1. Collins, Amy M. Managing Editor


A program that helps nurses find their leadership potential.


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Karen Cox knew from a young age that she wanted to be a nurse leader. Describing herself as being "born old," Cox got her one-year LPN diploma right after high school and planned to work in a long-term care facility as a charge nurse. But within a month of her first job, she realized she wanted to be in a leadership role, which at the time meant being manager of a nursing unit.

Figure. Karen Cox, P... - Click to enlarge in new windowFigure. Karen Cox, PhD, RN, FACHE, FAAN. Photo courtesy of Karen Cox.

So Cox began to work toward her goal, and within five years she had completed an associate's degree and a bachelor of science in nursing and was promoted to nurse manager on her unit.


"I learned what to do from both good and bad examples," she said. "I knew one manager who scared people to death, and I wanted to be different. I figured out pretty early on that you had to be a nice human being, help people, have a good attitude, and take good care of patients."


She continued to work in various leadership roles, eventually getting her master's degree and, 12 years ago, her PhD. She became the vice president of nursing at Children's Mercy Hospital in Kansas City, Missouri, in 1995 at the age of 35, and in 2006 she became chief operating officer-her current position. But Cox didn't stop there. She wanted to extend her love of leadership to other nurses.


The CSI Academy

Over the course of 20 years, while Cox was getting her education and working as a nurse, she was also involved in nursing on both a regional and national level. She was selected as a Robert Wood Johnson Foundation (RWJF) Executive Nurse Fellow, which she says not only helped her learn about leadership, but also enabled her to make many connections. One of these was with fellow RWJF honoree Susan Lacey, who also worked at Children's Mercy Hospital.


"We talked about how we have such a pool of talent in direct care nurses at the bedside," Cox said, "3 million nurses. And we don't often give them the authority, education, or time to do the things they can do better than the rest of us-and that's improve quality."


Using a 2008-2010 RWJF Partners Investing in Nursing's Future grant, with matched funding from the nonprofit Health Care Foundation of Greater Kansas City, Cox and Lacey helped found the Nursing Workforce Innovation Center, whose central program was a 16-month staff nurse leadership program called the Clinical Scene Investigator (CSI) Academy.


"A few years earlier someone told me to watch the TV show CSI," said Cox. "Later, at a nursing day event, I remarked that since everyone thinks it's so cool now, thanks to CSI, to be a crime scene investigator, we are going to have the best and brightest science minds taking care of dead people. Wouldn't it be great if these student investigators felt that nursing could give them the same opportunity?"


The aim of the CSI program was to teach nurses to develop and conduct quality improvement (QI) projects that would not only improve patient outcomes, but also impact the fiscal health of the nurses' hospitals. The nurses who take part are encouraged to become leaders who guide their peers in creating unit-based changes that can easily be scaled hospital-wide.


The Program Basics

The pilot CSI program involved seven Kansas City hospitals. Leaders from each hospital recommended a group of two to four nurses from one department or unit to work on a QI project for 16 months. The nurses met once a month and attended sessions in which they learned QI skills, project management, social entrepreneurship, how to make changes in a low resource environment, how to talk to people in the "C-suite," how to influence others, and other leadership skills.


"I'll never forget the first day of the program," said Cox. "Half of these nurses wanted to know why they were chosen. 'Your leaders see something in you that you don't yet see,' we would tell them. It was fun to see the transformation over a year and a half, when some of these nurses strutted into the last session, all dressed up, saying, 'We just came from talking to our hospital board,' like it was no big deal."


Encouraging Results

The results of the project were "solid," according to Cox, with the aggregate fiscal impact on the seven hospitals reaching $2.6 million in annual savings. The project also improved the nurses' confidence and changed their patients' lives.


One CSI group worked with the local Veteran's Affairs (VA) hospital, where there was a high incidence of heel ulcers. The group named itself Heels Angels. The nurses held mandatory skin and wound care classes for staff, hung posters on heel pressure prevention, and added heel lift boots to their inventory. In the end, the nurses reported having reduced the incidence of heel ulcers by 51% and projected that they saved the VA $946,000. The nurses were recognized nationally by the VA for their work.


Despite these encouraging results, the RWJF grant soon came to an end, and Cox and her colleagues were left with the challenge of finding a way to grow the program on a national level.


Expanding the Program

Enter Caryl Goodyear-Bruch, a colleague of Cox and Lacey's, who also happened to be past president of the American Association of Critical-Care Nurses (AACN). Goodyear-Bruch told the organization about the CSI pilot program, and the AACN stepped in to make a $1.25-million investment in the program's expansion. The AACN CSI Academy has now been replicated in six U.S. cities (Indianapolis, Indiana; Raleigh, North Carolina; Austin, Texas; Boston; Philadelphia; and New York City). Hospitals in these cities are chosen through an application process, and those selected receive $10,000 to support running the program.


Hospital leadership works with the chosen groups of nurses to pinpoint the focus of their QI project. Some of the issues tackled include health care-acquired conditions, infection prevention, preventing delirium in ICU patients, and early mobility for patients on ventilators. Each group of nurses has an on-site coach to help with questions or problems that might arise. A chief nursing officer in each region is also appointed to help champion the program. "We encourage people to pick a thorny problem that they haven't had success in," Cox said, "to see if this approach would work."


At the end of each 16-month regional academy, there is an AACN CSI Innovation Conference, during which each team has a chance to present their QI project, how they implemented it, their fiscal findings, and the outcomes they achieved. As of this writing, five of the six cities have presented their findings and results have been just as encouraging as in the pilot program. In Boston, for example, seven hospitals improved patient outcomes with a combined fiscal impact of close to $8 million in anticipated annual savings to the facilities. Some of the Boston teams' achievements include decreased length of ICU stay (by nearly eight days) for ventilated patients; a 50% reduction in pressure ulcers in the ICU; and improved communication between units, with a 100% reduction in patient handoff incident reports.


In addition to improving patient outcomes, Cox says that the program also helps promote interdisciplinary care. "It's a team sport. One of the things I like about interdisciplinary care is you can ask, 'For this problem, this patient, this situation, who has the best skill set to lead?' Sometimes it's the nurse, sometimes it's the social worker, sometimes it's the physician. And everyone else follows. This program teaches nurses not only that they can lead, but that they can follow as well."


The AACN has committed to continuing its investment in the program, Cox says, because it confirms the vital role nursing can and should play in the transformation of health care.


"One of my favorite things about this program is seeing each and every one of these nurses give their final presentations with a sense of confidence. At first they didn't know what an IV catheter cost. And now they're presenting as if they've been doing hospital finance forever. To see them connecting the dots between fiscal impact and QI has been really inspiring," Cox said. "Imagine if even 10% of 3 million nurses had these skills at the direct point of care. They are the ones who know what needs to happen. They just need the skills and authority to do it."-Amy M. Collins, managing editor