One of the nurse executive's most significant challenges is to create a culture of safety in a complex, patient-care organization while balancing that culture with efforts to contain the skyrocketing costs of healthcare. The utilization of the Magnet® Model, developed by the American Nurses Credentialing Center in 2007, is one approach to provide a framework for creating system alignment and better positioning organizations for success.1 The expectation of managing costs and quality outcomes, coupled with increasing pressure to create a culture of safety, the federal pay-for-performance reimbursement system, and the regulatory requirements of accreditation agencies, often makes these challenges seem insurmountable.
Breaking down barriers
In order to clearly understand how to create and ultimately lead a culture of safety, first examine the role of the nurse executive in patient safety. In 2011, the American Organization of Nurse Executives (AONE) published its Nurse Executive Competencies Assessment tool.2 A key competency identified by the AONE is that the nurse executive has a “knowledge of, and dedication to, patient safety.” Interestingly, although patient safety is among the group of core competencies according to the AONE, one study showed that neither the experienced nor the novice nurse executive ranked this competency in the top five most important skills of the nurse executive.3
In addition to his or her role in setting the strategic direction for safety, the nurse executive must also be actively involved in the removal of barriers to safe, cost-effective practice. One study identified five major typical attributes on nursing units in acute care hospitals that contribute to problems with patient safety: unclear unit values, the fear of punishment for errors, the lack of systematic analysis of mistakes, the complexity of teamwork, and inadequate teamwork.4 In order to effectively reach appropriate decisions balancing safety, quality, and cost, the nurse executive must consider these barriers and their removal as possible solutions.
When facilitating the breakdown of barriers, the nurse executive may discover other potential solutions to improve the culture of safety that may not necessarily add costs or resources. For example, if unclear unit values are a barrier, the nurse executive may facilitate a planning session with staff from various levels on the unit to develop and refine a values statement for the team. Using his or her influence, the nurse executive can guide the team to consider a culture of safety as a key value for the unit. With staff fully engaged and supporting the values, many units can experience a reduction in costs and improvements in quality with little to no change in resource levels.
One other key consideration is the complexity of the nurses' work. The highly variable workload on most patient-care units can contribute to errors and force the nurse to frequently make choices between meeting the goals of the organization and the goals of the patient. These decisions are all made in the context of the nurse's own perceptions of goals and priorities, factors that make it difficult for the nurse to develop a standard routine to get the work done.5 In addition, nurses are faced with constant changes in technology, equipment, supplies, treatments, and medications, adding to an already challenging workload. The nurse executive can intervene in these areas by fostering an environment of inclusion in decision making, particularly around technology equipment and supplies. The nurse executive can also communicate openly with staff and leaders about workload and productivity management, as well as remain open to feedback from staff on how improvements to these key areas can be made in support of a culture of safety.
Payment model changes
The Affordable Care Act of 2010 represents a major shift in the focus of the nurse executive because the new payment model places a significant emphasis on value-based purchasing, the expansion of quality reporting, and incentive programs to enhance quality. The marrying of financial payments and penalties to quality and outcomes represents the largest change in Medicare payments since the implementation of diagnosis-related groups in 1984. According to one researcher, the key components of the new payment models are all areas in which the nurse executive has expertise, including care across the continuum, the promotion of patient-centered care models, analysis of patient quality and satisfaction data, and expanded reporting of quality and cost measures.6
These requirements force the nurse executive to constantly balance the need for cost containment with the need to produce quality outcomes. Failure to do both in tandem may result in significant financial penalties for organizations. On the other hand, the nurse executive who can successfully lead interdisciplinary groups that produce better-than-expected outcomes will see financial benefits for his or her organization.
The new patient-care paradigm
Patient safety is seemingly a priority for every regulatory and accreditation agency working with healthcare facilities. Organizations, such as The Joint Commission, the Magnet Recognition Program®, and the Institute for Healthcare Improvement, provide frameworks in which organizations are expected to develop programs to keep patients in their care safe and free from harm. In addition to national organizations, state legislatures are becoming increasingly involved in the regulation of healthcare, particularly in the area of hospital staffing. This presents a unique challenge for the nurse executive because human resources represent one of the largest expenses in an organization.
One study examined the cost-effectiveness of various nurse staffing ratios, concluding that an 8:1 patient-to-nurse ratio was the least expensive ratio, but was associated with the highest mortality.7 As the ratio was lowered in various increments to 4:1, the cost increased as mortality decreased. Although this isn't surprising to an experienced nurse executive, the conclusion of the researchers has been widely cited as nurse executives work to improve patient outcomes and nurse staffing ratios. The various attempts by both regulatory agencies and legislatures to improve quality through regulation present an even larger challenge for the nurse executive in creating the right balance of cost containment with high-quality outcomes and the creation of a safe environment for care.
Creating alignment around the key issues of patient safety, work culture, and cost containment, the Magnet Model provides a framework to promote “systemness” among departments, organizations, and multiple hospital systems. Simply stated, the Model focuses on three key infrastructure components: structure, process, and outcomes. The elements of the Model allow the nurse leader to use broad categories to develop a common language, a shared platform, and a consistent methodology for measuring outcomes to drive the alignment necessary for sustained change and improvement.
The Magnet Model is centered on the production of empirical outcomes and encompassed by global issues in nursing and healthcare. Taking patient safety as an example, regardless of the issue, each of the Magnet components can be utilized as a way to create a case for change, develop a plan for action, engage staff and leaders in problem solving, implement a new process, and develop a method for measuring outcomes. Regardless of whether your organization is actively pursuing Magnet recognition, the Magnet Model is a solid basis for creating the necessary consistency required for true process change and sustainability.
A key responsibility of the nurse executive is to ensure that the highest ethical standards are maintained and discussed in the decision-making process. This is no different when balancing the need to lower costs and maintain or improve patient safety. One study identified six key principles of ethical behaviors in the nurse executive's role: respect for person, beneficence, nonmaleficence, justice, veracity, and fidelity.8,9 Each of these key principles is a consideration for the nurse executive in balancing the needs of patient safety and cost containment.
Respect for the person might include involving direct care nurses in the decision-making process of how safety programs will be implemented while meeting budget targets. Beneficence may include creating a practice setting in which nurses can provide safe, high-quality care. Nonmaleficence as an ethical consideration requires the nurse executive to ensure that processes are in place to prevent errors, as well as provide the appropriate staffing and skill mix in patient-care areas. When evaluating new programs or possible solutions, justice should also be considered. One researcher identified the use of mandatory overtime for specific nurses and not all nurses as an example of how distributive justice can be misused.8 Veracity and fidelity obligate the nurse executive to tell the truth and remain faithful to commitments. Both are integral parts of the discernment process to maintain the credibility of the nurse executive within the context of difficult decision making, as well as within the organizational structure as a whole.
Positioned for the future
The one permanence in the role of the nurse executive is change. As our new national healthcare delivery system continues to emerge in various stages, the nurse executive will be called on time and time again to lead organizations through difficult decisions. The movement to pay for performance based on quality outcomes is becoming increasingly hardwired in both private and governmental payor plans. As the reimbursement for services continues to decline or remain at historically low rates, the nurse executive will constantly face the challenge and tension inherent in creating a culture that produces highly reliable, consistent, and at or above target quality outcomes within a framework that's both safe and cost-effective. The consideration of ethics, removing barriers, and balancing quality and cost will be essential for the success of the nurse executive and his or her organization over time.
Nursing, and in particular the nurse executive, is well positioned to lead the healthcare reform effort. In fact, there may be no other role in the organization that's better able to understand the nuances and complexities involved in these critical decisions that balance quality and cost. Employing the strategies discussed in this analysis will allow the nurse executive to make decisions that are based on data and current evidence within the guidelines of regulatory and accrediting agencies while considering the overall impact on the organization's financials.
1. American Nurses Credentialing Center. Application Manual, Magnet Recognition Program
. Silver Spring, MD: American Nurses Association; 2007.
3. MacMillan-Finlayson S. Executive development: competency development for nurse executives: meeting the challenge. J Nurs Adm
4. Kalisch BJ, Aebersold M. Overcoming barriers to patient safety. Nurs Econ
. 2006;24(3):143–148, 155, 123; quiz 149.
5. Institute of Medicine. Keeping Patients Safe: Transforming the Work Environment of Nurses
. Washington, DC: National Academies Press; 2004.
6. Cady RF. Accountable care organizations: what the nurse executive needs to know. JONAS Healthc Law Ethics Regul
7. Rothberg MB, Abraham I, Lindenauer PK, Rose DN. Improving nurse-to-patient staffing ratios as a cost-effective safety intervention. Med Care
8. Bosek MS. Mandatory overtime: professional duty, harms, and justice. JONAS Healthc Law Ethics Regul
9. Beauchamp TL, Childress JF. Principles of Biomedical Ethics
. 6th. ed. New York, NY: Oxford University Press; 2008.