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Review key points and recommendations for Clarian Health's patients safety initiatives. [ABSTRACT FROM AUTHOR]

Much information and clinical data are available in health care. Unfortunately, much of it is not available for clinical decision making and management support. Analytics within the context of health information technology (HIT) will provide a framework to bring better reasoning and intelligence to HIT and nursing care. The missing link is the people who will bring this forward into the everyday lives of clinical nurses and nurse executives. With better competencies among staff and leaders in nursing and more credentialed nursing informatics leaders in influential positions, nursing will be a full participant in the digital revolution which, along with analytics, will lead to intelligent and effective systems.

It should be intuitive that happy people produce better results than unhappy people. It should be intuitive that leaders must be singularly focused on how they can create happiness within their companies so that people can grow and thrive and reach sustainable organizational goals. But in spite of such common sense, the data show us people are not too happy at work and it is not getting better. Health care has much to learn about creating happi ness that in turn creates a positive return on investment financially, as well as on patient outcomes and the well-being, growth, and productivity of the staff. (1) We need a serious call to action in health care that will implement the research about happy organizations and their success. Our stakes are high; we must do no harm.

Part of the culture of nursing is convincing everyone you are perpetually overworked and overwhelmed. The leadership style the leader chooses will determine whether he or she will be energized or overwhelmed. When the leader is unable and unwilling to surround him or herself with people who are more knowledgeable and astute, the level of stress and worry becomes unbearable. Relationships thrive when a structure is present. Your staff will be energized and empowered, and will reach incredible levels of productivity and the highest level of achievement possible. Doing "nothing" allows your staff to grow as people and as a team, and you will be free to do the work of the leader, and not be tired.

Major transitions and transformations are in our future as we begin to implement the various changes in the new health care reform environment. New programs developed with old thinking and leaders who have filtered their thinking through previous models will not be successful. We need people with a variety of experience to help us see our way through the new forest of health care reform--many of those could be outsiders. Outsiders can be very successful if health care leaders can be open to different and successful models that have been effective elsewhere. e must find these people and successfully recruit them to our organizations.

The role of the system chief nursing officer nationally and internationally has been traditionally structured as a staff model, a direct line model, or a hybrid that includes parts of each model. The choice of structure should be made after a thorough investigation of what outcomes the system wants this position to accomplish, developing the appropriate structure to achieve these outcomes, and then engaging a chief nursing officer with the skills indicated by the type of structure chosen. This article describes these 3 structures and the support infrastructure necessary for each model.

It should be intuitive that happy people produce better results than unhappy people. It should be intuitive that leaders must be singularly focused on how they can create happiness within their companies so that people can grow and thrive and reach sustainable organizational goals. But in spite of such common sense, the data show us people are not too happy at work and it is not getting better. Health care has much to learn about creating happiness that in turn creates a positive return on investment financially, as well as on patient outcomes and the well-being, growth, and productivity of the staff. We need a serious call to action in health care that will implement the research about happy organizations and their success. Our stakes are high; we must do no harm.

As leaders, we must feel a sense of moral obligation to implement evidence about end-of-life care in our practice setting. Nurse leaders can help patients and families orchestrate a beautiful experience that is an alternative to futile, expensive end-of-life care. Preparation is key in helping staff provide the best level of care. A plan built around the best care for patients can integrate with many diverse positions and people. Courageous nurse leaders are well adapted to maneuvering through political traps and advocating for patients and their families. Everyone benefits personally and financially, including our communities and nation, when courageous leaders advocate successfully for effective end-of-life care.

The question of whether management is a profession is hotly debated by our colleagues in business. We should learn from that dialogue and ask ourselves the same question regarding nursing management. Looking at our practice against the commonly accepted descriptions of professional practice, the answer is probably no. This is an ideal time to reflect on the practice of nursing management and executive practice. We must examine nursing management practice and learning deliberately from our experience.

The complexity of health care environments is far too complicated for solutions to be developed by a small group or isolated upper managers. This direct leadership approach often fails. Leaders who use a more oblique approach focusing on areas such as long-term economic value, creating significant benefits for the wider community, and building robust social capital within the company are successful. Obliquity leadership is very appropriate for health care because of its constantly changing environment. Obliquity leadership and shared governance are great partners in reaching higher levels of involvement and high performance.

When we feel connected and safe, the cerebral cortex of our brain responds by becoming involved, which leads to peak performance. When we work in a culture of constant fear, the deeper levels of our brain are activated to respond to the fear and our cerebral cortex is disabled. ultures that are negative and focus on people's weaknesses create "learned helplessness" lead to high rates of depression among the workforce, and cannot achieve the results of optimistic workplaces. The profession loses far too many excellent nurses every year because of the inability of managers and leaders to seriously connect with the front line. What we do as leaders creates a physiological reaction and a basis for effective or ineffective work units.

An offer of an executive-level promotion is not without risk. The transition to an effective executive is a continual journey, not a destination. Designing a roadmap with effective skills and strategies will help make your professional and personal life journey more rewarding and successful.

Success can easily breed hubris. As leaders become more confident, their success can limit their learning because they develop repetitive patterns of filtering information based on past successes and discount information that does not agree with their patterns of success. It is important for leaders to stay grounded in reality and effective as their success grows. Humility, gratitude, and appreciation will avoid the overconfidence that leads to hubris. Building confidence in others is the mark of a great leader. Hubris is not.

There are many examples of health care organizations that have morphed from the culture of low expectation to the culture of excellence. Ethically, to not drive to excellence means that we are settling from knowingly allowing harm to happen on our watch. The leader's obligation is to create that sonic boom that Black and Gregersen (2008) describe to break up the old mind maps, to create the movement, and to finish the cultural change in spite of change fatigue and other factors that could sabotage the process. Only then can the effective leader sleep well at night knowing that the infrastructure is being created that will provide a culture of excellence and safety for patients and their families. And it is being created on his/her watch.

Being confronted with a diversity of thinking can break up the old models in our head and open new pathways to innovation. In health care, it is extremely important to be exposed to very different situations that can potentially create very different answers for us; hence the trip to the zoo, to a factory known for quality outcomes, or other venues that will open new vistas in our mind. Anytime we try to do something that worked in the last 5 years, we are flirting with disaster. Health care is constantly changing and if we attempt to cover the present with the templates of the past, we will fail. Immersing people in situations where they can share openly with very diverse people and ideas will create the culture consistent with behaviors that eagerly engage in seeking diverse answers to the issues of the future.

Simplifying to the point of blaming limits learning and the ability to prevent similar occurrences in the future. Often, the characteristics of the blame culture are very subtle and what appears to be valuable work is actually a subtle sign of the blame game. Leaders must change the language to a proactive, future preventative state rather than focusing on the past and looking for single causes of events. Many nurses have left their positions because they have chosen not to work in a culture of blame. Eliminating all forms of blame is essential for excellence in patient care outcomes and loyalty of staff.

Traditional leadership is becoming rarer while distance or virtual leadership is more common because advancing technologies can support new models of health system communication. Successful virtual leaders learn how to cross time, space, and culture barriers to make improvements across small and large entities. The challenges of virtual leadership are the same as traditional leadership, but occur in a much different venue where direct supervision and interaction are impossible. It is a difficult adjustment for some leaders to move from traditional leadership modalities to the skills necessary for virtual leadership. New skills of creating a high-performance group across diverse boundaries are necessary.

It is common for leaders to be confronted with resistance that makes forward progress impossible. The easiest action for the leader is to label the resistance as denial. Labeling behaviors that do not agree with expectations is one way leaders keep their immune system intact and fight off valuable feedback. The enlightened, well-developed leader is aware of her/his own immune system and can monitor the filtering system effectively. We have many opportunities to help organizations and leaders think through the roadmap that makes our immune systems switch off when new, helpful information is trying to enter.

Adapting to change is the hallmark of survival. We can't predict accurately what is around the corner in 2010 and beyond, but we know it will be very different than 2009 and the pace of change will be greatly accelerated. Successful leaders balance the tension between optimism and realism in healthy ways that create the motivation among their people to mobilize and produce productive solutions. The successful leader will help staff prepare for several possible scenarios and will equip them with possibilities for the future. Adaptive leadership is a viable model to carry us into the future.

A patient's decision to recommend a health care organization and the patient's loyalty scores are largely determined by the interaction patients and their families have with the nurses. Hospitality is how the delivery of that product makes the person feel and is a dialogue that requires the server to be "on the guest's side" throughout the experience. The challenge for health care is to help our patients and their families transcend the usual routine care of our health care world and to experience an emotional connection that provides that sense of affiliation and emotional kinship with the organization and the staff. Moving from the service mindset in health care to the hospitality mindset that engages people positively and emotionally is what healing is all about.

The leader establishes the expectations and the organization follows. These expectations can be very permissive with no recognizable structure, or the expectations can be clear and reasonable. What the leader permits becomes the cultural norms of the organization. The leader must take a "no-compromise" position when actions violate values and standards. Passive leaders and leaders who are held hostage by the excuse of personal issues generate a rationale for challenging the no-compromise stance and create mediocrity. When staff own the organization's values and standards, they become the standard bearers, coaches, and enforcers of the drive to excellence.

An important field in leadership research is that of the social identity of the group and what that means for leadership. In health care, there are many different types of social identities that vary by hospital, geography, and profession. Leaders often sabotage their effectiveness when they do not consider the social values of the group. The work of leaders is to help move units and organizations to a higher level of performance. Identifying the social identity of the group is the first step. The most successful have expertise in assessing the social identity of groups and developing a commonality of a shared vision that represents the best work of the group and of the leader.

None of us are immune from the irresistible forces that sway our thinking in irrational ways. Pattern recognition is very helpful in familiar situations. However, it can mislead us in unfamiliar situations and cause us to overlook important details that would lead us to other conclusions. Leaders are prone to make mistakes, but we can take steps to lessen the inevitability of mistakes. Encourage dissent, discuss "red flag" conditions openly, and admit mistakes. The job of a leader is too important to allow irrational neuropsychological patterns of thought to rule.

When people believe that what they do is "good enough," excellence will never occur. As the demand for better health care escalates every year, achieving a ranking of very good doesn't count because it leaves many disenfranchised staff, errors, and dissatisfied patients. A leader can not be successful unless the culture of low expectations is eliminated. If there isn't a sense of caring, serving, and being an exemplar of the change, the leader won't succeed in moving the culture. When there is a sense of ownership and commitment to the mission and to patients, the culture of low expectations cannot exist.

There are jerks in this world. There are jerks at work. As managers and leaders we are obligated to insure that people have a healthy environment in which they can be nurtured and grow. Patient safety cannot be compromised because we allow jerks to create chaos. This is a serious issue that is very expensive in terms of the toll it takes on people, patients, and the organization. However, there are solutions so we must act. Jerks don't need to be a part of the culture of nursing. Incivility does not need to exist in hospitals and health care facilities. As Carter (1999) notes, the barbarians are truly at the door and this is true of hospitals and of nursing. However, we have the opportunity to change the self-interest behavior of jerks in our communities of caring. That is what leadership is all about.

A patient's decision to recommend a health care organization and the patient's loyalty scores are largely determined by the interaction patients and their families have with the nurses. Hospitality is how the delivery of that product makes the person feel and is a dialogue that requires the server to be "on the guest's side" throughout the experience. The challenge for health care is to help our patients and their families transcend the usual routine care of our health care world and to experience an emotional connection that provides that sense of affiliation and emotional kinship with the organization and the staff. Moving from the service mindset in health care to the hospitality mindset that engages people positively and emotionally is what healing is all about.

Converting to a culture that strives for perfection and accepts no less than zero defects is the work of leadership in health care today. Some cultures are made up of people who believe that average is good enough. The challenge of the leader is to break up those beliefs and embed new models of "Yes We Can." The leader must communicate four very effective messages that must go along with the passion for the work: (a) evidence and "best practice" data trump local, opinion-based beliefs; (b) morphing from an internal view of best practice to a national/international view of practices within and outside health care; (c) transparency; and (d) KISS: "Keep It Simple, Stupid.''

The successful leader must first make the commitment to practice evidence-based leadership by examining best practices and modeling her/his leadership practice after these models. We know from a plethora of evidence that the relationship-based leader who is also grounded in good operational abilities and can paint the picture of a compelling future is much more effective than the leader who is only selling facts and chooses to manage from her/his office. The leader who is driving toward success can use the saltshaker test: How often are you spreading "yes" to create that sense of connectedness and openness? Is the leader creating a sense of magnetism that comes from communicating the compelling story of optimism and hope for the future of the company that will draw people into an exciting future for the organization? We have great opportunities to watch the candidates for political office position themselves for election. Polls are telling the candidates what is working and what is not. Similar evidence about leaders and their characteristics tell us that relationships with people are what successful leadership is all about.

Simplifying to the point of blaming limits learning and the ability to prevent similar occurrences in the future. Often, the characteristics of the blame culture are very subtle and what appears to be valuable work is actually a subtle sign of the blame game. Leaders must change the language to a proactive, future preventative state rather than focusing on the past and looking for single causes of events. Many nurses have left their positions because they have chosen not to work in a culture of blame. Eliminating all forms of blame is essential for excellence in patient care outcomes and loyalty of staff.

An important field in leadership research is that of the social identity of the group and what that means for leadership. In health care, there are many different types of social identities that vary by hospital, geography, and profession. Leaders often sabotage their effectiveness when they do not consider the social values of the group. The work of leaders is to help move units and organizations to a higher level of performance. Identifying the social identity of the group is the first step. The most successful have expertise in assessing the social identity of groups and developing a commonality of a shared vision that represents the best work of the group and of the leader.

Nursing organizations and hospitals are not immune from the ravages of incivility. Toxic behavior can range from the very serious bullying and sabotage of very destructive people to the annoying and hard to cope behavior of just plain jerks. When a unit does not have a clearly defined "No Jerk" rule and infrastructure to support healthy behavior, communication suffers and errors occur. Nurse leaders have the opportunity of changing the self-interest behavior of jerks in our communities of caring.

Patient safety is a relatively new field, with many opinions and few effectively proven approaches. One factor is clear: optimal patient safety outcomes cannot be achieved in isolation. Although it is well recognized that multidisciplinary collaboration in the healthcare setting is necessary to effect patient safety, collaboration with resources external to healthcare-academia and industry in particular-will not only aid but also quicken the patient safety efforts. The authors outline a healthcare system's use of all available resources to build a patient safety program.

Clarian Health Partners is a system that includes Methodist Hospital of Indiana, Indiana University Hospital, and Riley Hospital for Children. The nurses of Clarian Health Partners are the recipients of many national awards for their leadership and innovations in critical care. Nurse leaders at Clarian have developed and implemented a unique framework for professional development based on the synergy model. In this article, the Chief Nurse Executive for the System, Dr. Karlene Kerfoot, and Marilyn Cox, the Senior Vice President for Nursing and Patient Care at Riley Hospital for Children, describe their vision of and strategies for a new approach to mentoring professional nursing staff.