answer questions based on the scenario.

Central Valley Hospital is a well-respected community hospital that provides a comprehensive array of medical and surgical services and maternal newborn services. The hospital has been recognized with Planetree and Magnet designations and is viewed in the community as one of the top hospitals for excellent services. Employees generally view the culture of the hospital as very positive, and management has implemented a multifocal strategy to enhance employee, physician, and patient satisfaction. The mission statement, values, and behavioral standards are posted openly where they can be seen by all, and every employee's performance expectations and performance appraisal include an evaluation of how that person lives the expected values and behavioral standards. The values include integrity, trust, honesty, professionalism, patient centeredness, and excellence.

Central Valley has an active quality department that reviews all patient and organizational outcomes and meets with department leaders to discuss ways of continually improving outcomes. There is significant emphasis on "excellence," and managers at all levels of the organization are evaluated on their ability not only to meet financial budget targets but also to meet various quality indicators and national benchmarks.

Reyna is a manager in a 32-bed general medical unit, and she has approximately 150 part-time and full-time employees who report to her. Reyna reports to the vice president of medical surgical services, who, in turn, reports to the chief nursing officer (CNO). Reyna has a Bachelor of Science degree in nursing and is currently in her second year of the graduate program in nursing with an emphasis on nursing administration. She has enjoyed her classes on leadership theories and their application in the healthcare setting, financial management, quality and program evaluation, and a practicum that focused on just culture, patient safety, and quality improvement using tools such as Lean and Six Sigma. Reyna tries to apply much of what she learns in the school setting to her daily work.

Every year Central Valley disseminates the results of the employee opinion, physician satisfaction, and patient satisfaction surveys to the management team. Feedback regarding the national benchmarking quality indicators such as NDNQI and CalNOC data is shared with the nursing management team. Reyna and her nurse manager colleagues appreciate the openness of the organization in sharing the results with them, but talking among themselves they realize how much stress is created when they receive results that do not meet expected standards. Reyna is faced with a decline in scores on the patient satisfaction, employee satisfaction, and culture of safety surveys. She attributes the decline of patient satisfaction to recent changes in the dietary department that have resulted in delays in tray delivery and a remodeling project on the unit that has created unexpected noise during the day.

She has also evaluated potential causes of the decline in employee satisfaction and identified a trend that has occurred annually with lower employee satisfaction scores during the months of July through October. During these months, the patient census and average patient acuity are higher than all other months in the year. Reyna does everything she can to ensure adequate staffing and to be visible and available to the staff more than usual during these times. She is surprised to see the decline in the culture of safety scores, and she begins to investigate potential reasons for the decline by talking with the staff to get their perspective on why they scored specific items so low. Reyna feels that she is held accountable for scores without being in control of all of the factors that cause staff and patients to score the surveys so low.

At a recent nursing leadership meeting, the directors announced that all managers who did not meet the targeted levels on the patient satisfaction, physician satisfaction, employee opinion, and the culture of safety surveys must prepare a report outlining their strategy to correct the problems and ensure that upcoming surveys demonstrate an improvement.

In her meeting with the director, the director is even more critical about Reyna's performance as a nurse manager in allowing these declines to occur. She tells Reyna that her performance is under scrutiny and that corrective actions need to be taken immediately to improve the scores; Reyna must demonstrate changes immediately on the unit to improve the situation. Needless to say, Reyna feels completely deflated at the end of the meeting and feels unfairly blamed and unsupported by her director. When she reflects back on her classes on just culture and leadership, she questions her director's approach with her. She feels that her director should do more to support her and give her encouragement and direction in improving the survey scores and in changing the potential causes of the problems that contribute to the dissatisfaction of staff and patients. When she discusses the situation with her colleagues, those who report to her same director experience the same concerns. Other managers with different directors indicate that their directors partner with them in identifying methods to continually improve scores on all quality indicators.

When Reyna reviews the items on the various surveys with her staff, she discovers that the staff do not have a clear understanding of the meaning of some of the questions. After discussing some of the items on both the employee opinion survey and the culture of safety survey, the staff inform her that they would have scored the items differently if they understood the meaning of the items. She begins to wonder whether patients felt the same way about their patient satisfaction survey or whether their overall satisfaction rate was unfairly weighted with their discontent with the noise factor and the late meal trays as contrasted to their overall level of satisfaction with their nursing care.

Reyna feels more frustrated than ever being held accountable for survey scores that contained items that are not in her control to change and improve. She also is frustrated with the attitude of her director, who seems to blame her for the scores and offers no insight or assistance in resolving the underlying problems that are reflected in the survey scores. Reyna feels powerless and victimized in the situation. As she prepares her report to submit strategies for improving the scores, she includes the discussions with her staff about their interpretation of the wording on some of the items and outlines how she and her staff would partner in improving the workplace environment to ultimately improve the survey scores. Reyna also includes the plans that she and her staff had developed together to enhance patient satisfaction. Reyna had met with the manager of the dietary department to negotiate a solution to prevent late tray delivery, which she believes is a major contributor to patient dissatisfaction. Despite her report and strategies to improve survey scores, Reyna dreads meeting with her director and feels that she could not trust her to evaluate her fairly or to manage her up to the CNO or other executives in the hospital. Reyna believes that her director is neither living the values of the hospital nor demonstrating the principles of just culture in blaming the managers rather than partnering with them to correct situations that contribute to lower survey scores.

Questions

1. How do you feel that the director's actions influenced the culture of her department and her nurse managers' work performance ?
2. If blame should be placed for the low survey scores on the patient satisfaction survey, the employee opinion survey, and the culture of safety survey, who should be blamed for the decline in scores?
3. If you were Reyna, what actions would you take to improve the scores on these three surveys?
4. If you were the director of the department, what might you do differently to facilitate improvement in the survey scores?
5. Managers are frequently held accountable for outcomes over which they do not have direct control. How can leaders influence managers in these situations to remain motivated and to continually improve the outcomes?