Building Effective Workforce Management Practices ...

Jacob Krive

Building Effective Workforce Management Practices Through Shared Governance and Technology Systems Integration EXECUTIVE SUMMARY In integrated delivery networks (IDNs) with complex management structures, shared governance in nursing is a proven model for health care delivery. After Advocate Health Care, the largest IDN in Illinois, implemented shared governance in its nursing, clinical, and non-clinical departments and restructured the organization’s technology use, it benefited greatly from a new, shared decision-making process. After listening to business consultants, clinical professionals, and information technology experts, hospitals should take the blended, or comprehensive, approach to new projects. They can succeed by promoting communication supported by an integrated computer platform that helps nursing and business executives reach a consensus. Traditional modes of operation, in which individual administrative, clinical, and technology departments separately introduce innovation, do not deliver an advantage. However, models that incorporate open communication, integration, and knowledge sharing will help large IDNs and other complex health care organizations make the best possible use of their resources and investments.

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United States have led to the consolidation of health care organizations into multi-facility, integrated delivery networks (IDNs). In IDNs with complex management structures, shared governance in nursing is a proven model for health care delivery (Evan, Aubry, Hawkins, Curley, & Porter-O’Grady, 1995). The shared governance model relies on increased nurse investment and participation (PorterO’Grady, 1991), while the necessity for nursing input at every level of a health care organization requires a nursing representative on the hospital board (MacLeod, 2010). Examples of successful shared governance in nursing include the Veteran Administration’s integration of hospitals in Brooklyn and Manhattan. These hospitals have integrated nursing structures into a clearly defined hierarchy that consists of clinical, research and informatics, education, and admi-

JACOB KRIVE, PhD, MS, MBA, CPHIMS, LSS Green Belt, is Project Manager – Information Systems, Advocate Health Care, Downers Grove, IL.

NURSING ECONOMIC$/September-October 2013/Vol. 31/No. 5

nistrative branches that report to the executive council (Miller, 2002). In Wisconsin, Aurora Health Care created a regional cabinet consisting of patient care councils and management councils with representation from all sites (Golanowski, Kurz, & Hook, 2007). Furthermore, in Texas, Seton Healthcare Family, part of Ascension Health, adopted a shared governance model that includes the system chief nurse executive (CNE), the nursing executive council, and nursing congress, with multi-disciplinary and multi-facility representation (Burkman, Sellers, & Batcheller, 2012). The role of the CNE in IDNs has changed as a result of the popularity of shared governance, which requires that nursing executives lead and inspire highly effective teams to promote innovation, accountability, and shared decision making (Drenkard, 2013). After Advocate Health Care, the largest IDN in Illinois, with 11 hospitals and over 250 sites of care, implemented shared governance in its nursing, clinical, and

ACKNOWLEDGMENT: The author thanks B. Torres for help in preparing this article.

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non-clinical departments and restructured the organization’s technology use, it benefited greatly from a new, shared decisionmaking process. To standardize financial and staffing processes across the organization, in 2008 Advocate incorporated a patient care council (PCC), which consists of all CNEs and the middle management level nurse staffing and finance (NSF) council, including nursing operations leaders from all hospitals. Information systems (I/S) joined the NSF council to represent the staffing and scheduling software application, the prime technology component for making nurse staffing decisions. The system-wide staffing and scheduling application was financed by the nursing department originally to aid in the automated scheduling processes for inpatient units. However, participation was voluntary and relatively low. At that time, I/S was the sole administrator of the staffing and scheduling software, an awkward situation for the nursing, finance, and technology groups who used and maintained the software. Both nursing’s and finance’s decisionmaking structures worked well internally; however, there was no communication between these groups. Hospital administrators therefore saw a need for change because of: (a) increased pressure on nursing to be accountable for its financial decisions, (b) the necessity for financial education and greater collaboration between nursing and finance organizations, and (c) a beneficial shift in health care information technology towards data integration and business analytics. A shared governance partnership between nursing and finance can be difficult to implement, especially when the only point of agreement for these departments is that hospitals are under pressure to make the best use of their resources. Finance generally believes managing a health care organization is a matter of managing

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cost, while nursing advocates for more resources to resolve patient satisfaction concerns (Brennan, Hinson, & Taylor, 2008). Yet a finance-nursing collaboration, and financial education for leaders in clinical areas, can and has led to measurable improvements (Studer, 2010). (The topics discussed in Advocate’s financial education for nursing staff included financial language, data-driven management and planning, linking safety outcomes to financial performance, understanding nurse staffing in light of an organization’s financial outcomes and operations, technologies used to track financial performance, and understanding the role labor costs play in the management of a health care organization.) Such a partnership has incurred lower expenses, tighter budget planning, decreased frustration, and improved understanding (Madigan & Harden, 2012). Health care systems that have documented the rewards of financial education for nursing leaders are Yavapai Regional Medical Center in Arizona (Brennan et al., 2008), University of North Carolina Hospitals in Chapel Hill, NC (Madigan & Harden, 2012), and Northwestern Memorial Hospital in Chicago, IL. The latter organization reported $4.9 million in productivity savings and $7.6 million in turnover cost reduction over 2 years as a result of financial education and cooperation between financial and nursing management teams (Douglas, 2010).

The Integration of Technology within a Shared Governance System At the same time that the necessity for cost controls mandated an alliance between clinical and administrative departments, the health care technology markets experienced tremendous growth. Technology’s new “big data” trend created a major domain for data integration and business analytics that is aimed at solving health care organizations’

quality and cost concerns. This technology is vital to the structure, delivery, and expansion of communication systems (Baird, Funderburk, Whitt, & Wilbanks, 2012). Information systems and common enterprise data warehouses that support information sharing, integration, and dissemination can supply shared governance teams with the solutions to make better and evidence-based decisions (Junttila et al., 2007; Murtola, Lundgren-Laine, & Salantera, 2012). Because this new technology had the potential to foster significant growth, Advocate Health Care decided to collaborate with its established software vendor to create a $4.3 million integrated workforce management platform that combined two applications – staffing and scheduling, and time and attendance – with a common database that served the entire organization. Expectations from this application included: 1. Overtime reduction resulting from better scheduling. 2. A powerful reporting platform that combined financial and scheduling data. 3. Reduced use of temporary staffing agencies. 4. Higher productivity. 5. Better support for centralized, hospital nursing management offices. 6. Contributions to associate satisfaction resulting from selfscheduling capabilities, easy access to timecards and schedules, and potential for open shift notifications. This latter technology has the potential to improve staffing effectiveness and the work environment (Valentine, Nash, Hughes, & Douglas, 2008). The greatest gain was expected to be in patient satisfaction. The workforce management practice and technology integration project, internally communicated and marketed as AdvocateWorks, was begun in 2009 amid huge expectations. Yet its greatest


challenge had little to do with technology. As the project team discovered during and after 2 years of implementation, the biggest challenge – and the greatest reward – was a fundamental redesign of shared governance that drew the nursing and finance teams into a productive collaboration. Making the processes of modern business technologies work (also called business process reengineering), is one of the biggest challenges to change in a large organization. In the case under discussion, the I/S department had to overcome its role as sole administrator, or “owner” of the staffing and scheduling application. In collaboration with the PCC, I/S created an innovative option in which the middle-management nursing operations council (the NSF committee) would take over as the collective site administrator. The NSF’s administration of the application would fit nicely within the existing reporting/escalation model to the PCC, since the NSF had already reported to this council. The major advantage was “automatic” buy-in for technology solutions, since every facility became a participant. The initial disadvantage was a slower decision-making process, since many people offered input and voted on solutions. Ultimately, however, Advocate developed greater speed in decision making and gained a significant advantage from the all-around participation. The shared administration of a core staffing application was a success.

Process Changes Moving I/S away from being the sole administrator of the organization’s technology encouraged all project participants to have a say in the development and management of the workforce management applications. As a temporary measure, the chair of the PCC joined the executive finance committee to provide the nursing per-

Figure 1. Creation of the Nursing/Finance Subgroup

Executive: Patient Care Council

Nursing Operations Leadership: Nurse Staffing and Finance Committee

Nursing/Finance Subgroup

Information Systems

spective. Eventually, however, a more permanent process was designed so that the participants could manage their new, shared applications and data. Decisions such as adding new departments and products, changing pay codes, scheduling features, and making major and minor changes were now approved by nursing and finance. After technology decisions were made, a new program was implemented in a computer system. One example of this shared process was AdvocateWorks’ change control, the first integrated process developed jointly by members of nursing, finance, and I/S teams. Another example was a new security framework that matches current industry practices by requiring “separation of duty,” in which no decision is made by one member of a team or one administrator. This was a significant departure from past processes, in which each administrator or the IS team had full control of such security components as role and access definitions. As a result of this change, however,


emotional and work attachments to old management routines were removed.

Implementing Shared Governance: Incremental Changes The work on change control and security processes represented the first important steps in a farreaching collaboration. The next step was the establishment of a permanent effective venue for nursing and finance technology administrators to make shared decisions. The new nursing/finance subgroup included representatives of both groups from various leadership levels. This subgroup meets monthly to discuss a drastically different agenda from the separate nursing and finance councils, whose joint participation would have been ineffective because they were not prepared to discuss technology concerns. Figure 1 shows the new structure. After this group established its own protocols, scope, and goals, it was an instant success, and paved the way for further collaboration. However, because the higher-level councils had a strategic focus,

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with neither the time nor personnel to address technical concerns, they established a group in charge of the lower-level, more detailed, and often technical decisions. This new group, functional system administrators (FSA), which was founded in May 2012, meets monthly and is chaired by I/S. The FSA includes representatives in staffing and scheduling “super user” roles from all hospitals. Figure 2 shows the adjusted process. All controls at the technical administration level within I/S remained functioning, with adjustments to operations to enhance nursing and finance collaboration. Figure 3 shows the I/S management structure related to the workforce management application. After the new technology was integrated and upgraded, administration processes were in place, and communication channels opened for site administrators, the new system was ready for extension to non-nursing departments. Since all staff already utilized AdvocateWorks to report time through the time and attendance module, the implementation of one scheduling system for the entire organization was easily justified. The system-wide application would eliminate the cost of paying multiple vendors, replace paper-based scheduling practices, provide leaders with access to meaningful data and reports, standardize organizational business processes, establish common goals, and share such popular features as self-scheduling. Feedback from nursing leadership was solicited to incorporate all clinical departments that could benefit from a staffing and scheduling rollout under the AdvocateWorks master plan. The departments initially included radiology, cardiology, surgery, respiratory, and emergency department areas. After initial success and overwhelming leadership support, as well as gaining experience

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Figure 2. Addition of the Monthly FSA Group

Executive: Patient Care Council

Nursing Operations Leadership: Nurse Staffing and Finance Committee

Technical: FSA Group (Monthly Meeting)

AdvocateWorks Business Owners Nursing/Finance Subgroup

Information Systems

Figure 3. Information System AdvocateWorks Workforce Management Structure

Information Technology Center (help desk)

AdvocateWorks Application Team

Technical Services Team (servers, databases, network, telecom)

I/S Security Administration

Change Management and Disaster Recovery Team


Figure 4. Advocate’s Road to Shared Governance Success 2005 - 2008

Staffing & Scheduling: Optional departmental use for inpatient nursing

FSA Group

Shared ownership by NSF with escalation & reporting path to Patient Care Council

Staffing & Scheduling Roadmap: Ancillary clinical departments

AdvocateWorks: Integrated workforce management platform

with scheduling practices in nonnursing departments, a number of areas were added, including gastrointestinal, dialysis, obstetrics, pain, intensive care, and pharmacy. Following success in the clinical areas and the new corporate funding for extending application licensing to the non-clinical and outpatient departments/organizations, pilots were started with food services and nutrition, environmental services, labs, patient representatives, guest services, and other groups. A pilot with Advocate Medical Group is currently under consideration.

Project and Process Success: Bringing it All Together The success of these changes and the new partnerships with department administrators throughout Advocate could not have been possible without the steps that established ownership of applications, shared governance, and regular, open communication over 3 years. These basics are frequently

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AdvocateWorks: Core labor management product, varied use, busy roadmap

the forgotten dangers of seemingly innovative technology solutions. Such solutions may fail because of the inadequacy of managerial processes or the failure to re-engineer processes to match new technology structures. In the case under discussion, as administrators and technology worked together, it became unnecessary to continue to survey the staffing and scheduling system; that system had become the mechanism for decision making on nursing staffing. The staffing and scheduling system is now required for all nursing operations and the nonnursing and/or non-clinical departments that participate in the project. In most cases, it was not necessary to enforce mandatory utilization of the system; the new software works so well that its users have no desire to return to their old routines. Figure 4 summarizes Advocate’s road to shared governance success. Specific outcomes resulting from the use of AdvocateWorks


AdvocateWorks Roadmap: Open to all Advocate units with scheduling needs

include: 1. Automation of staffing and scheduling practices enabled nurse leaders to make immediate staffing decisions, forecast overtime, and standardize practices to eliminate gaps between same or similar departments at several hospitals in the system. The NSF council is the discussion and policymaking venue for standardization of practices, and AdvocateWorks is a single platform where these practices are implemented. 2. Comprehensive reporting capabilities enabled nurse leaders to measure, track, and compare their outcomes over time, and discuss their successes and challenges with finance leaders. 3. Employee engagement tools, such as self-scheduling and shift trading, helped increase the utilization of hospital staff (as opposed to hiring from an outside agency). The staffing application also gave managers easy views of scheduling gaps

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and forecasting tools that alert them to upcoming needs early in the planning process, thus reducing reliance on emergency measures that typically lead to agency assistance. 4. Managers became more productive with the elimination of redundant tasks needed to manage time and attendance and staffing and scheduling applications, automated staffing templates and scheduling grids, reports that combine meaningful data from a single integrated database, real-time tools showing the department staffing situation, and integration with other major applications to provide a single source for accessing financial, staffing and scheduling, acuity, census, and professional licensing data. Associates became more productive with the ability to request, change, and review their schedules at any time and place. Associates were more satisfied by being able to take charge of their schedules and use the latest technology; this has also helped retention. 5. Centralized nursing operations support offices received one core application that contained all data and tools needed to support leaders and associates in the hospitals.

Lessons and Challenges The following lessons for shared governance and implementation of new technology are based on the success of the AdvocateWorks project. 1. It is usually possible to innovate and take risks with shared governance initiatives when the traditional models do not work. 2. Team ownership of technology applications, processes, and systems can work well in shared governance, despite drawbacks, because buy-in from all team members outweighs the inefficiency of deci-

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sion making by individuals, teams, and executive councils. 3. By getting shared governance right, organizations can make key strategic technology initiatives successful. 4. Successful ownership of technology applications and shared governance strategies are key for future organization and technology innovation. Advocate is now in a great position to utilize the strength of its integrated nursing and financial data and to examine the options of adding acuity, patient classification and assignment, business analytics, and shift forecasting solutions to its computer systems. Organizational challenges that might alter the current governance structure are rooted in the success of the AdvocateWorks master plan, which outlines the path for expanding access to automated staffing and scheduling technology to additional clinical and nonclinical areas, with the goal of including every department in AdvocateWorks. The initial success of the AdvocateWorks project, followed by the expansion into other departments, does pose potential problems. New departments may have difficulty joining the current nursing/finance governance structure, particularly with regard to software applications. Such a challenge was addressed by inviting new FSAs to join the FSA group and participate in a shared, lower-level decision-making process. It will certainly be necessary to develop new methods that engage non-nursing and non-finance leaders in the shared governance process, and to meet the challenges that occur as the organization grows and adds new facilities and departments. It is difficult to manage largescale change in complex IDNs and challenging to standardize the implementation and structure of new technology when many people believe their way is best. To meet the pressing efficiency, qual-

ity, and financial challenges of the next 5 years, however, it will be necessary to develop a shared governance system that includes nursing, clinical, and support departments. In technology management, it will be important to integrate disparate software applications and clinical/workforce administrative structures that support shared governance models; and equally important to integrate approaches to care delivery. If hospitals view shared governance models and software applications that support nursing and administrative initiatives as separate initiatives, they may unwittingly increase complexity and inefficiency. Hospitals would obtain the best benefits by developing their own innovative models of blending governance and technology. After listening to business consultants, clinical professionals, and information technology experts, hospitals should take the blended, or comprehensive, approach to new projects. They can succeed by promoting communication supported by an integrated computer platform that helps nursing and business executives reach a consensus. Traditional modes of operation, in which individual administrative, clinical, and technology departments separately introduce innovation, do not deliver an advantage. However, models that incorporate open communication, integration, and knowledge sharing will help large IDNs and other complex health care organizations make the best possible use of their resources and investments. $ REFERENCES Baird, B.K., Funderburk, A., Whitt, M., & Wilbanks, P. (2012). Structure strengthens nursing communication. Nurse Leader, 10(2), 48-52. Brennan, T., Hinson, N., & Taylor, M. (2008). Nursing and finance: Making the connection. Healthcare Financial Management, 62(1), 90-94.

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