The Exec: What Nursing Practice Redesign, or Evolution, Looks Like at Indiana University Health

A shared leadership/professional governance mindset is key to a successful practice redesign, CNE says.

Editor's note: This article appears in the June 2023 edition of HealthLeaders magazine.

Care models had not wavered much since hospitals became medicalized in the early 20^th century, and particularly since the Centers for Medicare & Medicaid Services (CMS) were created in 1965, says Jason Gilbert, PhD MBA RN NEA-BC, executive vice president and chief nurse executive, Indiana University Health.

But now, nursing shortages, increased patient acuity, and workforce pipeline challenges are requiring nurse executives to configure different care models.

Gilbert spoke with HealthLeaders about how he and his organization are approaching practice redesign and best practices to implement a redesign.

This transcript has been lightly edited for clarity and brevity.

HealthLeaders: What is your definition of practice redesign?

Jason Gilbert: I love this question, because we've had a big debate about that. There’s a lot of confusion in the literature and healthcare in general, about the difference between what a staffing model is and what a care model is. Both of these are very important, but they have a distinct focus.

Staffing plans are all the activities that are required to ensure that there's an adequate number and mix of healthcare team members to provide care. Nationally, this has been a big focus on ratios and with benchmarking—supply and demand.

But the definition we’re using for care model delivery models is the way tasks, assignments, responsibility, and decision-making authority are structured to accomplish quality patient care outcomes. These define which healthcare worker is responsible for which tasks, and then who has the authority to make decisions.

With all of that said, I don't think you can separate one from the other. There’s been a great focus nationally about staffing plans and nurse-to-patient ratio, but in my opinion, not enough emphasis on nursing care model redesigns.

We need to get away from thinking about redesign as if we’re going to be finished with this in the near future. It’s really care model evolution. These need to continue to evolve.

Both staffing models and care delivery models have that impact on quality, safety, mortality, affordability, and health equity, but you need to assess the contextual issues—geography of your units, availability of technology, your level of preparation, experience of your available caregivers, your pipeline, financial resources, licensing, accreditation, state practice acts, and then of course, patient and family.

Jason Gilbert, PhD MBA RN NEA-BC

HL: When is it necessary to re-engineer, or evolve, the way patients receive care?

Gilbert: The burning platform that's caused this necessity has been the huge supply and demand mismatch between the number of caregivers available and patient demands and acuity. We’ve been through many nursing shortages in the past but nothing really quite like this one. This has been exacerbated over the last several years with accelerating retirement rates, more work options outside of acute-care settings or in healthcare for nurses, and changing expectations in the workplace.

We have a pipeline issue with lack of faculty in nursing schools and a great number of qualified applicants are turned away every year just because there aren't enough to teach the next generation. We’re also experiencing a knowledge complexity gap in the profession. Millennials and Gen Z are now the largest portion of the workforce, which flipped in 2020 when baby boomers—and I hate those labels of generations—once were the largest sector in the healthcare workforce. They’re taking a lot of experience with them as they retire, so we have to rethink the way we provide care and onboard and partner with schools.

So, we need to continue to evolve improved quality and safety and patient care in the way it's delivered and to make care more affordable and equitable. Our past models are just not sustainable, not only for our patients, but for our direct caregivers, as well, and we saw a lot of this exacerbated during the pandemic. Our patients are telling us that they don't always like to receive care in the way that it's designed, and our caregivers are telling us they don't always like providing care in the way that it's been designed in the past.

We have lots of data on this and it's time to change our mindsets and embrace the changes that are ahead of us. As a profession, nurses have the duty to ensure that patients receive quality healthcare, so we're going to have to take a more active role in care model redesign.

HL: What does practice redesign look like at Indiana University Health?

Gilbert: As we are entering in this work, we want to be thoughtful about how this is going to be different. A lot of times we trial things, but then we don't always get good data for what works or what doesn't, or we try to wait for the perfect model before we would implement anything because, quite frankly, the stakes are high and there is that innate fear that you're going to make a mistake that's going to cause you not to give quality care.

So, we created a vision statement for care model redesign, and then associated guiding principles: we wanted to engage our frontline team members, we've encouraged autonomy, rapid testing, and frequent evaluation. We’re trying to get a little more agile and nimble with what works and what does not and spread that so we share the lessons learned across our system.

We have a lot of different pilots going on in the system and we have a research study that's going on with five innovation units across the state, so we're not waiting for perfection on this, but once we communicate the vision and the criteria, we developed some change management tools for our frontline leaders to help with how to go about this.

Part of the mindset shift for this has been to lead more through guiding principles that are not a one-size-fits-all. There were some who were probably waiting for me as the chief nurse executive to say, “This is the care model at IU Health; now everyone go out and implement this and everything will be fine.” I don't think that you can lead this way. I could have done that, but I think it would have failed miserably.

HL: What are key tips you would suggest in implementing practice redesign or evolution?

Gilbert: Balancing that structure and autonomy and not waiting for the perfect model that's going to work for everyone. Care is so complex across different patient populations, and different acuity levels that we have to lead more through guiding principles and really involve the front line and the voice of the patients and families in redesign.

It's been key to equip the frontline managers with the change management tools because there is a fear of, “What if this doesn't work?” or “What are we going to have to ask the staff to do?” It’s a shift to say that we want the staff to come up with the ideas and help with the redesign.

Leverage your professional governance structures and the Magnet principles—team empowerment, continual improvement mindset, focus on quality, safety, affordability, and equity. The biggest step is to let go of the past and challenge the status quo. Ask the “why,” and then help communicate the “why” with team members.

HL: Change in healthcare is traditionally slow, so how do you encourage others to let go of the past?

Gilbert: I have found that these initial pilots really work with the willing. There are many who want this change. They live with this every day, and they're frustrated and they want to provide care in different ways. Our frontline team members see the deficiencies, so who better to be involved in the changes?

Letting go of that traditional paternalistic command-and-control models of leadership and getting into that shared leadership/professional governance mindset is the key to the future with this. The best ideas come from our front line on how we're going to change care or do things more efficiently.

HL: What have you learned from your efforts to implement practice redesign?

Gilbert: That you can't look only within the four walls of your organization to change this, so we've taken a very active role in partnerships outside of the hospital with some of our partner universities. IU Health has given grant money to both Ivy Tech Community College and to the IU School of Nursing for expanding enrollment to help with some of the issues they have. We're also looking for community partners with high schools and vocational schools to look at pipelines for healthcare workers.

You also have to take a very active role in advocacy for public policy. You have to do a full assessment of the communities you serve, community partnerships, and if we're going to change practice, we have to work with our state and federal legislators in order to do that as well.