How nursing leaders are changing the C-suite: A Q&A with Advisory Board’s new CNO

The Daily Briefing's Thomas Seay sat down with Carol Boston-Fleischhauer, Advisory Board's first-ever chief nursing officer, for an exclusive Q&A about her new role and the key strategic challenges that nurse executives face.

Among the topics: What are the biggest challenges facing nurse leaders today? Are nurses ready for accountable care? Should executive teams be concerned about increased nurse turnover?

Q: Let's start with a big-picture question. You've been in health care for more than 35 years now. How have you seen the role of nurse leaders evolve in that time?

Boston-Fleischhauer: When I first graduated from college, nurse executives were called 'nursing directors' and were typically focused on ensuring that inpatient nursing care was compassionate, safe, and effective—period. Quite frankly, they were viewed as providing operations support critical to the organization's mission and vision by keeping the care trains running 24/7, 365 days a year.

Fast forward to today. As acute care hospitals have merged with systems, become part of clinically integrated networks, or created affiliations with post-acute providers to support cross-continuum care, the scope of the nursing enterprise has greatly expanded, as has its impact. Notably, organizations recognize that nursing is core to the strategic achievement of outcomes, including clinical, financial, growth/market share, and the like. Remember, nursing is the largest, most trusted workforce in all of health care and a critical asset to leverage.

Thus, the chief nurse executive of today's health care organizations and systems are part of the C-suite, working directly with the chiefs of medicine, finance, strategy, IT, and quality, among others, to drive achievement of strategic as well as operational goals.

So I am thrilled to assume the role of chief nursing officer within Advisory Board. It comes at a time when groups such as the National Academy of Medicine (formerly called the Institute of Medicine) have called for nursing to be at the table in leading health care change, and it represents Advisory Board's solid commitment to recognizing the value, contribution, and impact that nursing brings to care system transformation.

Q: What do you see as top of mind priorities for CNOs across the country?

Boston-Fleischhauer: Well, given the incredible diversity in organizational size, structures, affiliations, and so on, the challenges that face a CNO in a free-standing community hospital will understandably vary somewhat from those of a CNO leading the nursing enterprise in a 40-hospital system.

That said, it is critical right now that every CNO have in place a solid strategic plan to ensure that precious nursing resources are directly aligned with the organization's larger strategic objectives. For example, if my system is challenged by avoidable readmissions, I am accountable for assessing and addressing every nursing-sensitive component of the discharge/readmission process to ensure that my system will improve. Likewise, if my system is part of the Comprehensive Care for Joint Replacement Model, I as a CNO am accountable for eliminating care variation throughout the bundle's entirety, to ensure that my system succeeds. In fact, given that CMS has clearly indicated that there are more bundles to come, my strategic plan for nursing must confront unwarranted care variation throughout the broader nursing enterprise. Organizations and systems preparing for risk must count on a highly reliable nursing enterprise here.

At the same time, given the aggressive reimbursement cuts that all organizations are experiencing and the increased pressure to tightly manage total cost of care, the CNO must be vigilant in designing and sustaining care models that use nursing resources as efficiently as possible. That includes ensuring that all nursing professionals are working at the top of their license in all settings and eliminating non-value-added work. It's no longer just an option to pursue the type of transformative care model design that accountable care calls for—it's essential, even though it conflicts with what many of our nurses have done for decades.

So, the good news is nursing is being looked to for help in leading this transformative change in partnership with other colleagues and, in particular, our physicians. Unfortunately, this also comes at a time when statistics about nurse retention are alarming.

Q: Let's talk about more about that. What's going on with the nation's nursing workforce? Is it a supply issue? Is it a demand issue? And what's driving increased nurse turnover?

Boston-Fleischhauer: We absolutely have more RNs in the pipeline than ever before, with a bumper crop of new graduates for health systems to employ. However, national, first year turnover rates for new hires is nearing 25 percent; in fact, I was working with a major health system last month whose first year turnover rate has exceeded  33 percent. And millennials, in particular, are a highly vulnerable population right now, for all sorts of reasons. Remember, these folks are new to the workforce, and new to your organization, with more career opportunities in front of them than ever before—so loyalty to one's first employer is no longer automatic.

So CNOs and HR executives  must work together to develop a strategic workforce plan that not only continues to recruit top talent, but also addresses the key drivers of employee loyalty, in addition to the widely recognized drivers of nurse engagement and strong practice environments. Sustaining an inspired nursing workforce is the ultimate ambition here.

This is hard, no question about it, but let me put this into context: For every RN that turns over, on average, it costs the organization 1.5 times that RN's salary. So you pay an RN $60,000, you lose $90,000 in direct and indirect costs if he or she leaves. If you turnover 20 RNs in the span of a year, we are looking at some serious costs here. That's why RN turnover is a statistic that should be on everyone's radar.

Q: Can you give an example of how to develop millennial loyalty to confront what you are talking about here?

Boston-Fleischhauer: Well, one of the most significant drivers of millennial loyalty is simple on its face: "My current job is a good match for my skills." Achieving that is easier said than done. For example, we know that the transition from college to employment for new RNs is harder now than ever before. Care intensity is high as are the stakes, fundamentally from the standpoint of quality and patient safety. But currently, only about 50 percent of hospitals have residency programs for new registered nurses, which are formal bridges between academia and practice that provide technical skills training, behavioral competencies, and social or emotional support to ensure a successful transition.

Compare that to what happens for new medical school grads, where every single medical student goes through a very principled and extended internship and residency. Savvy health care organizations and CNOs are realizing that we have got to invest in more comprehensive nurse residency programs to bridge this skills gap, cultivate RN loyalty, and as a result, increase retention.

The bottom line is this: Retaining top nursing talent is a strategic priority, not just for the nursing enterprise, but for the entire health care system. Beyond the financial costs of increased turnover, the disruptions to productivity, team dynamics, and care quality from turnover have been solidly documented. So organizations have to ask themselves: Am I going to invest in nurse retention on the front end? Or am I going to pay for it on the back end?

Q: We mentioned the challenge that organizations face as they prepare for risk-based contracts. How should nursing be leveraged to ensure cost-effective and seamless care?

Boston-Fleischhauer: Achieving efficient and effective care transitions between settings in clinically integrated networks is key to managing the cost of a care episode. CNOs are looking beyond just ensuring that acutely hospitalized patients are effectively stabilized and transitioned to the next level of care. For instance, nursing executives are developing care transition models that include aggressive management of patients at high-risk of readmission or an ED visit, thereby controlling episodic costs while ensuring the patient remains clinically stable. Likewise, nurse leaders have developed approaches to efficient patient education and self-management through the use of cutting-edge technology and community-based support systems. Because today's inpatient length of stay is so incredibly short, ensuring efficient care transitions pushes the nursing enterprise to design processes and systems that extend way beyond the walls of the inpatient hospital.

As organizations assume more and more risk, the need to ensure that the patient is efficiently cared for in the most cost-effective setting within the network is paramount. In fact, some would argue that in the longer term, an inpatient hospitalization represents a process failure, unless the patient cannot be cared for safely and effectively anywhere else in the care network. Achieving this vision for cross-continuum care will require nurses and physicians to innovate, designing care models and processes that ensure  every patient receives the right standard of care, every time and in the most cost-effective setting.

Finally, there has been a lot of talk about increased consumerism in healthcare. Way beyond a focus on HCAHPS, organizations and systems are developing strategies to ensure that services in any setting are viewed as value-added, from the consumer's standpoint. Given nursing's traditional relationship with patients in health care, the power of integrating nursing's perspective on designing a consumer oriented service strategy is essential.

Q: You've talked a lot about cross continuum care, but many of our members are acute care hospitals, with volumes busting at the seams. How are CNOs responding?

Boston-Fleischhauer: Well, in addition to a laser-like focus on workforce retention, CNOs tell me they have several key priorities. First, beyond cross-continuum care model design, they are focusing on pursuing true inpatient care model innovation. This includes piloting various approaches to staffing for complex care needs at the operating unit level, and using all human resources, including but not limited to nursing, as efficiently as is possible. More often than not, the CNO is responsible for clinical employees other than nursing: pharmacy, the therapies, and care management, to name a few. So, CNOs are leading the design of  very creative, interdisciplinary care team models that best leverage all resources for complex, acute care. This requires, by the way, our CFOs loosening up the traditional productivity metric of hours per patient day. Indeed, with inpatient care innovation at the levels I am talking about, hours per patient day may go up, but total labor costs per unit will go down. So, the ultimate measure, total cost of care, along with quality and effectiveness, are all positively impacted.

Likewise, CNOs and their organizations are taking a serious look at the role of the front-line nurse manager, a role that historically has gotten bigger and more complex, often without any support systems to ensure success. Depending on unit size, front-line managers could have spans of control that exceed 100 employees, and a plethora a quality, safety, and financial measures to achieve. But, beyond a serious look at span of control and dedicated business, finance, or human resource support at the front-line manager level, organizations are experimenting with innovative, leadership models as well: for example, physicians and nurse managers 'co-managing' a unit or units with a dyad structure; or even  triads, with physicians, nurse managers, and quality all accountable together. This pushes the envelope for sure, but innovations in leadership are making a big difference on clinical, financial, and safety outcomes in our increasingly complex acute care environments.

Q: Let's close with a slightly different question. How might your appointment as CNO impact nursing at Advisory Board?

Boston-Fleischhauer: Internally, my goal is to ensure that our nursing research portfolio is both value-added and highly dynamic, to meet the rapidly changing needs of our Nursing Executive Center (NEC) members at various levels within their organizations, with best practices that are responsive to the ever-broadening footprint of nursing in accountable care. And with our growing international nursing membership, the opportunity to exchange proven ideas and solutions with our global colleagues is accelerating as well. Because I travel every day and work with CNOs on their pressing issues and challenges, I look forward to being very close to our members' pulse and ensuring that we are indeed providing timely solutions that are actionable and impactful. This includes a critical eye and responsive support for the changing skills and competencies essential for leadership in the fast-paced world we all live in.

Externally, making connections with organizations addressing common nursing challenges and issues will be a priority for me as well. Whether we're addressing patient experience, patient education, clinical practice, technology, or even academia and opportunities to elevate the profession, partnering with industry leaders can only serve to strengthen the services that NEC provides to its members and therefore, to health care organizations and systems more broadly.

All in all, like my colleagues across the country, I am up for the challenge of what health care transformation is demanding of us as nursing leaders in health care, as well as the incredible opportunities for the profession as a whole.

The national prescription for nurse engagement

The National Prescription for Nurse Engagement

It's more important than ever for frontline nurses to be engaged in their work, committed to their organization's mission, and capable of delivering high-quality care in a complex and constantly changing environment.

Our Nursing Executive Center report identifies the unique challenges of engaging nurses and equips nurse leaders with five strategies for building a highly engaged workforce.

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