10 thoughts from Jacob Kupietzky on the evolving roles of CNOs and mid-level clinical executives

Jacob Kupietzky serves as president of HCT Executive Interim Management and Consulting, a national firm that provides tools, consulting services and interim leadership to hospitals and health systems. The firm does consulting work for hospitals and provides interim executives for hospital C-suite positions as well as middle management and clinical specialty roles.

As president of HCT, Mr. Kupietzky has served some of the top healthcare organizations in the country. He has personally worked in well over 250 hospitals as a consultant.

Before starting HCT eight years ago, he was vice president for Dallas-based Tenet Healthcare Corp. In that role, he offered operational oversight and strategic direction for Tenet's key initiatives including Commitment to Quality, Clinical Program Development, Balanced Scorecard and Target 100. Prior to Tenet, he was a consultant for Fortune 500 companies on efficient ways to leverage technology in their core businesses. Mr. Kupietzky also previously served as a political consultant and a public sector consultant to the United States Marine Corps and HHS.

Becker's Hospital Review recently spoke with Mr. Kupietzky about the roles of CNOs and mid-level clinical executives.

Here are 10 thoughts from Mr. Kupietzky on these roles in today's healthcare environment.

1. Financial responsibility. As hospitals look to contain and/or reduce costs, clinical executives, including CNOs, have greater responsibility for financial outcomes than in the previous five or 10 years. When a CNO is looking at their line of responsibility, certainly there's a major clinical component to it. But they also must understand and know how to impact the hospital's finances through improved outcomes and managing costs. They're "expected to understand real line-item budgeting, understand the variance between staffing — what's expected versus actual demands — [and] make sure that they're playing a role in other functions such as capital expenditures," Mr. Kupietzky says. "So there's a lot more emphasis on secondary degrees for chief nurse executives, making sure they have a more expansive business understanding of the hospital space."

2. Wearing multiple hats. While CNOs are dealing with financial responsibility, they also are asked to wear multiple hats, maybe even more so than in the past. It's not unusual for a chief nursing executive or CNO to be responsible for not only all clinical operations, but on an as needed basis, also run a specific area while a colleague is on leave or there's a vacancy. "So that's stretching them even more than they were before," Mr. Kupietzky says.  

3. Expanding number of metrics. Hospitals are keeping close tabs on metrics as part of healthcare reform. These organizations are publicly reporting information they never did before, but they also have tools such as dashboards to internally track performance down to the unit level. In the past, it was mainly progressive hospitals that were closely tracking patient satisfaction, according to Mr. Kupietzky. But now every hospital has to do so to affect improvement with their scores on the Hospital Consumer Assessment of Healthcare Providers and Systems survey. "It really requires the CNO or chief nursing executive to have their team in line across the board because one or two underperforming units will directly impact a hospital's overall performance, which is tied to reimbursement," Mr. Kupietzky says. That's why chief nurses and the rest of the C-suite are looking at clinical metrics more frequently. Closely monitoring performance is now part of leadership priorities. But now, with so much information available online, they'll see a real opportunity to differentiate themselves on the basis of quality. "So those organizations that are performing better can proudly trumpet their results, listing these types of accolades in performance, not just in the lobby of their hospital, but also on their website, publications and other types of media. They'll have marketing campaigns geared toward showcasing their performance," says Mr. Kupietzky. "Conversely, hospitals that are underperforming often times have to be prepared to have a public response because the local newspaper will often times report how they are performing. So it puts the spotlight on clinical performance in a way that CNOs didn't have to face before."

4. Burnout. But with a spotlight on metrics and increasing responsibility comes the potential for burnout. Mr. Kupietzky says there's a self-selection process that takes place at some point. These professionals may decide they are ready to retire, and identifying the next wave of senior clinical leaders is not as easy as it once was because the expectations are so much greater. "For the new person to assume that role, they're expected to have that second degree...They really need to understand how to drive performance, both clinically and operationally. It doesn't matter if it's a small or large institution. The expectations of a management team are that their clinical executive will possess all required skills and traits," he added.

Mid-level clinical executives

5. Fiscal constraints. Overall, fiscal constraints in the last number of years have strained those in the middle management tier, which includes directors and managers of units as well as specific directors of specialty areas such as infection control. That's especially true at the director level, according to Mr. Kupietzky. "They're required to track a lot more information than they did before. They are dealing in an environment that continues to evolve and change much more so than five years ago," he says. He notes that infection control used to be a part-time role at some hospitals. Hospitals often would shift people around to assume different roles, depending on the focus of the hospital at that time. But with the rise in outbreaks, both domestic and international, hospitals have been forced to move these resources from part-time positions to dedicated full-time professionals to support these specialties.

6. Pressure for quality talent. Hospitals across the country are struggling to find the right talent when it comes to mid-level clinical leaders, according to Mr. Kupietzky. Hospitals are looking for professionals who are an expert in the field and whose previous experience is not solely staffed on a part-time basis. And Mr. Kupietzky says this factor is causing a strain in finding the right leaders. For instance, hospitals across the nation learned last year during the Ebola outbreak how complicated it is to create a new program for a hospital that requires unique training across all hospital employees. In the past, the hospital may have leveraged management to conduct such training throughout the hospital. However, some hospitals today are required to train every clinical resource. "And the training is not something that can be done just over the Internet. It needs to be in-person training with true practitioner support which is a compliance requirement from governing bodies at both state and federal levels. That type of requirement takes substantial investment and resources," Mr. Kupietzky says. "There really is a shortage of experienced professionals in the infection control and infection prevention areas. We see the same thing with some other mid-level clinical management positions as well. We often hear about a need for more clinical leadership."

7. Career options. Hospitals are recognizing the value of strong. mid-level, clinical executives. As a result, these professionals have more career options today. So mid-level clinical executives are fielding new career opportunities, but also are comfortable to remain in current positions today, according to Mr. Kupietzky. "They're being treated the right way. They're being recognized for their performance. So this factor is making the shortage even greater," he says.

8. Hybrid approach to filling vacancies. Mr. Kupietzky says when his firm helps hospitals fill these mid-level clinical leadership positions; there is a natural marriage between strong clinical experience coupled with real operational knowledge and expertise. "This hybrid type of clinical professional is so critical for organizational success, and they are very difficult to find," he added. "But hospitals need this type of professional more so today than they did in the past...It is so important from a retention standpoint. These leaders are being asked and expected to retain staff while also motivating their teams." 

9. Long time frame to fill roles. Mr. Kupietzky's firm estimates C-suite level and management positions at hospitals have a 20 percent turnover rate. He says this is a significant challenge for an organization to deal with. It means they're frequently going through transitions. There's ongoing pressure to bring new people in and try to retain them over time. At the same time, it's taking a longer period of time to fill these roles, Mr. Kupietzky says. It's not uncommon for hospitals to invest up to a year to find the right talent to join their team. "It's a big challenge for our clients. We've provided interim talent for leadership roles while our clients wait for extended periods of time to find a permanent candidate," he added.

10. Growing complexity and ever-evolving industry require a new type of leader. Clinicians have long prided themselves on their specialty certifications and patient care skills to act as a stepping stone toward leadership. Neither health system nor hospital can build a management team without expecting and demanding more business skills from clinical leaders. Performance improvement, customer satisfaction, financial impacts and operational metrics are at the heart of today's healthcare leadership. "If your organization is not currently mentoring or encouraging the development of business skills and knowledge, this is an imperative for the new year," says Mr. Kupietzky. "Without grooming internal talent, you [the hospital] may be faced with vacancies on your management team in the near future. Today, this type of hybrid clinician is still not abundant in numbers. So it is important to cultivate internal talent and prepare them for the future."


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