Visionary
Leader 2011
Baggett,
Margarita M.
Author
Information
The
following manuscript is the winning Visionary Leader 2011 entry submitted to Nursing Management in recognition of Margarita M.
Baggett, MSN, RN, chief nurse officer at UC San Diego Health System.
Margarita was formally recognized for her achievements during the opening
ceremony of Congress2011, October 25, in Las Vegas, Nev. There, she received
the award, sponsored by B.E. Smith.
Nomination
author: Gerard Phillips, MBA, BSN, RN, director of Medical Surgical
Specialties/Care Coordination, University of California, San Diego Medical
Center.
California-based nurse executive
earns the journal's annual leadership award.
Margarita
M. Baggett joined UC San Diego (UCSD) Health System in July 2006. Her
transformational leadership over the last 5 years has been a compelling force
in establishing an environment of engagement and excellence across the
continuum of UCSD Health System's services. Margarita is directly responsible
for over 1,900 staff and functions related to Nursing, Pharmacy, Care
Coordination, and Volunteer Services.
Margarita
joined UCSD during a period of transition and challenge. The UCSD nursing
division was experiencing increased nursing vacancies, increased use of
contract labor, decreased staff engagement and morale, and a clinical practice
environment facing increased scrutiny related to California's mandatory
reporting of significant events. At the organizational level, UCSD was facing
the need to grow patient volumes without adding any additional inpatient beds.
At the time, the average length of stay (LOS) was rising and contributing to
patient flow challenges, especially impacting admissions from the ED, Transfer
Center, Postanesthesia Care Unit, and direct admissions from clinics. These
influencers were creating conflicts among nursing units and affecting RN-MD
relationships. Evidence of shared decision making and accountability for
professional practice was lacking.
Margarita
put the nursing division on a journey of transformation by empowering all
levels of nurses to embrace the full scope of professional practice. Having an
engaged workforce was essential to improving the nurse practice environment and
clinical outcomes. From the beginning, Margarita was a champion of two
concepts: building initiatives around clear structures, processes, and
outcomes; and helping all levels of staff reach their hopes, dreams, and
aspirations. These two concepts laid the foundation for building a culture of trust,
an engaged workforce, and significant improvements in clinical outcomes.
Nurse
vacancy rates and considerable use of contract labor were creating a vicious
cycle, eroding career nurses' confidence in nursing leadership to address
staff's concerns. Margarita demonstrated the importance of “framing” an issue,
creating structures and processes to generate sustainable improvements. The
first thing Margarita did was to change the vocabulary from a negative to one
that's forward thinking and allows building upon current achievements. Nurse
vacancy were reframed to nurse fill rates, and nurse turnover rates were
reframed to nurse retention rates. This subtle but important concept
transformed how nurse leaders, decision support, and staff nurses approached addressing
the challenge of attracting talented nurses and retaining career staff.
Collaborating
with finance, nursing directors, and nurse managers, Margarita developed and
implemented monthly tracking of key indicators at the unit, division, and
overall nursing level. Monthly, each unit manager receives a nursing dashboard
that's formatted around UCSD's Pillars of Excellence: People, Quality, Service,
and Finance. This information is shared at all levels. All units have
communication boards that post these monthly reports. Through multiple forms of
communication—email, communication boards, staff meetings, and town hall
meetings—nurse leaders and staff are kept informed of the current progress on
all indicators.
Another
structure put into place was to have the nurse recruitment team partner with
each nurse manager to tailor recruitment efforts to meet the unique
characteristics of each nursing unit. The nurse recruitment team developed an
on-boarding process to ensure new staff members were supported during the
initial period of orientation. They proactively addressed concerns with new
hires.
Outcomes
from these initiatives are: nurse retention rates have improved from 88% to
98%; nurse fill rates have improved from 86% to 105%; contract labor dropped
from $11 million to $4 million; career staff premium labor dropped from $1.6
million to $750,000; and in the most recent employee opinion satisfaction
survey, new RNs scored 4.44 rating out of 5 on readiness to practice.
Having
a stable workforce provided the genesis of engaging staff members through a
shared governance structure. Margarita challenged the nursing leaders and staff
to advance the practice of nursing through the development of unit-based
practice councils (UBPCs) and nursing division level shared governance
councils. Development of UBPCs and nursing shared governance councils provided
a forum for staff-driven initiatives that increased nurses' autonomy over their
nursing practice. Communication was layered so that there were both vertical
and horizontal communications between UBPCs and shared governance councils.
The
shared governance structure has matured to the level where most units have a
UBPC, and there are eight nursing division shared governance councils. Due to
the engagement and energy brought forth by the shared governance structures,
nurse leaders and staff sit not only on nursing councils but also on
organization-wide councils. Nursing staff and leaders contribute to filling 330
memberships across 29 Medical Staff Executive Committees and Organizational
Task Forces. Through Margarita's participatory leadership style, she has
positioned nursing to advocate for patients and improve the work environment,
thus changing the image of nursing at UCSD.
One
of Margarita's passions is skin care. From the very moment she joined the UCSD
team, she set forth the goal of zero hospital-acquired pressure injuries. Very
soon after Margarita joined UCSD, the California mandatory reporting
requirements went into effect. At the time, we didn't have an organized approach
to skin care. Working through the shared governance structures, Margarita
listened to staff nurses and managers. During this appreciative inquiry time,
Margarita directly observed how patients were being treated, the nursing
practice, and barriers to nurses effectively advocating for their patients.
Cultivating
innovation at the unit level and sharing best practices led to a nursing
division standardization of skin care carts and digital cameras with printers
for each unit, standardized woundcare documentation, a formalized process for
consulting with in-house wound care nurses, and implementation of “Wound
Wednesday.” Wound Wednesday is a partnership between staff nurses and nurse
managers to ensure the integrity of the nursing skin assessments. Every patient
within the inpatient setting has his or her skin checked by the unit's nurse
manager and the nurse taking care of the patient. Through this process, we've
changed the culture to one of proactive management of patients' risk for
pressure injuries. Although we haven't reached our goal of zero pressure
injuries, we've dropped from 15% of inpatients having a pressure injury to our
most recent data being 1%.
Another
strategy Margarita used was to have nurse managers keep their staff engaged
with preventing pressure injuries by posting the number of days their unit has
gone without pressure injuries. To maintain and continue to work toward our
goal of zero pressure injuries, Margarita instituted a comprehensive daily skin
report that's shared with the entire nursing leadership team. For any patient
with a stage II or greater pressure injury, the nurse manager from the sending
unit will contact the nurse manager of the receiving unit to discuss the
patient's condition and all interventions implemented. This has improved
relationships across units and created a shared responsibility among all
nurses. Margarita's passion for skin care continues to challenge the nursing
staff to seek additional improvements. One unit has achieved a stellar outcome
of over 980 days without a pressure injury.
Patient
flow is an important component of a health system's operations. In 2006 through
early 2007, UCSD's LOS was on the rise and had reached a high of 6.4.
Margarita's vision was to have Care Coordination, the department responsible
for utilization management and discharge planning, to report through the
department of nursing. Margarita was successful in advocating for these
changes; Care Coordination responsibility was transferred to one of the nursing
directors and given approval to implement a new model of care coordination that
was unit-based.
To
ensure her vision of Care Coordination, Margarita adopted a medical-surgical
unit to actively participate in one of the changes—multidisciplinary rounds.
Margarita participated at least two times a week on this medical-surgical
unit's multidisciplinary rounds. She was there to observe, coach, and mentor
the nurse manager, nursing staff, case managers, and social workers. Through
this process, effective multidisciplinary rounds were developed and shared
throughout the nursing division.
Another
strategy headed by Margarita was to establish a review committee comprised of
representatives from Admissions, Compliance, Revenue Cycle, Finance, Care
Coordination, Nursing, and physicians to review all patients with barriers to
discharge, high dollar charges, and/or with a LOS greater than 20 days. Through
this process, actions were identified to facilitate these complex discharges.
As a result, UCSD has seen a drop in LOS from 6.4 to 5.5 and an increase in
admissions from 21,000 to 24,000. This improvement in LOS has decreased the
wait time of admitted ED patients from 209 minutes to 163 minutes over the
course of 1 year.
Margarita
had a vision to develop the professional role of the nurse. Examples include
clinical ladder promotions, increasing certifications, encouraging professional
organization involvement, and participation in UCSD-sponsored education
opportunities. In alignment with Margarita's belief, we're here to assist staff
members to reach their hopes, dreams, and aspirations. Below are the outcomes
of this vision:
1.
Margarita set the vision that nurses
can advance through the clinical ladder. With Margarita's endorsement of the
clinical ladder process, authority was vested with the Professional Development
Council to manage the process for promotion. Since implementation of this
practice in 2009, clinical advancements have averaged 49 promotions per year.
2.
Margarita embraced the value of
advanced practice nurses and facilitated the creation of a shared governance
council to represent their interest. An outcome of this council developed a
comprehensive resource list of field experts.
3.
Professional certifications have
increased from 20% in 2008 to 31% in 2010.
4.
30% of nurses report membership in
professional organizations.
5.
UCSD-sponsored educational
opportunities grew from 6,000 to 11,000 attendees.
6.
Each year since 2008, 40 staff
nurses have taken advantage of participating in a Front Line Leadership
Academy.
Most
recently, in recognition of Margarita's significant contributions to the
organization, she has a direct reporting relationship to the CEO and serves on
executive decision-making committees.
Margarita's
vision has positively influenced the nursing division at UCSD. Over the last 5
years, her dedication to promoting a professional nursing practice model has
engaged the whole organization. It's quite common to hear senior leaders
quoting Margarita and sharing her vision of establishing sustainable structures
and processes to guide our organization into the future.
© 2012 by Lippincott Williams &
Wilkins, Inc.
