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5-Step Guide to Engaging Nurses


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By Jennifer Thew, RN

About four years ago, leaders at Appalachian Regional Healthcare System in Boone, North Carolina, realized they had a serious problem with employee engagement.

Staff engagement scores were in the basement—around the 19th percentile on the Bivarus employee engagement survey—and a nurse called The Joint Commission to complain that electronic medical records were affecting nursing workflows.

"I think [the nurses] felt like their only option was to report that externally," says Amy Crabbe, MBA, CHHR, senior vice president of people services at Appalachian Regional. "That really got our attention that we had some significant issues around engagement."

Additionally, the health system with two hospitals and more than a dozen medical practices was struggling with other metrics, such as HCAHPS scores.

"Some questions had hit rock bottom. Some of the questions were as low as the 5th percentile; some were in the 30th percentile," Crabbe says. "On average, we were well below the 50th percentile, and that is not where we wanted to be."

A C rating by the Leapfrog Group added salt in the wound.

"We just went, ‘Holy cow! How can this be, that we're a C?' " says Kim Bianca, MSN, RN, senior vice president of hospitals and acute services and CNO at Appalachian Regional. "We don't consider ourselves C people or a C organization, but to have someone externally grade us that way … our CEO was quite concerned about it."

Today, however, the organization is leaps and bounds from where it was. Here's how it bolstered employee engagement and improved service and quality outcomes. 

Step 1: Take a critical look at leadership

The Joint Commission complaint was a sign that nurses didn't think their concerns would be heard and acted upon by internal leaders.

"Our nurses were feeling like they didn't have a voice," Crabbe says.

So the first course of action to improve staff engagement was to take a hard look at the system's leadership team. This meant moving some leaders into new positions, both within the organization and outside of it, that better matched their skills and strengths. 

"[Getting] the right people in the right leadership positions was our first decision and the impetus to some significant changes," says Crabbe.

"We took some key personnel and moved them to positions that would drive outcomes in a more specific way," explains Bianca, whose own position was changed from vice president of many ancillary services—including service lines, home health, and outpatient—to her current role, which includes responsibility for inpatient nursing.

"The very first thing we did was get the right people on the bus," she says.

Two qualities were essential for members of the retooled leadership team—an ability to focus on data-driven and strategic outcomes, and a mastery of change management, says Crabbe.

Step 2: Increase visibility with employee rounding

Even before subpar metrics were staring them in the face, leaders at the health system had discussed working with the Studer Group to change the organization's culture. They have since signed on with the consulting firm and implemented many of its tactics, including employee rounding.

"The very first thing that I started immediately, which was a Studer tactic, was being as visible as I could possibly be," Bianca says. "I was rounding, rounding, rounding, rounding. I was in every nook and cranny of every unit—in the nighttime, the daytime, on the weekend, on the holidays. I think I pretty much lived here, probably for about a year, honestly. I wanted them to see that I cared about them … that we care, not just myself, but our leadership."

Today, leaders continue to round on their employees, and all employees get face-to-face time with their supervisor each month.

The meetings focus on a standard set of questions:

    What's working well?
    Who would you like to recognize?
    What systems are working or broken?
    What tools and equipment do you need?

"It's the kind of questions that will get at the heart of what's getting in the way of the employee doing meaningful, value-based work, and being recognized for it," Crabbe says.

Step 3: Make communication transparent

Leaders at Appalachian Regional have standardized communication boards in each department that articulate the organization's vision to employees, and that same information is covered during rounding.

The health system's CEO began hosting quarterly town hall meetings to which all employees were invited. Those meetings have evolved from canned questions to uncensored back-and-forth dialogue.

"When we first had town halls, we would ask people to send their questions in advance, and we would answer them in a scripted way," Crabbe says. "Now we're just to the point where we just open up the floor and ask, ‘What's on your mind? What do we need to do?' "

Crabbe says this is evidence that trust has formed between leadership and staff.

Step 4: Give recognition where it's due

To thank employees for their work to improve care outcomes, leaders have put their money where their mouths are.

In the first year after committing to revamp its vision and leadership team, Appalachian Regional found itself with a $2 million budget surplus due to a 2% increase over budget in operating margin.

Without hesitation, the CEO at the time said, "We're going to give it back to the employees that got us there," Crabbe recalls.

"It was a great day for Kim and I and our whole leadership team. We stood in our auditorium, and by surprise, we handed out $500 checks to every single employee."

However, recognition does not always have to come with money attached.

Thanks to her rounding, Bianca knows the names of the employees involved in patient care, and she takes the time to send them handwritten thank-you notes.

"People really do appreciate it, and they really feel very special when they get one of those notes at their house," Bianca says.

Step 5: Measure results

By rounding on patients and employees, providing sincere rewards and recognition, fostering leadership development, and creating transparent two-way communication, the hospital system achieved the following measurable results:

  • Improved employee engagement from the 19th to 86th percentile within 10 months
  • Moved quality from below the 50th to the 75th percentile in four of eight HCAHPS domains in 18 months
  • Achieved HCAHPS rankings at the 75th percentile in six of 10 patient experience domains
  • Achieved a $2 million budget surplus, due to a 2% increase over budget in operating margin

Judging by these numbers, it seems the old adage that happy employees equal happy patients is true.

"Our thought was that when we have engaged employees, everything else doesn't just automatically fall into place," Bianca says, "but it obviously lays an infrastructure for the patient experience and for quality."