Author Affiliations: Vice President and Assistant Chief NurseExecutive (Dr Mosier), Vice President of Care Delivery and Perfor-mance (Dr Roberts), and Senior Vice President and Chief NurseExecutive (Dr Englebright), HCA Healthcare, Nashville Tennessee.

The authors declare no conflicts of interest.Correspondence: Dr Englebright, HCA Healthcare, One Park

Plaza, Nashville, TN 37203 ([email protected]).DOI: 10.1097/NNA.0000000000000815

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JONAVolume 49, Number 11, pp 543-548Copyright © 2019 Wolters Kluwer Health, Inc. All rights reserved.

T H E J O U R N A L O F N U R S I N G A D M I N I S T R A T I O N

A Systems-Level Method for DevelopingNursing Informatics Solutions

The Role of Executive Leadership

Sammie Mosier, DHA, MA, BSN, NE-BC, CMSRN, BCWm. Dan Roberts, PhD, RN, ACNPJane Englebright, PhD, RN, CENP, FAAN

Nursing leadership can play an essential role in the de-velopment of nursing informatics solutions by virtue oftheir broad understanding and oversight of nursingcare. We describe a systems-level method for creatingnursing informatics solutions with clearly defined struc-ture and leadership from nursing executives. Based onthe guiding principles of clear lines of responsibility,respect for expertise, and commitment to projectaims, this allows nursing executive leadership to orga-nize, set up, and own the development of nursing infor-matics solutions.

Data about nursing care have become a critical com-ponent of operational and patient care decisions.These data can potentially affect the productivity, ef-ficiency, performance, effectiveness, cost, and valueof nursing care when properly collected and used.The management and processing of data into knowl-edge for use in nursing practice have become an im-portant specialty within the last decade.1

Nurse executives are dependent on data for effec-tive decision making. The American Organization ofNurse Leaders has identified essential competenciesin informatics that are necessary for effective leader-ship of this technology and data-informed environ-ment.2 In the age of big data, nurse executives areresponsible for creation of the framework that allowsfor nurses and other experts to apply their knowledge,

er H

such as through the creation of a data culture, the de-velopment of data competencies, and the establish-ment of data infrastructure.3

Together, nurse executives and nurse informaticistsare forging new solutions to improve nursing processesand patient care. The challenge is in determining howbest to coordinate the efforts of subject matter expertsfrom nursing, informatics, and information technol-ogy to design, develop, and deploy solutions to verycomplex problems. Nursing leadership is well poisedto influence these processes by virtue of their broadunderstanding and oversight of nursing care. Whilenot usually engaged in the development of nursing in-formatics solutions, we propose that executive leader-ship is necessary to this process.

Here we discuss our development of a systems-levelmethod, with clearly defined structure and leadershipfrom nursing executives, to create nursing informaticssolutions that enhance patient care. This article willdescribe the method and provide case examples of2 successful applications.

MethodsThis project was conducted within a large network ofhospitals with affiliated facilities across the United Statesand United Kingdom. The goal was to develop a methodfor aligning leadership, clinical experts, informaticists,and information technology experts to design, develop,and deploy nursing informatics solutions.

The chief nurse executive (CNE) developed theframework to harmonize the work efforts of dispa-rate groups of clinical and informatics experts thatwere necessary to design, develop, and deploy nursinginformatics solutions. The framework was based on3 guiding principles: clear lines of responsibility and

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authority, respect for each type of expertise necessaryto the project, and clear commitment to the aims ofthe project.

Figure 1 depicts the structure. Clear lines of re-sponsibility consisted of dedicated leadership for eachcomponent of the process, starting with executive spon-sorship and guidance. A steering committee of nurs-ing executives set the vision, objectives, scope, andguiding principles. The steering committee served asa resource for the other teams and an arbitrator ofdisputes between conflicting priorities. Teams of con-tent experts and end-users were tasked with defininggood practice and ideal workflow to generate tech-nology requirements. Technical experts were chargedwith designing the technology solutions that could meetrequirements, support the workflow, present contentoptimally, and incorporate decision support when pos-sible. The clinical and technical teams work iterativelyto develop and test aspects of the proposed solution.

Subject matter experts provided critical input onregulatory requirements, answering questions andproviding audit and review services. Project manage-ment resources ensured the appropriate flow of decisionsand work products among the teams in the appropriatesequence and ensured that any issues were escalatedto the steering committee expeditiously.

Respect for different types of expertise ensuredthat each of the above responsible parties was able tooperate fully within their area of expertise. Technicalexperts deferred to clinicians on content and workflow.Clinical experts deferred to informatics experts on the

Figure 1. Structure.

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best way to design input and output and the use of de-cision support. Regulatory experts deferred to clinicalexperts on content and workflow while providingguidance on regulatory requirements, including eval-uation of the final product.

Commitment to the vision and guiding principlesestablished by the steering committee was a require-ment for all colleagues participating in the project. Aclearly articulated set of guiding principles was usedin each work session to guide team members as theydesigned, developed, and deployed the new solution.Final success was measured on how well the solutionadhered to these guiding principles.

This framework was used to develop 2 distinctnursing informatics solutions within a large hospitalsystem: Evidence-Based Clinical Documentation (EBCD)and the Nursing Data Portal (NDP). These informat-ics solutions were designed to meet the operationalgoals of: 1) minimizing nursing documentation intoan evidence-based story of the patient; 2) creating amore useful and usable patient-centric record thatguides and informs the provision of safe, effective,and efficient care by the interdisciplinary team; and3) rendering standardized and normalized data forthe purpose of performance visibility and evaluationof nursing care of individuals and population at boththe process and outcome levels. Through adherenceto the framework, the resulting informatics solutionsconstructed to contribute to the healthcare learningenvironment through the continuous generation ofknowledge and feedback to clinical practice.

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Results

Evidence-Based Clinical DocumentationIn the development of EBCD, clear lines of responsi-bility began with the chief nursing officer (CNO) Coun-cil (Figure 2). The CNO Council served as the steeringcommittee for EBCD, overseeing the progress of theproject teams. This group served as a champion ofthe organization's nursing agenda and provided guid-ance and input into decisions related to patient care,including operational issues and prioritization of clin-ical projects. The CNO Council defined the guidingprinciples for the process and product, ensured adher-ence to the overall vision, and acted as an arbitratorof conflicting viewpoints.

The Content Team was led by clinical leaders andincluded ad hoc committees of clinical experts orga-nized by specialty. Each ad hoc committee focusedon the specific tasks and questions relevant to theirarea of expertise. Clinical experts with current patientcare experience were able to define the data flowneeded to support the previously developed idealworkflows,4 use evidence reviews to develop content,and identify the desired decision support.

Development of the decision support, creation ofa style guide, and review of existing screen designswere the responsibility of technical experts. Regula-tory subject matter experts addressed questions aboutregulatory compliance, billing compliance, and riskmanagement and performed on-site assessment forregulatory compliance. Throughout the entire process,

Figure 2. Evidence-based practice clinical documentation proje

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the project management team managed to timeline,maintained communication, designed implementa-tion and education strategies, and assisted the collab-oration between teams to resolve issues.

With the clear lines of responsibility defined andrespect for expertise established, the development ofEBCD progressed in alignment with the vision for thisproject. The overall vision for this project was to cre-ate a patient-centric record that guides and informsthe provision of safe, effective, and efficient care bythe interdisciplinary team and produces data to valu-ate care of individual and population of care (Figure 3).To achieve this vision, guiding principles were devel-oped in regard to design and content.

The guiding principles of EBCD design were es-tablished to ensure that the final product enhancedand supported the process of patient care documenta-tion, such as strict adherence to the style guide forconsistency and alignment with the previously definedideal workflows.4 The guiding principles of EBCDcontent ensured that documentation entered throughthis system would be meaningful to patient care ornecessary for regulatory or billing requirements andthat the resulting documentation would support theethical and competent clinician.

Nursing Data PortalIn the development of the NDP, the steering commit-tee consisted of the CNO Council with representationfrom CNEs and unit directors, the 2 primary end-users for the product. Responsibility for content was

ct team.

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Figure 3. Flow of information for patient centric record.

designated to corporate clinical leaders and dataowners. Technical responsibility was shared betweenthe nursing analytics, data science, and informationtechnology teams. Other defined responsibilities wereassigned to subject matter expert teams, including pa-tient experience, human resources, and financial andexecutive leaders. Strong project management pro-cesses facilitated the iterative flow of decisions andtool development (Figure 4).

The focused expertise of these teams was key tothe success of this project. The steering committee iden-tified 4 domains of performance (clinical outcomes,patient experience, efficiency, and nursing engage-ment) and provided final approval of the indicatorsthat would be used in the completed product. Techni-cal experts were the backbone of all the data needs forthe final project. They created the data visualizationplan, transformed data to usable scoring methods,harmonized time frames from disparate data sources,

Figure 4. Nursing data portal project team.

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and aligned the data to other reports with the samemetrics. The various subject matter experts suggestedcommon metrics that were to be included in the finalproduct. These teams also validated all data post-transformation prior to the creation of data visualiza-tions. In essence, the subject matter experts verifiedthe work of the technical experts before any data werereleased for viewing. Project management team mem-bers designed the implementation and education strate-gies for this project and also managed communicationand issue resolution among the teams to meet the pro-ject timeline goals.

With the clear lines of responsibility establishedand experts assembled for the various project compo-nents, the development of the NDP progressed towardits singular unifying vision: one common platform forsharing nursing performance data (Figure 5). Throughthe careful design of source system screens and datapathways and requirements, nursing performance

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Figure 5. Platform to share nursing performance data.

metrics from multiple systems could be conciselydisplayed on 1 page for maximum accessibility. Thevision of the NDP was achieved through adherenceto the guiding principle of easily understood dataand visualizations.

DiscussionThrough the creation of a systems-level frameworkthat clearly defined responsibility, roles, and vision,we successfully designed and implemented 2 large-scale nursing informatics solutions. These informaticssolutions were different from each other—1 clinicallyfocused and 1 focused on leadership—but were builtupon the same systems-level framework. In this method,there was a clearly defined role and responsibility fornursing executive leadership from the beginning ofthe project to the end.

Multiple contemporaneous articles have demon-strated the supportive role of nursing leadership andinformatics.5,6 Specific leadership roles, such as chiefnursing informatics officers and nursing informaticsexecutives, have emerged as central to the support oftransformation and the use of appropriate technologysolutions in clinical practice.7,8 Outside these specificroles, there is a need for nurse leaders, including CNEs,to have knowledge about informatics and its role inpatient care.9 Nurse leaders should be allowed oppor-tunities to both gain these competencies and applytheir knowledge to decision making regarding infor-matics system and nursing care.9-11

Our systems-level method demonstrates the roleof specific leadership in guiding the ideation, design,development, data mapping and visualization, andapplication of the products developed during the in-formatics and technology life cycle. Each of these

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components is integral to the functionality, adoption,and use of the final solution. Nursing executive lead-ership must not only develop a clear structure, time-line, and goals for the entire process but also providevaluable insight into product development. This lead-ership contributed to the effectiveness of these solu-tions as part of the continuous feedback loop withina learning healthcare environment. The knowledge andunderstanding of clinical practice gained through thesesolutions can be applied to subsequent applicationsand efforts to refine and innovate within nursing care.

Furthermore, our method maximizes the exper-tise of those most knowledgeable about individualcomponents. The clarity of roles ensured that criticalinput was provided by the appropriate team mem-bers. For instance, technical experts and informaticsprofessionals focused on the best way to design inputand output and the use of decision support while cli-nicians were responsible for content and workflow.

An added benefit of this method is improved adop-tion of the resulting solutions. Leadership engagement isa key component of implementation processes.12-14 Inour method, leadership are engaged early and often inthe design process, ensuring that the solutions also metthe needs of leaders. Leadership engagement allowedfor local needs and workflow considerations to be in-corporated into the design, improving end-user uptake.

In summary, we have developed a systems-levelmethod that allows nursing executive leadership toorganize, set up, and own processes related to the de-velopment nursing informatics solutions. Our organi-zation has used this structure for several projects withpositive results. Use and adaptation of the strategiesof this method may offer a way for nursing leadershipto guide and influence future solutions.

References

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2. American Organization of Nurse Executives. AONE NurseExecutive Competencies. Chicago, IL: AONE; 2015. https://

www.aonl.org/sites/default/files/aone/nurse-executive-competencies.pdf. Accessed July 25, 2019.

3. Englebright J, Caspers B. The role of the chief nurse executive inthe big data revolution. Nurse Lead. 2016;14(4):280-284.

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4. Mosier S, Englebright J. The first step toward reducing docu-mentation: defining ideal workflows. Comput Inform Nurs.2019;37(2):57-59.

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The Journal of NursiInstructions f

Instructions for Authors can be fbelow. To ensure that your manuwith new submission proceduresdocument carefully before manumanuscripts must be submitted esystem.

Please visit http://JO

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and Informatics: A Position Statement. Chicago, IL: HIMSS;2011. https://www.himss.org/position-statement-transforming-nursing-through-technology-and-informatics. Accessed July 25,2019.

11. Oakes M, Frisch N, Potter P, Borycki E. Readiness of nurse ex-ecutives and leaders to advocate for health information systemssupporting nursing. Stud Health Technol Inform. 2015;208:296-301.

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13. Aarons GA, Sommerfeld DH. Leadership, innovation climate,and attitudes toward evidence-based practice during a state-wide implementation. J Am Acad Child Adolesc Psychiatry.2012;51:423-431.

14. Gifford WA, Davies B, Edwards N, Graham ID. Leadershipstrategies to influence the use of clinical practice guidelines.Nurs Leadersh. 2006;19:72-88.

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