The following manuscript is the winning Visionary Leader 2009 entry submitted to Nursing Management in recognition of Deborah Kumar, MSN, RN, NEA-BC, Director, Medical Division, The Reading Hospital and Medical Center, West Reading, Pa. Deborah was formally recognized for her achievements during the opening ceremony of Congress 2009, September 9, in Chicago, Ill. There, she received the award, sponsored this year by B.E. Smith.


Article Content

In 3 years, this nominee's visionary leadership has helped drive the transformation of the medical- surgical work environment in a 750-bed, level II trauma center. Employing creative strategies to engage leaders and direct caregivers, this nurse administrator has helped lead an organizational initiative to improve patient flow and implemented divisional initiatives to develop leadership, strengthen shared governance, and foster staff accountability for outcomes.

Figure. No caption a... - Click to enlarge in new windowFigure. No caption available.
Figure. No caption a... - Click to enlarge in new windowFigure. No caption available.


In 2006, this nominee assumed the position of medical division director in an organization that was undergoing rapid growth and expansion to accommodate changing healthcare needs within the community. A small, local hospital's relocation from outside the city limits resulted in increased volume and patient demographic shift for this organization. Volume of inpatient admissions and ED visits were further increased by expanding specialized services and partnerships being forged by the organization to provide a broader scope of care. The organization was undergoing unprecedented growth, both on the main campus and throughout the community. In 2007, the increase in ED volume peaked at over 100,000 annual visits, making the department one of the busiest in the state. Hospital administrators were struggling with patient flow issues that lengthened emergency wait times, slowed admission and discharge processes, and fueled patient dissatisfaction and staff frustration.


During this time, the nominee was challenged within the division with low staff satisfaction, lateral violence, ineffective shared governance, low level of autonomy, and lack of accountability for patient outcomes. Managers were disconnected from their staff and bogged down in meetings that took them away from their units. Turnover impacted all levels of nursing, including management. Direct care nurses felt powerless over their practice and work environment. The nominee identified the need to transform the medical-surgical work environment and restore a sense of value and staff empowerment.


Deep dive exploration

Employing a strategy presented by leadership development consultants contracted by the hospital, this director began "deep diving" into workplace issues with staff. The deep dive exploration process (Ideo, 2007), designed to engage participants in generating innovative new ideas, was modified to involve staff in envisioning the optimal workplace and what was needed to achieve it. Dive sessions included all nursing skills sets, as well as support staff from other departments. Involving diverse members of the healthcare team in process improvement is a fundamental concept in the national Transforming Care at the Bedside (TCAB) initiative (Robert Wood Johnson Foundation, 2004) and is identified by the Institute for Healthcare Improvement (IHI) as critical to effective workplace transformation (Lee, 2005 and Brown & Martin, 2005). The dives brought to light obstacles and barriers that staff was encountering in their current work environment and, at the same time, fostered staff creativity in envisioning the "perfect" patient experience. The process energized and inspired direct caregivers and led to the proposal of hundreds of ideas to be explored. These were categorized and prioritized. Categories included admission and discharge processes; customer service for patients, families, and colleagues; staffing and support; communication processes; equipment; patient education; patient flow; patient safety; support services; and even food services. Some were identified to be within the locus of control within the division; others were clearly ideas to improve organizational processes that were impacting care at the bedside. Results were shared with all staff members and also with hospital administration.


Hospital administrators recognized that dive session ideas were aligned with organizational needs to improve patient flow processes and workflow efficiency. The nominee was sent to an IHI conference with administrative colleagues from the ED to explore best practices for managing growing organizational capacity and then was asked to serve on the organizational patient flow steering committee. She has subsequently led multiple interdisciplinary teams to implement process improvements, many of which originated from the medical division's deep dive sessions.


The deep dive was the first step to transform the medical-surgical environment. From the ideas generated in the sessions, the nominee developed a plan for divisional leadership development, strengthening of shared governance, and fostering greater unit accountability for outcomes. At the same time, she continued advocating for the organizational process changes that were needed to support the transformation in the division.


Divisional improvement outcomes

Unit visioning

Units developed vision statements that captured the shared values and goals that staff identified in the dive sessions. This was a new process for both managers and caregivers. The nominee served as a coach and a mentor for the visioning process. The vision helped to guide staff and managers in addressing the underlying issue of horizontal violence that was pervasive in many of the units. Staff participated in developing working agreements and commitments that stated their shared values and expectations of each other. Visions were patient-focused, which served as a unifying factor among caregivers. One unit within the division surveyed staff members regarding horizontal violence and then repeated the survey within 18 months of developing the unit's vision and working agreement. The frequency of every horizontally violent behavior included in the survey decreased, with five of 14 behaviors being reduced from occasionally to never, and the remaining nine decreasing from occasionally to almost never.


Leadership development

Recognizing that transformational leaders were necessary to transform professional practice and the work environment, the nominee implemented a leadership development action plan for divisional managers and educators that focused on visioning, goal orientation, data-driven decision-making, nurse-physician collaboration, retention, time management, performance management, and staff engagement. Activities included readings, group discussion, and action planning. An example of these development activities is "Ask Me 3," an exercise that engaged leaders in a dialogue with physician colleagues about effective communication, support for physicians, and improved patient care.


Another example is "Job Sculpting," a process in which managers worked with staff to identify both career and life interests and to develop plans to incorporate interests into an individual's current job. This process helped to redirect staff to shared governance councils and unit activities that better aligned with their interests and passions. A final example is that of time reprioritization. The nominee coached managers to track their daily activities, reexamine commitments that took them away from the unit setting, and to reallocate time to managing the unit. As a result, time spent by managers to coach and mentor staff increased from 25% to 60%, time off the unit decreased from 25% to 10%, time for other administrative activities decreased from 20% to 10%, and clinical time on unit decreased from 35% to 20%.


The work of this nominee to transform managers into leaders is evident in one new nurse manager's comments, "I spent a year trying to manage my staff and not being able to meet our outcome benchmarks; now I am learning to be a leader and my staff is more engaged and our outcomes have significantly improved!!" Pressure ulcer incidence in this unit has been reduced from 33% to 0% over two-quarters; certification has increased from 0% to 32%; turnover has decreased from 26% to 3%; and patient satisfaction has increased from less than the 10th percentile to greater than the 50th percentile in 6 months.


Shared governance

Unit shared governance structures and processes were redesigned and council work was refocused on unit vision, goals, and outcomes. Staff membership was realigned with staff interests, thus improving engagement. Divisional council structure was realigned organizationally, resulting in the creation of a medical division coordinating council, which provides support for stronger decision making at the unit level and a forum for sharing ideas and best practices. Efforts to support staff involvement in shared governance are ongoing with a greater focus on tying work to outcomes.


Dive session ideas that are being explored and implemented by unit councils include:


* personalized customer service and welcoming approach from first contact


* improved nurse-patient relationships


* patient-focused care initiatives


* improved communication with patient and family using info cards and white boards


* centralization of unit supplies


* patient quiet/rest times


* improvement of patient education processes


* improved pain control


* staffing and scheduling: using national benchmarks for nursing hours per patient day to create full-time equivalent budgets and monitor staffing resources


* shift facilitators without patient assignment.



Organizational innovations and improvements from deep dive ideas

Demand capacity project

All nursing skills sets from diverse medical-surgical units were involved in a "demand capacity" project that examined how beds were utilized and the movement of patients to and from beds. The diversity of the group strengthened the data that were collected. The project was the starting point for patient flow improvement.


Discharge process improvements

To improve patient flow, an organizational goal was set to discharge patients before 13:00. A discharge team was formed to examine and improve discharge processes, which included medical-surgical staff nurses who participated in the deep dive sessions and demand capacity project. In the dive sessions, staff identified that the discharge process was cumbersome and disorganized. Some of the deep dive ideas offered by staff to improve discharge that have been implemented include:


* Discharge lounge: a centralized area, staffed by an LPN and unlicensed assistant, which offers a pleasant area for patients to wait for their family or ambulance transport. Discharge lounge staff helps to facilitate transport to home or other facility, ensure comfort and meals are available while waiting, and also reinforce discharge instructions. All inpatient units have experienced a 10% to 20% increase in the number of patients discharged before 13:00 since the inception of the discharge lounge.


* Discharge nurse: a model that has been successfully implemented in units with a large number of daily patient turnovers.


* Clear and explicit discharge instructions: a newly implemented process for automated discharge instructions that has significantly improved the discharge instruction process and has reduced amount of discharge paperwork.


* Physician medication reconciliation at discharge


* Ambulance service: long waits for ambulance transport prompted staff to request an organization-owned and operated ambulance service; although this wasn't economically feasible, the organization was able to contract to provide preferred ambulance service with an ambulance and wheelchair van parked on campus and readily available to patients.



Admission process improvements

Slow admission processes and long waits in the ED further compounded the organization's patient flow issues. Medical-surgical staff recognized the need for prompt admission of patients, especially from the ED; however, they struggled with balancing the time needed to process a single admission with care of existing patients. The nominee led a multidisciplinary admissions team that included medical-surgical and ED nurses, which created an:


* Express Admissions Center: Staff strongly felt that an admissions nurse or admissions center that specialized in expediting the patient's admission process would greatly improve patient flow and the patient experience. The creation of an Express Admissions Center (EAC) is a direct result of staff feedback in the deep dive sessions. The nominee led the design of the unit, which was based on dive session feedback and The Advisory Board Company's "Express Admission Portal" model (2006). Recommendations from the Institute on Healthcare Improvement's White Paper: Optimizing Patient Flow (2003) and the Clinical Excellence Commission on improving access to acute care (2005) were also incorporated into EAC structure and processes. The Center now processes approximately 925 to 1,020 admissions monthly. This includes completion of the comprehensive admission assessment and expediting of admission diagnostic testing. Ongoing process improvement has involved close collaboration of both inpatient and emergency nursing staff.



Bed management improvements


* Bed management system: organizational investment in a bed management system addressed deep dive ideas to minimize and better coordinate movement of patients.


* Expanded hours for transport services: an increase in 24-hour testing prompted staff requests for transport assistance on night shift.


Equipment and design improvements to support workflow efficiency


* Unit workspace design: feedback regarding the need for computers and supplies to be more readily available prompted the inclusion of nurses in planning new and renovated unit design. Involved staff is very satisfied with the new workspaces that they helped to create, which include computers and supply stations in every room.


* Shift to private rooms: staff identified semiprivate rooms and frequent relocation of patients related to semiprivate room issues as a major patient and staff dissatisfier; this has resulted in an organizational initiative to shift to all private rooms by 2010.


* Improved lift devices: a minimal lift environment team was also formed and a full assessment of needs related to lifting devices was conducted in high-risk areas.


Patient safety improvements


* Physician order entry: staff identified that a single, electronic process for physician orders is a best practice for patient safety; this has helped to drive the transition for all physicians to use the available technology.


* Improved patient ID badges: badges were changed to a product that has better accuracy for barcode scanning, thus improving patient ID procedure compliance.


Collaboration and communication


* Multidisciplinary rounds: staff identified the need for improved communication among members of the healthcare team. This has resulted in multidisciplinary rounding that involves the entire team in planning care and discharge.


Organizational use of deep dive exploration

The success of the deep dive process in the medical division has prompted its use as a model for engaging staff in transforming the work environment throughout the organization. Dives have also been used to improve processes within the ED and in several other inpatient nursing divisions.



Many of the transformational initiatives outlined in this nomination are nationally recommended best practices that could have served as an external stimulus for transforming the medical-surgical care setting in this organization. This nurse leader had the vision to drive transformation from the point of care using the deep dive strategy. The 200 staff members who participated in the dive sessions clearly identified the need for process changes at both the unit and organizational levels. The ideas they generated echo many of the TCAB initiatives.


Because the ideas were proposed and implemented by staff, there's a greater sense of accountability for the success of initiatives. The nominee's continued focus to "close the loop" with follow-up on unit projects, leadership development activities, and organizational advocacy for change has been instrumental to successfully transforming the work environment. Next steps include a "resurfacing" activity that will pull staff together to review improvements and outcomes. This will be followed by another deep dive to generate ideas for how to further improve the work environment and patient outcomes, a responsibility taken over by the unit councils with this nominee's guidance.


This nominee is a transformational leader who has been an agent for the much-needed change at every level of the organization. It is with greatest admiration that I nominate her for Nursing Management's Visionary Leader 2009 Award.




1. Lee B. Enhancing teamwork: targeting innovations to the team survey response. Institute for Healthcare Improvement; 2005.


2. Brown K, Martin SC. Leading transformational change: UPMC. Institute for Healthcare Improvement; 2005.


3. The story of transforming care at the bedside. Robert Wood Johnson Foundation; 2004.


4. Improving patient access to acute care services. Clinical Excellence Commission. http://www.cec.health.nsw.gov.files/patient-flow-safety/resources/toolkit.pdf.au.


5. Institute for Healthcare Improvement. White paper: optimizing patient flow: moving patients smoothly through acute care settings. http://www.ihi.org/IHI/Results/WhitePapers/OptimizingPatientFlowMovingPatientsSm.


6. Cracking the code to hospital wide patient flow. Institute for Healthcare Improvement Conference; June 5-6 2007; Boston, MA.


7. Streamlining admissions processes: express admission portal. The Advisory Board Company, Washington, DC; 2006.