News
June 2008
"A Different Voice: Nurses on the Board"
By Susan Meyers
For years, nurses have been missing from the ranks of the hospital boardroom, with its chairs reserved for the CEO, physicians, lawyers and community leaders. Health care leaders say the prevailing stereotype of nurses simply as implementers of care rather than decision-makers of care has contributed to this exclusion.
A 2008 study conducted by the Health Research & Educational Trust, "Governance in High Performing Organizations: A Comparative Study of Governing Boards in Not-for-Profit Hospitals," examined the composition of community health system boards and found that among 2,046 board members across multiple organizations, 2.4 percent were nurses, and 22.1 percent were physicians.
An informal 2007 survey conducted by the Robert Wood Johnson Foundation (RWJF) of the top 10 U.S. health care organizations leading the quality improvement agenda found that fewer than 2 percent of all board positions were held by nurses.
Yet nurses have always been known for the critical role they play in providing care and comfort to patients. According to 2007 Gallup polls, nurses were the top-ranked professionals in honesty and ethics for the sixth year in a row. Many of today's nurses are highly educated, hold several degrees and have held leadership positions in the hospital setting and community.
Now nurses and leaders in the health care industry are challenging the pervading stereotype and working to raise the status of the nurse to boardroom level.
Today, more than ever, nurses' knowledge and expertise is needed, say health care leaders. RWJF is taking this message to health care professionals across the country with the campaign "Nurse Leaders in the Boardroom," a project created to facilitate relationships between health care organizations and nurses and to train future nurse leaders.
What can nurse leaders offer?
Often representing the largest body of employees in a hospital, nurses have a direct and critical impact on quality and safety. As such, their voice can be a valuable asset to the board, says Susan Hassmiller, R.N., Ph.D., senior program officer and team leader for RWJF in Princeton, N.J.
"There are so many decisions made on a C-suite level between the CEO, chief medical officer and board of trustees … that impact nursing and the quality of care provided," Hassmiller says, "but oftentimes, no one has checked with front-line nursing about why or how [a certain initiative] will work."
As today's hospitals face mounting scrutiny from regulatory bodies in nearly every aspect of patient care delivery, nurses can provide an essential point of view on a number of critical clinical issues currently facing hospital boards, two of the most important being safety and quality of care.
The Institute of Medicine (IOM) found that nurses are the health care professionals most likely to intercept medical errors, which cost hospitals $3.5 billion annually. However, the connection between adequate nurse staffing levels and improved quality and patient safety is often lost by policy-makers and board room executives, who, according to a recent study published in Nursing Economics, have limited comprehension of nursing quality issues.
The study revealed that chief nursing officers (CNOs) have a much greater familiarity with IOM reports on patient safety and quality of care than CEOs do.
"If you look at the important role that patient safety and quality plays in the governance of a hospital today, the nurse brings a unique perspective to how the hospital can meet these patient care requirements in a way that blends and enhances the conversations … and brings a richness to the dialogue," says Pamela Thompson, R.N., CEO of the American Organization of Nurse Executives.
"A nurse who has served in a leadership position brings a wealth of experience and a perspective about the operations of providing and managing care and how that occurs," Thompson says. "Many nurse leaders also have good financial backgrounds [and] strategic thinking and can bring a lot of high-level skill sets to the governance of hospitals."
The nurse's presence in the boardroom is one that is overdue, agrees Gail Warden, president emeritus of Henry Ford Health System in Detroit, where he served as president and CEO from April 1988 until June 2003. "The nurse brings the ability to translate and demonstrate evidence-based kinds of safety and quality improvements to the board and brings an in-depth understanding of the patient care process," says Warden. "The nurse can make or break an institution in terms of quality and safety.
"[Their absence] has been a product of the way hospitals and health systems have been managed. It took a long time for nurses to be on the C-suite team. If hospitals now have nurse executives, it makes even more sense for them to be a part of board decisions as well. This is just another step in the process of looking at how boards can bring the most value to a hospital or health system."
Kathryn Mershon, R.N., a member of the Alegent Hospital, Omaha, Neb., board of directors from 1999 to 2007, says her clinical and leadership nursing experience allowed her to bring a unique understanding to the board about what quality and safety means from a nursing perspective and a governance level.
Also a former senior vice president for Humana Inc. from 1980 to 1992, her understanding and personal passion for quality and safety helped her raise the importance of these issues to a governance level.
At one time the quality committee at Alegent consisted of members with delegated authority from the hospital board and was more focused on credentialing and privileging. Mershon played a major role in transforming the committee's structure, charter and accountability. The quality committee now comprises various hospital leaders including physicians, nurses and board members, with the board being fully accountable for the hospital's performance in quality and safety.
"The quality committee is now fully engaged in quality conversations and establishes quality agenda and targets," says Mershon.
Connie Blietz, R.N., chief nurse executive for Alegent Health Mercy Hospital in Council Bluffs, Iowa, says Mershon's experience as a nurse and nurse executive helped her raise the importance of specific clinical outcomes and what these mean to patients.
"She understands the impact for nursing and the role that nursing plays in meeting these outcomes," Blietz says. "She played an invaluable role in being able to put a face on these issues for our nonclinical board members."
Patient satisfaction is another issue rising to the top of board agendas—a topic that is directly related to nursing care, says attorney Penny Brooke, a member of the AHA Committee on Governance and a trustee for Intermountain Health Care Inc. in Salt Lake City for the past 20 years.
With the Centers for Medicare & Medicaid Services (CMS) announcing plans to condition full payment updates in part on hospitals' disclosure of patient satisfaction data, hospitals are scrambling to find new ways to boost patient satisfaction. "There have been many polls that have shown that a patient's experience is directly related to the care they receive from nurses," says Brooke. "The nurse is the glue that connects the team and the eyes and the ears of the patient around the clock. They know what it takes to provide a positive experience for their patients."
CMS is also tightening its oversight of preventable errors—another clinical area that directly impacts nursing care. CMS recently announced plans to expand the "never events" ruling, which if passed will no longer reimburse hospitals for 28 "never events," or specific preventable errors, a patient can incur in a hospital. These include: procedures or surgery that are performed on the wrong patient or wrong part of the body; incorrect blood transfusions; certain types of falls and trauma; surgical site infections; pressure ulcers; and urinary tract infections.
"Nurses can provide important feedback in this area and how some of these issues can be resolved and, most importantly, prevented in the first place," says Hassmiller.
Perhaps one of the largest crises facing health care is the nursing shortage, an issue that cannot be tackled without the voice of nursing leadership, says Hassmiller. "CEOs and trustees do not always fully understand why nurses leave their institution so readily," explains Hassmiller. "A nurse leader on the board can provide an inside view on why nurses leave, the impact on quality that a shortage has, and strategies for keeping nurses for the long term."
Do boards need physicians and nurses, too?
Some board members question the wisdom of adding nurses to the board when many boards enjoy ample representation from physicians who can offer a clinical perspective.
While both play an essential role in patient care, doctors' and nurses' roles are very different, and both points of view are critical to the board, say health care leaders.
"It's not an 'either/or' conversation," says Thompson. "It's an 'and' conversation. The physician manages the diagnosis and treatment of the patient, but the nurse is the one who actually carries out the care for a multitude of patients. The nurse is responsible for the 24-hour management of that environment. If you don't have the nurse at the table, then I don't know who can adequately state that perspective."
John Lumpkin, M.D., senior vice president for RWJF and a board member of Robert Wood Johnson University Hospital, New Brunswick, N.J., agrees. "The nurse is closest to the patient in terms of providing care. That insight is essential to the governance of hospitals. Quality of care is dependent upon physicians and nurses working as a team, and the nurse is an important member of that team."
The IOM's recent recommendation that all hospitals adopt patient-centered care is another strong reason supporting the need for nursing representation on hospital boards, says Lumpkin.
Patient- and family-centered care involves integrating patients and their families into medical care by supporting their active participation in their own health care experience. The nurse, whose time at the bedside is significantly longer than that of the physician, plays an important role in supporting patient-centered care and understanding the needs of the patient and family, notes Lumpkin.
Are nurses ready for a seat?
Nurses are ready and willing to provide a leadership voice. At a 2006 national nurse leaders summit, "In Pursuit of Quality, Safety and the Public's Health: A Summit on the Future of Nursing Care," sponsored by RWJF, when nurse leaders were asked to list the No. 1 priority for their profession, the prevailing comment was that nurses need more representation on quality of care committees and health care boards across the country, says Hassmiller. "They felt they had a lot to share, but no one was asking them to come to the table," she says.
Before nurses can win adequate representation on hospital boards, they must break down the stereotype of nurses as the implementer rather than the decision-maker, notes Hassmiller.
"Many hospital boards see a great person in front of them [when looking at nurses], but they are not chosen because of the stereotype that exists," she says. "If board members don't perceive nurses as great leaders, they are not naturally going to be drawn to nurses."
In addition, up until now nurses have not done a good job of being their own advocates, says Hassmiller. "Nurses need to step up to the plate and convince leaders that they can bring value to the board," she says. "They need to be familiar with and speak up authoritatively on a broad spectrum of health care issues as well as understand cost and quality issues."
While nurse representation on the board can provide broad insight into patient care issues, health care leaders stress the importance of including nursing leadership such as the CNO in board meetings. "Having CNOs attend board meetings allows them to engage in dialogue and answer questions so boards can really understand what's happening in the nursing workforce," says Thompson.
Boards need to become aware of the nurse leaders in their community and look at them in terms of the value they can bring. Seeking out nurse leader candidates for hospital boards should become a natural part of the nominating process when filling new seats, says Lumpkin.
"The board needs to look at the composition of their current board, identify the voids, and then consider potential nurse candidates that can meet these roles," says Lumpkin.
Susan Meyers is a freelance writer in Omaha.
This article 1st appeared in the June 2008 issue of Trustee Magazine.
