nursing’s Dual mandate...nursing’s Dual mandate 3 Michael Porter, Ph.D. Harvard Business School achieving high value for patients must become the overarching goal of health care

Rese aRch and insights Perfo rm a n ce T ech n o lo g ies Ta l en T D e v elo Pm en T

ReseaRch BRieFing

InternationalGlobal Centre for Nursing Executives

leading the charge Towards value-Driven care

nursing’s Dual mandate

2 global centre for nursing executives

We’re all being asked to do more with less.

nowhere is that more evident than in nursing and patient care services.

nurses are at the frontline of care transformation. an ageing population means more patients and fewer nurses. increasing patient complexity requires higher care standards and stronger skill sets. and evolving patient expectations now make the care experience as important as its efficacy.

at the same time, meeting the needs of today’s patient population (let alone tomorrow’s) is harder than ever. as organisations look to cut costs, many begin with the biggest line item in the budget: the nursing workforce.

But we won’t meet patients’ and payers’ rising demands by simply stripping the organisation of perhaps our most valuable asset. instead, we need to shift the conversation.

We need to radically rethink nursing’s role in the organisation. The only way to deliver value-driven care is to elevate nurses to work at the full extent and scope of their training—and leverage their expertise and breadth across the health system to ensure we simultaneously meet our effectiveness and efficiency goals.

nursing’s Dual mandate 1

Director of Finance NHS England Foundation Trust

nursing is our single biggest labour cost. so whatever you think about nursing and what nurses can do and can’t do, then a small impact on a big cost is usually a big impact. so i think recognising nursing as an area to pay some attention to is good from that perspective.”

small impact on a Big cost has a Big impact

By enfranchising nurses to lead care transformation, organisations ensure they can deliver on their dual Mandate—delivering more efficient, cost effective care while also improving care quality and the patient experience.

The nursing workforce has an unprecedented opportunity to lead the way when it comes to securing value across the system.


value: looking at Both sides of the equation

Too often, organisations optimise one side of the value equation at the detriment to the other. costs balloon when you establish quality-improvement initiatives, for example, or patients suffer during times of radical reorganisation. What we really need are innovative ways to increase quality while cutting costs.

nurses are in the best position to realise this goal.

many nurses rightly look to protect patient care at all costs, even when refusing to innovate may threaten the organisation’s sustainability. so it’s important that nurses understand why health care systems must transform and how to align their priorities to ensure the long-term system sustainability.

the purpose of this brief is to do just that—to help nurses better understand the key imperatives for health system transformation and to help executives across the organisation better understand the key opportunities for nurses to lead these efforts.


Michael Porter, Ph.D. Harvard Business School

achieving high value for patients must become the overarching goal of health care delivery, with value defined as the health outcomes achieved per dollar spent...Yet value in health care remains largely unmeasured and misunderstood.

since value is defined as outcomes relative to costs, it encompasses efficiency. cost reduction without regard to the outcomes achieved is dangerous and self-defeating, leading to false ‘savings’ and potentially limiting effective care.”

Value: the Overarching ambition


Key opportunities for nursing innovation

so where are the best opportunities to make the health system more efficient and raise quality at the same time?

First: workforce. it’s no secret that we simply won’t have enough nurses (or money) to adequately care for our older, sicker population. meanwhile, study after study recommends investing in more highly trained registered nurses. so we need to change the nurse staffing model to build the high-value care team.

next: clinical operations. The hospital of the future simply won’t have enough beds to handle patient influx. every patient interaction must be as efficient and effective as possible. small changes to streamline clinical operations can mean big changes for both quality and efficiency.

Finally: chronic disease management. it’s better for patients—and for health system finances—for treatment to occur closer to home, so nurses must play an elevated role to manage care across the continuum. That means building relationships with patients, families, and caregivers both in and out of hospital to ensure patients are best equipped to self-manage whenever possible.

Understand, the nursing enterprise’s lasting goals—continuous improvement in patient quality and patient experience (and the necessary workforce and leadership development to fulfill these aims)—remain the foundation of success.

But we think these are the three areas where patient care services strategy must evolve today to align with tomorrow’s overarching health system agenda.


imPeraTive nUrsingmeDical

sTaffancillarY

sTaffexecUTive

Team

Build the high-value care team

streamline hospital operations

manage care across the continuum

impact of nursing vs. Other stakeholders on Organisational imperatives

no impact

minimal impact

moderate impact

significant impact

exclusive impact

inDUsTrY insighT

We need to let the nurses lead change because if it won’t work operationally in the end, we’re going backwards. ‘nurses are the constant.’”

Nursing Leader New Zealand


Building the high-value care Team

nurses are a highly trained, highly skilled workforce, but that also means they’re a relatively expensive one. While that investment is well justified, organisations need to ensure structures are in place to make the best use of this group, especially as rising patient acuity continues to strain resources.

Canadian Chief Nursing and Health Professions Officer

if money was no object, i could pick up all rns to provide that care, because their scope is all encompassing...but unfortunately none of us live in an environment where we have an endless supply of resources, you do have to make some choices.”

Making difficult tradeoffs

learn more in our study Building the High-Value Care Team, available at advisory.com/gcne or email [email protected]


Barriers to staffi ng Up to Patient needs

Relationship Between nursing hours and care complexity

Required to Meet Patient Needs

Actual Supply of Nursing Hours Available

Nu

rsin

g H

ou

rs

Care Complexity

increasingly complex patient population

impending workforce shortage

constant fi nancial pressure


To care for complex patients with current staffing resources, leaders must maximise the value of each nursing hour. But many struggle to do this—why?

1 Underleveraging RN skills and training—

elevate the Role of the Bedside nurse

2 Uncoordinated interprofessional care—

align interprofessional goals and Work

organisations over-rely on bedside rns to complete work that support staff or other non-rn care team members can safely accomplish. nurse leaders should ensure all care team members are working to the full extent of their scope and training, and they must carefully evaluate whether their current model effectively allows them to do so.

Uncoordinated interprofessional care often leads to duplicative efforts and wasted resources. The most effective organisations closely align care team goals and workstreams, and they also encourage real-time collaboration whenever possible. Technology can be a huge help in succeeding on this front.



elevate the role of the Bedside nurse

nurses often spend too much time away from the patient bedside. and when they’re caught up searching for supplies, transporting patients, and cleaning up messes, they’re simply not working to the full extent of their scope and training.

not taking Full advantage of the Rns We have

Nurses’ Time Spent on Non-Value-Added Time

Activities That Other Care Team Members Could Safely Accomplish

• Transporting stable patients

• scheduling diagnostic tests

• searching for extra linens

• fixing broken equipment

• carrying specimens to lab

1

rn wages spent on non-value-added time per med/surg unit$756,724

36%


something needs to give. But what should nurses be doing? and why aren’t they doing it today?

it’s not economic rocket science. You want your highly skilled workforce doing highly skilled work.”

Nursing Administration Quarterly

i tell staff all the time that they didn’t go to school for four years and spend thousands upon thousands of dollars to answer a phone and look for equipment...[T]hey went to school to learn how to assess, diagnose, plan, intervene, and evaluate...[T]hey went to school to learn judgement...[n]ow we need to give them the one thing they need...time.”

not the culture of nursing

inDUsTrY insighT

Chief Financial Officer United Kingdom


The first step to build the high value care team is to define the bedside nurse’s ideal role and responsibilities. The following eight items are the core responsibilities for registered nurses at the bedside, but they also work across care settings.

look closely at these. how are your nurses spending their days? Do they spend too much time on certain activities? not enough on others?

When nurses can effectively execute on each of these responsibilities, they achieve what we call “top-of-license” nursing practice. That is, each member of the care team works to the full extent of his or her skills and training.

core nursing Responsibilities across settings

1 assess clinical and psychosocial patient needs

2 establish patient goals and track progress

3 Provide patient-centred outcomes-focused care

4 educate and engage patients and their families

5 manage key components of the clinical record

6 coordinate care with interprofessional caregivers

7 facilitate safe patient transitions to the next care setting

8 assess and incorporate new technologies and evidence-based practice

Defining ‘Top-of-license’ Practice by Patient needs

learn more in our study Achieving Top-of-License Nursing Practice, available at advisory.com/gcne or email [email protected]


Protect Rns from avoidable time sinks

once nursing responsibilities are defined, we need to streamline nursing processes to eliminate wasted time. for example, proper documentation is a critical element of nursing care, but documenting the same things in multiple locations unnecessarily takes nurses away from the bedside.

Beyond that, nurses also spend time on tasks that could be safely carried out by other members of the care team (or even technology). Why? Because they’re the last line of defence—if they don’t do it, who else will?

To remedy this, nurses need to delegate certain tasks to staff they trust. many organisations around the world are looking to change the inpatient staffing model by incorporating other caregivers into the team.

“Building a Culture of Innovation by Maximizing the Role of the RN” Nursing Administration Quarterly

We introduced lower-level caregivers in the hospital years ago, but the nurses were not used to working with them. it took a very long time for the nurses to understand that it’s possible for the support staff to do a lot of work for us: washing, cleaning, and feeding is not the nurse’s task. it’s been a 10-year process to teach nurses that they need to be comfortable with and responsible for support staff.“

Underleveraging Potential support


encourage collaborative, team-Based care

But these nurse staffing models simply won’t work without significant investments to ensure support staff, such as health/patient care assistants, are used appropriately. We can’t simply allocate tasks among various caregivers because patients are becoming too complex—and when caregivers are no more than taskmasters, we lose the holistic vision of the patient.

challenges associated with task-Based approach to Role Redesign

Regulatory Requirements Vary

regulations vary across countries and regions and change over time as they are updated

One Activity Can Serve Multiple Aims

it’s often more efficient to combine more than one care activity into a single event

Dependent on Patient Acuity Level

identifying the most appropriate caregiver requires professional judgment in the moment

Patient Safety Trumps Role

caregivers must “pitch in” to ensure patient safety, even if the activity is not their primary responsibility


delegating to and collaborating with staff

We must design a care team—and the roles and tasks of individuals within it—around the needs of the patient. instead of assigning specific activities to each care team member, nurse leaders should examine the eight core nursing responsibilities to build a model that enables care teams to collectively meet their patients’ needs.

even in organisations where support staff are integrated properly, nurses still may not trust them. To remedy this, organizations should redesign assistants’ workflow to ensure trust among rns that someone will always be able to help them, and that routine tasks will be completed as expected.

frontline nurses also need training to become care team leads, which requires special focus on elevating their delegation skills. as one assistant nurse manager put it, “it was hard to say, ‘i’m waiting on a phone call. can you do it?’ That’s not in the culture of nursing.”

inpatient nurse staffing Models

Rat

io o

f RN

: An

cilla

ry S

taff

Degree of Collaboration Necessary for Success

Primary

Total Patient CareHybrid

(Task or Functional)

Incorporating Lower-Level Caregivers

RN Team Leadsingle rn responsible for patient’s care across entire stay

single rn responsible for patient’s care across nurse’s shift

single rn responsible during

shift but can delegate task to

ancillary staff

rn leads team of ancillary staff

jointly responsible for all assigned

patients


two dimensions of care team design

Nu

rsin

g Te

am E

ffici

ency

Interprofessional Team Integration

align interprofessional goals and Work

organisations must improve the inpatient nursing staffing model to truly deliver value-driven care. But this requires collaboration beyond the nursing team. By closely aligning interprofessional goals and work streams, nurse leaders can ensure that care teams are well coordinated and equipped to deliver higher-quality and more efficient patient care.

Efficient, Siloed Care Team

Inefficient, Siloed Care Team

Inefficient, Interprofessional Care Team

nurses practice to the full extent of their training and skills but within professional silo

Efficient, Interprofessional Care Team

interprofessional care team collaborates efficiently and effectively, providing high-quality, low-cost care

nurses do not practice to the full extent of their training skills; caregivers work in professional silos

nurses and other caregivers collaborate to provide care, but nurses do not practice at top of license

2

optimal care Team


enhance interprofessional Understanding of nursing’s Role

appropriately incorporating support staff into the nursing workforce allows nurses to spend more time doing higher-level tasks. But they also have to be trusted and given the authority to take on these responsibilities.

interprofessional colleagues often struggle to understand each other’s roles and how they can support each other’s work. in some instances, the traditional paternalistic professional culture can reinforce staff perceptions of hierarchy among different disciplines. in addition, siloed reporting structures often reinforce siloed goals.

But even well-intended doctors are often unaware of the full scope of nursing practice. student nurses and doctors are educated separately, and doctors may have misperceptions about the legal scope of nursing practice.

successful organisations take a proactive approach to making the care team more interprofessionally collaborative. often these practices not only increase other professionals’ understanding of nursing’s role but also help nurses more fully understand the roles of other disciplines—and their own.

learn more in our study Strengthening Interdisciplinary Collaboration, available at advisory.com/gcne or email [email protected]


1 give all care team members the same set of goals

2 expand nurse clinical decision making to provide timely patient care

3

4

5

assess appropriate opportunities to transfer work to specialised team members

gather doctors and nurses at the bedside at the same time

Keep care teams as consistent as possible

steps to align interprofessional Workstreams

establish structures for efficient interprofessional collaboration

once organisations overcome nursing practice misperceptions, they must work to ensure that structures are in place so care can be delivered as efficiently as possible.

interprofessional team members frequently deliver patient care in silos, rather than as integrated teams. By closely aligning interprofessional goals and work streams, nurse leaders can ensure that care teams are well coordinated and equipped to deliver higher-quality and more efficient patient care.


streamline clinical operations

a high-value care team attempts to use labour resources in the most efficient way possible. nurses aren’t wasting time on inefficient processes. Tasks that require less skill are delegated to less skilled individuals. nurses and doctors work together to ensure tasks are done right the first time, every time.

But while workforce represents the largest hospital budget item, there simply won’t be enough time, space, or money to effectively treat the future influx of patients. acute care is not going away. By 2033, for instance, we predict a 214% increase in admitted patient services.

hospitals need to find savings wherever possible. and small process changes hardwired within the nursing workforce can mean big changes for clinical operations.

Deputy Director of Nursing NHS Foundation Trust, UK

There is a lot of ‘systems stuff’ that needs to be done, which i think—as nurses—we can contribute to because we understand the patient better. and i also think that we understand the patient flow better than other professions do.”

Leveraging a Unique Perspective


A US Chief Information Officer

The administration wants to run the hospital; doctors think they run the hospital; but nurses really do run the hospital.

nursing at the core

encourage Frontline Ownership of Process improvement

nurse leaders around the world have pursued a diverse set of process-improvement methodologies. Their success has hinged on how involved and engaged frontline staff was in the efforts.

frontline staff can identify and effectively prioritise the biggest opportunities—and when they own the improvement process, changes are more likely to stick.

There are also downstream benefits to frontline ownership. staff who feel empowered to make positive changes in their practice are more engaged. They work harder (and better), and they stay longer with the organisation.

learn more in our study The Highly Productive Nursing Organisation, available at advisory.com/gcne or email [email protected]


encourage nurses to Lead effective and efficient discharges

With more ownership—nurses can help save time and money in a variety of ways: leveraging their clinical expertise to better negotiate prices on supplies. collaborating with iT to ensure electronic patient records hardwire efficient documentation practices. Partnering with pharmacists to ensure more effective and efficient medication administration.

one process should be at the top of every nurse’s mind, though: discharge.

With nurses at the helm, discharges can be more efficient, reducing unnecessary bed days and creating virtual bed capacity.

But perfecting the discharge process is not only important to reduce length of stay. When nurses start to think about discharge right at the beginning of the patient’s stay, they can work with patients, families, and other caregivers to prevent unnecessary readmissions.

steps to ensuring efficient discharge

Predict Date of Discharge

ensure effective coordination

Target care Planning to

neediest Patients

Provide Through Patient Education

Prevent Day-of-Discharge

Delays

learn more in our study Nurse-Led Strategies for Preventing Avoidable Readmissions, available at advisory.com/gcne or email [email protected]


manage care across the continuum

all health care leaders seem to agree that care integration is vital to both the health of their patients and the health of their institutions. But there’s currently little consensus on what integration actually means.

We define an integrated health care system as one that proactively provides patients with timely, high-quality care in the lowest-cost setting without unnecessary duplication of health care services.

Different health systems around the world employ different structures to formally or informally integrate care. some health systems have full administrative and budgetary ownership across different care sites—and sometimes for both health and social care.

But even organisations with clear authority across the continuum have found that such control is no guarantee of providing integrated care. instead, integration must be pursued as a deliberate strategy.


this is not an integrated care experienceSiloed Care Sites Yield a Fragmented Care Experience

outpatient facility Physician clinic home healthhospital

Patient lacks transportation from hospital to home outpatient care

team fails to transfer patient’s active medication list to a physician office

clinic nurses provide patient education conflicting with inpatient education

3

Building a nursing Blueprint for integration

as the leaders overseeing the largest hospital workforce (and the one that touches patients in every care setting), we believe nurse executives must play an active role in health system integration. nurses are often at the helm of successful care transformation efforts—truly working together with patients across care settings to help better engage them in their own care.

21


The provision of truly comprehensive, patient-centred care requires far more than assembling a provider network that covers the full care continuum. nursing leaders need to understand how to establish:

We distilled six key questions nurse leaders must answer to advance integration:

structures Processes

to ensure consistent care across settings

to ensure seamless transitions between structures

1 What is the right scope of authority for the senior-most nurse leader?

2 What is the right reporting structure for nurses?

3

4

5

6

Which nurse leaders should work across multiple settings?

What is the right infrastructure for guiding patients to the appropriate care setting?

how can you ensure interdisciplinary collaboration across care settings?

how can you instill a system-level perspective among frontline nurses?

learn more in our study The Integrated Nursing Enterprise, available at advisory.com/gcne or email [email protected]


nurses are vital to ensure organisational sustainability in a way that still advances care quality. as organisations struggle to do more with less during this once-in-a-career health care transformation, nurses can and must play a central role. if given the right opportunity, nurses can lead towards value-driven care by furthering the strategies outlined in this briefing.

But organisations won’t make much progress on any of these strategic objectives without an energised nursing workforce at the front line. We can’t expect to charge blindly ahead, focusing solely on hitting performance and financial targets, and assume our nurses will be enthusiastic about additional checklists, regulations, and responsibilities on their already full plates.

any nursing strategic plan must focus not only on these areas of innovation, but also on continuous workforce and leadership development. as care becomes more complex, nurses need certain skills to lead these innovations. But perhaps more than that, they need to feel supported by the organisation. This will foster a sense of pride and ownership in the organisation’s ultimate success.

energise the nursing Workforce

learn more in our study Energising the Nursing Workforce, available at advisory.com/gcne or email [email protected]


This research briefing draws on the following studies, all of which we strongly recommend to nurse leaders who would like more detail on specific tactics that will help them fulfill nursing’s dual mandate.

• The highly Productive nursing organisation

• achieving Top-of-license nursing Practice

• Building the high-value care Team

• strengthening interdisciplinary collaboration

• nurse-led strategies for Preventing avoidable readmissions

• The integrated nursing enterprise

• energising the nursing Workforce

not a member of the global centre for nursing executives? email [email protected] to request one of the studies.

learn more


We provide research for an international network of nursing executives charged with leading the largest and most critical element of the health care workforce in a time of great challenges.

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Research and insightsTake an in-depth look at the results of our research initiatives, including best practices and implementation tools. You can also participate in web-based educational intensives to accelerate your adoption of these insights.

expert guidanceWorking on an initiative but don’t know where to begin? We offer unlimited telephone and email consultation.

global centre for nursing executives

learn more at advisory.com/gcne

legal caveaT

The advisory Board company has made efforts to verify the accuracy of the information it provides to members. This report relies on data obtained from many sources, however, and The advisory Board company cannot guarantee the accuracy of the information provided or any analysis based thereon. in addition, The advisory Board company is not in the business of giving legal, medical, accounting, or other professional advice, and its reports should not be construed as professional advice. in particular, members should not rely on any legal commentary in this report as a basis for action, or assume that any tactics described herein would be permitted by applicable law or appropriate for a given member’s situation. members are advised to consult with appropriate professionals concerning legal, medical, tax, or accounting issues, before implementing any of these tactics. neither The advisory Board company nor its officers, directors, trustees, employees and agents shall be liable for any claims, liabilities, or expenses relating to (a) any errors or omissions in this report, whether caused by The advisory Board company or any of its employees or agents, or sources or other third parties, (b) any recommendation or graded ranking by The advisory Board company, or (c) failure of member and its employees and agents to abide by the terms set forth herein.


sources

Page 3: Porter m, “What is value in health care?,” The New England Journal of Medicine, 363 (2010) 2477-2481, http://www.nejm.org/doi/full/10.1056/neJmp1011024?viewType=Print.

Page 10: storfjell J, et al., “The Balancing act: Patient care Time versus cost,” JONA, 38, no. 5 (2008): 244–249.

Page 11,12: everett l, sitterding m, “Building a culture of innovation by maximizing the role of the rn,” Nursing Administration Quarterly, 27, no. 2 (2013): 194-202, http://www.nursingcenter.com/_PDf_.aspx?an=00006216-201307000-00005.

global centre for nursing executives interviews and analysis.

Project DirectorPatricia Wynn, mBa

contributing consultantsmarygrace apostolilauren clinton hawkins

Project editorJohn Wilwol

DesignerKevin reardon

managing Directorandrew rosen, mBa

image credits

cover: istock.

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nursing’s Dual mandate...nursing’s Dual mandate 3 Michael Porter, Ph.D. Harvard Business School achieving high value for patients must become the overarching goal of health care