Question: What insights do you have about the value of care coordination and population health management?

We have used multiple strategies to move our nurses, social workers, and others toward a more contemporary understanding of care coordination and population health. Our 1st intervention was to reframe the discharge process to a "transition to an appropriate level of care." Although we are certainly not the 1st organization to operationalize this redefined concept of care coordination, we have done this so in such a way that our nurses and others understand that the concept of discharge has an incredible finality to it. We want our nurses to understand what happens to the patient when they leave our care. This includes what requirements are needed before discharge such as appropriate education and access to resources so that patients are able to leave with restored health and avoid unnecessary readmissions.

In 2012, we received a Center for Medicare and Medicaid Services/Center for Medicare & Medicaid Innovation grant focusing on transitioning patients from our quaternary care hospital to their home community by establishing relationships with clinical coordinators in critical assess hospitals (CAHs). Many of our patients are transferred from CAHs or live in communities where CAHs are their primary providers of inpatient care. Through the grant, a nurse coordinator role was developed at multiple CAH facilities in our catchment area. The objective of the program was to foster a more efficient transfer of care between University of Iowa Hospitals and Clinics (UIHC) and area CAHs with the goal of reducing readmissions through communication of care plans between clinical coordinators. As a result, the readmission rates for this specific population significantly decreased. This outcome justified making the nurse coordinator positions permanent in both our facility and CAHs after the grant concluded.

The benefits of this intrafacility care coordination mechanism have been appreciated by the CAHs but beyond. As a member of several accountable care organizations, we are committed to having nurse navigators who work with patients, families, and long-term care communities to ensure that patients within our network have the resources they need to restore and advance their health while remaining outside the hospital. This kind of program puts nursing in a powerful position to impact readmission rates as it is nursing that is driving coordinated care in this part of the country. Interestingly, there are requests from organizations outside our network to be part of this care coordination, which demonstrates the power of coordinated care and the tremendous impact of nursing on care delivery.

Question: What strategies do you use to support patient quality and safety?

On average, UIHC hires 450 RNs per year and have 3000 nurses throughout the enterprise. In each nurse orientation session, I present the concept of value-based purchasing, its impact on quality and safety, and its impact on the fiscal integrity of the organization. In addition, I present an overview of our initiatives focused on such things as hand hygiene and chlorhexidine (CHG) bathing and use data to demonstrate the importance of outcomes to patient care and organizational outcomes. You cannot get compliance rates of 90% in an organization this complex until you have done the due diligence of educating nurses and enhancing their understanding of the role they play in producing high-quality, safe patient care. For example, I show graphs with superimposed data that demonstrate the inverse relationship between CHG treatment bathing and our central line-associated blood stream infection, catheter-associated urinary tract infections, and clostridium difficile rates. When the new nurses see these data presented in this fashion, they understand the incredible role that nurses play in addressing these issues.

We have a great deal of data that generate powerful information, and we use it to our advantage to enhance our practice. For example, in a partnership with the University of Iowa (UI) College of Engineering, our nurses developed real-time data dashboards that identify specific patients' risks by monitoring specific patient factors. As patient information is updated in the electronic medical record, these data compute risk factors that are posted on plasma screens located throughout the units. Through this mechanism, providers can readily review the screen and act accordingly to minimize those patient-specific risks. It is all about quality and providing the appropriate data for providers to take a proactive stance on a potential risk rather than a reactive stance on a real risk.

Question: What other factors contribute to your organizational success?

Our partnership with the UI College of Nursing (CON) has allowed us to excel at quality and safety. This relationship provides us an extraordinary scientific advantage to impact the delivery of patient care. Moreover, we have extended our partnership to other colleges such as the UI Tippie College of Business where we are working to develop time-driven activity-based costing (TDABC) strategies that will inform our nursing operations. This research is groundbreaking as it will allow us to look at staffing levels and the associated costs based on the intensity of nurses' work rather than by hours per patient day. We would like to incorporate the principles of TDABC with other variables impacting the cost of nurse staffing including the geography of the unit and the skill mix of the nurses. Combined, these powerful variables will lead us to an even greater understanding of nursing operations. Through leveraging these types of relationships, we have the power to influence our care delivery systems.

Question: Are schools of nursing meeting the needs of today's healthcare organizations?

Our academic partnerships are critical to our success. I meet with Dean Rita Frantz of the UI CON to communicate our needs and to better understand how we can support their mission of nursing education and research. For example, in the midst of a national nursing shortage, UIHC has a vacancy rate of approximately 4.5%. Although the overall vacancy rate is low, the bulk of the open positions making up the vacancy rate is in the operating room. One of the strategies we implemented was to highlight perioperative nursing in an effort to stimulate interest in the specialty. So, we set up an open house for students at the CON, which generated great interest. As a result, our colleagues at UI CON are in the process of developing a perioperative elective to help stimulate interest.

Question: What are the emerging roles for today's nurse leader across the care continuum?

Given that nursing administration is advanced nursing practice, we need to use evidence-based practice and principles in our work. When you think about it, the minimal requirement for most chief nursing officers (CNOs) is an advanced degree, either a Master's or doctoral degree. This supports the notion there is a breadth and depth of knowledge needed and that success of a nurse administrator comes with advanced education. For example, I am looking at reorganizing the administrative structure as a reflection of contemporary nursing practice. I believe that, as we move toward the process of quantifying the cost of nursing, using data to impact care delivery surrounding nursing care, nurse leaders need to have a greater sense of leadership and business acumen. They need to understand health economics, supply chain management, and human resource science. There are many organizations around the country that are combining the CNO role with the chief operating officer role. This combination of roles is an evidence that there is great appreciation of the business acumen acquired through a deep understanding of nursing operations. Nurse educators around the country must begin incorporating business principles in their curricula both in the hospital and in academia. I do not want to teach nurses about value-based nursing on their 1st day; I want nurses to come into the organization knowing about value-based nursing.

Question: In closing, how can an organization like the CGEAN enhance nursing and leadership practice?

Organizations like CGEAN are critical to professional practice as they partner with us in leading and promoting change. One way CGEAN can enhance nursing practice is in the establishment of professional standards of practice. For example, supporting Master's level education for nurse leaders is imperative given the current challenges organizations are facing, so working toward establishing guidelines for Master's education would be welcomed. We all need to be part of the change process for the change to be successful.