Module

 3.  Leadership  of  the  Future  

Leadership  Competencies  

Chappell,  K.  et  al,  (2013)  states  that  nurse  managers  should  focus  on  self-­‐development  and  
peer  group  development  through  nursing  leadership  development  programs  that  prepare  
nurses  for  present  and  future  leadership  in  the  changing  health  care  environment.  They  further  
note  that  current  nursing  leadership  programs  are  slow  in  developing  nurses  with  the  vision  
and  capability  for  improving  health  care.  With  the  complexity  and  unpredictability  of  healthcare  
the  expectation  is  that  professionals  are  prepared  to  succeed  based  on  their  formal  education,  
and  that  nurse  leaders  will  identify  and  hone  needed  skill  sets.    

 
Nursing  education  programs  and  healthcare  organizations  must  prepare  nurses  to  be  effective  
leaders.  Responsible  nurse  leaders  help  organizations  to  stay  focused  on  mission  and  goals,  and  
to  question  and  redirect  policy,  politics,  and  practice.  They  become  effective  leaders  using  
challenges,  innovation,  and  learning  to  maintain  a  balance  between  the  role  and  the  self.  

 
The  Amy  Cockcroft  Fellowship  program,  a  graduate  nursing  initiative  at  the  University  of  South  
Carolina,  was  evaluated  to  determine  if  there  were  measurable  differences  on  the  impact  of  
nursing  leadership  development  programs.  Four  themes  were  identified,  which  provide  the  
basis  for  creating  measureable  indicators  for  nursing  organizations  to  use  in  determining  the  
value  of  nursing  leadership  development  programs.  Impact  areas  for  program  development  
were:    

 
1. Improved  Conflict  Resolution/negotiation  skills:  This  is  a  learned  skill  of  
reframing,  decreasing  emotional  response,  and  employing  systems  thinking.  
2. Strong  Communication  Skills:  Organizational  communication  is  vital  to  
increased  development  in  the  nurse  leader  role.  Nurse  leaders  are  required  to  
effectively  communicate  with  multiple  parties  –  patients,  staff,  providers,  
families,  peers,  and  outside  vendors.  This  involves  active  listening  and  
improved  handling  of  crucial  conversations,  as  well  as  growth  in  decreasing  
personal  or  emotional  reactions  during  conflict.  
3. Personal  Development:  Pursuit  of  higher  education.  
4. Career  action  or  change:  Empowerment  to  move  up  within  the  organization,  
make  a  lateral  move,  or  become  a  visionary.  
 

These  four  themes  are  supported  in  current  leadership  development  literature  (Chappell,  K.  et  
al,  2013).  Leadership  is  a  set  of  skills  that  can  be  learned,  and  once  mastered  can  be  
incorporated  to  change  workplace  cultures  (Mathena,  2002,  cited  in  Chappell,  2013).    

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Module  3.  Leadership  of  the  Future  

Economically  strapped  healthcare  facilities  are  challenged  with  allocating  money  to  develop  
leaders.  Determining  effective  means  of  developing  competent  leaders  is  essential  for  survival.  
For  Chappell,  K.  (2013)  it  is  essential  to  develop  strong  nursing  leaders  who  are  not  afraid  to  
make  a  difference  and  who  have  a  voice  and  understand  that  they  play  an  important  role  in  our  
communities,  in  legislation,  and  in  the  financial  arenas  in  our  work  places  (Chappell,  K.  et  al,  
2013).  

Evidence  Based  Leadership  Practices  (Hall  &  Roussel,  2013)  

Leadership  Models  (Chap.  7)  

• Quantum  Leadership  
• Model  of  interrelationship  of  Leadership,  Environments,  and  Outcomes  for  Nurse  
Executives  (MILE  ONE)  
• Evidence-­‐Based  Management  
 
Quantum  Leadership  

Every  discipline  must  have  some  idea  regarding  the  specific  contributions  it  makes  to  
patient  care  and  must  be  able  to  clearly  delineate  those  contributions  within  the  
language  of  its  discipline.  Physicians,  nurses,  therapists,  technologists,  and  
pharmacists,  must  all  possess  some  level  of  internal  clarity  about  their  own  
contribution  to  the  myriad  of  activities  that  clinically  impact  patients  (Porter-­‐
O’Grady  and  Malloch,  2008).  Porter-­‐O’Grady  and  Malloch  (2008)  were  the  first  to  
introduce  an  evidence-­‐based  framework  for  nursing  leadership.  The  framework  
underpins  the  importance  of  processes,  behaviors,  and  managing  infrastructure.  
They  identify  five  key  elements  of  Evidenced  Based  Practice  (EBP)  leadership:  
Physical  environment,  caregiver  demographics,  operational  structures,  culture,  and  
technology.    

The  belief  is  that  greater  integration  of  complex  systems  and  relationships  among  
leaders  and  frontline  staff  workers  reduce  barriers  and  improve  care.  The  impact  of  
differing  combinations  of  culture,  technology,  delivery  models,  care-­‐givers,  and  the  
physical  environment  on  multiple  outcomes  such  as  patient  satisfaction,  length  of  
stay,  fall  rates,  medication  errors,  number  of  emergency  codes,  pressure  ulcers,  
caregiver  satisfaction,  turnover,  and  labor  cost  per  day  can  now  be  examined  using  
multiple  metrics  and  aggregated  evaluation  (see  Fig  3).    

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Module  3.  Leadership  of  the  Future  

       
Figure  3.  Evidence-­‐based  leadership  evaluation  Model  Porter-­‐O’Grady  
and  Malloch  (2008)  

Critical  skills  of  new  leaders  include  the  abilities  to  innovate,  think,  plan,  and  
implement.  Measures  of  success  are  determined  by  patient  and  caregiver,  and  
by  organizational  and  financial  outcomes  (Porter-­‐O’Grady  &  Malloch  2008).  

To  make  this  happen,  leaders  must  continually  think  as  innovators  to  become  
comfortable  challenging  the  status  quo  and  to  develop  better  processes  and  
more  effective  structures.  Integrating  evidence-­‐based  principles  into  leadership  
DNA  is  a  significant  step  along  the  nursing  continuum  that  provides  opportunity  
for  reflection,  innovation,  and  challenge  (Porter-­‐O’Grady  &  Malloch  2008).  

Model  of  interrelationship  of  Leadership,  Environments,  and  Outcomes  for  Nurse  
Executives  (MILE  ONE)  

The  American  Nurses  Association  (ANA)  has  created  an  evidenced-­‐based  model  
for  the  Scope  of  Standards  for  Nurse  Executives  and  the  American  Organization  
of  Nurse  Executives  competencies  called  the  Model  of  Interrelationship  of  
Leadership,  Environments,  and  Outcomes  for  Nurse  Executives  (MILE  ONE).  The  
aim  of  this  model  is  to  operationalize  chief  nurse  executive  (CNE)  influence,  
identify  measures  of  success,  and  delineate  patient,  workforce,  and  
organizational  improvement  (Adams,  2009).  A  paradigm  shift  is  implied  in  the  
interrelationship  among  the  CNE,  Professional  Practice  Work  Environment  
(PPWE),  and  patient  and  organizational  outcomes.  A  lack  of  universally  accepted  
standards  of  success  contributes  to  the  role  conflict  experienced  by  nurse  
executives  (Adams,  2009).  Mile  ONE  shifts  focus  away  from  patient  outcomes  to  
emphasize  the  PPWE  and  emphasizes  three  major  concepts.  The  3  concept  areas  
include  the  following  (Adams,  2009):  

1. Nurse  executive  influence  on  the  PPWE  

• Emphasis:  executive  influence,  leadership  development,  knowledge-­‐  
based  practice,  role  clarity  

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Module  3.  Leadership  of  the  Future  

• Measurement  strategies:  the  use  of  existing  PPWE  tools    

 
2. Professional  practice/work  environments  influence  patient  and  organizational  
outcomes  
• Emphasis:  staff  engagement,  staff  empowerment,  staff  “ownership”  
of  outcomes,  knowledge-­‐based  practice  
• Measurement  strategies:  quality  indicators,  staff  recruitment,  staff  
retention,  staff  satisfaction,  etc.  
 
3. Patient  and  organizational  outcomes  influence  nurse  executives  
• Emphasis:  outcomes  management,  data  management,  reporting  
strategies,  informatics,  budget  management  
• Measurement  strategies:  CNE  recruitment,  CNE  retention,  CNE  
satisfaction,  etc.  
 
The  MILE  ONE  Model  is  useful  when  applied  to  exemplar  work  on  improving  
documentation,  as  has  been  evidenced  by  the  Adams  (2010)  study.  The  MILE  
ONE  provides  an  evidence-­‐based  framework  as  an  initial  step  in  the  exploration  
of  the  chief  nurse  executive’s  (CNE)  influence  on  organizational  and  patient  
outcomes,  as  well  as  the  work  environment.  The  use  of  the  MILE  ONE  in  
education,  policy,  practice,  research,  and  theory  development  offered  a  way  to  
frame  the  interrelated  nature  of  leadership,  environments,  and  outcomes,  
providing  focus  to  both  individual  and  organizational  enhancement  efforts.  
Continued  understanding  and  defining  the  measures  of  success  for  the  CNE  are  
imperative.  Ultimately,  it  is  the  CNE  who  leads  nursing  care  and  impacts  quality,  
cost,  and  patient-­‐centered  care.    
 

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Module  3.  Leadership  of  the  Future  

 
 

Figure  1.  Model  of  the  interrelationship  of  leadership,  environments,  and  
outcomes  for  nurse  executives.  CNE  indicates  chief  nurse  executive;  PES-­‐NWI,  
practice  environment  scale  of  the  nursing  work  index;  PNWE,  perceived  nursing  
work  environment  scale;  Professional  Practice  Work  Environment,  professional  
practice/work  environment;  NWI-­‐R,  nursing  work  index—revised;  RPPE,  revised  
professional  practice  environment  survey.  Copyright  ©  The  Bogart  Group,  Inc.  

Evidence-­‐Based  Management  

The  systematic  application  of  the  best  available  evidence  to  business  processes,  
strategic  decisions,  and  the  evaluation  of  managerial  practices  are  known  as  
Evidence  Based  (EB)  Management  (Kovner,  Fine,  &  D’Aquila,  2009,  p.1).  In  EB    
Management,  basic  employee  and  organizational  performance  data  are  required  
for  application.  

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Module  3.  Leadership  of  the  Future  

In  2006,  Kovner  and  Rundall  suggested  an  Evidence  Based  model  for  
management  consisting  of  five  steps  for  decision-­‐making:  

1. Formulating  the  research  question  

2. Searching  for  relevant  research  findings  and  other  evidence  
3. Determining  the  validity,  quality,  and  applicability  of  the  evidence  
4. Presenting  the  data  in  a  manner  to  promote  use  of  evidence  in  
decision-­‐making  
5. Applying  the  evidence  in  decision-­‐making  

The  Evidence  Based  model  is  similar  to  Evidence  Based  Practice  clinical  models  
and  uses  the  fundamental  steps  of  process  improvement.  The  model  was  
designed  specifically  to  address  questions  in  three  management  categories  –  
business  transaction  management,  operational  management,  and  strategic  
management.  Some  exemplar  questions  (Kovner  &  Rundall,  2006)  include:  

• How  can  nurse  absenteeism  be  reduced?  

• Does  hospital  discharge  planning  and  follow-­‐up  improve  patient  outcomes?  
• Does  the  implementation  of  an  electronic  medical  record  improve  patient  
care?  

Smith  and  Roussel  (2013)  noted  that  although  an  abundance  of  evidence  is  
available,  Evidence  Based  management  practices  continue  to  be  weak.  There  is  a  
greater  reliance  by  managers  on  the  trial  and  error  phenomenon  than  on  
evidence-­‐backed  practices.  Often,  when  information  has  been  available,  
managers  did  not  use  it.  Little  encouragement  and  support  exists  around  
Evidence  Based  management.    Leaders  are  urged  to  request  sound  evidence  to  
support  practice  changes,  examine  the  logic  underpinning  evidence,  and  use  
pilot  programs  prior  to  dissemination  of  findings.  

Good  to  Great  Company  Leaders  

A  15-­‐year  study  by  Collins  (2001)  cited  in  Hall  and  Roussel  (2013)  demonstrated  the  
qualities  of  leaders  who  transformed  good  companies  into  great  companies.  These  
leaders  were  found  to  be  “self-­‐effacing”,  reserved,  quiet,  and,  in  some  cases,  shy.  They  
did  not  display  the  typical  powerhouse  image  so  often  portrayed  by  top  leaders.  
According  to  Collins  these  were  top  or  level  5  leaders  who  possessed  characteristics  of  
humility  and  professional  will.  They  had  a  relentless  drive  toward  the  success  of  the  
company  and  basically  did  what  was  necessary  to  get  the  job  done  and  to  meet  the  
organization’s  goals  and  objectives.  Leaders  of  great  companies  recognized  that  having  

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Module  3.  Leadership  of  the  Future  

the  right  people  in  place  is  important  to  organizational  success.  With  the  right  people  in  
place,  employees  take  stock  within  the  company,  which  means  leaders  spend  less  time  
coaxing  employees  toward  the  organization’s  goals.  

Antecedents  of  Leadership        

Effective  Leaders  (Delineated  on  pg.  137  Hall  &  Roussel,  2013)  

No  clear  outline  or  blueprint  for  leadership  success  has  been  identified,  but  Smith  &  
Roussel  (2013)  have  delineated  some  of  the  recurrent  antecedent  themes  of  effective  
leaders:  

• Relate  the  principles  of  complexity  science  to  the  healthcare  system,  noting  dynamic  
subsystems  and  relational  components  
• Identify  traditional  hierarchical    and  individual  locus  of  control  leadership  styles  as  
obsolete  in  multi-­‐faceted  dynamic  enterprises  
• Appreciate  the  knowledge,  talents,  diversity,  and  contributions  of  workers  from  all  
spheres  of  an  organization  as  they  apply  to  process  improvement  
• Recognize  the  importance  of  staff  engagement  to  promoting  commitment,  
ownership,  and  sustainability  of  process  change  
• Value  the  importance  of  positive  work  environments  and  their  link  to  nurse  
satisfaction  
• Understand  the  significance  of  staff  empowerment  to  satisfaction  in  the  workplace  
and  intent  to  leave  
• Appreciate  the  importance  of  relationships,  effective  communication,  collaboration,  
and  teamwork  as  applicable  to  promotion  of  patient  safety  

The  effective  nurse  leader  not  only  knows  and  understands  the  precursors  of  effective  
leadership  but  also  examines  them  and  translates  them  into  practice.  

Health  Information  Technology  and  Impact  on  Nurse  Leadership    

In  the  United  States,  Health  Information  Technology  (HIT  or  Health  IT)  is  slowly  being  
adopted  (Institute  of  Medicine  [IOM]  2012).  Health  IT  includes  a  broad  range  of  products,  such  
as  electronic  health  records  (EHRs),  patient  engagement  tools  (e.g.,  personal  health  records),  
and  health  information  exchanges.  More  recently,  Health  IT  has  evolved  into  EHRs  and  other  
forms  of  technology  that  engage  not  just  in  transactions  and  data  storage  but  also  decision  
support  and  the  capacity  for  clinicians  and  patients  to  see  the  patient’s  clinical  progress  and  
data  more  easily.  Clinicians  and  health  care  systems  can  potentially  benefit  from  studying  
populations  of  similar  patients,  leading  to  learning  health  care  systems  (IOM,  2012).  Clinicians  
expect  Health  IT  to  support  delivery  of  high-­‐quality  care  in  several  ways,  including  storing  

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Module  3.  Leadership  of  the  Future  

comprehensive  health  data,  providing  clinical  decision  support,  facilitating  communication,  

engaging  patients,  and  reducing  medical  errors.  In  the  near  future,  it  is  likely  that  patients,  
specifically  those  with  chronic  diseases,  will  consistently  use  the  Internet  to  track  their  own  
health  through  personal  health  records  and  handheld  device  applications  (IOM,  2012).  Current  
Health  IT  products  are  still  improving  in  terms  of  their  capacity  to  increase  communications  and  
reduce  errors  by  making  the  right  thing  to  do  easier  to  do.  It  is  important  that  Health  IT  
maximizes  patient  safety  while  minimizing  harm.  

In  an  effort  to  improve  health  care,  the  U.S.  government  has  invested  and  will  continue  to  
invest  billions  of  dollars  toward  the  meaningful  use  of  effective  Health  Information  Technology  
in  the  hopes  of  improving  the  quality  of  care,  decreasing  the  cost  of  care  through  improved  
efficiency,  and  guiding  clinicians  to  choose  the  most  effective  care  interventions  (IOM,  2012).  
See  BOX  S-­‐4  below  from  the  Institute  of  Medicine  Report.  

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Module  3.  Leadership  of  the  Future  

Health  Information  Technology  (Health  IT)  is  not  one  specific  product  that,  once  
implemented,  can  immediately  result  in  highly  safe  and  effective  health  care.  It  
includes  a  technical  system  of  computers,  software,  and  other  devices  that  
operate  in  the  context  of  a  larger  sociotechnical  system—a  collection  of  
hardware  and  software  working  together  within  an  organization  that  includes  
people,  processes,  and  workflow.  It  is  widely  believed  that,  when  designed  and  
used  appropriately,  Health  IT  can  help  create  an  ecosystem  of  safer  care  while  
also  producing  a  variety  of  benefits  such  reduced  administrative  costs,  improved  
clinical  performance,  and  better  communication  between  patients  and  
caregivers  (IOM,  2012).  When  seen  from  this  perspective,  Health  IT  is  a  very  
positive  force  for  delivering  quality  healthcare.  

The  Institute  of  Medicine  (2012)  developed  a  strategic  framework  for  a  Learning  
Health  System,  which  is  depicted  in  the  diagram  below.    

 
Charter  of  the  Institute  of  Medicine  Roundtable  on  Value  &  Science-­‐Driven  Health  
Care  

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Module  3.  Leadership  of  the  Future  

• Generate  and  apply  the  best  evidence  for  the  collaborative  health  care  choices  
of  each  patient  and  provider    
• Drive  the  process  of  new  discovery  as  a  natural  outgrowth  of  patient  care  
• Ensure  innovation,  quality,  safety,  and  value  in  health  care.  
   

 
 

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Module  3.  Leadership  of  the  Future  

Federal  Health  Information  Technology  Strategic  Plan  

 2011  -­‐  2015  

 
The  American  Organization  of  Nurse  Executives  on  Technology  Acquisition    

The  chief  nurse  executive  (CNE)  plays  a  critical  role  in  the  selection  and  
implementation  of  information  systems.  Acquiring  new  systems  is  a  complicated  
process  that  impacts  the  entire  facility.  Although  some  tasks  may  be  delegated,  
the  chief  nursing  officer  (CNO)  must  remain  actively  involved  in  the  overall  
decision-­‐making  and  implementation  process.  These  guidelines  serve  as  a  tool  
for  the  CNO  and  are  not  meant  to  identify  all  aspects  of  acquiring  and  
implementing  information  technology  in  an  organization.  

1.  Pre-­‐Acquisition  

The  CNO  focuses  on  framing  the  institution’s  need  and  gaining  necessary  
knowledge  about  the  information  technology  (IT)  industry.  

2.  Acquisition  –  Before  Selection  of  Vendor  

The  work  that  occurs  prior  to  the  actual  selection  of  a  vendor  lays  a  critical  

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Module  3.  Leadership  of  the  Future  

foundation  for  success.  It  is  helpful  for  the  selection  committee  to  develop  a  
standard  set  of  questions  to  be  used  in  the  selection/rejection  process  and  for  
site  visits.  Clinicians  should  be  leaders  of  clinical  implementations.  Although  
operational  responsibility  is  delegable,  the  CNO  remains  accountable  for  this  
process.  

3.  Contract  and  Negotiations  

Although  the  CNO  may  not  be  the  executive  who  manages  the  contracting  
process,  once  there  is  a  contract,  he/she  should  review  the  entire  contract,  
paying  special  attention  to  the  parts  of  the  contract  that  refer  to  clinical  
practice,  phasing,  resources,  and  expectations  for  the  CNO.  

4.  Implementation  –  Managing  the  Process  

The  CNO  plays  a  critical  role  in  managing  an  implementation  process  that  
should  be  congruent  with  his/her  vision  for  the  future.  He/she  should  review  
the  project  timeline  and  budget  to  assure  that  it  covers  necessary  activities  
and  resources  anticipated.  

5.  The  Return  on  Investment  (ROI)  –  Benefit  Management  and  Value  

The  CNO  should  work  with  other  members  of  the  senior  leadership  team  to  
determine  the  value  proposition  beyond  the  usual  proposed  saving  of  full-­‐
time  equivalents.  The  CNO  should  integrate  patient  safety  and  quality  into  the  
ROI  analysis/processes,  regardless  of  where  they  are  conducted.  Base  benefits  
on  sound  evidence  whenever  possible.  

6.  Post  Implementation  

The  CNO  should  participate  in  the  executive  leadership  meetings  regarding  all  
stages  of  IT  acquisition  and  assure  nursing  representation  in  user  group  
meetings.  He/she  should  proactively  evaluate  current  and  new  technology  to  
know  how  these  can  serve  the  organization.  

7.  Understanding  the  Overall  Policy  Issues  Related  to  IT  

 Policy  depends  on  data,  leading  to  information  that  leads  to  knowledge.  In  
addition  to  the  CNO’s  local  responsibility  for  the  acquisition  and  
implementation  of  IT  systems  in  the  organization,  he/she  should  maintain  a  
global  perspective  on  information  technology  and  its  impact  on  policy.  

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Module  3.  Leadership  of  the  Future  

8.  Survival  Tips  for  the  CNO  New  to  the  Organization:  Stop.  Look.  Listen.      

A  CNO  hired  by  an  organization  that  has  recently  made  an  IT  decision  must  
learn  the  IT  strategic  plan  for  the  facility  and  how  it  fits  with  nursing’s  strategic  
plan  and  priorities.  It  will  be  critical  for  the  CNO  to  establish  a  collaborative  and  
sustainable  working  relationship  with  the  Chief  Information  Manager  (CIO),  
(American  Organization  of  Nurse  Executives,  2009).    

Leading  in  a  Rapid-­‐Change  Health  Care  Environment  

The  United  States  ranked  in  the  66th  percentile  on  a  High  Performance  Health  System  Scorecard  
by  The  Commonwealth  Fund  Commission  (Berwick,  D.  et  al,  2008).    The  Commission  notes  that  
although  U.S.  health  care  expenditures  are  much  higher  than  the  expenditures  of  other  
developed  countries,  the  results  are  no  better.  U.S.  spending  on  health  care  is  nearly  double  
that  of  the  next  most  costly  nation,  yet  the  United  States  ranks  thirty-­‐first  among  nations  on  life  
expectancy,  thirty-­‐sixth  on  infant  mortality,  twenty-­‐eighth  on  male  healthy  life  expectancy,  and  
twenty-­‐ninth  on  female  healthy  life  expectancy  (Berwick,  D.  et  al,  2008).      

With  the  health  care  delivery  system’s  complex  and  quickly  changing  landscape,  leaders  are  
urged  to  make  highly  reliable  and  safe  care  across  the  continuum  the  norm  and  not  the  
exception  (Berwick,  D.  et  al,  2008).  A  recent  focus  has  been  on  an  improvement  initiative  called  
the  Triple  Aim,  which  aimed  at  delivering  high-­‐value  care  to  individuals.  The  Triple  Aim  has  
three  objectives:  improve  the  individual  experience  of  care;  improve  the  health  of  populations;  
and  reduce  the  per  capita  costs  of  care  for  populations.  

The  idea  of  the  Triple  Aim  is  still  in  its  infancy,  as  many  health  care  delivery  systems  may  opt  to  
adapt  each  part  separately  or  at  most  address  two  of  the  three  aims.  Several  obstacles  to  
pursuit  of  the  Triple  Aim  continue  to  slow  its  progression.  Supply  driven  demand,  new  
technologies  with  limited  outcomes,  limited  foreign  competition  to  drive  change,  physician-­‐
centered  care,  and  little  interest  by  clinicians  and  organizations  in  system  knowledge  are  all  
factors  which  contribute  to  the  challenges  in  meeting  Triple  Aim  success  Berwick,  et  al  (2008).  

For  Berwick,  however,  integration  of  the  aims  is  not  impossible.  Some  examples  of  innovations  
that  have  begun  challenging  the  U.S.  health  care  market  and  that  align  with  the  Triple  Aim  
objectives  are  the  primary  care  medical  home,  retail  clinics,  non-­‐location  specific  care  through  
telecommunications,  and  medical  tourism.  Another  example,  offered  by  Virginia  Mason  
Medical  Center  and  others,  is  the  adaptation  of  systems  knowledge  by  implementing  the  “Lean  
Production”  to  healthcare.  

Berwick  (2008)  suggests  three  design  constraints  essential  to  accomplishing  the  Triple  Aim:  1)  
recognition  of  a  population  as  the  unit  of  concern,  (2)  externally  supplied  policy  constraints  

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Module  3.  Leadership  of  the  Future  

(such  as  a  total  budget  limit  or  the  requirement  that  all  subgroups  be  treated  equitably),  and  (3)  
existence  of  an  “integrator”  able  to  focus  and  coordinate  services  to  help  the  population  on  all  
three  dimensions  at  once.  

Triple  Aim  Progress  would  look  like  this:  

In  our  lighter  moments,  we  have  tried  to  imagine  the  most  elegant  possible  “Triple  Aim  Test,”  
asking,  “How  would  we  know  at  first  glance  that  the  care  for  a  population  is  actually  making  
progress  on  the  Triple  Aim?”  Our  proposed  test  has  only  three  items.  First,  hospitals  involved  in  
the  Triple  Aim  would  be  trying  to  be  emptier,  not  fuller.  They  would  celebrate  as  success  that  the  
hospital  is  less  and  less  often  needed  by  the  population.  Second,  Fisher  and  Wennberg  would  be  
happier.  They  would  observe  that  the  dynamics  of  supply-­‐driven  care  are  no  longer  strong  and  
that  patients  pull  resources,  rather  than  vice  versa.  And  third,  patients  would  say  of  those  who  
try  to  maintain  and  restore  their  health:  “They  remember  me.”  They  would  recognize  that  the  
health  care  system  is  mindful  of  their  needs,  wants,  and  opportunities  for  health  even  when  they  
themselves  forget.  Health  care  would  also  be  mindful  that  people  have  excellent  uses  for  their  
wealth  other  than  paying  for  care  they  do  not  need  or  for  illnesses  they  could  have  avoided.  

High  -­‐  Impact  Leadership    

According  to  the  Institute  for  Healthcare  Improvement  (2013),  leadership  is  the  
cornerstone  for  delivering  results  in  health  care  for  individuals  and  for  populations.  The  
goal  is  the  Triple  Aim  focus  of  simultaneously  maximizing  or  optimizing  what  is  in  the  
best  interest  of  patients  and  community:  Improve  the  care  experience,  improve  
population  health,  and  reduce  per  capita  health  care  costs.  

• Growing  Leadership  focus  to  achieve  Triple  Aim  results  for  populations  
• Triple  Aim  is  a  shift  from  volume  to  value  
• Three  Interdependent  Dimensions  of  leadership:  
1. New  Mental  Models  
2. High-­‐Impact  Leadership  Behaviors  
3. Institute  for  Healthcare  Improvement  High-­‐Impact  Leadership  Framework  

  How  Leaders  Think  

High-­‐impact  leadership  requires  the  adoption  of  new  mental  models:    

1. Individuals  and  their  families  are  partners  in  care.    

2. Compete  on  value,  with  continuous  reduction  in  operating  cost.    
3. Reorganize  services  to  align  with  new  payment  systems.    
4. Everyone  is  an  improver.    
                               

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Module  3.  Leadership  of  the  Future  

How  leaders  think  and  view  the  world  is  critical  in  shaping  their  approach  to  
transforming  from  volume-­‐based  to  value-­‐based  health  care  delivery.    

High  Impact  Leadership  Behaviors  

The  Institute  for  Healthcare  Improvement  (IHI)  has  identified  high  impact  behaviors.  
These  behaviors  are  an  outgrowth  of  the  mental  models  and  align  with  the  updated  IHI  
High  Impact  Leadership  Framework.  The  behaviors  consist  of:  

1.  person-­‐centeredness,  

2.  frontline  engagement,  

3.  relentless  focus,  

4.  transparency,  and    

5.  boundarilessness.  

The  Institute  for  Healthcare  Improvement  urges  leaders  to  adopt  these  5  behaviors  and  
have  confidence  that  they  will  be  mobilizing  themselves  and  their  organizations  in  the  
right  direction,  which  facilitates  transitioning  from  volume  to  value,  ultimately  driving  
towards  better  performance.  

The  Leadership  Framework  

The  Institute  for  Healthcare  Improvement  High-­‐Impact  Leadership  Framework  explicitly  

addresses  three  new  required  leadership  efforts  and  actions:    

1. Driven  by  persons  and  community  

2. Shape  desired  organizational  culture  
3. Engage  across  traditional  boundaries  of  health  care  systems  
 
The  framework  actions  and  initiatives  are  shaped  by  the  New  Mental  models  and  are  
supported  by  the  High-­‐Impact  Behaviors  previously  discussed.  The  focus  of  this  model  is  
to  lead  improvement  and  innovation.  It  is  a  distillation  of  broad  leadership  experience,  
practice,  theory,  and  approaches.  

Role  of  the  Nurse  in  Health  Policy  and  Health  Systems  

Essential  ingredients  for  renewed  public  health  enterprise:  

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Module  3.  Leadership  of  the  Future  

• Ensure  adequate  and  sustainable  funding  for  governmental  public  health    

– Generate  info  on  influences  on  population  health  
– Lead  or  support  interventions    
• Reform  how  governmental  public  health  infrastructure  is  funded  and  
operated  (e.g.,  change  funding  allocations  to  align  funding  with  needs,  
escape  silo  funding…)  
• Use  Public  Health  knowledge  to  help  reform  delivery  of  clinical  care  
quality  with  emphasis  on  
– Efficiency  
– Appropriateness  
– Integration  with  Public  Health  population-­‐based  efforts      
 

Recommendations  fall  into  four  general  areas:  

• Setting  a  national  health  improvement  target  

• Reforming  public  health  and  its  financing  
• Informing  the  investment  in  health  
• Strengthening  funding  sources  and  structures  to  build  public  health  
 

Successful  Health  Systems  and  Health  Systems  Research  

In  1985,  the  philanthropic  Rockefeller  Foundation  published  Good  Health  at  Low  
Cost  to  discuss  why  some  countries  or  regions  achieve  better  health  and  social  
outcomes  than  others  at  a  similar  level  of  income,  and  to  show  the  role  of  
political  will  and  socially  progressive  policies  (Balabanova,  D.,  et  al.,  (2013).  After  
25  years,  the  Good  Health  at  Low  Cost  project  revisited  these  places  but  also  
looked  at  Bangladesh,  Ethiopia,  Kyrgyzstan,  Thailand,  and  the  Indian  state  of  
Tamil  Nadu,  all  of  which  have  either  achieved  strong  improvements  in  health  or  
access  to  services,  or  implemented  innovative  health  policies  in  comparison  to  
their  neighbors.  Comparative  case  studies  spanning  2009  to  2011  looked  at  how  
and  why  these  changes  were  achieved.  Balabanova,  D.,  et  al.,  (2013)  cited  
attributes  of  success  as  good  governance  and  political  commitment,  effective  
bureaucracies  that  preserve  institutional  memory  and  can  learn  from  
experience,  and  the  ability  to  innovate  and  adapt  to  resource  limitations.  In  
addition,  the  ability  to  respond  to  the  needs  of  populations  and  to  build  
resilience  into  health  systems  in  the  face  of  economic  crises,  political  unrest,  and  
natural  disasters  was  also  important.  Transport  infrastructure,  female  
empowerment,  and  education  also  played  a  part  Balabanova,  D.,  et  al.,  (2013).    

Given  the  complexity  of  health  systems,  there  is  no  simple  recipe  for  success.  

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Module  3.  Leadership  of  the  Future  

However,  in  the  countries  and  regions  that  were  studied,  great  progress  was  
demonstrated  through  institutional  stability;  with  continuity  of  reforms  in  spite  
of  political  and  economic  turmoil,  lessons  learned  from  experience,  taking  
advantage  of  opportunities,  and  ensuring  sensitivity  to  context.  These  
experiences  show  that  improvements  in  health  can  still  be  achieved  in  countries  
with  scarce  resources,  but  strategic  investment  is  needed  to  address  new  
challenges  such  as  complex  chronic  diseases  and  growing  population  
expectations  (Balabanova,  D.,  et  al.,  2013).  

Kraushaar,  et  al.  (2012)  discussed  the  value  of  building  stronger  interdisciplinary  
networks  of  stakeholders  internationally  to  address  imbalanced  health  systems.  
There  is  growing  acknowledgement  that  health  system  performance  problems  in  
low-­‐  and  middle-­‐income  countries  are  a  major  obstacle  to  making  more  rapid  
progress  in  achieving  the  Millennium  Development  Goals  and  ensuring  universal  
health  coverage.  More  research  is  needed  to  address  the  reasons  for  health  
system  weaknesses  and  the  ways  and  means  of  improving  performance  
(Kraushaar,  et  al.,  2012).  While  there  is  substantial  ongoing  research  in  this  area,  
no  regular  forum  exists  where  findings,  methodologies,  and  tools  can  be  shared.  
As  a  result,  the  participants  of  the  First  International  Symposium  on  Health  
Systems  Research,  in  Montreux,  Switzerland  (2010),  called  for  the  creation  of  an  
international  society  for  health  systems  research  (Kraushaar,  et  al.,  2012).  

Health  Systems  Global  (HSG),  which  is  the  new  society  for  health  systems  
research,  intends  to  be  a  platform  at  the  local  and  global  levels  where  
researchers,  policy  makers,  civil  society  organizations,  and  concerned  citizens  
interact  to  align  research  with  national  and  global  priorities  and  to  ensure  
research  findings  inform  policy  that  leads  to  health  systems  transformation.  
Ultimately  the  organization  has  broader  advocacy  goals  of  achieving  universal  
healthcare  (Kraushaar,  et  al.,  2012).  

17