Mission Medical Center is a 700-bed hospital in an urban city in the Southwest. Mission is part of a vertically integrated healthcare system with a number of physician medical groups, ambulatory care settings and surgical centers, a psychiatric hospital, an orthopedic specialty hospital, and a children’s specialty hospital. All hospitals are within a 50-mile radius of one another. At Mission Medical Center, the nursing division is organized under a chief nursing officer (CNO) who is also designated chief operating officer (COO) for the medical center.

John has 25 years of experience in nursing leadership, and for the past 10 years he has been the CNO for Mission Medical Center. Six nursing directors report to John and provide supervision and direction to Medical-Surgical Services, Surgical Services, Maternal-Newborn Services, Rehabilitation Services, Intensive and Emergency Services, and Professional Support Services. John meets with the directors once a week for a Nursing Operations Council that focuses on the operational aspects of providing and coordinating patient care with other professional disciplines. Once a month, John meets with the directors and the clinical nurse specialists (CNSs) for the Nursing Executive Council. The purpose of the Nursing Executive Council is to promote the professionalism of nursing, advance strategies and initiatives to improve patient care outcomes, promote research and evidence-based practice, and ensure a healthy work environment that attracts and retains nurses. Mission Medical has been designated as a Magnet organization and is currently working toward redesignation, which is scheduled in approximately 2 years.

As an organization, Mission Medical is very forward-thinking and is considered to be one of the top hospitals in the state. One of the reasons that Mission has earned its reputation is because of its recruitment of top medical specialists, attractive new patient bed tower, state-of-the-art capital equipment for patient care and surgical services, and a strong financial foundation.  Whereas Mission Medical has strategically sought to advance its market penetration into competitor territory, it has also ben thoughtfully conservative not to overbuild beyond its financial capacity. The strategy to emphasize excellence in patient care services, excellence in the work environment, and excellence in medical staff has attracted a growing market share of insurers that wish to contract with Mission Medical and individuals in the community who have elected to purchase medical care through the Mission Medical Plan.

At one of the Nursing Executive Council meetings, a discussion ensues about changes that may need to occur as a result of penalties incurred from the Affordable Care Act and stagnation in the 30-day readmission rate over the last few years. John and the directors realize that reimbursement has been strongly tied to patient outcomes, readmissions to the hospital within 30 days, and other operational metrics. Although the nursing-sensitive indicators, Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) scores, and satisfaction levels of patients, physicians, and nurses are extremely high, the directors realize that they must ensure that every patient is ready to be discharged and able to care for him- or herself at home to prevent readmissions within 30 days of discharge. The directors and clinical nurse specialists discuss a number of ideas. John encourages the open discussion and listens to each of the ideas with interest. While he quietly listens to the input from the nursing leaders, he considers the various organizational structures and processes that might need to change to support some of the ideas. He realizes that he must also encourage nurse leaders to consider how they will measure the effect of the changes that they would like to implement, but he does not want to discourage the open dialogue and freethinking during the initial stages of the discussion.

One of the major points of discussion is about lowering readmissions within 30 days of discharge. Because of the major financial impact that this issue has on the hospital’s bottom line, John and the nurse leaders are keenly interested in any innovative thinking as to how to reduce occurrences. After several hours of open dialogue, John asks the CNSs and the nursing directors to divide into three teams and challenges them to work together in their teams to identify a strategy around reducing admissions. To incentivize the groups, John states that the team with the best idea will be rewarded with a prize for their respective areas. He also tells them that their ideas must include not only the intervention but also methods of measuring the effect of the intervention on reducing readmission rates. He suggests that the directors work with the chief financial officer (CFO) to develop a return on investment (ROI) on their respective ideas. The group agrees that they will reconvene in 1 month for each group to present their ideas.

Three groups return a month later with posters to illustrate their respective plans, formal PowerPoint presentations, and supporting evidence to substantiate their innovative thinking. Group 1 recommends developing a role in each unit for a discharge resource nurse, who would not be counted in the daily staffing, but who would be responsible for reviewing each patient’s status for discharge. The discharge resource nurse would coordinate a patient’s needs with social services, the discharge planner, the physician, and the patient’s family to ensure that all of the resources that the patient needs after discharge would be readily available upon arrival home. In addition, the discharge resource nurse would assess patients’ understanding of their illness each day and their knowledge of their medications, required therapies, and appointments with their primary providers. A significant part of the discharge resource nurse’s role would include patient and family education and assessment of the patient’s readiness for discharge. Group 1 suggests they would measure success by reducing the number of readmissions per quarter from the existing baseline. They estimate that the cost savings from potential losses in reimbursement without the intervention would more than pay for the expense of the new discharge resource nurse position.

Group 2 proposes a very similar intervention; however, they based their proposal on evidence that demonstrated the effectiveness of a patient-centered approach to care in improving patients’ knowledge and ability to care for themselves prior to and after discharge. Group 2 proposes defining “patient-centered care” to be patient empowerment, engagement, and activation in their care. The new definition of patient-centered care would reflect nursing’s involvement in educating the patient and empowering patients with knowledge to be completely engaged in decisions related to their care, and thereby activating patients’ own resources to care for themselves at home. Group 2 presents the notion that every nurse believes that he or she provides patient-centered care without fully understanding the concept or realizing the nurse’s role and responsibility in ensuring patients’ involvement in their own care. The CNSs in Group 2 propose an educational platform for nurses to promote the new definition of patient-centered care and provide standardized educational plans for high-risk conditions that have been correlated with readmissions in the past. The CNSs propose that they would measure the effectiveness of their plan by having patients and/or their families complete a readiness for discharge assessment tool that they had reviewed in the literature and to measure the patients’ knowledge and abilities to follow up with their proposed treatment plan during hospitalization and after discharge.

Group 3 recommends a collaborative, interprofessional approach using team rounding with patients each morning to ensure that patients and family are knowledgeable about the plan of care. In addition to the team rounding, Group 3 suggests changing the unit structure to include a clinical nurse leader (CNL) who would be assigned to approximately 12 patients with a team of primary care nurses. The CNL would be coordinate each patient’s care among the various disciplines and ensure that patients were instructed in self-care and engaged in their care. In addition, the CNL would coordinate with the discharge planner, social services, and other specific disciplines to meet with the patient each day of his or her hospitalization in preparation for discharge. Group 3 also proposes adding a responsibility to the primary nurse’s role to call each of the discharged patients 1 week after discharge to ensure that they are adequately cared for and following up with medications, therapies, and provider appointments. Group 3’s proposal includes the addition of several new positions. They present several studies where the role of the CNL saved money in other organizations and improved patient satisfaction, physician satisfaction, and nurse satisfaction rates as well as patient outcomes.

John invites the CFO, the CEO, and a guest consultant to hear each of the proposals and to provide feedback to each of the teams. It is a time of great excitement because of the competitive nature of the presentations, but also friendly engagement in discussions about the merits of each of the proposals. It is suggested that the best intervention would be a combination of all three proposals with the development of the CNL who would act as a patient care coordinator and a resource nurse to support direct care providers. In addition, it is suggested that the discharge nurse coordinators assume a greater role in assessing patients’ readiness for discharge and that the CNS group and nurse educators assume a greater role in assessing patients’ level of knowledge and ability to care for themselves and to follow up with the proposed treatment plan during hospitalization or after discharge. It is decided that a previously published instrument, the readiness for discharge assessment tool, would be used with all patients to assess their level of empowerment through education, engagement in decision making and planning, and activation of their own skills for self-care. It is also decided that the readiness for discharge tool would be used again in a follow-up phone call by a discharge liaison nurse (new role) who would contact each of the discharge patients for the unit on day 2, day 5, and then weekly for a month after discharge. In addition, the group develops a “Call a Nurse” hotline to facilitate decision making among discharged patients relative to their questions about their health status, follow-up instructions, or care questions.

The CFO offers to work with the directors to estimate the expense of the new positions and the return on the investment for minimizing the number of readmissions each quarter. All participants realize the risks involved in adding new full-time equivalents (FTEs), but also realize the potential loss of revenue that would result from failure to reduce admissions within 30 days of discharge. The CEO and CFO are particularly impressed with the evidence shared from other hospitals that had implemented the CNL role and subsequently reported positive outcomes from having nurses with master’s degrees coordinating the care, discharge, and after-hospitalization experience of a small group of assigned patients. This idea coupled with the other support roles seems to be the best innovation to address the problem of loss of revenue related to readmissions within 30 days of discharge. 

Questions:

1. What are your thoughts about John’s approach to using friendly competition among the three groups to motivate them to think creatively about solving the problem?

2. Because the three groups were charged with designing an innovative solution to the problem, how do you think that the morphing of their proposals into a fourth solution affected the nurse leaders’ motivation to think creatively in the future?

3. What barriers, if any, do you think that the nursing leaders will encounter when implementing the final proposal to reduce admission rates?

4. Address what leadership theory is in use.