ractica m atters BUILDING BLOCKS OF GOOD GOVERNANCE After the Planning is Over Once the board has mapped out an organizational strategy, its role changes to monitoring progress By Cindy Fineran and Nicole Matson he board's foremost responsibil­ by board members. Throughout this ity is to own the organization's process, the board must avoid w an­ mission and vision and ensure a dering into operations. consistent focus on the strategic path to achieve them. While the board is Everyone's on Board responsible for setting strategic direc­ Inspiring a sense of strategic part­ tion, it is not responsible for creating nership and accountability across an or managing implementation plans. organization can magnify opportuni­ But this doesn’t m ean that trustees' ties for success. All stakeholders must work is done after the strategic plan­ understand their link to the plan and ning process ends. Boards must con­ leverage their role to achieve the or­ tinually monitor the plan's progress, ganization's initiatives. To gauge the be alert to changes in the environ­ executive team 's readiness, trustees m ent and be prepared to adjust the should ask these questions: strategic course as needed. 1. What actions do you plan to take to ensure successful, on-time execu­ M ission Com es First tion of the strategic plan account­ Strategic plans often fail because the abilities? board does not make strategic think­ 2. What leadership and m anage­ ing, planning and im plem entation ment skills will you use or strengthen high priorities. Once the strategic di­ to achieve success? rection has been scrutinized by the 3. In which areas are we most at board, trustees must ensure that the risk of falling short of our planned plan is comm unicated and em bed­ outcomes? ded throughout the organization. 4. In which areas do you think our Every employee, partner, affiliate organization most needs board lead­ and volunteer m ust understand his ership? or her role in helping to carry it out. 5. W hat resources do you most Trustees m ust dem and that every need and depend on to achieve the board agenda include adequate time desired results? to review strategic performance indi­ Senior leaders also must communi­ cators, assess progress toward objec­ cate goals and plans and inspire par­ tives and discuss relevant new infor­ ticipation. mation. Hard and sometimes contro­ Trustees, meanwhile, need to be versial questions should be addressed strong advocates, educators and pro­ T 6 FEBRUARY 2015 T ru ste e moters of the hospital in the commu­ nity — building awareness of and loy­ alty to the hospital and its role as the community’s most important health care asset. M easuring Success Defining precise targets, consistently measuring progress, and identifying current and emerging strategic gaps will ensure that strategies are con­ sistently at the center of governance attention. The executive team is re­ sponsible for establishing the most relevant performance measures as in­ dicators of the hospital or health sys­ tem’s progress in attaining its strategic objectives. These indicators should be driven by the critical success factors identified for each strategic goal. If the goal is to maximize Medicare reim bursem ent under value-based purchasing, for example, a critical IMAGE BY NEILWEBB/THEISPOT The Board's To-D o List Change in today’s health care environment requires the board’s continual attention and oversight to achieve success. This includes the following responsibilities: • M aking strateg ic p la n n in g a to p p rio rity Ensuring th a t e veryone recognizes and u nd erstands his o r her role and th e value o f th e ir respective c o n trib u tio n s to th e o rg an izatio n's strateg ic plan • C o n tin u a lly m o n ito rin g a c h ie v e m e n t o f m ilestones and progress to w a rd goals H o ld in g execu tive m a n a g e m e n t a ccou nta b le , p la n n in g fo r u n c e rta in ty and re w a rd in g success • M aking strateg ic p la n n in g a co n tin u a l process o f real-tim e responsiveness E xh ibitin g leadership; m o tiv a tin g , in sp irin g and p ro v id in g th e b e n e fit o f expe rie nce and expertise — success factor may be to achieve the benchmark threshold for all quality measures. Key performance indica­ tors would include measures of clini­ cal quality as well as patient satis­ faction and employee engagement. Other areas in which strategic perfor­ mance measures are commonly de­ veloped include finance, operations, human resources and growth. No single indicator can tell a com­ plete story. The performance indica­ tor dots must be connected for the board to monitor progress, ask the right questions and challenge ques­ tionable assumptions. N o Excuses When progress falls short of expec­ tations, trustees are responsible for redirecting the course to the desired outcomes. When significant gaps be­ tween projected and actual perfor­ C.F. andN.M. mance are identified, senior leaders should be ready to recommend to the board specific actions to close them. Trustees and executive team s should expect the unexpected, and anticipate that challenges, change and complexity are more common than not as the health care system transform s itself. Engaging in sce­ nario planning and creating contin­ gency plans can strengthen the orga­ nization's ability to respond quickly to change and achieve success in spite of the barriers it may encounter. N o E n d p o in t Strategic planning is a continual pro­ cess of real-time responsiveness to change, not a finite task. What health care leaders know today will be differ­ ent from what they will know tomor­ row. Asking "so what?" questions will help to keep the board alert to unex­ pected events that might derail strate­ gic plans; for example: “So, what are the implications of these new data for the hospital?” and "So, what new health care needs are emerging in the community, and how should we ad­ dress them?” Additionally, honing skills in sce­ nario thinking and identifying criti­ cal "what if” variables to assumptions or dependencies allow trustees and executives to develop contingency plans, which will contribute to the board’s readiness to respond nimbly in the face of change. According to the 2014 National Health Care Governance Survey by the American Hospital Association's Center for Healthcare Governance, nearly nine in 10 board chairs and 85 percent of chief executives reported that, at least annually, their board as­ sesses the hospital's strategic perfor­ mance using measures established at the beginning of the year. At the same time, 14 percent of CEOs reported that their board did not review the hospital’s performance at least an­ nually, and a small percentage of CEOs and board chairs did not know whether this review took place. Ideally, strategic planning and re­ view is not a one-time annual event, but a thread woven through all board thinking and discussion. New infor­ mation, data, perspectives and ideas should feed trustees’ strategic discus­ sions at every meeting and generate a perpetual stream of strategic development opportunities. T Cindy Fineran (cf@walkercom pany.com) and Nicole Matson ■ H M H (nm@ walkercompany.com) are K i j tm k senior consultants a t the Walker C o . Healthcare Consulting LLC, J M E M m Wilsonville, Ore. T ru s te e FEBR U ARY 2 0 1 5 7 Copyright of Trustee is the property of Health Forum and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use. © FoNS 2014 International Practice Development Journal 4 (2) [4] http://www.fons.org/library/journal.aspx ORIGINAL PRACTICE DEVELOPMENT AND RESEARCH The importance of inspiring a shared vision Jacqueline Martin*, Brendan McCormack, Donna Fitzsimons and Rebecca Spirig *Corresponding author: University Hospital Basel, Switzerland Email:jacqueline.martin@usb.ch Submitted for publication: 25th June 2014 Accepted for publication: 3rd September 2014 Abstract Background: Leadership programmes have been used to support nurse leaders in developing their skills and equiping them as transformative change agents in healthcare organisations around the world. For this purpose, the Royal College of Nursing’s Clinical Leadership Programme has been adapted, implemented, and evaluated in Switzerland. Although a shared vision is a key element in leading organisations and in change, the impact of such a vision on clinical practice is rarely described in the literature. Aims and objectives: To determine qualitatively the benefits of a shared vision as one essential feature of leadership behaviour. Methods: In the context of a mixed methods research study, individual interviews with nurse leaders, as well as focus group interviews with their respective teams, were recorded and transcribed verbatim prior to qualitative content analysis. In order to integrate all findings, a triangulation protocol was applied after separate analysis. Findings: Having a vision helped leaders and their teams to become inspired and committed to a shared goal. Moreover, the vision was a strong driving force for ongoing and systematic practice development and thus established a culture that favoured quality and safety improvement in patient care. However, the strategic direction needed to be tempered; the positive impact on teams and their care practices generated a great deal of enthusiasm, which had the potential to overload the organisation through taking on more than could reasonably be accomplished. Conclusion: The study found that a vision provides orientation and meaning for leaders and their teams. It helps them to focus their energies and engage in the transformation of practice. However, it is very important for leaders to monitor closely the energy level of teams and the organisation, in order to maintain the balance between innovation/transformation and relaxation/recovery. Implications for practice: • A vision provides orientation and meaning for leaders and their teams and is a strong driving force for ongoing and systematic practice development • The enthusiasm at the beginning brought about the danger of starting too many activities, thus overloading the organisation. Therefore, it is important for leaders to maintain the balance between innovation/transformation and relaxation/recovery • Care should be taken to ensure that a vision and corresponding core values are realistic and achievable. Otherwise, the vision might remain an unattainable illusion, and the individuals who are supposed to turn it into reality may become frustrated and demotivated Keywords: Leadership programme, nurses, vision, practice development, evaluation, triangulation 1 © FoNS 2014 International Practice Development Journal 4 (2) [4] http://www.fons.org/library/journal.aspx Introduction Effective leadership is an essential attribute for the provision of professional and high quality healthcare, which refers to care that is person centred, evidence based and outcome oriented (Kramer et al., 2004; Manojlovich, 2005a; 2005b; Alleyne and Jumaa, 2007). Effective leadership is also critical for improving the quality and safety of patient care while balancing the increased demands for cost effectiveness (Wong and Cummings, 2007; Watkins, 2010). One key element in effective leadership is inspiring a shared vision, which is a major element of change processes in terms of providing orientation and engaging the whole system towards excellence in healthcare practice (Lukas et al., 2007; McCormack et al., 2007). However, to achieve effective leadership practices, there needs to be a shift from hierarchical approaches to leadership styles that encourage shared governance and facilitate staff empowerment (Williamson, 2005). With this kind of leadership approach, leaders are better able to convey the need for change, question existing practice, create a vision for the future and develop new models of service provision (Dixon, 1999; Porter-O’Grady, 2003). Transformational leadership is one such approach and has been shown to have a high impact in nursing – on practice changes in care provision and on the development of an organisational culture that is receptive to progression and change (Shaw, 2005; Field and FitzGerald, 2006). The development of transformational leadership skills among nurse leaders is important for healthcare organisations seeking to achieve high quality care (Trofino, 2000; Donaldson, 2001; Cook and Leathard, 2004; Davidson et al., 2006; Watkins, 2010) and an effective workplace culture (Manley et al., 2011). Therefore, a Clinical Leadership Programme for nurse leaders was set up in 1995 by the Royal College of Nursing (RCN) and then delivered internationally (Cunningham and Kitson, 2000). The need for enhanced leadership skills is also evident in the Swiss healthcare context (De Geest et al., 2003) and in 2006, the RCN’s programme was adapted and implemented in the German speaking part of Switzerland for nurse leaders. One of the adaptations was an explicit focus on the development of a unit based vision, since ‘to inspire a shared vision’ is one of the main competencies of transformational leaders (Kouzes and Posner, 2007; 2010). Previous research asserts that a vision is an extremely powerful tool for driving an organisation toward excellence, and developing a clear vision is the best way to clarify the direction of change (Hoyle, 2007). Moreover, the aim of a vision is to display a picture of a better and more worthwhile future state, which, in healthcare, means an improvement in service delivery. Therefore, participating ward leaders were challenged to develop a shared vision for their unit, as well as corresponding goals and actions, and thus to focus available resources on targeted and evidence based developments in practice. It should be noted that German speaking nurses and nurse leaders seldom use the word ‘vision’, preferring terms such as ‘strategy’ and ‘strategic direction’. Although there is a shared understanding in the literature of how important and critical a vision is for outstanding leadership and effective change in organisations (Viens et al., 2005; Felgen, 2007), little is known about the experience of nurse leaders and their teams in developing a vision, or about the impact of a vision on their work and on practice development. Greater knowledge and understanding in this regard may help healthcare leaders to focus energy in this area and secure the resources required to achieve the targeted transformation in practice. This paper reports on findings from the second, qualitative phase of a mixed methods research study whose overall purpose was to evaluate the impact of the Clinical Leadership Programme in Switzerland. The study was organised in two distinct sequential phases. The first, quantitative phase focused on the evaluation of leadership competencies of programme participants; the second, qualitative phase focused on explanation and validation of the quantitative results obtained in the first phase by exploring participants’ views in greater depth. One particular goal of the qualitative phase was to determine the benefits of a shared vision and corresponding strategies for leaders and their teams, as one essential practice of leadership behaviour 2 © FoNS 2014 International Practice Development Journal 4 (2) [4] http://www.fons.org/library/journal.aspx (Kouzes and Posner, 2007). Therefore individual interviews with nurse leaders, as well as focus group interviews with their respective teams, were conducted. In order to integrate the findings of all indepth interviews, a triangulation protocol was applied. This article reports on the triangulated results from the qualitative follow-up to address the research question: What was the influence of a vision or strategic direction on practice/practice development? Theoretical framework This study was underpinned by two theoretical perspectives. First, the theory of learned leader behaviours of Kouzes and Posner (2007), a transformational leadership theory that postulates that leadership behaviour can be observed and learned. Research within the field has documented a consistent pattern in the characteristics of admired leaders across countries, cultures, organisations, hierarchies, gender, education, and age groups (Kouzes and Posner, 2007). The five fundamental practices of exemplary leadership have been defined as: 1. Modelling the way 2. Inspiring a shared vision 3. Challenging the process 4. Enabling others to act 5. Encouraging the heart The second theoretical perspective was the conceptual framework of practice development by Garbett and McCormack (2004), who define practice development as a systematic and ongoing process towards effective and person-centred care. Practice development facilitators initiate and support an emancipatory process of change that reflects the perspectives of patients and healthcare providers (Garbett and McCormack, 2002; Sanders et al., 2013). This emancipatory approach aims to empower and enable healthcare teams to transform the culture and context of care in a way that will result in sustainable change (McCormack and Titchen, 2006; Shaw, 2013). Over the past 10 years, various researchers have explored and further developed conceptual, theoretical and methodological elements in the framework to guide practice development activities internationally (McCormack et al., 2007; Manley et al., 2008). Moreover, an international network has been established to facilitate the systematic collaboration and sharing of knowledge in this field. The two perspectives serve as the theoretical framework not only for the study but also for the Swiss Clinical Leadership Programme. Method Design A qualitative research approach within a mixed methods design was used. The overall evaluation study was guided by a sequential explanatory strategy, characterised by collecting and analysing quantitative data in phase one, with a qualitative follow-up in phase two (Creswell and Plano Clark, 2007). In the second phase, the quantitative results obtained in the first phase were further explored by in-depth interviews. The priority in the study was given equally to the qualitative and quantitative approach, because the two phases of the study had shared as well as individual goals. By collecting the quantitative data with Kouzes and Posner’s (2003) Leadership Practice Inventory instrument, all five leadership practice behaviours, including ‘inspiring a shared vision’ were described. However, to be able fully to interpret and to enhance the understanding of these results (Morgan, 1998), the quantitative data were supplemented by qualitative data, gathered through focus group and individual interviews. The integration of methods occurred in different stages of the research process but mainly at final stage by the use of a triangulation protocol (Farmer et al., 2006). Triangulation enhances the validity of research results when multiple methods are employed and produce convergent findings about the same empirical subject (Erzerberger and Prein, 1997). This can lead to a multidimensional understanding of complex phenomena (Farmer et al., 2006), enhanced data richness and greater trustworthiness of findings (Lambert and Loiselle, 2008). Taking a triangulation approach for the study meant that it was possible to gain a more comprehensive understanding about the impact of a vision on clinical practice. 3 © FoNS 2014 International Practice Development Journal 4 (2) [4] http://www.fons.org/library/journal.aspx Participants In mixed methods, sequential, explanatory design, different options exist for case selection in the qualitative part: exploring a few typical cases, or following up with outlier or extreme cases (Ivankova et al., 2006). In this study, nurse leaders and their respective teams were purposefully selected with an extreme case sampling approach for individual in-depth and focus group interviews. The sample population comprised 14 nurse leaders from the first two cohorts of the Clinical Leadership Programme, who were recruited on a voluntary basis after extensive information about the programme’s intentions and content. The six interview partners, three women and three men, were selected from this sample population by calculating and selecting the participants with lowest and highest scores of Kouzes and Posner’s (2003) Leadership Practice Inventory subscale ‘inspiring a shared vision’ in the quantitative data. Focus group participants were recruited from teams of interviewed nurse leaders and were identified in a similar way, resulting in four groups, with four to seven participants each. All needed to be registered nurses or midwives with different lengths of job experience. In total, 20 team members participated in the focus group interviews. Data collection Data were collected using semi-structured interview guides developed in two independent discussions with members of the research team (two research professors and a senior educator/practice developer), focused on material related to the study’s objectives. The phrasing and sequencing of questions followed the recommendations that questions should be conversational and easy to understand, open enough and non-directive to give participants as much latitude as possible for responses. Questions should also be ordered in a logical flow from general to specific (Krueger and Casey, 2001; Helfferich, 2005; Kruse, 2014). All interviews were audio recorded and transcribed verbatim for analysis. The focus group interviews were conducted by the first author as moderator and an experienced qualitative researcher as co-moderator; the latter took additional field notes about the group engagement processes, to provide context. After each interview the co-moderator undertook member checking (Kidd and Parshall, 2000), by summarising key points of the group discussion and asking participants for confirmation, clarification or completion. Directly after the discussion, moderator and co-moderator exchanged their overall impressions and key insights as a first step in the analysis. Data analysis The data were analysed using Mayring’s (2000; 2003; Mayring and Gläser-Zikuda, 2005) qualitative content analysis, which allows a large quantity of material to be reduced to a manageable size and the most significant content to be obtained. There are two main approaches within these procedures of text interpretation: inductive development of categories and deductive application of categories. In this study, inductive category development was applied by working through the data and developing the categories as close as possible to the material, in a tentative and step-by-step process. For focus group interviews, this step-by-step process was combined with cognitive mapping (Northcott, 1996; Pelz et al., 2004), which is useful for handling a large amount of data material in a structured way. At the same time, it encourages creative and imaginative work (Northcott, 1996; Semple and McCance, 2010). After the inclusion of representative quotes from the transcribed text, a peer review of the categories and themes was carried out by three experienced qualitative researchers, and some participating leaders provided feedback on the findings of the individual interviews to ensure that their own meanings and perspectives had been represented. Thus, different techniques were applied to enhance the rigour of the analysis, such as member checking, peer debriefing, and a comprehensive description of findings, with participant quotations to illustrate the themes and interpretations (Graneheim and Lundman, 2004; Tong et al., 2007). In order to integrate the research findings from the various sources and gain a more complete picture that would increase the validity of results, a triangulation protocol was applied. The triangulation process consists of a number of steps, which are described in more detail by Farmer and colleagues (Farmer et al., 2006). The findings from each component were first sorted and listed on the same 4 © FoNS 2014 International Practice Development Journal 4 (2) [4] http://www.fons.org/library/journal.aspx page in order to decide whether there was agreement, partial agreement, discrepancy/dissonance or silence between them regarding the research question. Silence in this context means that a theme occurs in one dataset only and not in others. This assessment was then displayed in a convergence coding matrix (see page 8). In the last step, the triangulated results were discussed in the research group for review and clarification (Farmer et al., 2006). Ethical considerations Participation in the study was voluntary. Informed consent procedures were designed to provide nurse leaders and team members with sufficient information to allow for a considered decision about the potential inconveniences and benefits of participation in the interviews. The study operated according to principles of confidentiality and, as such, all statements by participants made during the qualitative phase of this project have been handled anonymously and appropriately. Leaders and their team members selected a pseudonym from a list of names and these were used in the transcripts to guarantee confidentiality. Consent for the study was obtained from the local ethics committee, the hospital’s management, and a university. Findings Nurse leaders’ characteristics Half of the six interview participants were women. All leaders were between 41 and 55 years of age. The mean length of work and management experience in healthcare was high at 25.3 years (minimum 19, maximum 30 years) and 11.8 years (minimum one, maximum 21 years), respectively. Only one of the six was a novice leader at the beginning of the programme; all others were experienced clinical leaders with a minimum of eight years in a leading function. Team members’ characteristics Overall, 15 women and five men took part in the focus groups. All worked in different clinical settings, but only seven people were in full-time employment. They worked on inpatient and outpatient units and the spectrum of fields ranged from geriatric to intensive care. The mean age of participants was 47.15 years (minimum 29, maximum 61 years old) and the mean years of job experience was also rather high at 24.5 years (minimum five, maximum 42 years). Application of the triangulation protocol, step 1: sorting The two sets of findings were reviewed separately to identify the key themes related to the guiding research question: What was the influence of a vision or strategic direction on practice/practice development? The key themes identified from the individual and focus group interviews were: • Mediating/providing orientation and meaning • Steering practice development systematically • Facilitating motivation, integration and identification • Promoting quality improvement • Promoting collaboration and recognition • Acceleration • Dilemma • Incongruence The selected findings were then sorted and displayed in a unified list of themes for comparison. Table 1 presents an overview of the findings. The left hand column lists the identified themes with the number of mentions in each dataset. In the last column on the right, specific quotes from the interview sets are listed to support or explain the themes. 5 © FoNS 2014 International Practice Development Journal 4 (2) [X] http://www.fons.org/library/journal.aspx Table 1: Sorting of key themes regarding the influence of a vision on practice Theme Focus group interviews Number of mentions Individual interviews Number of mentions Quotes: examples Mediating/ providing orientation and meaning 12 10 Q1: Mark: ‘I need to know where I’m going in the longer term… and that’s also incredibly helpful in a leadership role too because it enables you to develop a strategy based on the vision, to know what the key milestones are and what we ultimately want to achieve together’ (leader) Q2: Juliette: ‘I think the more you are aware of it (the mission statement), perhaps re-reading it occasionally, the more it becomes internalised. It becomes part of your own beliefs and values. You buy into it or you don’t… It gives me a real sense of direction, something to really hold on to’ (team) Steering practice 0 development systematically 13 Q3: Alexandra: ‘I believe that any practice development should be informed by the vision… I do believe that’s helpful because it encourages me to stop and think if something makes sense or not – is it right, am I on the right track?’ (leader) Q4: Anne: ‘You need to break the vision down into measurable, bitesized chunks in order to make it real for staff working at the frontline, either through training or project work... otherwise there would be no consistency in the direction of travel. There would just be lots of finished pieces of work but it helps in sorting and prioritising them and establishing the extent to which progress is being made’ (leader) Facilitating motivation, integration and identification 15 16 Q5: Meret: ‘There is more obligation to engage or to try hard to provide good care. Therefore, it gives you a push… I think one needs something repeatedly that gives you the motivation to work at your best’ (team) Q6: Simone: ‘I raise it. Usually there is a situation involving a patient, or you hear something at a meeting, or something goes wrong – I can seize those opportunities… Using case studies can also be really helpful. One way or another, I need to address it’ (leader) Promoting quality improvement 21 10 Q7: Tobias: ‘I think there has been a really significant shift over the past few years: we now have some clear standards. We are trying to gather an evidence base so that I can go to my colleagues and say something is outdated and we need to start doing it differently based on the evidence’(team) Q8: Mark: ‘This means working together with the team in accordance with the vision and strategy. Enabling them to become more autonomous. Improving quality in the context of the vision’ (leader) 18 Promoting collaboration and recognition 5 Q9: Robert: ‘In the meantime, our case study presentations have become so popular that we’ve had to open them up to staff from other wards… It’s like a new way of working’ (leader) Q10: Paula: ‘I think the standing of our ward has improved across the entire hospital… We get calls from other departments about managing confusion… they want our help and that is another indication that we are accepted and respected’ (team) Q11: Jasmin: ‘Patients can tell that the team is clear about its purpose. I think it is great when patients give us feedback which suggests they perceive us working well as a team. They don’t talk about having a vision but that we work well as a team and that tells me we are making it tangible’ (team) Acceleration 11 3 Q12: Sarah: ‘With a mission statement the tendency is to do more and more. But I think sometimes it’s important to press the pause button occasionally… to recharge the batteries’ (team) Q13: Alexandra: ‘I really make sure it doesn’t place excessive demand on colleagues. I think it has been difficult in the past because sometimes there has been loads of change and every now and again they have said they are fed up with it all’ (leader) Q14: Robert: ‘That was exactly this issue in the team. High levels of motivation and at the same time a kind of weariness because we hadn’t really allowed sufficient time for things to bed down, for the team to become confident in the new way. We’ve made enormous strides and so, too, the team. But this year we’ve decided to focus on smaller wins, to take things a bit more slowly... and the team has responded really well to this change in pace’ (leader) Dilemma 9 0 Q15: Judith: ‘It all comes down to what we understand by a mission statement and what would be optimal for us. If we’re not able to make it happen then it is frustrating’ (team) Incongruence 10 0 Q16: Jenny: ‘It’s waved in front of us when it suits but when we are short staffed for example and we draw attention to it, then it’s always – yes, yes, I’m sorry, there’s nothing we can do about it, you just have to make do… Well, then it feels wrong to me because we are not giving the mission statement the importance it deserves’ (team) © FoNS 2014 International Practice Development Journal 4 (2) [4] http://www.fons.org/library/journal.aspx Mediating/providing orientation and meaning: Leaders and team members experienced that visions had provided clear orientation and a strong purpose in practice. A vision helped nurse leaders to stay on track while working towards the common goal, and accordingly to set priorities in practice development work. Most of the team members participating in this study reported that reflecting on the vision and on core values helped them to become aware of what was requested and to be able to internalise the direction for change. Moreover, it supported their engagement with the same goals in the transformation of practice. As a result, they were able to focus their energies and work in the same direction. Steering practice development systematically: It was evident from the results that clinical leaders steered practice development more systematically and efficiently if they employed strategic goals, heading towards a higher goal as articulated through a shared vision. In the sometimes messy reality of day-to-day work, some leaders did find it a challenge to carry out practice development systematically. Despite this, they described how the vision and strategic goals helped them in their decision making processes, as well as in setting priorities and evaluating the progress in practice development. However, no information about this issue was offered by participants in the focus group interviews. Facilitating motivation, integration, and identification: Identification and hence ownership depends on the integration of teams in the developmental process of a vision. In this study, it was clearly easier for leaders of smaller teams to involve their teams in a bottom up approach, meaning that the team was integrated from the very beginning into the creation of a shared vision. By contrast, leaders of larger teams had a greater challenge regarding the achievement of a shared vision, reflecting the wider span of control. They could only create the vision in a top down approach with a small selection of staff members, so the integration of the entire team remained a huge challenge in the following transfer phase. Irrespective of the size of team, the most important steps towards integrating teams were undertaken in practice development projects, where team members were part of the project team and knew how the project connected to the overall vision. Focus group participants experienced the strategic direction and the shared values as a strong driving force in their clinical practice. They described how it provided a purpose that facilitated motivation and identification at an individual level. Promoting quality improvement: A strategic direction with defined values and corresponding practical activities was also seen as promoting quality improvement in the field. Team members experienced a shift from more traditional to evidence based, standardised care in their clinical practice, which helped them to, among other things, speak up and address outdated behaviours that they observed in others. Most importantly for the participants, the vision mediated the need for continuous development in practice – as a result of working with a vision or mission statement, participants realised that change is inherent in today’s world. Although quality improvement was not a subtheme in the individual interviews with the leaders, they did talk about it in the context of the vision, but it was less in their focus. Promoting collaboration and recognition: The vision or strategic direction had an impact on both the individual practitioner and the entire team. In one focus group, participants stated that having the vision had provoked a higher commitment to professional practice, which in turn facilitated their personal growth. This resulted in greater confidence and self-mastery in respect of their practice expertise, as well as a feeling of greater autonomy in practice. This increased confidence in turn gave them greater recognition within the interprofessional team and the broader organisation. A further positive aspect of a vision which was discussed was that participants experienced the strategic direction as a basic requirement for team and interprofessional collaboration, since it provided a unifying framework and all members of the team could engage in working towards a shared goal. These combined efforts enhanced their likelihood of success, they felt. 7 © FoNS 2014 International Practice Development Journal 4 (2) [4] http://www.fons.org/library/journal.aspx Acceleration: The findings discussed above show clearly that there were a number of very positive aspects to using a vision in nursing practice. However, this positive impact on teams and their care practices had a negative counterpart: the acceleration trap. Because many team members felt so enthusiastic at the beginning of the change processes in their units, they sometimes ran the risk of starting up too many activities at the same time and thus overloading the organisation. As a result, the team began to feel overwhelmed by the scale of the changes and stopped feeling so engaged with the transformation of practice. Dilemma: On a personal level, participants experienced dilemmas when they had not been able to perform according to the defined values and standards. Some described feelings of frustration when confronted with the restraints of the institution, since they knew exactly which kind of care they wanted to perform in order to act professionally but, because of organisational constraints, felt unable to provide that care. This gap between the ideals of the vision and the care that could be provided sometimes provoked feelings of shame and distress. Incongruence: In their day-to-day practice, some focus group participants experienced that the priorities and activities were not always congruent with the strategic goals and common core values. They acknowledged that it is not always possible to focus on best practice but they were critical that the decision making process of the management was not transparent enough and thus not sufficiently comprehensible for team members. Application of the triangulation protocol, step 2: convergence coding In the second step, the two sets of findings were compared regarding the meaning and interpretation of themes, the prominence and coverage of themes, and respective quotes that supported a specific theme. Afterwards, the convergence coding scheme was applied to decide whether the findings agreed (convergence), offered complementary information or contradicted (dissonance) each other (Table 2). Table 2: Convergence coding matrix Theme Theme meaning, prominence, and coverage Agreement Partial agreement Silence Dissonance 2 3 3 0 Mediating/providing orientation and meaning Steering practice development systematically Facilitating motivation, integration and identification Promoting quality improvement Promoting collaboration and recognition Acceleration Dilemma Incongruence TOTALS 8 © FoNS 2014 International Practice Development Journal 4 (2) [4] http://www.fons.org/library/journal.aspx Application of the triangulation protocol, step 3: convergence assessment In the comparison of findings, there were two themes in which there was agreement in meaning, prominence and coverage. One of these themes was providing/mediating orientation and meaning and the other was facilitating motivation, integration and identification. Although the wording of both themes was slightly different in the two sets of data, the meanings behind them were broadly similar. For leaders as well as for team members, a vision or strategic direction provided orientation in practice in a way that transcended the daily workload. This was true for all leaders and all focus groups, and the frequency with which the themes were mentioned by interview participants was comparable. It was also evident throughout both datasets that team members had been integrated in the developmental process of strategic directions to some extent but mainly in the area of clarification of core values and in the subsequent translation of the strategy into practical activities. It can therefore be said that the integration and identification of teams took place mainly in relation to the conjoint transfer of the vision into practice. This theme had agreement on all three components of comparison too. In contrast to the themes discussed above, the themes promoting quality improvement, promoting collaboration and recognition, and acceleration had only partial agreement. Each of these themes originated from the four focus group interviews and was also mentioned by some of the leaders, but only as isolated quotes. However, there was quite a large difference in either the prominence or in the coverage, as only some of the groups or leaders addressed the subjects during the interviews. For example, acceleration was mentioned by three out of four focus groups but only by three leaders during the individual interviews. Although the aspect of acceleration was not mentioned in one team, that team’s leader (Q14) raised the topic spontaneously in his individual interview, revealing that a year ago they had slowed down the pace of change because he realised that, while his team members were highly motivated, they were also exhausted by the high number of practice development projects. So it can be concluded that acceleration was a problem for all participating teams. The last three themes, steering practice development systematically, dilemma and incongruence were silent from one dataset to the other. In all three subjects this can be explained by the different perspectives of interview participants. Leaders addressed the issue of steering practice development systematically from the point of view of their leading position and responsibility. It would have been very surprising if staff members had addressed practice development in a similar way, unless they had been designated to perform a special role in this context. It was also expected that the other two themes – dilemma and incongruence – would be experienced primarily by staff nurses because they work in practice and can perceive a tension between the ideal of the vision and the reality of their work. In summary, there was either full or partial agreement between the two datasets on 62.5% of the themes and no instances of dissonance of findings in the convergence assessment. Application of the triangulation protocol, step 4: completeness comparison Based on the convergence assessment, it is evident that many core themes are confirmed or partly confirmed by the two qualitative datasets, but with a different emphasis. The two sets provided a different perspective on key themes but the triangulation of findings enabled the views of the leaders and those of the teams to be related to and compared with each other regarding the research question. The triangulation provided a more complete picture and thus enriched the findings of this study on the influence of a vision on practice development. Practice development is a continuous change process that a leader can only initiate and pursue as a goal together with his/her team; it is therefore of value to bring the two perspectives purposefully together. Discussion This qualitative study part explored the effect of a shared vision or strategic direction on practice and practice development. It showed that the influence of such a vision is considerable and thus it is 9 © FoNS 2014 International Practice Development Journal 4 (2) [4] http://www.fons.org/library/journal.aspx essential to underpin practice development work. A vision provides the direction for change and helps to inspire individuals as well as to focus the energies of all team members. The data also revealed some threats on a personal and organisational level, which need leadership attention. Leaders and team members experienced that the vision had provided clear orientation and a strong purpose in practice. It helped them to stay on track and to set priorities accordingly. Moreover, it helped them to engage towards the same goals in the transformation of practice. Although most of the focus group participants did not talk about ‘a vision’ – instead they talked about terms such as ‘strategy’, ‘strategic direction’, ‘mission statement’, and ‘portfolio’ – the importance of having shared values and defined goals was pointed out. The importance of a vision for practice development has been widely addressed in the literature too (Manley, 2001; Garbett and McCormack, 2004; Hickey and Beck Kritek, 2012). A common vision across stakeholders provides clarity of values and beliefs and is essential to guarantee that there is an agreed focus and targeted outcomes (Boomer et al., 2008; Shaw et al., 2008; Mayer and Carroll, 2011). A vision can be of help in doing practice development work more systematically, which means that evaluations of all projects need to be planned in order to judge the effects of practice change and not rely solely on anecdotal evidence (Manley and McCormack, 2004; Wilson et al., 2008; Hardy et al., 2013). In this study, the vision and the subsequent annual strategic goals helped the participating leaders to sort, focus, prioritise, and evaluate practice development projects. Moreover, it made them aware of the necessity to evaluate their performance in order to steer change processes purposefully in practice. Practice development research is increasingly calling on practitioners to take a systematic approach to the task of improving patient-centred care (Barrett et al., 2005; Bucknall et al., 2008; Wilson et al., 2008). The main argument used to justify such calls is that systematic work is more likely to result in successful outcomes, enhanced credibility to the health authority and greater cost effectiveness (McCormack and Garbett, 2003; Garbett and McCormack, 2004). A key purpose of practice development work is to transform the culture of care into that of an effective workplace that adapts and responds to change (Manley, 2004; Bevan, 2010; Manley et al., 2011). Such a culture enables individuals to develop their own potential and their practice (Manley, 2004; Manley et al., 2011). The empowerment of team members is key for this process as individuals need to have a sense of vision and ownership (Shaw et al., 2008). However, this identification and hence ownership also depends on the integration of teams at the ward level in the development of the vision. In this study, it was clearly easier for leaders of smaller teams to involve their teams in the development process because they could use a bottom up approach, meaning that the team was integrated from the beginning into the creation of a shared vision (Martin et al., 2014). By contrast, leaders of larger teams had a greater challenge regarding the achievement of a shared vision, reflecting the wider span of control. They could only create the vision in a top down approach with a small selection of staff members, so the integration of the entire team remained a huge challenge in the following transfer phase. Irrespective of the size of team, though, the most important steps towards integrating teams were undertaken in practice development projects, where team members were part of the project team and knew how the project connected to the overall vision. The vision or strategic direction had an impact on the individual practitioner and the entire team. In one focus group, participants said having the vision had provoked a higher commitment to professional practice, which they felt had in turn facilitated their personal growth. This resulted in greater confidence and self-mastery as well as in greater autonomy in practice. Empowering practitioners in order to develop their professional competencies as well as their collective service is a key purpose of emancipatory practice development work (Manley and McCormack, 2004; Dewing, 2008). In this study, a strategic direction with defined values and corresponding practical activities was seen as promoting quality improvement in the field. Focus group participants experienced a shift from more 10 © FoNS 2014 International Practice Development Journal 4 (2) [4] http://www.fons.org/library/journal.aspx traditional to evidence based, standardised care in their clinical practice. Most importantly, the vision mediated the need for continuous development in practice – as a result of working with a vision, participants realised that change is inherent in today’s healthcare arena. A similar emphasis on quality improvement is also the raison d’être of practice development work, in order to achieve better or best care for healthcare users (Manley and McCormack, 2004). One risk of working with a vision that was identified in this study is the danger of having too many activities, and thus overloading the organisation at the unit level. This risk was identified by focus group members and also some nurse leaders. Although numerous organisations do undergo regular change and therefore experience the acceleration trap – a phenomenon that was for the first time described in the management literature by Bruch and Menges (2010) – a publication addressing a similar phenomenon could not be found in the nursing literature. This is likely to be because this issue of acceleration in change has not been studied in healthcare. However, it would be interesting to do further research with this focus in clinical practice and compare the results with the overall performance of the organisation, since it is very likely that people become exhausted by the accelerated pace of change and that this has an impact on their work. The two other threats, dilemma and incongruence, address the gap between the ideals of the vision and the current service provision, experienced on a personal and organisational level. On the personal level, some participants described feelings of frustration and shame when they had not been able to perform according to the defined values and standards. On the organisational level, they described the incongruence between the shared values and the priorities and activities in daily practice. However, there is a positive aspect to these responses, as the primary driver for developing practice is precisely this awareness of a lack of fit between the care provided and the needs of the users. A learning process is then required to identify and analyse problems (Clarke and Wilson, 2008). Moreover, emancipatory practice development can enable practitioners to recognise the power and limitation of their individual influence and to deal with restraints more creatively (Manley and McCormack, 2004). Nevertheless, the experiences of participants in this study emphasise that care should be taken to ensure that a vision and corresponding core values are realistic and achievable. Otherwise, there is a danger that the vision will remain an unattainable illusion, and the individuals who are supposed to turn it into reality will become frustrated and demotivated. Limitations of the study This study explored and described the effect of a shared vision or strategic direction on practice and practice development as experienced by nurse leaders and their teams. The average age and leadership experience of the included nurse leaders was high, which might be an advantage in developing and implementing a vision into practice. However, due to the lack of a comparison group with younger/less experienced leaders, and to the small sample size, this study cannot verify that. Moreover, the study was undertaken in only one Swiss hospital and therefore provides only preliminary results that need to be verified through further research. The triangulation of two datasets and the selection of interview participants as extreme cases according to their scores from the quantitative part strengthen the study results. Nevertheless, more studies in this field are needed in order to describe fully the phenomenon in healthcare settings and to see whether similar patterns emerge in other organisations/countries. Conclusion Engaging team members in a shared vision is not only a key component of a transformational leadership style but is also essential in practice development activities in order to provide direction and clarity of purpose (Felgen, 2007; McCormack et al., 2007). Thus, inspiring a shared vision is a very strong tool for the successful transformation of practice, as a vision releases four main forces in an organisation: attracting commitment and energising people, creating a meaning for people’s work, establishing a standard of excellence, and bridging the present and future (Nanus, 1992). 11 © FoNS 2014 International Practice Development Journal 4 (2) [4] http://www.fons.org/library/journal.aspx Implications for practice This study found that a vision or strategic direction provides orientation and meaning for leaders and their teams and is a strong driving force for ongoing and systematic practice development. It helped participants to focus their energies and engage in the transformation of practice. However, it is very important for leaders to monitor closely the energy level of teams and the organisation, in order to keep the balance between innovation/transformation and relaxation/recovery. References Alleyne, J. and Jumaa, M. 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Acknowledgements Many thanks go to Dr Katharina Fierz and Dr Elisabeth Kurth for the critical discussion of findings during the qualitative content analysis. Furthermore, a lot of thanks to Ms Barbara Schwaninger for the verbatim transcripts of all interviews. We also thank particularly the participating nurse leaders and their teams who shared their experience regarding vision and practice development work. This study was funded by the Ebnet Stiftung, Switzerland and was promoted by the University Hospital of Basel. Jacqueline S. Martin (PhD, RN), Executive Head, Department of Nursing and Allied Healthcare Professions, University Hospital Basel, Switzerland. Brendan McCormack (DPhil Oxon, PGCEA, BSc Hons, RMN, RN), Head of Division of Nursing, Queen Margaret University, Edinburg, Scotland; Professor II, Buskerud University College, Drammen, Norway; Adjunct Professor of Nursing, University of Technology, Sydney, Australia. Donna Fitzsimons (PhD, RN), Senior Manager, Nursing Research Belfast Trust; Professor of Nursing, University of Ulster, Belfast, Northern Ireland. Rebecca Spirig (PhD, RN), Executive Head, Department of Nursing and Allied Healthcare Professions, University Hospital Zurich and Professor of the Institute of Nursing Science, University of Basel, Switzerland. 15 Copyright of International Practice Development Journal is the property of Foundation of Nursing Studies and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use. SPONSORED Management for Strategic Agility \ STRATEGIC AGILITY SERIES, REPORT 2 SPONSORED BY GE CAPITAL It's never easy for hospital and health system leaders to balance short - term revenue challenges against investments that will meet future needs for clinical technology and equipment. Information management systems, and bricks and mortar. Yet this task has taken on even greater levels of dif&ciilty—and importance—as of late. Many long-held assumptions about ways to optimize organizational resources are being cast aside as the industry pushes to improve value in healthcare delivery, striving to provide high-quality care at low cost. Shifts in payment models, service demand, and market competition are radically changing the landscape, creating a dynamic environment in which organizations must assess strengths and vulnerabilities. During this time of change, healthcare leaders need to anticipate and set in motion tactics and processes that wül not only mitigate economic pressures on revenue in the current fee-for-service enviromnent, but also prepare for the healthcare world ñve years from now—one that is likely to be focused largely on outcomes and capitated approaches toward delivery. Strategic agüity, or readiness to meet the demands of tomorrow, wül require forming creative partnerships; making progressive investments in systems, technology, and facilities; and developing and managing novel healthcare delivery networks.' How well leaders are able to optimize the organization's assets wül play a key role in having not only the resources to take part in these value - driving efforts but also the confidence to know the organization won't become so overburdened with obligations as to impede nimbleness and competitiveness. Significance of Asset Management Imprudent asset investment imposes a heavy toU on agility. When an organization faus to optimize assets—signing a $100,000 contract for equipment that is used in fewer than lOO procedures a year, for example—it not only experiences poor ROI, but it also becomes less able to devote resources where greater value can be derived. Similarly, although ownership traditionally has been a key strategy used to maximize the useful life of assets, it needs to be pursued with much greater diligence these days given its potential to hold the organization back from obtaining nextgeneration capabilities or efficiencies or from redeploying assets to address changes to patient mix, payment, or service demand. How effectively an organization manages its assets is of particular concern in today's dynamic environment as threats of underutilization have become particularly frequent. Heightened merger and acquisition activity can quickly leave an organization with replicated equipment, technology that isn't well suited for integration, or facilities in service areas that are suddenly oversaturated with similar providers. Many hospitals are learning the hard way that revenue-producing areas today can easily become cost centers tomorrow. 2 August 2013 © 2013 Heaithcare Financial ManagemenI Association hlina.or9 To react quickly in the face offluidlocal and industrywide healthcare trends and operate with greatest efficiency, providers need to be able to reevaluate their presentfleetof technology, equipment, and real estate assets and analyze for value; What is the cost of owning or operating each asset? Is it used enough? Is it deployed in the right place, used at the right time, targeted for the right patient populations? Are organizational resources being used in the most effective way to support the long-term, strategic objectives ofthe organization? How might demand relating to use of the asset change in the future, and how wiU the organization likely respond? As providers look to support strategic aguity through optimal asset management, four critical actions will be necessary; • Aligning changes in long-term strategy with asset deployment • Staying vigilant to external influences on asset value • Reexamining asset capabilities to support integration « Redistributing organizational resources to support growing product lines The following examples demonstrate how progressive organizations are meeting and addressing shifting asset needs in each of these areas. Aligning Changes in Long-Term Strategy with Asset Deployment Peoria-based OSF Healthcare, one ofthe largest integrated healthcare systems in Illinois, is transforming the way it delivers care—and adjusting its approach to managing its assets accordingly. Rather than continue as a community-hospital-based organization that follows an episode-of-care delivery model, OSF is becoming a longitudinal system that delivers healthcare services at a variety of sites across large geographic areas. Regional-level CEOs at the organization are examining costs, care delivery practices, and asset deployment to address this change in vision. Managing investments in imaging equipment and services has been one area where leaders have made particular strides. "In the past, our individual hospitals often were competing against each other for volume for certain imaging services," says Dan Noeth, executive director of sourcing and contract administration. "If one hospital or outpatient center attempted to gain additional volume, then it frequently cannibalized volume from another OSF facilityftveto 4,5 nules away. Also, the investments rarely achieved organizational synergy to best serve patients in terms of leveraging staff, sharing best practices, and optimizing technological capabñity." The new regional focus has led OSF Healthcare to create optimization and strategic road maps for high- end technology, such as computed tomography (CT), magnetic resonance imaging, nuclear medicine, and mammography. As Noeth explains, OSF began with the assumption that go percent of the cost of large imaging equipment involves lease cost or depreciation, labor, and maintenance. Leaders then calculated the cost per procedure performed with each piece of equipment and categorized imaging units on the basis of cost, clinical capability, and safety, with the core objective of determining whether an OSF region was utüizüig imaging equipment effectively and efficiently. Common questions asked as part of this effort included: Do volumes support the current installed base of imaging machines? Which units are highest in cost? Can machines be redeployed to maximize volumes and/or patient care? Can imaging units he closed without adversely affecting patient care? How many machines are clinically obsolete? How many machines can be replaced with newer, safer technolog)'without increasing costs? "We found we didn't need aU of our imaging units," Noeth says. "In CT, we were able to shut down three units, and we were able to acquire or upgrade CT units with low- dose capabilily while actually reducing our costs. In three years, we lowered our cost for CT from $13.5 million to just a little over $10 million." The organization's cost range, which was $60 to more than $1.000 perprocedure in 2010, went to $48 to $250 in 2012, he says, whue procedure volume went up 3 percent. Patients also benefited, as the organization increased the number of patients being serviced on low-dose capable machines. "We went from 17 percent to 91 percent of patients being scanned with low- dose capable units, resulting in a 400 percent increase in our use of low- dose technology," Noeth says. OSF has applied the same method of asset review across other imaging modalities, most recently in mammography. Noeth notes that the organization is shutting downfiveof its ?6 units and upgrading 80 percent of the fleet to tomosynthesis capabüity. "We wül have one of the largest breast tomosynthesis fleets in the country. Our radiologists wul use 3-D capability to find much smaller lesions sooner, supporting less invasive treatment with better outcomes," he says. "We also wül reduce our operating cost by ahout 20 percent whue reducing the number of false positive studies." As part of its regional model of healthcare delivery, OSF is continually exploring demographic density and procedure volume across the system. OSF also has engaged external expertise to help support its anal3^ic efforts, including equipment suppliers, a group purchasing organization, radiology group leaders, and a nationally recognized healthcarefinanceconsultingfirmwith expertise in optimizing equipment management. This team's supplemental data and insight are helping OSF to determine optimal clinical, operational, andfinancialvalue. With population data and demand forecasting, OSF has been able to make more rational decisions about the niimber, location, and technology level of its imaging services. "Some of our locations, such as Escanaba, Mich., and Pontiac, 111., can support only one tomosynthesis machine, as opposed to their previous two mammography units. In larger regions, not all units required tomosynthesis capability. No region was identified as needing additional capacity, although some units required relocation to achieve optimal asset utilization," Noeth says. After OSF retires its units that aren't required, it will stül have ABOUT THE STRATEGIC AGILITY SERIES In the face of downward payment pressure and payment structures that reward efficiency and quality, healthcare organizations recognize the need to transform their organi zations to deliver value—high quality at low cost. Carrying out this strategy will involve an array of activities, from integrating with physicians to implementing electronic health records to using formal process improvement to drive out waste to pursuing collaborations with other organizations. Financing the value strategy is a formidable challenge. Not only are the components of this strategy expensive, hut for many hospitals, payment and volume pressure means that they are challenged to provide funding through cash from operations and may need to access capital through bonds and other traditional sources. This is especially true for the "have-not" organizations—hospitals that are financially challenged because of factors such as payer mix or location. As hospitals and health systems navigate shifting patient volumes, new payment models, and the uncertain competitive landscape ahead, those organizations hest positioned for success wiU be able to demonstrate "strategic agility." Rapid response to shifting market dynamics requires preparedness in both capital planning and management. Specifically, leaders should focus on: • Heeding the call for strategic agüity • Optimizing asset management for strategic agüity • Maintainingfinancialflexibüity for strategic agility • Managing productivity for strategic agility This report is the second in a series of reports from HFMA, with sponsorship from GE Capital, that wül explore each of these important endeavors. To view prior reports and stay abreast of latest offerings in the series, see www.hfma.org/strategicaguity. HFMA EDUCATIONAL REPORT 3 STRATEGIC AGILITY SERIES, REPORT 2 SPONSORED BY GE CAPITAL capacity to increase its regional procedural volume by 2,0 percent ormore,hesays. Taking part in this review is a multidisciplinary group that includes the organization's medical imaging leaders and staff, radiologists, radiology group leaders, supplier representatives, and OSF staff from finance, revenue cycle, marketing, contract administration, and women's health. This mix has been important not only to gain operational, clinical, and financial perspective but also to drive buy-in across the enterprise to implement the data-driven recommendations. Procedure and cost data are making it clear to stakeholders why cost per procedure analytics are essential in today's challenging healthcare environment, Noeth says. Of course, knowingwhether demand can support a service is just one consideration. Even when organizations recognize the need to provide access to services, they also should examine which strategies will be cost-effective and provide low-level risk should utilization, usefulness of technology, or payment change. At East Texas Medical Center, in rural east Texas, for example, an ownership change suddenly brought 15 hospitals into a network of healthcare providers. Leaders used leasing on a fee-for-scan basis as a low-riskway to bring MRI services equivalent to those offered at a larger hospital to the small, rural setting. With a hub and spoke approach, leased mobue scanning equipment serves a series of hospitals as small as 25 beds that surround the Tyler facility within a 50 mile radius. The payment arrangement incents the equipment vendor to garner physician huy- in and help market the imaging services. As one executive at the medical center put it succinctly, "If we don't get patients, they don't get paid."^ By forgoing equipment purchase of an MRI at a stationary facility, the organization not only has found a cost-effective way to provide services to areas without enough utilization to support the investment, but it also positions itself to be more responsive should utilization patterns change as the network continues to mature under its new ownership structure. interconnected system of care to serve patients and promote community Wellness by means of alliances with community hospitals and physicians. "We've always heen a big user and owner of property," says Jason Ruggles, director of corporate real estate. "But now we also are looking at other arrangements in real estate as a valuable tool to accomplisb our healthcare goals." One example can be seen in Ochsner's acquisition of many campus-adjacent single-famuy homes, some ofwhichwere abandoned after Hurricane Katrina. "Although the investment is outside of our core business, we have been able to turn those residences into a pretty successful operation to house our medical students, residents, and fellows," says Ruggles. "Over the long term, the properties will give us the opportunity to expand our footprint." Also, although Ochsner primarily has owned and operated its properties in the past, it now has a variety of real estate partnerships. "We have become so spread out that we're looking at relationships more strategically and saying, 'OK, how does each individual location benefit our ultimate goal of patient care, and what kind of partnership relationship is best,'" Ruggles says. The nature of the real estate relationship depends on the capacity and service needs of each locale. With such a large presence—Ochsner employs 840 physicians and has developed relationships with 1,4,00 community physicians—the executives at the system level do not have the benefit of day-to-day interaction with physician partners and the local community. So Ochsner relies on the COOs and CEOs in its regions to make many of the decisions on how its real estate assets can generate the most value. "We Kke them toftgureout strategically what kind of relationship makes sense for the physicians and the use of their hospital," says Bui Ward, senior vice president of facilities, real estate, and support services. The desired strategy often can mean the purchase of medical office buildings, a lease arrangement, or a tenant partnership. Purchase is less preferred these days, however. Reevaluating the role of assets within the organization is just one component of strengthening organizational aguity. Also important is keeping abreast of potential opportunities beyond the organization's walls to enhance asset value. "We are not going to be in the business of buying bricks and mortar or acquiring a lot of physician practices," Ward says. "We arc looking at affiliations so we can offer a suite of complementary services that give physicians and hospitals the independence to do well. Rather than simply conducting a real estate deal, we are looking at arrangements that make sense for health care, for Ochsner, and for us to be able to provide better and higher quality care." Market viguance has helped New Orleans-based Ochsner Health System get the most from its investment and use in real estate during recent years. Ochsner has been pursuing a bold plan for growth and progressive, integrated care delivery that will expand its footprint and create a regional In the same spirit, Ochsner is examining existing relationships with tenants to determine whether the facilities can be put to better use. Looking at the best way to make use of real estate assets wiU be important to ensuring the organization can provide appropriate access and service mix as market forces change. Staying Vigilant to External Influences on Asset Value 4 August 2013 © 2013 Healthcare Financial Managemenl Association hfma.org One example has been the organization's focus on improving primary care access. "With healthcare reform, we know we should be expecting additional focus on Wellness and chronic care management in lower intensity settings," Ward says. This lack of integration impeded efficiency and effectiveness. The organization bad developed a lot of paper-based processes involving different hand-off and transition-of-care documents due to tbe lack of integration between systems. Anticipating increased use of outpatient services and these changes in delivery models, the health system is in the process of converting two warehouse -luce facilities into an internal medicine complex. The properties were acquired 15 to 30 years ago and rented out over time to a national food chain and a multipurpose retailer. In the past two years, Ochsner has transformed one of the buildings into a covered parking garage, and it is transforming the other into 150,000 square feet of internal medicine/primary care, academic, and other medical space. Ochsner also is constructing a bridge over a four-lane state highway to cormect the new facility to tbe main campus to make it easier for patients to access services. "We are essentially doubling our capacity to offer primary care," Ward says. What's more, in June aoia, MercyCare and Univeristy of Iowa Healthcare formed a Medicare accountable care organization (ACO), and then joined with two additional healthcare organizations to form Tbe University of Iowa Health Alliance (UIHA). Tbe UIHA now represents 50 hospitals and more than 160 clinics to provide expertise sharing, support services, and IT. To derive greatest benefit from tbe collaboration, Mercy needed better data sharing capabilities with tbe other entities. Redeploying Assets to Support Integration Another common consideration for optimizing asset use going forward is adequately planning for data sharing across different settings of care. As the industry seeks to reduce costs through better management of population health, providers will likely assume much greater risk and require far better understanding of quality and cost drivers throughout tbe patient encounter. In addition, organizations should be looking to systems that will help support accountability for care outcomes spread across tbe care continuum.^ As such, investing in tbe right IT goirrg forward involves not only doing what's needed for desired efficiencies and intelligence within tbe organization but also doing it in a way that makes sense for broader organizational strategies around integration. One organization takingthis approach to its technology management is MercyCare Service Corporation, Cedar Rapids, Iowa, wbicb includes one bospital, a cancer center, family practice and specialty clinics, urgent care, and other outpatient centers. MercyCare has been moving away from a care delivery model designed around individual services areas and is redeploying IT to better support integration. "Dataflowused to be limited between service areas," says Jeff Cash, MercyCare'sseniorvice president and CIO. "We were utilizing an integrated inpatient bospital information system, but we bad deployed individual electronic medical records in many bospital-based outpatient areas, including the emergency department, medical and radiation cancer centers, obstetrics, OR, and dialysis. We also bad a complete but separate electronic medical record and revenue cycle system in our ambulatoiy clinics." Recognizing these challenges, MercyCare's leaders began testing the boundaries of integration to determine bow tbe various parts of tbe organization's system could work together more efficiently and identifying existing redundancies and gaps. One barrier addressed was tbe organization's eight disparate medical record systems and data warehouses. "We bad lots of data, but users bad a bard time drawing meaning from the data or being able to access the data with tbe level of detail ortimeliness needed to make decisions. Pulling together a what-if analysis' to answer questions from a physician or strategic adviser ofien became a monumental project," Casb says. Each system bad its own set of self- contained workflows, which was a real barrier to patientflowthrough tbe system. Based on the analysis, organizational leaders decided to invest in a single electronic patient record system and data warehouse across tbe entire health system, wbicb was recently implemented. "Tbe strategic goal is to bave one patient record for clinical care and allow it to be used for multiple workflows, and we now have a single data repository we can work from to identify sources of deviation that need to be corrected or best practices that should be shared," Casb says. MercyCare and tbe UIHA also explored technology that would best support efforts to manage population-based health statistics and bealtbcare delivery within the multi-organization ACO. Greatest value could be found with a system that would integrate with other participants and provide integrated workflows and data sharing throughout tbe delivery system. With its ACO partners, MercyCare and tbe UIHA bave contracted with a population bealtb data management vendor so "tbose of us wbo share care coordination for a patient can look at shared patient data, and we can also de-identify and aggregate tbe data to see bow we are performing at the individual bealtb system level and as a collective organization within the state of Iowa," Cash explains. HFMA EDUCATIONAL REPORT 5 STRATEGIC AGILITY SERIES, REPORT 2 SPONSORED BY GE CAPITAL The path to integration has led MercyCare to take a granular as well as global view of strategic projects and to engage more stakeholders. Although the health system reviews every project on its own merits, it also examines asset investments as part of the fabric of the future. "We thought we couldn't stop projects that were in process because we were making business investments at different times to meet the cHnical needs of different service lines and didn't think we couldfindthe right time to stop making those investments," Cash says. "But instead of just thinking about individual projects, we refocused on a common goal: the wholesale replacement of what we were using for the electronic medical record." Redistributing Organizational Resources to Support Growing Service Lines At Andalusia Regional Hospital, Covington County, Ala., leaders are taking a fresh look at the utilization and productivity of core assets and business lines to identify and bolster those that are clinically efficient andfinanciallystrong and add service lines that take advantage of patient population characteristics in the marketplace. When deciding how to best structure assets for the future, sometimes tough choices have to be made. The organization has had to reconfigure or drop those service lines that do not currently justify a major commitment in facilities or technology or that do not clearly place the organization in a competitive position going forward. Leaders at the lOO-bed facility closed the spine and kyphoplasty program in 3010 and an inpatient rehabilitation unit in aoia. "Changes in the reimbursement structure, a low overall census, a return that was not as high as it needed to be, and volume that did not coverfixedcosts led us to those decisions," says Shirley Smith, CFO. Refocusing resources in this way has allowed the hospital to capitalize on opportunities to create new product lines. Cancer care and wound care arc just two service areas bcnefitting from redistribution of resources. In aoio, the hospital leased property to 21st Century Oncology to build a Y,42o-square-foot regional clinical cancer and radiotherapy treatment site that is equipped with a linear accelerator and positron-emission tomography scanner. In conjunction with 21st Century Oncology and Sacred Heart Cancer Center, Andalusia opened a comprehensive cancer care center in 3011. A little more than a year later, the cancer center was providing more than 150 treatments a week. At present, the hospital is converting a recently vacated medical office building Into a wound care center that has the potential to reduce outmigration, increase outpatient revenue, and raise volumes and revenue for clinical departments, including general 6 August 2013 © 2 0 1 3 Healthcare Financial Management Association hlroa.org medicine, the cath lab. outpatient imaging, and vascular, general, and orthopedic surgery. Andalusia Regional Hospital expects to make asset distribution decisions more effectively and dynamically going forward, as it improves its capabilities to gather volume, cost, and profitability data across clinical service lines. The hospital is installing data management tools that will tap into internalfinancialand operational data and plumb external data sources tofindpoorly performing sectors and areas with exeess capacity as well as profit centers that could benefit from more careful use of resources. "We need to dig in to see how our results differ from our expectations—if volumes aren't there or costs are higher than we thought they would be—once a m.onth or bimonthly," says Smith. "We can't wait and look at this once a year. We need to meet with physicians to talk about overall strategy and the directions the hospital needs to take, to share market trends and track outmigration. We need to determine what is going on with our utilization and cost, so that we can decide when improvements should be made orwhenwe should continue a program. The data will also help us determine which services should be added to better serve our community." Of course, examining which services are best supported is only part of staying strategically agile. Leaders also need to analyze ways to manage the desired service lines to best support longterm needs. As part of this review, health system leaders may explore whether consolidating services at different settings into one location will make the most sense to optimize utilization and best leverage clinical expertise. In other instances, organizations may even align with competitors to optimize asset use. Collaborating with competitors can be a key means tofillservice gaps, create efficiencies/enhance bargaining power, reduce competition in a weak market, and share investment risk. Such strategic alliances can range from j oint operating agree ments on the highly integrated end to joint ventures and shared service organizations, such as the alliance referenced earlier with MercyCare and the UIHA, on the loosely integrated end of the spectrum. Joint operating agreements operate in a merger-Kke fashion in which most or all organizations arc combined, but the collaborating organizations stop short of combining assets and allow certain reserve powers to remain. More common are various types of focused joint ventures and shared service organizations. In these arrangements, the alliances are narrowly drawn, usually involving a single venture or, at most, a few areas.* The Role of the CFO Agile asset management rests on anticipating the new, postreform world of healthcare delivery in terms of top-line revenue and likely competition to form a strategy that is relevant for the communities served. This visioning will need to factor in OUR SPONSOR SPEAKS THE IMPORTANCE OF CHALLENGING TRADITIONAL PARADIGMS TO OPTIMIZE ASSETS Jeff Wagoner, U.S. commercial leader, healthcare financial services, with GE Capital, discusses how redefining certain constructs regarding asset management will be essential to maintaining strategic agility in the lace of ongoing market uncertainty. W hat are some core considerations for hospitals and health systems when managing assets for strategic agility? The level and duration of change created by the Affordable Care Act—from definition and passage through long-term implementation—underscores several key considerations all health systems will face when examining asset use in the foreseeable future. Uncertainty is now the norm. The abüily to buud future flexibility into today's capital investments is critical. Incremental actions are not enough. The degree of financial performance risk created by the ACA is significant and diverse. Replacement strategies, for example, need to be elevated to a broader focus—clinicaEy, operationally and economically— for bigger impact. Decision variables are expanding. In the shift from volume to value-based reimbursement, a much more complex set of assumptions is required to vision capabüity and capacity needs. Identifying and routinely traeking these assumptions will best position the organization to recognize when course changes or corrections arc needed. The Importance of asset ownership is changing. In many organizations, there has been a historical belief that owning certain types of assets is the clearest path to maximize rettim on investment. However, in a market environment that is dynamic, maintaining ongoing flexibility is key. Asignificant cost of ownership therefore is the potential to limit the organization's abüity to realign capabilities and eapacity in the future if actual demand varies from assumptions made to justify investments. The consideration of alternative funding vehicles or operating structures can create opportunities to reset if needed, thus helping to ensure today's optimization plans continue to be effective over time. Traditional supplier relationships and operating structures may not be enough. To achieve and sustain ongoing strategic agüity, it is essential that key suppliers be equally as agüe. Factors such asflexibüityand the willingness to sbare risk created by uncertainty are as important in the supplier evaluation process as cost. When navigating tbe shift to asset optimization, hospitals and health systems shotild keep these considerations front of mind, as they wül significantly influence the prioritization and deployment of capital investments. Source; GE Capital. greater coordination and integration with a range of delivery partners to ensure assets are deployed in a way that supports investment for greatest efficiency and effectiveness. The CFO wül play a vital role in shaping this strategy. Working with clinical and operational leaders,financialexecutives should seek to incorporate the following actions when identifying the right asset deployment to support value going forward. Understand the utilization and productivity of core revenueproducing assets and business lines. Where is use highest? What factors would improve utüization? Where is utüization likely to be most vulnerable? How might utüiza...
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