Question

Describe the influences of the IOM, AHRQ, and Magnet status on healthcare systems. How does this influence the nurse leader?

Answer 1

1)

The IOM Report: Accelerating Nursing Leadership in Health and Health Care

It is exciting and humbling to witness and talk about the positive transformation that nursing has been experiencing since the release of the 2010 Institute of Medicine (IOM) report on the future of nursing. The report emphasizes development of leadership programs that harness nurses’ capacity to lead change, and advance health and health care by creating innovative opportunities for education and professional growth. In addition to many other recommendations, the report calls for interdisciplinary collaboration and underscores the imperative for diversity of the nursing workforce to more appropriately reflect the diversity of the United States population.

More than ever before, nurses are recognized as key to leading successful and sustainable health care for the nation. Nurses are at the forefront of health and health care improvements, leading many quality initiatives. Comprehensive, cost-effective patient and family-centered models of care led by nurses are increasingly becoming popular.

With more nurses obtaining advanced degrees and practicing to the fullest extent of their education and skills, they are engaging side by side with members of interdisciplinary care teams to collaborate in clinical practice, and conduct research and enquiry that can provide solutions to some long-standing clinical problems.

As director for the Office of Diversity and Inclusion at the Hospital of the University of Pennsylvania (HUP), our mission is to create environments where diversity is embraced, inclusion is promoted, and culturally competent health care services are delivered to all patients.

On November 14 and 15, 2014, the Office of Diversity and Inclusion at HUP will hold its 4th biennial cultural competence symposium titled: Cultural Competence: Delivering on the Promise of Justice, Equity and Equality in Health Care. This program that started as an initiative in the department of nursing has now expanded to include members from other disciplines, thus evolving into a hospital-wide initiative, exemplifying the significance of nursing leadership that is delineated in the IOM report.

It is easy to see how the IOM report has provided direction and accelerated nurses’ leadership in health care. Nurses, the largest group of health care professionals, are equipped with new tools to meet the changing needs of patients, communities, and health care delivery system of the nation.

This commentary originally appeared on the RWJF Human Capital Blog. The views and opinions expressed here are those of the authors.

2)

Most health care organizations are still striving to attain high reliability—the ability to minimize adverse events while consistently providing high-quality care in the context of a rapidly changing environment. Workers at the sharp end are best positioned to identify hazardous situations and address system flaws. Although the concept of leadership has traditionally been used to refer to the top rungs of an organization, frontline workers and their immediate supervisors play a crucial leadership role in acting as change agents and promoting patient-centered care. As the safety field has evolved, there is a growing recognition of the role that organizational leadership plays in prioritizing safety, through actions such as establishing a culture of safety, responding to patient and staff concerns, supporting efforts to improve safety, and monitoring progress. Research using a variety of methodologies has defined the relationship between leadership actions and patient safety and has begun to elucidate key organizational behaviors and structures that can promote (and hinder) safety efforts.

This Patient Safety Primer will discuss the role of organizational leadership in improving patient safety. The crucial roles that frontline and mid-level providers play in improving safety are discussed in the related Safety Culture and High Reliability Patient Safety Primers.

The Historical Role of Hospital Leadership in Quality and Safety Activities

All hospitals are overseen by a board of directors, whose responsibilities include (but are not limited to) formulating the organizational mission and key goals, ensuring financial viability, monitoring and evaluating the performance of high-level hospital executives, making sure the organization meets the needs of the community it serves, and ensuring the quality and safety of care provided by the organization. However, hospital boards have traditionally had relatively little direct engagement in evaluating and improving quality and safety. As a 2010 review article explains, board members historically have been community leaders with little to no health care experience, often lacking the knowledge to interpret complex data on the quality and safety of care. Boards also had limited ability to address quality issues that lived within the domain of practicing physicians, given that most physicians are not directly employed by the hospital.

Surprising as it may seem, despite being accountable for the quality and safety of care being provided in their organizations, until recently board, executive, and medical staff leadership at most hospitals in the United States placed relatively little emphasis on identifying and addressing safety issues. A 2010 survey of more than 700 hospital board chairs found that only a minority considered improving the quality of care to be one of the board's top two priorities, and very few board chairs had any direct training in quality or safety. This situation is changing, driven by data on the influence of leadership engagement, as well as greater emphasis on quality and safety in general. Today, we are seeing a shift toward more direct oversight of quality and safety at the organizational level.

How Leadership Can Influence Patient Safety

An emerging body of data now demonstrates a clear association between board activities and hospital performance on quality and safety metrics. A 2013 review found that high-performing hospitals—defined as those ranking highly on objective measures of quality and safety—tended to have board members who were more skilled in quality and safety issues and who devoted more time to discussion of quality and safety during board meetings. Insight into how boards can positively influence quality was provided by a recent study of hospitals in the US and England, which found that boards of high-quality hospitals used more effective management practices to monitor and improve quality. These practices include structured use of data to enhance care, both by setting specific quality goals and regularly monitoring performance dashboards. They also included explicitly using quality and safety performance in the evaluation of high-level executives and focusing on improving hospital operations. Examples of organizations that have transformed their practices and organizational culture to emphasize patient safety include the Dana-Farber Cancer Institute, which responded to a serious and widely publicized preventable death by ingraining patient safety into the responsibilities of clinical and organizational leadership and emphasizing transparency with patients and families, and PeaceHealth, which created a governance board overseeing all safety and quality activities across the system and tied executive compensation to specific quality and safety goals.

Hospital boards influence quality and safety largely through strategic initiatives, but data also shows that executives and management can improve safety through more direct interactions with frontline workers. Leadership walkrounds—visits by management to clinical units in order to engage in frank discussion around safety concerns—can positively impact safety culture. Although walkrounds are widely used and recommended as a safety intervention, recent research indicates that relatively small differences in the way walkrounds are conducted can markedly enhance or limit their effectiveness. For example, issues raised by frontline staff during walkrounds must be promptly addressed, lest staff view the rounds as simply a visibility exercise for leadership. Similarly, voluntary error reporting systems often lack credibility among frontline staff due to insufficient follow up after an error is reported. By engaging with those who take the time to report errors and devoting time and resources to structured follow through, hospital leadership can both address specific safety issues and tangibly illustrate the importance of patient safety as an organizational priority.

An important area in which hospital leadership can directly address safety concerns is through managing disruptive and unprofessional behavior by clinicians. As boards have oversight over the medical staff, they have the ability to ensure unprofessional or incompetent clinicians do not put patients at risk. Although there is limited evidence regarding specific strategies leadership can use to prevent disruptive behavior, some organizations have developed a structured approach that emphasizes early intervention by hospital leadership for clinicians who display recurrent unprofessional behavior or are the subject of multiple patient complaints.

3) Magnet Hospitals and the Attraction and Retention of Professional Nurses

The original magnet study began in 1981 when the American Academy of Nursing appointed a task force to investigate the factors impeding or facilitating professional nursing practice in hospitals. The four researchers on the task force were working from the knowledge that despite a nursing shortage for a large number of hospitals, a certain number “had succeeded in creating nursing practice organizations that serve as ‘magnets’ for professional nurses; that is, they are able to attract and retain a staff of well-qualified nurses and are therefore consistently able to provide quality care”. Therefore, the research goal was set to explore the factors associated with success in attracting and retaining professional nurses.

Through an extensive nominating process, 41 hospitals from across the country were selected to participate in the study based upon their known reputations as being good places for nurses to work and the evidence they submitted to document a relatively low nurse turnover rate.9 Subsequently, a series of group interviews was held with representatives from each hospital. Two interviews were conducted in each of eight geographically dispersed locations. In the morning, one of the task force researchers interviewed the chief nurse executives from the participating hospitals in that area. Then, in the afternoon, a second group interview session was held with staff nurses. Each staff nurse who participated in the interviews was selected by his or her chief nurse executive.

Based upon their analysis of this interview data, the task force researchers identified and defined a set of characteristics that seemed to account for the success the 41 reputational magnet hospitals had enjoyed in attracting and keeping a staff of well-qualified nurses at a time when other hospitals around them were not able to do so. The labels given to these characteristics, which have come to be known as the forces of magnetism, are listed below in Table 1. Many of the insights they embody have a long history of study within the sociological literature related to organizational performance, leadership, worker autonomy and motivation, decentralized or participative management, work design, coordination and communication, effective groups and teams, and organizational innovation and change.

The Magnet Characteristics of a Professional Practice Environment

The relationship of a magnet environment to quality was recently described by one of the original task force researchers. Looking back on the original magnet study more than 20 years later,

We found that all these settings had a commonality: their corporate cultures were totally supportive of nursing and of quality patient care. What we learned was that this culture permeated the entire institution. It was palpable and it seemed to be almost a part of the bricks and mortar. Simply stated, these were good places for all employees to work (not just nurses) and these were good places for patients to receive care. The goal of quality was not only stated in the mission of these institutions but it was lived on a daily basis.

The Magnet Recognition Program of the American Nurses Credentialing Center (ANCC)*

In the early 1990s, the American Nurses Association (ANA) initiated a pilot project to develop an evaluation program based upon the conceptual framework identified by the 1983 magnet research. The program’s infrastructure was established within the newly incorporated American Nurses Credentialing Center of the ANA, and the first facility to receive Magnet recognition was named in 1994.11 Interest in Magnet™ has been increasingly accelerating. While only about 225 organizations have achieved Magnet recognition since the program’s inception, nearly two-thirds of them did so within the last 3 years, and the applicant list continues to expand.

Applicants for Magnet recognition undergo a lengthy and comprehensive appraisal process13 to demonstrate that they have met the criteria for all of the forces of magnetism shown in the right column of Table 1. Currently, documentation or sources of evidence are required in support of 164 topics.11 Organizations that receive high scores on written documentation move to the site-visit stage of the appraisal and a period of public comment. The philosophy of the program is that nurses function at their peak when a Magnet environment is fully expressed and embedded throughout the health care organization, wherever nursing is practiced. Magnet organizations submit annual reports and must reapply every 4 years to maintain their recognition.

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