It's been just a few years since Northern Michigan Regional Hospital in Petoskey made headlines for its difficult relations with organized nurses. The hospital goes on record as having the longest nursing strike in the United States: half its RNs went on strike in 2002 in a work stoppage that wasn't resolved for five years. It was a painful and divisive event that not only rocked the hospital, but also divided the Lake Michigan resort community of 6,000 people.
Today the hospital is a paragon of progressive nursing management, achieving the American Nurses Credentialing Center's Magnet designation in 2011, which in part involves strong nursing representation at the top of the organization. Also, hospital CEO Reezie DeVet is a registered nurse, as is chief operating officer (and chief nurse executive) Mary-Anne Ponti.
Elise Hayes, a member of the hospital's board since 2006 (the last year of the strike), says the hospital's efforts to bring nursing concerns to the fore were not in response to the strike, and would have happened either way. Still, she acknowledges the focus on nursing has improved communication with bedside nurses. The previous CEO was responsible for setting in motion a nursing strategic plan and other efforts to update the hospital's management style. Hayes also credits Ponti, who was hired in 2007 and soon thereafter championed the Magnet Recognition Program process.
For the board, the increased attention to nursing has meant integrating nursing concerns into every meeting, and having the chief nursing officer in attendance to answer questions. In particular, applying for Magnet designation helped the board better understand the importance of such nursing-centric issues as quality, safety and patient-centered care. "It just brought a whole different culture to our organization," says Hayes. "It brought us closer to the nursing staff, which was a good thing."
Quality, Safety Resource
Northern Michigan's evolving focus on nursing in the board room is a common one for small and medium-sized community hospitals that are finding nurse leaders' input crucial to meeting modern expectations about documenting quality improvement and bolstering both patient and staff satisfaction. The increased use of tools like balanced scorecards are opening trustees' eyes to issues beyond the balance sheet, and boards are realizing that fiduciary duty encompasses measures of patient safety and improved outcomes.
Having a nurse leader in regular contact with the board is crucial to making this transformation, nurse leaders and trustees say. "I would be very concerned for organizations that do not have exposure to their nursing leadership," says Ponti. "I'm at every board meeting as a staff person. You've got to have exposure to the board so if they ever have questions and concerns, or hear something in the community, they will pick up the phone and ask me. You have to have trust, and it has to go both ways."
At the same time, trustees need to be ready to hear what nurses have to say, says Beth Brooks, R.N., president of Resurrection University, a health sciences institution associated with Resurrection Health Care in Chicago. Prior to this role she spent some time as a member of a hospital board that was more traditional, focusing largely on financial and physician issues. She found that the community and patient care points of view received less time on board meeting agendas.
"The nurse on the board will make unique observations and perhaps uncomfortable comments," Brooks says. "When a board appoints a nurse, the board needs to be ready for comments and questions about community health and wellness, disease prevention, health promotion, patient safety, quality, and the expanding role of advanced practice nurses to provide primary care, which may not have been raised when there was not an RN on the board."
Nurses bring a different world view to the table, she adds. "A lot of times boards have community members with expertise in banking, finance, insurance and law," Brooks says. "While these experts bring valuable knowledge to the board, they often need basic education around quality, patient safety and community health. Nurses can bring that expertise to the table."
"I grew up in the days when the nurse executive was never at the board meeting," says Laura Caramanica, R.N., vice president and CNO at WellStar Kennestone Hospital in Marietta, Ga., and president of the American Organization of Nurse Executives, an American Hospital Association subsidiary. "Now it's unusual for them not to be there. I really do think that more people realize what nurses bring to the table in terms of quality and safety."
Keeping the Board Up-to-Date
Boards can bump into the issue of where they draw the line between the big-picture strategic issues handled by trustees and the operational topics that are the purview of management. While the basic advice hasn't changed about avoiding getting into the weeds of operations, boards are finding that they may benefit from learning some specifics about particular projects so they can better understand the strategic initiatives' relevance to the bottom line.
Sandy Reed, R.N., a former CNO and now consultant with B.E. Smith, sees a clear demarcation between the board's business and that of management. "You need to share with the board how they're doing in achieving the metrics they've set as goals," says Reed. "What the board doesn't want to get involved with is how you achieve it. You leave that to the operations people."
Nurse executives may address the same issues with the board and with their staff, but the conversations are different, Caramanica says. "With the board, you want to convey to them what you are trying to do to mitigate a problem and ensure safety and quality," she suggests. "That's a different conversation than what you have with your troops, which is talking about the barriers that are getting in our way and what we need to do about them."
Sometimes specific examples can help the board better understand the problems facing the hospital and how they are being resolved. That information, in turn, can help trustees when they go out into the community and answer questions from patients and other stakeholders. For Hayes, who is also president of the hospital's foundation board, it's valuable to be able to explain why health care costs so much.
"From a fundraiser's point of view it's very important for me to understand the quality and safety issues, so I can speak intelligently about the cost of care," she says. At her hospital, the board gets a regular briefing from CNO/COO Ponti about the balanced scorecard, with regular deep dives on particular aspects of it.
When there is a major project such as the rollout of a computerized provider order entry system, the board gets briefed at a deeper level because of IT's wide-ranging impact on patient care processes and physician satisfaction and the risk of something going wrong along the way. Before the CPOE implementation began, Ponti gave the board a presentation that emphasized the importance of the project to patient safety while acknowledging how disruptive the change can be to many people's jobs. In the presentation she talked about why CPOE is important — its potential in eliminating the ambiguity of handwritten orders, the benefits of alerts and allergy checks, how it enables medication reconciliation — and how physicians and staff members were prepared for the change. She spent about 20 minutes covering how the system works and explaining what would happen when it went live, including the possibility that there could be technical difficulties. As it turned out, there were some glitches that prompted a delay from September to November. "I was so glad I had given them this heads up," Ponti says in retrospect. "I presented to the board on a Monday and later that week we had to postpone" the go-live date.
The board received weekly updates on the project and once it was up and running for a few months, Ponti gave a new presentation on what the organization had learned up to then. This kind of board education can pay off in ways that are hard to measure. "They may run into physicians in the grocery store, and they have to be prepared" to discuss why the hospital was making such a major change to their daily work life, Ponti says.
Ponti also makes use of case studies, which she presents to the board's quality and finance committee. Often these describe the root cause analysis of near-miss situations, and the patient stories help convey the human side of a topic that can be painfully dry.
While the board may hear most often from the CNO and other nurse managers, there certainly could be times when front-line nursing staff address the board, and that experience can be particularly empowering for individual nurses.
"It's a wonderful idea, and I've seen that many times," Reed says. "You have a large strategic objective and it's driven down through the organization at all levels, and a final presentation is brought to the board." The board likely doesn't have time to hear such presentations at each meeting, but they can be valuable both for the trustees to see how strategy makes its way to the patient's bedside, and it's inspiring for staff nurses to have the chance to address the board of trustees directly.
One way to keep quality and finances in perspective is to combine the topics on a board committee, as was done by Northern Michigan Regional Hospital. Trustee Hayes says the setup has been particularly helpful in keeping both quality and finances in mind in every decision, and successfully balancing the two.
Bottom Line Impact
Consultant Reed says she sees organizations across the spectrum, from those with traditional financially oriented boards to others that have expanded their focus to include patient care and the nursing perspective. "We're seeing more inclusion of the chief nurse," says Reed. "They're being very interactive with boards because it's become very complex, with quality and satisfaction becoming more important financially."
Nurses learn in school to look at the entire continuum of care, with an emphasis on wellness and prevention. "That's a very different world view from the acute care model that a lot of hospitals are struggling to move away from," says Brooks. "We lead with, 'we're here for patients,' rather than the traditional 'we have to buy this piece of equipment to draw physicians to practice here.'"
Organizations increasingly rely on the CNO to have a wide array of skills, Reed says. "To be successful (as a CNO) you have to have great financial knowledge as well as quality knowledge to meet the expectations of government requirements and reimbursement," she says. Brooks also differentiates between the "old-style" CNO who focuses largely on managing a nursing workforce, and the modern version, who is a leader in quality, safety and satisfaction, and even may oversee departments beyond nursing.
"It's very important for boards and CEOs of those organizations to understand they need to have, in this day and age, a very quality, outcome-driven person in that role," Reed says. "That's where they need to move. They need to reevaluate that position in their organizations."
Reed sees a lot of hospitals, particularly smaller and rural organizations, that need to get up-to-speed on evidence-based practice, and the nursing leadership can help. Culture change doesn't happen overnight, notes Les MacLeod, interim CEO at Huggins Hospital in Wolfeboro, N.H., where he is taking a leave from his position as professor of health management and policy at the University of New Hampshire in Durham. But, he adds, hospitals that need to evolve quickly don't have a long time to get used to the idea of a bringing the nursing perspective into the board room. "The health care system is changing quickly, and what used to take a decade [to evolve] is now taking a year or even months," MacLeod says.
Trustees need to remember that day-to-day patient care — the domain of nurses — relates directly to the bottom line. "Nurses play such an essential role in all aspects of your organization," MacLeod says. "So many of your resources are determined by a nursing perspective. And nursing is essential to patient satisfaction. If your nurses aren't happy, your patients aren't going to be happy."
Other nurse leaders and consultants agree that this is the time for the board to be listening carefully to the nursing perspective.
Small and rural hospitals are looking at affiliations with bigger systems to take advantage of their economies of scale and management expertise. Northern Michigan, in fact, just inked a deal with Flint-based McLaren Health Care after four years of considering its options. Northern Michigan will be the only one of the system's 10 hospitals to have Magnet status.
Ponti is happy to have been part of the conversation about the affiliation question. "The board seeks my input on all kinds of issues," she says. "We've got a very good board. They've been very thirsty to learn and know what's been going on with nursing."
Meanwhile, hospitals are being encouraged by payers to learn and use the concepts of coordinated care, about which nurses can be a crucial resource. "It's important that we figure out how to manage a patient throughout the continuum of a hospital stay and beyond," Reed says. Nurse leaders who are able to do that will be successful in leading their organizations in this fast-evolving health care environment.
Cheryl Hoying, R.N., senior vice president for patient services at Cincinnati Children's Hospital Medical Center, has been brought in to participate in board discussions on coordinated care. "You can't do the coordination of care and be interdisciplinary if you don't have nursing's voice there," she says.
At the board's retreat in June, Hoying has been given a coveted spot as the speaker kicking off the meeting, in part because of her position as a national leader in AONE and as interim dean at the University of Cincinnati College of Nursing. "I'll be up in front of the board and able to showcase all the things nursing does and how it impacts our organization," Hoying says. Despite the competition for the attention of busy, high-level people, Hoying argues that nurses need to push for a place at the table. "Nurse leaders shouldn't back off, they need to have their voices heard."
Jan Greene is a freelance writer in Alameda, Calif.
Sidebar - Poll: Increase Nurse Influence on Policy
Trustees with nursing backgrounds can bring valuable expertise and insight to governance. For more, see the Web-only feature "Adding a Nurse to the Board."