CMO-CNO partnerships can drive patient safety and quality

For Baylor Scott & White Health Chief Medical Officer Dr. Alex Arroliga and Chief Nursing Officer Janice Walker, having a close working relationship built on mutual respect, constant communication and shared goals and accountability before COVID-19 hit meant the system was better prepared to save lives and protect front-line nurses and doctors as the pandemic worsened.

During the peak of the pandemic, Arroliga and Walker—who lead under a CMO-CNO dyad at BSWH—were talking two to three times a day, making decisions that would affect patient care and employees at all of the system’s 51 hospitals. Without that leadership structure, BSWH’s COVID response might have seen “increased variability” that “could have promoted more harm, more fear and more chaos,” said Walker, who has been in her role for three years.

“And that’s not to be boastful. It comes out of a sense of how organized and orchestrated we became to protect our soldiers,” Walker said.

Over the years, studies have shown that poor communication and coordination between physicians and nurses—both at the leadership level and on the front lines—can have a harmful impact on everything from patient care to employee satisfaction and retention.

Their leadership efforts before and during the pandemic helped land Arroliga and Walker on Modern Healthcare’s list of the 50 Most Influential Clinical Executives.

A dyad—a team of two people operating as co-leaders of a system, hospital or other organization—isn’t a new phenomenon in healthcare, but more traditional dyads typically involve a CMO working with an administrative leader, like a CEO or chief operating officer, said Dr. Peter Angood, CEO of the American Association for Physician Leadership. The model has also been tried with varying degrees of success with two CEOs jointly running a hospital or health system.

Some organizations have gone a step further to form “triads,” with CMOs, CNOs and either a CEO or COO leading together.

Having a joint leadership approach can help meet goals around patient care, efficiency and costs, experts say, and break down traditional silos between nurses and doctors.

“It’s a natural fit to have them come together administratively in that dyad with their focus predominantly on safety, quality and efficiency of patient care, and less focused on finances and other administrative issues,” Angood said.

Benefits can include improved safety and quality of care, healthier cultures and relationships between clinical staff, nurses and physicians. BSWH said its culture of safety index improved 2.5% compared with the previous year.

“When those are working well—those dyad models—they certainly do improve safety, quality and efficiency, but it also trickles into the culture of the workplace on the clinical delivery side, and it makes it far more positive,” Angood said.

He added that CMO-CNO dyads are a natural fit for organizations where a high percentage of medical staff are employed by the institution rather than working in private practice with admitting privileges. Employed staff tend to be more invested in an organization’s goals.

A 2018 report published by the American Hospital Association argued that clinical partnering between physicians and nurses can help undo professional silos and power dynamics that get in the way of effective collaboration.

“Historically, we’ve been operating in silos, with medicine and one side and hospitals and nursing on one side with no alignment in making progress on quality and safety,” said Mo Kasti, CEO and founder of CTI Leadership, which helps train physician leaders.

“If (a dyad) is done right, it has many positive outcomes because there is better engagement, a feeling their voices are heard and that they are co-creating a business together.”

Leaders interviewed by the AHA about their CMO-CNO dyads claimed it had a “positive impact” on achieving goals, including excellence in patient care, increased performance metrics and staff engagement.

Leaders also cited better decision-making, higher job satisfaction, and an ability to implement changes more quickly.

For example, BSWH had to “completely rebuild” the employee health command center in response to the COVID-19 pandemic. “If we hadn’t taken that process by the reins as system leaders, each entity would have had to create their own employee health outreach and testing protocols, and we had 46,000-plus employees we had to protect,” Walker said.

Less than 1% of staff caring for COVID patients tested positive for the virus, according to BSWH.

Bringing in a CNO ensures nurses are always at the table for decisions that impact themselves and patients and it helps establish better collaboration and communication between nurses and physicians, who have had a historically tense relationship.

“The whole system realized these guys are working so closely and they’re understanding each other. When Janice is speaking, everyone knows she’s speaking on my behalf and vice versa,” Arroliga said. “When both of us are working together, the product we generate at the end is going to be better than what I would have generated by myself.”

It sends an important message to front-line workers that “in order to take care of a patient, you need a team—and the product is going to be better,” Arroliga added.

“We’re trying to make sure the front lines understand we need each other in order to create something better for our patients,” Walker said.

50 MOST INFLUENTIAL CLINICAL EXECUTIVES - 2021