A Strategic Approach to Confronting Nurse Turnover€¦ · A Strategic Approach to Confronting...

Key Issues and Best Practices

HR Advancement Center/Nursing Executive Center

A Strategic Approach to Confronting Nurse Turnover

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Road Map

©2016 The Advisory Board Company • advisory.com • 32724C

The Scope of the Challenge

Prioritizing your Solutions

The Critical Role of the Nurse Manager


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Nursing at the Heart of Transformative Change

Future of Nursing: Leading Change, Advancing Health

Working on the front lines of patient care, nurses can play a vital role in helping realize the objectives set forth in the 2010 Affordable Care Act, legislation that represents the broadest health care overhaul since the 1965 creation of the Medicare and Medicaid programs.

Institute of Medicine

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Source: Institute of Medicine, “The Future of Nursing: Leading Change, Advancing Health,” available at: http://www.iom.edu/Reports/2010/The-Future-of-Nursing-Leading-Change-Advancing-Health, accessed November 11, 2011; Nursing Executive Center analysis.


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Source: Advisory Board interviews and analysis.

A Reminder of Human Resource Costs

1) Excluding capital expenditures. 2) Other services, professional fees, utilities, etc.

Representative Hospital Operating Budget1

20.3%

45%

6.5%

14.6%

13.6% Salary and Wages

Benefits

Medical Supplies & Products

Prescription Drugs

Other2


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Source: Annual Turnover, Vacancy, and Premium Labor Benchmarks, HR Advancement Center.

1) Turnover rate is determined by dividing total number of separations among all full-time and part-time employees between January 1 and December 31 by the average of the total number of full-time and part-time employees over that time frame. Excludes PRN, per diem and casual employees.

2) N-value for 2015 benchmark cohort.

A Clear and Troubling Trend

8.7%

9.8% 10.1% 10.6%

11.1%

12.0%

2010 2011 2012 2013 2014 2015

Median Bedside RN Turnover Rate1 n=3762


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Quickly finds clear, concise job posting

Does Your Recruitment Strategy Need an Overhaul?

Source: HR Advancement Center interviews and analysis.

“Employer-Centric” “Candidate-Centric”

Eventually has impersonal interview with hiring manager focused on needs of organization

Stumbles on daunting, requirement-heavy job description

Spends 1-2 hours completing lengthy application

Experiences “radio silence” for 2+ weeks

Receives offer several weeks later

Enjoys stimulating interview with hiring manager who promotes employee value proposition and sells the job

Spends 3 minutes to “express interest” in posted position

Receives phone call from recruiter within one day

Receives offer within a few days

Organizations taking this status quo approach to recruiting ~ 90% Organizations reaping

competitive advantage of candidate-centric recruiting

~10%


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Source: “Labor Force Statistics from the Current Population Survey, Table 11B, Employed persons by detailed occupation and age,” Bureau of Labor Statistics, 2015, http://www.bls.gov/cps/cpsaat11b.pdf; Nursing Executive Center analysis.

A Look at the Health Care Workforce by Generation

Proportion of the RN and Hospital Workforce by Age Group in 2015

Millennials Baby Boomers Gen X

< 1%

4%

24% 24% 24%

19%

4%

1%

6%

25%

22% 24%

19%

4%

16-19 20-24 25-34 35-44 45-54 55-64 65+

RN Hospital


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Losing First-Year Staff at an Unsustainable Rate

Source: Annual Turnover, Vacancy, and Premium Labor Benchmarks, HR Advancement Center.

1) N-value for 2015 benchmark cohort.

Percentage of Nursing Turnover Attributed to Employees with Less than One Year of Tenure

20.0% 18.2%

23.2%

2013 2014 2015

n=3051


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The Now Well-Established Case for Engagement Linking Engagement to Outcomes

Source: “The Loyalty Connection- Patient Loyalty Starts with Employees,” Press Ganey Associates, available at: www.pressganey.com, accessed October 31, 2006; “Working Today: Understanding What Drives Employee Engagement,” Towers Perrin Talent Report, 2003; Nursing Executive Center analysis.

Revenue Growth

Cost of Goods Customer Service

Customer Focus Score

Engagement

Growth Rate

Engagement

Growth Rate

Engagement

Patient Satisfaction

Employee Satisfaction



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Defining the Engagement Ambition

Source: “Employee Engagement Higher at Double-Digit Growth Companies,” Hewitt Research Brief, 2004; “Working Today: Understanding What Drives Employee Engagement,” Towers Perrin Talent Report, 2003; Wellins RS, et al., “Employee Engagement: The Key to Realizing Competitive Advantage,” DDI, 2003; Harter JK, et al., “Business-Unit-Level Relationship Between Employee Satisfaction, Employee Engagement, and Business Outcomes: A Meta-Analysis,” Journal of Applied Psychology, 2002, 87(2): 268–279; Harter, JK, et al., “Well-Being in the Workplace and its Relationship to Business Outcomes: A Review of Gallup Studies,” American Psychological Association Press, 2003; “Driving Performance and Retention Through Employee Engagement,” Corporate Executive Leadership Council, 2004; Laschinger HK, et al., “Organizational Trust and Empowerment in Restructured Healthcare Settings: Effects on Staff Nurse Commitment,” Journal of Nursing Administration, 2000, 30(9): 413–425; Kahn WA, “Psychological Conditions of Personal Engagement and Disengagement at Work,” The Academy of Management Journal, 1990, 33(4): 692–724; May EL, “Are People Your Priority?,” The Great Place to Work Institute, Healthcare Executive, 2004; HR Investment Center analysis

Willing to exceed expected level of effort

Inspired to do best work

Personally motivated to help

organization succeed

Key Attributes of Engaged Employees


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Acknowledging Difficult Times

Source: Nursing Executive Center interviews and analysis.

Market Forces Exacerbating the RN Engagement Challenge

Exhausting Pace of Change

Downward Margin Pressure

A More Personal Challenge “Years ago, I was largely a hospital-focused leader of a nursing workforce. Today, my responsibilities include departments well beyond nursing.”

Chief Nursing Officer

” Future

Uncertainty


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A Distinction with a Strategic Difference Disengaged Staff Require a Different Strategy

Source: Advisory Board Survey Solutions interviews and analysis.

Disengaged Ambivalent Content Engaged

Engagement Distribution

Up or Out Build Engagement


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Three Guiding Principles

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2

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Millennials aren’t from Mars

The ties that bind the health care workforce are stronger than the ties that divide

Don’t lose sight of the forest for the trees (especially with data)



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Source: Advisory Board Survey Solutions’ National Employee Engagement Database, 2015; HR Advancement Center analysis.

1) The 2015 model for Millennial respondents includes 27 of 42 drivers with an r2 value of .603. 2) The 2015 model for all respondents includes 27 of 42 drivers with an r2 value of .602. 3) For the overall cohort, the 9th driver was “My organization helps me deal with stress and burnout” (the 12th driver in the millennial cohort).

Drivers of Engagement: Millennials vs Overall

Top 10 Drivers by Impact on Engagement Determined by Multivariate Regression Analysis of 42 Engagement Drivers

Overall Rank² Driver

1 I believe in the organization’s mission 1 2 Organization provides excellent care 2 3 I am interested in promotion opportunities 3 5 Executive actions reflect our mission and values 4 4 My current job is a good match for my skills 5 6 My ideas and suggestions are valued 6 7 I understand how my work contributes to the organization’s mission 7 8 My recent performance review helped me to improve 8 11³ Organization recognizes employees for excellent work 9

Millennial Rank¹

10 10 Training and development opportunities helped me to improve


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Source: Advisory Board Survey Solutions’ National Employee Engagement Database; HR Advancement Center analysis.

1) Average of 6-point responses to four statements: This organization inspires me to perform my best, I am willing to put in a great deal of effort in order to help this organization succeed, I would recommend this organization to my friends as a great place to work, I am likely to be working for this organization three years from now.

Quantifying Engagement and Likelihood to Stay

Engagement Index1 “I am likely to be working for this organization three years from now.”

< 3.50

3.50-4.49

4.50-5.49

5.50-6.00

Disengaged Ambivalent Content Engaged

1.00

2.00

3.00

4.00

5.00

6.00

Strongly Disagree

Disagree Tend to Disagree

Tend to Agree

Agree Strongly Agree

Likelihood to Stay Score:


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Early-Tenure Millennials: Engaged, But Not Yet Loyal


Age Tenure

Less than 1 year (n=32,223)

1-3 years (n=72,917)

4-6 years (n=38,573)

7-15 years (n=73,021)

Greater than 15 years (n=50,346)

Younger than 25 (n=12,317)

0.44 0.41 -- -- --

25-35 (n=68,856)

0.20 0.23 0.09 -0.03 --

36-45 (n=61,277)

0.09 0.10 0.01 -0.06 -0.17

46-55 (n=64,621)

0.06 0.05 -0.01 -0.09 -0.17

Older than 55 (n=60,027)

0.19 0.18 0.17 0.16 0.29

Gap between Engagement Index and Likelihood to Stay Score


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1) The 2015 loyalty model for under-age-25 respondents includes 12 of 42 drivers with an r2 value of .30. 2) The 2015 loyalty model for aged 25-35 respondents includes 21 of 42 drivers with an r2 value of .35.

Identifying the Most Impactful Drivers of Millennial Loyalty

Top Drivers by Impact on Loyalty for Staff with Less than Three Years of Tenure Determined by Multivariate Regression Analysis of 42 Engagement Drivers

Age 25-35 Rank² Driver Under Age 25

Rank1

I am interested in promotion opportunities

My current job is a good match for my skills

Organization provides excellent care

Organization helps me deal with stress and burnout

I believe in the organization's mission

My most recent performance review helped me to improve

Organization does a good job selecting new technologies

The benefits provided by my organization meet my needs

Organization pays me fairly for my job

Training and development opportunities have helped me to improve

I have helpful discussions with my manager about my career

My unit/department has enough staff

1 2 3 4 5 6 7 8 9

10 11 12

1 2 6 3 4 7

10 18

5 8 --

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Getting in the Millennial Mindset

Millennials Think more in short-term increments

Millennials Have more opportunities than ever

Millennials Have fewer past work experiences for perspective


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Contributing Factors for Turnover-Where to start?

Stress

Staffing

Teamwork

Commitments Outside of

Work

Source: Advisory Board Survey Solutions’ interviews and analysis.

Location of Organization

Nurse Manager Effectiveness

Inolvement

Growth Opportunities


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Best Practices to Retain Millennials

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Bolster New Hires’ Ability to Cope with Workload

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Embed Short-Term Growth in Entry-Level Roles

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Equip Managers to Detect Retention Risk

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Win Back Early-Tenure Staff Mid-Flight

3. Early-Tenure Career Ladder

4. Targeted Role Transitions

5. Career coaching

8. 30-60-90 Day Check-in Prompts

9. Manager-Led Flight Risk Assessment

1. Professional Mentor Corps

2. Cross-Calibrated New Hire Feedback

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Optimize Total Rewards for At-Risk Staff

6. Differentiated Frontline Merit Pay

7. Zip Code Compensation Analysis

10. Resignation Recovery Protocol

11. Status Change “Exit” Interviews

12. Alumni Return Campaign

Give Millennials a Sense of Early Accomplishment in their Role

Identify and Re-Direct Millennials Heading for an Exit Ramp


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Best National Opportunities to Improve Engagement

Source: Nursing Executive Center analysis.

• “My ideas and suggestions are valued by my organization.”

• “The actions of executives in my organization reflect our mission and values.”

• “My organization helps me deal with stress and burnout.”

• “I am interested in promotion opportunities in my unit/department.”

• “Training and development opportunities offered by my organization have helped me to improve.”

• “My organization recognizes employees for excellent work.”

• “Executives at my organization respect the contributions of my unit/department.”

42 Drivers of Employee Engagement

Seven Drivers with Greatest Opportunity for Improvement


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Best Practices to Sustain RN Engagement

• Source: Nursing Executive Center interviews and analysis

• Based on 42 proven engagement drivers.

• Developing a National Prescription for Nurse Engagement, 2014

Dimension Solvable Challenge Executive Strategy Recommended Practices

I. Executive Actions

Staff don’t fully appreciate market rationale for executive actions

Translate Market Forces into

Frontline Terms

#1: Mobile Town Hall Forums #2: Peer-to-Peer Strategy Liaisons #3: Nurse Manager “Doomsday” Exercise #4: Staff-Surfaced Rumor Control

II. Stress and Burnout

Disorganized change scheduling and communication exacerbate staff stress

Rationalize the Flow of Change

#5: Change Communication Hierarchy #6: Directive Email Color Coding #7: Change Calendar

III. Staff Input Staff uncertain about where organization most needs their help

Pursue Quality Ideas Over Quantity

#8: Issue Referral Form #9: Exemplar-Driven Ideas #10: Idea Progress Board

IV. Recognition Recognition under-values professional impact

Build Meaningful Recognition into Leaders’

Workflow

#11: Manager’s Frontline Recognition Kit #12: Principled Recognition Triggers #13: Executive’s Frontline

Recognition Routine

V. Training and Development

Professional development opportunities designed for yesterday’s needs

Broaden Access to Non-Traditional

Development Opportunities

#14: Individualized Development Portfolio #15: Targeted Role Transition Training


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Recognition

Select Best Practices in Key Practice Environment Drivers


The Practice Environment and Nurse Manager Impact

Advancement Opportunities

Career Development

Mentoring

Collaboration Administration Listens and Responds

1. Manager’s Frontline Recognition Toolkit

2. Unified Care Plan Development

3. Dedicated Daily Manager Rounding Time

4. Expert RN Role 5. Individualized Development Portfolio


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Remembering the Cost of Turnover How to measure the disruption…


1) Including replacement costs, onboarding new hire, and costs associated with vacant position.

Creates More Work for HR…

Recruit and screen new candidates

Onboard replacement staff

And for Managers…

Train new staff

Interview additional candidates

Absorb extra work

Quantifying the Cost of Turnover

Conservative estimate of the cost of turnover for non-physician turnover1

1.5x Salary Rough estimate for cost of one RN leaving the organization

$90,000

And for Staff…

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Road Map






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Bolster New Hires’ Ability to Cope with Workload

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Institute of Medicine releases The Future of Nursing: Leading Change, Advancing Health, which advocates for the expansion of nurse residency programs.

Nurse Residency Programs Gaining Popularity

Source: Institute of Medicine, The Future of Nursing: Leading Change, Advancing Health, http://www.iom.edu/Reports/2010/ The-Future-of-Nursing-Leading-Change-Advancing-Health.aspx; The Joint Commission, Health Care at a Crossroads: Strategies for Addressing the Evolving Nursing Crisis Strategies for Addressing the Evolving Nursing Crisis, http://www.jointcommission.org/assets/1/18/health_care_at_the_crossroads.pdf; Pittman P., et al., “The future of nursing: monitoring the progress of recommended change in hospitals, nurse-led clinics, and home health and hospice agencies,” J Nurs Adm, 45, no. 2 (2015): 93-97; Spector, N., Blegen, M.A., Silvestre, J., Barnsteiner, J., Lynn, M.R., Ulrich, B. & Alexander, M, Transition to practice study in hospital settings, Journal of Nursing Regulation, 5(4) (2015), 24–38; HR Advancement Center interviews and analysis.

1) American Association of Colleges of Nursing. 2) University HealthSystem Consortium. 3) N-value for 2013 cohort. n=84 for 2011 cohort.

Select Organizations Advocating for Expansion of Nurse Residency Programs

31.7%

41.6%

2011 2013

Percentage of Health Care Organizations Offering Nurse Residency Programs n=1043 2000

2002

2010

2015

AACN1 and UHC2 launch partnership to develop first major accredited nurse residency program

The Joint Commission issues report recommending hospitals implement standardized post-graduate nurse residency programs

National Council of State Boards of Nursing releases first multisite Transition to Practice® study highlighting importance of residency programs.

http://www.iom.edu/Reports/2010/The-Future-of-Nursing-Leading-Change-Advancing-Health.aspx

http://www.iom.edu/Reports/2010/The-Future-of-Nursing-Leading-Change-Advancing-Health.aspx

http://www.jointcommission.org/assets/1/18/health_care_at_the_crossroads.pdf


28 Residency Programs Surround Newly Hired RNs with Support

Source: Nursing Executive Center, Transitioning New Graduates to Hospital Practice: Profiles of Nurse Residency Program Exemplars, Washington, DC: The Advisory Board Company, 2006; HR Advancement Center interviews and analysis.

Build New Graduate Competence

Bridge gaps in resident’s clinical skill set and connect “book knowledge” to real-life clinical challenges

Create Emotional Support Network

Ensure ongoing support from leadership and peers and foster esprit de corps among resident class

Promote Professional Involvement Broaden resident’s understanding of healthcare delivery and empower residents to contribute to practice improvement

Key Components of Nurse Residency Programs


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Not Easy Being the New Person on the Team


Representative Open-Ended Feedback from Employees Under 35 with Less Than Three Years Tenure

I wish there was a more welcoming atmosphere for new people. When I first started, I was told by a couple of staff members that they did not like new people--that can make the new job experience very intimidating.

I might recommend education for current employees on embracing new ones. Starting here was very stressful for me, but it has gotten better.

I am a new employee and I am just beginning to like my job. In the beginning it was rough, and I didn't feel comfortable in my department, let alone around my supervisor. I am beginning to see the light at the end of the tunnel.

I felt new-employee training was lacking in general and in my department specifically. I'd like to feel more of a collegial environment…and not fear being judged if I ask questions.


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Informal Peer Support Not Enough for New Hires Practice: Professional Mentor Corps


Two Drawbacks of Peer Buddy Programs

Buddy programs are often decentralized and informal; quality of support new hires receive varies widely

Peer buddies not equipped to provide longer-term emotional support to new hires to help them cope with workload


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Unit-Based Mentorships Enable Scalability

Ratio of Mentees to Mentors

8:1 60 Total Number of Active Mentors

UnityPoint Health – Methodist | Proctor Professional Mentor Corps Structure

28 Total Number of Units with Active Mentors

Typical Mentor or Buddy Pairing Structure

Mentors:

New Hires:

Source: UnityPoint Health – Methodist | Proctor, Peoria, IL; HR Advancement Center interviews and analysis.


32 Unit-Based Mentorships Enable Scalability: Case Study Details


Case in Brief: UnityPoint Health – Methodist | Proctor • Two-campus, 489-bed hospital located in Peoria, IL; part of a 17-hospital regional

health system in Iowa, Wisconsin, and Illinois

• Introduced peer mentorship program in 2002 to supplement clinical orientation by helping newly hired nurses and allied health professionals adjust to their roles

• Each unit has one to three mentors, nominated by manager; each mentor works with approximately eight new hires as a cohort for two years

• Mentors and mentees receive up to 12 hours of paid time per year for onsite meetings; each unit receives approximately $500 annually to fund off-site events, food for meetings, and welcome gifts

• Mentors submit documentation to mentor program leader annually showing mentorship activities and distribution of funds; if a mentor fails to submit documentation, he or she will not receive funds for the following year

• Mentors meet in person twice a year to share best practices and also receive online training twice per year; training time is paid

• Clinical nurse educator spends 20% of time running mentor program


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The Support for New Hire Support

Paid Time

Annual paid time for mentorship activities for mentors and mentees

12 hours

Paid time includes: • Onsite group and one-on-one

meetings with mentees

• In addition, mentors have six paid hours of continuing education per year

Number of FTEs that oversee mentorship program

0.2 FTEs Program Oversight

Program leader responsibilities: • Recruitment of new mentors

• Coordination with HR for continuing mentor training and new hire support

• Development of budget for mentorship program

• Annual mentor recognition event

Annual discretionary fund per unit

~$500 Financial Support

Discretionary fund includes: • Food for on-site mentor meetings

• Welcome gifts for new hires

• Speaker costs for mentee meetings

• Education materials for mentor activities/meetings


Retention Funds Distribution Guidelines Available


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Manager and New Hire Perceptions Not Always Aligned Practice: Cross-Calibrated New Hire Feedback


Manager Perception “Compared to the last several new hires I’ve had, this one is getting up to speed quickly! She’s ready to fly solo.”

New Hire Perception “There’s so much going on every day. I keep making mistakes, and I’m embarrassed by them.”

Representative Scenario


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Cross-Checking Manager and New Hire Perceptions


1) Pseudonym.

1.The nurse is able to maintain composure and act effectively even under stressful conditions.

2.The nurse is competent and confident with various procedures, independent.

3.The nurse arrives on-time and prepared, reports off in an orderly and easy-to-follow manner.

New Hire Cross-Check for Macmillan Health System1 Nursing Unit

1 2 4

1 2 4

1 2 4

1. I am able to maintain composure and act effectively even under stressful conditions.

1 3 4

1 3 4

1 3 4

Always Usually Not Yet

Always Sometimes Not Yet Informal, non-judgmental language encourages honest assessment

Short; maximum of 10 questions

Completed at 30 and 90 days

New Hire Survey

Charge Nurse Evaluation Input Form

2. I know when to ask for help.

3. My manager has been a helpful resource.

2

2

2

Sometimes

3

3

3

Usually


36 Comparing Manager and New Hire Perceptions Side-by-Side


Side-by-Side Comparison of Manager and New Hire Perceptions

3.0

1.9

2.7

1.5

2.9

2.0

2.6

3.1

A. Jones B. Smith C. Rodriquez D. George

Asymmetrical responses suggest opportunity to align perceptions

Self Assessment Manager Assessment


37 Key Takeaways to Bolster New Hires’ Ability to Cope with Workload


Beyond technical support for their specific role, new hires need emotional and social support to adjust to the pace and intensity of work

Implement a unit- or department-based mentor model to extend the reach of individual mentors and create natural cohorts of new hires

At a minimum, recognize mentors by giving them dedicated time to devote to mentoring

Don’t look at manager and new hire assessments in isolation. Compare manager assessments of new hire performance with new hire self-assessments to triage your efforts to retain new hires

1 2 3 4


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Embed Short-Term Growth in Entry-Level Roles

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Remembering the Millennial Mindset


Representative Open-Ended Feedback from Employees Under 35 with Less Than Three Years Tenure

It is hard to see myself in an organization if I am in the same position for 3-5 years and feeling like I have not made any progress within the organization.

No growth prospects for junior level staff - not much appreciation even after good work.

It is fairly difficult to transfer to other departments which diminish growth opportunities.

It seems as though I am stuck in this position with no room for growth.


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What is a Career Ladder? Defining our Terms

A Clinical/Career Ladder for RNs is a professional development tool designed to recognize and reward nurses for education and certification, research, clinical expertise, and leadership abilities. Key components include levels, domains of practice, activities to reach each level, and preparation requirements.


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Using Career Ladders to Retain Staff

Source: Zimmer, M.J., “Rationale for a Ladder for Clinical Advancement,” Journal of Nursing Administration, 1972 Nov-Dec; 2(6): 18-24; HR Advancement Center interviews and analysis.

Excerpt of 1972 Article on Clinical Ladders

Rationale for a Ladder for Clinical Advancement

By Marie J. Zimmer

1972

Abstract

The concepts of responsibility, mutual attractiveness, integrative group, and professional growth are used to point out the dimensions, as well as the promise and limitations, of a system of positions for advancement of clinical nurses. It was concluded that recognition of excellence in practice via a promotional system will not alone achieve the results of retention in careers in clinical practice or development of expertness in practice. It is, however, one significant and essential means to this result.


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Clinical Ladder-time to revisit? 1. Criteria for advancement (vertical) versus achievement (horizontal) 2. Viewed as ‘busy work,’ versus value added 3. Aligned with or independent of career coaching 4. Tracks-yes or no 5. Aligned with pay 6. Achievement-based ‘steps’ versus process-based 7. Time sensitivity


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Selecting Other Roles for Career Ladders

Source: Overlake Hospital Medical Center, Bellevue, WA; HR Advancement Center interviews and analysis.

1) Called Patient Services Representatives at Overlake.

Overlake’s Criteria for Investment in Career Ladder

Medical Assistants

Clinic Front Desk Staff1

High Voluntary Turnover

Specialized Skill Set

Perceived Lack of Development Opportunities

Career Ladders Available


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Selecting Roles for Career Ladders: Case Study Details

Source: Overlake Hospital Medical Center, Bellevue, WA; HR Advancement Center interviews and analysis.

1) Medical assistant.

Case in Brief: Overlake Hospital Medical Center • 349-bed community hospital located in Bellevue, Washington with busy primary and

specialty care clinics throughout the region

• In 2014, Washington state passed a law requiring all medical assistants to be credentialed through the Washington State Department of Health, increasing competition for talent; a committee comprised of HR and operational leaders developed a medical assistant career ladder to address perceived lack of development opportunities for MAs1 at Overlake

• Overlake developed a Patient Services Representative (PSR) career ladder in August 2015 in response to the growing complexity of the role (such as increased payer demand for clinic quality metrics)

• Ladders were initially rolled out at manager meeting; managers were asked to announce the opportunity at staff meetings and discuss during annual performance reviews.

• Staff must meet minimum requirements for tenure, outcomes-based metrics, and behavioral competencies to move from Level I to Level II

• Staff who move from a Level I MA or PSR to a Level II MA or PSR receive 5% pay increases


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Many Mechanisms for Involving Frontline Staff Early and Often


No Need to Reinvent the Wheel

TCAB Teams

Representative Structures

Shared Governance Committees

Rapid Cycle Improvement Groups

Unit-Based Champions

Lean Workgroups

Quality Improvement Teams

Six Sigma Taskforces

Quality Experts

Unit-Based Practice Councils


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Unit Staff Councils Hold Potential for Early Growth

A Reminder: Interprofessional Unit Councils


An Underutilized Resource

Additional NEC/Global Centre Resources For more information, see our Tools for establishing a formal shared governance structure and our studies, Energizing the Nursing Workforce and Towards Staff-Driven Decision Making: Assessing, Building, and Sustaining Shared Governance on www.advisory.com/international/gcne or nec

Illustration of One Structure

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Perfectly positioned to help unit operations and professional growth

Practice Environment Initiatives

• Design processes for evidence-based guideline implementation

• Develop staff recognition and accountability mechanisms for clinical practice

• Create forum and strategy for staff dealing with stress and burnout

• Determine staff mentorship strategy

http://www.advisory.com/international/gcne


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Failing to Put the Pieces Together Organizations Not Matching Experienced RNs to New Staffing Needs

Practice: Targeted Role Transitions


RN Health System

• Experienced med/surg RN

• Desires new professional development challenges; bored in current role

• Exploring exciting new job roles posted by other organizations

• Needs experienced RNs for new roles

• Looking to fill positions through external hires

• Experiencing vacancies in hard-to-fill positions


48 Enabling Growth for RNs—and Building a Pipeline for Hard-to-Fill Positions

Source: Scripps Health, San Diego, CA; HR Advancement Center interviews and analysis.

Targeted Role Transition Process

Managers nominate candidates

Organization identifies hard-to-fill nursing roles

Nominated RNs apply and interview for position

Selected RNs train for new role

RN transitions to new role; new grad fills old position


49 Enabling Growth for RNs—and Building a Pipeline for Hard-to-Fill Positions: Case Study Details


Case in Brief: Scripps Health • Five-hospital system headquartered in San Diego, California

• In 2010, HR leaders began developing training programs to match existing staff to Scripps’ emerging staffing needs for cross-continuum care and hard-to-fill acute care roles

• Care Navigator Program identifies and trains staff to fill Care Navigator role; Care Navigators work collaboratively across the continuum to provide comprehensive, coordinated care to patients with multiple comorbidities

• Nurses currently employed by Scripps apply directly for role; applicants selected based on clinical, bedside, leadership skills, and behavioral interviews

• Transitional Pipeline Program identifies and trains experienced med/surg nurses to fill positions in complex, hard-to-staff units such as ICU and ED; staff nominated by managers for program go through intensive interview process, followed by didactic and hands-on training for new role; med/surg slot backfilled by new graduate nurse to ensure seamless transition

• Both programs contributed to Scripps experiencing lower turnover and vacancy than the national benchmark


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Low Turnover and Vacancy at Scripps

Source: Scripps Health, San Diego, CA; Annual Turnover, Vacancy, and Premium Labor Benchmarks, HR Advancement Center, 2015; HR Advancement Center analysis.

1) Excludes PRN, per diem, casual nurses.

7.1%

2.0%

National Median Scripps Health

2015 Bedside RN Vacancy Rate

11.9%

9.6%

National Median Scripps Health

2015 Bedside RN Turnover Rate1


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Specialty Transition Programs Also a Recruiting Tool


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52 General Medicine Nursing: The Latest Recognized Specialty

Source: Vanderbilt University Medical Center, Nashville, TN; HR Advancement Center interviews and analysis.

Screenshot of Vanderbilt Nursing Inpatient Medicine Unit Webpage

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Making Career Coaching Part of Tuition Assistance

Source: Beard, J, and Nethery, N, “Buy or Build: Implementing Strategic Workforce Planning” (presentation, Talent Management Alliance, June 11, 2015), available: https://vimeo.com/132558741; Norton Healthcare, Louisville, KY; HR Advancement Center interviews and analysis.

Two Strategies to Maximize Return on Tuition Assistance

Channel Tuition Assistance to Areas of Future Need

Guide Staff and Students to In-Demand Jobs

HR uses an Excel-based forecasting tool to project jobs that will be most in-demand in the future, based on factors such as: current turnover, time-to-fill, and age distribution

Staff and students must meet with a certified career coach before receiving tuition assistance to ensure education is for an in-demand role at Norton

Case in Brief: Norton Healthcare

• Five-hospital health system with 150+ physician practices headquartered in Louisville, Kentucky

• Offers tuition support to approximately 700 students (employees and non-employees) per year to earn credentials required for in-demand roles

• Three full-time and three part-time certified career coaches help employees and non-employee students plan their careers; part-time coaches split time with recruiting

• Retention in 2010 for staff receiving tuition assistance was 95%, compared to 69% for staff not receiving tuition assistance

https://vimeo.com/132558741


54

Helping Staff Grow—and Stay

Source: Wilson, R., Holm, A., “Guide to Making the Case for Investing in the Frontline Hospital Workforce,” Jobs for the Future / National Fund for Workforce Solutions, http://www.jff.org/sites/default/files/publications/CareerSTAT_031512.pdf; Norton Healthcare, Louisville, KY; HR Advancement Center interviews and analysis.

1) Analysis conducted in 2010.

“When you invest in people, they will invest in you.”

Tony Bohn, System VP, Chief Human Resources Officer

95%

69%

Staff Receiving TuitionAssistance

Staff Not Receiving TuitionAssistance

Norton Healthcare Retention Rate1

http://www.jff.org/sites/default/files/publications/CareerSTAT_031512.pdf


55 Key Takeaways to Embed Short-Term Growth in Entry-Level Roles


Talk about careers early and often

Invest in a career ladder for entry-level roles that have high turnover, several employees, and meaningful responsibilities for staff to assume as they move up a rung

Actively promote internal transitions for staff in entry-level roles. Match high-performing Millennials with roles the organization struggles to fill externally

Don’t overlook shared governance as early growth opportunities

1 2 3 4

Identify jobs with high organizational demand in the future and channel tuition assistance to helping staff prepare for these roles 5


56 56

Optimize Total Rewards for At-Risk Staff

3


57

Identifying Groups of At-Risk Millennials


Staff in areas with unusually high volume

Groups of At-Risk Staff

Staff with major commitments outside work

Staff in areas with low morale

Staff with a long commute

Staff with ineffective managers

Highest performers


58

Strategy Linked to Reason for Risk


Directly within Nursing Control-outside of the Total Reward Discussion

High Volume Low Morale Ineffective Managers

Review scope of role, span of control, supports, and competencies

Review and address engagement drivers and practice environment challenges

Confirm short- versus long-term adjustments needed


59

Strategy Linked to Reason for Risk Nursing and Human Resources Responding to Root Cause in Collaboration-within the Total Reward Discussion


Staff with major commitments outside work

Staff with a long commute Highest performers


60

Millennial Satisfaction with Benefits and Pay


1) Includes Tend to Agree, Agree, Strongly Agree responses.

Percentage of Employees Agreeing1 with the Statement:

“The benefits provided by my organization (such as health care, retirement savings, etc.) meet my needs.”

86.2% 83.5%

All Employees Under 35, Less ThanThree Years Tenure

“My organization pays me fairly for my job.”

71.5% 73.1%

All Employees Under 35, Less ThanThree Years Tenure


61

Known Best Practice Even More Important Today Merit Pay Sends Strong Signal to Top Talent

Practice: Differentiated Frontline Merit Pay

Source: Springer M, et al., “Texas Educator Excellence Grant (TEEG) Program: Year Three Evaluation Report, Chapter 8: Teacher Turnover in TEEG Schools,” National Center on Performance Incentives, July 2009; HR Advancement Center interviews and analysis.

Low Performers Top Performers

Expected turnover rate in absence of pay-for-performance

0%

10%

20%

30%

40%

50%

0 $1K $2K $3K $4K $5K $6K

Turnover rates for low performers surged

Turnover rate for top performers fell dramatically

Turnover Rate Among Teachers After Pay-for-Performance Program Rollout


62

11.2% 11.1% 12.4%

6.9% 5.2%

3.9%

2009 2011 2013

Health Care National Average

Top Talent at Baton Rouge

Reallocate Pay Increases to Reward Top Performers

Merit Pay Percentage Increases by Performance Rating

Performance Rating

Merit Increase Percentage

Percentage of Staff Receiving

Rating

Top Talent 5% 20%

Highly Valued 3% 70%

Less Effective 0% 10%

Turnover Rate

Program introduced Q2 FY09

Source: Baton Rouge General Medical Center, Baton Rouge, LA; HR Advancement Center interviews and analysis.


63 Reallocate Pay Increases to Reward Top Performers: Case Study Details

Source: Baton Rouge General Medical Center, Baton Rouge, LA; HR Advancement Center interviews and analysis.

Case in Brief: Baton Rouge General Medical Center • 590-bed hospital located in Baton Rouge, Louisiana

• As part of the larger talent management initiative, annual merit program for frontline employees is adjusted to provide higher incentive amounts to top performers and no incentive to bottom-rated individuals; a prescribed distribution determines the percentage of staff who receive each rating

• Retention of “Top Talent” employees has seen steady increases since implementation of talent management system in Q2 2009


64 Should We Bring Back Shortage-Era Scheduling Options?

Excerpt of Scheduling Option Inventory, circa 2000

Source: Nursing Executive Center, Reversing the Flight of Talent, Washington, DC: The Advisory Board Company, 2000; HR Advancement Center interviews and analysis.


65 Key Takeaways for Optimizing Total Rewards for At-Risk Employees


Don’t run to competitive salary wars as the core solutionReallocate pay increases to reward top performers

Merit pay should be reallocated to top performers

Consider offering additional scheduling options to retain staff with significant commitments outside of work

1

2

3


66 66

Equip Managers to Detect Retention Risk

4


67

Where There’s Smoke…


Showing up to work in a suit jacket or new dress

Sudden increase in requests for time off

Arriving late consistently

Updating LinkedIn profile

Disengaged or distracted behavior

Out-of-character complaining

??? Representative Signs of Future Turnover


68

Turning Managers into Turnover Detectives


How To Help Managers Detect Retention Risk

Tell them what to look and listen for

Help them regarding how to act on the information


69

The Questions to Ask at 30, 60, and 90 Days Practice: 30-60-90 Day Check-in Prompts

Excerpt of 30-60-90 Day Check-in Guide

Complete 30-60-90 Day Check-in Guide Available

Discussion Questions

Baseline Expectations

1. Has this job met your expectations? In what ways? Where has it fallen short?

2. Do you have the tools and equipment you need to do your job?

Acculturation

3. Which coworkers have been especially helpful to you?

4. From what sources have you obtained information about news in the department and the institution?

5. Tell me about some of your successes during your first [30/60/90 days].

Source: HR Advancement Center, The Manager’s Guide to New Hire Onboarding, Washington, DC: The Advisory Board Company, 2014; HR Advancement Center interviews and analysis.

• Answer to primary question is no

• Expectations about work conditions unrealistic

• Unable to provide examples of helpful colleagues or personal successes

• Information sources listed are unreliable

Signals of Possible Retention Risk


70

Bolster Accountability for New Hire Check-ins

Skip-Level Check-ins Process-Based Goal

Each check-in is with a different leader:

• 30-day check-in: With direct supervisor

• 60-day check-in: With director

• 90-day check-in: With vice president

Managers in areas with especially high turnover have both an outcomes-based goal for turnover and a process-based goal: percentage of new hire check-ins completed

Source: Baptist Health System, Jacksonville, FL; Methodist Health System, Dallas, TX; HR Advancement Center interviews and analysis.

Two Options


71 Bolster Accountability for New Hire Check-ins: Case Study Details

Source: Baptist Health System, Jacksonville, FL; Methodist Health System, Dallas, TX; HR Advancement Center interviews and analysis.

Case in Brief: Baptist Health System

Case in Brief: Methodist Health System

• Five-hospital health system located in Northeast Florida

• HRIS department sends auto-generated emails prompting manager to conduct a new hire check-in; email includes list of questions to ask

• Senior leaders (e.g. directors and vice presidents) are strongly encouraged to conduct skip-level check-ins at 60 and 90 days, to ensure new employees are settling in well, and confirm managers conducted the 30-day check-in

• Four-hospital system headquartered in Dallas, Texas

• Each manager has no more than seven goals; one is staff retention for their entity

• Managers at hospitals with higher turnover also have a process-based goal; goal requires managers to complete 80% of their 30- and 90- day check-ins

• Learning management system sends automated reminders for the 30- and 90-day check-ins

• At 60 days, new hire receives online survey; the purpose is to allow employees to give feedback to someone other than their direct manager


72

Assessing Flight Risk of Staff Beyond Onboarding Practice: Manager-Led Flight Risk Assessment


Two Approaches to Prioritizing Staff for Flight Risk Assessment

Conduct flight risk assessment for staff earning top performance rating; top performance rating serves as proxy for “high impact” departure

Assess departure impact of each team member individually


73

The Red Flags Managers Should Look For

Excerpt of Flight Risk Assessment


Complete Flight Risk Assessment Tool Available

1. How are this team member’s relationships with his or her colleagues?

Assessment for the following team member: ________________________________________

Completed by: _______________________________________________________________

Date: ______________________________________________________________________

2. How is your relationship as a manager with this team member?

3. Is there an opportunity for this team member to take on new responsibilities? (e.g., becoming a team lead or taking on a significant new project)

4. How does this team member seem to feel about their compensation?

Exceptionally strong

1

2 Weak

4

Exceptionally strong

1

2 Weak

4

Yes, within the next year

1

2

Not within the next two years

4

Positive 1

2

Negative 4

3

3

3

3


74

Interviewing Staff to Understand How to Retain Them

Source: Carroll Hospital Center, Westminster, MD; HR Advancement Center, Data-Driven Prescription for Leader Engagement, Washington, DC: The Advisory Board Company, 2015; HR Advancement Center interviews and analysis.

Carroll Hospital’s Stay Interview Guide

2 What might entice you to leave?

What is your dream job and what can we do to support your progress toward it? 1

5 Do you feel we recognize you? What kind of recognition is most meaningful to you?

Are we fully utilizing your talents? 3

4 What is the one thing that would make your job more satisfying and rewarding?


75 Key Takeaways to Equip Managers to Detect Retention Risk


Managers are well-positioned to assess retention risk factors for individual employees; support their efforts by giving them specific red flags to look for and clear guidance on what to do next with employees who exhibit risk factors

Look into automated options to remind managers about approaching 30, 60, and 90-day anniversaries of new hires; include everything managers need to have an effective new hire check-in directly in the notification

Ask managers to conduct in-depth flight risk assessments only on staff whose departures would have the greatest impact

Equip HR business partners or senior department leaders with stay interview questions to use in conversations with staff who have high flight risk scores

1

2

3

4


76 76

Win Back Early-Tenure Staff Mid-Flight

5


77

Resignation Conversations Often Very Short Practice: Resignation Recovery Protocol


Typical Resignation Conversation

Employee Manager

Says…

Thinks…

“I think this job is just not working out for me.”

“Sorry to hear that, but best of luck on your future endeavors.”

“I need a new challenge.”

“How am I going to pay for grad school now?”

“Not another vacancy!”

“I’ll have to completely re-do the schedule.”


78

Resignations Not Necessarily Final

Source: Novant Health, Winston-Salem, NC; HR Advancement Center interviews and analysis.

Case in Brief: Novant Health • Four-state integrated network of physician clinics, outpatient centers and hospitals,

including 13 medical centers

• Novant Health business partners called acute care RNs and LPNs who put in their 30-day notice; goal was to collect real-time data on the drivers of turnover and potentially retain employees if issues could be addressed

• During 30-day campaign, 60 eligible employees were called, and 36 participated; three employees decided to stay

Process for Novant Health’s “Project Re-Engage”

Business partner calls nurse

Novant Health takes action to retain if possible

Managers enters notice into system

Nurse submits 30-day resignation


79

The Case of the Disappearing Nurse Practice: Status Change “Exit” Interviews


Representative Trajectory of a Nurse About to Voluntarily Turnover

Full-Time Employee Part-Time Employee Former Employee


80 Adding Staff Who Reduced Hours to Exit Interview Queue

1) Pseudonym.


Top Reasons Cited in Exit Interview Results for Staff Who Reduced Hours

Case in Brief: Gladstone Health1 • Seven-hospital system located in the South

• HR executive concerned that nurses who significantly reduced hours (e.g. full-time to part-time, part-time to PRN) were going to eventually leave organization altogether

• Local vendor conducted phone exit interviews throughout 2015 with nurses who reduced their hours (in addition to staff who left); goal was to understand reasons for reduction

• To better capture impact of reduced hours, HR executive added number of nurses who increased and decreased hours to monthly turnover report

To care for a family member

To pursue a degree

To use their advanced degree elsewhere (e.g., NP)


81

The Grass Isn’t Always Greener Practice: Alumni Return Campaign

Source: Merriam-Webster, http://www.merriam-webster.com/dictionary/boomerang, Accessed 19 Mar 2016; HR Advancement Center interviews and analysis.

Definition: Boomerang 1.A curved, flat wooden tool that can be thrown in

such a way that it returns to the thrower

2.An employee who leaves the organization for another opportunity but returns to the organization in the future

http://www.merriam-webster.com/dictionary/boomerang


82 Asking Former Team Members Directly: Would You Like to Come Back?


Key Steps in Novant Health’s “Project Return”

HR reviewed list of voluntary turnover within the past 12 months; ensured individuals were in good standing and left voluntarily

External vendor called former team members; used scripted dialogue to assess interest in returning to Novant Health

If the former team member expressed interest in returning, external firm passed the candidate to a recruiter; the hiring process was expedited

Vet List of Former Team Members

Call Former Team Members

Pass Interested Candidates to Recruiter


83

Would You Like to Come Back?: Case Study Details


Case in Brief: Novant Health • Four-state integrated network of physician clinics, outpatient centers and

hospitals, including 13 medical centers

• HR leaders pulled and vetted list of 553 nurses that voluntarily left in the past 12 months, October 2014 – October 2015; external vendor called individuals over the course of six days; goal was to share new initiatives and compensation changes and assess interest in returning to Novant Health

• The external vendor handed off interested individuals to Novant Health’s Talent Acquisition team to call back with more information, schedule interviews and make offers

• 21 nurses returned in the first four months following the calls

• Many nurses appreciated being contacted, and some who could not return immediately expressed interest in returning later


84

The Benefits of Being a Boomerang Employee


Total number of former employees contacted

497 Number of former employees interested in returning

155 Number of employees hired back to organization in four months following campaign

21

Additional Benefits for Boomerang Employees at Novant Health

No Orientation

Employees that return within one year do not go through orientation again

Immediate Retirement Fund Match

Employees normally must work one year or more to receive company match

“Comeback” Bonus

Employees received a $3000 bonus, paid in three installments: in the first paycheck, and at 3- and 6-months


85

Not “Goodbye” But “See You Later”


Employees asked to update personal email before departure

Newsletter sent out twice a year includes current job opportunities

Highlights notable “alumni” employees

Advisory Board Company Alumni Newsletter

IMA

GE

CR

ED

IT: A

BC

O.

Includes invitations to company service events


86 Key Takeaways to Win Back Early-Tenure Staff Mid-Flight


Consider piloting rapid-response interviews with staff who submit their resignation, especially in areas with high turnover

Identify someone other than the direct manager (such as an HR business partner or senior operational leader) to conduct resignation recovery interviews and give explicit guidance on the levers they can pull to retain staff

Add the number of staff who have reduced hours to regular turnover reports to capture “invisible” turnover

Actively recruit former employees, especially after the organization has gone through a period of significant change (e.g., EMR rollout, merger)

1

2

3

4

87

2

3

1

Road Map






88

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Problematic Fair Good Excellent

Perc

enta

ge o

f Res

pond

ents

Manager Effectiveness Category

Disengaged Engaged

<1%

85%


1) Based on multivariate regression of the impact of the drivers within the Manager Effectiveness Index (see next slide) on engagement score.

Manager Impact Proven through Data Analysis Impact of the Perception of Manager Effectiveness on Staff Engagement1

17%

25%


89

As Perceived by Staff

• Source: Advisory Board Survey Solutions interviews and analysis

Seven Advisory Board Company Survey Solutions Questions Indicating Manager Effectiveness

“I have helpful discussions with my manager about my career.”

“I receive regular feedback from my manager on my performance.”

“My manager communicates messages that my coworkers need to hear, even when the information is unpleasant.”

“My manager helps me balance my job and personal life.”

“My manager helps me to learn new skills.” “My manager is open and responsive to staff

input.” “My manager stands up for the interests of

my department.”

Manager Effectiveness Index

42 Drivers of Employee Engagement


90

Address the Role

Eliminating Unnecessary Work, Improving Efficiency, Leadership Potential

Moving to New Reality

Non-Managerial Work

Strategic Oversight

Daily Managerial Work

Strategic Oversight

Daily Managerial Work

Freed Up Time



91

Professional Development not an option…..

Source: “The AONE Nurse Executive Competencies,” AONE, http://www.aone.org/resources/leadership%20tools/nursecomp.shtml; Nursing Executive Center.

A Wide Array of Competency Models

Nurse Manager and Executive Competencies

Workforce Planning

Systems Thinking

Strategic Management

and Prioritization Succession

Management

Communicating Effectively

Financial Acumen

Forging New Partnerships

Developing and Retaining Talent

Building and Strengthening Relationships

Motivating and Influencing

Standards and Accountability

Service Orientation and Patient Care Quality

Process Management

Personal and Professional

Growth

Giving Feedback

Managing Vision and Purpose Initiative

Knowledge of Health Care Environment

Information and Technology

Management

Complete List of Nurse Executive Competencies and Definitions Available

__________________________

http://www.advisory.com/Research/Nursing-Executive-Center/Resources/2014/2014-2015-Meeting-Resources/Changing-CNO-role


92

Positive Work Environment Makes the Difference Stronger Impact on Nursing Behaviors than Staffing, Skill Mix

Source: Ausserhofer D, et al., “Prevalence, patterns and predictors of nursing care left undone in European hospitals: results from the multicountry cross-sectional RN4CAST study,” BMJ Quality and Safety, 23 (2014): Advisory Board interviews and analysis.

Positive Work Environment Has Strongest Effect “The quality of the work environment had the strongest effect, suggesting that specific elements such as nurse manager ability, leadership, support of nurses, and collegial nurse-physician relations influence the way nurses organize and deliver necessary nursing care.”

Ausserhofer D, et al., “Prevalence, Patterns and Predictors of Nursing Care Left Undone in European Hospitals”

1) Multiple multilevel linear regression model with hospital-level as random and country-level as fixed effects, accounting for the hierarchical structure of the data (nurses nested within hospitals within countries). Nursing care left undone reflects the process of care and was defined as necessary nursing activities that were missed due to a lack of time. N=33,659 nurses.

2) Measured by a unit change in the number of patients per nurse. 3) Measured with a revised version of Lake’s Practice Environment Scale of the Nursing Work Index.

Practice Environment Scale Components of Positive Work Environment


Nurse Staffing2

Nurse Work Environment3

.09 (2.2)

Association Between Nurse-Related Organizational Factors and Nursing Care Left Undone1

p value < .0001

Career Development

Mentoring Recognition

Collaboration

Administration Listens and Responds


93

Evidence Seen in Engagement and Workforce Metrics

Source: Advisory Board Talent Development Division; Advisory Board Employee Engagement Initiative Division; “Nurse Leadership: Being Nice is Not Enough,” Hay Group, http://www.haygroup.com/uk/downloads/details.aspx?id=2521; Advisory Board interviews and analysis.

1) Based on multivariate regression of the impact of the drivers within the Manager Effectiveness Index on engagement score from Advisory Board’s Employee Engagement Initiative Division.

2) Average turnover per unit in the high performing group was 18% compared to 29% in the low performing group. 3) Average absenteeism per person in the high performing unit manager group was eight days per year, in the low

performing group 18 days per year.

Manager Key to Creating Positive Work Environment

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Problematic Fair Good ExcellentManager Effectiveness Category

Disengaged Engaged

<1%

85%

Impact of Staff Perception of Manager Effectiveness on Engagement1

17% 25%

Perc

enta

ge o

f Res

pond

ents

Lower staff turnover achieved by high-performing

unit managers2

36%

Reduction in staff absenteeism in units with

high-performing managers3

57%

People with excellent managers are five times more likely to be engaged, and virtually none are disengaged


94

Recognition

Nurse Managers Leading the Way


Select Best Practices to Address Practice Environment


Career Development

Mentoring

Collaboration Administration Listens and Responds

1. Manager’s Frontline Recognition Kit

2. Unified Care Plan Development

3. Dedicated Daily Manager Rounding Time

4. Expert RN Role 5. Individualized Development Portfolio


95

Recognition Top Driver of Both Nursing Quality and Engagement

Source: Nursing Executive Center Clinical Practice Environment Survey, 2005-2010; Employee Engagement Initiative Engagement Survey, 2006-2010; Nursing Executive Center interviews and analysis.

The Importance of Commending a Job Well Done

Engagement Survey Regression Analysis Correlation to Nurse Engagement

CPES Survey Regression Analysis Correlation to Outstanding Nursing Care

Driver Beta

Nurses providing clinically excellent care receive positive recognition 0.447

My manager and nurse colleagues routinely and openly discuss unit weaknesses and vulnerabilities along with potential solutions

0.445

Each member of the multidisciplinary care team (physician, nurse, and other caregivers) is aware of their patients’ daily goals

0.408

Nurses know their units’ performance goals for quality indicators (pressure ulcers, infection rates, falls, etc.)

0.398

Driver Beta

I receive positive recognition for providing excellent care. 0.615

I understand how my daily activities contribute to the hospital’s mission 0.525

I have access to one or more clinical experts to answer my questions 0.507

I feel comfortable raising concerns with other nurses on my unit when I see something that may negatively affect patient care

0.391

I feel comfortable raising concerns with physicians when I see something that may negatively affect patient care

0.340

n=15,417 n=11,920


96


1) Composite.

Recognition Often Applied Inconsistently

O’Brien Hospital1 Medical Unit Patient Satisfaction Scores

Q1 Q4 Q2 Q3

Unit receives letter from patient praising nurses for superior care given; letter posted publically, chocolate distributed

Multiple patients commend nursing care to manager during rounds; manager throws pizza party

Reward Pitfalls Informal rewards not typically tied to specific goals or criteria perceived as ad hoc by staff; ultimately, do not create as strong an incentive to improve as intended

!


97

Defining “Meaningful” Professional Recognition


Key Elements of Meaningful Recognition

Delivered Promptly Following Achievement

Linked to Specific Accomplishments

Provided by Someone Professionally Important


98

Manager’s Have the Time and Tools to Recognize • Recognition Under-Values Professional Impact


Dear Rebecca, You are a Gold Star nurse. Thank you for your commitment to excellence! Sincerely, Anna

Dear Rebecca, Thank you for sitting down with Mr. Jones last night after your shift ended. I know how much it meant to him, having someone there while he was waiting to go into surgery. He was nervous, and you went out of your way to make him as comfortable as possible. Your work truly exemplified our commitment to excellence and patient-centered care. Sincerely, Anna

It’s Easy to Tell the Difference


99

Timely, Meaningful Recognition Not Easy to Achieve


• Practice: Manager’s Frontline Recognition Kit

Can’t find nurse’s home address

Manager decides to recognize a nurse’s excellent work with a hand-written note

Manager out of note cards

Representative Challenges to Manager Sending a Note Home

Note never gets written; opportunity for meaningful recognition missed

Emergency on the unit


100

Placing Recognition Tools Within Easy Reach

• Source: St. Joseph’s Hospital Breese, Breese, IL; Nursing Executive Center interviews and analysis

• Practice: Manager’s Frontline Recognition Kit

Key Elements of St. Joseph’s “Mission Box”

• Contains note cards, envelopes, addresses, and stamps

• Additional cards available in managers’ break room

• Includes additional activities to help managers, staff connect with mission and values, including an exercise to encourage staff to verbally recognize peers demonstrating values

• Managers add new unit staff’s addresses to box as they join the unit

• Leaders revisit box every two months and ensure all staff are represented

Contains All Needed Supplies

Updated Frequently Provides Additional Recognition Activities

Pre-Assembled for Managers

• Assembled every two months by two nursing directors

• Delivered to managers in a management meeting


101

Collaboration Not Getting Any Easier

Source: Clough J, “Collaboration Between Physicians and Nurses: Essential to Patient Safety,” Forum (26):2, 2008; MEDPAR 2001, 2005, 2010; Nursing Executive Center analysis.

• New Challenges Complicating Interdisciplinary Collaboration

Additional Caregivers

Higher Patient Complexity

Proliferation of Communication Technology

Care teams larger and more specialized, often including: hospitalists, intensivists, physician’s assistants, residents, and cross-continuum navigators

Hospitals now caring for more patients with multiple comorbidities and higher acuity level

Communication between caregivers increasingly likely to occur via telephone or a screen rather than face-to-face


102 Hardwiring Care Plan Collaboration and Management

Source: ThedaCare, Appleton, WI; Nursing Executive Center, Achieving Top-of-License Nursing Practice, Washington, DC: The Advisory Board Company, 2013; Nursing Executive Center interviews and analysis.

Practice: Unified Care Plan Development

Key Components of ThedaCare’s Expanded Care Planning Process

Collaborating to Develop Initial Care Plan

Tracking Patient Progress Against Key Milestones

Ensuring Appropriate Clinicians Attend Daily Rounds


103

Case in Brief: ThedaCare

Source: Toussaint J, Gerard R, and Adams E, On the Mend: Revolutionizing Healthcare to Save Lives and Transform the Industry (Cambridge: Lean Enterprise Institute, 2010); Bielaszka-DuVernay C, “Redesigning Acute Care Processes in Wisconsin,” Health Affairs, 30 (2011): 422-425; “Collaborative Care,” ThedaCare Center for Healthcare Value, available at: http://www.createvalue.org/resources/case-studies/collaborative-care/, accessed November 10, 2012; ThedaCare, Appleton, WI; Nursing Executive Center, Achieving Top-of-License Nursing Practice, Washington, DC: The Advisory Board Company, 2013; Nursing Executive Center interviews and analysis.

Including the Nurse Every Step of the Way

• Five-hospital system headquartered in Appleton, Wisconsin

• Interdisciplinary team redesigned inpatient care model through the application of lean methodology beginning in 2006; supported by grant from the Robert Wood Johnson Foundation’s Transforming Care at the Bedside initiative

• Clinical trios of nurse, hospitalist, and pharmacist meet patient within 90 minutes of admission to develop a single plan of care

• Collaborative Care model includes team of RN, LPN, and CNA caring for six patients on medical units; RN responsible for managing patient progression toward discharge and ensuring needed clinicians participate in daily care conferences

• Collaborative Care pilot unit opened in 2007; original pilot unit staff received six weeks of training offsite to prepare for new care model; today, new staff train on original pilot units

• Pilot unit redesigned to support Collaborative Care; supplies and medications decentralized, located in patient rooms; all rooms made private; nurses station replaced with series of “consultation alcoves” outside patient rooms

• Pilot Collaborative Care unit achieved average cost per case that is 20% less than cost per case on non-Collaborative Care unit; admission medication reconciliation errors decreased from 1.05 errors per chart to 0; patient satisfaction increased from 68% to 90%; nurse satisfaction increased 17% from 3.72 to 4.37 on 5-point scale


104

Collaborating to Develop Initial Care Plan Nurse, Physician, Pharmacist Meet Admitted Patients Within 90 Minutes

Source: Rose J, “Radical Redesign,” Inside Healthcare, December 1, 2008, available at http://www.createvalue.org/docs/inside-healthcare.pdf, accessed November 10, 2012; ThedaCare, Appleton, WI; Nursing Executive Center, Achieving Top-of-License Nursing Practice, Washington, DC: The Advisory Board Company, 2013; Nursing Executive Center interviews and analysis.

Representative Patient Timeline

Patient is admitted to unit

Nurse pages hospitalist to report admission

Hospitalist, nurse, pharmacist huddle outside patient’s room

Hospitalist, nurse assess patient together

Pharmacist performs bedside medication reconciliation

Trio collaborates to develop care plan

“The physician, nurse, and pharmacist admit the patient as a trio, sharing their professional knowledge and critical thought processes at the bedside. The value of this collaborative approach is that everyone is on the same page, and patients have confidence that their care team is working together.”

”

Chief Nursing Officer ThedaCare


105

Collaborative Care Pilot Unit Providing Better Care

Source: Toussaint J, Gerard R, and Adams E, On the Mend: Revolutionizing Healthcare to Save Lives and Transform the Industry, (Cambridge: Lean Enterprise Institute, 2010); Bielaszka-DuVernay C, “Redesigning Acute Care Processes in Wisconsin,” Health Affairs, 30 (2011): 422-425; “Collaborative Care,” ThedaCare Center for Healthcare Value, available at: http://www.createvalue.org/resources/case-studies/collaborative-care/, accessed November 10, 2012; ThedaCare, Appleton, WI; Nursing Executive Center, Achieving Top-of-License Nursing Practice, Washington, DC: The Advisory Board Company, 2013; Nursing Executive Center interviews and analysis.

1) On a five-point scale. 2) During last two years of study period: 2008, 2009.


3.72

4.37

2007 2008

68%

90%

2006 2008

19% Reduction in length of stay from 2006 to 2009

20% Decrease in average

cost per case compared to non-Collaborative Care units

0 Number of

admission medication reconciliation errors2

Nurse Satisfaction1


106

Yet Majority of Managers Do Not Consistently Protect Time to Round

Practice: Dedicated Daily Manager Rounding Time

Source: Global Centre for Nursing Executives’ 2015 Frontline Manager Survey; Global Centre for Nursing Executives, Re-Envisioning the Nurse Unit Manager Role, Washington, DC: The Advisory Board Company, 2015; Advisory Board interviews and analysis.

1) Responses to the question “Do you protect time on a daily basis to round on patients and staff and provide in-the-moment coaching and feedback?” Possible responses included; “Yes, everyday,” “Sometimes, but I often get caught up in other work,” “No, I do not routinely protect time.” N=148 Australian and New Zealand nurse unit managers.

Manager-Led Rounding Improves Clinical Outcomes

Manager increases staff nurse accountability for care and service through leading by example; as well as being VISIBLY PRESENT on the unit for staff

Leading by Example

Responding to Concerns In-the-Moment

Manager proactively solicits and responds to concerns and complaints

Key Benefits of Manager Rounding

51% 30%

19%

Yes, everyday

No, I do not routinely protect time

Sometimes, but I often get caught up in other work

Percent of Surveyed Nurse Managers Indicating Whether They Protect Time on a Daily Basis to Round on Patients, Staff1


107

Source: Global Centre for Nursing Executives, Re-Envisioning the Nurse Unit Manager Role, Washington, DC: The Advisory Board Company, 2015; Advisory Board interviews and analysis.

Case in Brief: Winant Hospital

• 400-bed hospital located in the United States

• Hospital began to focus on service excellence; leadership rounding introduced to support this effort

• Nurse manager time protected from 7:00am-9:00am to facilitate rounding


108

Protected Time, Weekly Reporting Make an Amorphous Activity Tangible


New Structures Help Managers Prioritize Rounding

Daily meeting free block allows managers to prioritize rounding every morning between 7am and 9am

Consistent Time Block

Weekly Rounding Report to CNO

Weekly report submission prompts manager to reflect on unit needs/strategy and informs CNO on unit performance

Wednesday Daughter of patient 501 complains the purpose of new tests not explained

Thursday Patient 512 notifies manager that nurse Lee didn’t explain why his medication changed

Friday Patient 519 complains aide drew blood without explaining why

Weekly Summary Manager decides to set up staff training on explaining procedures to patients

Example of How Daily Rounding Notes Can Inform Unit Strategy

Core Components of New Rounding Practice


109


1) Pseudonym.

Leading to Sustained Patient Satisfaction

Helping Managers to be PRESENT

“It takes a lot of dedication and a lot of vigilance on the part of the nurse managers to get the kind of satisfaction results we have been getting, and it isn’t always easy in our busy, hurry-up world…to stay on top of that service component. A positive patient experience is the goal of our work, and we have built in accountability systems to make sure that happens.”

CNO, Winant Hospital1

Winant Hospital’s Press Ganey Percentile Ranking After Rounding Re-Started Overall Patient Experience

76

95

50

75

100

Year 1 Year 3 Year 4 Year 5

99

87


110

Designating an Expert RN to Improve Unit Performance

Practice: Expert RN Role

Source: Nursing Executive Center, Building the High-Value Care Team, Washington, DC: The Advisory Board Company, 2014; Nursing Executive Center interviews and analysis.

Key Components of Unit-Based Expert RN Role

No Patient Assignment

Demonstrated Expertise

“At-the-Elbow” Guidance for Staff RNs

To protect time for unit-level oversight, no direct patient assignment for expert RN

Expert RN easily accessible to staff nurses on unit; provides in-the-moment advice, coaching to frontline nurses

Expert RN has proven expertise, typically through combination of experience, educational preparation, and performance


111

Adding an Expert RN Role Without Increasing FTEs

Source: Riley Hospital for Children, Indianapolis, IN; Mercy Health Saint Mary’s, Grand Rapids, MI; Nursing Executive Center, Building the High-Value Care Team, Washington, DC: The Advisory Board Company, 2014; Nursing Executive Center interviews and analysis.

1) Clinical Nurse Leader (CNL) is a registered trademark of the American

Association of Colleges of Nurses. 2) Of the six assistant nurse managers, four entered the CNL program, one

transitioned to an educator role, and another moved back to a staff nurse role. 3) Growth in patient volumes covered remaining CNL FTEs.

Staffing Trade-Offs Made to Add Expert RN Role

New Expert RN Role Organization Staffing Trade-Off

Attending RN Riley Hospital for Children

• Comprehensive role redesign involving all unit-based care team members

• Decreased proportion of RNs in nursing skill mix from 95% to 70%

Clinical Nurse Leader1

Mercy Health Saint Mary’s

• Eliminated assistant nurse manager role, freeing up six FTEs2

• Converted palliative care coordinator, diabetes outpatient educator, and two nurse educators to CNLs3


112 Deploying the Attending RN on Mass General’s Innovation Units

Source: Erickson J, Ditomassi M, and Adams J, “Attending Registered Nurse: An Innovative Role to Manage Between the Spaces,” Nursing Economic$ 30 (2012): 282-287; Erickson J, Jones D, and Ditomassi M, Fostering Nurse-Led Care: Professional Practice for the Bedside Leader from Massachusetts General Hospital (Indianapolis: Sigma Theta Tau International, 2012); Nursing Executive Center, Building the High-Value Care Team, Washington, DC: The Advisory Board Company, 2014; Nursing Executive Center analysis.

Serves as Consistent Contact for Patients

• Manages care of patients on single unit from admission to discharge

• Works five eight-hour shifts to promote consistency

• Meets with patients and families regularly to discuss care plan, treatment goals

• Provides coaching to promote self-care

Facilitates Care with Interprofessional Team

• Develops and revises patient care goals with clinical team daily

• Coordinates meetings for timely clinical decision-making and optimal handovers across the care continuum

Case in Brief: Massachusetts General Hospital • 950-bed academic medical center in

Boston, Massachusetts; part of Partners HealthCare

• In March 2012, 12 “Innovation Units” implemented new model of patient care delivery, including Attending RN role; goal to provide more integrated, patient-centered, evidence-based care

• Each Innovation Unit determines number of Attending RNs on unit and number of patients within Attending RN’s responsibility

• Attending RN role budget-neutral; created out of existing FTE allocations

• Since implementing Attending RN role, preliminary length of stay and patient experience data indicate improvements

Key Functions of the Attending RN Role at Mass General


113 Recognizing the Need for an Attending RN Role at Riley Hospital for Children

Source: Riley Hospital for Children, Indianapolis, IN; Nursing Executive Center, Building the High-Value Care Team, Washington, DC: The Advisory Board Company, 2014; Nursing Executive Center interviews and analysis.

Reasons for Introducing the Expert RN Role at Riley

Essential Attributes of Attending RNs at Riley

Significant skill mix change

High percentage of inexperienced RNs

Five or more years of direct care nursing experience

Ability to engage with individual patients, families to help them achieve their goals

Strong interpersonal skills, clinical leadership, and ethic of responsibility

Case in Brief: Riley Hospital for Children • 430-bed children’s hospital in Indianapolis, Indiana; part of Indiana University Health

• In May 2013, piloted new nursing care team model on 24-bed pulmonary unit; to promote top-of-license practice, new model decreased proportion of RNs in skill mix from 95% to 70%

• Attending RN part of new nursing care team; goal of role is to provide expert clinical oversight

• Since implementing Attending RN role on pulmonary pilot unit, average LOS decreased by 26% from 5.8 to 4.3 days; readmission rate decreased from 13% to 6%


114

Defining Clear Boundaries for the Attending RN Role

Responsibilities of Unit-Based Nursing Positions at Riley

Attending RN

• Mentors and coaches less-experienced nurses

• Bridges communication gaps between nursing and interprofessional caregivers

• Proactively identifies and resolves barriers to timely patient progression to next care setting

Charge Nurse1

• Assigns patients to RNs

• Coordinates staff scheduling

• Conducts quality assurance audits

• Assists unit manager with operational duties

Nurse Manager

• Regularly updates staff on unit performance, communicates strategies to improve performance

• Manages budget

• Hires staff and coordinates training

• Conducts staff evaluations

• Develops unit policies and procedures

Leader with Clinical Focus Leaders with Operational Focus

1) Also referred to as “Day Shift Coordinator” at Riley Hospital for Children. Source: Riley Hospital for Children, Indianapolis, IN; Nursing Executive Center, Building the High-Value Care Team, Washington, DC: The Advisory Board Company, 2014; Nursing Executive Center interviews and analysis.


115

Developing the Clinical Nurse Leader Role

1) Clinical Nurse Leader; CNL is a registered trademark of the American Association of Colleges of Nurses. 2) American Association of Colleges of Nursing.

Key Attributes of the CNL1 Role 2003 Year AACN2

developed the CNL role

2,939 Number of board-certified CNLs in the United States

107 Number of CNL academic

programs in the United States

11 Number of unit-based CNLs at

Mercy Health Saint Mary’s

Clinical care coordinator for a specific population, most often on a particular unit

Outcomes manager of specific outcomes for the population

Educator and mentor for staff nurses through one-on-one coaching and just-in-time intervention

Care team leader responsible for helping all staff learn about quality and performance improvement

Advocate for patients, families, and staff

Information manager to analyze nursing-sensitive outcomes and processes

Source: American Association of Colleges of Nursing, Washington, DC; Mercy Health Saint Mary’s, Grand Rapids, MI; Nursing Executive Center, Building the High-Value Care Team, Washington, DC: The Advisory Board Company, 2014; Nursing Executive Center interviews and analysis.


116

Source: Mercy Health Saint Mary’s, Grand Rapids, MI; Nursing Executive Center, Building the High-Value Care Team, Washington, DC: The Advisory Board Company, 2014; Nursing Executive Center interviews and analysis.

Developing the Clinical Nurse Leader Role

Case in Brief: Mercy Health Saint Mary’s • One-hospital system headquartered in Grand Rapids, Michigan; includes several ambulatory

centers; part of CHE Trinity Health

• Trinity Health leaders partnered with the University of Detroit-Mercy to implement CNL curriculum; goal for Saint Mary’s to develop expert nurses to cost-effectively manage outcomes, improve processes at unit level

• Trinity Health provided 17 of Saint Mary’s staff full-paid scholarships to earn CNL certification through 18-month program at University of Detroit-Mercy; Saint Mary’s CNL students worked for health system full-time while attending school

• After completing CNL program, each CNL placed in new clinical area to promote CNL focus on new responsibilities in new role

• Currently 14 CNLs across system; 11 unit-based, one in ED, two focused on specific patient populations; unit sizes range from 34 to 46 beds; all CNLs report to Clinical Service Directors

• Addition of CNLs FTE neutral; eliminated assistant nurse manager role, centralized nurse educator role

• Since implementing CNL role on psychiatric medical unit, average length of stay decreased by 21% on unit from 19 to 15 days

• Saint Mary’s Trinity Health quality GPA improved from 2.8 in 2010 to 3.7 in 2012 on a 4-point scale; GPA in 2012 highest among Trinity Health hospitals of similar size and complexity


117

Defining Clear Boundaries for the CNL Role

Source: Mercy Health Saint Mary’s, Grand Rapids, MI; Nursing Executive Center, Building the High-Value Care Team, Washington, DC: The Advisory Board Company, 2014; Nursing Executive Center interviews and analysis.

Responsibilities of Unit-Based Nursing Positions at Saint Mary’s

For Clinical Nurse Leader job description, see website.

CNL

• Translates, implements evidence into practice

• Develops improvement plans for efficiency, effectiveness

• Mentors and coaches frontline nurses

• Facilitates coordination of clinical care and resource management

• Leads daily interdisciplinary rounds

Charge Nurse

• Assigns patients to RNs

• Facilitates patient flow

• Assists nurse manager with operational duties

Nurse Manager

• Has ultimate responsibility for unit's financial, clinical outcomes

• Manages, coordinates unit operations

• Focuses on professional development of staff

• Provides ongoing performance management

• Develops unit policies and procedures

Nursing Case Manager

• Conducts utilization review

• Coordinates discharge plan and arranges for any needed support

• Ensures correct level of care documented


118

An Innovative Professional Development Framework Practice: Individualized Development Portfolio

Source: Gundersen Health System, La Crosse, WI; Nursing Executive Center, National Prescription for Nurse Engagement, Washington DC: The Advisory Board Company, 2013. Nursing Executive Center interviews and analysis.

”

“Traditional fixed or directed career tracks do not meet the needs of the future generations of nurses or health care environment. Nurses want to do a blend of management, educator, quality assessment, and practice.”

Characteristic Traditional Clinical Ladder Gundersen’s Emerging Model

Level of Flexibility Staff confined to one track Staff encouraged to mix and match opportunities

Structure Hierarchical ladder; goal to advance upward by tier

All nurses expected to practice at highest level, no hierarchy; structured through portfolio development; goal to grow in place by pursuing individual interests

Growth Opportunity

Once at the top tier, no additional opportunities for growth at bedside

Encourages continued growth and development throughout career; no growth ceiling

Merit Payment Distributed annually based on ladder tier

Awarded based on specific unit or individual outcomes, distributed as outcomes are achieved

Mary Lu Gerke

CNO

Comparison of Gundersen’s Model with Traditional Clinical Ladders


119

Source: Gundersen Health, La Crosse, WI; Advisory Board Survey Solutions’ Employee Engagement Initiative National Database, 2013; Nursing Executive Center, National Prescription for Nurse Engagement, Washington DC: The Advisory Board Company, 2013. Nursing Executive Center.

An Innovative Professional Development Framework

Case in Brief: Gundersen Health System • 6-hospital system headquartered in La Crosse, Wisconsin

• Eliminated traditional clinical ladder in 2012 due to concerns it limited staff growth and provided insufficient flexibility to motivate younger nurses; held focus groups across 2013 to assess staff preferences for next professional development model

• New model allows frontline staff to choose from menu of options and create their own professional development plan; staff encouraged to pursue opportunities across multiple areas simultaneously including leadership, education, and clinical development

• Pay differentials now tied to specific achievements and unit outcomes rather than clinical ladder tier

• Staff required to maintain a portfolio of experiences gained through the program; goal to promote self-reflection, track professional growth

• 2013 Advisory Board Survey Solutions engagement survey found 64.3% of RNs agree training and development opportunities helped them to improve, 59.8% agree they are interested in promotion opportunities


120

Building an Individual Practice Portfolio


Key Components of Professional Portfolios

Easily Accessible

Required for All Nurses

Updated Frequently

• Staff required to track all achievements in portfolio

• Training provided on proper method for logging achievements

• Staff expected to update portfolios at least every six months

• Updates must reflect all newly acquired education and skills

• Model portfolios available for viewing online via intranet

• Template available for staff to fill in updates

Reviewed with Manager

• Staff and manager review goals and achievements during annual evaluation

• Manager provides guidance for staff to create individualized career path


121

A New Philosophy for Flexibility in Development


• Meets the needs of all five generations in the workplace

• Promotes shared caring

• Aligned with Gundersen’s strategic plan

• Aligned with Gundersen’s plan for health care reform

• Promotes self-care

• Standards-based

• Self-directed; staff can move in and out of career pathways as goals change

• Encourages nurses to stay at the bedside if that is their career decision

• Flexible, based on each individual nurse’s career path and interests

• Based on individual professional accountability, standards, and evidence

• Encourages personal and professional reflection

Guiding Principles of Gundersen’s Framework

Gundersen Taking a “Bottom-

Up” Approach


122

Reallocating Staff Incentives

Source: Gundersen Health System, La Crosse, WI; Nursing Executive Center, National Prescription for Nurse Engagement, Washington DC: The Advisory Board Company, 2013. Nursing Executive Center interviews and analysis

Options for Earning Differentials

RN 1

RN 2

RN 3

RN 4

RN 5

Old Model New Model

Achieving Specialty

Certification

Precepting New RNs

Publishing a Performance Improvement

Project

Meeting or Exceeding

Quality Goals


123

Source: Gundersen Health, La Crosse, WI; Advisory Board Survey Solutions’ Employee Engagement Initiative National Database, 2013; Nursing Executive Center, National Prescription for Nurse Engagement, Washington DC: The Advisory Board Company, 2013. Nursing Executive Center analysis.

1) RNs responding “Agree” or “Strongly Agree.” 2) “Training opportunities at my organization have helped

me to improve.” 3) “I am interested in professional development

opportunities in my unit or department.”

Driving Engagement at Gundersen

Percentage of RNs Agreeing1 They Are Interested in

Promotion Opportunities3

NationalBenchmark

GundersenHealth System

2013

53.6%

59.8%

NationalBenchmark

GundersenHealth System

2013

Percentage of RNs Agreeing1

Training and Development Opportunities Helped Them Improve2

64.3%

60.4%


124

Source: Mackoff B, Triolo PK, “How to Keep Great Nurse Managers,” Gallop Business Journal, 13 March 2008, http://www.gallup.com/businessjournal/104425/how-keep-great-nurse-managers.aspx; Advisory Board Survey Solutions Employee Engagement National Database; Advisory Board interviews and analysis.

Engaging Managers, So They Can Engage Their Teams

Executive actions reflect mission and values

Training and development helps me improve

Interested in promotion opportunities

Executives respect contribution of department

Kept informed of organisation’s plans

Organisation recognises employees

My ideas and suggestions are valued

Organisation helps me deal with stress and burnout

Performance review helps me improve

Manager has helpful discussions with me about my career

I have a manageable workload

Top Drivers of Manager Engagement with Opportunity for Improvement

1

2

3

4

5

6

7

8

9

10

11

Engagement’s Ripple Effect “There’s strong correlation between staff nurses’ positive relationship with their nurse manager and their engagement and longevity.

Ultimately, if you want to get the staff manager and staff nurse to stay, then you want to cultivate an engaged manager – the manager is the key to staff nurse engagement.”

Mackoff B and Triolo PK, “How to Keep Great Nurse Managers”

Adjusting to a New Reality with Care Teams

More to Consider

1. Achieve Top-of-License Nursing Practice

2. Right-Size the Proportion of RNs in the Skill Mix

3. Building the High Value Inter-Professional care team


126

Worth the Effort


To win in the market place, you must first win in the workplace Doug Conant, CEO; Campbell Soup

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