As the US healthcare environment continues to evolve in response to calls for lower cost, higher quality, and an improved patient experience, healthcare organizations are undergoing fundamental change. This in turn requires the system chief nurse executive (CNE) to adjust and embrace new competencies. These include improving population health, increasing quality, expanding provider coverage, and managing increasingly complex health information technology systems. System nursing leaders must take on these issues while at the same time ensuring safety across the continuum of care and keeping financial viability in mind. The system CNE also must remain prepared to respond to evolving changes in ownership or partnership of their healthcare organization.
The American Organization of Nurse Executives has responded to the changing role of nurse executives by providing research and strategic thinking. The organization recognized the need to provide insight into the role of system CNEs in helping to lead the transition of the US healthcare system from a focus on acute care to the entire continuum of care. The contributors to a white paper outlining this role change reviewed literature predicting future changes in the healthcare system. This article is a summary of that document. White paper contributors identified 3 areas of competency that will be important for system CNEs to obtain and maintain:
1. Supporting the healthcare system's ongoing transition from acute care to continuum of care
2. Participating in an interdisciplinary team approach through shared leadership
3. Enlarging the role of the advanced practice registered nurse (APRN) in relation to the integration and synthesis of clinical services
Focus Area 1: Adjusting to New Models of Care
As the healthcare system moves to paying for value rather than volume, system CNEs will be under pressure to help ensure that their organizations are coordinating care across the continuum. The system CNE is well positioned organizationally to lead or partner with other clinical executives to prepare system environments for this change. Regional or system-level executive teams will be responsible for integrating settings. The system CNE often will take responsibility for deciding how practice variability will be managed, which involves assessment of each care delivery site. This will likely also include determining where to allow variability in nursing practice, taking into account a number of factors, including the potential impact on patient/family-centered outcomes.
The system CNE can also play a key role in partnerships with academia to prepare the nursing workforce of the future in the provision of care across the continuum. These partnerships can take place in various structures, including appointments to academic boards of governance. As case management and care coordination expand to cover more sites of care, curricula must keep pace. Colleges and universities must incorporate concepts of team-based care in their curricula. Curricula should reflect the complexity and microsystems that will become more prevalent in the healthcare system. Educational models that respond to these system changes should be evaluated by outcomes measures based on the Triple Aim: population health, experience of care, per capita cost.1
Research must support the evolution of nursing education and nursing leadership as the system changes. Research and education should be coordinated for synergy. Research projects that could address these issues include the most effective use of telemedicine, remote patient monitoring techniques, and effective methods of providing discharge information to patients.
Some mature healthcare organizations have already begun moving to the new payment and care delivery paradigms, providing best practices that can be of use to others. Exemplars include Advocate Healthcare and Advocate Physician Partners, which have aligned a strong physician base with a healthcare system to create a "super Physician Hospital Organization" to drive population health and clinical integration. The University of Pennsylvania uses APRNs in the inpatient setting to evaluate patients who may be at risk for readmission and schedule home care follow-up visits, reducing readmissions among high-risk patients. Texas Health Resources has set up 12- to 16-patient microsystems that are coordinated by clinical nurse leaders in collaboration with care transition management staff, resulting in improved outcomes and lengths of stay and reduced readmissions.
Focus Area 2: Shared Leadership to Improve Interdisciplinary Teams
Team care is becoming the new delivery model in the US healthcare system. Just as other clinical specialties are evolving to take this model into account, clinical management must change from the hierarchical, discipline-oriented models of the past. Leaders with separate clinical affiliations, skills, education, and experience should lead together to manage multiprofessional teams. Coleaders of the system's clinical enterprise should include both the system CNE and chief medical officer (CMO).
Coleadership can sometimes be challenging; gender and professional cultures may make it difficult for coleaders to overcome traditional management structures. These partnerships can be successful and transformational to their organizations when partners are willing and able to grow, change, and learn together.
Through shared leadership, the economic shift for paying for value instead of volume will have its greatest impact. These partnerships will make it possible to implement models such as bundled payment systems. Results will be demonstrated through excellence in quality measures and patient engagement. The system CNE will be an influential source in ensuring patient- and family-centeredness throughout the continuum.
Focus area 3: Role of the APRN
The future will also require greater use of advanced practice providers. The APRN plays a key role in transforming healthcare systems to provide more integrated care. The system CNE helps to establish professional standards and align nursing practice across all sites of care within the system to achieve organizational goals. Top-of-license practice requires several essential actions. Most importantly, APRNs must provide leadership within the organization to make sure that there are broad understanding and acceptance of their scope of practice. This requires the CNE to establish a mechanism for professional governance for advanced practice and ensure that APRNs serve in leadership roles. Governance processes for credentialed and employed APRNs should be standardized across a healthcare system. These processes should define credentialing and privileging, including peer review, and require APRN involvement.
The CNE is positioned to establish strategic healthcare system structures that document the outcomes of care of individuals and communities and monitor efficacy of care delivery. There are 2 primary elements in this area. The electronic health record provides the foundation for recording care and measuring the impact of care provided. Also, data systems support outcome measurement and research to demonstrate efficacy of teams, including the role of the APRN.
The National Council of State Boards of Nursing consensus model should be used by the system CNE to establish core structures and processes for APRNs. Not all states have implemented the consensus model, so it would be the CNE's responsibility to learn more about the relevant states' scope-of-practice regulations and status in relation to the consensus model. Often, the system CNE will be responsible for establishing and nurturing a professional home for APRNs across the health system. The clinical dyad of the CMO and the system CNE is often responsible for leadership in establishing APRN practice governance; the duo also may need to define and measure the contribution of APRNs to the organization's goals.
The reforming healthcare system demands that the system CNE, as a transformational leader, identify new roles for APRNs in care delivery systems. Nurses at all levels must be responsible for the clinical and financial impact they bring to patients, consumers, and healthcare systems. Advanced practice registered nurses allow improved access to care and enhanced caregiver team effectiveness to achieve these outcomes. The system CNE is in a strategic position to advance important structures and processes and demonstrate outcomes of APRN team practice.
Conclusion
The system CNE must be prepared for rapid changes in the healthcare industry. The 3 areas of competency identified in this report may not be comprehensive but are meant to build a foundation for this topic and provide the opportunity for system CNEs to contemplate the skills they will need to do their jobs effectively in the future. The committee recommends that system CNEs carry out a self-assessment that takes into account the areas of focus identified in this article and the environmental, economic, technologic, and provider role shifts expected for the future. Managing this change will require high-performing interdisciplinary teams and effective coleadership. And the insights of system change will need to be translated to the educational system to ensure that nurses in training are prepared to become the system nurse leaders of tomorrow.
Acknowledgments
White paper contributors: Gary Blank, Carol Bradley, Marilyn Chow, Joan Shikus Clark, Kathy Harris, Anna Kiger, Sharon Pappas, Pamela Rudisill, Kathleen Sanford, Colleen Shwartz, and Pam Thompson.
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