Margarita M. Baggett joined UC San Diego (UCSD) Health System in July 2006. Her transformational leadership over the last 5 years has been a compelling force in establishing an environment of engagement and excellence across the continuum of UCSD Health System's services. Margarita is directly responsible for over 1,900 staff and functions related to Nursing, Pharmacy, Care Coordination, and Volunteer Services.
Margarita joined UCSD during a period of transition and challenge. The UCSD nursing division was experiencing increased nursing vacancies, increased use of contract labor, decreased staff engagement and morale, and a clinical practice environment facing increased scrutiny related to California's mandatory reporting of significant events. At the organizational level, UCSD was facing the need to grow patient volumes without adding any additional inpatient beds. At the time, the average length of stay (LOS) was rising and contributing to patient flow challenges, especially impacting admissions from the ED, Transfer Center, Postanesthesia Care Unit, and direct admissions from clinics. These influencers were creating conflicts among nursing units and affecting RN-MD relationships. Evidence of shared decision making and accountability for professional practice was lacking.
Margarita put the nursing division on a journey of transformation by empowering all levels of nurses to embrace the full scope of professional practice. Having an engaged workforce was essential to improving the nurse practice environment and clinical outcomes. From the beginning, Margarita was a champion of two concepts: building initiatives around clear structures, processes, and outcomes; and helping all levels of staff reach their hopes, dreams, and aspirations. These two concepts laid the foundation for building a culture of trust, an engaged workforce, and significant improvements in clinical outcomes.
Nurse vacancy rates and considerable use of contract labor were creating a vicious cycle, eroding career nurses' confidence in nursing leadership to address staff's concerns. Margarita demonstrated the importance of “framing” an issue, creating structures and processes to generate sustainable improvements. The first thing Margarita did was to change the vocabulary from a negative to one that's forward thinking and allows building upon current achievements. Nurse vacancy were reframed to nurse fill rates, and nurse turnover rates were reframed to nurse retention rates. This subtle but important concept transformed how nurse leaders, decision support, and staff nurses approached addressing the challenge of attracting talented nurses and retaining career staff.
Collaborating with finance, nursing directors, and nurse managers, Margarita developed and implemented monthly tracking of key indicators at the unit, division, and overall nursing level. Monthly, each unit manager receives a nursing dashboard that's formatted around UCSD's Pillars of Excellence: People, Quality, Service, and Finance. This information is shared at all levels. All units have communication boards that post these monthly reports. Through multiple forms of communication—email, communication boards, staff meetings, and town hall meetings—nurse leaders and staff are kept informed of the current progress on all indicators.
Another structure put into place was to have the nurse recruitment team partner with each nurse manager to tailor recruitment efforts to meet the unique characteristics of each nursing unit. The nurse recruitment team developed an on-boarding process to ensure new staff members were supported during the initial period of orientation. They proactively addressed concerns with new hires.
Outcomes from these initiatives are: nurse retention rates have improved from 88% to 98%; nurse fill rates have improved from 86% to 105%; contract labor dropped from $11 million to $4 million; career staff premium labor dropped from $1.6 million to $750,000; and in the most recent employee opinion satisfaction survey, new RNs scored 4.44 rating out of 5 on readiness to practice.
Having a stable workforce provided the genesis of engaging staff members through a shared governance structure. Margarita challenged the nursing leaders and staff to advance the practice of nursing through the development of unit-based practice councils (UBPCs) and nursing division level shared governance councils. Development of UBPCs and nursing shared governance councils provided a forum for staff-driven initiatives that increased nurses' autonomy over their nursing practice. Communication was layered so that there were both vertical and horizontal communications between UBPCs and shared governance councils.
The shared governance structure has matured to the level where most units have a UBPC, and there are eight nursing division shared governance councils. Due to the engagement and energy brought forth by the shared governance structures, nurse leaders and staff sit not only on nursing councils but also on organization-wide councils. Nursing staff and leaders contribute to filling 330 memberships across 29 Medical Staff Executive Committees and Organizational Task Forces. Through Margarita's participatory leadership style, she has positioned nursing to advocate for patients and improve the work environment, thus changing the image of nursing at UCSD.
One of Margarita's passions is skin care. From the very moment she joined the UCSD team, she set forth the goal of zero hospital-acquired pressure injuries. Very soon after Margarita joined UCSD, the California mandatory reporting requirements went into effect. At the time, we didn't have an organized approach to skin care. Working through the shared governance structures, Margarita listened to staff nurses and managers. During this appreciative inquiry time, Margarita directly observed how patients were being treated, the nursing practice, and barriers to nurses effectively advocating for their patients.
Cultivating innovation at the unit level and sharing best practices led to a nursing division standardization of skin care carts and digital cameras with printers for each unit, standardized woundcare documentation, a formalized process for consulting with in-house wound care nurses, and implementation of “Wound Wednesday.” Wound Wednesday is a partnership between staff nurses and nurse managers to ensure the integrity of the nursing skin assessments. Every patient within the inpatient setting has his or her skin checked by the unit's nurse manager and the nurse taking care of the patient. Through this process, we've changed the culture to one of proactive management of patients' risk for pressure injuries. Although we haven't reached our goal of zero pressure injuries, we've dropped from 15% of inpatients having a pressure injury to our most recent data being 1%.
Another strategy Margarita used was to have nurse managers keep their staff engaged with preventing pressure injuries by posting the number of days their unit has gone without pressure injuries. To maintain and continue to work toward our goal of zero pressure injuries, Margarita instituted a comprehensive daily skin report that's shared with the entire nursing leadership team. For any patient with a stage II or greater pressure injury, the nurse manager from the sending unit will contact the nurse manager of the receiving unit to discuss the patient's condition and all interventions implemented. This has improved relationships across units and created a shared responsibility among all nurses. Margarita's passion for skin care continues to challenge the nursing staff to seek additional improvements. One unit has achieved a stellar outcome of over 980 days without a pressure injury.
Patient flow is an important component of a health system's operations. In 2006 through early 2007, UCSD's LOS was on the rise and had reached a high of 6.4. Margarita's vision was to have Care Coordination, the department responsible for utilization management and discharge planning, to report through the department of nursing. Margarita was successful in advocating for these changes; Care Coordination responsibility was transferred to one of the nursing directors and given approval to implement a new model of care coordination that was unit-based.
To ensure her vision of Care Coordination, Margarita adopted a medical-surgical unit to actively participate in one of the changes—multidisciplinary rounds. Margarita participated at least two times a week on this medical-surgical unit's multidisciplinary rounds. She was there to observe, coach, and mentor the nurse manager, nursing staff, case managers, and social workers. Through this process, effective multidisciplinary rounds were developed and shared throughout the nursing division.
Another strategy headed by Margarita was to establish a review committee comprised of representatives from Admissions, Compliance, Revenue Cycle, Finance, Care Coordination, Nursing, and physicians to review all patients with barriers to discharge, high dollar charges, and/or with a LOS greater than 20 days. Through this process, actions were identified to facilitate these complex discharges. As a result, UCSD has seen a drop in LOS from 6.4 to 5.5 and an increase in admissions from 21,000 to 24,000. This improvement in LOS has decreased the wait time of admitted ED patients from 209 minutes to 163 minutes over the course of 1 year.
Margarita had a vision to develop the professional role of the nurse. Examples include clinical ladder promotions, increasing certifications, encouraging professional organization involvement, and participation in UCSD-sponsored education opportunities. In alignment with Margarita's belief, we're here to assist staff members to reach their hopes, dreams, and aspirations. Below are the outcomes of this vision:
* Margarita set the vision that nurses can advance through the clinical ladder. With Margarita's endorsement of the clinical ladder process, authority was vested with the Professional Development Council to manage the process for promotion. Since implementation of this practice in 2009, clinical advancements have averaged 49 promotions per year.
* Margarita embraced the value of advanced practice nurses and facilitated the creation of a shared governance council to represent their interest. An outcome of this council developed a comprehensive resource list of field experts.
* Professional certifications have increased from 20% in 2008 to 31% in 2010.
* 30% of nurses report membership in professional organizations.
* UCSD-sponsored educational opportunities grew from 6,000 to 11,000 attendees.
* Each year since 2008, 40 staff nurses have taken advantage of participating in a Front Line Leadership Academy.
Most recently, in recognition of Margarita's significant contributions to the organization, she has a direct reporting relationship to the CEO and serves on executive decision-making committees.
Margarita's vision has positively influenced the nursing division at UCSD. Over the last 5 years, her dedication to promoting a professional nursing practice model has engaged the whole organization. It's quite common to hear senior leaders quoting Margarita and sharing her vision of establishing sustainable structures and processes to guide our organization into the future.