10/29/2012

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Strategic Planning and Cultivating Nursing RolesStrategic Planning and Cultivating Nursing Roles –

Developing a Five SEVEN Year Plan

The Norton Healthcare Experience

Tracy E Williams, DNP RNSenior Vice President and System Chief Nursing Officer

Kim Tharp – Barrie, DNP RN, SANESystem Vice President , NHC Institute for Nursing

Making the Case

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Health Care Reform

Government Health ReformFour components of Health Reform:

Coverage Reform puts everyone into the market for health care by mandating that everyone be covered by 

insurance

Delivery System Reform. The proposed regulations issued by CMS on Accountable Care Organizations 

and the Medicare Shared Savings program may prove unworkable – but all the buyers in this market (commercial health plans, state governments, employers and individuals) are demanding that providers address efficiency, cost and effectiveness deficits.

Payment Reform. In 2012, the Medicare Hospital Value Based Purchasing (VBP) program will cover all 

acute care providers, and in future years the program will expand to cover outpatient care. CMS describes the VBP as the latest stage of the evolution of CMS from a “passive payer of claims based on volume to an active purchaser of care based on the quality of care beneficiaries receive.”

Quality Improvement. A hospital admissions reduction program for preventable Medicare inpatient 

hospital admissions starting in FY 2013 which can reduce payments by one percent for targeted cases and up to 3% in 2015 and subsequent years.

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A Prescription for Patient ValueThe Value Proposition

• Achieving universal coverage and access to care are essential, but not enough

• The core issue in health care is the value of health care delivered

• Value: Patient health outcomes per dollar spent

• Value is the only goal that can unite the interests of all system participants– Patient / Physician / Provider / Payor

• How to construct a dynamic system that keeps rapidly improving

• The central goal in health care must be value for patients, not access, volume convenience or cost containmentvolume, convenience, or cost containment

Value = Health Costs / Cost of Delivering the Outcomes

Hospital ‐ ER services, OP services, IP stays

Value in the Future is…the Patient Care Continuum

Specialty Physician

Diagnostic Center

Skilled Nursing;  LTAC; Rehab

Patient Home

HomeICC

Care Team Center

Wellness Center

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The Norton Healthcare Accountable Care Ecosystem

Population ManagementHumana – Brookings Dartmouth Partnership

Medicare AdvantageHealth Department Partnerships Coordinate Manage to

Components of Accountable Care

Effective Health Management

Employers PatientsHospitals Physicians Acute, sub‐acute and long‐term care providers 

The Players

p pHealthy Start Flu VaccinationNeeds Assessment

N‐Good Health Employee Program Cost and

Efficiencies

Effective Health Management

Coordinate Items and Services

Manage to Quality

Standards

Manage Costs and Efficiencies

Manage to Quality Standards

Coordinate Items and Services

Clinical Effectiveness with Integration of:

Ambulatory care centers Pharmaceutical companiesMedical device manufacturers Care Givers (physicians, nurses, home health, clinical social worker, clinical psychologist, and other ancillary providers)

Payors Federal government

Care Management Service ExcellenceQuality

Quality Transparency  ReportingData Management and Analytics

EpicAmalga

Norton Nursing Institute

Risk Management Finance and Accounting Integrated in Quality Prioritization

Disease management with Cost Data from External Partners (i.e. Humana, Anthem, United)

Measurement of Clinical, Operational and Financial Key Performance Indicators in Combined Dashboard

Norton Healthcare Center for Wellness and Prevention

Practice Health Navigators Telemedicine (Rural)UK Partnership for Outreach for a Healthier Commonwealth

Supply Chain MaximizationWomen and Children’s Agenda

Community Health Needs Assessment

• Patient Protection and Affordability Care Act

• Applies to all 501 3C Organizations

• Every three years 

• Documented action plans

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Clinical Re‐Engineering…the Nursing Perspective

• Improved care coordination and communication

• Improved access – physician extenders – email – phone call etc.

• Prevention and early diagnosis

• ED and Immediate Care Center visits

• Increase generic medication utilization

• Hospital re-admissions and multiple ED visits

• Improved management of complex patients

– Care Coordination and High Resource Utilizers

Institute of Medicine Report

Six Aims for Improvement

•SafeSafe

•Effective

•Patient Centered 

•Timely

•Efficient

•Equitable

Crossing the Quality Chasm: A New Health System for the 21st Century; National Academy Press, 1999

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IOM Report

Ten Rules for Redesign:1. Care is based in continuous 

healing relationships.2 C i i d2. Care is customized 

according to patient needs and values.

3. The patient is the source of control.

4. Knowledge is shared and information flows freely.

5. Decision making is evidence‐ based.

6. Safety is a system property.7. Transparency is necessary.8. Needs are anticipated.9. Waste is continuously 

decreased.10. Cooperation among 

clinicians is a priority.

Crossing the Quality Chasm: A New Health System for the 21st Century; National Academy Press, 1999

IOM report, Future of Nursing Key Messages

– Nurses should practice to the full extent of their education and training.

– Nurses should achieve higher levels of education and training through an improved education system that promotes seamless academic progression.

– Nurses should be full partners, with physicians and other health professionals, in redesigning health care in the US.

– Effective workforce planning and policy making requireEffective workforce planning and policy making require better data collection and an improved information infrastructure.

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IOM report, Future of Nursing Recommendations

Remove scope of practice barriers.

Expand opportunities for nurses to lead and diffuse collaborative improvement efforts.

Implement nurse residency programs.

Increase the proportion of nurses with a baccalaureate degree to 80% by 2020.

Double the nurses with a doctorate by 2020.

Ensure that nurses engage in lifelong learning.

Prepare and enable nurses to lead change to advance health.

Build an infrastructure for the collection and analysis of interpersonal health care workforce data.

• What are the framing questions we need to ask...and answer?

So How Do We Begin….

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• What is Nursing’s role?

Framing Questions

• If Nursing doesn’t manage Nursing, someone else will…

• What are we willing to change?

Framing Questions

• How can nursing drive care across continuum?

• How can nursing create 

patient centered focus?

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• Are we willing to “diminish” inpatient hospital care?

Framing Questions

hospital care?

• If Nursing stays defined within the four walls of acute care, what is itsacute care, what is its future? 

• How will we evaluate and VALUE Nursing’s

Framing Questions

Nursing’s contribution?

• What are the metrics tometrics to determine success and establish ROI?

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• Is this strictly a “MD” thing? A Hospital thing?

Framing Questions

• What is Nursing’s role to be in this new reform culture?

• How do we shift the roles within the 

kf ?

Framing Questions

workforce?

• What are the implications and models for care delivery?for care delivery?

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• And finally…

• What are  the 

Framing Questions

implications for Nursing professionals?

• What are the implications for Nurse Executives?Executives?

Call to Action

IOM

Nursing Strategic Plan

Pt Protection & 

Affordability Act

Health care Reform

ACO Transparency

Value Proposition

Workforce Needs

Meaningful Use

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Change Process vs. Grief Process

Evolution vs. Revolution

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Integrated Delivery Network of 

Five Not‐for‐Profit Hospitals

15 Out‐patient Centers

Norton HealthcareNorton Healthcare

1.6 Million yearly patient encounters

$1.6 Billion yearly revenue

11,000 Employees

4800 Registered Nurses

600 Employed Providers

2,000 Physician Medical Staff

1,857 Licensed Beds

60 000 Admissions/year60,000 Admissions/year

46% market share

Validated Key Findings

• Functioning within silos; not working as a system• Everything is a priorityN d d f• No standard of care across system. 

• Limited resources were not effectively used• Lack of education, understanding• Non‐hospital divisions view of value and reform as a “clinical” issue

• Scattergun and “flavor of the month”• System resources view of “ownership”• System resources view of  ownership• No accountability structure• No incentives to “succeed” • Results not achieved and sustained

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Risk AnalysisRISK MITIGATION STRATEGY

Erosion of the bottom line financials and/or a reduced market share that may realign the organization’s priorities No margin = no mission

Align to mission, vision, values.Align to strategic plan in multiple areas.“Mission critical” to achievepriorities. No margin = no mission. Mission critical to achieve objectives.

Non achievement of significant results in a short time frame.

Set the right stretch achievable goals.Support owners with system resources.Visibility of success to BOT, Execs, etc.Celebrate!

Lack of alignment of incentives for key leadership

Connect to variable compensation (short term).Connect to perform appraisals (LT).Sr. leaders presentations to BOT, etc.

The program costs are too high for long term sustainability.

Use and retool existing resources.

Strategic Principles

• System Level Initiative

• Within all components of strategic plan• Within all components of strategic plan

• Drive Focused Measurable Approach– Quality– Safety– Service– Process OutcomesProcess Outcomes– Financial

• Engagement of the Entire System

– Key Distinction

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Internal Stakeholder Assessment

• BOT, Executive, Operations & System Leadership, Service Line, MD leaders

• Patient/ Family/Community focus groups

• Identification of Need & Validate – Issues, concerns, frustrations, suggestions

– 1:1 interviews (informal conversation supplemented with interview guide)

– Document review

– Feedback of findings & validation of accuracy

Integration and Alignment

• Prioritize efforts by facility/division

• Integrate Quality, Safety, Process, Service and Fi i lFinancial

• Align work across Norton Healthcare

– Balancing system vs. “local” needs

– Sharing information

– Replicating process and practice

– Aligned Incentives• Executive compensation

• Managers’ evaluations

• Staff evaluations

• Reward & Recognition

• Physician goals

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• Engagement of the broad stakeholder base in all phases of the project. S d b “ h i ” j d hi ( d

Internal marketing plan

• Structured to be “their” project and ownership (and accountability) resides with the operations leaders. 

• Opportunities for the “owners” to visibly share their experiences, successes and difficulties are built into the process. 

• All reinforce: the programs the programs,  reinforce behavior,  support cultural change,  influences compensation (both variable and performance reviews) 

and  breed success. 

Nursing 2020Creating Care that is Accountable to Patients & Families

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• Model of Care – Acute Care

– Patient and Caring Focused

Nursing 2020

– Differentiated Practice Model

– Credentialing and Privileging

– Family Care Partners

– LPN Acute Care

– Multidisciplinary Team PerformanceMultidisciplinary Team Performance

– Individual Accountability

• Model of Care – Acute Care– RN placement and transitions of patient based on care needs– Patient Cohort alignment based upon Nursing care needs

Nursing 2020

Patient Cohort alignment based upon Nursing care needs (clean/potentially contaminated; high flow/low flow; high RN intensity/low RN intensity)

– Nursing centralization of expertise• “EICU” (and use with regional “affiliates”)• Remote Central Monitoring• Central Order Management• Placement and Transition• Pt/Family education and support• Continuum Management• Nursing Hospitalist• CNS/NP/Educator Model• Acute Care and Critical Care NP model

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• Model of Care – Acute Care

– Program Development (chronic, elderly, specialty surgical high recidivism)

Nursing 2020

surgical, high recidivism)

– Enhanced communication tools for patient/family

– Enhanced Technology/Automation (equipment interface and auto population, remote monitoring, documentation

– Nursing Sensitive Indicators

• Unit based dashboards

• Individual measurement of performance 

• Model of Care – Continuum Management– Multi specialty Nursing Practice at key locations matched with key physician partners and practices to leverage

Nursing 2020

with key physician partners and practices to leverage relationships

– Neighborhood “watch”

– Health ministries expansion and redefinition

– Alignment with Schools for provision of care and education

– Alignment with Community agencies for provision of care and education

– RN in physician practices to manage D/C, transitions, pt education and pt follow up – Practice Navigator

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• Nursing Systems– Credentialing and Privileging

Nursing 2020

– Clinical Advancement Programs (RN, LPN, PCA)

– Certification

– Nursing Sensitive Indicators

– NDNQI

– CERP and Prioritization

– Patient/Family Advisory Councils

– Clinical Design and Transformation

– Nursing Finance and Modeling

• Nursing Systems– Grants

• RWJ Kellogg IHI etc

Nursing 2020

RWJ, Kellogg, IHI, etc.

– Practice Governance• System Governance Launch

• Non hospital governance launch

• Expansion of acute care governance (care providers)

– Nurse Leader Development• Nurse Executive Initiative

• Nurse  Executive Fellows

• Nurse Leadership Initiative

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• NHC Institute for Nursing– Workforce Preparation

• Preparation of “continuum care practitioners”• Specialty orientation extension programs (ED, OB, Children)

Nursing 2020

p y p g ( )• PCA development/upgrade/transition• Defined education/orientation units• “Personal/cultural “nursing orientation

– School of Nursing Affiliations• Joint Appointments• LPN Acute Care Models• CNS certification program• “Faculty practice” model• “Faculty practice” model• “Shared class” faculty

– Simulation• Mobile/Fixed• Development of Affiliation Relationships (SON, Rural Network)• Development of Learning Laboratory

Workforce

• RN credentialing and Privileging

• BSN

• Role requirements

• Differentiated Practice

• Advanced Practice

• Doctoral preparation

• Roles beyond hospitals (i.e. Navigators, “Neighbors”, etc.)

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Executive Nurse Leadership IntensiveGED

N‐CAPCredentialing/

Leadership Development

Norton A d

NHC Workforce Development

Career Development 

School at Work

Credentialing/ Privileging 

Harnessing Our 

Learning Culture

Workforce Development

Norton University

Continuing Education

Academy

ShadowProgram

pProgram

at Work

College at Work 

Partnerships

PCA Development Program Norton Scholars 

& Educational Assistance

Institute for Nursing

ExternProgram

Lessons Learned

• Integration vs. Silo

• Pilot, adapt, adopt, system

• Local Constituencies vs. Standardization of System

• Hardwiring 

• Accountability structure

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Lessons Learned

• Be Revolutionary in thought and Evolutionaryi tiin action.

• No is not a “forever” answer.

• Negotiation is not a one time thing.

• Be a good mother and let the child grow up and move on beyond youand move on beyond you.

NHC 30 day select chronic readmission pattern 5/1/08 – 10/31/09

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44

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Defying Gravity

Questions