Leading the Way

Enculturating the value of process improvement

Staff engagement within a culture of ownership and accountability makes the difference between successfully achieving and sustaining organizational outcomes. As healthcare organizations respond to the external pressures of rapidly evolving complexity and increasingly demanding regulation, the impact of organizational culture emerges as a critical element for organizational success. Key factors for successfully creating and sustaining a culture of nursing excellence include

  • providing support for accountable, authentic, engaged leadership, including developing and deploying a leadership competency model
  • hardwiring structures and processes that drive front-line staff engagement
  • creating a strategic plan that clearly demonstrates the integration and impact of the work of nursing on organizational priorities
  • developing a systematic approach to strategy deployment, including ongoing support through feedback
  • deploying a robust rapid-cycle process improvement design that is enculturated at the front line.

A key factor is to engage front-line staff so they believe in the organization’s vision, understand and embrace the cultural values, and demonstrate behavioral based expectations. A critical driver of engagement is nurses’ perception of the support provided by their nurse manager. Front-line staff are more likely to become engaged when their suggestions are valued, their contributions are respected, and their good work is recognized by their leaders.

To achieve optimal engagement, it’s essential to develop leadership competency and to put processes in place.

Leadership competency

Transformational leaders inspire the workforce with a clear, shared vision that describes the compelling reason to achieve organizational goals. Leaders create the culture that delivers results. It is worthwhile for organizations to create a leadership competency model that describes technical and behavioral core competencies to which leaders can aspire. The model is a guide for assessment of individual and organizational leadership competency. Once competency is assessed and areas for growth are identified, education is provided to assist leaders in achieving and demonstrating the competency essential for the organization to achieve strategic goals.

Creating structures and processes

Nursing leaders at the division and unit level can transform culture by creating structures and processes that engage front-line staff in a manner that focuses on process improvement rather than simply on compliance. Six-sigma and Lean methodologies that engage front-line staff in the work leads to important improvements in acute care organizations.

Standards such as the Baldrige Criteria for Performance Excellence provide an improvement framework that high-performing healthcare organizations can use to guide their work toward achieving and sustaining improvement. The Transforming Care at the Bedside program developed jointly by the Robert Wood Johnson Foundation and the Institute for Healthcare Improvement provides a proven methodology that engages and empowers front-line staff on medical/surgical units to redesign their work processes to achieve improved clinical outcomes. (See Transforming care.)


Transforming care

The methodology for Transforming Care at the Bedside begins with front-line staff who deliver the majority of bedside care coming together to identify gaps in their actual performance compared to their desired outcomes. The team identifies potential barriers in their care processes and prioritizes the barriers according to impact. Next, the team creates a hypothesis about what will improve the process and quickly tests this hypothesis using a rapid-cycle improvement method while generating quantitative and qualitative data. When the intervention has been tested and the hypothesis proven using data, the intervention is spread and evaluated for sustainability.

One foundational element we have found to be important to engaging front-line nursing staff is the creation of a nursing strategic plan that demonstrates the integration of nursing goals and actions that are directly aligned with overall organizational goals. The plan is created by and vetted with direct-care nurses and their colleagues as well as with middle and senior leadership within the organization. The process of creating the nursing strategic plan and the plan itself demonstrate that the work of nursing directly contributes to organizational success. Our organizational goals cascade to division and unit goals, which then cascade to individual goals. Staff nurses and their colleagues see that the work they do every day has a direct impact on the success of their unit, which in turn contributes to the success of the organization.

The Baldrige Criteria for Performance Excellence and the Commission on Magnet Recognition share a similar model that has proven essential to achieving success. Both models focus on the importance of employing a systematic approach to developing and deploying processes. Listening to and learning from our front-line staff and integrating our learning into the improvement work is essential if we are to ensure that our processes will deliver the outcome we desire. A critical factor in successfully achieving a highly reliable organization, however, is how we enculturate this work. Methods to obtain the voice of customers, including patients and colleagues we serve, as well as the voice of the process, are essential to improvement. Creating a systematic approach to deploying the work, supporting the work, especially in the early stages, and holding all accountable for process and outcome are critical for success.

Working wall

One such approach we are employing across Inova Health System is use of the strategy deployment wall. Known informally as the “working wall,” it’s a single place where we post strategic goals and the process improvement work that supports achievement of these goals.

The improvement process begins by identifying a gap in our achievement of outcomes. Once we identify the gap we use the Toyota inspired A3 to begin our team-based approach to describe, understand, and solve problems. While A3 refers to a size of paper on which we document the important information that tells the story of the work of the team, A3 is really a way of thinking.

Once the gap has been identified and the barriers identified and analyzed, the team develops a hypothesis as to what might improve the outcome. Using Deming’s Plan-Do-Study-Act methodology, an action plan is developed and the team implements small tests of change. Real time information about the work and the outcomes of the work are readily available for staff and drives interest and engagement in the work.

The wall is reviewed daily at the change of shift huddle by the charge nurses. Division leaders as well as senior leaders from the hospital and the system round with staff on the working walls to validate and support the work. Staff are proud and understand that their work contributes to the achievement of outcomes.

Obtaining results

Nurse leaders must inspire front-line staff to focus on process improvement rather than on fulfilling compliance requirements. Developing leadership competency, along with creating structure and processes that invite and drive engagement, are essential elements that will support a healthcare organization’s ability to achieve and sustain outstanding results.

Cheri Goll is chief nursing officer and Shirley Cahill is senior strategic process improvement consultant at Inova Fair Oaks Hospital in Fairfax, Virginia.

Selected references

2014 Magnet® Application Manual. American Nurses Credentialing Center, Silver Spring, MD; 2013. http://www.nursecredentialing.org/Magnet.

Rivera RR, et al, Closing the RN engagement gap: which drivers of engagement matter?” J Nurs Adm. 2011;41(6):265-272.

Wildermuth C, Pauken P. A perfect match: Decoding employee engagement – Part I: engaging cultures and leaders. Industrial and Commercial Training. 2008;40(3):122-128.

Nursing Executive Center, The Advisory Board Company Energizing the Nursing Workforce. The Advisory Board, The Nursing Executive Center 2013-2014 National Meeting Series, Washington D.C.

Kouzes JM, Posner BZ. The Leadership Challenge. 5th ed. San Francisco, CA: John Wiley and Sons; 2012.

Connors R, Smith T. Change the Culture, Change the Game. New York, NY: Penguin Group; 2011.

Access Baldrige Performance Excellence Criteria for Health Care Organizations at http://www.nist.gov/baldrige/publications/hc_criteria.cfm

Access information related to the Transforming Care at the Bedside program at http://www.rwjf.org/en/library/research/2007/10/transforming-care-at-the-bedside.html

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