nurses Credentialing Center (ANCC), and it's based on both nursing excellence and quality patient care. A key aspect of the Magnet model is that it empowers frontline staff to take ownership of their practice.
To achieve Magnet designation, hospitals embark on a multiyear process called a Magnet journey — which is a fitting name, when you consider everything involved. But it's really worth the effort. Research suggests that Magnet organizations have lower mortality rates and better patient safety metrics.  Patient, physician, and staff satisfaction tend to be better. And only about 8 percent of hospitals are Magnet designated, so it really places you among the best in the country.
How did you achieve buy-in for this initiative?
The CNO of our sister hospital [John Muir Medical Center – Walnut Creek] also wanted to take her hospital on a Magnet journey. So together we researched the idea and presented it to the Board of Directors.
Our administration was very supportive, but the frontline staff was initially reticent. They supported the concept, but were unsure how this would impact their clinical and professional practice.
In 2004, you got the green light to proceed. What changed?
One of our initial changes was to establish unit-based councils. These councils assume ownership for professional practice, outcomes, and application of evidence-based practice. Nurses are encouraged to bring recommendations to the council for consideration.
Council-based governance affirms the professional status of nurses. After all, our nurses are closest to our patients. We value their ideas and opinions and want to bring them forward.
Councils can take several forms. Each nursing unit selects interested staff to participate in its unit-based councils. Unit-based staff also participates on practice and quality councils. We’ve established a collaborative practice committee spanning several disciplines —including lab, radiology, hospitalists, and respiratory therapy — to support interprofessional collaboration. And councils can work for any discipline. Our respiratory therapy team successfully established a unit-based council, expanding the concept beyond nursing.
One of our early successes occurred when the Nurse Practice Council expressed a desire to organize Nurses Week activities. They created Nightingale Awards to recognize positive attributes in nurses. The awards are so meaningful, the practice council sponsors them each year during Nurses Week.
In 2007, you applied for Magnet designation.
Preparation is a multiyear process, and what a process it was. We submitted an extensive application. Then the ANCC conducted a three-day on-site visit that included interviews with nurses, physicians, board members, administrators, and community members.
So it was pretty tough when we didn't get recognized our first time around. The reviewers felt that while we'd made a lot of positive changes, they weren't really enculturated yet.
We talked about next steps, and our staff was still really enthusiastic about moving forward. But instead of reapplying in six months, which was the minimum wait period, we decided to take two years to fully enculturate both our practice and shared governance models. And it paid off. We were recognized in 2010.
Do you think this journey has changed your culture?
At our last Magnet survey in May 2015, one of the reviewers asked, "What is it about this place? There's a sense of caring that you don't feel everywhere. Is it in your DNA?"
Our hospital president Mike Thomas replied "yes," and I have to agree. In my 45 years in nursing, I've never before encountered a hospital with this level of caring, collegiality, and compassion. The sense of working together as a team is one of our strengths.
I understand that only 11 percent of Magnet hospitals are unionized, and you're one. How do you make it work?
Philosophically, unions haven't always been supportive of Magnet. Collective bargaining requires a degree of self-governance while Magnet is all about shared governance. So it can be an interesting line to walk.
What's helpful is that Magnet addresses many areas that collective bargaining doesn't. All nurses, unionized or not, want to have a voice in how they deliver patient care. It also helps that we have a good relationship with the California's Nurses Association and provide lots of transparency around what we do.
You know, our physicians have a lot of praise for the work you've done.
The CEP America physicians have been huge supporters of our Magnet journey — and of our nurses in general. Mike Thomas really believes that strong dyads between nursing and medical directors are essential to our success. And that's consistently been the case in our ED.
The ED physicians and nurses have collaborated on a long list of projects, including an ED redesign, the launch of Rapid Medical Evaluation (RME)®, nurse-initiated order sets, security procedures, and our Code Green surge policy.
So when it comes to culture change, do you ever get there?
I think Magnet is a great metaphor for culture change, because the journey never really ends. We're reevaluated every four years, and the ANCC adds new standards every cycle. So we're always working toward outcomes that can be improved.
Hospital culture works the same way. There are always new problems to solve, new dynamics to manage, and personalities to integrate. It's incredibly challenging to keep all the moving parts working in harmony, but it's incredibly rewarding as well.

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