Using a Nursing Balanced Scorecard Approach to

nursing research

Using a Nursing Balanced Scorecard Approach to Measure and Optimize Nursing Performance Lianne Jeffs, RN, PhD Director, Nursing/Clinical Research and Scientist, Keenan Research Centre Li Ka Shing Knowledge Institute, St. Michael’s Hospital Early Nursing Research Career Award, Ministry of Health and Long Term Care Assistant Professor, Lawrence S. Bloomberg Faculty of Nursing, University of Toronto Toronto, ON Jane Merkley, RN, MScN Vice President, Programs, Services & Professional Affairs and Chief Nurse Executive Bridgepoint Health Toronto, ON Sandy Richardson, BSc (Hons Kin), MEd (Couns Psych) President & Managing Consultant, Strategy Focused Business Solutions Toronto, ON Jackie Eli, RN, MN Clinical Director, Rehabilitation & Ambulatory Services Bridgepoint Health Toronto, ON Mary McAllister, RN (EC), PhD Director, Professional Practice, Nursing Bridgepoint Health Toronto, ON

Abstract The authors give an overview of one healthcare organization’s experience in developing a nursing strategic plan and nursing balanced scorecard (NBS) using a focused planning process involving strategy mapping. The NBS is being used at this organization to manage the nursing strategic plan by leveraging and improving nursing processes and organizational capabilities as required, based on data and transparent communication of performance results to key stakeholders. Key strategies and insights may help other nurse leaders in developing or refining strategic approaches

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Nursing Leadership Volume 24 Number 1 • 2011

to measuring nursing performance. Vital to the success of an organization’s strategic plan are ongoing endorsement, engagement and visibility of senior leaders. Quality of decisions made depends on the organization’s ability to collect data from multiple sources using standardized definitions, mine data and extract them for statistical analysis and effectively present them in a compelling and understandable way to users and decision-makers.

Introduction Over the last decade, substantial progress has been made towards developing performance measurement and quality improvement frameworks associated with the delivery of healthcare (Clancy 2007; Klassen et al. 2010). Underpinning these efforts have been pressures for healthcare organizations to be more responsive to patients’ demands while simultaneously improving quality and efficiency (Lorden et al. 2008; Mumolie et al. 2007; Naranjo-Gil 2009; Smith 2007). The predominant organizational performance framework in the healthcare system is the balanced scorecard methodology that integrates all clinical services and healthcare professionals (Kaplan and Norton 1996, 2001). In addition to exploring the outcomes associated with inter-professional approaches to care, there are growing efforts that focus on nursing-specific or nursing-sensitive outcomes to quantify the profession’s contribution to quality and safety (Albanese et al. 2010; Doran and Pringle 2011; McGillis Hall 2002; McGillis Hall et al. 2003; Naranjo-Gil 2009). This work is grounded in the view that nursing plays an integral role in quality management and performance improvement owing to nurses’ significant interaction with patients (Gallagher and Rowell 2003; Smith 2007).

This paper examines the experience of one organization, Bridgepoint Health (“Bridgepoint”), in developing and implementing a nursing balanced scorecard (NBS) to measure and optimize nursing performance. We review key literature on balanced scorecards and the measurement of nursing performance to provide context for Bridgepoint’s efforts. We then describe the process, including the factors that facilitated success and the insights that were gained, and cite examples of outcomes from the first six months of implementation. We hope that Bridgepoint’s experience in designing and implementing its NBS will help other organizations in their efforts to measure performance, whether it is disciplinespecific or interprofessional in nature. What We Know about Balanced Scorecards and Nursing Performance Measurement As part of the larger accountability movement in healthcare, many organizations are creating comprehensive performance measurement frameworks using

Using a Nursing Balanced Scorecard Approach to Measure and Optimize Nursing Performance

the balanced scorecard methodology (Kaplan and Norton 1996, 2001). Balanced scorecards provide information on a healthcare organization’s performance in the following four dimensions: organizational capabilities, internal processes, stakeholders and financial management over a specified period of time (Kaplan and Norton 2004). A key function of the scorecard approach is to translate an organization’s vision, mission and strategy into a condensed set of performance measures that evaluate and communicate progress towards achieving that vision, mission and strategy (Fottler et al. 2006; Lorden et al. 2008; Naranjo-Gil 2009). Trended data from the balanced scorecard can be used to identify areas for improvement in a healthcare organization, measure improvements, identify best practices and serve as performance benchmarks (Albanese et al. 2010; Clancy 2008; Doran and Pringle 2011; McGillis Hall 2002; McGillis Hall et al. 2003, 2008; Smith and Jordan 2008). In terms of nursing-specific performance, a growing interest has emerged in quantifying the contribution of nursing to quality of care and patient safety at both the systemic and the organizational levels (Donaldson et al. 2005; Kurtzman and Jennings 2008a,b; Nagle et al. 2010). At the systemic level, efforts include the National Quality Forum in the United States (Donaldson et al. 2005; Frith et al. 2010) and the Health Outcomes for Better Information and Care (HOBIC) and the Nursing Report Card (McGillis Hall 2002; McGillis Hall et al. 2003; MOHLTC 2007) in Ontario, Canada. Through these efforts, nursing-sensitive outcomes have been delineated to assist organizations and nurses to plan care and evaluate its effectiveness by benchmarking with existing information relative to other patients (Hannah et al. 2009; Orchard et al. 2006; White and Pringle 2005). For many organizations, using nursing quality benchmarks or indicators as part of operational dashboards and translating data to drive performance excellence have become a strategic imperative (Albanese et al. 2010; Donaldson et al. 2005; Frith et al. 2010; Gallagher and Rowell 2003; Smith 2007). Genesis of Nursing Balanced Scorecard at Bridgepoint Health In 2008, Bridgepoint Health released its strategic plan that set forth the vision, “Being Canada’s Leader in the Prevention and Management of Complex Disease and Rehabilitation – the New Frontier of Health Care.” Key to achieving this vision is an optimal and efficient nursing workforce and professional practice work environment. However, an internal scan conducted as part of the strategic planning process revealed that a transformation was required to enhance Bridgepoint’s professional nursing services and the practice setting in order to meet the changing needs of the population being served. Key stakeholders, including clinical nurses, nurse educators and administrators, identified priority areas to advance professionalism in nursing. Underpinning the priority areas was the need to create a commonly shared vision and action plan to guide professional nursing services, promote nursing excellence and maximize nurses’ scope of practice

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to meet changing complex patient care needs. Specific priority actions included strengthening the nursing professional care delivery model, implementing a new clinical skill-mix model and enhancing the nursing governance structure to ensure that the future plan for nursing aligns with the corporate strategic plan. In response to the key priority areas identified in the internal scan, the vice-president of patient programs, services and professional affairs, together with the chief nurse executive, spearheaded efforts to optimize nursing performance at Bridgepoint. The Nursing Balanced Scorecard: An Essential Element of the Strategic Planning Process Engaging in a strategic planning process enables a systematic approach to develop a sustainable nursing strategic plan aligned with the hospital’s strategic plan (Ingersoll et al. 2005; Jeffs et al. 2006). Building on the foundational work of Bridgepoint’s internal scan, stakeholders identified the development of an accountability framework – one that is aligned with corporate priorities, enables assessment of organizational performance against targets and allows for changing circumstances – as essential for monitoring and evaluating nursing performance.

A focused planning approach was used to develop the performance framework for nursing services at Bridgepoint. This approach drew on a previous strategic planning exercise involving multiple stakeholders (Jeffs et al. 2006) and an integrated strategy mapping (Richardson 2009) and balanced scorecard development process (Kaplan and Norton 2004). The NBS was developed by a diverse team, with representation from clinical directors, nursing educators, front-line nurses, health disciplines, medicine, business management representatives, senior nursing staff, the corporate balanced scorecard manager and external nursing practice and research experts. The engagement of front-line nurses was instrumental in ensuring that the indicators that were part of the NBS were relevant to their daily practice. Clinical areas provided release time to enable front-line nurses to attend the NBS workshops and working group sessions. The initial phase of planning involved a literature review and an organizational benchmarking exercise. These data sources were synthesized into a list of potential indicators, data collection tools and other data sources. Over the course of regular meetings, the working team developed the NBS from a synthesis of the nursing strategy map, the nursing strategic objective definitions, the Bridgepoint corporate balanced scorecard, a list of existing indicators in use at Bridgepoint and a list of best practice nursing indicators. During the development phase, the working team consulted with key stakeholders and periodically presented the NBS material to the nursing advisory committee (NAC) and management team for review, comment and endorsement. Through their efforts, the working group developed


and refined a series of strategic objectives and related indicators aimed at appropriately capturing the strategic and operational progress associated with nursing performance at Bridgepoint Health. Bridgepoint Health’s Nursing Balanced Scorecard To select the final list of indicators to be included in the NBS, the working group applied a predefined filtering process that balanced relevance (does this indicator align with the definition of each strategic objective and with nursing practice?), evidence (does this indicator reflect established best practice?) and feasibility (is this indicator already in use at Bridgepoint, and can it be monitored?). Through the prioritization of the strategic objectives and indicators, the inaugural NBS comprised 22 strategic objectives and aligned indicators (Tables 1, 2, 3 and 4).

Table 1.

Nursing resource management domain

Strategic Objective

Indicators

Attract and retain the best nursing professionals

Nurse Retention Index External turnover rate Attrition rate Nurse Recruitment Index Nurse satisfaction survey results

Build and optimize nursing resource allocation and services

Efficiency Index RN-worked hours per patient day RN-worked hours per patient day (agency, sick time and overtime)

RN = registered nurse

Given that ongoing monitoring of strategic objectives and measures is a hallmark of effective performance measurement (Kaplan and Norton 2001; Naranjo-Gil 2009), the working team developed several strategies to monitor the NBS and ensure its ongoing relevance for measuring nursing performance. One strategy was to assign a weighting to each strategic objective, placing it in a priority sequence for the organization’s attention over a defined period of time (Richardson 2009). Strategy map weighting also gives organizations a way of communicating their business priorities to stakeholders. As part of the NBS report, a colour-coding schema was developed to monitor progress towards achieving targets on each of the indicators (see Table 5). A second strategy that has been embedded into the NBS is a quarterly review process with key stakeholders at Bridgepoint, including the executive team,

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Table 2.

Nursing internal processes: care delivery and clinical practice domain

Strategic Objective

Indicators

Implement the Chronic Care Model and the Live Well philosophy

Continuity and transition, % positive scores

Leverage information and apply knowledge for best care and service

Electronic clinical documentation, Sustainability Plan achievement

Put quality and safety first every day

Quality Index Falls Infection rates Medication incidents Pain assessment compliance Pressure ulcers

Strengthen our academic and clinical education infrastructure

Peer-reviewed papers Peer-reviewed conference abstracts

Develop advanced nursing knowledge in specialty areas and chronic disease prevention and management

Specialty Certification Index Nursing expertise

Generate, disseminate and apply new knowledge at the point of care

Falls prevention strategy plan implementation

Cultivate discovery and innovations in care

Advanced practice nurse recruitment rate

Set the standards and models for healthcare in the 21st century

Implementation of Royal Bank of Canada (RBC) grant

Enable inspired and proactive nursing leadership

% completion of performance appraisals Practice Environment Scale

Influence health system priorities and decisions

No. of nurses on academic and hospital-related external boards/committees/Local Health Integrated Network (LHIN) committees

Be accountable

% compliance with clinical documentation audits Staff response time to patient call

senior management, clinical leadership and NAC. A template was developed that includes, in addition to the quarter’s target and actual report of each indicator, a commentary and action plan section to be filled out. As part of the quarterly review process, the working team developed a series of questions for stakeholders. The questions include (a) progress updates towards meeting targets (e.g., how are the indicators and strategic initiatives performing compared to targets? how have our strategic objectives been performing over the past quarter?); (b) probes to provide explanation for good or poor performance (e.g., what is our rootcause analysis telling us about critical issues? what are results telling us about the


health of our strategic objectives?); and (c) strategies that are required to address performance issues (e.g., what corrective actions are planned? are changes in direction required – objectives, relationships, strategy?).

Table 3.

Outcomes domain

Strategic Objective

Indicators

Safe and reliable patient-centred/partnershiporiented care

Patient satisfaction

Efficient care processes

Sick time Overtime Agency time

Knowledge generation and enactment

Intravenous insertion competency

Nurses leading change

Staff RN committee participation


Table 4.

Nursing organizational capabilities domain

Strategic Objective

Indicators

Implement the nursing service delivery model

Clinical model of care Clinical skill mix

Enable nursing leadership development and succession planning

RN leadership training

Create communities of nursing practice

Number of mentors

Build professional practice infrastructure

Unit councils

Foster inter-professional care and partnerships

RN academic appointments Nursing student hours Pre-graduate placements


A third strategy was the establishment of an annual process for the NAC to assess each of the objectives and indicators for value and relevance and to review potential new indicators and data sources. Strategy Mapping in Action: The Inaugural Bridgepoint Health Nursing Quarterly Performance Report The inaugural Bridgepoint Health Nursing Quarterly Performance Report was presented to the NAC and senior management in November 2009. Results

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included 12 indicators identified as green, 13 as yellow and 4 as red; data were not available for 12 additional indicators. Assessing the progress being made for each indicator also includes classification into three general categories: successes, anticipated shortfalls and unexpected underperformance. This further classification enabled a more balanced and comprehensive oversight of the objectives and initiatives that may require re-prioritization. For example, for some initiatives there was a purposeful and strategic decision to slow the pace of implementation so that appropriate change management supports were in place to ensure sustainability and quality outcomes.

Table 5.

Nursing Balanced Scorecard colour coding schema

Colour

Description

Green

Progress is meeting or exceeding expectations.

Yellow

Progress is being made towards the target but no changes are required yet.

Red

Progress is below expectations – root-cause analysis and corrective action plans are required to achieve performance improvements.

Presentation of the quarterly NBS data provided an opportunity for nursing leadership to review progress towards performance milestones and targets and to explain any variances. Nursing leadership identified a predominant focus on the nursing skill-mix change and the implementation of the professional care delivery model project (nursing organizational capabilities) during the first six months of 2009/2010. This focus resulted in other priority initiatives being delayed. Despite this re-prioritization, many other aspects of the nursing strategic plan were advanced and flagged for ongoing monitoring to ensure that nursing performance at Bridgepoint does not fall significantly behind on timelines or deliverables. One example is the change in practice reflected in the rates of pain assessments completed on admission, rising from 54% to 98% over six months. While monitoring progress in advancing the nursing strategy is important, the NBS indicators offer evidence of the quality of nursing care being delivered organization-wide. Assessing patients’ baseline pain upon admission is essential in a rehabilitation hospital; patients require effective pain management if they are to progress with their rehabilitation goals. Nurses can consistently plan care that reflects this individualized and timely pain assessment once the admission pain assessment is completed. Momentum is expected to be gained upon completion of the skill-mix initiative, when resources can be diverted to address strategic initiatives that are categorized


as yellow and red. Moreover, the target objectives that are lagging behind are not major concerns at this time because they are less operational and more strategic in nature. Finally, the colour classification of objectives allows the organization to identify priorities with respect to resource allocation, development of mitigation strategies and future action planning. Examples of future actions associated with selected performance outcomes include successes, anticipated shortfalls and unexpected underperformance. Successes As previously described, the professional nursing care model (clinical model of care) and the nursing skill-mix project were high-priority actions to build the foundation of the nursing strategy. Progress to date is on schedule, and the outcomes have met or exceeded expectations. The ongoing roll-out of these two projects will continue to be the primary focus for nursing until March 31, 2011. We anticipate that the initial successes will have a cascade effect on many other strategic objectives as they branch from this foundational transformation. Anticipated shortfalls The implementation of unit councils has been delayed to align with launch of the revitalized corporate governance structure (NAC). Attention to unit councils is expected take place in 2011. There were also barriers to establishing clinical competence in IV insertion owing to decreased access to mentorship opportunities with the clinical unit team and external partners. Future action includes investigating renewal of mentorship opportunities with additional external clinical partners. Unexpected underperformance Despite efforts, the targets for reducing new stage 2 or greater pressure ulcers was not achieved in the first six months of fiscal 2010/2011. While these results have been validated based on current documentation, it is unclear whether truly new stage 2 and greater pressure ulcers are being correctly documented by clinical nurses. Future action includes conducting a corporate pressure-ulcer prevalence study, led by the advanced practice nurse: wound care team, to clarify the accuracy of clinical assessments and inform strategies. Key Success Factors and Insights Gained Key critical success factors and insights gained from the strategic planning and NBS journey at Bridgepoint Health are as follows.

• The use of a focused planning approach facilitated by experts to create an actionable strategic plan (strategy map and NBS aligned with the corporate strategy map and performance measurement system) was instrumental in optimizing nursing performance.

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• Engagement of key stakeholders, particularly staff nurses, throughout the entire planning and development phases of defining strategic objectives and aligned indicators is required for initial organizational buy-in and sustaining the momentum of optimizing nursing performance and achieving quality outcomes. • Executive endorsement and embedding the nursing performance indicators into quarterly reports to senior management and the board of directors is paramount to ensure sustained monitoring of nursing performance and quality improvement initiatives. • Leveraging existing indicators to create the initial NBS and then revisiting them on a regular basis ensures that the most relevant indicators for measuring nursing performance are captured and reported. • A further key sustainability strategy is to establish a strong nursing professional governance structure and secure institutional resources to oversee the implementation of the strategic plan, monitor progress towards the plan, identify priorities in response to changes in performance and move the nursing strategic plan forward. Implications and Conclusions This paper provides an overview of one healthcare organization’s experience in developing a nursing balanced scorecard using a focused planning process involving strategy mapping. The NBS is being used to manage the nursing strategic plan by leveraging and improving nursing processes and organizational capabilities based on data and transparent communication of performance results to key stakeholders. Nurse leaders who embark on developing or refining strategic approaches to measuring nursing performance are encouraged to engage key stakeholders so that they have a clear understanding of strategic objectives, initiatives and performance results associated with nursing care, and are enabled to take ownership of them (Kaplan and Norton 1996, 2001). Ongoing endorsement, engagement and visibility of senior leaders in the organization are also vital to success when operationalizing the strategic plan and ensuring that it is embedded in daily practice (Albanese et al. 2010; Doran and Pringle 2011; Frith et al. 2010; Jeffs et al. 2006; Naranjo-Gil 2009).

Indicators that are comprehensive, yet context specific, are essential if they are to reflect meaningfully the outcomes associated with nursing care and the contribution to broader patient, financial, organizational and system-level outcomes. Moreover, performance results should be presented in a manner that fosters the understanding of the data by the target audience. When an organization has the capability to mine data and extract them for statistical analysis and then effectively present these data in a compelling and understandable way to users and decisionmakers, then the quality of decisions being made can only improve. Data generated from a nursing balanced scorecard not only offer organizations opportuni-


ties to evaluate their progress in realizing their strategic goals, but also provide a mechanism to evaluate their success in achieving operational and quality targets while ensuring that key stakeholders are engaged in the process. Acknowledgements The authors would like to thank the planning team and participants in the series of workshop days to develop the Nursing Balanced Scorecard at Bridgepoint Health.

Correspondence may be directed to: Lianne Jeffs at St. Michael’s – [email protected]. References Albanese, M.P., D.A. Evans, C.A. Schantz, M. Brown, M. Disbot, J.S. Moffa, P. Piesieski and R.C. Polomano. 2010. “Engaging Clinical Nurses in Quality and Performance Improvement Activities.” Nursing Administration Quarterly 34(3): 226–45. Clancy, C. 2007. “The Performance of Performance Measurement.” Health Services Research 42(5): 1797–801. Donaldson, N., D.S. Brown, C.E. Aydin, M.L.B. Bolton and D.N. Rutledge. 2005. “Leveraging NurseRelated Dashboard Benchmarks to Expedite Performance Improvement and Document Evidence.” Journal of Nursing Administration 35(4): 163–72. Doran, D. and D. Pringle. 2011. “Patient Outcomes as an Accountability.” In Nursing Outcomes Second Edition. Doran, D. (Ed). Jones & Bartlett Learning, LLC: Sudbury, MA. Fottler, M.D., E. Erickson and P. Rivers. 2006. “Bringing Human Resources to the Table: Utilization of an HR Balanced Scorecard at Mayo Clinic.” Health Care Management Review 31(1): 64–72. Frith, K.H., F. Anderson and J.P. Sewell. 2010. “Assessing and Selecting Data for a Nursing Services Dashboard.” Journal of Nursing Administration 40(1): 10–16. Gallagher, R.M. and P.A. Rowell. 2003. “Claiming the Future of Nursing through Nursing-Sensitive Quality Indicators.” Nursing Administration Quarterly 27(4): 273–84. Hannah, K.J., P. White, L.M. Nagle and D.M. Pringle. 2009. “Application of Information Technology: Standardizing Nursing Information in Canada for Inclusion in Electronic Health Records: C-HOBIC.” Journal of the American Medical Informatics Association 16(4): 524–30. Ingersoll, G.L., P.A. Witzel and T.C. Smith. 2005. “Using Organizational Mission, Vision, and Values to Guide Professional Practice Model Development and Measurement of Nurse Performance.” Journal of Nursing Administration 35(2): 86–93. Jeffs, L., J. Merkley, J. Jeffrey, E. Ferris, J. Dusek and C. Hunter. 2006. “Reconciling the Quality and Safety Gap through Strategic Planning.” Canadian Journal of Nursing Leadership 19(2): 32–40. Kaplan, R.S. and D.P. Norton. 1996. The Balanced Scorecard: Translating Strategy into Action. Boston: Harvard Business School Press. Kaplan, R.S. and D.P. Norton. 2001. The Strategy Focused Organization: How Balanced Scorecard Companies Thrive in the New Business Environment. Boston: Harvard Business School Press. Kaplan, R.S. and D.P. Norton. 2004. Strategy Maps: Converting Intangible Assets into Tangible Outcomes. Boston: Harvard Business School Press. Klassen, A., A. Miller, N. Anderson, J. Shen, V. Schiarti and M. O’Donnell. 2010. “Performance Measurement and Improvement Frameworks in Health, Education and Social Services Systems: A Systematic Review.” International Journal for Quality in Health Care 22(1): 44–69. Kurtzman, E.T. and B.M. Jennings. 2008a. “Capturing the Imagination of Nurse Executives in Tracking the Quality of Care.” Nursing Administration Quarterly 32(3): 235–46. Kurtzman, E.T. and B.M. Jennings. 2008b. “Trends in Transparency Nursing Performance

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Measurement and Reporting.” Journal of Nursing Administration 38(7/8): 349–54. Lorden, A., A. Coustasse and K.P. Singh. 2008. “The Balanced Scorecard Framework – A Case Study of Patient and Employee Satisfaction: What Happens When It Does Not Work as Planned?” Health Care Management Review 33(2): 145–55. McGillis Hall, L. 2002. “Report Cards: Relevance for Nursing and Patient Care Safety.” International Nursing Review 49(3): 168–77. McGillis Hall, L., D. Doran, H.S. Laschinger, C. Mallette, C. Pederson and L. O’Brien-Pallas. 2003. “A Balanced Scorecard Approach for Nursing Report Card Development.” Outcomes Management 7(1): 17–22. McGillis Hall, L., J. Peterson, R. Baker, A. Brown et al. 2008. “Nursing Staffing and System Integration and Change in Acute Care Hospitals.” Journal of Nursing Care Quality 23(3): 242–50. Ministry of Health and Long-Term Care (MOHLTC). 2007. HOBIC Measures. Retrieved February 3, 2011. . Mumolie, G.P., L.K. Lichtig and R.A. Knauf. 2007. “The Implications of Nurse Staffing Information: The Real Value of Reporting Nursing Data.” Nursing Economics 25(4): 212–27. Nagle, L., P. White and D. Pringle. 2010. “Realizing the Benefits of Standardized Measures of Clinical Outcomes.” Electronic Healthcare 9(2): e3–e9. Naranjo-Gil, D. 2009. “Strategic Performance in Hospitals: The Use of the Balanced Scorecard by Nurse Managers.” Health Care Management Review 34(2): 161–70. National Quality Forum. 2004. National Voluntary Consensus Standards for Nursing-Sensitive Care: An Initial Performances Measure Set. A Consensus Report. Washington, DC: National Quality Forum. Orchard, C., C. Reid-Haughian and R. Vanderlee. 2006. “Health Outcomes for Better Information and Care (HOBIC): Integrating Patient Outcome Information into Nursing Undergraduate Curricula.” Canadian Journal of Nursing Leadership 19(3): 28–33. Richardson, S.L. 2009. The Practical Guide to Strategy Mapping: A Hands-on Approach to Translating Strategy into Action. Retrieved February 3, 2011. . Smith, A.P. 2007. “Nursing Sensitive Care Measures: A Platform for Value and Vision.” Nursing Economics 25(1): 43–46. Smith, D.P. and H.S. Jordan. 2008. ”Piloting Nursing-Sensitive Hospital Care in Massachusetts.” Journal of Nursing Care Quality 23(1): 23–33. White, P. and D. Pringle. 2005. “Collecting Patient Outcomes for Real: The Nursing and Health Outcomes Project.” Canadian Journal of Nursing Leadership 18(1): 26–33.