Leaders Create the Culture They Want:

The Importance of Cascading Behavior

in Leadership
Gregory Hair, MS, BSN, RN and Lawrence D. Fredendall, BS, MBA, PhD

This paper uses a simple leadership model to explain how an urban emergency
department (ED) used action plans to achieve dramatic sustained improvement in
multiple value dimensions in less than 2 years. The consistent use of action plans to
focus member attention on goals is a simple best practice that can be implemented
in all facilities.

ealth care organizations must constantly in- volume of 106,500 patients in 2019 and is both a Level 1

H
crease the value they provide their Adult
patients. The key to increasing value is
leaders who
engage others in this goal. Particularly when leaders
are managing professionals, such as nurses, in a
large urban emergency department (ED), the leader
must engage nurses at all levels. It is through
engagement of the nurses and nurse managers that
leaders can change the workplace culture and
increase value.
We use a simple model to explain a
leadership practice that was routinely used in the
ED of Prisma Health Greenville Memorial facility
to reduce costs almost 25% in less than 2 years
while simultaneously improving the patient
1
experience. We discuss the changes in terms of
value added in 3 key dimensions: clinical, operational,
2
and experiential. Clinical value was added by
improving patient outcomes. Opera- tional value was
increased by improving both cost and time
measures, and experiential value was increased via
an improved patient experience. Leadership is the
key to improving each of value dimensions.
To create successful change, the leader not only
needs a vision to improve all 3 value dimensions, but
also needs to simultaneously perform 3
leadership roles: adaptive, administrative, and
3
enabling. In their adaptive role, leaders help staff
adapt to the emerging dynamics and tensions that
inevitably arise in a busy ED. In the administrative
role, leaders plan and coor- dinate activities to
effectively meet the hospital’s goals. In their
enabling role, leaders facilitate the flow of
knowledge and help develop creative innovations.

ED ACCOMPLISHMENTS
The Greenville Memorial Emergency Department is
part of an Academic Medical Center in the Prisma
Health system that experienced a total patient

Trauma Center and Level 2 Pediatric
Trauma Center. In addition, this facility is
an accredited Chest Pain Center and
an accredited Comprehensive Stroke
Center. Our goal is to provide
compassionate, high- quality patient-
4 experience scores. The facility responded to
centered emergency care. It is part of a
large academic health center with 814
beds and an attached children’s hospital
5 KEY POINTS
with 183 beds.
All EDs are complex, challenging
environments and if staffing,
communication, and supply systems are not
fully functioning, each ED process becomes
more difficult, more time consuming, and
takes more effort to perform. In the third
quarter, 2017 staff vacancy was
35%, which means that knowledge
embedded in the staff about how to
perform critical tasks and the social
relationships that facilitate coordination
among staff were disappearing from the
www.nurseleader.com
6
unit. Nurse turnover (i.e., staff vacancy) also affects
the patient experience and increases costs. In
7
addition, low patient experience scores can affect
reimbursement as third-party pro- viders reduce
their reimbursement rates due to low patient
8
Providing a vision is an important function
of leaders.
Successful leaders create plans that
operationalize the vision.
Effective leaders provide clear, measurable
goals and ensure staff commitment to
achieving the goals.
Leaders must express confidence that plan
completion will achieve the vision.
The first step for change is to add value by
eliminating waste.
Month 2021 1
 50
Emergency Department Total Expenses (AWI) per APC RelaƟve Weight

45
WEight
40
RelaƟve
APC35
er Prisma Health Greenville Memorial
p Hospital
adj) Vizient AMCs and Major Teaching
2Q19
30
(25th)

(AWI Vizient AMCs and Major Teching

2Q19 (50th)
25
Vizient AMCs and Major
Teaching 2Q19 (75th)
Expense
20
Total

15
3Q 2017 4Q2017 1Q 2018 2Q 2018 3Q 2018 34Q 2018 1Q 2019 2Q 2019
AMC = Academic Medical Center

Figure 1. Emergency department total expenses (AWI) per APC relative weight.

the high staff vacancy by using overtime and 9

services. Ending 2Q 2019, Greenville Memorial
tempo- rary nurses. Overtime hours were 7.2% of ED had also improved the other 2 value
total hours worked. Also, expenses for temporary dimensions. Improved patient experience value was
nurses were high at the end of the second quarter measured by reduction in patient length of stay to
(2Q) 2018. Temporary staff ensures someone is discharge by
available to work, but their limited unit knowledge 23.3% and a reduction in patient complaints
reduces productivity. Patients demonstrated frustration from
with the service by nearly 6% who left without being 1
1,074 in 2017 to 693 in 2019. Improvement in
1
seen (LWBS) in 2Q 2018. clinical value was shown by the reduction in the
A series of leadership actions led to significant fa- percentage of LWBS patients from 4.7% in October
cility improvements in all 3 key value 2018 to 0.9% in
dimensions: clinical, operational, and experiential. August 2019.
1

Cost reductions are highlighted with a dashed line in

Figure 1. At the end of 2Q 2018, the total
expense per Ambulatory Payment Classification
(APC) code was $30.21, but was only $22.72 at
the end of 2Q 2019. In this same time period, the
median of comparable Vizient ED facilities
(AMCs/Major Teaching) increased from
$31.60 to $32.54 (3% increase), whereas this facility
1
had a 24.8% reduction. The APC is the
weighted adjusted index payment rate established by
the Centers for Medicare & Medicaid Services to
pay for outpatient
LEADERSHIP PRACTICES
Atom of Work
As stated above, successful change requires more
from the leader than a vision. A simple four stage
leadership model called the Atom of Work (Figure
2) is used to explain how the leader performs
their adaptive, administrative and enabling roles to
facilitate the needed changes. The model is a
compilation of both research findings and empirical
10
experience about how leaders structure their
communication to direct others’actions towards
achieving goals. Every

Figure 2. Atom of work.

2 Month 2021 www.nurseleader.com
 Table 1. Example of Action Plan (3/13/2018)
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Completion Date/Barrier
Action Item Target Time Responsible to Complete

Goal 1: Adequate Subgoal: Increase Discuss agency overtime February DON/NM March
staffing to awareness costs with unit CN,
reduce temporary of temporary RN supervisors
staff staff overtime
Subgoal: Reduce Plan schedule to use all Biweekly NM Biweekly
overtime available resources (core
temporary RNs staff,
to zero (0) float RN), and OT to core
staff
Schedule maximum RNs Ongoing—pre-existing NM Complete—ongoing
allowed by budget per shift process monitoring
7 a.m. RN
9 a.m. RN
11 a.m. RN
7 p.m. RN
11 p.m. RN
1 a.m. RN
3 a.m. RN
Assign maximum number of Ongoing NM
RNs per shift & allow
staff to pick up any open
shifts
Stop prescheduling February NM March
temporary agency RN OT
Require prior approval from February CN Ongoing
DON for temporary RN OT
Require justification report Ongoing NM Biweekly
Month

for temporary OT in
biweekly reports

(continued on next page)

3
 Table 1. (continued)
4

Completion Date/Barrier
Action Item Target Time Responsible to Complete
Month

Goal 2: Support Clemson University Ongoing NMs/supervisors Completed/ongoing

Recruitment recruiting events
of RN staff
Support student practicum, NMs/team NMs/supervisors Ongoing—multiple
student residency Ongoing new hires
programs—recruit new throughout ED
hires from ED practicum and
externships
Investigate/find 4/1/2018 NM TBD
opportunities for ED NMs to
speak to Clemson and/or
other
local/regional nursing
schools senior nursing
students
Continue to review Ongoing NMs/supervisors Ongoing
applications/schedule
interview panels every
Thursday
Consider ENA conference TBD DON TBD
attendance using a
recruiting booth
Goal 3: Maximize a Biweekly meetings with Completed Educators, NMs, supervisors Ongoing
Orientation successful educators, preceptors, NM/
of new RN employee supervisor
orientation to
maximize
retention
www.nurseleader.co

New-grad residency Completed Educators, NMs, supervisors Ongoing

program dedicated to ED
(continued on next page)
 Table 1. (continued)
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Completion Date/Barrier
Action Item Target Time Responsible to Complete

Goal 4: Retention Maximize retention Flexible scheduling Ongoing NMs/supervisors Ongoing

of ED staff strategies
Staff meetings/ Completed DON/NMs Ongoing
communication
Supervisor employee Ongoing Supervisor Ongoing
rounding
Manager employee TBD Manager TBD
rounding
Active unit engagement; April Start Re-launch Manager Ongoing
unit council/PPC
Teambuilding events TBD DON/NMs/supervisors TBD
CN, charge nurse; DON, director of nursing; ENA, emergency nurses association; NM, nurse manager; OT, overtime; PPC, professional practice council; TBD, to be
determined.
Month
5
 1
interaction is an opportunity for the leader to 5.88%. There were 4 major goals, and
increase the effectiveness of work being performed. the first goal
Step 1 of the model is to “Prepare Clear, Specific (i.e., adequate staffing to reduce temporary
Goals,” staff) had 2 subgoals.
which is an administrative leadership role when the
goals in- crease value to the patient. Step 2 clarifies
whether the person who is responsible for
accomplishing a task and through interaction with
them (i.e., Negotiation) the leader helps staff
adapt and provides resources to overcome barriers
to task completion. By ending this Step with a promise
about what to do and when to finish, there is clear
communication about expecta- tions, which
operationalizes the leader enabling role. Step 3,
“Performance”, is when staff perform the promised
tasks. The leader performs an enabling role here by
asking staff to declare a task completed or
declare a breakdown as soon as it is clear they
cannot complete it. A breakdown may require
moving the conversation back to Steps 1 or 2.
Step 4, “Assess- ment”, requires the leader to
assess what was completed and to share their
satisfaction or lack of it with staff and for both the
leader and staff to evaluate their communication
effectiveness. At this stage the leader performs all
three roles of assisting adaptation, administratively
adjusting goals and enabling future action of staff
by recognizing their work.
The goal setting, performing, assessing cycle in
the atom of work is embedded in the “Action
Plan”used at this facility. Establishing leadership
routines is partic- ularly important when interacting
with many nurses and staff over extended periods
of time. Leadership routines provide structure
and reinforce learning. While the ED is open
24/7 with leaders present for a minimum of 50
hours a week, the typical acute care nurse works
three 12-hour shifts. While everyone has different
11
rates of learning and forgetting, there will be
significant forgetting between shifts, followed by
12
relearning on the next shift when the leader
follows- up on whether the desired work practice is
used. This means that implementing new work
practices requires extended leadership effort and
multiple interactions with staff to reinforce practices.
Creating change by using Action Plans creates a
leadership routine that facilitates learning and
ensures that new processes are not forgotten.

Action Plans
Although multiple actions were taken to make
the improvements described here, the action plan
to improve staffing efficiency in Table 1 was very
important. This action plan was implemented
to initially reduce and then eliminate the use of
tempo- rary nurses, and it reduced the percentage of
overtime hours worked to total hours worked
from 7.2% to

6 Month www.nurseleader.co
 This structure of this action plan implements Step 1 in the
“Atom of Work.”
Goals are clearly identified, along with who is responsible for
goal accomplishment. Discussion of goals during staff
meetings implements Step 2 in the Atom of Work. The clear
deadline date creates a promise to complete the action. Step 4
of the assessment is in the last column of the action plan. This
tool is effective in part because of goal setting. Research has
demonstrated that on average clear, specific goal setting
13
improves performance by one-half a standard deviation.
Specific goals have deadline dates and metrics, which focus
attention and effort to task completion and encourages
staff to fully use their relevant knowledge and skills. This
can motivate staff to expend extra effort to attain goals and to
14
persist even when goals are difficult to achieve. Skillful use
of action plans improves productivity and reduces
communication waste. By using the action plan, the leader
engages in all 3 leadership roles (adaptive, administrative, and
enabling) on a routine basis. It is important for the action plan
for the leader to make it a routine to prevent forgetting as
discussed above. Through routine use of action plans at
every staff meeting, the leader reinforces learning through
goal accomplishment.
ED nurses are competitive. They like clear, chal- lenging,
but achievable, goals. This has been found to increase
15
performance and generate sustained enthu- siasm. The
action plan in Table 1 demonstrates that the goal to reduce
temporary nursing costs is achiev- able by listing the subgoals
and activities required to accomplish it. During the Step 2
negotiation phase (Figure 2) about performing goal-related
activities, the leader helps staff adapt to a new way of
working. By discussing how to achieve the action item with
staff, the leader obtains buy-in, so there is a real commitment
to accomplishing the action item by the deadline. As staff
verbally commit to completing tasks by the deadline, they
will prioritize task completion.
By modeling this leadership approach through the use of an
action plan, the leader models behaviors for managers who
report directly, but this leadership behavior can cascade
through the ED as nurse man- agers and charge nurses learn
how to use action plans by themselves committing to and then
completing their assigned action items. These leaders can then
engage their own direct reports in developing and performing
action plans to meet their own subunit goals. The ac- tion plan
is a vehicle to improve communication and work in the
department. Further, as leaders practice achieving difficult
goals by first creating action plans, they are willing to accept
even more difficult goals than before. By routinely creating and
using action plans increased leadership capability cascades
through the unit and the culture begins to accept that they can
solve problems and increase patient value.

7 Month www.nurseleader.co
 The assessment step in Figure 2 immediately fol- to share goals clearly and help identify the steps
lows the performance phase. Performing the assess- to accomplish these goals? Do they get
ment is a critical leadership function. Managers commitments from staff to perform the goals? Do
undermine themselves when they do not hold they assess the results of efforts by the staff ? Is
staff accountable for performing assigned tasks. In there accountability present for action items? By
Table 1, the action plan column labeled routinely using these best practices, leaders empower
“Completion Date/ Barrier to Complete”refers to their staff to make major improvements in a short
assessment. To be effective, it is important that the period of time.
leader goes down the list of action items at the next
meeting, asking staff for progress reports. Routine
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routine use oftheaction
operationalize goal plans
settingsuch
and asfeedback
shown in Table
process
in1helps the leader management
the day-to-day stay focusedpractices
on theof larger
a large Gregory Hair, MS, BSN, RN, is Director of
ED.picture Nursing, Emergency Services, at PrismaHealth-Upstate
and ensure
those capablethatof the appropriate
performing tasks
them. are delegated
Table 1 also to Emergency
Trauma Center, Greenville Memorial Medical Campus, in
helps
the leader hold themselves accountable. Are they Greenville, South Carolina. He can be reached at
able
www.nurseleader.com Month 2021 7
 Gregory.Hair@PrismaHealth.org. Lawrence D. Fredendall, 1541-4612/2021/$ See front matter
BS, MBA, PhD, is Trevillian Distinguished Professor at Copyright 2021 by Elsevier Inc.
Clemson University in Clemson, South Carolina. All rights reserved.
https://doi.org/10.1016/j.mnl.2021.03.009

8 Month www.nurseleader.co