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Strategic Planning for the Director of Nursing in Long Term Care

Health Care reform has made a significant impact on the health care industry and on the professional practice of nursing. Nowhere has this impact been more dramatic as in the acute care setting. The primary site of care has shifted from the acute care setting to the community and to long term care. The image of long term care facilities as "a place where people go to live out their last days" has changed to one of planning for discharge, provision of high tech care in specialty units and progressive rehabilitation. These dramatic changes have placed a special need for planning within the long term care industry. They have also created the need for nurse executives in long term care to become actively involved in the planning of the essential care factors needed to provide safe, cost efficient and quality care.

Additional skills are necessary for the Director of Nursing (DON) in long term care. Knowledge of marketing and business applications are essential tools in the new health care environment. New terms are being introduced to the daily operations run by the DON. New terms such as marketing, competitive analysis, financial planning, business plan development and trends will become (if they have not already) part of the day-to-day language within the health care setting. In order to thrive in this new environment of health care reform, it is important that Nurses begin with the development of a strong planning process. It is from this base that nurses can effectively move within the "new system" and create positive change within the facility. Flexibility is the key to immediate and future success.

There are many approaches to the process of planning. The most extensive is the Strategic Planning Process. Strategic Planning may be simply defined as a process which assists an organization in focusing on its capabilities as well as its weaknesses in order to determine future directions. This process defines the steps required to reach desired goals. As is known from the Nursing Process (assessment, planning, implementation, and evaluation), planning will enable the nurse to better utilize and coordinate resources. It will also encourage quality control of the resources used through evaluation and monitoring of performance (outcome management).

Planning, like patient care planning, is a dynamic process. It is based on historical information and assumptions for the future. Planning is dependent upon the experience levels of those involved. Experience helps to define and identify the trends of the business or service (patient care needs) and to determine the results to be achieved (patient care outcomes).

At this point you may be asking yourself, "This is all very interesting, but I am a patient care oriented nurse. How does all of this affect me?

The Department of nursing and each nursing unit have a unique opportunity to play a key role in the transformation of health care within the long term care setting. Nursing is the focal point of patient care, interacting with every department and contributing agency (acute care, physicians, home care) involved in the overall delivery of care. This interdepartmental and interagency exchange must be defined, analyzed and justified in order to meet the requirements of measuring patient care outcomes. The complexities involved in this process require establishing and remaining focused on a shared vision and common goals. Interaction and involvement with administrative and corporate levels of the facility will prove to be valuable in meeting the challenges of the future design of sites for the delivery of patient care.

A second reason for the involvement of nursing in the Strategic Planning Process is to provide an opportunity to establish a suitable environment for nursing practice. This directly involves the nursing unit, since it is the primary site of practice. There is nobody more important in the planning of the practice environment than the nurse! Examples of issues which can be addressed through the planning process include (but are not limited to):

- Involvement in organizational policy development

- Involvement in organizational decision making

- Development of standards for authority, autonomy, and accountability

- Establishment of partnerships with physicians and other professionals

- Establishment of standards of care and measurements for evaluating quality of patient care outcomes

- Development of education and credentialing standards

- Creation of a clear and positive image of nursing

- Involvement in development of guidelines for contributions to local, state and national policy formation and legislation

- Maintaining quality of care within the mandate of regulatory bodies

- Budgeting allocations and justification

With these issues in mind, the development of a Strategic Planning Process for nursing will involve several key components. These include:

- A vision for the future

- A value statement for the Professional Practice of Nursing

- An assessment of strengths, weaknesses, opportunities, and threats for the nursing organization

- Development of opportunities for nursing within the changing health care environment

- Development of strategic partnerships among health care providers

- A commitment and "ownership" of change by all levels of staff

- Development of action plans and strategies to accomplish goals and desired outcomes

- Development of an evaluation plan

It is important to remember that the Strategic Planning Process is not stagnant. In fact, it is fair to say that the plan is never complete. It changes continuously in order to maintain a strong presence in a complex environment. The plan becomes a blueprint and guide to move the unit, the department and/or the organization in a forward, focused and positive direction.

The Strategic Planning Process is valuable only if there is commitment from all levels within the organization. It can be a difficult process since it is based on open and honest communications. The honesty involves a realistic look at the individual, the organization, common goals and, most important, the changes that need to happen. It may require a "positive anger" - anger with complacence with ourselves, our organization, and our colleagues.

Historically, organizational Strategic Planning has primarily involved the planning for bricks and mortar with little emphasis on programs, human resources, or strategic alliances. The challenges of health care reform have placed an increasing emphasis on the need to include these critical factors in the Strategic Planning Process. The nurse executive, the staff nurse, and each associate are "stakeholders" in the value and quality of care provided, the patient care outcomes and the quality of the practice environment. The stakeholder must share the mission and the goals and must work within the atmosphere of mutual respect and cooperation. This leads to effective partnerships that can function within an offensive framework rather than a defensive environment.

Identifying opportunities for change generally represents a departure from traditional patterns and methods of doing business. Examining the purpose of health care and re-directing commitments toward new goals, demands strong partnerships, not only internally, but externally with the community. A well conceived and developed planning process can build and strengthen these alliances. The outcome: health care success.

The basis of the Strategic Planning process involves the use of a simple but effective planning tool - the SWOT Analysis. SWOT stands for Strengths, Weaknesses, Opportunities and Threats. The analysis is effective because it can be used for many areas involved in the planning process. It can be applied to a unit, a department, individual roles, or to the entire organization. It is also a useful tool in completing a competitive analysis and using the information in developing effective marketing strategies.

The critical success factor in using a SWOT Analysis format is honesty. It is generally not a difficult task to identify strengths. However, it is often very difficult to openly recognize and acknowledge weaknesses. If this appears to be a problem, the SWOT Analysis can be completed as an anonymous submission with a group discussion of collective information of the analysis. Keep in mind that it is the goal of the planning process to change weaknesses into potential opportunities and eventually into added strengths. The outcomes of the SWOT Analysis represent short and long term objectives for change. The strategies developed to accomplish change must be built on strengths.

Determining opportunities requires a strong working knowledge of the unit, the department, organization and the external forces that affect the practice and care environment. This phase of the SWOT Analysis involves gathering data, completing a needs assessment, gathering financial information, technology changes and social and cultural trends.

Sources of information include: patient satisfaction surveys, focus groups, organizational data, and literature searches. It is important to identify the types of information that will be required, and to seek out the most efficient sources for collecting that information. Many planning efforts have failed simply because there was too much data and the tasks became overwhelming. Help is available from the planning and/or financial departments within the organization. Establishing communication lines early in the planning process will greatly reduce the potential for "information overload."

When you are determining the information that you will need for the planning process, ask yourself some simple but important questions:

"What information do I need to gather?"

"Why do I want this information?"

"What will I use this information for?"

"What is the most efficient avenue to gather this information?"

The Strategic Planning Process involves identification of critical issues and/or choices the department will face in the future. The listing of critical issues and/or choices will be the summation of all the information gained. Examples of questions that will form the basis of identification of critical issues are:

What will impact the growth of the unit, department, organization?

What will impact the unit, department, organizations' viability in the changing health care delivery system?

What will affect the unit, department, organizations image within the overall organization and the community?

Once the critical issues/choices have been listed and prioritized, goals and strategies will need to be developed. Goal setting and strategy development need not be difficult and complex. Simplicity is the most effective way to keep a plan focused and on track. When setting goals and determining strategies, keep the following guidelines in mind:

The current and anticipated changes in the health care delivery system will have a tremendous effect of the practice environment for nursing. It is critical to the survival of organizations that they recognize the creative and innovative talent at every level. The focus of purpose for all health care is successful individual health care management. The majority of work related to this purpose is done on patient care units, in clinics, emergency departments, operating rooms, long term care units, specialty units, etc. The best strategy for the future is to involve those who are most affected by the changes. The long term care nursing executive and the staff nurse do make a difference in patient care and will make a significant difference in the planning of the future delivery of cost effective quality patient care.

In her book, Change From Within: Nurse Entrepreneurs as Health Care Innovators (1990, ANA Publishing), author Jo Manion states this very well:

"The deeper within the organization the planning goes, the more likely it will be successful. Staff must be involved in the decisions that affect them. Change produces anxiety in an individual when it is done to the individual, but it can be exhilarating when done by the person."

Nursing Staff at all levels within the organization must accept the challenges and opportunities of the future design of the health care system and its implications for how and where they will practice professional nursing. Accepting the challenge is a choice that all must make. The risks are high...and...the potential rewards for continued and enhanced quality patient care and for the professional practice of nursing are without limits. It is the nurses, after all, who are the backbone and the lifeline of patient care delivery. Nurses CAN make a difference!

References:

Carolyn S. Zagury MS, RN, CPC

Garner, J.F., Smith, H.L., Peland, N.F. (1990). Strategic Nursing Management: Power and Responsibility in a New Era. Aspen Publishers: Rockville, MD.

King, W., Cleland, D.I. (1987). Strategic Planning and Management Handbook. Van Norstrand Reinhold Company: New York, NY.

Manion, Jo. (1990). Change From Within: Nurse Entrepreneurs as Health Care Innovators. ANA Publishers: Kansas City, MO.

Sheridan, D.R., Bronstein, J.E., Walker, D.D.(1984). The New Nurse Manager. Aspen Publications: Gaithersburg, MD.

Wilson, K.W.(1992). Building New Nursing Organizations: Visions and Realities. Aspen Publications: Gaithersburg, MD.

Wolf, A.R. (October, 1989). "Uncovering the Hidden Work of Nursing." Nursing and Health Care, 10(9).

Zagury, C.S.(1995,R). Nurse Entrepreneur: Building the Bridge of Opportunity. Vista Publishing: Long Branch, NJ.