Discuss The Role of Executive Leadership

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Discuss The Role of Executive Leadership

Discuss The Role of Executive Leadership

Author Affiliations: Vice President and Assistant Chief Nurse Executive (Dr Mosier), Vice President of Care Delivery and Perfor- mance (Dr Roberts), and Senior Vice President and Chief Nurse Executive (Dr Englebright), HCA Healthcare, Nashville Tennessee.

The authors declare no conflicts of interest. Correspondence: Dr Englebright, HCA Healthcare, One Park

Plaza, Nashville, TN 37203 (Jane.Englebright@hcahealthcare.com). DOI: 10.1097/NNA.0000000000000815

JONA � Vol. 49, No. 11 � November 2019

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JONA Volume 49, Number 11, pp 543-548 Copyright © 2019 Wolters Kluwer Health, Inc. All rights reserved.


A Systems-Level Method for Developing Nursing Informatics Solutions

The Role of Executive Leadership
Sammie Mosier, DHA, MA, BSN, NE-BC, CMSRN, BC Wm. Dan Roberts, PhD, RN, ACNP Jane Englebright, PhD, RN, CENP, FAAN

Nursing leadership can play an essential role in the de- velopment of nursing informatics solutions by virtue of their broad understanding and oversight of nursing care. We describe a systems-level method for creating nursing informatics solutions with clearly defined struc- ture and leadership from nursing executives. Based on the guiding principles of clear lines of responsibility, respect for expertise, and commitment to project aims, this allows nursing executive leadership to orga- nize, set up, and own the development of nursing infor- matics solutions.

Data about nursing care have become a critical com- ponent of operational and patient care decisions. These data can potentially affect the productivity, ef- ficiency, performance, effectiveness, cost, and value of nursing care when properly collected and used. The management and processing of data into knowl- edge for use in nursing practice have become an im- portant specialty within the last decade.1

Nurse executives are dependent on data for effec- tive decision making. The American Organization of Nurse Leaders has identified essential competencies in informatics that are necessary for effective leader- ship of this technology and data-informed environ- ment.2 In the age of big data, nurse executives are responsible for creation of the framework that allows for nurses and other experts to apply their knowledge,

er H

such as through the creation of a data culture, the de- velopment of data competencies, and the establish- ment of data infrastructure.3

Together, nurse executives and nurse informaticists are forging new solutions to improve nursing processes and patient care. The challenge is in determining how best to coordinate the efforts of subject matter experts from nursing, informatics, and information technol- ogy to design, develop, and deploy solutions to very complex problems. Nursing leadership is well poised to influence these processes by virtue of their broad understanding and oversight of nursing care. While not usually engaged in the development of nursing in- formatics solutions, we propose that executive leader- ship is necessary to this process.

Here we discuss our development of a systems-level method, with clearly defined structure and leadership from nursing executives, to create nursing informatics solutions that enhance patient care. This article will describe the method and provide case examples of 2 successful applications.

Methods This project was conducted within a large network of hospitals with affiliated facilities across the United States and United Kingdom. The goal was to develop a method for aligning leadership, clinical experts, informaticists, and information technology experts to design, develop, and deploy nursing informatics solutions.

The chief nurse executive (CNE) developed the framework to harmonize the work efforts of dispa- rate groups of clinical and informatics experts that were necessary to design, develop, and deploy nursing informatics solutions. The framework was based on 3 guiding principles: clear lines of responsibility and


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authority, respect for each type of expertise necessary to the project, and clear commitment to the aims of the project.

Figure 1 depicts the structure. Clear lines of re- sponsibility consisted of dedicated leadership for each component of the process, starting with executive spon- sorship and guidance. A steering committee of nurs- ing executives set the vision, objectives, scope, and guiding principles. The steering committee served as a resource for the other teams and an arbitrator of disputes between conflicting priorities. Teams of con- tent experts and end-users were tasked with defining good practice and ideal workflow to generate tech- nology requirements. Technical experts were charged with designing the technology solutions that could meet requirements, support the workflow, present content optimally, and incorporate decision support when pos- sible. The clinical and technical teams work iteratively to develop and test aspects of the proposed solution.

Subject matter experts provided critical input on regulatory requirements, answering questions and providing audit and review services. Project manage- ment resources ensured the appropriate flow of decisions and work products among the teams in the appropriate sequence and ensured that any issues were escalated to the steering committee expeditiously.

Respect for different types of expertise ensured that each of the above responsible parties was able to operate fully within their area of expertise. Technical experts deferred to clinicians on content and workflow. Clinical experts deferred to informatics experts on the

Figure 1. Structure.


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best way to design input and output and the use of de- cision support. Regulatory experts deferred to clinical experts on content and workflow while providing guidance on regulatory requirements, including eval- uation of the final product.

Commitment to the vision and guiding principles established by the steering committee was a require- ment for all colleagues participating in the project. A clearly articulated set of guiding principles was used in each work session to guide team members as they designed, developed, and deployed the new solution. Final success was measured on how well the solution adhered to these guiding principles.

This framework was used to develop 2 distinct nursing informatics solutions within a large hospital system: Evidence-Based Clinical Documentation (EBCD) and the Nursing Data Portal (NDP). These informat- ics solutions were designed to meet the operational goals of: 1) minimizing nursing documentation into an evidence-based story of the patient; 2) creating a more useful and usable patient-centric record that guides and informs the provision of safe, effective, and efficient care by the interdisciplinary team; and 3) rendering standardized and normalized data for the purpose of performance visibility and evaluation of nursing care of individuals and population at both the process and outcome levels. Through adherence to the framework, the resulting informatics solutions constructed to contribute to the healthcare learning environment through the continuous generation of knowledge and feedback to clinical practice.

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Evidence-Based Clinical Documentation In the development of EBCD, clear lines of responsi- bility began with the chief nursing officer (CNO) Coun- cil (Figure 2). The CNO Council served as the steering committee for EBCD, overseeing the progress of the project teams. This group served as a champion of the organization’s nursing agenda and provided guid- ance and input into decisions related to patient care, including operational issues and prioritization of clin- ical projects. The CNO Council defined the guiding principles for the process and product, ensured adher- ence to the overall vision, and acted as an arbitrator of conflicting viewpoints.

The Content Team was led by clinical leaders and included ad hoc committees of clinical experts orga- nized by specialty. Each ad hoc committee focused on the specific tasks and questions relevant to their area of expertise. Clinical experts with current patient care experience were able to define the data flow needed to support the previously developed ideal workflows,4 use evidence reviews to develop content, and identify the desired decision support.

Development of the decision support, creation of a style guide, and review of existing screen designs were the responsibility of technical experts. Regula- tory subject matter experts addressed questions about regulatory compliance, billing compliance, and risk management and performed on-site assessment for regulatory compliance. Throughout the entire process,

Figure 2. Evidence-based practice clinical documentation proje

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the project management team managed to timeline, maintained communication, designed implementa- tion and education strategies, and assisted the collab- oration between teams to resolve issues.

With the clear lines of responsibility defined and respect for expertise established, the development of EBCD progressed in alignment with the vision for this project. The overall vision for this project was to cre- ate a patient-centric record that guides and informs the provision of safe, effective, and efficient care by the interdisciplinary team and produces data to valu- ate care of individual and population of care (Figure 3). To achieve this vision, guiding principles were devel- oped in regard to design and content.

The guiding principles of EBCD design were es- tablished to ensure that the final product enhanced and supported the process of patient care documenta- tion, such as strict adherence to the style guide for consistency and alignment with the previously defined ideal workflows.4 The guiding principles of EBCD content ensured that documentation entered through this system would be meaningful to patient care or necessary for regulatory or billing requirements and that the resulting documentation would support the ethical and competent clinician.

Nursing Data Portal In the development of the NDP, the steering commit- tee consisted of the CNO Council with representation from CNEs and unit directors, the 2 primary end- users for the product. Responsibility for content was

ct team.


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Figure 3. Flow of information for patient centric record.

designated to corporate clinical leaders and data owners. Technical responsibility was shared between the nursing analytics, data science, and information technology teams. Other defined responsibilities were assigned to subject matter expert teams, including pa- tient experience, human resources, and financial and executive leaders. Strong project management pro- cesses facilitated the iterative flow of decisions and tool development (Figure 4).

The focused expertise of these teams was key to the success of this project. The steering committee iden- tified 4 domains of performance (clinical outcomes, patient experience, efficiency, and nursing engage- ment) and provided final approval of the indicators that would be used in the completed product. Techni- cal experts were the backbone of all the data needs for the final project. They created the data visualization plan, transformed data to usable scoring methods, harmonized time frames from disparate data sources,

Figure 4. Nursing data portal project team.


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and aligned the data to other reports with the same metrics. The various subject matter experts suggested common metrics that were to be included in the final product. These teams also validated all data post- transformation prior to the creation of data visualiza- tions. In essence, the subject matter experts verified the work of the technical experts before any data were released for viewing. Project management team mem- bers designed the implementation and education strate- gies for this project and also managed communication and issue resolution among the teams to meet the pro- ject timeline goals.

With the clear lines of responsibility established and experts assembled for the various project compo- nents, the development of the NDP progressed toward its singular unifying vision: one common platform for sharing nursing performance data (Figure 5). Through the careful design of source system screens and data pathways and requirements, nursing performance

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Figure 5. Platform to share nursing performance data.

metrics from multiple systems could be concisely displayed on 1 page for maximum accessibility. The vision of the NDP was achieved through adherence to the guiding principle of easily understood data and visualizations.

Discussion Through the creation of a systems-level framework that clearly defined responsibility, roles, and vision, we successfully designed and implemented 2 large- scale nursing informatics solutions. These informatics solutions were different from each other—1 clinically focused and 1 focused on leadership—but were built upon the same systems-level framework. In this method, there was a clearly defined role and responsibility for nursing executive leadership from the beginning of the project to the end.

Multiple contemporaneous articles have demon- strated the supportive role of nursing leadership and informatics.5,6 Specific leadership roles, such as chief nursing informatics officers and nursing informatics executives, have emerged as central to the support of transformation and the use of appropriate technology solutions in clinical practice.7,8 Outside these specific roles, there is a need for nurse leaders, including CNEs, to have knowledge about informatics and its role in patient care.9 Nurse leaders should be allowed oppor- tunities to both gain these competencies and apply their knowledge to decision making regarding infor- matics system and nursing care.9-11

Our systems-level method demonstrates the role of specific leadership in guiding the ideation, design, development, data mapping and visualization, and application of the products developed during the in- formatics and technology life cycle. Each of these

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components is integral to the functionality, adoption, and use of the final solution. Nursing executive lead- ership must not only develop a clear structure, time- line, and goals for the entire process but also provide valuable insight into product development. This lead- ership contributed to the effectiveness of these solu- tions as part of the continuous feedback loop within a learning healthcare environment. The knowledge and understanding of clinical practice gained through these solutions can be applied to subsequent applications and efforts to refine and innovate within nursing care.

Furthermore, our method maximizes the exper- tise of those most knowledgeable about individual components. The clarity of roles ensured that critical input was provided by the appropriate team mem- bers. For instance, technical experts and informatics professionals focused on the best way to design input and output and the use of decision support while cli- nicians were responsible for content and workflow.

An added benefit of this method is improved adop- tion of the resulting solutions. Leadership engagement is a key component of implementation processes.12-14 In our method, leadership are engaged early and often in the design process, ensuring that the solutions also met the needs of leaders. Leadership engagement allowed for local needs and workflow considerations to be in- corporated into the design, improving end-user uptake.

In summary, we have developed a systems-level method that allows nursing executive leadership to organize, set up, and own processes related to the de- velopment nursing informatics solutions. Our organi- zation has used this structure for several projects with positive results. Use and adaptation of the strategies of this method may offer a way for nursing leadership to guide and influence future solutions.


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2. American Organization of Nurse Executives. AONE Nurse Executive Competencies. Chicago, IL: AONE; 2015. https://

www.aonl.org/sites/default/files/aone/nurse-executive- competencies.pdf. Accessed July 25, 2019.

3. Englebright J, Caspers B. The role of the chief nurse executive in the big data revolution. Nurse Lead. 2016;14(4):280-284.


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4. Mosier S, Englebright J. The first step toward reducing docu- mentation: defining ideal workflows. Comput Inform Nurs. 2019;37(2):57-59.

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6. Liebe JD, Hüsers J, Hübner U. Investigating the roots of suc- cessful IT adoption processes—an empirical study exploring the shared awareness-knowledge of directors of nursing and chief in- formation officers. BMC Med Inform Decis Mak. 2016;16:10.

7. Institute of Medicine. The Future of Nursing: Leading Change, Advancing Health. Washington, DC: The National Academies Press; 2010.

8. Hussey PA, Kennedy MA. Instantiating informatics in nursing practice for integrated patient centred holistic models of care: a discussion paper. J Adv Nurs. 2016;72(5):1030-1041.

9. Simpson RL. Chief nurse executives need contemporary infor- matics competencies. Nurs Econ. 2013;31(6):277-287; quiz 2887.

10. Healthcare Information and Management Systems Society (HIMSS). Transforming Nursing Practice Through Technology

The Journal of Nursi Instructions f

Instructions for Authors can be f below. To ensure that your manu with new submission procedures document carefully before manu manuscripts must be submitted e system.

Please visit http://JO


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and Informatics: A Position Statement. Chicago, IL: HIMSS; 2011. https://www.himss.org/position-statement-transforming- nursing-through-technology-and-informatics. Accessed July 25, 2019.

11. Oakes M, Frisch N, Potter P, Borycki E. Readiness of nurse ex- ecutives and leaders to advocate for health information systems supporting nursing. Stud Health Technol Inform. 2015;208: 296-301.

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14. Gifford WA, Davies B, Edwards N, Graham ID. Leadership strategies to influence the use of clinical practice guidelines. Nurs Leadersh. 2006;19:72-88.

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