There is something I think CNOs deal with all the time that doesn’t get talked about enough.
A hospital metric moves in the wrong direction and everybody looks at nursing.
CLABSI goes up? Nursing.
Falls increase? Nursing.
Patient experience drops? Nursing.
Length of stay becomes a problem? Somehow nursing is in that conversation too.
Now, I’m not suggesting nursing shouldn’t be accountable. Of course it should.
But there is a difference between being accountable for helping solve a problem and actually being the cause of the problem.
That distinction matters.
Let’s use infections as an example.
A hospital sees an increase in CLABSI. The natural response may be more nursing education, more audits, competency checks and additional monitoring.
Maybe that is exactly what needs to happen.
But what if it isn’t?
What if the real problem involves how long physicians are leaving lines in? What if there is an ordering issue? What if there is variation in testing? What if equipment availability or another clinical process is contributing to the result?
You can educate nurses all day long, but if nursing isn’t causing the problem, you’re not going to fix it.
You are just creating more work.
The same thing happens with discharge.
Everybody wants better throughput, and the patient is physically sitting on a nursing floor, so it is easy to make nursing responsible for getting that patient out.
- But why hasn’t the patient left?
- Are we waiting for a specialist?
- Are medications ready?
- Did somebody arrange transportation?
- Are we waiting on a post-acute placement?
- Did the physician round late?
- Is an authorization still pending?
Those are very different problems, and most of them cannot be fixed by telling the nurse manager to improve discharge performance.
That is why I think one of the most important things a CNO can do is ask a few very simple questions whenever a metric becomes a problem:
Who actually influences this outcome?
What process is producing the result?
And who has the authority to change that process?
Sometimes the answer will absolutely be nursing.
And if it is, fix it.
But sometimes nursing is simply where the problem becomes visible.
Patient experience is another good example.
Obviously, nurse communication matters. A lot.
But think about everything else the patient experiences while they are in the hospital. They may have waited hours in the emergency department. Maybe nobody explained why a test was delayed. A physician may have given them a different message than the nurse did. Their discharge may have taken six hours longer than expected.
Then the survey comes back and everybody is talking about nursing communication.
That can be way too simplistic.
I think strong CNOs have to be willing to dig underneath the metric before deciding on the solution.
And they also need the credibility to bring other people into the conversation.
That means being able to sit across from physicians, operations, quality, HR and finance and say, “Here is what the data is showing us, here is what we believe is actually driving it, and here is who needs to be involved in fixing it.”
That isn’t avoiding accountability.
That is better accountability.
It is also becoming more important as hospitals change the way care is delivered. Team-based models, different workforce roles, new technology and staffing redesign mean outcomes are going to be even more interconnected than they have been historically.
The org chart doesn’t take care of the patient.
People do.
And those people cross departments all day long.
This is something I think CEOs and boards should also consider when hiring a CNO.
Obviously you want somebody who has produced good quality results.
But I would go one step further.
Ask them how they produced those results.
What was wrong when they arrived? How did they figure out what was causing it? Who did they have to bring into the process? Was there resistance? What changed? What happened to the metric?
That conversation tells you whether somebody understands quality or whether they simply managed a department that had good quality numbers.
There is a big difference.
It is also something a recruiter who understands hospital leadership should be digging into before a candidate ever reaches the interview table. A résumé may say someone reduced infections or improved patient experience. The real value is understanding how.
At the end of the day, I don’t think CNOs need less accountability.
I think they need more accurate accountability.
If nursing owns the problem, nursing should fix it.
But if the problem crosses nursing, physicians, operations and ancillary departments, then the solution better cross those areas too.
Otherwise, everybody stays busy and the metric stays exactly where it was.
