MedCity Influencers, Hospitals

 How to avoid the fallout after a change in nurse leadership

when there is not a clear succession plan, interim leadership is likely the best and least expensive option overall to maintaining and improving a nursing unit until a permanent leader can be sought and transitioned into the role.

Imagine this: The Emergency Department nursing director has just given their resignation and it is clear that the newly-hired manager is not ready to transition into this challenging role. Though the four-week notice was generous, the process to obtain approval to post the position often takes that long, followed by one week for the position to be posted internally, before it is finally posted externally. It takes another month before the first candidates have been vetted and are ready for interviews. After four to six weeks of interviews and no strong candidates in sight, it looks like it may be a long-term process to find a permanent leader. Meanwhile, in the Emergency Department, metrics are declining, the number of patients leaving without being treated is rising, patient complaints are increasing, and overtime is the highest it has ever been. To make matters worse, two nurses gave their resignation this week, perhaps indicating that staff are uneasy. With a Joint Commission visit on the horizon, senior leaders are getting nervous about the state of the department.

Nursing leaders are essential in driving vision and healthcare transformation. In particular, the front-line leaders, directors and managers are critical to the success of unit-based initiatives, patient safety and quality metrics, as well as staff engagement and satisfaction. Maintaining improvements in department operations are crucial and a few missteps can negatively impact hard-won improvements.  Despite the benefits and cost savings of nurse leader succession planning, many organizations lack a replacement plan of all leadership positions.

Nurse shortages and their financial impact on healthcare organizations are getting worse. The use of travelers and agency personnel jeopardize unit quality metrics, although working short-staffed is not an answer either. Along with the nursing shortage, there follows a nursing leadership shortage, noticeably more at the unit manager and director levels. These middle management roles are some of the most difficult jobs in healthcare organizations and, as such, are often hard to fill. Leadership positions are often open for long periods of time, leaving vacancies that are hard to cover and operational erosion that is even more difficult to recover from after they are filled.

Benefits of an Interim
An interim leader has the goal to create stability while moving the department forward. The interim leader’s work is to stabilize the workplace, keep staff engaged, and keep the unit safe and running efficiently. Interim leaders also bring a fresh set of eyes to the department. They see opportunities for improvement and have the ability to clean up any loose ends before a permanent leader is brought in.  This is even more critical if the former leader was not a high performer. In that case, often there are many incomplete tasks (e.g. incomplete evaluations and actions plans and unfilled open positions) as well as other important safety and quality initiatives not rolled out. Additionally, the interim leader has the benefit of being able to create some long-sought changes to the unit, which ultimately allows the new leader to be successful once hired.

If the leader was beloved by the staff, the use of a savvy interim leader brings an element of stabilization, allowing the staff to grieve and helping to prepare the staff to accept a new traditional leader once one has been identified. Ideally, this is done in conjunction with running unit operations and adding operational improvements. This process assists staff in their emotional transition from the departed leader to an acceptance of a new leader.

The interim leader helps allow time to assure the best leader is selected for the unit, not one selected out of the urgency of the situation. Selecting the wrong permanent leader can have long-term repercussions for the hospital, staff and patients. Having an interim allows the organization to take the time to thoroughly vet and select the right candidate. Once they find and hire the candidate, having a handover period is crucial to transition the now well-running department to the new director. This allows for the new director to onboard appropriately, attend orientation and spend the first weeks meeting the team as they are slowly given the reins of the department. This preparation sets the new leader up for success and tempers the transition.

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Costs of an Interim
The costs of an interim, although higher than the salary of the permanent leader, can bring cost savings to an organization in many ways. Lost revenue opportunities occur with lack of oversight to key performance indicators (e.g. LWBS) or increasing costs on the unit (overtime, productivity) and can be a financial burden. Conservative estimates of the cost of replacing staff nurses vary from $92,000 for a medical-surgical nurse to $145,000 for a specialty-trained nurse (ICU, ED).  So, in the case of our opening example, if two ED nurses left, that is conservatively a $290,000 cost to the organization. The cost to replace a nurse manager is reported to be 75-125% of their annual salary and the cost to keep the wrong manager is even more challenging to calculate. While hiring the right person is costly, hiring the wrong person has significant costs and potential downstream negative effects on the organization that may last for years. Assuring the best candidate is hired is critical for the long-term success of the unit and delivery of patient care.

There’s a strong financial case to be made for a comprehensive succession planning process and it likely represents the single best way to replace a leadership vacancy. But when there is not a clear succession plan, interim leadership is likely your best and least expensive option overall to maintaining and improving a nursing unit until a permanent leader can be sought and transitioned into the role.

Picture: marchmeena29, Getty Images

Beth Fuller and Will Stewart are consulting principals of ED Services of Philips.
Beth has over 35 years of emergency, ICU, and critical care transport leadership experience in academic medical centers and community hospitals. She possesses extensive clinical and leadership knowledge and experience and has led ED change and reduced cost while improving patient satisfaction and employee engagement. Beth has assisted several organizations in redesigning their triage systems based on best practices, resulting in substantial decreased length of stay, decreased left without being seen rates, and improved patient satisfaction. She holds nursing certifications in critical care, emergency nursing, and flight nursing.

Will has decades of experience helping emergency departments increase efficiency and throughput capacity and boost patient and staff satisfaction, while lowering costs. He has assisted health care providers to reduce ‘left without being seen’ rates by as much as 80% and raise charge capture rates. Results have been realized by leveraging performance improvement best practices while providing focus on safe care for both patients and staff. Will brings a keen awareness to organizational and unit culture which is important when implementing sustainable change. With a focus on process and culture, Will excels at mentoring new leaders.

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