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Operationalizing a Nursing Innovation Center Within a Health Care System

Nancy M. Albert, PhD, RN, CCNS, CHFN, CCRN, NE-BC, FAHA, FCCM, FHFSA, FAAN

In nursing, the terms “innovation” and “innovative” are used freely, especially when individuals or groups either develop something new or improve upon current practice. Innovation is often considered adjunct work, not part of foundational work that aims to meet the vision, mission, and values of the organization. Nurse leaders must include innovation as an important theme of this foundational work. Innovation must become a core expectation of all nurses and nursing team members. Team members can provide ideas that lead to innovations. They can also carry out roles that enhance or cultivate ideas, promote prototyping, ensure innovative ideas are efficacious and effective, and facilitate dissemination and diffusion into practice. To ensure that innovation is incorporated as part of nursing practice and then sustained over time, horizontal (elemental) and vertical (global) infrastructure and processes are needed. In this article, operationalization of a Nursing Innovation Center is described and rationale for specific horizontal and vertical services and features is discussed. Key words: inventions, nursing innovation, nursing innovation ideas, nursing leadership strategies, organizational innovation

“INNOVATIVE APPROACHES,” “behav- iors,” “partnerships,” “interventions,”

and “leadership” are terms commonly used by nurse leaders, educators, and clinicians. They are all considered to be means to meet chal- lenges of health care organizations, including current needs for increased safety, improved outcomes, and cost-effectiveness. The terms “innovation” and “innovative approaches” are used in titles of many nursing articles that have research, clinical practice, or education focuses. Innovative interventions described in the literature have created value by

Author Affiliation: Nursing Research and Innovation, Nursing Institute, Cleveland Clinic, Cleveland, Ohio.

The author declares no conflict of interest.

Correspondence: Nancy M. Albert, PhD, RN, CCNS, CHFN, CCRN, NE-BC, FAHA, FCCM, FHFSA, FAAN, Nurs- ing Research and Innovation, Nursing Institute, Cleve- land Clinic, 9500 Euclid Ave, Mail code J3-4, Cleveland, OH 44195 ([email protected]).

DOI: 10.1097/NAQ.0000000000000266

enhancing clinical research,1 augmenting hy- dration without invasive measures,2 building self-confidence of nurses completing gyneco- logical procedures,3 and sharing professional education.4 While these and other articles describe nurse innovations, most health care organizations may not have the foundation or resources needed to empower nurses to raise and cultivate innovative ideas, move ideas from the bench into clinical research, or diffuse innovation into clinical practice. Nurse leaders can create an invitation to innovation for their teams by developing a center for nursing innovation that includes infrastructure components and core support.

There is often an assumption that nurses who work within health care centers are em- powered to be innovative in thought and ac- tion and that innovation is fostered as part of work role expectations. Research on innova- tiveness among hospital-based nurses is not abundant, but there are some reported stud- ies. In these, variability between nurse and hospital characteristics has been reported. In

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44 NURSING ADMINISTRATION QUARTERLY/JANUARY–MARCH 2018

one study, managers, certified nurses, and nurses with graduate degrees were found to be more likely to generate creative ideas and promote or champion innovative ideas than other nurses (clinical, noncertified, and nurses without graduate degrees).5 In an- other, it was found that nurses who had won awards for creativity were more likely than other nurses to be older and married or cohabitating. They were also more likely to have children, a higher education, and fewer years of working in nursing.6 Factors that facilitated innovative behaviors among 347 nurses in a third study were self- leadership, creative self-efficacy, and individ- ual knowledge sharing.7 Finally, when nurses from one Magnet-designated hospital were evaluated for perceptions of personal inno- vativeness, the mean personal innovativeness score was low (32.1 on a scale of 0-70), but scores were higher among direct care nurses than non–direct care nurses.8

Innovativeness had been correlated with certain hospital characteristics. When 6 hospitals (>300 beds each) were compared for nurses’ innovative behaviors, scores were higher in sites with change-oriented organiza- tional cultures that appreciated organizational knowledge sharing.7 In another report, it was shared that nurses who had a stronger fit with their organizations had higher self- and physi- cian ratings of innovative work behaviors. They also were found to display knowledge- sharing behaviors with coworkers, which strengthened the fit between the person and the organization.9 In a Magnet-designated hos- pital, nurses completed a survey on percep- tions of hospital innovativeness.8 The mean score of 91.5 (on a scale of 25-125) reflected that the hospital was at an early adopter stage but that they were not innovative.8 Further- more, researchers assessed factors associated with perceptions of hospital innovativeness and learned that nursing unit environments were important. Intensive care units showed the lowest innovativeness scores, whereas medical-surgical environments reported the highest.8 Results from 2 other reports showed that nurses who work in large (vs

small- or medium-sized) hospitals5 and those who worked in a medical center (rather than a regional or local hospital)6 were more likely to demonstrate creativity.

Learning that innovation is associated with specific nurse and hospital characteristics is troubling for 2 reasons. First, nurses do not go to work and say, “Today I am going to inno- vate.” Innovation may happen spontaneously, based on circumstances or positive deviance; it may happen incrementally; or it may be me- thodically planned out over time as a solution to an uncomfortable situation. All nursing per- sonnel, no matter the job role, hierarchal sta- tus, or reporting structure, can be innovative. Personnel closest to patients or to the purpose and goals of nonpatient care jobs may have the best innovative ideas. Nursing leaders must be ready for innovation to happen. Innovation and early adoption are key elements neces- sary for creating changes that can improve quality of life, reduce costs, meet specific un- met needs, cure or treat conditions, and pre- vent unwanted conditions. When researchers surveyed nurse leaders to assess critical com- petencies for innovation success, they found significant gaps in 18 of 19 important innova- tion competencies.10

The second reason that reading about gaps and disparities in innovation was concerning is that innovation can be taught.11-13 How- ever, it is imperative that resources, in the form of structures, systems, and processes for innovation, are available to nurses. Equally im- portant, nurse leaders must believe in teach- ing nursing personnel to innovate by raising their voices when ideas present themselves. Review of nursing research cemented the idea that a center should be implemented and sup- ported for a system that sees nursing innova- tion as a valuable resource for addressing the current needs of health care organizations.

With the aforementioned background, this article focuses on operationalization of the Cleveland Clinic Foundation (CC; Cleveland, Ohio) Nursing Innovation Center. Cleveland Clinic is composed of 10 hospitals in North- east Ohio that include 2 small (100-bed) community hospitals, 4 mid-sized community

Operationalizing a Nursing Innovation Center Within a Healthcare System 45

hospitals, 3 tertiary care 500-bed teaching hos- pitals, and 1 large academic, quaternary care medical center. In addition, the system has a 200-bed hospital in Weston, Florida, and in Abu Dhabi. All hospitals within this integrated system receive support, services, and initia- tives (including nursing innovation) from the enterprise. Prior to the start of the innovation journey, the main campus included a “unit of the future,” where innovations were tested (researched) or assessed (evaluated) when- ever possible. When Nursing was integrated systemwide, 4 other units were identified as patient care areas that would evaluate inno- vations. They became part of a global inno- vation assessment program labeled “Ideas-2- Innovations.”

INITIATION OF A NURSING INNOVATION CENTER

The CC Nursing Innovation Center was founded in early 2013, after approximately 6 months of initial planning. Its conception was an outcome of a health care system senior nurse leader retreat, where strategic themes were raised, sorted, and discussed. A push for more innovation rose to the top of the leader’ list. As a result, a committee was developed, involving an interdisciplinary team of 22 participants. The team included nursing leaders (1 chief nursing officer and associate chief nursing officers who served the system in quality, informatics, and re- search/innovation), nurse educators, clinical nurse specialists, clinical nurses, 1 physician, 1 marketing department liaison, a member of the continuous improvement team, and an in- formation technology liaison. Also invited to join the team were 2 liaisons from CC Inno- vations, a commercialization arm of CC, an institute devoted to fostering innovations and inventions while assisting innovators in get- ting products to market.

The initial committee goals were to de- fine innovation and determine the scope of services of the proposed center. The team wanted the definition of innovation to be writ- ten in a way that encompasses multiple forms

of innovation because there was a belief that nurses do not understand the totality of the term. It was perceived that nurses think of in- novations as something that involves gadgets and devices; something they can touch and manipulate. The initial definition of innova- tion was “the first practical, concrete imple- mentation of an idea by or for Nursing that cre- ates new knowledge; improves care, patient safety, and clinical outcomes; achieves effi- ciencies or administrative effectiveness; and allows for internal or external recognition to an individual, a department, or the CC.” As stated, the definition applied to internal in- novations, reflecting those that benefited CC by saving costs, time, and/or effort while en- hancing nursing excellence. In addition, it in- cluded those ideas that could be commercial- ized and marketed externally.

As a way of introducing innovations as a strategic theme within nursing, the team chose to limit the focus of the Nursing In- novation Center to 3 areas. This was based on a marketing principle that when you discuss 3 or fewer themes at one time, it is memo- rable. The Nursing Innovation Center was not a physical space. Rather, it was an intranet site that was initially backed with systems and pro- cesses and, later, with structures. The team did not want people to get lost in verbiage or to be overwhelmed when they went to the site. The 3 service themes chosen were “gen- eral information” on programs that would in- crease nurse awareness of nursing innovation support, “innovation education,” and “awards and recognition.” Each of the themes is dis- cussed as follows, as initially developed.

General information

The intranet Web site initially provided a link to tips on planning nursing practice inno- vative approaches and frequently asked ques- tions and responses. Two initial programs presented aimed at increasing awareness of and facilitating innovation. Programs and pro- cesses that facilitated innovation growth were considered part of the vertical structure of the overall program. Nursing personnel could

46 NURSING ADMINISTRATION QUARTERLY/JANUARY–MARCH 2018

choose to participate or use the resources as desired. There was no minimum standard ex- pectation that nursing personnel needed to actively participate (Table 1). Other general intranet information included links to the CC Innovations Web page, a nursing innovation contacts page, a handout on steps to moving innovations and inventions forward, and links to the CC institutional review board and CC Nursing Research Center.

Innovation education

To enhance nurses’ knowledge about the scope of innovation and to develop nurses as disruptive innovators, multiple interventions were developed. CC Innovations agreed to conduct multiple in-services with nursing staff members to share services provided by their team. An inaugural 1-day Nursing Innovation Summit was convened in October 2013 to fo- cus on driving innovation. The chief execu- tive officer, both an innovator and an inven- tor, presented personal stories on past ideas for innovation. A creativity workgroup ses- sion was focused on creating simple steps to initiate and sustain innovation. Innovation opportunities, issues, new thinking, and im- plementation were all discussed. Nurses com- pleted the creative processes of divergent and convergent thinking while working in small groups. Two panels of inventors (internal and external to CC) discussed how they cultivated their innovations and moved them forward. Inventors discussed barriers, setbacks, and lessons learned when they worked with attor- neys, prototyping companies, and marketing firms. Other themes of the inaugural and 2014- 2016 Nursing Innovation Summits are pre- sented in Table 2. Some themes were repeated on the basis of their importance. These in- cluded leadership support, nurses telling their innovation stories, and a lawyer’s discussion on the importance of protecting intellectual property and its effect on commercialization. The CC Nursing Innovation Center intranet site contains a link to innovation references in the literature. It also shares a series of steps on how to move innovative ideas forward.

Education on innovation is needed to help novice innovators understand the steps of in- novation and to help them understand that in- novation often involves failure. It is important that nursing innovators understand they may fail often. It is best when they fail fast, rather than attempting to cultivate an idea that has little chance of moving forward, because it is too similar to patented and/or commercial- ized items in the market, not feasible, or does not hold value. (It fails to adequately answer the question, “Why should I care?”)

Awards and recognition

It is important to recognize and reward in- novators publicly. It is also essential to allow innovators to share their stories so that col- leagues can understand the possibilities for themselves and can see the value of innova- tions that were brought forward. This value can take on many forms. While immediate benefits may be obvious, there are also rami- fications of innovative implementations over time. Cost avoidance is an important value addition for many hospitals. Therefore, when recognizing employees for innovations, lead- ers should point out how these ideas may de- crease spending even if they do not gener- ate income. Figure 1 provides a schematic of the importance of awards and recognition and how they can spur future innovation.

MATURATION OF A HOSPITAL-BASED NURSING INNOVATION PROGRAM

Between 2013 and 2015, the Nursing In- novation Center successfully nurtured and created multiple nursing innovations. Nurses submitted to both the Step Forward and In- novation Inventory programs. Nurse innova- tors were recognized locally. For example, at an annual nursing leadership summit that includes more than 300 nurse leaders from CC, 3 successful innovators participated in a panel discussion, answering audience ques- tions about being innovative. CC Innovations also invited nursing innovators to their annual recognition and awards program.

Operationalizing a Nursing Innovation Center Within a Healthcare System 47

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48 NURSING ADMINISTRATION QUARTERLY/JANUARY–MARCH 2018

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Operationalizing a Nursing Innovation Center Within a Healthcare System 49

Table 2. Nursing Innovation Summit Content Themes

Inaugural Meeting Second Summit Third Summit Fourth Summit

• Getting ideas for innovations— personal stories from the chief executive officer

• Leading with creativity

• Cultivating nursing innovations

• External resources

• Creative thinking

• Moving nursing innovations forward

• Nurse inventors tell their stories

• The inventor’s mind

• Learn from non–health care innovators

• Nurse inventors tell their stories

• Protecting intellectual property

• Resources that foster innovation

• Moving innovation into practice

• Prototyping innovation

• Concept to reality

• Innovation and improvement

• Nurse inventors tell their stories

• Searching for prior art

• Making the pitch • Enabling

innovation for practice and academia

• Innovation leadership

• Moving toward being innovative

• Innovation leadership— benefits and competencies

• Innovation through gamification

• Protecting intellectual property

• Joys of prototyping

• Nurse inventors tell their stories

• Selling your product

Each year, the system saw an increase in Step Forward submissions, but it soon became evident that only a few nursing personnel were involved. At an annual retreat, the Office of Nursing Research and Innovation team discussed what they believed were root causes for this limited involvement. The team felt there were 3 areas of concern. The first in- volved staff turnover. Nursing personnel were constantly changing. New hires may have not received information about the program or were overwhelmed upon hire. They were focused on day-to-day work. Stable nursing personnel also changed roles as new opportu- nities became available. They may have forgot- ten about the focus on innovation or did not believe that they were innovative individuals. They ignored intranet site information, flyers, and registering for the annual summit. In addition, the team perceived that when nurse managers like the status quo or are too busy to consider or act on new ideas when voiced by their team, nursing personnel may slow or stop initiating ideas altogether. Finally, pro- grams that had been developed were in line

with the strategic plans and were supported by high-level nurse leaders but were missing a key component: having all nursing personnel understand that innovation is a foundational component of our mission and goals.

To reemphasize and promote nursing innovation as a foundational component of nursing work life in 2016, executive nurse leaders discussed the foundation for nursing innovation and suggested methods of achiev- ing success. Foundational work included 3 components: ensuring that all nursing job performance reviews had 1 key job responsi- bility that was specific to innovation; ensuring that innovation was part of the lowest-level step (and all higher steps) of the professional ladder; and increasing emphasis of innova- tion within the shared governance councils. Furthermore, leaders wanted to ensure that innovation needs were raised from both the highest level of nursing leadership and the frontline clinical staff, who are most likely to understand the needs of their teams. The current model of innovation is represented in Figure 2.

50 NURSING ADMINISTRATION QUARTERLY/JANUARY–MARCH 2018

Figure 1. Recognizing and awarding nurse innovators; benefits and opportunities.

Figure 2. Nursing innovation program elements. *Initially, this was the label for a program that facilitated assessment/evaluation of innovations—new, untested products, processes or services (externally intro- duced or internal), and commercialized products new to our healthcare center. It included 4 nursing units that were the primary evaluation sites. Currently, this is an umbrella term for the Nursing Innovations Program above, including the 4 innovation units.

Operationalizing a Nursing Innovation Center Within a Healthcare System 51

Foundational (horizontal) infrastructure

The annual performance review process provides a unique opportunity for nurse man- agers to discuss strengths, opportunities, and goals with individual nurses. In 2016, an ad- ditional key job responsibility statement was added to the annual performance review form (to go into effect in the January 2018 review cycle). Key terms included in the statement were that nursing personnel need to voice ideas for innovations and explore care deliv- ery solutions or rapid-cycle changes. A second foundational element, ensuring that innova- tion is included in all levels of the professional ladder, was a paradigm shift for the commit- tee responsible for updating the program. Committee members (and nursing personnel in general) had traditionally placed research and innovation projects at the top (or near top) step in the ladder process. To provide rationale for including innovation as a founda- tional element of nursing and therefore of the professional ladder, a PowerPoint slide set was created. Executive leaders and members of the professional ladder team agreed to the change, but revision of the paperwork was slow. Revisions are planned to be distributed in 2017, with a 2018 implementation date.

The Cleveland Clinic professional prac- tice model includes innovation as one of 4 core elements. However, shared gover- nance councils did not previously spend time proactively focusing on innovation. The fo- cus was most often on policies and proce- dures and evidence-based practices. In 2015, executive nursing leadership embraced the continuous improvement model as a way of standardizing process improvements across units while maintaining standardized pro- cesses over time. During problem-solving and strategy sessions, leaders began noticing that innovative ideas were being raised. As per- sonnel from more units are introduced to the continuous improvement process, it is expected that nursing staff members will become more comfortable raising ideas for change and novel solutions to problems. Over time, at the nursing unit level, the continu-

ous improvement process is expected to be embedded into normal work processes. Al- though continuous improvement and innova- tion are 2 parallel pathways, the end point of continuous improvement, when improve- ment solutions are ineffective or nonfeasible, is to jump into the innovation pathway. When all 3 of the foundational elements of innova- tion are live in 2018, an upsurge in nursing innovation is expected.

Vertical programs aimed at promoting innovation

To ensure that executive nurse leaders and nursing personnel at the unit level are more visible in the innovation process, 2 new non- foundational programs that support facilita- tion and promotion of innovation have been added. The CC Innovations has developed an ideation suite to promote creative solutions to problems, issues, or needs. At an execu- tive nursing leadership council meeting, nurse leaders were asked to raise issues requiring novel solutions. Seven themes were raised to be voted on by the team. The theme ranking highest in importance was the first to be ex- plored using the ideation suite. Nurse leaders can invite personnel to attend the innovation suite session. In that way, leaders are active in letting nursing personnel know that they value innovation and the process of develop- ing novel solutions. Generally, attendees at innovation suite sessions are multidisciplinary stakeholders. The initial process can take be- tween 2.5 and 4 hours, depending on the topic complexity. Once novel solutions are discussed and the best solution or strategy is agreed upon, process work can be delegated to personnel with the right skills. Some work can be completed via teleconference and elec- tronic communication.

To promote participation of all nursing personnel in the sharing of innovative ideas, a program called “I Innovate” was initiated (see Table 1). Unlike the earlier programs, I Inno- vate requires a program manager. The pro- gram manager records innovative ideas sub- mitted and categorizes them by themes. Nurse

52 NURSING ADMINISTRATION QUARTERLY/JANUARY–MARCH 2018

managers and other leaders who actively sup- port the program are recorded so that they can be rewarded. Innovative idea themes that recur are tabulated so that ideation suite ses- sions can be developed. It is important to reg- ularly communicate the number of I Innovate ideas generated and to give credit to nursing unit personnel and leaders who participate. In this way, the program will be diffused into the culture of the unit more rapidly.

DISCUSSION

Innovation programs can be operational- ized in many ways. Some centers use in- novation challenges that resemble a “shark tank” experience. Innovators are encouraged to provide a brief elevator speech to judges where they explain the problem, the inno- vation, and why it is important. The innova- tion may have been recently conceived or may have been cultivated and prototyped. Innova- tion challenge awardees often receive mone- tary prizes that can be used to advance innova- tions. Another approach involves a kiosk that can be placed in a lobby or other high traffic areas of hospitals so that curious or engaged personnel (and visitors) can walk in, discuss their innovative ideas, and learn the hospi- tal’s process for moving innovations forward. The kiosk or dedicated space may house a 3- dimensional printer and other prototype ma- terials so that budding innovators can bring in- novative ideas to life. Other centers may iden- tify common problems and challenge nurs- ing personnel to contact external health care or non-health care sites to question, observe, and/or network with others to learn alterna- tive solutions to problems. By exploring how others solve problems, nurses may create as- sociations or connections that can lead to dis- ruptive innovations.14

Our approach has been not only more tra- ditional but also more global. Focusing on a recurring innovation challenge or a problem- solving ideation approach supports innova- tion, but only when the challenge is ac- tive or nurses have time and resources to gather external knowledge. Using a brick-

and-mortar approach minimizes the visibil- ity and availability of innovation resources in health care systems that are geographically di- verse. As more nurse leaders develop strategic plans that encourage and facilitate innovation among all health care personnel, it is hoped that innovative approaches will be used to de- velop innovation programs!

Innovation itself can occur in many ways. Often, it is serendipitous or occurs after previ- ous failures to meet needs. It may occur when multiple disciplines meet and understand a mutual problem from the perspective of each discipline. In some cases, a product or ser- vice that has nothing to do with the business at hand sparks a new idea.15 It is important in any innovation program to allow for mul- tiple ways of creating, cultivating, or refin- ing innovation. In our program, trained per- sonnel are available to assist individuals and teams in advancing innovations. Employees are encouraged to interact with other stake- holders and liaisons. Ideation sessions, prod- uct revision sessions, and evaluation sessions are often composed of people from multidis- ciplinary groups, as the voice of many disci- plines can strengthen and optimize ideas be- fore implementation and before taking steps for commercialization.

Acceptance of, and diffusion of, innovative ideas needs to be addressed in any innova- tion program. In health care, personnel are trained to be risk-averse and may avoid consid- ering novel solutions that have not been fully vetted and evaluated. Novel ideas often un- dergo multiple revisions before the best plan is available. Even when the best plan is avail- able, the innovation may be disruptive and re- quire structure, system, and process changes. Nursing and innovation leaders must under- stand the disruptive nature of innovation and accept the idea that failures are a part of the process. To drive system transformation, leaders must be purposeful and directed in change management.16 Having a key job per- formance metric related to innovation will not be a strong enough component of the pro- gram to overcome long-held beliefs about be- ing risk-avoidant. However, a job performance

Operationalizing a Nursing Innovation Center Within a Healthcare System 53

metric can become the basis for verbal, mon- etary, and other support that nursing leaders use on the journey of start-up, refinement, evaluation, and diffusion of individual inno- vations, as well as visibility of the innovation program.

CONCLUSION

Operationalization of an innovation pro- gram requires planning, leadership backing, and personnel who are trained to provide

support. Once initiated, the program can be built up slowly or rapidly, depending on initial response. It is important that the program includes foundational infrastructure. In addition, adjunct programs, services, pro- cesses, and resources that facilitate awareness of innovation and nurse participation are essential. Nursing personnel at every level, and with any educational background, can be innovative. They should be encouraged to innovate to advance patient care and create workplace efficiencies.

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