Improving Healthcare Delivery from a CNO’s Perspective

February 2, 2018

“Barbara?” It was 3:30 a.m. and she knew it was the hospital switchboard as soon as she looked at her cell phone.  “I’ll connect you to the night supervisor,” the operator said.  “There’s something happening on the cardiac floor.”

“Sorry to call at this hour, Barbara, but wanted to give you a head’s up.”  The calm voice of Steve J., a veteran RN perfectly suited for the lonely job of managing staff on the cardiac unit while patients slept, was even but serious.  “You’re probably going to have to meet with Risk Management and then a family when you get in.  We had an open-heart patient make it up to the floor without pain med orders and it’s taken a while to track down the on-call doc.”  He paused.  “The patient has been awake the whole time.”

Over the course of 30 years, Barbara had worked her way to the highest position a registered nurse can attain: hospital Vice President & CNO (chief nursing officer).  Responsible for oversight of all inpatient and outpatient services at a 900-bed acute care medical center, she had paid her dues to get there—from a scared, fresh-out-of-school 22- year old slogging through the trenches of the ER, then obstetrics, intensive care, pediatrics, telemetry—caring for patients who would heal and go home and for patients who never would.

Barbara’s passion for the work had kept her going, giving her the drive to go to school at night for advanced degrees.  Now, she had arrived.  The hours were long (11-hour days were not uncommon), but the pay was good (six figures) and she had always wanted to have a greater influence on patient care.  Finally, she could.  Or could she?

Her schedule is filled with back-to-back meetings in conference rooms far from patients, and those with the CEO always begin and end with discussions about money.  She is constantly being asked to justify expenses, to find ways to increase revenue.  To help with this goal, the hospital has hired a consultant (whose expertise, by the way, is improving manufacturing assembly-line processes) who recommends reducing staff.  CNAs (certified nursing assistants—a nurse’s “right hand”) were let go right away, and RN schedules were “flexed.”  Some of the most senior nurses left, and Human Resources replaced them with per diem staff.  Barbara wants enough staff to provide safe patient care.  The CEO wants to keep the hospital out of the red.  Welcome to American healthcare today.

Back to Barbara’s story.  She was roused at 3:30 a.m. regarding the open-heart patient’s pain management incident. By 7:00 a.m. she had met with the patient’s nurse, questioned the floor’s nurse manager, reviewed notes from the OR’s hand-off team, and had a brief, unpleasant phone conversation with the patient’s surgeon.  A meeting with the head of Risk Management would be required but first she had to sit down with her counterpart, Jim, the equally busy chief medical officer.  Their conversations never seemed to go well, and this one was no exception:

Barbara: This incident poses a serious risk for the hospital. Why did it take over four hours for one of the on-call doctors to answer the charge nurse’s multiple pages?

Jim: We were short-staffed that night because one of our physicians called out. There was a patient in the ICU who had coded and the doctor who was covering that floor was tied up trying to save her life.

Barbara (becoming irritated): How many times have we talked about your staffing issues? Why does this keep happening? Why can’t another doc be called in to help?

Jim (on the defensive): You know damn well why this happens! I can’t get budget approval from the CFO to hire another doc for the overnight shift. What do you want me to do, answer the page myself?

Barbara (sarcastically): Maybe you ought to. I do.

Stalemate.  Animosity.  Once their frustrations had boiled over into the open it was only harder for them to work together.  Two highly successful healthcare professionals, dedicated to helping people, feel stuck and feel they have failed—themselves, their staff, and patients. They cast blame but no process changes are made.  And the patients continue to suffer.  Sound familiar?

Oh, that open heart patient who had not received pain medication after surgery?  That was me.  That terrifying experience was the impetus for the launch of a new stage in my career as an organizational psychologist.  It was the turning point at which I became dedicated to helping find answers to the complex challenges facing healthcare systems.

The first discovery in my journey to improve healthcare delivery was that many leaders and staff often feel frustrated in their effort to make changes. And that leads to playing the blame game, defensiveness, and finally stonewalling. This downward spiral is the opposite of what’s required – collaboration.

Stay tuned for next week’s post to learn how a top ranked hospital was able to achieve excellent patient outcomes by eliciting high levels of staff engagement.

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