The Satisfaction Snapshot is a monthly electronic bulletin freely available to all those involved or interested in improving the patient/ client experience. Each month the Snapshot showcases issues and ideas which relate to improving patient satisfaction and customer service, improving workplace culture and improving the way we go about our work in the healthcare industry. The Satisfaction Snapshot features: «relevant articles from healthcare industry experts «case study success stories «tips and tools for quality improvement «patient satisfaction and other industry research findings «articles with ideas to help achieve success in your role DEVELOPING THE NEW FRONTLINE MANAGER Lauren Arnold, PHD, RN and Greg Nelson Edited by Terry Grundy, Managing Director Press Ganey Associates Australia If you would like your colleagues to receive the Satisfaction Snapshot please send us their names and email addresses. The Satisfaction Snapshot is published by Press Ganey Associates Pty Ltd. All material is copyright protected. Quotation is permitted with attribution. Subscribers are permitted and encouraged to distribute copies within their organisations. Subscription to the Satisfaction Snapshot is FREE! Never before has the role, skills and performance of the front line manager in healthcare been so critically important. With nursing shortages, financial pressures and ever increasing patient volumes, the ability of a front line manager to effectively manage these complexities is fundamental for the success of any healthcare organisation. With the growing body of evidence highlighting that employee retention, patient satisfaction and continuous quality improvement impacts on clinical outcome, operational efficiency and financial outcomes 1 it is no longer sufficient for line managers to be just technically good at their job. The June 2008 Satisfaction Snapshot provides an overview of key tactics to develop this key resource in your workforce. Please direct any comments, suggestions or article submissions to: Sharon Kerr Manager of Client Relations snapshot@pressganey.com.au www.pressganey.com.au P: 07 5560 7400 F: 07 5560 7490
page 2 DEVELOPING THE NEW FRONTLINE MANAGER Lauren Arnold, PHD, RN and Greg Nelson You're a critical care nurse and a very good one. Your clinical skills, selfless hours of sacrifice, and ability to quickly quell multiple crises have paid off. You've captured the attention of the Director of Nursing, and she wants to promote you to frontline manger. You're flattered and proud, but reticent. You've seen other high-flying colleagues who have crashed and burned in less than a year under the added responsibility and pressure. So you turn down the Director of Nursing's offer, and your hospital is is the big loser. Similar scenes play out hundreds of times each week in health care systems across the country. Frontline nurse managers are leaving in droves, and not enough qualified nurses are stepping up to fill these leadership roles for multiple reasons. Health care systems are too preoccupied with other priorities - reimbursement issues, quality initiatives, patient satisfaction programs, staffing shortages, and more - to give nurse leadership problems the attention they deserve, so the leadership door continues to revolve. Why is that? Part of the problem is that, traditionally, nursing hasn't done a good job of demonstrating its valueproducing contributions to really focus management's attention. As the caring profession, nursing hasn't quite achieved the level of visible standing required to garner resources from cashstrapped organisations. Increasingly, the industry is being challenged to structure and support nursing organisations to create strategic value for hospitals and their customers. It is critically important to stress the importance of using metrics as a framework to help nurses demonstrate value to senior management in terms of quality, safety, doctor/nurse relationships, and patient satisfaction. These measures will help the nursing profession articulate its organisational value like never before. And frontline nurse leaders will be at the centre of that attention because they drive clinical unit performance. Leaping into First-Time Leadership Roles Frontline managers arguably hold the most important jobs in the hospital. They implement every decision, every new policy or program, every new regulation. Without strong leadership at this level, organisations struggle. The shortage of skilled frontline managers, primarily a result of retirements, budget cutbacks, and younger nurses unwilling or unable to take on the responsibility, is well documented. 3 By 2010, the average age of the working nurse is projected to be 50; 4 the average age of frontline managers is projected to be even higher. This trend has caused many organisations to rush some nurses into leadership roles without adequate preparation, often without notice. Many are evaluated on their clinical knowledge, organising proficiency, and ability to communicate effectively with doctors and patients, skills that are prized at the bedside but do not constitute the complete set of competencies and skills required to succeed as leaders. For many nurses, the transition to first-time leader is the most formidable career challenge they will ever face. Overnight, their universe expands from a limited number of patients to responsibility for care delivered by dozens of direct reports across a unit. They become management representatives and change agents, expected to articulate and implement policy and assume accountability for those policy implications. Their daily reality checks for the first time include managing payroll, resolving conflict, and coaching employees to improved performance, in addition to making rounds and talking with doctors, patients, and family members. Considering the job complexity and increasing demands, it's not surprising that just 38% of health care workers have a high degree of confidence in their supervisors' abilities. 5 No wonder so many firsttime leaders fail. The consequences can be devastating: quality drops, errors persist, morale sinks, and turnover and its related costs skyrocket.
page 3 Sculpting the New Frontline Manager Given the current turmoil in health care, it's not surprising that two-thirds of health care organisations do not have a systematic process of identifying and developing candidates for leadership positions. 5 What may be more revealing is that one third of them report that they indeed have such a system in place. More health care organisations are beginning to take a strategic approach to developing leaders by adopting behaviour-based competency modeling used in the business sector since the early 1970s. These organisations link strategic goals and unit performance with behaviour competency models. Then they use this framework to identify leaders, develop them, evaluate their performance, and promote them. This succession management process ensures a constant flow of competent, motivated people through your leadership pipeline. And when this pipeline is visible to all, your units will have the tools to demonstrate value contribution, career pathways are unequivocal, and staff will have a greater confidence that the organisation is headed in the right direction. While the degree of skill, knowledge, ability, and motivation differs for each level, the basic framework for building a leadership pipeline will be the same, regardless of whether you're constructing a plan for frontline, operational, or strategic leaders. Five steps are essential to building an effective leadership development pipeline: 1. Gaining management support for the leadership pipeline 2. Creating a success profile of the ideal leader 3. Determining fundamental leadership skills and gaps 4. Training for gain 5. Sustaining momentum STEP 1: Gaining management support for the leadership pipeline. How do you gain leadership buy-in for a succession management program when so many other fires are burning out of control? By addressing it on management's terms: value-based contributions. What are the key goals you expect to addressquality, retention, patient throughput? Present your case for leadership development as it applies to achieving these organisational strategic priorities with a realistic timeline for delivery. STEP 2: Creating a success profile of the ideal leader. Five Steps to Preparing New and Incumbent Nurse Leaders for Success There are three types of nurse leaders: Frontline or people leaders who directly manage staff and oversee the value-producing work of the unit; Operational leaders who are experienced in managing others and counted on to drive change and affect staff performance across multiple units; Strategic leaders who are called on to drive organisational performance system-wide. What knowledge, skills, abilities, and motivations are required by your leaders for your organisation to succeed? Success profiles are excellent tools to help answer that question. Nurses and hospitals need a common set of parameters for defining individual success profiles. Objective, behaviour-based competency modeling provides this framework for selection, development, retention, performance management, and promotion. Competencies define effective performance behaviours. They enable the organisation to create clear and realistic expectations that nurses, managers, and senior leadership can agree on, thereby eliminating surprises, emotion, and "gut feelings." This process isn't as complex as it may sound. A group of senior-level nurses at one large health system did it by creating a profile of their ideal nurse leaders. The goal was to establish a common set of competencies and skills among all levels of nurse leaders so that system-wide strategies could be implemented uniformly and rapidly. To begin, the group selected appropriate competencies that had been used for more than a generation to identify successful leadership attributes in the business sector.
page 4 After receiving input and feedback from other experts and senior-level nursing executives, the group narrowed the list to 10 competencies and then identified specific behavioural sets for each nurse leadership level. For example, the Director of Nursing is expected to have a different level of skill in managing resources than is a nursing unit manager. This set of competencies formed the foundation for interview and selection guides and ultimately can form the foundation for performance management and learning and development. Of course, you don't have to start from scratch to create your own ideal nurse. A number of organisations have issued standards and competencies that you can reference. The American Society for Healthcare Human Resources Administration, for instance, defines 11 different behavioural competencies for nurse middle managers, ranging from results orientation, skilled communications, and team building to agent for change, commitment to service, collaboration, analytical thinking, and talent development, among others. 6 Besides using competency modeling in your leadership success profile, don't overlook the importance of motivational fit. Some individuals, despite exemplary clinical skills, interpersonal behavioural traits, and a strong commitment to the nursing profession, simply don't want to take leadership roles. They don't want the hassle and extra responsibility that comes with assuming a seemingly impossible job, carrying added administrative burdens, dealing with 50 different personalities, and being further removed from delivering bedside care. Interviewing and selecting candidates based on an agreed set of competencies will increase the likelihood that you will be able to screen out candidates who lack the motivational fit for a challenging nurse leader role. Without the proper motivation for leading others, candidates fail. STEP 3: Determining fundamental leadership skills and gaps. Using the competency model as a measuring stick to assess the leadership potential of current and future leaders is the next step in creating a pipeline to serve the organisation. This assessment process will reveal an individual's strengths and vulnerabilities, as well as what competency gaps exist organisationwide. For instance, as nurses advance in their careers, they often rely on personal traits, styles, or approaches to help them achieve goals. In leadership positions, however, these favoured styles can become problems or derailers when leaders overuse them. While this is particularly true of senior-level leaders, it's also prevalent among frontline managers. For example, a nurse who once received praise for close attention to detail now is perceived by direct reports and peers as a micromanaging leader. The individual who avoids the ambiguous situations that confront health care leaders every day and chooses instead to focus on short-term projects she can control seems short-sighted. The person who perceives herself as maintaining high standards comes across to others as overly critical. Common assessment tools include: Written tests that reveal critical thinking skills Behavioural interviewing that asks probing questions into how one goes about making decisions 360-degree surveys that gather feedback from managers, peers, direct reports, and others Executive assessment centres for more senior leaders that provide a well-rounded picture of leadership capability through "day-in-the-life" simulations When choosing an assessment instrument, it's absolutely essential that you define in advance how the results will be used, match assessment results against the success profile you created, and openly communicate the process so that it is perceived as fair. Properly completed assessments will clearly show where you need to focus development efforts and which individuals don't have what it takes to succeed in a leadership role. STEP 4: Training for gain. Once leadership skill gaps have been identified, design a curriculum to close those gaps. Few people are natural born leaders; most learn leadership behaviour, (good and bad) from others. And that's how your people can learn leadership skills, by instructive role modeling. A blended learning approach that integrates classroom learning, exercises, simulations, role playing, and even online interactivity is best. Assigned mentors and coaches help fledgling and senior leaders learn how to get through rough patches unscathed. STEP 5: Sustaining momentum. Injecting a degree of tension into learning ensures that training sticks with your leaders and they use their newfound skills on the job. For instance, many organisations make leadership development training mandatory and back it up with consequences for those who miss sessions. Others go much further by measuring how leaders' behaviours have improved after training.
page 5 You can sustain momentum even more through additional classroom learning, online/situational learning, project work, and temporary "stretch" assignments, in addition to proactive mentoring, coaching, and role modeling. And you can extend the length of your pipeline by training your current leaders how to identify nurses with the potential to assume future leadership roles. Overcoming Resistance While few would argue that ensuring a dependable nurse leadership pipeline is a good idea, the action has to come from within the organisation. The plan has to be measurable with metrics linked to the organisation's strategic priorities. It has to be endorsed and actively supported by an influential management sponsor. And it has to be sold to and embraced by the leadership ranks and staff. There's little question that you're going to receive resistance. Both management and staff will contend that there is precious little time and scarce resources to invest in a leadership pipeline. Your plan may be perceived as making little difference or just another "program of the month." And it requires a significant shift in perception of the organisation's hiring, orientation, promotion, and performance evaluation systemssystems that have been in place for decades. But the results for those organisations that have taken the time, invested the resources, and bought into the behaviour-based competency model for building a leadership pipeline show a significant return on their investment, with reduced turnover, higher levels of staff engagement, and improved job performance. That's strategic value any senior manager can understand. References 1. Satisfaction Snapshot Volume 7 Issue 1 - January 2008 - Satisfaction Improvement - Demonstrated Return on Investment, (available from Press Ganey Associates (61 7 5560 7400) 2. Joint Commission on Accreditation of Healthcare Organisations. 2005 national patient safety goals. Oakbrook Terrace: The Commission; 2004. 3. Joint Commission on Accreditation of Healthcare Organisations. Leadership and performance improvement standards. Oakbrook Terrace: The Commission; 2004. 4. American Hospital Association. 5. Buerhaus P, Staiger D, Auerbach D. Implications of an aging RN workforce. JAMA 2000;283:2948-54. 6. Development Dimensions International. 2003-2004 leadership forecast. Pittsburgh: DDI; 2002. 7. American Hospital Association's Commission on Workforce for Hospitals and Health Systems. In our hands: how hospital leaders can build a thriving workforce. Chicago: The Association; 2002. p. 33