Taking the Next Steps...Planned Succession

The career handoff: Intentional sharing of knowledge and wisdom ​Chapter from The Career Handoff, an STTI book.

By Kathy Malloch and Tim Porter-O'Grady

This chapter from The Career Handoff: A Healthcare Leader's Guide to Knowledge & Wisdom Transfer Across Generations examines the critical components of successful communication, transition, handing off, and succession planning in the healthcare profession.   “Tell me and I forget, teach me and I may remember, involve me and I learn.” –Benjamin Franklin Every year, Tim and I schedule time for a retreat to plan what we are going to focus on in the next year. We select a special place where we can both think and play and do something special. At our latest retreat at the Ojai Valley Inn & Spa in California, we found ourselves wondering how many more revisions of our work we could do—and how much longer our ideas and strategies would be relevant for healthcare organizations. And then came the even tougher question: What would happen to our textbooks? Would Quantum Leadership just sail into the sunset? We humbly wanted the information that would be meaningful to future generations not to be lost; we did not want future generations to rediscover what we had already identified and shared. These questions got us to think about how to hand off our successful ideas to younger colleagues and selectively discard that which is no longer relevant. From that conversation, we began to strategize and learn about how to hand off knowledge and wisdom to younger generations, and this book is a result of those ideas.   We realized from our consulting practices that highly successful professionals are often reluctant to consider retirement, and many people avoid the thought of moving away from active engagement with colleagues in sharing knowledge and wisdom. It is even more challenging to figure out how to hand off or give one’s intellectual property to another colleague. As an unprecedented number of baby boomers move closer to retirement, there is much to share with succeeding generations. There is also some content or intellectual property that might not be applicable in future generations. We believe a formalized process for sharing and designating intellectual property and products would be helpful to not only our baby boomer colleagues but also to other generations of colleagues.   The Need for Generational Sharing Our professional consulting focus has been on the importance of leadership and in helping others to learn as much as possible about leadership—to embrace new ideas to become the most successful leaders possible. Our belief has always been that everyone is a leader, regardless of whether they have a formal leadership title. Whenever two individuals are together, one person begins the dialogue or movement in the simplest way, and leadership is evident. Each one of us has some special knowledge and expertise that future generations should or might want. Creating a culture as well as validating the science that assists others in handing off and nourishing our colleagues with our wisdom is important to both of us. Cultivating a culture of giving to others with minimal expectations of receiving something in return will allow future generations to grow and move on with what is vital to them. Our focus has shifted from figuring out what to give and how to instruct them to “love our stuff” to identifying interested colleagues and turning our work over to them to sort out and retain what is deemed valuable. It is also time for us to get out of the way of future leaders and shift from driving the boat to creating a safe space for others learning how to manage the boat’s journey!   Soon after our retreat, I was invited to keynote a leadership summit group; my focus was on this topic of generational sharing. Participants at this meeting included successful professionals from three generations, including chief executive officers, nurse executives, consultants, real estate executives, and physicians. As part of the keynote, I presented the plan Tim and I developed to hand off two of our books (see the feature that follows) and the discussion began to flow. Participants were highly interested in learning more and becoming involved in advancing the science of both giving and receiving intellectual property and the wisdom of ages.   Handing Off Our Publications After many years of writing books and revising those books, Tim and I wondered what would happen to our book content when we were really finished writing. So, after some thought, we decided to be proactive and formally pass on the writings. Over the course of our careers we had had many excellent students and colleagues; we selected two who we thought embraced our philosophy about innovation and leadership and had a track record for getting things done. We asked Dr. Dan Weberg and Dr. Sandra Davidson if they would be interested in taking on the work of combining our evidence-based practice (EBP) books with our Innovation Leadership book to make one “Innovation–Evidence Dynamic” book. They were extremely excited and ready to set up and pursue a plan to make this happen. Our next step was to contact the publisher and present our idea. The publisher developed a contract, and Tim and I reviewed and approved it. Then it went to Dan and Sandra as the new lead authors. For this new book, Dan and Sandra would be the lead authors while Tim and I followed them. In the next edition, only Dan and Sandra will be listed as authors, and Tim and I will be contributors as the new authors deem necessary. Dan and Sandra skillfully took the chapter content from both books, rearranged it, added new chapters, and deleted those they thought were less relevant in today’s healthcare world. Interestingly, this process seemed complicated when we began; however, with the highly professional new authors, the book has taken on a life of its own and is due to be published in the fall of 2015. We are excited to see the new book and know that Dan and Sandra will have exceeded our expectations. Reflecting on these ideas, we created a book proposal with the interested retreat participants. We now had a team of wisdom experts to join us on this journey and, most importantly, the authors represented three generations of interested professionals. We realized quickly that the importance of sharing generational wisdom was significant and that there was much interest from younger generations in learning more about our work and how to keep the useful knowledge alive and contemporary. Rather than seeing ourselves as the fading generation, it is time to see ourselves as a generation who now has much to share with the younger generations! We believe we created a talented team of wisdom managers to assist in this work. Further dialogue with the contributing authors provided clarification and enhancement of our ideas and solidified the importance of documenting and sharing generational wisdom, successes, and strategies that we would not repeat. We believe formalizing this process and providing guidelines for colleagues will be an important contribution to professional nursing practice. Each one of our authors has included specific discussion on what the handoff is, some practical tips for sharing knowledge, and exemplars to demonstrate personal experiences (and, of course, some irreverent humor; we all need to laugh and enjoy the nuances of our journey!). This book reflects our commitment to professional coaching, mentoring, and assuring that our young nurses are not chewed up by the system but are supported proactively. Mentoring is a vital professional behavior and an ethical obligation to our profession; we need to nourish our young rather than engage in the proverbial “eating our young.” In the next section, we share our personal and scholarly connections to the art and science of mentoring. Life Journey: Membership in the Profession Transitions and transformations are a fundamental part of the journey of life. Naturally, as we age and grow, we gather information, skill, insight, and wisdom that accumulate and aggregate in a way that becomes a part of our characters and personalities. As professionals, one of the most important considerations is the responsibility that membership in the nursing profession brings. Who we are and what we are become a part of our professional identity such that our person and profession become one and the same thing (Malloch & Porter-O’Grady, 2010). As we journey through our careers and our lives and are recognized as professional nurses, we essentially become the “person of the nurse.” As professionals, we integrate our work, our relationships, and our individual persona in a way that creates the frame for who we are and provides the substance of the image we present to the world. Consider a notice you might see in a newspaper about the appointment of a position to an administrative or public role—the writer acknowledges the relationship between the person and profession by identifying the particular individual as a “physician.” However, when a nurse is appointed in a similar fashion to an administrative or public role, he or she will more frequently be identified as a “former nurse.” For the physician the identity is singular; for the nurse the same identity is dual (a nurse is a job different from the administrative or public role and, therefore, cannot be identified in singular terms). Sage Insight Shared Across the Generations  We have had many opportunities to work with a number of organizations in helping to increase awareness of the many “sage” resources within those organizations. Often, the usual obligations of work overtake the value of reflection on past experiences, special skills, organizational tenure, insights, and wisdom gained from many years of providing healthcare services. In their haste to embrace contemporary challenges and opportunities for innovation, leaders often forget to access the tremendous acumens and talents of the more mature and long-tenured contributors in their midst. At the same time, those with gifts and wisdom to share need also to be available to their colleagues and new members of the professional staff in ways that are open, responsive, and engaging. A positive and renewing attitude that generates a sense of accomplishment and confidence provides a firm foundation out of which connections between a mentor and mentee can stimulate more positive relationships, meaningful interactions, and learning that can occur only between generations. Handing off knowledge to successive generations implies commitment and communication with those among us who have fresh ideas and different perspectives that need to be included in the dialogue among generations. As consultants with long tenure, we have been able to bring insights from outside the organization that may have already been available inside the organization, but leaders were often tied up with the challenges of the day in ways that didn’t make the same important insights easily visible to them. Taking advantage of these sage resources, leaders can fully access for the organization and for themselves the utility of the wisdom, insight, and history of those in the organization who have much to share. Often, a part of this scenario is the need to formally access and provide continuity to use of clinical and management leaders who have much of value to share. Sometimes decisions lacking sage information could lead to organizational challenge or failure. As consultants, we often communicate with more mature staff regarding long-term implications of a particular current crisis or challenge in a system. Often, what we have found is that the current critical issue has a direct or implied relationship to a continuum of decisions and actions predicated on a set of assumptions that could have been better informed had the key stakeholders been a part of the decision. Through the consultant’s lens, when leadership uses a succession or leadership handoff system that provides the right information, tools, and insights, many challenges and possible errors in leadership insight and strategy can be easily avoided. The trajectory of our experiences gives us information with regard to how complex systems work and represents the substance of our development. Along with our learning, our experience provides the platform for translating what we know and what we do in a way that has an impact on our own lives and on other people’s lives and experiences. At the same time, the experience and skills of colleagues and others that are significant in our lives have as much an impact on our development and growth, and those people do their part in influencing the course of our lives and the people we become. In our personal life journeys, there is a sort of developmental dance among our learning, our experiences, insights gained from others, and the relationships we share with people with whom we intersect (Patton, Zalon, & Ludwick, 2015). Each of these influences and the sum of them link within our persona to create a unique and individual life lens and insight related to our world and how we have lived in it.  “I am not a teacher, but an awakener.” –Robert Frost One of the joys of this life journey is the increased knowledge, insight, and skill we develop as we aggregate experiences and learning relationships. If we have had an open attitude in all these arenas, we have been available to the opportunities to deepen our insights and understandings and broaden our awareness in a way that helps us develop expertise that advances our talent as professionals. One of the urges this dynamic generates is the desire to share and to extend these insights and talents in a way that benefits others who are also eager for learning and personal development. This desire to share knowledge and skill is an outgrowth of our own openness and availability to learning and personal development. Those individuals who understand this dynamic also recognize that embedded in it is the give-and-take reflected in the interaction of all who share a commitment to growing, learning, and deepening their knowledge and understanding.

Nurse staffing and patient experience outcomes: A close connection

Focus on...Quality and Patient Safety

Nurse staffing and patient experience outcomes: A close connection

Publication Date: January 2016 Vol. 11 No. 1

Author: Nell Buhlman, MBA

As healthcare providers set and refine their strategies for staying competitive in a value-based delivery and payment system, a sharper understanding of the interplay between inputs and outputs becomes a strategic imperative. Nurse staffing is a key input for acute-care hospitals—key both for its impact on care and its budget prominence. This puts it squarely at the center of hospitals’ efforts to deliver on their value promise.
The relationship between staff­ing and patient outcomes across quality, safety, and experience domains is appreciated intuitively, if not always precisely understood. The imperative to strike the perfect balance drives considerable interest and research in fine-tuning this understanding. Yet vast scholarship on the topic hasn’t produced a precise staffing formula that will lead predictably to desirable outcomes.

That’s because high-quality nursing care hinges on much more than the number of nurses on the job for a particular patient load. It also depends on multiple under­-lying structural and process factors, such as nurses’ skills and education, availability of sufficient supplies and equipment, staff training, facilities, and reliable use of demonstrated best nursing practices—as well as such factors as interprofessional relationships, nurse engagement, and job satisfaction.
To fully understand the impact of staffing levels on patients’ clinical and experience outcomes, we must consider the relationships within and among these variables—something we can do only through data integration and cross-domain analytics.

Value of NDNQI data

In 2014, Press Ganey acquired the National Database of Nursing Quality Indicators® (NDNQI®)—the industry gold standard for assessing nursing excellence—from the American Nurses Association. NDNQI national benchmarking data are invaluable for monitoring key nursing-sensitive structure, process, and outcome measures. Similarly, Press Ganey’s vast patient experience database offers critical insight into patients’ perceptions about the effectiveness of hospital operations, clarity of the care team’s communication, and caregivers’ ability to meet patients’ needs.
As with nurse staffing, a growing body of evidence shows associations between patient-experience outcomes and clinical outcomes. Combining NDNQI and patient-
experience data provides unprecedented access to the relationships among key pieces of information. Together, these measures can help nurse leaders identify how performance changes in certain structural and process indicators affect patient safety, experience, and clinical outcomes.
Given the enormous impact of nursing on the patient experience—and because nurse staffing often is a lightning rod in the debate on how to deliver high-value care—using the combined dataset to better understand how the two relate is a research priority. Our early analyses show that performance on both Press Ganey and Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) domains correlates significantly with nursing hours per patient day and RN hours per patient day, with the latter showing stronger associations in every domain. (See Correlations between nurse staffing and HCAHPS scores.) The link between more bedside nurses and a better patient experience isn’t surprising. That the correlations stretch across all experience domains—not just those that examine quality and frequency of nurse-patient interactions—is eye-opening.

Staffing that meets patient needs and reduces suffering

While domain-level correlations confirm long-held beliefs about the relationship between staffing and patient experience, we seek to understand which aspects of the patient experience are most sensitive to staffing. Where do staffing levels make a difference in caregivers’ success in meeting patient needs? Where can staffing serve as a lever to improve performance?
Item- and question-level analyses help answer these questions. In the two tables HCAHPS scores and nursing hours per patient day and Press Ganey mean score, we see that for HCAHPS top-box scores and Press Ganey mean scores, every item showed sensitivity to staffing levels. Where the difference in patient experience scores is greatest (meaning when hospitals in the top decile of staffing ratios dramatically out­-perform hospitals in the bottom decile), staffing can be viewed as a more powerful performance-improvement lever.

Reducing patient suffering

Of particular interest are differences in performance on key patient-experience questions related to patient suffering, which may indicate how effectively an organization provides patient-centered, personalized care. Press Ganey staff believe that relieving suffering should be central to efforts aimed at providing patient-centered care.
Patient suffering falls into two categories:

• Inherent suffering results from the patient’s diagnosis, treatment, or both. It can’t be avoided entirely, but it can be mitigated. Some types of inherent suffering are well understood and addressed with some consistency—for instance, using pain control and explaining and managing symptoms. Inherent suffering includes psychosocial suffering, which caregivers are less comfortable with and therefore less practiced at addressing. Such suffering includes fear, anxiety, confusion, loss of dignity and autonomy, and uncertainty about self-care after discharge.
• Avoidable suffering arises from systemic defects, which may include long waits to receive treatment, poor communication, poor coordination among providers, errors, and failure to follow best practices. An important first step in determining how to avoid that kind of suffering is to understand that dysfunction creates additional suffering for people already burdened by inherent suffering.

Inherent suffering can be reduced by understanding and meeting inherent patient needs. Performance on certain patient-experience survey questions can tell caregivers much about how well they’re meeting patients’ needs. Examining the relationship between staffing ratios and performance on these questions is illuminating. The table Reducing suffering: Top-decile vs. bottom-decile hospitals illustrates the dramatic differences in performance between top-decile and bottom-decile hospitals on questions relating to patient anxiety, autonomy, and the need to be informed about and involved in their care. These differences speak volumes about the importance of adequately resourced nursing units to give caregivers sufficient time to meet these patient needs.

It’s never just one thing

These findings don’t suggest that increasing nurse-patient ratios will automatically lead to performance improvements. Certainly, adequate nurse staffing is key to a range of outcomes, but changing staffing volume alone won’t produce optimal outcomes. Multiple aspects of structure and process also shape outcomes, and these findings must be leveraged with that in mind.
Such factors as demographics of the nursing force, education and certification, engagement, and organizational staffing models are associated with patient-experience outcomes, as are cultural and structural practices and processes. In this regard, answers to the questions below also factor into outcomes:

• Is the nursing staff following best practices associated with better patient experiences?
• Are they executing on those best practices consistently and in the prescribed manner every single time?
• Do nurses have the right resources and training to promote consistency?

For example, a best practice such as purposeful hourly rounding on patient experience can have a dramatic impact. A 2013 Press Ganey study shows that patients who report they were visited by staff hourly during their hospital stay were much more likely to give top box scores on all HCAHPS questions—a clear sign their needs were being met more consistently. See the table Effect of hourly rounding on HCAHPS scores for details.

The concept of value over volume extends beyond changes to delivery and payment models. For hospitals, “getting it right” with their nursing organizations is particularly important because nursing care provides much of the value hospitals create. Adequate human resources are critical, but they’re not enough on their own. Nurse leaders must consider the full range of inputs—in addition to adequate human resources—that drive outcomes, including staff quality or caliber, the environment in which they operate, and shared commitment to providing a high-value experience for patients.

Nell Buhlman is senior vice president of Clinical and Quality Solutions at Press Ganey Associates in South Bend, Indiana. Note: Charts are copyrighted by Press Ganey and used with permission.

Selected references
Armstrong K, Laschinger H, Wong C. Workplace empowerment and Magnet hospital characteristics as predictors of patient safety climate. J Nurs Care Qual. 2009;24(1):55-62.
Dempsey C, Reilly B, Buhlman N. Improving the patient experience: real-world strategies for engaging nurses. J Nurs Adm. 2014; 44(3):142-51.
Halm MA. Hourly rounds: what does the evidence indicate? Am J Crit Care. 2009;18(6): 581-84.