From Evidence to Innovation: Measuring the Foundations of Practice and Value
Case Study 5-1
Are We a System or a Confederation of Hospitals?
Pacific Grove Healthcare System comprises six community hospitals located in a 100-mile radius, two major integrated physician organizations (IPOs), a healthcare plan, a hospice and home health service, and a freestanding rehabilitation center. The corporate executives recently hired a chief nursing executive (CNE) to simplify the reporting structure for all of the CNOs at each hospital and IPO. The new CNE has a PhD in nursing and is nationally recognized for his success in developing integrated systems for health care. The new CNE has just completed a 10-year engagement at another large healthcare system that made dramatic changes in nursing services resulting in a system-wide Magnet designation by the American Nurses Credentialing Center (ANCC). The CNE published many papers and spoke at national conferences about the challenges and successes of integrating nursing services across a multihospital system.
One of the first changes that the CNE made was to develop a new structure for nursing services that included several system-wide councils for (1) operations, (2) research and innovation, (3) professional development and scholarship, and (4) clinical excellence. The CNE announced that the intent and purpose of these system-wide councils were to facilitate planning, implementation of programs and services, and evaluation of the effectiveness of nursing services across the system. The CNE emphasized the importance and value of creating the system-wide councils and the need to lead the system effort and let go of the traditional unilateral decision making by inviting others in the organization to participate in decisions that affected patient care and nursing practice.
At first the CNOs at each hospital resisted reporting to the system CNE and participating in the expansion of membership on the various system councils to individuals other than the CNOs. They viewed this structure change as marginalization of their roles and power structure. The CNE met with them individually and as a group in a planning retreat to address their concerns and shared stories and case studies from his previous organization that illustrated the benefits and outcomes of integrating nursing across the system. As a group they developed a list of attributes that they believed essential for a fully functioning system and the strategic actions that would need to take place before nursing in the system could be completely integrated. They also discussed the benefits and barriers to system work. The CNE led them through a mind-mapping experience to expand their thinking about the challenges and opportunities in leading system work. From the mind-map bubbles, the CNOs explored scenarios that would illustrate some of the situations that they might be facing in the future. The group discussed possible leaders and the membership for each of the councils and decided to invite some of the top leaders from each hospital’s Magnet council structure to participate in the system-wide councils.
To facilitate the effectiveness of this change, the CNE also engaged the services of an academic partner from one of the local universities to facilitate a professional development curriculum focused on leading group meetings, building consensus, managing conflict, managing change, financial planning and management, and system integration. Once the membership was decided and the leadership selected for each of the system-wide councils, each of the members was invited to participate in the learning experiences to build their skills and competencies in system work.
The CNE invited all of the system council members and CNOs to participate in a retreat where he presented his vision for an integrated nursing service line across all system entities. He shared that “success” would have many definitions, but one measure of success would be system-wide Magnet designation. He presented the characteristics of a high-performing system with examples of cost savings, financial gains, and program and service expansions from other system organizations that had achieved integration of patient care and nursing services across their systems. He outlined several measures that would guide the evaluation of their work, including financial, quality, satisfaction, work environment, and patient-outcome metrics. He indicated that each hospital would continue to report their individual progress on these metrics, but the aggregate of all of the system entities was a better measure of system performance. Each of them would also be evaluated on system metrics in addition to their individual entity goals. Each of the councils would include clinical nurses who were active in their unit practice councils and their entity’s collaborative governance councils.
Bolstering his vision for integrated patient care and nursing services, the CNE mentioned several business partners whose companies were interested in funding and involvement in the Research and Innovation Council, which was a tremendous opportunity to expand patient care and nursing research efforts. Academic partners representing the local colleges would also participate in the Professional Development and Scholarship Council in an effort to provide additional opportunities and resources to advance the education level and leadership skills of clinical nurses and frontline managers. It was also suggested that patient representatives be selected to participate in the Clinical Excellence Council to ensure that the “voice of the customer” was heard as a focus area for planning. Clinical nurses and interprofessional partners would be invited to participate on the Operations Council to integrate efforts of nursing and other professional providers.
At the end of the planning retreats, the CNOs and others who had participated were excited but a bit overwhelmed at the layers of change that were planned for each of their entities and for the entire system for patient care and nursing services. Some had doubts about the value of such a change, but most trusted that the new CNE would be able to direct and facilitate such a change because of his experience and reputation for accomplishing a similar process in another organization. Most were eager and pleased to be empowered to participate in such a lofty goal of integrating nursing services across the entire organization.

Questions
What is your impression of the new CNE’s plans for a layered change process to integrate patient care and nursing services across the healthcare system?
What barriers do you think will challenge the efforts toward system integration?
How do you think that the CNE can ensure accountability of his CNOs to support such change and promote systemness in their own organization as opposed to promoting their own entity’s interests?
What other metrics or measures would you recommend to assess the success of the integration process?
Describe the attributes that you think would be essential for a fully integrated nursing system.
To achieve the attributes that you outlined in question 5, what developmental elements would be needed to achieve an integrated nursing system?