Dani:

Welcome back to the Handoff from Trusted Health. I'm Dr. Dani Bowie, Chief Nursing Officer of Trusted Health. This season we're covering all things healthcare innovation and the importance of fearless leadership for change. In this episode, I have the pleasure of speaking with Dr. Nancy Blake, Chief Nursing Officer of LA General Medical Center. Today, we discuss key components of leadership such as building credibility as a leader, establishing a healthy work environment, and the importance of investing in the frontline staff for the development of workforce programs. We also cover pivotal moments in her career and her perspective on the innovations necessary for the future of nursing. Here's my conversation with Dr. Nancy Blake.

Welcome to the handoff. I am so excited to be speaking with Dr. Nancy Blake, who is the chief nursing Officer of LA General. Nancy, welcome to the handoff.

Nancy:

Thank you. I'm happy to be here.

Dani:

Nancy, I would love to start the show off by centering us back to our purpose and keeping the patient at the forefront of the work that we do. Is there a particular patient experience or story that has had profound impact on you that you could share with our listeners today?

Nancy:

I think back on a patient I took care of when I was first a nurse, actually I was young and the patient was 25 and I was actually younger than him and I was working at Children's Hospital Los Angeles, and he was a Downs patient that had chosen to have congenital heart surgery because he was starting to get tired and he wanted to be free from his parents. He had a job, he was starting to have to sit in a wheelchair. I think back of all the things I could have done better, but I also think of the relationship I built with his parents because I took care of him for two weeks. But it always grounds me in that you need to look at the patient and their family and all the issues surrounding their personal life and not just think them as a patient with a diagnosis that were just taking care of that piece.

Because his goal was not only to have his open heart surgery, but to be able to go back to his job that he created. One of those things that they made mosaic tiles that you actually see on the wall in most places, and he was very proud of his job, but he ended up having a cardiac arrest and dying. And I just think of all that went into his decision making, went into his parents, allowing him to make the decision and they were older and they were thinking about who was going to take care of him. So in the long run they believed it was better, but in the short run I felt like we failed him and that his goal was to be back as a person in society without his health issues. And that has grounded me ever since, and that was 40 years ago. But we can't just think of the patient as they are in the hospital or in the clinic. We have to think about how we can help them care for themselves so they're not relying on the healthcare system.

Dani:

You bring up a really valid point about seeing the patient who they are outside of just the immediate care that you're providing them. And one thing that you said stuck with me and I'm sure we'll stick with our listeners, we do think about those patients that we cared for in our early careers and think about the things that we learned through our journey and how we could do things better. But what I'm hearing too is the intent to care for him and his family and the impact that that had on them and the journey to make a decision that will help him live the life he wanted to live and that was the key factor. So that's such a moving story. Thank you Nancy for sharing that. I would like to switch a little bit and talk more about you and your career, which you mentioned that was the beginning of your career and you've had quite a distinguished one. Can you share some pivotal career moments or passions that have motivated you to continue to do the work that you're doing today?

Nancy:

Early in my career, I became a manager and you want to do well. You want to do everything to fix all the problems, and I realized early that you don't fix the problems by yourself. And as a manager, I got more what I call currency when I allowed the staff to have a say in what they do, and I went to a leadership class probably middle of my career and something stuck with me that you can't withdraw from the bank unless you have currency. So really building strength and relationship with your staff, allowing them to do what they can, but also doing what you need to do because it's right. I always wanted to be at a place that cared for the staff and the patients that they served and mid-career looking for another job. It was really rough. I went to a lot of interviews where I didn't believe my moral compass was in line with the hospital's mission, and so making sure that you care for the staff, you allow staff to make decisions and some pivotal moments are the magnet journey at Children's Hospital, which was before 2010, and now coming to this facility which I've been at for two years and working with the staff to be on the magnet journey, set up shared governance, change the culture to allow staff to have more of a say while still maintaining the hospital's mission is world-class care for all in a county hospital that deals with a lot of unhoused, deals with a lot of patients with not only medical issues but psychological issues, but providing the best quality care at a place where the staff can have a healthy work environment as well.

Dani:

The currency of management, that is actually something that I haven't heard mentioned often, but I really appreciate how you bring that up and that it sounds like is a theme and thread throughout your whole career, which is elevating the voice of the nurse, creating infrastructure to allow for the shared decision making and the voice of the nurse or those that you're leading to have a say in the solutions and their work environment. So that is a wonderful attribute and thank you for sharing that and bringing it to light of how important that currency is as we lead people to engage and allow for leadership from within and those that you serve to have the voice of change. You talked about LA General and your career journey and how you've looked at different places that align with your moral compass and the things that are important to you as a leader. Specifically, what are some notable opportunities or priorities that you've championed since joining LA General Medical Center as the C N O?

Nancy:

Well, first was to help get shared governance. They were on the journey. They had a professional practice model, they had some really good things in place, but really shared governance in a facility that had been very much a decision-making. And so it was a complete change in culture and trusting that the staff understood the decisions that they were making and that we set the appropriate parameters so they knew what they could choose. We can't make decisions on salary salary's negotiated. We work in a facility that's represented by a union. We have a good relationship with the union, but that is not something I can put on the table and say everybody needs a raise. So prioritizing those things that they can have a say over self-scheduling staff can really move their schedules around to balance a schedule when given the responsibility to do that. And if they can't, then at that point the manager may need to make some changes.

Right now, especially post covid, people want to balance life. They want to be able to disconnect. They want to be able to have time with their family, but they also, when they're at work, they want to be able to make decisions and they also want the organization to invest in their professional development. So yes, we're not the highest paid. I think we're paid competitively. Our benefits are better than any place I've seen, but making sure that we have that balance of a healthy work environment, allowing them to make decision, allowing them to work things that they can, and I always say if you want to know what's wrong with an organization, you go to the frontline staff If you want to know how to fix it for very little money, the frontline staff can tell you, and I say, I'm at the 10,000 foot level, the managers at a thousand foot level frontline staffs at the street and at the street, they can tell you exactly what needs to be fixed and if you trust in them, they trust in you.

Dani:

Another great example of how you've navigated some changes at LA General, I really appreciated how you define what can you make a decision on? No, we cannot make a decision on pay, but let's talk about practice and the thing that actually is really important, another high hitting priority that you mentioned, Nancy, outside of pay is control over your schedule and the ability to influence how you're scheduled, what it looks like work-life balance. And so being able to bring that to the forefront of your clinicians is something that is just as impactful if not more impactful than pay per some of the surveys that I've conducted and seen. Now bringing change is not easy and you're talking a lot about shared shared governance decision-making, getting the frontline involved. How have you navigated these transformations both at LA General but in places that you've been in the past of designing the infrastructure for shared, shared decision-making, engaging your frontline to trust you and trust the process in that? So we would just love some of your wisdom around this tenured career and leading this way.

Nancy:

I think some of it is educating people, brought in consultants on shared governance to actually talk about what it looks like, make it more tangible than this lofty goal. When you come into a place like that, the managers don't want to give up control because they're concerned they have the ultimate responsibility. I do bring a consultant in to do training both for the leadership and for the frontline staff on what it looks like. What do the bylaws need to be, what decision-making at the meeting. If people don't speak up in a meeting, silence is consensus. And that was something that Jeni was our consultant said, silence is consensus. If people don't speak up at the time, then we move forward with the decision that is being made at the table. I brought Rose Sherman in to talk to our leaders. She's very in touch with what's going on across the country.

I didn't know why, but she does focus groups and it's an interactive workshop and she had done 70, I think when she did ours last year. I brought her in for boss's day the last couple of years and really getting people to understand that you're not alone. We're not making these changes on our own. A lot of people come here and stay here for their entire career, so they haven't worked at places and I think good story, bad story. I've worked at other places. I've seen other places sitting on the board of directors at A C N I got to go to other hospitals. I've done consulting at other hospitals. I'm a magnet appraiser, so I've seen what it looks like when it's fully vetted and worked out. Getting people to trust me that I know what I'm talking about and that it will be okay was one of the biggest things because the leaders weren't too sure how to trust me.

We started a residency program last year at this time and it was very different than our traditional orientation program for new graduates. It's been very successful. Our turnover is almost nothing, and the last two groups have had 89 and the group we have now has 94, of which I think we lost one who has a difficult pregnancy, so she'll probably be back, but most of those people are committed to stay with the organization and so I think the turnover numbers, people see that they're not just here for the training and that the people in orientation do see that we're investing in them and that we're giving them the support throughout the residency program that they were looking for in an organization. Organiz, I've implemented so much and I tell my directors, please tell me, raise your hands and say uncle, when I've gone too far. But I am pretty far in my career, so I want to be able to fix all the problems at once, and I understand if you move too fast, that's a risk as well. So I have to take it slowly, but I think it's all good and I think it's very positive. Even the union is very positive about many of the changes that I've made.

Dani:

I found it interesting as I was listening to your story because Nancy, you mentioned I've been in other places. I've been on the a C N board magnet appraisal, so you've seen it in action and you have great exposure and yet you were humble enough to also bring in some other experts to support your message and bring a broader perspective. And that's a really powerful demonstration of leading and being able to say, I do have expertise, but there's others as well that can really help amplify what you build at your organization. Rose Sherman is a wonderful, wonderful leader. We actually had her on the podcast as well just sharing more about how she's helped transform the healthcare space. So I loved hearing that and also you're putting your words, your action, where your words are, for instance, your nurse residency program and investing in the resources of the frontline to give them the experience that they need for success. Can you just give a little bit more insight into your nurse residency program at LA General and how you brought that to life? We're hearing and you're saying retention is improving and we're seeing great impact, but to share a bit more, because LA General is a county hospital, it is different. It's not the same as a non-public hospital in that sense. And so help our listeners know how you brought that to life there.

Nancy:

Sure. I was at Children's Hospital Los Angeles when the verse and R in residency program began. That was developed by a group of leaders in education that built it from the ground up. And so I had that experience. I worked there for 25 years after it went live, and actually their president, Larissa Africa was in the first residency class. So it was pretty fun. I actually saw it and we went from 38% turnover in the first two years to almost nothing. And so I had to go to the literature to old and new articles that show the retention rates of the residents in year one and year two we had a leadership retreat. We talked about it. I brought some frontline staff into the leadership retreat with the nursing executive committee. We also brought nurse practitioners, nurse midwife, CRNAs. They don't report up through nursing, but they're part of nursing.

And so we're trying to bring everybody inclusively so everyone hears the same message. We talked about it, they hadn't gone directly into the I C U in the past and it was like, oh my gosh, we have to do this. And I had to convince my boss that investing in this, we'd see a better return on investment. We did see about a 30% turnover in our new grads in the first year or two out of almost 250 people we've put through, I think we've lost five to 10. Many of them are because their husband was transferred or they might've been in the wrong place, which we've been able to move them to the right place or the gas prices driving into downhill in la, they just can't do it. The reasons for turnover are not as much about not feeling supported, but more about the other things that we have no control over.

So I think it's been really good. Our staffing has gotten much better. We're slowly but surely weeding out the registry as we hire our own. So now that we've been in place for over a year or almost a year, I think our first group started October 1st. I think staff understand that this is a good thing and they're talking about how great it was. But I tell you last year at this time it was not a popular idea, but it's gotten so much better and they actually see it and we're keeping staff as well. So I think just wadding through the difficult times. That first group, we only brought in 39 and they were really the ones that gave us a lot of feedback before the second group started in January, and that second group finished in May, June. And the third group is really a stellar group because we were able to recruit based on experience. So friends tell friends and people were coming here for the residency program because we're on the magnet journey because of shared governance. And I always said, you have to put your money where your mouth is and you can't talk about something unless you're able to implement it yourself.

Dani:

Amazing results. I also really like how you mentioned you built and then it continued to grow. So the first cohort we're smaller. You take feedback, you adjust and you grow and maybe isn't as popular in the very beginning when you're rolling it out. But through time and adaption and being able to improve and also just continue to change culture, it takes off. And I think that's a key message for leaders is just the time it takes to change and solidify that change in culture is oftentimes I think one of the biggest proponents or biggest challenges we face as a leader for leading change. Nancy, I know that you are a big proponent for a healthy work environment, authentic leadership. You understand the value of nursing and advocating for appropriate staffing, all of which are more important now than ever. What do you believe needs to change to make those things a reality?

Nancy:

Well, I think working with the frontline staff, and I was on the board of directors one a SAN rolled out the healthy work environment standards, and I did a review of the literature that was published in 2004 before the standards were published in 2005 with Janie Heath, who was another board member who was doing her dissertation on this, and Wanda Johanson who was the C E O at a C n. And we found that everything falls into those six standards. I did my dissertation looking at leadership, communication, collaboration, and its impact on a risk adjusted length of stay, risk adjusted outcomes, central line infections and nurses intent to leave. It's not rocket science to know the better communication collaboration, RN to RN and RN to md, the better the patient outcomes and the better the nurses view their leadership, the lower the intent to leave.

That has changed a bit with this current generation because many of them are not committing to anything more than two years in advance. But I think those things really invest in leadership development because we take clinicians, we move them into a leadership spot many times for their clinical expertise, and if we don't give them that leadership training, then they don't know how to deal with conflict resolution with that difficult employee that you really have to stay on because the rest of the employees are watching. If you don't do anything inaction an action. So not dealing with that problem employee who brings down the work environment. I worked 12 hour shifts with somebody whose personality was up and down and when she was in a bad mood, we all kind of hid out in our rooms because it was just a horrible work environment. So making sure we deal with it, staffing is mine to own and really trying to bring in more people, trying to retain people is really helping.

But I also looked at before we had the acuity system that we're implementing across the house that really does pick the acuity that the patient needs. We built some one-to-one criteria because we staff by minimum ratios in California, but we also have to have an acuity system. So we have two laws that are in opposition and we staff by acuity unless it falls below the ratio. But I created, and I haven't seen anything like this nor is a document with the frontline staff to identify who are those one-to-one patients. At first we sat down and they said, oh, somebody on C R T, no, somebody on C R R T alone that's stable is not driving 24 hours of care. So we actually put some if then statements if they have this and this. And we created a really good document that I had to with nurses from all over the system, four hospitals, mostly two hospitals.

I was at Harbor U C L A at the time, so the majority of that was driven by some nurses in the ICUs there. And then I had to bring it to the C e O group and add the C e O group buy off on it. So I brought it to all of D H SS leadership. I said, okay, this makes sense. There were a few things that were controversial like the end of life when we're actually doing organ donation. There's a lot of work that goes into preparing those, but it's a lot of work on the nurse and people were saying, but this patient is at end of life, but they're also trying to give the lungs and the heart and there's different places that need different labs and different vent settings and you have to add drips sometimes. So we were able to come up with a document that is pretty solid and every nurse I've shown outside of our hospitals has said, this is really great.

But it really was driving 24 hours of care, those patients that were one-to-one, but that was staff driven. There was a couple of CNSs that helped with that group. They did it all on teams from the different hospitals and they came up with a pretty solid document that when I presented it to the CNOs, they made a couple of tweaks. But when I presented it to the D H S leadership and the CEOs, they were all okay with it. But that was something that if they didn't come out as 24 hours of care in the acuity system, this would help drive it. ECMO patients, I mean ECMO patients, their acuity systems can only give you 24 hours of care. Well, you have to have somebody to run the pump and somebody to take care of the patient. So now we have the data and we've incorporated into our acuity system as something that you can tag and actually make somebody a one-to-one when they're 17 hours of care, maybe because you know something's going to happen or somebody who goes to surgery and they're going to come back post-op cardiacs. They may be in the cardiac I C U once they go to surgery and then those first eight hours of care, there's a lot of work to be done. So that was something for staffing as far as leadership, getting the leadership, the training that they need, and then communication, collaboration, there's so many other things we can do. So that was a long-winded answer I know, but I live and breathe healthy work environments.

Dani:

Yes, you do. And I was listening and trying to take some mental note of things that were sticking out to me. One that stuck out to me that you said inaction is action. I fundamentally believe that it is a form of action if you aren't choosing to make a decision. Leadership development was key and critical is what you were mentioning. And taking a nurse that moves from a clinical space into a leadership space needs training and support around communication and how to handle critical conversations to deal with the teams that they manage. And as you said, looking at your teams and managing up high performers, don't farewell when there are low performers, dragging down the culture and being able to address that and change culture. And then you went into patient acuity, which is one of my passions and one of the most complex things I've ever studied in that there isn't a gold standard across the states or even the country, and it can be pretty subjective, but what I liked hearing is that you were taking your technology, the input of your frontline staff and continuing to enhance how to define patient acuity.

You're absolutely right. End of life wouldn't seem like it would be a lot of work, but there are things as you mentioned that go into it that require the skill and effort of a nurse ECMO patients and how to define care there. And so what you mentioned I think are some really key takeaways that our listeners can latch onto for healthy work and think about how to transform that for their places of work. I want to talk some more around innovation. What are some type of innovations that you are starting to see and some of the efforts people are making and talking about it and maybe what are some things that aren't being talked about but need to be talked about for the profession of nursing and innovation?

Nancy:

My new quote is, I don't know what our work environment and our staffing model will look like or our care model will look like in the future, but it has to be different. We can't afford to continue to pay nurses high salaries when they are not working at top of license. It's not innovative, but I became a nurse in 1980. I remember the full team model, I don't want to go back to that, but allowing other team members. I think at one point in time we said we have to give the bath, we have to draw the blood, we have to do well. We have to allow the lab to draw the blood, and we have to have the support staff to do that. We have to allow nurses to work at top of license. So when you talk innovation, speaking to the union to talk about some of the grants that the state of California are giving to look at different ways of providing care that may be different than our laws, that might be something that we can work on together to figure out what a new model of care looks like to make sure nurses can work up top of license.

Because when they're doing the day-to-day care, and unfortunately here we're struggling hiring nursing at attendants because one of my staff sent me a picture going into Panda Express Cooks make $28 an hour, nursing attendance don't make that much. And they said, no wonder we're struggling. So making sure we have the support staff, making sure we have secretaries at the desk and the nurses aren't trying to answer the phone, making sure we have that appropriate support, but what kind of innovative models can we do differently where the nurse can do the assessment, the nurse can provide the care. Are there things other people can do? And I know nurses struggle giving that away and delegating, although there's a really good algorithm in N L N when I was teaching the undergrads at U C L A, I would show them this delegation model on how to delegate and what you're responsible to make sure when you delegate, but are there things other people can do was interesting.

During the pandemic, we had military teams with us and the corpsmen that we had working in our emergency department could do a lot more than we allowed them to do. But when we talked about drawing blood, starting IVs, putting in Foleys, putting in NG tubes, some of those things are forbidden in the state of California to be done by anyone but a nurse. And we really need to look at how we can do things differently. And like I said, I give that as a good example because some of those people challenge the L V N exam and then they do some training to be L V N to rn, but we had some great corpsman, which really saved us in transporting and just doing some of the basic things. So looking at what we can do to have that non-nurse and what they can do to help us do non-nursing tasks.

Dani:

You bring up a good point about delegation, and I would love to know the model from U C L A. I was like, man, I need to re-study that because even as a leader you can learn how do I delegate appropriately? What you were mentioning too is delegation, but also probably a little bit of the conflict with the state laws. And then ultimately the goal is top of licensure work for nursing. And you mentioned you won't get innovation or the type of innovation that I think we need without top of licensure working and being open to transformation around past practices that really asking the question, does this require an RN license or can we delegate out and open up this sphere of different support staff and music to my ears, man, the amount of phone calls that you take as a nurse on a unit answering those phones. So just getting the support staff of a secretary or someone to handle calls is critical and really an impactful way, influencing and helping the work of the frontline to do the things that we're called to do, which is caring for patients. Nancy, this has been a wonderful conversation. I would love to know where our listeners can find you.

Nancy:

Well, I am at nBlake@dhs.la county.gov. I'm on LinkedIn. I'm willing to talk to anyone. I think with 43 years as a nurse comes some wisdom. 40 of those years in leadership. And I know as a new manager I wanted to do well and learned pretty quickly that the ones that challenged me the most were my friends. So promoting from within your department sometimes is a problem, even though I left for a year and came back, but just the amount of trial and error, I failed. Absolutely. But you have to admit, I made the wrong decision and really take ownership when you make the wrong decision and move forward. And like I said, staff will trust you if you become defensive, it's not going to work. But I'm happy to talk to anybody. I really think those of us that have been around and have done a lot of things need to be available for those that are coming in because they're our future. And someday I'm hoping to get to Italy and cruise down the Italian coast and that I'm hoping that someone can jump right into this seat when I'm gone and I have to help my staff get to that point. So when it's time for me to retire, we've got two or three people that are ready to step in. So thank you so much for having me. I really appreciate it and I really think that we have to make ourselves available for the up and comers, a rising stars that are going to take our place.

Dani:

My pleasure. This was a wonderful conversation and I want to say thank you for your years of service and the transformation that you're bringing in. The way that you are building up the next generation to lead is so critical. And we look at the literature and we see the workforce. Are they going to stay, are they not? That's been a big conversation piece. But with leaders like yourself, I have hope for the future that we are being trained well. We can gain insight and knowledge from the wisdom of those that have gone before and continue to build on the legacy that you have so diligently spent your career putting into investing into. So thank you Nancy. I really appreciate the time and can't wait for some of the final touches that you put on your career. So we'll check back in before you are cruising to Italy.

Nancy:

Okay. Thank you so much.

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