Nurses are essential for a hospital

Darryl Harper Prof studies Ass II

Within the hospital and specialized clinic setting a synergy between business practice and clinical practice is vital to the success of the organization. In my experience as a nurse manager, while attending monthly management meetings, I have experienced hospital administrators (CEO's and CFO's) that understand nurses are essential for a hospital or health clinic to function, and to maintain a high quality of care. These same administrators also express concerns that department managers were not doing what administration needed them to do. In these instances it appears that the administrators and department managers are out of "sync" in what they understand the job role to be. This perception may not be due to a lack of clinical expertise but more a lack of business skill and understanding of expectations from the nurse managers view and the opposite from the administrators, that may be causing a disconnect. This paragraph needs work. - separate out ideas

The reason that I have chosen this topic is to establish how I can utilize business principles to improve the preparation of nurses as they assume management positions within specialized cardiac care clinics in providing effective patient management and care. From this, I plan to outline a personal development plan to enhance my own management and leadership skills.

This paper will

  • Examine basic business practice, and models, applicable to the management of a network of specialized cardiac clinics.
  • Discuss the impact that the management models, six sigma, and lean practices have in enabling effective management in the clinical setting
  • Identify business resources that will enable the successful development of nurse managers within the specialized cardiac clinic
  • Organize my learning into a personal management and development plan

Healthcare organizations are working to provide optimal care in cost effective ways. The tension between these two objectives is challenging for all levels of management . Managers are being challenged to develop optimal planning algorithms, patient satisfaction surveys, or building new clinical paths, such as cardiac care service lines for focused cardiac management. Choices ultimately have to satisfy clinical objectives ( optimal care, outstanding communication and collaboration or information transparency, just to name a few). At the same time organizational issues need to be addressed in order to deliver products and services in a sustainable way (cost effective, evidence based, and state-of-the art ) Nurse managers are required to work beyond their clinical training and become experts in the fundamentals of business management. The solution in building sustainable specialized cardiac clinics will require a balance of views that provide value to the consumer as well as value for the healthcare organization. This will require specialized training to develop the skills and models to support the development of effective nurse managers.

Historically hospitals and health clinics have been run by doctors with the assistance of finance and operations managers. From a clinical perspective, it is well documented that nurse managers play a vital role in hospitals and other organizations. (Lin & Wu, 2007) They must effectively communicate with other functional areas and other organizations, manage nursing resources, and support hospital strategy aligning with the focus of specialized clinics. Specialized cardiac clinics have a competitive nature in that the sites offering specialized cardiac programs wish to be identified as centers of excellence, competing not only for patients, but also highly experienced staff to attract funding for research and development. The specialty program is designed to optimize clinical patient management, while meeting fiscal and quality initiatives. Within healthcare, business success can be identified as being achieved through secondary tactics such as the provision of quality staff, resources and facilities, quality clinical practices and functional business practices (Ref).

Nurse managers have come to be regarded as one of the most important assets within healthcare. (Aroian & Horvath, 1997) Nurse managers in many instances do not receive adequate training in management principles compared to other industries. The gap in management and business preparation among nurse managers is an area that could be improved. (Noyes, 2002) This can be expanded to include the nurse managers within specialized heart failure clinics.

Interviews (field notes)

To better understand the integration of business expectations and the role of the nurse manager I conducted semi-structured interviews with key stake holders and support experts (CMO, CFO, DON, Purchasing Manager, Nurse Managers) With the permission of the individuals I documented field notes to later review to validate perceived gaps existing between the clinical and the business model within the specialized cardiac clinic. The interviews were structured based on clinic management, operational management, value proposition, market segment, strategic position, clinical strategy, and cost structure / revenue potential. This structure provided a framework to categorize the differing responses to identify the applicability of a business model framework as relevant theory to establish a clearer understanding of the elements required to build a nurse manager development strategy. (run on needs work)

Need to review field notes and refine....

Nurse manager 1:

Q: what are you main concerns as a nurse manager?

My most pressing concern is how to manage tasks. I have been the nurse manager for over a year now, my initial training could be labeled as a baptism by fire. No one was there to show me the ropes. I know that I got the job due to being the go to person for the cardiac step down unit, I was the unit expert and got the job. I know that I do not fully understand the manager role beyond staffing and patient flow. I find myself most days putting out fires and getting behind on the true job of managing.

Nurse Manager 2:

Q: what are the biggest challenges that you experience as a nurse manager? Time management would be the biggest challenge for me personally. I feel that is because I have more tasks than time available

Q: How do you manage this?.

Nurse Manager 2: Well to keep my family life separate , I have started myself with what are the 20% of things are that are going to get me 80% of my goals or results in terms of productivity and quality, these are the things that I place at the top of my list. The remaining 80% are where I set priorities, delegate, , or just say no.

Q: how would you describe the support in regards to supply management and marketing within the cardiac unit?

Nurse Manager 2: Ha - supplies just appear from the central supply stores, and anything not on the supply list we basically cannot have. And marketing that is another department, you know we have a billboard on the interstate with models and actors playing nurses, and a silly tag line - Number 1 in cardiac services, I'm not sure how they got that claim. We are good but number 1?

When asked what would a successful nurse manager would look like, the majority of answers indicated that success was interpreted as maintaining staff satisfaction and avoiding patient complications, dealing with the day to day problems associated with the patient flow through the clinic.

The most successful nurse managers work with purpose and create, a sense of urgency. Acknowledging what is working on their units, and at the same time look for opportunities to improve. If something related to patient safety, patient satisfaction, or compliance is out of whack, these managers immediately take action and make corrections to get back on track. (The nurse manager in these instances is not making rash decisions. They use the data at hand to get back on track as quickly as possible).

There is often a level of distrust across healthcare organizations. Nurse Managers are often caught between the executive team and medical staff. On a positive note nurse managers can serve as a bridge that builds trust and alignment throughout the organization. Leadership skills may be learnt on the job but are also skills that should not be left to chance.

Although some nurse managers expressed familiarity with budgeting and performance improvement, they also felt that these were also out side of their control, as budgets are passed down without consultation.

DON - Many Nurse Managers have not successfully made the leap from staff nurse to management. The most effective nurse managers balance both results and relationships. They achieve results through strong alliances based on personal leadership, critical thinking skills, commitment, and development of mutual respect, .

MD director: -I see some Nurse Managers actually sabotage the organization that has promoted them and pays them. For instance, the managers sometimes complain to medical staff and enlist the medical staff to argue for them, rather than going through the appropriate channels making a case for change. This not only creates extra work but undermines leadership's credibility with the medical staff, and the manager's credibility with leadership. Nobody wins.

Purchasing manager: - Many clinic nurse managers don't seem to take ownership of the operational management of their departments. I have experience supporting a number of clinics where nurse managers don't speak up, or attend organization planning, or strategy meetings, and as a result the organization goes around them when it comes time to make key decisions. Sometimes these Managers complain in the background . There is a right and a wrong way to communicate as a leader; few Nurse Managers have been taught how to influence people across their organization. Not many nurse managers know how to develop a business case for an investment or change in patient care model for a specialized clinic?

Management identified that while the Nurse Manager has the most important role in the clinic, setting the tone for quality of care and serving as the determining factor in retention of staff, they are rarely considered experts in the logistics associated with the supply, operational, and fiscal management. Where am I going ?Need to clarify here

Administrators agreed that nurse managers have a difficult position, in that they have 100% accountability for the service, quality, and productivity in the specialized clinic - but not 100% authority. The most effective nurse managers are identified as those who accept full accountability for setting the tone within the clinic and for the outcomes that the clinic achieves.

The outcomes of the interviews are two-fold, on one side it can be seen that the business model structure is an integral part of a healthcare strategy and are relevant to the clinic decision - makers, and on the other side there is a expressed anxiety on how change could be structured and accomplished

In addition to the strategic issues found through field research, I reviewed the following four sources in literature (Darzi 2007, MacKinnon 2002, Makee and Healy 2002, NVG vereniging van ziekenhuizen 2000.) Upon review of the literature it can be identified that healthcare strategies focus on pre-defined solutions, rather than techniques and tools to build strategy. I have been able to identify four distinct uses of healthcare business models: strategic choice, linking strategic domains, focus on value creation and a focus on value appropriation. One healthcare business model as identified in Chesbrough and Rosenbloom 2002 is well operationalized. A graphical overview can be seen in appendix II. This model consists of 6 different elements linked in a sequential order - value proposition, market segment, strategic position, value chain, competitive strategy, and cost revenue / revenue potential. At the start of this model customer preferences or needs drive the value proposition and the result is delivered.

The notation of value is the core of the business model, value as input and value as output. This is important in the success of the business and the management. Value for the specialized cardiac clinic can be defined in the following dimensions - it must be viewed from the customers perspective, it must span the complete disease state, and be deliverable through a sustainable process.

Specialized clinics should not have to reinvent the wheel, with the adoption of methods, tools and techniques the specialized clinic could evaluate current strategy and test future scenarios. There must be a perceived need for change with decision makers. During the field research I discovered many instances that indicated a need for change as well as the need for inclusive ways of framing seemingly complex problems. This was verbalized through feelings o frustration and inadequacy.

The healthcare knowledge that nurse managers must possess has changed and continues to change dramatically. Obtaining and retaining nurse managers who have the skills and knowledge to manage specialized cardiac clinics is extremely important. Management development is a highly necessary pursuit ( Tanner 2002, Srsic-Stoehr et al 2004) for nurse managers to assist in addressing the challenges in their positions. West and colleagues (2002) indicate that progressive human resource management practices positively impact both clinical practice and business principles.

Need transition - entry here ........

Models such as Six sigma and Lean can assist the specialized cardiac clinic to improve the performance of any core process or service in any business or organization. Healthcare organizations really need the ability to cut costs and lean Six Sigma training is the best option. Six Sigma courses are designed to teach employees and management ways to cut costs by eliminating wasteful processes that cause productivity to slow, affecting the patients in a negative way. Six Sigma training aims to automate processes, minimize error and better utilize resources. (ref web / 6 sigma article)

Lean methodologies are sometimes misunderstood, taken to imply paring or cutting back, the books lean thinking and lean solutions (Womack and Jones 1996, 2005 ) describe how the underpinning principles of a "Toyota" like approach can be applied to any form of work. The lean approach suggests the most effective way of making improvement is to focus on eliminating the non-value add steps as opposed to seeking the more obvious but smaller improvements to be had by improving the value adding steps (Womack and Jones 1996, 2005 ) This is a culture change for healthcare but is essential for the management of successful specialized cardiac clinics. A fundamental method for embedding this form of culture change and achieving ever - improving transformation is the use of "Rapid Improvement Events" (RIEs) These are week long hands - on change activity workshops with a cycle of planning, executing and following up change which build better end to end processes for the patient. The training of managers in lean transformations will facilitate positive change but the process has also been likened to trying to build a plane while trying to fly in it. Training managers in lean process management can bring radical improvements.

Insert Business resources


Insert Personal management and development plan


Develop improved flexibility in situational management as well as in the style and strategies used to influence others

Set up a support network to help managers discuss and resolve challenges.

As nurse managers lack a broad understanding of the hospital system and the goals/vision of the key leaders. .... Seek out and attend "senior leadership rounds" and board member / executive town-hall meetings.


Leadership course


A possible way to develop in-house leadership is with a Nurse Leadership Academy. The program could include elements such as::

  1. Selection of high-potential candidates from within the clinic staff. Starting with the existing Nurse Managers to create a common language and way of thinking about leadership helps prepare and develop staff.
  2. A two day retreat to explore the key elements of being a successful clinic manager and leader. Participants could discuss ambitious goals to improve quality, service, and cost within the organization.
  3. Monthly follow up meetings to discuss progress on goals, hear presentations from clinic and organization leadership (e.g., a board member might discuss the role of the board), and learn additional content.
  4. Support of ongoing one-on-one mentoring and coaching as needed.
  5. Identify three goals: an individual/professional development goal; a unit goal; and a hospital-wide goal. To learn with a focus on practical real-time issues, supporting the development of nurse managers to achieve organizational successes.
  6. A formal academy graduation or recognition after meeting specific milestones.

If this kind of program is initiated, it can expand and begin developing an internal cadre of coaches and mentors.

A nurse Leadership Academy can make a huge difference in recruiting, retaining, and developing staff ; ultimately improving results taking 100% accountability for the quality, productivity, service, and employee retention/satisfaction .

This approach can be applicable to other managers.


To be added from article list

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