Our Problem
Since 2008 SVPH has reported Press Ganey patient satisfaction data at the 96th percentile when compared with peer hospitals. Our problem is how best to sustain such exemplary data in an increasingly competitive market and in light of escalating patient expectations. Sustaining excellence is always an issue in a high performing organisation because complacency and inertia can quickly replace the drive to achieve high standards once they have been attained. We needed another goal that required us to demonstrate excellence that was nursing led and, unlike the ACHS accreditation for example, was not mandated but rather, voluntary. The American Nurse Credentialing Centre's highly prestigious Magnet Recognition Program(R) was our vehicle of choice. In what follows we demonstrate how we have embraced the challenge of becoming the first Magnet designated private hospital in Australasia to resolve our problem.
How we planned the solution
Stage 1
While the Magnet Program had been on our strategic agenda for some years, we had never felt we were quite ready to embark on such a complex and demanding journey. But in late 2007, after winning the Press Ganey Success story competition, and with a couple of years of very compelling data from a range of indicators, including Press Ganey scores to bolster our aspirations, a small subset of our leadership team undertook a study tour of five Magnet facilities in the USA. We wanted to see firsthand exactly how Magnet hospitals stood out from the rest and what it took to achieve such status, especially since this accolade is relatively unknown and untested here in the Australasian context (currently only two public hospitals in Australia have gained Magnet Recognition). This study tour provided robust evidence that the Program(R) was the most appropriate vehicle for the hospital to maintain its reputation for excellence in nursing care quality and safety (photo 1).
The official journey to Magnet was a well planned and staged process developed, in consultation with the Nursing Executive, by the Magnet Program Manager who was appointed in early 2008. The leadership team was fully engaged and executive support enlisted at the outset; this was an important strategy to ensure commitment from the highest levels of hospital governance.
Stage 2
In preparation, the hospital sent representatives from the Nursing Executive Council to the 2008 Magnet conference to learn about the very recently revised Magnet model. On return and armed with the up-to-date information about the latest iteration of the program we undertook a gap analysis to determine areas of strength and weaknesses in preparation for Magnet document submission. This preliminary stage of the process was augmented by data from a hospital wide survey of nurses at all levels which provided Magnet hospital benchmarked data and provided compelling evidence that we were well on target for application and preparation of the full documentation required (see Walker et al, 2010 for full report).
Stage 3
In June 2009 formal application to join the Magnet Recognition Program(R) was made to the American Nurse Credentialing Centre (ANCC); Magnet Champions and Super-Champions were enlisted from all clinical units to gather data for our submission and to engage all staff with the journey. A live-to-air video launch was broadcast across the hospital's CCTV system during which each unit and department was asked to light a special Magnet candle as a symbolic marker of the journey's commencement. This reflected our Catholic mission and values and the ways in which such symbols reinforce our commitment to providing compassionate care. This was a key strategy as Magnet is very much concerned with the ways in which the leadership engages and support its nurses and enables their presence to be felt and their voices to be heard.
Stage 4
The very extensive documentation to demonstrate the sources of evidence and make our case for recognition was prepared between June 2009 and early 2010. This work was completed through a deliberately collaborative and consensual process involving a range of senior nurses who worked cooperatively to draft and edit the documents. We chose this methodology to reinforce the fact the Magnet is a whole-of-staff initiative and that it cannot be assigned to just a few select players. While this made the process more complex and at times, more fraught, the end product can truly be said to be the result of the ideas and energies of many and as such, reflects and gives strong expression to the expectations embodied in the Magnet Program itself. These were submitted to the ANCC at the end of May 2010.
Stage 5
In August 2010, after a request from the reviewers to provide additional information, we reconvened the original authors and busied ourselves with preparing this extra documentation. This comprised mostly of more detailed descriptions and demonstrations of the evidence requested rather than any radically new material. This document has been favourably reviewed and we will host a site visit from three appraisers February 14 through 16 this year. Once the appraisers have compiled their report for the ANCC, the Board of Commissioners will make their decision whether or not to ward Magnet designation to our hospital.
Implementation of Programs and Initiatives
As discussed above, the Magnet Recognition Program(R) is a whole of hospital nurse led initiative. It has been implemented through a range of structures and processes facilitated by the Magnet champions and super champions mentioned above. Importantly and in order to maintain the impetus the Magnet program manager devised a series of activities for these groups in order to stimulate creativity and foster a strong sense of involvement. Activities included: a poster competition depicting what Magnet meant for each clinical area; a competition for the development of a Magnet badge to be worn by staff; a Magnet quiz and; presentations by each department about what Magnet meant to them (not using PowerPoint), among others.
As well, the nursing executive was charged with implementing other programs as discussed below, in response to the gap analysis in order to demonstrate compliance with the sources of evidence required.
Overall, the program was enthusiastically embraced by staff. Initially, however, there were some concerns from senior staff about the costs and reasons for pursuing Magnet given the hospital's already strong reputation for delivering excellence in patient care outcomes. But when it was explained that the major problem with high achieving organisations was sustaining such a reputation, these staff were able to better appreciate the need to continue to find models of excellence that took the organisation to even higher planes than previously attained.
Importantly, the Magnet Recognition Program(R) comprises four 'model components':
* Transformational Leadership;
* Structural Empowerment;
* Exemplary Professional Practice;
* New Knowledge, Innovations and Improvements.
Each component must be articulated through a wide range of sources of empirical evidence which describe and demonstrate the extent to which the organisation meets the criteria within each component, as discussed below.
Transformational Leadership
This component is strongly centred on the Director of Nursing and requires demonstration that he/she is a 'knowledgeable, transformational leader who develops a strong vision and well-articulated philosophy, professional practice model and strategic and quality plans in leading nursing services' (Magnet application manual 2008 p. 24).
The hospital leadership, in collaboration with the Director of Nursing, have launched a raft of programs and initiatives to prepare the organisation for designation including:
* Implementation of a 'shared governance' model to facilitate staff engagement with the strategic plan that comprises four 'clinical councils' with responsibility for the following key performance areas: Quality and safety; education, training and development; policy and procedure; and research and practice development. Each council reports to and is overseen by the nursing executive council;
* Implementation of evidence-based practice underpinned by our professional practice model and a practice development and research framework whereby all units now participate in a wide range of projects designed to improve patient care quality and safety and health service delivery;
Implementation of the 'best practice rostering system' which mandates all nurses to rotate through all three shifts in an equitable and fair manner. This has resulted in a happier staff, more just distribution of workload and more satisfied patients.
Structural Empowerment
This component is centred on the nursing staff (at all levels) and requires evidence that 'nurses throughout the organisation are involved in self-governance and decision-making structures and processes that establish standards of practice and address issues of concern [and that] nurse leaders throughout the organisation serve on committees and task forces that address excellence in patient care and safe, efficient, and effective operation of the organisation' (Magnet application manual 2008 p. 26)
Nurses at all levels are supported and encouraged to further their professional development through a range of programs and initiatives including:
* The competency-based new graduate and accelerated progression pathways which recognise that everyone has a unique set of skills and expertise and that education programs must take this into account;
* Succession planning framework that enables nurses to act up into more challenging positions when the incumbents are on leave or when they exit the organisation;
* High levels of involvement in policy and other key decision-making forums where nursing will be affected and patient care is at stake;
* The clinical nurse specialist framework which recognised and rewards experienced nurse clinicians with higher status and financial compensation in return for more complex and sophisticated role definition.
Exemplary Professional Practice
This Magnet model component is undoubtedly the most important of all four in respect of the hospital's reputation for high standards of care. It requires we prove evidence that nurses 'create patient care delivery systems that delineate the nurses' authority and accountability for clinical decision-making and outcomes [and] collegial working relationships within and among disciplines are valued by the organisation and its employees' (Magnet application manual 2008 2 p. 28) At SVPH these are manifest in the following:
* A well defined and promulgated professional practice model that articulates clearly the ways in which nurses and other health professionals plan, deliver and evaluate their care;
* Web-enabled deLacy IT system for clinical care monitoring, documentation and communication is used by all nurses to facilitate effective care planning, delivery and evaluation;
* A staff injury management program accredited with the International Disability Management and Standards Council that achieved the highest score in Australia in 2009;
* A well embedded risk management framework that defines and identifies key risks, outlines processes and ranks risks as well as a reporting tool (Riskman(R)) that enables the effective communication and resolution of problems in a timely fashion.
New Knowledge, Innovations and Improvements
This component underpins the organisation's quest to constantly seek fresh approaches to patient care and enhance service delivery. It also requires that 'Magnet organisations conscientiously integrate evidence-based practice and research into clinical practice and operational processes [and that] knowledge gained through research is disseminated to the community of nurses' (Magnet application manual 2008 p. 32). It is manifest in the following programs and initiatives, as follows:
* In 2008 a hospital-wide Warfarin medication safety project that significantly improved patient care in this high-risk area;
* In 2009 another hospital-wide project (VTE prevention) that significantly improved clinician compliance with VTE risk assessment, prophylaxis and awareness amongst nurses and doctors;
* In 2010 a randomised controlled trial investigating the effects of pre-warming shoulder arthroscopy patients on patient temperature and comfort is well under way;
* Since 2008 a raft of practice developments projects have been implemented ranging from vascular risk management to better managing para-stomal hernias;
* In 2008 the appointment of the inaugural chair in nursing (applied research) at SVPH and in 2009 the appointment of the inaugural clinical research fellow and launch of the SV&MHS ACU Nursing Research Institute.
Results of our Programs and Initiatives
Transformational leadership
SVPH is proud to be able to demonstrate tangible and very pleasing results from
* Best Practice Australia survey demonstrates that in 2009 SVPH is in a 'culture of success' with 75% of staff saying 'SVPH is truly a great place to work';
* The SVPH practice environment scale demonstrates that on all sub-scales and the composite scale nurses rate the hospital as 'magnet-like';
* Press-Ganey VMO satisfaction score at 92% in 2009 - an increase from 86% in 2007. In the top 8% of the all database external benchmark.
Structural Empowerment
* Increased access to scholarships by staff;
* Successful negotiation of the 2009 SVPH enterprise bargaining agreement;
* Improved New graduate retention rates;
* Decreased agency nurse use;
* 0% vacancy rate and 6.3% turnover rate.
Exemplary Professional Practice
* Press-Ganey patient satisfaction remains at 96% and in top 4% of peer group of hospitals of 151-300 beds;
* ACHS periodic review November 2009 achieved 8 excellent achievements (EA) and 1 outstanding achievement (OA) and awarded outstanding improvement by ACHS on risk assessment with >90% of patients risk assessed;
* 80% compliance with OH&S injury management profile in July 2009;
* Nurse sensitive indicators well under the ACHS benchmarks.
New Knowledge, Innovations and Improvements
In the Warfarin Medication Safety Project (2008-2009) a number of excellent patient outcomes was achieved as follows:
* Compliance with warfarin loading protocol increased by 12% (42% to 54%);
* Patient education prior to discharge increased by 54% (31% to 85%);
* INRs > 5 decreased by 2.6% (3.7% to 1.1%);
* Abnormal bleeds fell by 1.2% (1.2% to 0%).(see Duff et al 2010a for more)
In the VTE prevention project (2009-2010) an equally impressive range of patient outcomes was established, as follows:
* The proportion of patients receiving appropriate VTE prophylaxis increased by 19% from 49% to 68% (p=0.02).
* Surgical patient prophylaxis increased by 21% from 61% to 83% (p=0.02)
* Medical patient prophylaxis increased by 26% from 19% to 45% (p=0.05).
* The proportion of patients with a documented VTE risk assessment increased from 0% to 35% (p<0.001) (see Duff et al 2010b for more).
Conclusion
Embarking on the journey to Magnet has been an enlivening experience for everyone as it has galvanised staff at all levels of the organisation to present their achievements and reflect on the difference they make to patient outcomes. The Magnet Recognition Program(R) is an exemplary vehicle for articulating and sharing the enormous contribution that nurses make to the lives of the sick and needy in our communities. As a voluntary program it enables the work of nurses to be both recognised and rewarded as they take great pride in showcasing their achievements in the documentation and to the appraisers. Of course, once the journey to first designation has been successfully completed this is merely the beginning; re-designation is only four years away and all that has been demonstrated must be demonstrated again in order to maintain the credential. This is why it is such a compelling strategy for sustaining excellence in nursing care and patient outcomes.
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