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Integrative Nursing Leadership
Lori Knutson RN, BSN, HNB-BC
Administrative Director
Integrative Health & Medicine
Hackensack Meridian Health Network
New Jersey
Disclosure
Objectives
• Understanding the Big Picture in Healthcare
• Overview System-Wide Integrative Health & Medicine
Program & Services
• Integrative Nurse Leadership/Whole Systems
Approach
Create a Personal Purpose Statement
(Christine Whelan, Ph.D)
1. Think of three of your personal strengths, or things that
you are good at. (These can be skills you have acquired
over the course of your life, or qualities and talents you
were born with.)
2. Think of three personal core values. (What values underlie
your actions? What is most important to you?)
3. Think of three persons, situations, or groups of people that
you would like to impact. (What or who would you like
most to change or influence?)
These will be your building blocks for your
purpose statement. Put them together into your
personal purpose statement by filling in these
blanks:
I will use my strengths in _______, _______, and _______ to
promote my values of _______, _______, and _______ in
order to impact _______, _______, and _______.
Understanding the Big Picture in Healthcare
Incorporating the Healthcare Climate
Win vs. Woe
• Accountable Care Organization (ACO)
• Meaningful Use (Electronic Health Record)
• HealthGrades (public/consumer information-transparency)
• HCAHPS (Inpatient satisfaction survey)
• Triple Aim (Improve health, improve healthcare experience, decrease cost)
• P4P
• Total Cost of Care (TCOC)
• Value Based Contracts
• Preventable Admissions/Preventable Re-admisssions
Integrative Health: The Gap Opportunity
Care Continuum Alliance • Implementation and Evaluation: A Population Health Guide for Primary
Care Models
While in financial management the term ROI refers to a single ratio,
SROI analysis refers not to one single ratio but more to a way of
reporting on value creation. It bases the assessment of value in part on
the perception and experience of stakeholders, finds indicators of what
has changed and tells the story of this change and, where possible,
uses monetary values for these indicators.
Health-Creation Value-Based Proposition
http://www.socialvalueuk.org/resources/sroi-guide/
Health Impact Assessment
Social Return on Investment:
Health Creation Value Proposition
Social Return on
Investment
Capacity to Work
Community Engagement
“Appropriate” Reduction in Utilization of Healthcare Resources
Overview System-Wide
Integrative Health & Medicine
Programs and Service
One Model Example
Hackensack Meridian Health
• Hackensack University Health Network and Meridian
Health Merged July 2016
Mission
Our mission is to provide the full spectrum of life-
enhancing care and services to create and sustain
healthy, vibrant communities.
Vision
We will set the standard for providing quality care, for
humanizing the health experience, and for defining
the future of medicine.
Hackensack Meridian Health Network
• 13 Hospitals in 7 counties
• Eleven acute care hospitals, two children's hospitals
and 120 other locations that provide ambulatory care,
surgical care, urgent care and assisted living services.
• 28,000 employees and nearly 6,000 physicians
• New Seton Hall Medical School Fall 2018
(Inter-professional)
HMH Integrative Health and Medicine
• Seed Funded $10 Million Cash Gift
• Supported at all levels of the organization
• Service Line Integration: Oncology, Cardiology,
Neurosciences, Orthopedics, Physical Medicine and
Rehabilitation, WomenCare, Pediatrics, Behaviorial
Health
• Primary Care
• Population Health
• Community Outreach
A Health System Model for Integrative Care:
Five Pillars of Health and Wellbeing
TEAM
Epigenetics
22
Five Pillars of Health and Wellbeing
Nutrition
Obesity
Malnutrition
Recovery
Activity
Beyond Rehab
Daily Activity
Functional Capacity
Sleep
Sleep Hygiene
Fatigue
Apnea
Resilience/Stress Management
Psychological Health
Capacity to Cope with Adversity
Purpose
Give Meaning to Situations and Goal
Setting
Integrative Health and Medicine
Operational/Functional Core Components
Care and Service
Across the Healthcare Continuum, Service Lines, Primary Care and Specialty
Care
Education/Training
Patient/Consumer/Community
Healthcare Professionals
Research
Clinical, Health Services,
Population Health
Integrative Health and Medicine
T
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e
s
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.
L
e
a
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:
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s
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e
tr
a
i
n
e
r
q
u
e
s
ti
o
n
s
.
Learner:
Tells the
trainer to
perform a
step and
responds
to
questions
from the
trainer.
Trainer:
Performs
each step
and asks
the
trainee
questions. Learner:
Explains
the step,
gets
permission
and then
performs
each step
as
directed.
Trainer:
Gives
permission
, observes
each step
and asks
questions
as the
learner
performs.
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Course 700
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Introduction
to Safety
Managemen
t 1 2 3 4
5 6 7 8
Course
Homepage
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Exam Con
tact
Instructor
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•7.1
•7.2
•7.3
•7.4
•7.5
•7.6
•7.7
•7.8
•7.9
•7.10
•Quiz
Element 7:
Education and
Training
Introduction
All of these
impact our
safety
performance.
(Click to
enlarge)
This module
will introduce
you to
general
OSHA
requirements
for education
and training.
However, I
will
emphasize
"getting
beyond
compliance"
by addressing
best practices
in effective
safety and
health
education
programs. To
learn more
about safety
education and
training, be
sure to
complete
OSHAcadem
y Course 703,
Introduction
to OSH
Training. The Big Picture Safety education and training is extremely
important to ensure all processes in your
company's safety and health management
system are effective. If this critical element
is missing, none of the other system
elements can, or will be effective. But, this
element is often neglected or managed
ineffectively because the benefits may not
be immediate, tangible, and directly
related to profits. Managers may find it
difficult to see the long-term improvements
in process and product quality that result
from an effective safety education and
training program. It's hard to see the
accidents that don't
actually
happen.
Education vs. Training Safety education is effective in saving
lives by primarily increasing our
knowledge. Increased knowledge will
improve attitudes and skills. For example,
Gary, a recent OSHAcademy student
wrote:
"I stress to my
co-workers
that a life
jacket is
mandatory on
deck. We
hired a young
guy who was
a swimmer in
college. He
felt his
swimming
skills were
such that he
did not need
the jacket.
We educated
him on
hypothermia
and that he
could not
save himself
if he fell over
in 35 degree
water. Once
he
understood
the hazard,
he wore the
jacket at all
times,
because he
wanted to, not
because he
had to."
He's suffering
the natural
consequence
of missing the
nail.
He's suffering
a system
consequence
after violating
a safety rule. Educate To Show Why There are many definitions for education.
Within the context of occupational safety
and health, education describes who,
what, where, when, and most importantly,
why safety procedure and practice are
necessary. Education informs, persuades,
and motivates to affect attitude.
The number
one reason
employees
don't follow
safety rules
is that they
don't know
why they are
important!
To make sure
safety
education and
training is
effective, it's
necessary to
tie the training
to
accountability.
One of the
most effective
ways to do
this is to
emphasize
the natural
and system
consequence
s that result
from the
appropriate
application of
what's being
learned.
Consequence
s represent
the why in
safety
education.
Natural
consequenc
es describe
the type of
injury/illness
that might
result if we
don't follow
procedures.
For instance:
•An employee
breaks an
arm or leg as
the result of a
fall.
•An employee
escapes
injury by
properly using
a personal fall
arrest system.
System
consequenc
es describe
the
organizational
response to
performance.
For instance:
•An employee
would be
subject to a
disciplinary
process for
failing to
comply with
safety rules.
•An employee
might be
recognized
for meeting
goals or
exceeding
expectations.
Remember,
we do what
we do in the
workplace
because of
the
consequence
s. Safety
education and
training must
make
consequence
s clear.
Train To Show How Training, as a form of education, has a
slightly different definition. Safety training
is primarily concerned with affecting
attitude through improving skills.
This is
generally
accomplished
through
demonstratio
n -- showing
how to safely
accomplish
the steps of a
particular task
or procedure.
For instance:
•I might train
someone how
to accomplish
the
procedures
for performing
lockout/tagout
of a machine
prior to
servicing or
maintenance.
•I may train
employees on
how to
properly clean
up an
incidental
chemical spill.
•I might train
a confined
space entry
team on how
to perform
emergency
rescue
procedures.
Earlier I said
that education
tells the "why"
in a learning
process. In
safety and
health, the
"why" can
save a
person's life.
By far the
most common
reason
workers do
not follow
safety rules
(or any rule)
is that they
don't
understand
why doing so
is important.
They don't
understand
the
consequence
s.
For instance,
I'll bet your
company has
a list of safety
rules that they
asked you to
read when
you were first
hired. Did
anyone
discuss each
rule with you
at that time,
and why that
rule was
important to
follow?
Maybe not.
(There's
always an
exception to
this, and if
you are
one...congrat
ulations!) If
you only have
a list of rules,
you may want
to suggest
incorporating
a short
paragraph
explaining
why the rules
are important.
Don't assume
it's obvious.
If your
company
attempts to
institute
change in any
part of the
safety and
health
program (or
any other
program), the
effort will fail if
the company
only trains
people how to
change
without
educating in
such a way
that not only
informs, but
also
motivates and
persuades
workers that
the change is
necessary
and in
everyone's'
best interest.
Safety
education and
training
doesn't have
to be difficult
or expensive:
it's not rocket
science. So,
what is
probably the
best and most
common
method to
train specific
safety
procedures?
On-the-job
show and tell. Seven-Step On-The-Job Training
(OJT) Process Safety training should be simple training.
Hopefully, it's done where the task is
performed. Hopefully the supervisor - the
person responsible for the worker's safety
- is conducting the training. Why...? Well, if
a supervisor isn't knowledgeable enough
to train safe procedures, how can he or
she properly supervise, discipline, or
recognize safety behaviors adequately?
(Sorry...got on my soap box again.)
On the next
two tabs, I've
included a
simple seven-
step OJT
training
process that
helps to
ensure new
employees
don't get hurt
while being
trained. Now I
know that
might sound
funny, but it's
happened.
Especially
notice in Step
4 that the
employee
must get
permission to
continue.
That's a
critical
component of
the safe
procedure.
Step 5: Conclude
Once the formal training is finished, the
trainer should:
•Recognize
the student's
accomplishm
ent - "Good
job!"
•Reemphasiz
e the
importance of
the procedure
and how it fits
into the
overall
process.
•Remind the
employee
about their
responsibilitie
s and
accountability
by discussing
the natural
consequence
s (hurt/health)
and system
consequence
s
(reprimand/re
ward).
Step 6: Validate
After the conclusion of the OJT session,
the trainer, or better yet, the supervisor
should observe the employee applying
what they've learned in the actual work
environment. Doing so results in strong
documentation that helps to legally protect
both the employee being trained and the
employer.
Recommend
ation: To
prove the
employee has
the
knowledge
and skills to
do a job
safely, have
the employee
teach you
how to do the
job. If the
employee can
effectively
train you how
to do the job,
he or she is
qualified and
you can sign
them off. If
they can't,
you should
not qualify
them; it's time
for some
retraining.
By the way,
When OSHA
inspects, the
compliance
officer may
ask
employees
about the job
they are
doing. The
employees
won't be able
to hide their
ignorance
and it won't
take long for
the
compliance
officer to
determine if
the employee
is qualified to
do the job. Step 7: Document
The well-known OSHA adage, "if it isn't in
writing, it didn't get done," is true for any
kind of safety training. For OJT training,
documentation should be more than an
attendance sheet.
To document
the training,
the trainee
certifies:
•training was
accomplished
•questions
were
answered
•opportunities
provided to
do procedure
•accountabiliti
es
understood
•intent to
comply
The
instructor
certifies the
trainee has:
•demonstrate
d adequate
knowledge
•developed
the skills to
complete the
procedures
See the
sample
training
certification
documents in
Course 721,
Module 5. It
represents
one possible
way to
document
training.
Where We
Are
15220 NW
Greenbrier
Parkway
Suite 230
Beaverton,
OR 97006
USA
Contact Us
+1 (971) 217-
8721
instructor@os
hatrain.org
Office Hours Pacific Standard Time
Copyright
©2000-2015
Geigle Safety
Group, Inc. All
rights
reserved.
Federal
copyright
prohibits
unauthorized
reproduction
by any means
without
permission.
Students may
reproduce
materials for
personal
study.
Disclaimer
This material
is for training
purposes only
to inform the
reader of
occupational
safety and
health best
practices and
general
compliance
requirement
and is not a
substitute for
provisions of
the OSH Act
of 1970 or
any
governmental
regulatory
agency.
OSHAcadem
y
Occupational
Safety and
Health
Training is a
division of
Geigle Safety
Group, Inc.,
and is not
connected or
affiliated with
the U.S.
Department
of Labor
(DOL), or the
Occupational
Safety and
Health
Administratio
n (OSHA).
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Original text Contribute a better translation
Resilience Sleep Activity Nutrition Purpose
Low Risk Self-managed stress
mindfulness
exercises
Self-managed online
MCBT
Group walking
activity and self-
managed exercise
Group nutrition
education and self-
managed diet
Group offerings
addressing “Living
on Purpose”
Med Risk IHM consult
SMART program
Coaching support
IHM consult
MCBT
Coaching support
IHM consult
Yoga, tai chi, qi gong,
group exercise
Coaching support
IHM consult
Nutrition counseling
Coaching support
IHM consult
Health Coaching
consult
Med/high
Risk
Integrative Disease
Management Health
Promotion Care
Pathway
Integrative Disease
Management Health
Promotion Care
Pathway
Integrative Disease
Management Health
Promotion Care
Pathway
Integrative Disease
Management Health
Promotion Care
Pathway
Power of Purpose
Program/Life
Reimagined
High
Risk
Triage to primary
care physician and
possible psych
consult
Triage to primary
care and sleep study
referral
Triage to primary
care and physical
therapy
Triage to primary
care
Consultation with
Behavioral health
and/or Spiritual Care
Report Card
Patient Stress Questionnaire
Pittsburgh
Sleep Quality
Par Q
Borg Scale
Nutrition Status
MLQ HOPE
Hackensack Meridian Integrative Health and Medicine Clinical Protocols
Patient survey tools not exhaustive. Utilization dependent on clinical indication.
HMH Integrative Disease Management Health Promotion Care Pathway©
Levels of Complexity
and Care
Level I**
(Pre-Disposed
Family/Environment)
Time Span: 2-3
Months
Cost/Case Rate
Level II**
(Root Analysis
Indicates Potential
Disease Pathway)
Time Span: 3-6
Months
Cost/Case Rate
Level III**
(Diagnosed:
Symptoms Mild-
Moderate)
Time Span: 6-9
Months
Cost/Case Rate
Level IV**
(Diagnosed:
Symptoms Severe)
Time Span: 9 – 12
Months
Cost/Case Rate
Physician/
Nurse Practitioner
Initial Visits 60 Minutes
Follow-up Visits 30
Minutes
Initial Visit
Assessment and
Recommendations
Follow Up Visit (4-6
Weeks): 1
Initial Visit
Assessment and
Recommendations
Follow Up Visits (4
week intervals): 2
Initial Visit
Assessment and
Recommendations
Follow Up Visits (4
week Intervals): 3
Initial Visit
Assessment and
Recommendations
Follow Up Visits (4
week Intervals): 4
Nutritionist
Initial Visit 60 Minutes
Follow-up Visit 30
Minutes
Initial Visit
Nutritional Assessment
and Recommendations
Initial Visit
Nutritional Assessment
and Food Plan
Follow Up Visits (4
week intervals): 2
Initial Visit
Nutritional Assessment
and Food Plan
Follow Up Visits (4
week intervals): 4
Initial Visit
Nutritional Assessment
and Food Plan
Follow Up Visits (4
week intervals): 6
Health
Coach/Psychologist
Initial Visit 60 Minutes
Follow-up Visit 30
Minutes
Initial Visit
Readiness for Change
Recommendations
Initial Visit
Readiness for Change
PAM Assessment
Coaching Plan
Follow Up Visits (2-4
week intervals): 4
Initial Visit
Readiness for Change
PAM Assessment
Coaching Plan
Follow Up Visits (2-4
week intervals): 6
Initial Visit
Readiness for Change
PAM Assessment
Coaching Plan
Follow Up Visits (2-4
week intervals): 8
**See Detail Description for Each Level of the Health Promotion Care Pathway
Integrative Health and Medicine
Service
Ortho/Rehab
Behavioral
Health
Pediatrics Neuroscience Cardiovascular Oncology Women
Care
I
n
t
e
g
r
a
t
i
v
e
H
e
a
l
t
h
a
n
d
M
e
d
i
c
i
n
e
Integrative Health and
Medicine
Across Service Lines
Across Continuum of Care
Integrative Health and Medicine Programs and
Service Continuum
Community
Key Focus: Healthy Living Education, Training, and Self Care Skill Development
Health Promotion Interventions
Healthcare Theatre
Outpatient/Ambulatory/Primary Care
Clinical Interventions
Education/Training
Self Care Skill Development in Symptom Management
Inpatient
Clinical Interventions
Key Focus: Broad Spectrum Pain Management
Managing Patient Expectation/Building Resilience
Self Care Symptom Management
Hubs and Spokes
Comprehensive Hub
Employers
Faith-Based Communities
Schools
Civic Organizations
Jackson Meridian Health Village: Hub #1
Entry points to
Integrative Health and Medicine
Integrative Health and Medicine
Service/Programs
Service Lines
(Specialty Care)
Community Self Referral
Employer Referral
Primary Care
Primary Care Integration
• Physician Training in Integrative Medicine
• Primary Care Clinic Onsite Integrative Therapies
(Acupuncture, Nutrition Counseling, Health Coaching,
Mind Body Therapies)
• Classes/Workshops (Medical Yoga, Mindfulness
Based Stress Reduction, SMART program)
Financial Modeling
• Current Insurance Coverage (MD, NP, Nutritionist,
Health Psychologist, Acupuncturist)
• Cash Payment applied to all services where needed.
• Building new models of payment with Insurers.
• Community Partnerships that offset costs (Spokes)
• Employer contracts
• Embed in Service Line/Bundled Payments
• SROI and Downstream Catchment
• Retail Product
• Franchise Model
• And yes Philanthropy
Integrative Nursing Leadership
Whole Systems Approach
Leading through Systems
Leadership in Integrative Health
Applies holistic principles and integrative practice to lead
people and systems to wholeness.
It is the capacity to awaken the power of collective
wisdom to attain the full potential of individuals and
systems.
Wisdom
“Wisdom reflects a capacity for sound judgment, discernment,
and the objectivity
to see what is needed in the moment”.
Briskin, A., Erickson, S., Ott, J., & Callanan, T. (2009)
The Power of Collective Wisdom and the Trap of Collective Folly.
San Francisco, CA:Berrett-Koehler Publishers Inc
Collective Wisdom
“Collective wisdom reflects a similar capacity to learn
together and evolve toward something greater and wiser
than what we can do as individuals alone. It emerges
from a deep conviction that we have a stake in each
other and that what binds us together is greater than
what drives us apart.”
The Power of Collective Wisdom and the Trap of Collective Folly
Practical Application:
Building System-Wide
Integrative Nursing Practice
Integrative Nurse Roles
Integrative Nursing
Integrative Nurse Practitioner
Integrative Nurse Clinical Program
Manager
Integrative Inpatient/Service
Line Nurse Manager
Integrative Executive
Leadership
Integrative Nurse Coaching
Integrative Staff Nurse Practice
Integrative Nursing Needs Assessment &
Training Program
• IN Needs Assessment: Surveyed Hospital Based Nurses
• Intention: Identify the gap between knowledge and
Practice
• BirchTree Center Training
• Integrative Nursing Council
• Integrative Nursing roles
Inner Life of the Integrative Nurse Leader
“THE SUCCESS OF AN
INTERVENTION DEPENDS ON
THE INTERIOR CONDITION OF
THE INTERVENER.”
William O’Brien
Former CEO of the Hanover Insurance Company
Beliefs, Values, and Attitudes
• A belief is an internal feeling that something is true, even though that belief
may be unproven or irrational.
• A value is a measure of the worth or importance a person attaches to
something; our values are often reflected in the way we live our lives.
• An attitude is the way a person expresses or applies their beliefs and values,
and is expressed through words and behavior.
“You never know how much you really believe
anything until its truth or falsehood becomes a
matter of life and death to you.”
― C.S. Lewis
“It's not hard to make decisions when you know
what your values are.”
― Roy Disney
“An attitude of gratitude brings great things.”
― Yogi Bhajan
F.E.A.R
has two meanings—
Forget Everything And Run
OR
Face Everything And Rise
The choice is yours.
Integrative Leadership:
Informed Mindfulness
Informed mindfulness is
self-awareness and self-regulation
coupled with knowledge, skills, values
and wisdom.
Pebble in the Pond
Leadership in Integrative Healthcare
Duke University
Liz Wiseman and Greg McKeown. Multipliers: How the Best Leaders Make Everyone Smarter.
Harper Collins, New York 2010
Presencing Institute, Otto Scharmer
Theory U:
Leading from the Future as it Emerges
Whole Systems Approach to Integrative
Healthcare Leadership: Intrapreneurship
• Innovating From Within
• Failing Up
• Letting Go
Intrapreneur
A person within a large corporation who takes direct
responsibility for turning an idea into a profitable finished
product through assertive risk-taking and innovation.
Failing Up
“To derive gain in spite of failure that would usually
either preclude said gain or have adverse
consequences.” (The Urban Dictionary)
In other words, to capitalize on what may not have worked to
understand how it might.
Optimism
FAIL: First Attempt In Learning
END: Effort Never Dies
NO: Next Opportunity
A. P. J. Abdul Kalam, one of India's most distinguished scientists and the 11th
President of India stated
Letting Go
Remember the Intrapreneur
Doesn’t Own Anything!
Personal Purpose Statement
