As the population ages, it is imperative to ensure that older adults receive evidence-based care. Age-Friendly Health Systems is a national initiative to spread the evidence-based Age-Friendly What Matters, Medication, Mentation, and Mobility Framework and is supported by the Institute for Health care Improvement. A key driver to spread this effort is the use of transformational leadership, a leadership model used by nurse practitioners at MinuteClinic, the convenient care clinics in select CVS Health Pharmacies, to implement Age-Friendly What Matters, Medication, Mentation, and Mobility care during the COVID-19 pandemic. Recommendations are provided for aligning leadership principles of front-line staff, managers, and executives to encourage the implementation of evidence-based care using the transformational leadership model.
With the aging of a large segment of the United States population who will require health services for seniors over the next decade, there is a need for leadership to drive systems and processes for the delivery of evidence-based, age-friendly care in all health care settings. A solution to this challenge is through transformational leadership, a powerful, process-based approach to inspire staff to contribute to organizational efforts. The first conceptualization of transformational leadership was presented by Bass
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, as idealized influence (role modeling), inspirational motivation, intellectual stimulation, and individualized consideration. The model has been revised and built on most recently by Kouzes and Posner.3
The results of transformational leadership are impressive, and include the implementation of evidence-based practice, nurse satisfaction, psychological engagement, and innovative work performance.4
Transformational leadership was used in MinuteClinic, the convenient care clinics in over 1100 CVS Health Pharmacies in 35 states and the District of Columbia, to inspire over 3300 advanced practice providers, family nurse practitioners and physician associates, to ensure that care for older adults in a convenient care retail health clinic is “Age-Friendly.” Age-Friendly Health Systems (AFHS) is defined using an evidence-based framework, the “4Ms”—What Matters, Medication, Mentation, and Mobility—critical components of health for older adults that do no harm and improve outcomes when incorporated across settings of care.
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In this paper, we describe transformational leadership and how it was used by nurse practitioners in MinuteClinics to implement the AFHS 4Ms.A Framework to Inspire Implementation of Evidence-based Practice
Transformational leadership style has been used as a framework by many organizations to move through substantive changes to achieve high-functioning organizational processes and practices. Transformational leaders motivate employees to take ownership for their roles and perform beyond expectations. The original transformational leadership model was introduced by Bates et al.
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, and later enhanced by Kouzes and Posner.3
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Kouzes and Posner expanded Bates’ work and identified 5 practices, model the way, encourage the heart, inspire the shared vision, enable others to act, and challenge the process), that are essential to be effective in leading organizations to implement successful change.Transformational leaders “model the way” by setting an example to facilitate commitment through daily actions that create progress and forward movement. They have a clear understanding of their own values, beliefs, and vision, and how those relate to the mission and vision of their organization. This allows leaders to set standards that they model, and then these standards are followed in turn by others in the organization, so that common goals are pursued in ways that make the organization unique and distinctive. Effective leaders show by example that they live by the values they advocate and believe that consistency between words and deeds builds their credibility as transformational leaders.
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Successful leaders “encourage the hearts” by communicating inspirational stories and acknowledging staff. Encouraging the heart starts with high expectations for the leaders themselves and their employees to influence employee motivation to achieve goals set by the organization. Transformational leaders play a special role in encouraging the heart by celebrating individual and group achievements. By celebrating achievements of team members, leaders allow employees to have a sense of ownership of the change, and feel they are part of something significant.
“Inspire a shared vision” is the third practice of transformational leaders and is vital for bringing people together to foster a commitment to a shared, co-created future. Transformational leaders believe that they can make a difference, with a vision for the future that includes an ideal and future image of what the organization can become. Sharing the vision and celebrating achievements is key and creating an infrastructure and communication plan to share the vision keeps all staff on track.
Transformational leaders also “enable others,” the fourth action, by involving their staff in planning and decision-making. Enabling others to act allows followers to do their job and to realize their full potential results in increased collaboration and empowerment. They consider the needs and interests of their staff and facilitate staff ownership and responsibility in the organization. In addition, they provide feedback to staff and encourage them through recognition and celebration.
Finally, these leaders “challenge the process” by either creating new ideas or recognizing and supporting new ideas from staff. They show willingness to challenge the system in order to turn ideas into actions and to adopt new products, processes, and services. They look for innovative ways to improve their organizations and are willing to change. Challenging the process involves making mistakes because every failure leads to learning and improving. Instead of punishing failure, transformational leaders encourage it by learning from their mistakes and not shifting the blame on someone else.
The MinuteClinic Experience Using Transformational Leadership
The journey of the national-scale Age-Friendly Health Systems initiative implementation at MinuteClinic started in 2018 when faculty from the Frances Payne Bolton School of Nursing and the Quality and Safety Education for NursesInstitute at Case Western Reserve University asked MinuteClinic senior nurse executives to collaborate in an academic-practice partnership for the purpose of improving care for older adults in the ambulatory convenient care setting. With the support of The John A. Hartford Foundation and the Institute for Health care Improvement (IHI), an implementation team, including nursing faculty, geriatric nursing consultants, nurse executives, educators, managers, and direct-care family nurse practitioners, was created to lead, plan, and implement the AFHS 4Ms Framework across all 1100 MinuteClinics in 35 states and the District of Columbia.
In the first year, planning and data collection to understand the barriers and facilitators was completed.
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The MinuteClinic team used transformational leadership methods and implementation science to guide the uptake of the AFHS evidence-based practice. Over the course of 2 years, the team achieved the IHI designation of “Committed to Care Excellence” for 100% of the MinuteClinic regions and over 300,000 visits that included one or more M and 30,000 4Ms complete visits.8
The journey to AFHS Committed to Care Excellence status was guided by the IHI’s program, which includes guidebooks, an action community, and coaching (The IHI, “What is an Age-Friendly Health System” [n.d.] https://www.ihi.org/Engage/Initiatives/Age-Friendly-Health-Systems/Pages/default.aspx), and a detailed education plan.- Pohnert A.
- Schiltz N.
- Ball S.
- et al.
Achievement of age-friendly health systems committed to care excellence designation in a convenient care health care system.
Health Serv Res. 2022; (e-publication)https://doi.org/10.1111/1475-6773.14071
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The journey to the IHI designation of Committed to Care Excellence was supported by a strong MinuteClinic organizational structure rooted in transformational leadership and designed to capitalize on top talent to continuously innovate and improve. MinuteClinic is led by health care professionals at all levels of the organization, committed to driving patient-centered, high-quality, and cost-effective care to all patients served. Its structure follows the American Nurses Credentialing Center Pathway to Excellence pillars, including shared decision making, a shared-leadership concept where all employee voices are heard and considered when contemplating or implementing any practice changes.
There is a chief nurse practitioner officer dedicated to support the workforce to deliver an exceptional patient experience and to make MinuteClinic the employer of choice for nurse practitioners and physician associates interested in working in retail health. Under her leadership, there is an associate chief nurse practitioner who leads key aspects of the group practice, including but not limited to clinical quality, clinical practice support, professional development and staff education, and clinical practice team staffing. There are 6 area directors, all health care providers, who oversee field operations across multiple states. Clinical level support is provided by 72 senior practice managers, each responsible for a region of 20 to 23 clinics and up to 60 nurse practitioners and/or physician associates.
Professional development is a key focus area for MinuteClinic, and there is a professional advancement model that guides providers who are interested in further career development. The model provides a rich array of resources to support any providers interested in professional advancement, such as mentorship opportunities, stretch assignments, and leadership workshops designed to identify strengths and support personal and professional growth. With such a robust model of transformational leadership, MinuteClinic was well-positioned to increase the breadth and depth of the implementation of Age-Friendly care across the organization.
The existing leadership structure and the use of the transformational leadership model outlined above facilitated the success of the AFHS 4Ms implementation in multiple ways. Table 1 describes how each of the 5 transformational leadership principles were integrated into the executive, middle management, and frontline providers' work. Highlights from “Modeling the way” were leaders embracing the frontline experience of providers testing the 4Ms and helping define how they should be assessed, acted on, and documented at MinuteClinic; managers and champions modeling the implementation of the 4Ms through shared stories of personal commitment to caring for older adults; and senior leaders echoing their own commitment to quality and safe care for older adults, sharing personal perspectives with an authentic voice.
Table 1Application of the Transformational Leadership Model to Ignite the Implementation of Age-Friendly Health Systems 4Ms Framework into the 1100 MinuteClinics across the Nation
| Senior Clinical Leadership:Chief Nurse Practitioner Officer, Associate Chief Nurse Practitioner Officer, Directors and Educators | Middle management:Senior Practice Managers | Front line providers:Nurse Practitioners and Physician Associates, Champions, Regional Quality Leaders (RQLs) | |
|---|---|---|---|
| Model the way | Deliver high-impactkick-offcommunicationsincluding authenticcommunication the “why”behind the initiative Cascade authenticcommunication to alllevels within the organization Share personal perspective of theimportance of quality and safecare for older adults such asexperience with a family member’s care or from a personal patient care delivery experience Model the culture by sponsoring collaboration with external partners | Demonstrate leadership andpersonal commitment tothe 4Ms at the regional level Reinforce authentic messages withthe team, including “the why”behind the initiative (teamhuddles, clinic rounds) Participate in “booster” activities tolearn the process along with thefrontline providers and share their own experience with the initiative | Individual frontline providerswho mastered the process shareexemplars from practice Champions engage colleagueswith personal experiences of qualityand safe care with older adults RQLs model support throughcoaching and implementation ofthe 4Ms in their own practice Ensure that champions and RQL are 4Ms experts |
| Encourage the heart | Share patient stories in national practice venues and in internal and external communications Celebrate and recognize achievements in implementation and improvement at the national level Stress cultural implications of the 4Ms from a health equity lens Foster corporate communication with patient/population stakeholders/resources | Disseminate and featurecommunications within regionalmanager emails and communications. Add their own “why” and theirown stories to further engage staff Elevate provider stories with executive leaders Celebrate and recognizeachievements at the regional andindividual provider level on team huddles, meetings, and huddles Strive to collect an inspiring story every field visit and share in huddles | Share own stories of 4Ms patientexperiences with colleagues Share meaningful 4Ms experiences from patient visits with managers/Champions Celebrate and recognize colleagues for incorporating successfully 4Ms intopractice and supporting betterpatient care outcomes Work with other health careprofessional at clinic site andshare AFHS 4Ms care delivery |
| Inspirea shared vision | Facilitate communication of the message: MinuteClinic delivers age-friendly care to every patient – every time Engage corporate communications and marketing teams for internal and external communications featuring age-friendly health systems messaging Bundle 4Ms and age-friendly messaging with other clinical initiatives, clinical training, and new service introduction Facilitate use of social media platforms such as Linked- In, Twitter, at the senior leadership level to share stories and drive message of commitment to quality and safe care for older adults. Educators leading virtual orientation sessions feature the AFHS intranet page – to plant seeds early in orientation regarding organizational commitment to 4Ms framework and quality and safe care for older adults | Discuss 4Ms age-friendly health systems (AFHS) initiative with manager colleagues to share ideas to build competency in 4Ms use within regional team Foster communication between providers about AFHS – drive horizontal share in a virtual environment Incorporate 4Ms in shared vision of a quality and safe culture within the region Facilitate a friendly competition and celebrate success at the regional level. Conduct a survey of direct care providers who have geriatric/gerontology backgrounds to identify future champions and subject matter experts | Share the age-friendly care vision with patients through routine use of practice-based tools: The MinuteClinic 4Ms patient brochure and 4Ms pocket card Engage patients in expecting/requesting “age-friendly” care wherever they receive health care services Reach out to colleagues about experiences and vision for AFHS in their own practice RQLs engage preceptors to share the vision with new hires (introducing and reinforcing the MinuteClinic quality and safety standard to use the 4Ms in practice with all patients 65 and older Build understanding among providers that telling stories is LEADERSHIP- influencing people Add AFHS committed to care excellence logo to email signature Share stories with clinic team via the clinic communication book, email or group text |
| Enable others to act | Provide resources and structure forthe initiative including professionaldevelopment, practice-based toolsand data analytics Disseminate information and resourcesto middle management and direct careproviders Create varied training and development resources to meet diverse learning needs of direct care providers Demonstrate commitment throughsystem changes such as extended visit time for patients over 65 Set national practice level goals for performance of the 4Ms in practice Conduct focus groups to listen to feedback from managers, providers and patients regarding the 4Ms experience Facilitate comment and suggestion sharing through a monitored email inbox | Facilitate direct-care providers completing AFHS training modules with dedicated training time Engage providers in attending grand rounds and other professional development activities Set expectations with direct care providers regarding inclusion of AFHS 4Ms framework performance in mid-year and annual evaluations Communication performancedata in regional and one-on-one direct care provider meetings and calls Monitor performance using dashboards and encourage direct care providers to view AFHS 4Ms performance on their own dashboard within the electronic health record platform | Complete all educational modules and participate in age-friendly related grand rounds Take the time to watch videos and participate in virtual clinic training Review all job aids and tip sheet related to AFHS and incorporation of 4Ms into clinical workflow Ask for support from a champion or RQL if needed RQLs and champions support direct care providers with shoulder-to-shoulder coaching to facilitate understanding of assessing and acting on the 4Ms within the clinical workflow and efficient documentation within the electronic health record |
| Challenge the process | Weekly monitoring using data to assess impact of interventions and needed support for middle managers and direct care providers Be open to direct-care provider innovations and support dissemination of practice-based tools that facilitate implementation of the 4Ms in practice Identify issues with reports and facilitate improvements in data collection Hardwire the bundle of both chronic care and AFHS within clinical workflow in evidence-based clinical guidelines, clinical workflow processes, and electronic health record documentation Facilitate challenges or competitions with rewards between regions and areas to meet national and regional goals Support research projects to identify continued improvement opportunities to sustain the 4Ms in practice | Be open to feedback from individual direct-care providers and communicate feedback trends and requests and to leadership for action and improvement Encourage a growth mindset among staff, asking for new ideas, supporting open dialogue about the 4Ms in practice Facilitate challenge at the regional level and support champions to recognize and reward improvements weekly Embrace front-line innovations to implementation strategies | Check personal dashboard to monitor progress and ask for clarification of data as needed Create innovative tools or processes to facilitate 4Ms in practice and conduct individual “plan-do-study-act” (PDSA) tests to improve tools and processes. Share tools with champion, RQL or manager Ask patients for feedback with their experience of answering 4Ms questions and sharing 4Ms information Gather pearls of wisdom from colleagues who are effectively using the 4Ms in practice—identify efficiencies to overcome barriers Participate in 4Ms “booster” activities to increase and sustain 4Ms framework use in practice Identify routine and dedicated time to pause and read stories for self-engagement and competency development Communicate practice level needs for process improvement and innovation Participate in research studies related to 4Ms |
Examples of “encouraging the heart” included using MinuteClinic’s multiple venues for storytelling—sharing narratives of the 4Ms in direct patient care to engage and inspire frontline providers to complete training modules and begin to practice the 4Ms. “Inspiring a shared vision” was integrated by bundling communications across internal and external channels and directly engaging the patient in the 4Ms with practice-based, patient-facing tools (a brochure and pocket card that explain how the 4Ms support them in their health journey). Examples of “enabling others to act” included using a “champion model” to support coaching and improvement, and multidirectional conversations about the process of implementation and identifying frontline provider innovations as solutions to be embraced. “Challenging the process” was integrated by gathering regular feedback through focus groups, creating open channels of communication such as a dedicated, monitored email inbox for providers to ask questions and request updates, and surveys of providers to identify further opportunities for transformation.
Recommendations
Implementation of evidence-based practice is complex and requires leadership to initiate and sustain it. Transformational leadership principles are essential at all levels of an organization, from the frontline direct-care provider to the chief nurse practitioner office and other members of the senior executive team. Although we highlighted the MinuteClinic’s implementation of the AFHS 4Ms care, transformational leadership is important during any change initiative. When challenged with organizational change, our recommendation is for organizations to convene a group that includes leaders from the executive, managerial, and frontline levels who are asked to use the principles of transformational leadership and identify opportunities to apply the principles at all levels directed at the needed change. This idea formation activity might use the design thinking principle of empathetic listening at all 3 levels to ensure that a wide net of understanding and idea generation is encouraged.
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The result of this idea formation will lay the plan for transformational leadership to live and influence culture throughout the organization. Most important, the voice of all levels of the organization will be heard. Coordination among the 3 levels needs to be supported by infrastructure changes and resources, and acceptance of the dynamic nature of change. This activity will encourage the implementation of evidence-based care using the transformational leadership model.Conclusion
Transformational leadership takes vision and the ability to inspire nurses at all levels of an organization. Transformational leaders build trust, facilitate teamwork, share clinical expertise, and identify innovative solutions. These actions build a culture of inclusivity, collegiality, autonomy, and the acknowledgment of performance in the workplace. With transformational leadership, nurses at all levels of an organization can create new pathways for evidence-based practice implementation.
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Biography
Mary A. Dolansky, PhD, RN, FAAN, Sarah C. Hirsh Endowed Professorship in Evidence Based Practice Implementation, Frances Payne Bolton School of Nursing, Case Western Reserve University, Cleveland, Ohio. She can be reached at [email protected] Holly Kouts, MBA, MSN, RN, FNP-C, Area Director, CVS Health, CVS MinuteClinic, One CVS Drive, Woonsocket, Rhode Island. Anne M. Pohnert, MSN, RN, FNP-BC, Lead Director of Clinical Quality, CVS Health, CVS MinuteClinic, One CVS Drive, Woonsocket, Rhode Island. Latina Brooks, PhD, RN, CNP, FAANP, Assistant Professor & Director, MSN & DNP Programs, Frances Payne Bolton School of Nursing, Case Western Reserve University, Cleveland, Ohio.
Article info
Publication history
Published online: November 24, 2022
Footnotes
Funding: This work is supported by a grant from The John A. Hartford Foundation to the Case Western Reserve University Frances Payne Bolton School of Nursing. Note: Acknowledgement of MinuteClinic leadership: Sharon Vitti, David Fairchild, Donna Learned, Mary Czymbor-Hepburn, and Meredith Dixon. Acknowledgment of the AFHS team: Robin Hughes, Evelyn Duffy, Nicholas Schiltz, Elizabeth Zimmerman, Lilia Pino, Mary McCormick, Sarah Ball, Jennifer Nabong, Elizabeth Evans, Anna Bender, Megan Foradori, Barbara Tassell, Brian Crick, Jackson Fielder, Ronald Hickman, Kelli Qua, Haley Kuhner, Ilona Seaman. Acknowledgement of the Institute for Healthcare Team: Leslie Pelton, Sherry Greenberg, Kevin Little, Dylan Balcom, Joelle Baehrend. Editorial assistance: Matthew McManus.
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2022 by Elsevier Inc. All rights reserved.
