Leader to Honor Carol Bradley, MSN, RN, CENP Rose O. Sherman, EdD, RN, NEA-BC, FAAN C arol Bradley, MSN, RN, CENP, is the Senior Vice President and Chief Nursing Officer, Legacy Health System in Portland, Oregon. Legacy Health, based in Portland, Oregon includes 6 hospitals and a regional network of primary care clinics. The system employs 3,500 nurses and approximately 200 advanced practice nurses. This is Carol s third experience as a health system nurse executive, and she considers this to be her destination job. Legacy Health is on the cutting edge of what is happening in healthcare. Oregon is a very progressive state in promoting healthcare access and is actively involved in care transformation. Within Legacy, all of the primary care clinics have adopted the health home model, and the organization has a strong orientation toward performance excellence and patient engagement. professional Among Carol s many contributions is her service as American Organization of Nurse Executives (AONE) president in 1999. ROS: You have a rich and varied career in nursing and healthcare; describe your career progression. CB: Nursing has been very good to me during my 40-year career. I became a new graduate nurse shortly before my 21st birthday. During my career, I have worked as a staff nurse, clinical specialist, a clinical director, then chief nursing officer [CNO], and finally, a system CNE [chief nursing executive]. I assumed my first CNO position in my early 30s, and have enjoyed the executive nurse leader role tremendously. I www.nurseleader.com have also enjoyed being involved professionally in nursing, which has included speaking, writing, consulting, and nursing organizational work; including leadership roles in the Association of California s [ACNL], the American Organization of Nurse Executives, and various other hospital/healthcare organizations. These various experiences have introduced me to nursing colleagues throughout the U.S. and internationally. ROS: What do you consider to be the major challenges for nurses in healthcare leadership positions today? CB: Given the state of change in healthcare today, nurse leaders have some responsibilities right now that are important to the future of patient care as well as nursing. First and perhaps most important is to be the chief advocate to ensure that the voice of nurses is at the table in all of these conversations around redesign and reform. Nurses have a unique perspective about patient management that needs to incorporated into health 15
system redesign efforts. As I think about the impact of health reform on my nursing staff, I have an obligation is to ensure that our nurses begin moving away from a hospital-centered frame of thinking. We need to look at patient care and the process of care from a much more holistic care continuum perspective. This will be a huge change because historically our health systems have been designed to deliver episodic care, 1 event or service at a time. Nurses are in the best position to help patients travel across that continuum of care, regardless of where that may take them. I see my principal responsibility right now to ensure that nurses are fully prepared to respond to the demands of the new care delivery system as it evolves and actively contribute to its development. ROS: How do you do that, Carol, because that s a huge challenge; this is a real shift in thinking when many nurses have been so acute care focused. CB: Today, almost all of the metrics that health systems are being held accountable for are controlled or significantly impacted by nursing care. This places a lot of 16 responsibility for our organization s clinical and financial success on the shoulders of our nurses. However, the historical compartmentalization of nurses within the hospital environment has limited the perspective of how nurses view their patients to a certain degree. My job now is to help nurses widen the lens by which they view their patients and look at care from the entire continuum. The care provided by nurses influences how the hospital is ultimately rewarded or penalized financially. It is critical that nurses understand the financial infrastructure. They need to understand how important it is for them to know whether that patient gets their prescription filled and whether their primary care visit is coordinated prior to discharge. By making sure that all of these steps are done well, nurses influence both the patient s outcome and their success in transitioning home, as well as their organization s financial success. I just don t think nurses have necessarily connected those dots historically because of the way that we have organized hospitals. ROS: Many nurse leaders today are looking at initiatives to prevent patient readmissions within 30 days. What are you doing in this area at Legacy Health? CB: Like other healthcare organizations, we have been looking at our readmissions from a process standpoint. Understanding what happens to patients after they leave our care and why is critically important. Most importantly, we are learning about how best to support patients in their transition from the acute care setting, and the value of having someone help navigate those early post-discharge days or weeks. For example, we have a new transition program that includes both nurses and pharmacists working with patients post-discharge. Their responsibility is to ensure that the care of patients is supported and continued appropriately post-discharge.they see that patients are connected back into their primary care clinic as soon as possible, with clear communication about discharge orders, prescriptions, therapy, and follow-up care needed within those first few days or weeks post-discharge. Our transition nurses, in some cases, may accompany the patient to that first follow-up appointment so they can be a translator of what happened during the April 2014
patient s hospitalization and what is needed for a smooth transition. We have a fully integrated electronic health record and review the hospital discharge plans and summaries. Having nurses there to support the plan of care has made a tremendous impact.the pharmacist s role is to manage and teach patients who are on multiple medications. They may make home visits so they can determine what medications the patient may have at home and how to best organize medication management. We are also evaluating the role that technology can play in better managing patients at home, such as directly transmitting data from patient monitoring devices such as glucometers into our electronic patient records. Our EMR has a patient portal that allows for making appointments, filling prescriptions, and receiving diagnostic test results. Patients love this access to their healthcare and their primary care clinicians. ROS: You are a systems chief nursing officer does this require a different skill set or competencies than when you were accountable for 1 hospital? CB: Yes, the focus of a system CNE is very different from a site-based CNO. My role is focused on strategy, integration, and systemization. At Legacy, I work collaboratively with the hospital CNOs as they report to their site administrators. However, from a systems perspective, my role is very clearly defined within the organization as being responsible for all of nursing. I view the CNOs as my colleagues and partners in overseeing the nursing function for the system. We work as a team and make decisions together. As a system CNE, you have to rely on your relationships and your ability to influence. It s less about direct reporting lines and much more about influence. Relationship management www.nurseleader.com becomes very important. Our organization depends on my role to monitor trends and forecasting to ensure that we are placing Legacy in the best position around our patient care management and nursing. I do have some responsibilities that extend beyond nursing strategy. I am responsible for the clinical education and practice support functions, the clinical resource (staffing) management, system pharmacy, and care management. The system nurse executive focus is less operational and much more strategically focused. This role is not about being responsible for a single function or department, but rather insuring that we are operating as a system and making decisions collectively. We are accountable to apply policies and procedures across the system, so we have a common standard of care based on the very best evidence available. I find this role to be very exciting. Most of my career, I was running the operational aspects of a hospital with little time to think or strategize. I truly feel like my role is to advocate for patient care and the nurses that care for them at the system level. ROS: Earlier in our conversation, we talked about how you are preparing staff for the changes with health reform. When you talk to staff about what the shift from a volume-based culture to a value-based culture will look like, what do you tell them they should be thinking about in terms of their own careers, their own development, and possibly, even their own future roles? CB: Amidst all the energy around changes in healthcare, I hope we are imparting to our nurses that this is also an exciting time that offers many opportunities. There is no question that new roles and new ways of caring for patients will evolve. 17
These represent opportunities for all of our clinical disciplines. With our nursing staff, we have been very focused on creating rewards in our environment to motivate our staff to return to school and advance their education. We want to make sure our nurses are adequately prepared for the demands of the healthcare delivery system as well as the new roles that will arise. We have increased the educational requirements for all of our leadership positions and provided a financial incentive for advanced education. I think that s just the first step in preparing people for the future. Legacy is fortunate to have highly tenured staff, but this means we can be somewhat insular as many of our nurses have not experienced healthcare in other settings or parts of the country. To overcome this, we have made it a focus to get our nurses to national meetings and exposed to how other organizations are meeting the same challenges that we are facing. We also have a very intensive system-wide 2-day leadership development program each fall. The agenda is planned based on our organizational needs, and we bring in nationally known experts to talk with our leaders. My goal in that 2-day event is to expose our nursing staff to what our future challenges are going to be. This year, the event is focused on what the external financial impact of healthcare reform is going to be, and what impact that s going to have on our internal systems of how we care for patients. We are focusing on performance excellence, patient engagement, and care management strategies. We need to be sure that our nurses are aligned with where the organization is going. ROS: Among your many achievements is service as the President of AONE; what impact did that experience have on your career and your leadership? CB: Like many nurse leaders, I had a great mentor Rhonda Anderson. Rhonda pushed me early in my leadership career to become involved in AONE. While in California, I was very involved in ACNL and then naturally migrated to work on a national level at AONE. It was a great experience for me, as it broadened my thinking about both nursing and the importance of volunteer leadership in the national nursing organizations. I had an opportunity to interface with other organi zations as chair of the Tri-Council (AONE, AACN [American Asso ciation of Colleges of Nursing], ANA [American Nurses Association], NLN [National League for Nursing]) during my term as AONE president. It was challenging because there are diverse constituencies and points of view that you had to navigate in order to make any progress. At that time, AONE was redefining our relationship with AHA [American Hospital Association], and we were recruiting a new CEO [chief executive officer] for AONE. Being AONE president taught me a lot about patience, negotiation, and the value of relationships. My daughters used to tease me that all my friends are nurses, and the truth is they re right. I have friends all over this country that I would not have met had it not been for opportunities such as serving on the AONE board and participating in the opportunities that holding office brought to me. ROS: Another very interesting component to your work is your service as President of the Board of CGFNS can you talk about your involvement with CGFNS. CB: The Commission on Graduates of Foreign Nursing Schools (CGFNS) is a very important organization in the whole scheme of American nursing and provides an essential function that is not very well understood or appreciated. The organization s most important contribution to nursing is that it serves as the gatekeeper for ensuring that migrating nurses meet the educational, licensing, and credential requirements of the nursing profession within the United States. During times of high immigration levels influenced by the nursing shortage, this has been a tremendous responsibility. In recent years, our role has expanded, and we now provide the same credentialing services for Canada. Due to its long-standing and historic credentialing function, CGFNS is considered the content expert for nursing credentialing documentation and academic credentials verification across the globe. With recent limits on immigration, CGFNS is currently navigating a change in our business model to respond to the changes in immigration. Given the challenges that CGFNS has faced, I think my operational experience in the hospital setting has come to good use. CGFNS will continue to be a very important organization in terms of maintaining the standards and expectations of our profession in the U.S. and across the globe. ROS: Our younger nurses often worry about work-life balance when they consider leadership positions. How do you achieve this in your busy life? CB: This is a tough question, and I think the answer is a very personal one for each nurse to determine for his/herself. I took my first nurse executive job the same year that I became pregnant with my first child. My daughters are now grown, and they have never known a time when I did not work fulltime. My daughters like to reassure me periodically that they are better for having a working mom. To do this successfully, I think you have to pick the right partner. I was blessed with a husband who truly shared all the parenting responsibilities. Between the 2 of us, our work commitments, various jobs, and things we were involved in seemed to ebb and flow in almost a coordinated fashion. As a nurse leader, you have to consciously realize that you are role modeling choices and behaviors for the nurses you work with. If they see you as a boss who works 16 hours a day, then you are not sending the right message to your team. In my leadership roles, I had the flexibility of being able to leave for a 2 o clock parent teacher conference. Enlightened healthcare organizations today are certainly attuned to the issues of both male and female parents. We need to create a work environment that can be flexible and responsive to those needs. In my capacity, I feel that it is my job to be a good role model for showing that balance. I hope that the nurse leaders I have worked with have felt the support to make a decision for themselves that was compatible with family priorities. ROS: What career advice would you give to young nurses today who are interested in becoming nurse leaders? CB: I think nimbleness and the ability to quickly assess what is happening in a changing environment is important. We are 18 April 2014
in such a compressed time frame now in terms of decision making. I think the ability to react and act based on a general set of understanding of what s happening in the environment is going to be a critical skill for nurse leaders. The days are gone when you set up a committee and spend 6 months considering all your options. I would also urge young leaders to get as many diverse experiences as you can possibly get. Whether it s being on a committee, working on something that s different from what you see every day, experience is the currency of being able to make decisions with a fair amount of speed in the future. I ve changed jobs in my career about every 5 to 7 years. I moved on when I got bored, or when I felt my ability to contribute was waning. I think it should be a real priority for our nurse leaders today to get experience quickly at a young age. This will help you to both better understand the system that you are working in and make timely decisions. Our future leaders also need to be innovators. We are so entrenched in healthcare with old ways of doing things, old structures. My mom was a nurse, and there are aspects of nursing in her era that are still the same today. While technology has changed many things, we have many structural elements that remain mostly unchanged, such as our work shifts. We need to be willing to essentially rethink our system and not be encumbered by what we did or learned 20 years ago. Openness to change and improvement is an important skill set. I have 1 additional challenge for our future nurse leaders. While our principal role is to lead nursing, and this advocacy is important, we also need to make sure that we realize that health reform is not about nursing. It is about access to care and how patients are being cared for. No one has greater influence on how patients experience their care than their nurse. We are in a unique position to ensure that patients are at the center of their care and that they will have an opportunity to take control of their healthcare. This will require nurses to give the patient the ability to direct their care in more meaningful ways, perhaps in conflict with our traditions of nursing or western medicine. It is our obligation to support these decisions. Patient-directed care is very different than patient centered. We will not achieve good health for our community without patients taking control of their own healthcare and the full support of physicians and nurses to let them. NL Hometown: Fullerton, Nebraska Current job: Senior Vice President and Chief Nursing Officer, Legacy Health Education: A.D.N/BSN University of Nebraska, MSN, University of Arizona First job in nursing: staff nurse, University of Nebraska Medical Center Being in nursing leadership gives me the opportunity to: Create the best possible practice environment for nurses Most people don t know that I: Am an artist at heart My best advice to aspiring leaders: Seek as much knowledge and experience in as many different things as you can. Learn to listen well. One thing I want to learn: Plein air painting (again) One word to summarize me: Creative Rose O. Sherman, EdD, RN, NEA-BC, FAAN, is a professor & director at Nursing Leadership Institute Christine E. Lynn College of Nursing, in at Florida Atlantic University in Boca Raton, Florida. She can be reached at rsherman@fau.edu. 1541-4612/2014 Copyright 2014 by Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.mnl.2013.11.007 Photography by Andie Petkus 2014 www.nurseleader.com 19