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MAKING THE BUSINESS CASE FOR INNOVATION Penny Moore and colleagues describe how a healthcare facility in the United States made a successful case for introducing clinical nurse leaders across the organisation Correspondence [email protected] Penny Moore is an assistant professor of nursing and co-ordinator of the clinical nurse leader programme at Texas Christian University, Fort Worth, Texas Darla Banks is director of the clinical nurse leader programme Brunella Neely is a clinical nurse leader Both at Texas Health Resources, Fort Worth, Texas Date of submission June 24 2014 Date of acceptance November 3 2014 Peer review This article has been subject to double-blind review and has been checked using antiplagiarism software Author guidelines nm-author-guidelines

Abstract In the current financial climate it is important for nurse leaders to be able to develop and present a business case for initiatives. This article describes how one US healthcare facility made a successful business case for implementation of clinical nurse leaders throughout the organisation. Keywords Clinical nurse leaders, return on investment, innovation

Introduction Understanding the business side of health care is an area that has been neglected by many nurses for too long, but it is vital for survival in today’s intensely competitive environment. Regulations from United States federal agency Centers for Medicare and Medicaid Services (CMS), such as Pay for Performance, Never Events, and Present on Admission, are just some of the factors putting financial pressure on healthcare facilities in the US (Barnett et al 2010) and which call for creative problem solving. Pay for Performance involves financial incentives for improvement in patient outcomes; Never Events are devastating and preventable events, and CMS will no longer cover their associated costs; and Present on Admission is a system in which hospitals must document certain conditions that are present on admission – and if they are not documented CMS assumes the condition was acquired during hospitalisation and will not pay for related care. Other developed countries face similar financial pressures. It is important, therefore, to be able to

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‘sell’ an innovative plan to those who hold the purse strings; learning to write and present a business case for innovation is a valuable skill for all nurse leaders. One innovative role in the US, the clinical nurse leader (CNL), was introduced and recently revised by the American Association of Colleges of Nursing (AACN 2007, 2013). CNLs are master’s-prepared advanced clinician nurses who have passed a national certification exam. When CNL students graduate, they are eligible to take the exam, which is set by the Commission on Nurse Certification; after passing the exam, they may use the CNL title after their name. There are no CNL educational programmes outside of the US at present, but the AACN model could be adapted to fit other countries’ educational systems. The Nurse First programme in the UK, launched in September 2011 and operated by the Queen’s Nursing Institute (QNI), Buckinghamshire New University and the Shaftesbury Partnership, is aimed at developing nurse leadership and business skills (Cook et al 2012). The vision behind the programme appears similar to the CNL initiative. The QNI also provides grants for nurse initiatives in district nursing. In the US, CNLs are used in community settings with positive outcomes (Adeniran et al 2012). The CNL role was introduced to a global audience at the International Council of Nurses congress in July 2009 in Durban, South Africa (Baernholdt and Cottingham 2010), but unfortunately shortly after this there was a significant downturn in the US economy. This made the decision to implement CNL roles difficult for healthcare administrators, who are responsible for budgets. The economic situation meant that developing a sound business case for CNL implementation was even more important. A good NURSING MANAGEMENT

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Art & science | acute clinicalcare nurse leaders business case can financially inform organisations and ensure they are prepared for change. Examples of business case strategies are found in various disciplines and in different parts of the world. One particularly comprehensive plan, called the Q4-Model of Productivity (Oeij et al 2012), has been applied to the industrial sector but is also applicable to health care (Oeij et al 2011). The authors state: ‘The model then can be used as a guide to develop concrete workplace innovation interventions with the purpose of improving productivity . . . (and quality). The result is an informed business case evaluation for cost-effective interventions for workplace innovation.’ The rest of the article discusses the development of a business case for implementation of CNLs in the US. The specified steps provide a roadmap for those interested in presenting a case for their own innovation.

Building support and understanding According to Sherman (2010), healthcare management or administration staff do not generally understand the value of the CNL role. These clinicians provide unit-based direct care and have no administrative or managerial functions (AACN 2007), which upper level administration might regard as an ‘extra layer’ and therefore an added expense. The person presenting the business case in this situation therefore needs to provide a succinct explanation of the CNL role. Some important points to include are: ■ CNLs remain at the bedside and collaborate with interdisciplinary teams to achieve lateral integration of care, they search for best practice and implement evidence-based care at the bedside, they manage clinical outcomes and the care environment of a unit (Begun et al 2006, AACN 2007). ■ The Institute of Medicine presents the need for action to increase care quality and safety (Institute of Medicine 2000, 2001a, 2001b, 2003, Joint Commission of Accreditation on Healthcare Organizations 2002). ■ In 2000, the AACN reported a need to change practice environments and nursing education (AACN 2000, Tornabeni and Miller 2008). Knowing the likely opposition to any innovation helps to prepare a business case, and one possible type of resistance to the CNL initiative is the perception among nurses and administrators that there is a significant overlap with other nursing roles (Goudreau 2008). The AACN (2004), however, anticipated the issue and developed a comprehensive comparison of the CNL and clinical nurse specialist (CNS) roles. Some of the differences include: 24 December 2014 | Volume 21 | Number 8

■ CNLs are advanced clinicians while CNSs are advanced practice nurses. In the US, advanced practice nurses often have prescriptive authority. CNS education and practice is client specific and population based, while CNLs co-ordinate client care for individuals and clinical cohorts not based on medical diagnosis, age, or other population-based parameters. ■ CNLs assess clients and co-ordinate care but also assess their units as their ‘clients’. For example, they will assess a unit for system issues that might affect patient outcomes and search for evidence of best practice. CNSs assess clients within their specific client population, frequently based on medical diagnosis and spanning more than one unit. They also search for best practice related to this population. Goudreau (2008) provides additional information about the issues that might arise when presenting plans for CNL implementation. A business case can be used as an opportunity to explain how a CNL role can benefit an organisation as well as patients; there are many examples in the literature that show how CNLs can contribute directly to saving money and enhancing care outcomes – and most of these examples have global application (Wilson et al 2013).

Practical application Texas Health Resources (THR), a 14-hospital healthcare system, has developed a purpose statement for its CNL programme to address defined problems such as the lack of continuity of care and gaps in care provision. This simple but powerful statement helps CNLs to focus on their primary purpose: closing gaps in patient care. CNL projects in THR hospitals demonstrate how they close gaps in care and produce money-saving, quality-enhancing outcomes. Including examples of the positive effects of CNLs in the business case can help to sell the role. CNLs are responsible for the care outcomes of a geographically defined population in a healthcare environment, but the projects can have far-reaching financial effects. Anticipated outcomes, unanticipated outcomes and system-wide (macrosystem) outcomes are three categories in which CNL projects can provide a return on investment or cost avoidance, or both. One example at the unit (microsystem) level is Progressive Action to Care for Hearts. THR staff identified high readmission rates of patients with heart failure on a 24-bed medical surgical unit, so a programme to increase patient education and compliance with the aim of reducing patient readmissions was developed. The programme began NURSING MANAGEMENT

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in February 2012 and monthly readmission rates declined from 31% in January 2012 to 0% between April and July 2012. It is important to consider unanticipated money-saving outcomes when assessing the effect of any new projects. When a programme was introduced to improve patients’ perception of pain control in the acute care setting, for example, evaluation showed a significant reduction in patients’ length of stay, a positive but unanticipated effect of the programme. Macrosystem implications of CNL projects often translate into financial savings for the entire facility. While CNLs implement projects based on their individual unit’s needs, sometimes these projects have such a positive effect that it results in system-wide implementation. A project to expedite the discharge process on two medical-surgical units was shown to improve patients’ discharge time, thereby decreasing the number of patients waiting in the emergency department for a bed.

This project was presented to the hospital’s administration staff, and they decided to implement a hospital-wide process to improve overall throughput. Cost savings from these two units funded the personnel needed for implementation. An unanticipated outcome of the project was better patient satisfaction scores, because patients want to go home as soon as possible on dismissal day, and reimbursement practices in the US mean that high patient satisfaction scores represent cost savings. In autumn 2014, THR reported on the progress of its CNL initiative: ‘There are 30 CNL students in 12 of the system hospitals. CNLs improve patient outcomes by providing continuity of care, interdisciplinary collaboration, mentoring nurses and implementing process improvement strategies within a microsystem. They have an impact in a variety of ways as they work at the bedside.’ Table 1 presents some of the more recent CNL innovations mentioned in this report. These projects received local and national recognition at THR system-wide research

Table 1  Examples of CNL innovations at Texas Health Resources Innovation



Introduction of Increase Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) scores

Medication cards created and implemented

The HCAHPS scores, medication section, increased from the seventh percentile before implementation to the 66th percentile after implementation

Discharge improvement: scheduling follow-up visits, filling prescriptions and detailed instructions before discharge

HCAHPS scores for ‘Did doctors, nurses or other hospital staff talk with you about whether you would have the help you needed when you left the hospital?’ increased from 78.6% to 90.9%; ‘Did you get information in writing about what symptoms or health problems to look out for after you left hospital?’ increased from 78.6% to 100.0%; overall score on discharge information increased from 78.6% to 95.5%. All of these figures reflect improvement

An unanticipated outcome of the medicationcard project was a lower readmission rate

Pneumonia readmission rate decreased from 12.9% to 10.3%; overall readmission rate decreased from 8.8% to 7.7%

Heart failure (HF) project: root-cause analysis, team teaching plan, post-discharge follow up for compliance with prescriptions and appointments

HF readmission rate decreased from 19.8% to 10.7%

Measures to decrease benchmark issues

To decrease missing established benchmarks, the following projects were implemented: daily chart reviews, mentoring programme, a new checklist to improve the surgical care process

Decreased by 92% in 2013

Measures to decrease infection rates

Before hip replacement: extra chlorhexidine bath and Staphylococcus aureus screening with treatment if colonised

Infection rate dropped from 8.4% to 2.8%

Measures to decrease readmission rates


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Art & science | acute clinicalcare nurse leaders or evidence-based practice symposiums and at the annual American National CNL Summit. Examples from other US hospitals can be found in the literature, two of which are: ■ A short interrupted-time-series design study measured patient satisfaction after integration of the CNL role, and showed improvement in patient satisfaction with admission processes, nursing care and keeping patients informed (Bender et al 2013). ■ Staff at Maine Medical Center, in Portland, adopted the CNL role early and reported better clinical outcomes attributable to CNLs (Wilson et al 2013). Outcome results tracked for 12 months or more on one or more specific units demonstrated a decrease in readmission rates, bloodstream infections, post-procedure length of stay, pressure ulcers in intensive care and on a medical unit, and pain on a ten-point scale. There was also an increase in flu and pneumococcal vaccine administration. Calculating the financial effects of these outcomes would illustrate the savings associated with CNL roles.

Business case specifics McGlynn et al (2003) suggest that the lack of business cases is a significant reason why healthcare organisations do not implement quality-improvement (QI) projects, despite research documenting their effectiveness. Those in charge of finance in healthcare facilities are most concerned about the monetary effects of new programmes in the current budget year (United States Department of Veterans Affairs 2004). A business case is one way to develop implementation readiness. When building a business case, it is important to remember who the audience is (Goldman and Schmalz 2012). For example, if the initiative will benefit the community or even society as a whole at some point, it is likely that the local healthcare facility budget holders will not want to include it in this year’s local budget. Presenting a business case that includes a positive financial or cost-avoidance return on investment in the short term will help to support investment in the initiative. Budget-neutral initiatives might be of interest to administration staff if QI can be demonstrated, and fortunately positive return on investment and QI indicators for the CNL role have been documented (Stanley et al 2008, Wesolowski et al 2014). To begin writing a business plan, the first step is to create an executive summary, a one-page document that introduces the CNL role and its potential effects on cost-efficient, high quality 26 December 2014 | Volume 21 | Number 8

patient outcomes. Next, define the problem. The CNL role was developed in response to the many gaps in care that then resulted in medical errors and poor care (Institute of Medicine 2000, 2003). Communication problems are at the core of many of these gaps (Bender et al 2012); for example, some registered nurses work 12-hour shifts, and therefore only three non-sequential shifts a week, while other staff work on rotating shifts; both can result in fragmented care and potential communication problems. CNLs work five days a week with 24-hour responsibility for care co-ordination, which can bridge any communication issues. At THR, it became evident that care co-ordination suffered over the weekend, so there are now plants to provide weekend-only CNLs through a central staffing pool. The next section of the business case involves several parts. First, a description of the plan is developed; THR’s plan description includes the deployment and reporting structure of CNLs, and their job descriptions and standards. Second, action items are identified, such as increasing the number of students from THR’s academic partner, aggressive recruiting and hiring, and CNL-specific orientation plans. Third, the implementation strategy is determined. One strategy used at THR is staging targeted recruitment efforts such as using a booth at the annual American National CNL Summit and posting vacancies on the Clinical Nurse Leader Association website. Finally a spreadsheet, or dashboard, is developed to reflect the average daily patient census of every unit, average daily discharges, and scores from Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS), a standardised survey instrument for measuring patients’ perspectives on hospital care. This information enables calculation of the estimated number of CNLs required to cover a unit and the subsequent budget costs. The dashboard metrics then help determine the return on investment and cost avoidance.

Presenting the case The business case presentation should answer the question ‘Why should we care?’ For example, if the audience is a group of chief medical officers who are concerned with quality metrics, this type of information should be included. In one hospital in the THR group, some units lost $215,000 (about £135,000) in one year from failing to meet all of the quality benchmarks. Preventing these benchmark issues can pay the cost of two CNLs who could help prevent such failures in the future. CNLs have a positive effect on a hospital’s finances and improve NURSING MANAGEMENT

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care, and this information can impress the audience for the business case. The beauty of the CNL role is that it can resolve more than one problem while co-ordinating care within the microsystem (Bender et al 2013). Any initiative must be aligned with the organisation’s strategic plan (Song et al 2012), and this should be included in the presentation; the programme at THR aligns with the quality and value component of the system’s strategic plan. It is vital to explain how the CNL role fits into the overall mission and vision of the institution. Finally, it is important to plan and practise the presentation. Take all the supporting materials to the presentation, including the proposal, spreadsheet details, job descriptions, success stories and journal articles. Be highly prepared; this is an exciting venture, so nurse managers should develop and present the business plan with passion, and target the audience’s passion.

Successful outcome In 2009, THR approved a business plan that enabled the initial roll out of the CNL programme with Texas Christian University (TCU) as its academic partner. The CNLs were hospital based during the first phase, and a new business plan provides full saturation of CNLs, one for every 12-to-16 beds,

in all 14 urban, suburban and rural hospitals in the system. The organisation’s plan is to deploy the CNL role throughout the entire hospital system in all medical-surgical, medical-surgical specialty, intensive-care and progressive-care units by the end of 2014. Since January 2014, CNLs in all 14 hospitals are supervised by and report to one person located in a THR corporate office. This proposal positioned the CNL role as an essential part of THR’s patient-care management model.

Conclusion Health care is big business worldwide and nurses need to possess business intelligence. One part of being a successful business partner is being able to develop and present business cases for nurse-led innovations. This article has described how nurses at one large hospital system in the US have successfully won financial support to implement a system-wide CNL programme spanning 14 hospitals. There are specific components that need to be included in a business case, and skills in preparing and giving presentations are needed to communicate with all levels of administration staff about what the plan is, how to make it happen, and how it will benefit the organisation and patients. This example from THR is intended to guide others to prepare for successful innovation.

Online archive For related information, visit our online archive and search using the keywords Conflict of interest None declared

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Making the business case for innovation.

In the current financial climate it is important for nurse leaders to be able to develop and present a business case for initiatives. This article des...
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