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August 2014 62 Nurse Leader

mbarking on the ANCC Magnet
Recognition Program

can be challenging for hospitals that are
up against resistance to change. Yet,
when opening a new hospital with the
goal of Magnet Recognition

within 2
years, it is imperative to embed the
Magnet model into the framework,
design, and opening of the hospital.
Regardless of the path taken, the role of
the chief nursing officer (CNO) of a Magnet
hospital is to be a transformational leader
who supports quality patient care and excel-
lence in nursing. Therefore, this is the exem-
plar journey of 1 CNO utilizing her skills as a transformational leader to propel a vision of nursing excellence
into the foundation of a brand- new nonreplacement hospital with the goal of Magnet designation in 2 years.
Baptist Health South Florida (BHSF) was created in 1990, but
its tradition of medical excellence goes back decades. The
dynamic blend of leading-edge medical care and old-fashioned
commitment to the community is the strength and spirit of
BHSF. Its network of services extends throughout Miami-Dade
and Monroe Counties with Baptist, Baptist Children's, South
Miami, Homestead, Mariners, Doctors, and West Kendall Baptist
hospitals; outpatient diagnostic and surgical facilities, such as the
conveniently located Baptist Medical Plazas; and home health-
care services in the region. Through these and other facilities,
BHSF serves more than 100,000 people each year. Our distinc-
tive pineapple logo, an age-old symbol of hospitality, reflects a
patient-centered focus of warmth and welcome.
The mission of BHSF, a Judeo-Christian faith-based
organization, is to improve the health and well-being of indi-
viduals, and to promote the sanctity and preservation of life,
in the communities served. There exists a commitment to
maintain the highest standards of clinical and service excel-
lence, rooted in the utmost integrity and moral practice.
Therefore, BHSF is dedicated to providing high-quality, cost-
effective, compassionate healthcare services to all, regardless of
religion, creed, race, or national origin, including, as permit-
ted by its resources, charity care to those in need.
Denise Harris, MBA, MSN, RN, NEA-BC, and Tanya Cohn, MSN, MEd, RN
Designing and Opening a New
Hospital With a Culture and
Foundation of Magnet

An Exemplar in Transformational
West Kendall Baptist Hospital (WKBH), which opened for
patient care on April 27, 2011, is a teaching hospital with
surgical, emergency, maternity. and diagnostic units. The hos-
pital represents the first completely new, nonreplacement
hospital built in Miami, Florida, in more than 35 years.
Designed, built, and gold certified for being a Green facility,
the hospital was built to withstand a category 5 hurricane
and incorporated design concepts and principles of patient-
and family-centered care.
The chief executive officer (CEO), appointed in January
2010, is an experienced hospital CEO from within BHSF. He
came from a twice-designated Magnet hospital and led their
hospital to achieve the esteemed Governors Sterling Award for
Quality. The CEO selected the CNO from within BHSF, also
an experienced nurse executive including Magnet designation.
This included being a contributing nurse leader during 3 suc-
cessful designations of the health systems flagship, Baptist
Hospital of Miami. This shared knowledge, understanding, and
professional commitment for quality was a foundation for creat-
ing the vision for WKBH, that of a culture of excellence within
a framework of patient and family centered care (Figure 1). The
collaborative synergistic relationship and shared vision by the
CEO and CNO set the stage for the CNO to create the vision
of Magnet for the new hospital. And so, the journey to Magnet
at WKBH began. Starting with this end in mind, the CNO
used the Magnet Model as a systematic framework in the
design, planning, and opening of WKBH.
As Jim Collins
outlined in Good to Great, organizational excel-
lence first starts with the right who. With this being an
aligned principle of Magnet, the CNO and the executive team
placed great emphasis on this process through evidence-based
practices to recruit and hire the best people to create a culture
of excellence. In addition to already defined core leader com-
petencies of BHSF, planning elements included a retreat to
define key behaviors and competencies, literature review, shared
learning from other CNOs and hospital executives who opened
new hospitals, and collaborating with human resources (HR)
on their current research and practices. As a result, new compe-
tency-based leader job descriptions and behavioral-based inter-
views to fit WKBH culture were created. Also, an enhanced
leader and staff onboarding process that included components
of the ANCC Magnet Recognition Program
(emphasis on
research, evidence-based practice, shared governance, and clini-
cal advancement) and patient- and family-centered care were
developed. In addition, consultative feedback from other health
systems opening a new hospital showed that they were able to
recruit only 20% to 40% from within their system. To preserve
the BHSF culture, without hurting affiliate entities, WKBH set
a target of 50% and, with thoughtful planning and processes,
were able to meet this goal. In addition, prior to opening, the 8
chief nursing officers collaborated at their Patient Care
Leadership Council and changed the job requirement for all
nurse managers to minimally have a Bachelors of Science in
www.nurseleader.com Nurse Leader 63
Figure 1. Culture of Excellence Framework
Nursing (BSN). This policy change enabled WKBH to open
with 100% of all nursing managers having a BSN or higher.
Nurse leaders above the role of nurse manager were already
required to minimally hold a BSN, with the MSN being pre-
ferred and required at the CNO level.
Hiring Process and Orientation
The hiring and orientation of over 800 employees required a
systematic process and was organized by the corporate coordi-
nator of clinical learning, a nurse, in collaboration with HR and
the executive team. All staff, whether transferring from a sister
hospital or new to BHSF, were required to participate in a
general orientation session. Current BHSF employees were
engaged through storytelling to assist in the enculturation of
new staff to the BHSF culture. The facilitator engaged every-
one in team-building activities throughout the program to help
establish the new WKBH team and utilized an interactive
blended model of learning. Fun was built into the program to
enhance the experience and set the tone of the organization.
All executives played a part in the orientation of staff and were
visible role models of the expected culture. The CNO present-
ed patient- and family-centered care in all general orientation
sessions and was identified as the Pillar Champion of Quality.
The CNO also participated in all nursing orientation sessions
to introduce the WKBH vision of nursing excellence and the
Journey to Magnet Excellence

. Modeling shared decision

making, the CNO introduced the draft WKBH nursing mission
and vision statement, asking for staff input during each session.
Nurses were invited to collaborate further through direct e-
mail, her open-door policy, and during leader rounding. Later
on, prior to opening, a nursing forum was held to aggregate
nurses input, to vote on the mission and vision statement, and
to pick a nurse theorist that represents WKBH nursing care.
In addition to general orientation, structured education was
developed and implemented for all employees. Six weeks of
structured education in staggered groups of 50 to 100 individ-
uals was planned to achieve necessary adoption of safe prac-
tices. This included introduction to the new hospital
environment, equipment, information technology (IT), docu-
mentation systems, policies, and protocols. Educational sessions
were designed to incorporate elements of team building, col-
laboration, empowerment, and continuous improvement. The
intent of the process was to ensure staff could effectively assim-
ilate a large amount of information in a relatively short time,
including understanding and application of all policies, Studer
(i.e., AIDET [Acknowledge, Introduce, Duration,
Explanation, and Thank You], hourly rounding, clinical alert
boards), and working as a team.
Initial Committees
Early structures included an evidence-based practice council
to define policies and practices to achieve standards of quality
and safety, and a culture of patient-centered care. This inter-
professional council, led by the director of Magnet, evidence-
based practice (EBP) and quality indicators, developed over
700 policies prior to hospital opening. All policies were
grounded in research and best practices, and the collaborative
process set the stage for a culture of shared decision making.
These policies were the framework for a successful Agency
for Healthcare Administration (AHCA) certification and The
Joint Commission (TJC) accreditation.
Prior to opening, simulated live scenarios were developed
and conducted as drills with quality evaluators to assess staff and
team performance, and identify gaps and system issues. Post
drills, the interprofessional leadership team, along with corpo-
rate partners, debriefed and outlined immediate system and
process improvements necessary to open the hospital with safe
quality of care. This team was known as the operations commit-
tee and was led by the CNO. The committee utilized princi-
ples of rapid-cycle performance improvement and was essential
and valuable to the organizations successful opening, which
included accomplishing TJC accreditation only 5 days after
opening. This committee still exists today and is used to main-
tain a high degree of collaboration, communication, and con-
tinuous improvement to operational processes and changes.
Nursing Leadership Retreat
In January 2011, the CNO held a nursing leadership retreat to
share the vision and structural components of Magnet and a
culture of nursing excellence for WKBH. The retreat was edu-
cational and designed in a way to build teamwork, recognize the
talent of the individuals, and embed fun on the journey to
Magnet designation. Because many WKBH nurse leaders were
hired from internal sister Magnet-designated hospitals, the adop-
tion of a journey to nursing excellence and Magnet was valued,
understood, and supported. The retreat included: a defined hir-
ing preference for BSN-prepared staff; a value for clinical
advancement, education, and research; belief in a shared gover-
nance model of practice; an introduction to the current BHSF
nursing strategic plan; and an understanding of current nurse
theorists with a crosswalk of their alignment to the values of
BHSF and WKBH. Through an open dialogue and process of
shared decision making, the following was accomplished:
The first draft of the mission, vision, and philosophy of
nursing at WKBH
The WKBH nursing strategic plan
A selection of the top 3 theorists, from which all WKBH
nursing staff would consider for adoption.
As foundational members of the nurse governance coun-
cil, the nurse leaders acted on the values of a culture of col-
laboration and shared decision making in this first retreat. The
final step was to include all levels of nursing practice in a
nursing forum led by the CNO. Held shortly before open-
ing, all nurses participated in finalizing and voting on the
nursing mission and vision statement, nursing strategic plan,
and the adoption of a nurse theorist for WKBH. This was
the initial step in the Magnet journey timeline (Figure 2).
Establishing the WKBH Shared Governance Model
Soon after opening, the WKBH Shared Governance model
(SGM) was established. The WKBH SGM empowers nurses to
August 2014 64 Nurse Leader
be involved in decision making and gives them a sense of
autonomy and responsibility of their actions over practice. This
SGM is bidirectional and decentralized, consisting of 7 major
councils, namely: nurse executive council (NEC), professional
development council (PDC), clinical practice outcome council
(CPOC), cultural competence council (CCC), unit-based prac-
tice council (UBPC), research and evidence-based council
(REBC), and nurse governance council (NGC). The result is a
main hub for summary communication. Each council has inter-
professional committees, workgroups, and task forces within
them to support shared governances and teamwork. This is the
framework that strengthens the staff nurses participation in
decision making, to improve the culture of the workplace envi-
ronment, and thus, significantly improve nurse, patient, and
organizational outcomes.
After the full deployment of the SGM, members of the
nurse governance council, made up of all levels of nursing, held
a working retreat to establish the WKBH nursing professional
practice model (PPM). The CNO acted as the executive
sponsor while the director of Magnet, EBP, and quality indica-
tors facilitated an educational, innovative, and interactive ses-
sion. The amazing teamwork during this session resulted in an
extraordinary visual guide incorporating the values and foun-
dation for nursing excellence at WKBH. The PPM is the driv-
ing force of nursing care in WKBH. It is a diagram illustrating
the alignment and integration of nursing practice with the
global community; the mission and vision of WKBH; and the
8 values that nursing has adopted. At the center are the patient
and family, and the model includes the organizations pillars of
success. The model serves as a guide for all nurses at all levels
and in all settings at WKBH (Figure 3).
Achieving Outcomes in Nursing Excellence
The exceptional outcomes of the teamwork and culture of
nursing excellence at WKBH can be seen in the 2012 year-
end results of the nursing strategic plan (Figure 4). Year-end
exceptional results include:
60% of all nurses held a BSN compared to 41.4% of
National Database of Nursing Quality Indicators

(NDNQI) like-size hospitals.

23% were certified compared to 13.4% of NDNQI like-
size hospitals.
12 advanced and 2 expert nurses were promoted
through the Professional Nursing Advancement Program
Highly satisfied rating on the Practice Environment
Scale (PES) and job enjoyment scale (registered nurse
[RN] NDNQI) was achieved.
99th percentile inpatient satisfaction (nursing and overall
rating) was achieved.
96th percentile emergency department patient satisfac-
tion (nursing and overall rating) was achieved.
7 of 10 HCAHPS indicators were at the top box (95th
92% of National Patient Safety Goals (NPSG) were at
the top decile.
All clinical NDNQI indicators were at or better than
www.nurseleader.com Nurse Leader 65
Figure 2. Magnet Journey Timeline
Physician satisfaction with nursing was at the 94th per-
Won 2012 Studer Excellence in Patient Care Award in
the HCAHPS most achieved category.
Won Studer Healthcare Organization of the Month
Fire Starter Award September 2012.
Developing a Strong Unit-Based Practice Council
The implementation of shared governance included an all-
day blended learning workshop for the newly elected UBPC
chairs and co-chairs. This program focused on shared gover-
nance practices, skill building in leading a committee, educa-
tion on NDNQI nursing outcomes, and exposure to the
Clinical Excellence Through Evidence-Based Practice
(CETEP) model
for EBP projects. Within the first year,
nursing UBPCs were active in all areas of the hospital.
UBPCs were empowered to work on their unit nursing
practice (RN NDNQI) and patient and family outcomes
(Clinical NDNQI and PG/HCAHPS) through the CETEPs
EBP model. All UBPCs have budgeted, protected, time allot-
ted for meetings and improvement activities including
research and evidence-based studies.
To further enhance learning and development, the initial
founding team of UBPC chairs and co-chairs attended the
2012 national NDNQI conference. The conference experi-
ence promoted mentorship and strengthened the new chairs
and co-chairs confidence and enthusiasm to take on their
new roles. Each chair was charged to report back to NGC
with 1 lesson from the conference and its applicability to
WKBH. To continue the shared governance and transforma-
tional leadership model, the chairs went to their unit councils
and began the collaborative work on evaluating and poten-
tially changing clinical practice.
At the end of 2012, results showed sustained patient satisfac-
tion at or above the 95th percentile throughout the hospital.
NDNQI scores were better than benchmark in a majority of
indicators throughout the year and a half, along with high
results in RN NDNQI job enjoyment scale and all PES scores
August 2014 66 Nurse Leader
Figure 3. Nursing Professional Practice Model
were achieved. In addition, core measures were at the top
decile in 90% or better of all indicators since opening.
UBPCs Shared Governance in Action
Two exemplars of WKBH UBPCs involvement in shared deci-
sion making were meeting medical-surgical staffing guidelines
and decreasing falls. Initially, the target for meeting medical-
surgical staffing guidelines was set at 80% based on the wide
variation in census that was anticipated with being in a new
start-up facility. However, the medical-surgical UBPC made the
recommendation to the NGC to increase the target to 90%.
This recommendation was approved by the NGC, and
improvements were made to achieve this goal. This included
working with the nursing staff office to create a new shared
employee pool cultivated from current Baptist Health nurses
who were experiencing call offs for low census. The shared staff
strategy was supported by the hospital CNO who also recom-
mended that the newly established centralized staffing center
(CSC) take over this program moving forward. Utilizing the
CSC when possible, managers also opened additional unit per
diem staff positions. In addition, daily bed crunch meetings
brought frontline leaders together and allowed collaboration on
sharing staff between medical-surgical units. Other service line
managers offered cross-trained clinical partners to assist during
high census. By the 4th quarter of 2012, the goal of meeting
medical-surgical staffing guidelines of 90% was achieved. In
addition, staff nurse feedback was positive, and a high RN
NDNQI score on staffing and resource adequacy PES score
showed that the work to improve the target goal for meeting
staffing guidelines made a difference. In 2011, the score was
3.07, which increased in 2012 to 3.20; both were way above
NDNQI benchmark of 2.90 for like-size hospitals.
Another key goal on the 2012 nursing strategic plan was
to decrease patient falls. A priority for the hospital, a fall
reduction team was developed. All levels of nursing were
represented and collaborating on this team. To align their
commitment with staff, in 2012, all nurse leaders had an
evaluation goal to reduce falls. The fall reduction team uti-
lized a systematic evidence-based approach to make improve-
ments and reduced falls to below the NDNQI benchmark.
This reduction has been sustained and continues to be a
focus of care.
Professional Nursing Advancement Program
Profession development is a value of BHSF and 1 of the 8
elements of the WKBH PPM (Figure 3). Staff nurses are
supported and coached in their clinical advancement by
nurse leaders, colleagues, and members of the PNAP.
www.nurseleader.com Nurse Leader 67
Journey to Magnet Designation

Strategic Goals Measurements Targets 2013 1
2013 2
2013 3
2013 4
Nursing Engagement Gallup Healthcare 80
Percentile Grand Mean Score on Overall RN
N/A N/A N/A 99

Bedside Nursing
NDNQI RN Survey Remain at Highly Satisfied in Job Enjoyment Scale
PES (Practice Environment Scale) > Grand Mean Score
Highly Satisfied
(Spring - 2012)
Highly Satisfied
(Spring - 2012)
Highly Satisfied
(Spring - 2013)
Highly Satisfied
(Spring - 2013)
Physician Engagement HealthStream > 90
Percentile Overall Satisfaction with Nursing 94

N/A N/A 99

Patient / Family
Press Ganey

CMS all Database HCAHPS
Percentile in Overall Nursing Care

> 95
percentile Top Box responsiveness of staff

Patient & Family
Centered Care
Press Ganey > 90
Percentile on Staff effort to include you in
decisions about your treatment
92nd 99
Improve Budget
Bi-weekly Productivity Report Volume adjusted budget at 90% or better for
inpatient units (Direct Patient Care Providers only)
116% 110% 109% 119%
National Quality
CMS Report >90% core measures at top decile 95% 95% 100% 100%
National Patient Safety
Dashboards 100% Compliance 11/13
Safe Workplace Incidence Reports Zero incidents of SPH injury
Zero needle sticks per quarter
2 2 0 0
2 2 0 3
Patient Safety NDNQI Patient Falls at or below NDNQI benchmark 1.17 1.48 1.65 Better than
(Results in Dec)
Sustained Safe Staffing
Business/Staffing Office
Productivity Reports
90% Med-Surg inpatient staffing meets RN DPC
91% 85% 91% 85%
Ensure long term
growth and
development of
Professional Nursing
Advancement program(PNAP)

WKBH Nursing Database
10 new Advancees

62% of all RNs have BSN by year end
26% of all RNs Certifications by year end
4 6 8 10
59.7% 61.2% 63.4 66.2
25.6% 27.3% 29.3 31.5
Community Education/
Education Programs led or co-
led by Nursing
Quarterly community education targeted to key
quality or growth areas of need: Safety (i.e. hand
hygiene in schools, Pool safety with children, surgical
procedures at WKBH)
In Progress 2 2

Oct 2013
Meets/Exceeds Target 75th 89th Needs Improvement < 75th Percentile or not meeting
Figure 4. 2012 Nursing Strategic Goals
Advancement is discussed at time of hire, and the BHSF
clinical ladder for professional nursing advancement is intro-
duced to all nurses with education to resources and processes
to advance. The journey to advancement generally starts
during 1-on-1 nurse leader rounding meetings. At this time,
professional development goals are discussed and an individ-
ual development plan created.
The program advances nurses from novice to proficient at
2 years of nursing experience, on to advanced and expert.
Advanced nurses are expected to be enrolled in a BSN pro-
gram, be certified in their specialty, and identify a clinical
practice change using the CETEP model. Expert nurses are
expected to have completed their BSN and an evidence-
based project using the CETEP model. The structure of
WKBHs collegially supportive model and a culture that
values professional development, reduced barriers and fears
with the advancement process, and strengthened staff personal
commitment to nursing excellence. This includes library
support services and a research specialist dedicated to pro-
moting and teaching research and EBP. Thus, by the end of
2012, in less than 2 years, 12 nurses had been promoted to
advanced nurse and 2 nurses had been promoted to expert
nurse. Additionally, throughout WKBH, 60% of all nurses
had a BSN, and 23% were nationally certified, which exceed-
ed the NDNQI benchmark for like-sized hospitals.
Generating New Knowledge and Innovation
Building, supporting, and sustaining a culture of inquiry
through shared governance stems from nurses having opportu-
nities to take part in EBP and research studies. Although utiliz-
ing the CETEP model is a requirement for advancement in the
identification of clinical practice questions and the development
of EBP projects, the decision to take part in and lead research
projects is ignited by the passion of nurses to question and
change clinical practice. Through the mentorship and guidance
of the WKBH research specialist, nurses are supported from
conception to dissemination of their research studies. Thus,
WKBH has over 12 institution review boardapproved research
studies that are either developed by or include direct patient
care nurses in the research team. One such example, in 2011, is
one of our medical-surgical nurses who lead a small nursing
team, with the support of the WKBH research specialist,
through the development and dissemination of a study examin-
ing the impact medication cabinets in medical-surgical patients
rooms had on nurses satisfaction with medication administra-
tion without altering medication charge accuracy and errors.
Not only has this study been disseminated at local, national, and
international conferences, but it is a step in an exemplar of
transformational leadership. Since this initial research study, the
lead nurse has moved on through the PNAP clinical ladder
from advanced nurse to expert nurse and is now leading an
interprofessional research team on a study funded by the
Academy of Medical-Surgical Nurses.
As part of the executive planning, 4 guiding principles were
established for the hospital: service, quality, diversity, knowl-
edge. Knowledge was used to represent the learning organi-
zation culture WKBH was establishing. The evidence of
WKBH living their principles can be seen in the coming
together to open a new hospital; applying their orientation
lessons in drills to assure safety; nursings commitment to use
of EBP and research in improving care; their enthusiasm for
professional development (including the use of CETEP, and
embracing the new family medicine medical students and
residents from Florida International University. Furthermore,
the results are self-evident in the high patient and family
satisfaction, physician satisfaction, nurse satisfaction, core
measures, and NDNQI bench marking. The outcomes vali-
date the WKBH nursing mission and the journey takes us to
our vision, Magnet designation. It is through the journey
that we have seen our collaboration, communication, and
celebration enhanced; our pride in practice increase; and
most importantly, the delivery of exceptional care to our
patients and families. This is reflected. not only in the men-
tioned results for 2012, but also the WKBH current 2013
accomplishments (Box 1).
On a final note, a lesson learned: it is easier to create a
culture than to change a culture. Not to forget is that the
exceptional culture and resources of Baptist Health South
Florida was a natural springboard for launching the strategic
vision of obtaining Magnet within 2 years.
Note: WKBH submitted their application for Magnet
Recognition in February 2014. NL
August 2014 68 Nurse Leader
Box 1. 2013 Spotlight
1. Sustained highly satisfied rating in RN NDNQI job
enjoyment and PES scale
2. Majority of NDNQI clinical indicators at or better
than benchmark
3. Inpatient satisfaction sustained at the 99th percentile
4. ED satisfaction sustained at 95th percentile (50 K
5. 19 advanced and 4 experts in total since opening
6. 63% BSN and 29% certified nurses (above the
7. 95% National patient safety goals at top decile (3rd
quarter at 100%)
8. Joint Commission Disease-Specific Certification in
Heart Failure
ED, emergency department.
Continued on page 77
www.nurseleader.com Nurse Leader 77
Designing and Opening a New Hospital
Continued from page 68
1. ANCC Magnet Recognition Program. 2013. http://www.nursecredentialing.org/
Magnet.aspx. Accessed September 13, 2013.
2. Collins J. Good to Great. New York, NY: Harper Business; 2001:41-64.
3. Studer Group Web site. 2013. https://www.studergroup.com. Accessed
September 13, 2013.
4. Collins PM, Golembeski SM, Selgas M, Sparger K, Burke NA, Vaughn BB.
Clinical excellence through evidence-based practice: a model to guide
practice changes. Topics Adv Pract Nurs J. 2007;7(4):1-4.
Denise Harris, MBA, MSN, RN, NEA-BC, is vice president/chief
nursing officer at West Kendall Baptist Hospital in Miami, Florida.
She can be reached at deniseh@baptisthealth.net. Tanya Cohn,
MSN, MEd, RN, is nurse scientist at Baptist Health South Florida
in Miami, Florida.
Copyright 2014 by Elsevier Inc.
All rights reserved.