On February 24, 2008, the Centers for Medicare and Medicaid Services withdrew certification for inpatient reimbursement to the Haywood Regional Medical Center (HRMC) in Clyde, North Carolina. The precipitating event was an inspection in late January by state officials finding pervasive medical errors and concluded that the hospital was in imminent jeopardy for patient safety.1 A few days later, 3 additional payers including Blue Cross and Blue Shield withdrew payment for inpatient care.2 In the ensuing days, the chief executive officer, the chief nursing executive, and chairman of the board of the hospital resigned. The leader of a consultant team attempting to recertify the hospital summarized the situation as a significant leadership failure.3

In an article in the local Smokey Mountain News, interviews with present and former HRMC nurses indicated that they felt that nursing care was not valued and the overbearing emphasis on controlling costs led to a high rate of regular staff resigning for other jobs.4-6 Open positions were filled with contract or traveler nurses. On June 6, 2006, findings from a survey conducted at HRMC found substantial deficiencies in nurse staffing. In particular, the report cited several nurses informing supervisors of dangerous staffing conditions in the intensive care unit.7

Haywood Regional Medical Center is the sole hospital in Haywood County and its third largest employer. Physicians scrambled to save their practices in the aftermath of the hospital losing Medicare payment by seeking admitting privileges in hospitals in adjacent counties.8 The overall impact of the lack of reimbursement for Medicare and Medicaid inpatient services will profoundly affect this rural community for many years. The sober lesson is the lack of communication with the nursing staff at HRMC and the apparent assumption by senior executives that nurses were a commodity. The reported lack of response by senior management to critical concerns raised by both nurses and physicians is difficult to comprehend in today's environment of collaboration. The key question that any nurse manager or nurse executive should ask is as follows: could this happen at my hospital?

As a nurse leader, just reading a few key documents (see reference list) will give you a very uncomfortable feeling. Although it is easy to retrospectively diagnose organizational ills, there are some personal and leadership lessons from this situation that can be applied to nurse executives facing organizational challenges.

Identify and Articulate a Clear Vision

Most organizations and hospitals have vision statements. How many nursing departments have these? In a complex or troubled environment, it is easy to wonder why people do not help to accomplish goals. Maybe the goals are not clear to all? Successful nurse leaders have to develop, understand, and articulate a clear vision and goals for nursing to ensure everyone is working in the same direction. During trying times, the vision needs to be revisited in every communication to remind staff that there is meaning to the work and that the vision was not developed in a silo. The vision should support organizational priorities and be developed with input from all levels of nurses throughout the organization.

Do Not Underestimate the Value of Culture

A very intuitive person said it takes 3 to 5 years of consistent, persistent leadership to change culture. In today's environment of immediacy, it is easy to force issues affected by culture; however, from experience, the changes will be transient. Examples of this have been repeated time and time again when hospitals try to introduce cost reduction programs. Who does not want to have cost-efficient care for our patients and community? Maybe it is time that we, as leaders, stop making the patient-staff-organization relationship triangle so complicated and focus on the basics. If the programs we sanction and decisions we make as leaders do not deliver improvements in care through supporting staff at the bedside, are these good decisions? Have we engaged staff from the point of service or are we telling them what to do? Do patients really care which pair of gloves or which brand of catheter we use? Are they focused on being treated with respect, caring, and dignity by an educated, caring nurse? What would we want if the patient was our family, spouse, child? As leaders, we want to be responsible stewards; yet, at what price?

Communicate With Skill

Communication is a challenge for all large organizations. With 4 and sometimes 5 generations of nurses in the workforce, communication needs to occur in multiple ways. No mechanism is sufficient to ensure the "message" is heard. Memoranda and e-mails are fine as were cited in the HRMC example; however, interpersonal interaction and 2-way communication are a must. Nursing staff members want job security and will understand better when some programs have to be altered or discontinued if they can have input into the overall plan. The principles of shared governance and employee empowerment can be used as mechanisms to support communication and buy-in.

Developing Credibility and Trust in the Organization

Nursing leaders are often asked to make daunting budgetary decisions. It is essential that when confronted with these situations, we do not lose sight of the people involved. To achieve goals, nurse executives must solicit necessary support from all levels in the organization. Drastic changes that result in increased and unmanaged turnover, disenfranchised staff, and care outside standard and acceptable practice are not acceptable. Nurse executives must assess the environment and, at times, develop appropriate plans to reduce cost. These plans, however, are not "rapid cycle" events and are often more acceptable if implemented in phases. Senior nurse leaders must ensure that accountabilities have realistic expectations and timeframes and the patient remains the focus of all decisions. Conditions such as HRMC did not occur overnight, and sustained change to address issues will not either!

Regulatory standards have shifted to a patient safety focus. It is time for nurse leaders to demonstrate commitment to patient safety through our leadership, decision making, and role modeling including during difficult financial times. The national standards for safety that are identified by groups such as Centers for Medicare and Medicaid Services and others are designed to protect the patient. From reading the articles on HRMC, it looks like plans are underway to address issues and concerns including those from nursing staff. As nurse leaders, we can all learn from difficult situations such as this to improve our leadership as we continue to focus on the patient.

References