The Problem: Faced with the challenges of a shrinking nursing workforce and budgetary constraints, hospitals must transform their organizational culture to be financially viable and continue to serve their patients and their communities.
The Proposal: Across the country, hospitals and health systems have been working to change the culture of their institutions to become supportive work environments that are conducive to nurse workforce retention, improved quality of patient care and financial stability. Transforming Hospital Culture supported 10 competitively selected hospitals to document—and share with other hospitals—their stories of improving organizational culture.
Grantee Perspective: “We become what we think about.” Those sage six words of Earl Nightingale, 1950s radio commentator and personal development pioneer, are etched in Karen Cox's consciousness. She recognizes that the dramatic changes that have transformed Children's Mercy Hospitals and Clinics in Kansas City, Mo., where she is executive vice president and co-chief operating officer, started with words that communicated a vision and were then translated into actions that yielded transformation.
Cox was in her early 30s and a nurse manager at Children's Mercy when Randall L. O'Donnell, Ph.D., its new president and CEO, made a simple and profound statement that would change the course of the institution: “We will be the best children's hospital in the world.”
“It seemed too big for us, for a little hospital in Kansas City,” remembers Cox of the declaration some 15 years ago that started the cultural evolution at Children's Mercy.
“Language is often the first thing you have to change. When you say it enough, it becomes true,” she says. “Then, you recognize who you are and what it is about your organization that is great. We didn't see the huge vision, but we did see that everyone worked at Children's Mercy because they wanted to support the kids of our community.”
Viewing its employees as its greatest asset—and the key to any change—Children's Mercy Hospitals and Clinics set out to create an environment that encouraged excellence. “You hold people accountable to be creative and be problem solvers—at the director and manager level, and at the staff and clinician level, at the point of care,” Cox says. “You get away from the notion of process for process sake, which means you don't have a quality improvement team that meets for two years to solve something that three or four smart people can figure out in one meeting.”
It helps, too, to have a rallying point. “We have a spirit of cooperation and concern about something bigger than one's self, one's work area—it is all about the kids,” says Cox. She points out that the legal name of the hospital is The Children's Mercy, “because the children own the hospital, they are the bosses. Whether it is a financial decision, a clinical decision or an operational decision, we are always asking how is this going to impact those kids.”
The staff stays connected to their “bosses” through the Family Advisory Board, which Cox calls “constructive advocates for the patients and families. They are the best free consultants that you could ever have because they are vested at a personal level in a way the rest of us cannot appreciate.”
She urges administrators to take the recommendations of advisory boards or employee focus groups seriously. “If you do not listen and follow up then it is better to not ask them for their opinions in the first place,” she says.
Children's Mercy's cultural transformation has been bolstered greatly by support from its board of directors and at the city, state and federal levels “to make sure we can take care of all kids regardless of their ability to pay. We have tremendous community support. People feel good about the hospital,” says Cox.
Part of having people feel good about Mercy is that the hospital lives up to its promises. “If you say on a billboard, ‘It has to be Children's Mercy,' and a pediatrician cannot get a child admitted to the hospital, then the message looses its meaning. You have to back up the words with commitment.”
Cox says that the RWJF Transforming Hospital Culture grant caused Children's Mercy to “step back and reflect. Now we are better able to describe our story, share it with students and new employees and mentor other leaders.”
“One day I looked up and looked at our hospital, and it had been transformed; but it really happened one day at a time, one patient at a time, one staff person at a time,” she adds.
Today transformation continues at Children's Mercy, as the hospital embarks upon a 15-year expansion project, which has a $43-million pledge from the Hall Family Foundation. “We are about to grow by another big leap,” Cox says. “It is good to remind ourselves how we got where we are and how we can get to the next level.”
RWJF Perspective: Transforming Hospital Culture is part of a three-prong RWJF effort “to improve the work environment for nurses and increase their satisfaction—and ultimately increase the satisfaction of all staff,” says Catherine Malone, M.B.A., RWJF program associate for the Human Capital Team.
“Looking at change processes was the first prong of the approach—to make things more efficient,” Malone says, referring to the Transforming Care at the Bedside national program, which seeks to create, test and spread prototype hospital nursing unit-level strategies to improve the work environment and quality of care
“The second prong was examining the physical design and changing the overall design and layout of nursing units and hospitals,” she says of Designing the 21st Century Hospital Initiative. “And the third prong is the organizational culture—having a supportive environment with good communications so nurses want to stay working in a hospital.”
In selecting the 10 grantees for the Transforming Hospital Culture program, RWJF sought “hospitals that were geographically diverse and represented different types of institutions so that any given individual hospital could say ‘I can relate to this one.' Among the grantees are an academic center, health systems, a cancer center, a small rural hospital—and a good collection of diverse perspectives,” says Malone.
Children's Mercy, like all of the 66 hospitals that submitted brief proposals for Transforming Hospital Culture, met the requirements of having achieved at least one of the following: Magnet designation, a Pebble or Planetree organization, or Baldrige Quality award winner. “Children's Mercy had a multi-tiered, ongoing quality improvement effort,” Malone says. “It is important to remember that transformation does not stop but is a continuous journey full of quality improvement and other types of initiatives.”