Running head: A NURSING LEADER

A Nursing Leader: CEO of Providence Hospital Hollis Misiewicz NURS 734

A NURSING LEADER A Nursing Leader: CEO of Providence Hospital Introduction

Providence Hospital in Washington DC is celebrating its 150th birthday this year. Recent years have seen a decline in patients as physicians have moved to other institutions citing lack of services and support. Fewer patients at Providence are commercially insured and this combination has led to financial woes for the hospital. Recently a new Chief Executive Officer (CEO) was brought into the organization and this paper will describe how she is moving to change Providence back to a hospital that attracts physicians and patients to seek the services provided here.

Characteristics of Providence Hospital Providence Hospital is a community hospital located in the northeast area of Washington, DC. It is affiliated with Ascension Health, the largest Catholic healthcare system with 500 locations in 19 states and the District of Columbia. Providence Hospital currently has 408 licensed inpatient beds and a nursing home/rehabilitation center with 250 beds. Specialty services offered at Providence include; (1) older adult services; (2) maternal/infant health; (3) behavioral health; (4) cancer diagnostics and treatment; (5) orthopedics; (6) a sleep disorders institute and; (7) a wellness institute. Providence has 2,000 employees working at the hospital and 400 employees at the nursing home/rehabilitation center, Carroll Manor (A. Freeman, personal communication, October 20, 2010). Service Area Demographics Providence Hospitals primary service area is comprised of approximately 475,000 people with almost equal numbers of commercially insured, Medicare and Medicaid patients.

A NURSING LEADER This population is racially diverse with Hispanic, African-American and Caucasian segments. The average age is considerably older than the United States as a whole. Demographics of this area compared to the entire United States indicate lower median income, greater poverty rates,

double digit unemployment and more than half with female heads of household. The secondary area serviced by Providence has a population of approximately 350,000 that is also racially diverse. This area compares favorably to the United States with a higher median income, lower poverty rate and single digit unemployment. 40% of the people in this area are commercially insured in comparison to 33% in the primary service area (Lurie et al, 2008). Providence competes with eight area hospitals in the District of Columbia and nearby Maryland. Identified Problems M. Jennings Consulting (2010) conducted interviews with 58 people including board members, physicians, administrative leaders and others to explore opinions on problems, challenges and opportunities for Providence Hospital. What they found was that participants had a much easier time identifying disappointments than successes. Overall it was felt that Providence ; (1) was lacking strategic direction, identity and focus; (2) was out of date, not progressive; (3) had a management team that lacked cohesiveness; (4) lacked electronic health records and IT infrastructure; (5) had low physician morale with conflicts between physicians and management; (6) had shabby facilities and; (7) had a lack of accountability. Although one third of the population in Providences service area has commercial insurance only 5% of patients served at Providence do. Providence does not have a Medicaid/self-pay problem, it has a commercially insured problem (Jennings Consulting, 2010, page 34). In addition to the above it was noted by the CEO that the entire infrastructure of the hospital system, such as policies and procedures, had not been reviewed or updated in twenty years (A. Freeman, personal

A NURSING LEADER communication, October 20, 2010). Providence was extremely behind the times and unable to provide services expected by many physicians so they began to treat and admit their patients

elsewhere. This has made the financial position of Providence Hospital very precarious. These interviews revealed problems at Providence that are consistent with issues at many hospitals in the United States. A survey of CEOs in 390 hospitals conducted by the American College of Healthcare Executives ranked financial issues, care of the underinsured and uninsured, and physician-hospital relations among the top three problems faced by their organizations (Erwin, 2009). Internal problems within the hospital have also contributed to the shaky ground that the organization stands on. Currently the vacancy rate for nurses and certified nursing assistants stands at 22%. Many of the staff are working overtime or agency staff are utilized to cover deficits in staffing (A. Freeman, personal communication, October 20, 2010). This can lead to employee burnout in addition to expenditures significantly exceeding the budget. Increased costs such as these prevent the hospital having the resources needed to improve services or increase employees salaries. Employees have voiced their concerns about overworking and what they consider an insignificant raise. Organizational Structure Providence hospital is affiliated with Ascension Health, a Catholic health system that is sponsored by six organizations that include four provinces of the Daughters of Charity, the Congregation of St. Joseph and the Sisters of St. Joseph of Carondelet. This large system enables hospitals to serve the needs of their local communities yet maintain their financial vitality and diversification of resources. Their primary principle of operation allows the hospital affiliates to maintain flexibility in order to meet local community needs. Each hospital board and

A NURSING LEADER CEO is allowed to operate in a manner that is appropriate to the people that they serve (A. Freeman, personal communication, October 20, 2010). Providence Hospital has its own Board of Directors that is the governing body that

influences the strategy of the hospital and oversees broad operational strategies and trends. They do not have any operational responsibilities. The Chief Executive Officer is the leader of the executive core team and has the highest level of responsibility for the viability of the organization and day to day operations. The executive team that directly reports to the CEO is composed of Senior Vice Presidents of; (1) Patient Care Services and Chief Nursing Officer; (2) Chief Financial Officer; (3) Behavioral Health and Support Services; (4) Medical Affairs and; (5) Clinical Operations. The Chief Information Officer and President/CEO of the Providence Health Foundation also report directly to the CEO. Reporting to the Senior Vice Presidents are the Vice Presidents of; (1) Mission; (2) Human Resources; (3) Marketing and Public Relations and; (4) Symphony and Risk Management. The Senior Director of Sustainability and Environmental Health and Safety and the Chief of Clinical Excellence also report to the Senior Vice Presidents. These people all make up the executive leadership team at Providence Hospital (A. Freeman, personal communication, October 20, 2010). CEO of Providence Hospital Approximately seven months ago the Board of Directors felt it was time for a change in leadership within the hospital in order to transform what had become an abysmal operational and financial situation. The CEO was fired and the Board hired Amy Freeman, previously a Senior Vice President at Mercy Medical Center. Ms. Freeman is a nurse. She received her BSN at Catholic University. She received her Masters of Nursing Administration at the University of Maryland. Following this she completed a post-graduate fellowship in nursing and hospital

A NURSING LEADER administration. After working for five years, she completed another fellowship in material management. She has a wide variety of nursing and hospital administration experience (A. Freeman, personal communication, October 20, 2010). When Ms. Freeman came on board at Providence Hospital last March, one of the first changes she made was to her executive team. Of the six Senior Vice Presidents, three have

arrived at Providence in the last three months including the Chief Nursing Officer who has been at Providence for only three weeks. With the help of this team a five year strategic plan was developed that has been recently finalized and approved by the executive leadership team. This plan is soon to be presented to the Board of Directors for their approval (A. Freeman, personal communication, October 20, 2010). Strategic Plan The five year strategic plan of Providence Hospital is based on the Strategic Directions of Ascension Health: Healthcare that Works, Healthcare that is Safe, and Healthcare that Leaves No One Behind. Strategies for Healthcare that Works include; (1) improving the physical appearance of the hospital, patient flow and service coordination to enhance patient satisfaction; (2) continue financial performance improvement processes; (3) implement an ambulatory services development plan to compete effectively for patients; (4) become more cost-effective on a per inpatient case; (5) strengthen fund-raising to support growth and development and: (5) become an environmentally sustainable organization. Strategies for Healthcare that is Safe encompass; (1) achieve new levels of error reduction; (2) demonstrate sustained improvement in Priorities for Action; (3) demonstrate continuous improvement in clinical outcomes measures tied to Value-Based Payment and; (4) engage physicians as co-leaders and decision-makers in the development of chronic care pathways, quality, safety and service initiatives. Strategies for

A NURSING LEADER Healthcare that Leaves No One Behind include: (1) partner and serve as a catalyst for focused Diabetes and Obesity prevention, education, and support programs; (2) focus advocacy effort around enhancing prenatal and peri-natal care, reducing diabetes and obesity and reducing the onset of preventable diseases; (3) obtain grant funding and pilot program funding to support health outcomes research and innovative models of healthy living and; (4) establish leadership position among District Hospitals in the community and develop strong relationships with area businesses and the District. Providence Hospital also plans on developing Centers of Clinical Excellence in orthopedics, bariatrics and diabetes (Jennings Consulting, 2010). Leadership Style

It is recognized that health care leaders in this day and age require different competencies than in the past. Executive leaders must have technical skills, knowledge of the industry, the ability to analyze and conceptualize problems, skills in negotiation, communication and the ability to work within a team. In addition, within an organization such as Providence Hospital, the CEO must have the skill to use turbulence as an adaptive rather than a disruptive force (Ford, 2009). This is difficult because as Ms. Freeman herself said This undertaking is particularly problematic because at the same time that we are projecting to the future and developing goals for the next five years we are also building a completely new foundation. Ms. Freemans predominant leadership style is one of transformational leadership. This is defined by the leader providing a vision and mission for the organization. Incorporating mission and vision into the organization strategy and structure is an important competency for healthcare administrators (Begun, White, & Masser, 2010). These leaders have high expectations, promote intelligence and rationality and encourage careful problem solving. The transformational leader considers each person an individual giving personal attention and

A NURSING LEADER advising and coaching as needed (Deckard, 2011). Ms. Freeman emphasized the mission and vision of Providence throughout the entire process of developing the five year strategic plan.

This mission is to serve all persons with joy, care and respect, giving special attention to the poor and vulnerable. The vision of Providence Hospital is to be the provider of choice for excellent, faith-based healthcare. The mission of Providence is actualized within the Strategic Directions of Ascension Health. Healthcare that Works, Healthcare that is Safe and Healthcare that Leaves No One Behind is incorporated into the goals of the five year strategic plan. The CEO led her executive team throughout the entire development of this plan never losing sight of the hospitals mission and vision. Ms. Freeman values intelligence in her executive leader team and stresses the importance of clinical knowledge. Many of her Senior Vice Presidents are physicians, nurses or pharmacists. They all have years of experience in direct patient care. Ms. Freeman expressed the thought that clinical knowledge brings a better understanding of problem solving within a healthcare institution. In addition, she feels that unless you have been there you cannot truly understand some of the concerns of the staff (A. Freeman, personal communication, October 20, 2010). The transformational leader recognizes individuals and gives personal attention (Deckard, 2011). Ms. Freeman has made it a point to walk the hospital several times a week ever since she arrived at Providence. In this way she felt she could truly see what was going on in the units, get a feel for the problems and get to know the staff. This was apparent as staff talked with her in the halls and elevators and she knew them all. This included dietary staff, housekeeping staff and nurses assistants as well as nurses and physicians.

A NURSING LEADER On rare occasions Ms. Freeman exhibits some characteristics of the transactional leadership style. This leadership style is directed toward the accomplishment of goals and the leader will take corrective action if it appears these goals will not be met (Deckard, 2011). On one occasion Ms. Freeman met with one of her Vice Presidents to review the presentation that

would be given at a Town Meeting in two hours. The slides were not appropriate for the staff to which they were to be presented and some vital content was missing. The CEO made it clear that this was not acceptable and needed to be remedied immediately. She was polite but firm. The changes were made prior to the meeting. Although the predominant style of leadership of Ms. Freeman is transformational, in specific circumstances she was able to utilize a style of leadership that would bring forth better results. The Change Process During the planning phase of developing the hospitals five year strategic plan requirements for effective change were addressed. Lewins change management model addresses the need for driving forces that originate in the goals, ambitions and needs of the organization in order to initiate change. His model of change consists of three steps; (1) unfreezing, where the need for change is communicated to the organization and defense mechanisms are overcome; (2) moving, which aims to strengthens change forces to allow the change to take place and (3) refreezing, which reinforces the new change to prevent participants from reverting to former behavior (Suc, Prokosch, & Ganslandt, 2009). During planning sessions for the five year strategic plan the CEO presented the requirements for effective change. The pressure to change originated with problems with internal performance issues, needs of the community that were not currently being met and a common definition of the opportunities and challenges that existed. These were the driving

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forces that drove the change and discussion of these forces began the unfreezing process for the executive leader team. This unfreezing stage is just being addressed within the hospital as a whole as the five year strategic plan is just now being presented to staff. For the executive leader team the capacity to change is encompassed in the belief that there is a compelling reason to change. The CEO is leading this change with relentless focus and persistence to overcome obstacles. All planned actions are tied to the hospitals vision and meaningful measures and targets are defined. This is encompassed in the moving step of Lewins change model along with the action plan of the hospital (Suc, Prokosch, & Ganslandt, 2009). This action plan delineates the implementation of roles, responsibilities, timetables and financial viability of the change (Jennings Consulting, 2010). Providence Hospital has not yet accomplished the refreezing stage of Lewins change model. Communication Patterns of communication flow can be upward, from subordinates to supervisors, horizontal, between managers or coworkers, and downward, from supervisor to subordinates (Guo, 2011). The CEO of Providence encourages communication between all levels of staff within the hospital. During the development process of the strategic plan both downward and horizontal communication flow was present. The CEO presented her ideas to her executive team in a downward flow of communication. They discussed their views among themselves in a horizontal flow and to the CEO in an upward flow of communication. The decision making style of the CEO is a combination of analytic, conceptual and behavioral. She desires information from her executive team and is willing to consider alternatives presented by them. She also considers data from multiple outside sources as well. She shows a concern for the hospital and the people who are a part of that organization. These characteristics are seen in the analytic,

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conceptual and behavioral decision style models (Borkowski, 2011). The five year strategic plan is just now being presented to the employees and this is being done in the form of Town Hall Meetings. A downward flow of communication is seen here as the CEO presents the plan to staff and, as the staff expresses their ideas and concerns to her, an upward flow of communication is seen. Conflicts Conflict can be either positive or negative (Borkowski, 2011). When asked about conflict within the executive team the CEO stated that she didnt feel that there was conflict but rather what she would describe as creative tension. She feels that differences in ideas among the executive staff stimulated discussions where solutions to problems were obtained in a collaborative fashion. This would demonstrate a positive type of conflict. The Town Hall Meetings brought to the forefront concerns that staff were having and conflict between the employees and management was expressed. Intergroup conflict involves problems between groups and this is vertical conflict when it occurs between employees at different levels within the hospital. At the Town Hall Meeting the two major concerns expressed by staff were: (1) dissatisfaction with the 1% raise and: (2) staffing shortages. The conflict-handling mode utilized by the CEO would be described as collaborative. This style involves behavior that is cooperative and assertive. This leader sees conflict as a way to come up with creative solutions and maximize goal accomplishment for all parties (Borkowski, 2011). Ms. Freeman conducted these Town Hall Meetings with the staff. In answer to the issue about the raise, she explained what the hospitals profit had been and how it was determined how much of that would go to staff raises. As the profit margin was narrow, most of it was used for staff raises and employees seemed to understand this. Ms. Freeman also discussed with the employees how many new nurses and

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nurses assistants had already been hired but had not yet begun employment and the future plans for continuing to decrease the vacancy rate. She explained that it will take time before staff/patient ratios are normalized. The collaborative style of managing conflict is very effective for the CEO as she has established her credibility with the employees by her constant presence on the units getting to know the staff as individuals. Conclusion Providence Hospital has recently been plagued by financial problems secondary to the inability to attract and keep physicians who will refer and admit patients to the facility. The Board of Directors elected to recruit a new CEO and she, in turn, recruited new people for the executive leadership team. This team has developed and approved a five year strategic plan for growth and are about to present this to the Board of Directors for approval. The CEO is strongly committed to the mission and vision of Providence Hospital and communicates this to her executive leadership team and employees of the hospital. She leads with energy and passion and although there remains much to be done to turn the fortune of the hospital around, great inroads have been made. The future of Providence Hospital appears to be bright with a strong leader and a dedicated executive team who truly believe that the patient comes first and that to ensure safe and compassionate care, employees need to feel empowered and fulfilled.

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Organizational Behavior in Health Care (2nd ed.) (pp. 285-306). Sudbury, MA: Jones and Bartlett Publishers. Deckard, G. (2011). Contemporary leadership theories. In N. Borkowski (Ed.), Organizational Behavior in Health Care (2nd ed.) (pp. 209-229). Sudbury, MA: Jones and Bartlett Publishers. Erwin, D. (2009). Changing organizational performance: examining the change process. Hospital Topics, 87(3), 28-40. doi:10.3200/HTPS.87.28-40 Ford, R. (2009). Complex leadership competency in health care: towards framing a theory of practice. Health Services Management Research, 22(3), 101-114. doi:10.1258/hsmr.2008.008016 Guo, K. L. (2010) Workplace communication. In N. Borkowski (Ed.), Organizational Behavior in Health Care (2nd ed.) (pp. 71-102). Sudbury, MA: Jones and Bartlett Publishers. Jennings Consulting (2010). Providence Hospital Hospital Planning Session #2 (confidential document). Lurie, N., Gresenz, C.R., Blanchard, J.C., Ruder, T., Chandra, A., Ghosh-Dastidar, B., Jones, K. (2008, January). Assessing healthcare and health care in the District of Columbia.

A NURSING LEADER Rand Health Working Paper WR-534. Retrieved from: http://www.dcasthma.org/rand_health_reports_2...

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Suc, J., Prokosch, H. U., & Ganslandt, T. (2009). Applicability of Lewins change management model in a hospital setting. Methods of Information in Medicine, 48(5), 419-428. doi:10.4314/ME9235