The trajectory of a partnership between CMOs and CNOs can range from a “dyad partnership” to a “business partnership” and, finally, a “strategic partnership.” The key characteristics of a strong partnership at all of these levels include alignment of mission, vision, values, strategy, and culture; co-leadership of overall performance; and inter-organizational relationships.
Professional Silos and Power Dynamics
Nurses and physicians have a rich history of collaboration and have fostered the evolution of our present-day healthcare delivery system. The relationship has a foundation in what some may describe as a hierarchy. As our system has evolved, so have the CNO and CMO roles. Their unique experiences and backgrounds as executives affect their perspectives.
Fostering the path of a strong partnership requires acknowledging the hazard of professional silos and power dynamics that can undermine the partnership. A phenomenal opportunity exists to bring diverse and vibrant perspectives together to accurately reflect our diverse and dynamic workforce.
Ideas to consider for building a healthy foundation include:
Engage in shared strategic planning.
Use synergy as strategy. This allows for shared decision-making and connection.
Remove titles when addressing one another. You are now in an interdependent role.
Ensure equity in conversation by seeking your peer’s perspective.
Be intentional in discussing the natural hierarchy that may exist between physicians and nurses and make a plan for creating a safe space to share feedback when discussions occur. Model the behavior with your direct reports.
Create an equitable foundation and a safe culture. Share this goal with the executive team and CEO for accountability.
Assume positive intent.
Partnering Intelligence
While the CMO and CNO have mutually beneficial objectives, they may still have competing priorities. To be successful, this partnership requires the highest level of emotional intelligence, with each leader committed to building trust and respect.
A CMO’s success depends on setting goals while sustaining a healthy partnership with the CNO. The process of building and cultivating a leadership dyad requires a high level of intentionality. It goes well beyond the “what” you do and expands into the realm of the “how” you do it.
Some strategies to consider for partnering intelligence include:
Cultivate trust and honesty through open, honest, and direct communication.
Spend time building the relationship. Be intentional with standing meetings and agendas.
Prepare one another in advance for difficult meetings. No one likes surprises.
Present as a united front. Be a united voice. Be diligent to lead jointly.
Sit in physical proximity in meetings and be conscious to defer to one another for support.
Self-disclose and provide and seek feedback.
Establish a foundation of alignment that others can clearly perceive.
Always consider the other side of the conversation.
Approach the relationship with authentic and genuine interest.
Remember that you cannot be transformational if you are transactional.
Show deference for expertise. The CNO and CMO have varying skill sets, which can be quite powerful when combined. Acknowledge and leverage the various expertise.
Have a future orientation. It is easy to get caught in the weeds. Stay heads up, looking forward together.
Consider all messaging and campaigns. Leverage opportunities to co-sign and co-lead.
Don’t be afraid to make mistakes. Support each other, even in failure.
In Your First Ninety Days
This section offers recommendations for CMOs new to their role, whether they were promoted from within the organization or newly hired into an organization. For veteran CMOs who find themselves struggling to harness the power of the dyad leadership structure, these steps may be a good starting point for a relationship reset.
Schedule a meeting with the CNO. Make this a priority within the first week. Consider making it less formal, non-transactional. Plan for the relational element you hope to achieve. Is it developing trust? Is it to learn more about your peer? What specifically do you want the person to feel at the end of the meeting? If this is a new relationship, be sure to emphasize that this meeting was one of your highest priorities because you see this relationship as integral to your shared success. If you are doing a reset, let the CNO know you are invested in changing the dynamics, and this meeting is the first step.
Find common ground and use your collective wisdom to build trust.
Define a regular cadence of 1:1 meetings and define more casual methods of connecting. These are preferences but can become problems if you don’t take the time to understand them. Are “drive-by” meetings ok? Texts? Early morning calls?
Take the time to understand the CNO’s top challenges. What elements are keeping the CNO up at night, and how can you partner to help? Seek an opportunity for an early shared win.
Meet with the medical staff together and share the expectations for the partnership.
Schedule rounding together in clinical departments.
Ask to attend a nursing leadership meeting.
This relationship matters to others in the organization as well. Organizational leaders are watching and want to see alignment.
Clinical Partnership
Quality is a strategic imperative for every healthcare organization. The dyad partnership between the CMO and CNO plays a critical role in developing the organizational capacity to realize this imperative. A strong clinical partnership is necessary to foster an environment of high reliability. Specific strategies that high-performing partners use to elevate quality and safety across the organization include:
Facilitate collaborative and intentional rounds in clinical areas focused on clinical outcomes. This is an opportunity to coach and add accountability.
Establish a shared vision for quality and safety — one expectation for all, regardless of position.
Participate in the onboarding of front team members and providers.
Celebrate the wins together.
Implement cross-functional support and collaboration to develop a robust root cause analysis process. This requires a high level of engagement of the dyad partnership for follow-up and accountability.
Develop a harmonized approach to peer review, which has historically been very siloed.
Work together to amplify the voice of the clinical teams by encouraging safety reporting while fostering a culture where all reports are addressed in a timely fashion.
Create a burning platform that you both can use to galvanize the clinical teams toward reaching the shared goal of exceptional patient care.
Be consistent in your deference to operations; go together to see and understand.
Initiatives are not made without consultation and collaboration. What may seem like a “slight” change in clinical practice can have dramatic implications. Engage your CNO partner early if there are changes in clinical workflows, programs, products, or processes.
Commentary by Rex Hoffman, MD, MBA
Nicole Beeson describes multiple tactics that are important in strengthening the CMO/CNO partnership. I am a fortunate CMO who has benefitted from having such a collaborative relationship with my CNO.
Having my office next to hers and being on speed dial makes us accessible to each other throughout the day. In addition, our relationship is one built upon mutual respect and a genuine interest in wanting the other to be successful. The success of the entire senior leadership team is greatly influenced by the CNO/CMO relationship.
With both of us committed to sustaining our hospital as a highly reliable organization, we share common goals and often find ourselves in lockstep when it comes to multiple initiatives, such as readmissions, hospital-acquired infections, and patient satisfaction.
To those who work with us locally or from afar, it is clear that we are working in unison and have each other’s back. On occasion, when physicians and nurses don’t see eye-to-eye, the two of us listen, gather information, and then seek out a compromise effective for both sides.
Our Evolving Relationship
To date, we have both been in our respective roles since January 2019. Not surprisingly, our relationship has evolved over time, which I will place into three buckets: pre-COVID, during COVID, and today.
Pre-COVID
Pre-COVID corresponded with our first year working together. During this time, we made a concentrated effort to attend each other’s meetings. We shared several priorities, which included avoiding hospital-acquired infections, attaining and maintaining high patient satisfaction in the inpatient setting and emergency department, and managing the sepsis patient population as efficiently and effectively as possible.
To address hospital-acquired infections such as CLABSIs [central line bloodstream infections] and CAUTIs [catheter-associated urinary tract infections], we worked together to establish multidisciplinary task forces, which included a nursing representative and a physician champion. Through such work, we were able to significantly decrease and nearly eliminate the number of such infections on our campus. Albeit rare, when such an infection does occur, rather than blame, there is an eagerness to seek out the root cause, with our two representatives leading the charge.
Tackling sepsis, we created a dyad model multidisciplinary task force led by a sepsis nurse navigator and a physician champion. With this patient population being a high priority, the Chief Nursing Officer and I were very engaged in this work. Whenever there was a meeting, whether at the hospital or system level, we both attended and participated in the discussion.
In the past, there were challenges with our physician champion and a new sepsis nurse navigator. Subsequently, both of us got involved—me with the physician champion and the CNO with the nurse navigator. By listening and looking for common ground, we were able to create a strong working relationship between the physician and nurse. When our team met and surpassed our desired goal, we celebrated “the win” as a team.
A lot of factors go into achieving the desired “high” patient satisfaction scores. To achieve the scores, we promote the idea that everyone who comes in contact with the patient is respectful and compassionate. We both lead by example. If the score dips in a particular area of the hospital, we convene our physician and nurse leaders to conceptualize opportunities to improve. Consequently, patient experience at Providence Holy Cross has consistently been among the highest in the Providence Health System.
Another area that we both saw an opportunity to improve was our medication reconciliation process. Physicians and nurses appeared to be confused with their role accountability. Subsequently, the CNO and I collaborated to identify leaders from the nursing team and medical staff, respectively, to take lead roles in this endeavor. With all of us working together, including the pharmacy department, we were able to clearly delineate who was responsible for each component of this process, which ultimately improved at our hospital.
During COVID
During the COVID-19 pandemic, it was important for us to have a cohesive multidisciplinary approach where everyone collaborated. We understood that the rapidly changing environment would require intense research and prompt policy development.
With a vast amount of information changing daily, neither one of us could analyze everything, so we sorted through the information together to ensure that we were delegating the information to the most appropriate task force.
Whether it was determining where to establish a COVID unit in the hospital, assemble a tent in the parking lot, or promote the appropriate use of PPE and therapy, each scenario benefitted from physicians and nurses working together.
At Providence Holy Cross, I, as the CMO, chaired the COVID Clinical Task Force, on which the CNO played a prominent role, and the CNO chaired the Incident Command Center/Operations Committee, on which I played a prominent role.
Exhibiting that the CMO and CNO can collaborate so effectively exemplifies how the physicians and nurses working toward a common goal will be successful. Navigating our hospital’s response to COVID-19 and relying on our relationships were key in attending to our 194 hospitalized COVI- positive patients in our 377-bed facility.
Here and Now
Today, as COVID appears to be leveling off, our priorities continue to evolve; however, our relationship is as strong as ever. Two recent initiatives continue to benefit from our close working relationship: addressing length of stay and congestive heart failure.
We are both engaged whenever there is a meeting on one of these topics. If one of us is unable to attend, we make sure that we designate someone to represent us, since we both recognize the importance of these two initiatives.
Length of stay is multifactorial, with a significant physician and nursing component. Together, we review the continuum of care from admission to discharge, looking for opportunities to improve the patient’s experience and ensure timely discharge. One area we are currently assessing is the span of time between when a discharge order is written and when the patient actually leaves the hospital. We have identified opportunities for improvement on both the physician and nursing sides and will work together to develop tactics to achieve our common goal.
Today, there is a system-wide initiative on congestive heart failure aimed at optimizing the continuum of care from pre-admit through the post-discharge visit. Because there are so many aspects of care throughout this continuum, we brought our physician and nursing experts to the table, with the CMO and CNO serving as executive sponsors of this work. Doing so ensures that we have influence, mutual respect, and a shared interest in getting this work done right!
The hospital runs more efficiently with the collaboration of nursing and medicine. Who better to lead this charge than the chief medical officer and chief nursing officer.
Given our respective roles as the lead physician and lead nurse, being on the same page has helped significantly with our ability to successfully navigate a variety of scenarios pre-COVID, during COVID, and in today’s environment.
Demonstrating that the CMO and CNO collaborate on a regular basis, whether in the hospital or in the community, has gone a long way toward conveying a solid working relationship. Who benefits? Our providers, our caregivers, our Chief Executive Officer, and most importantly, our patients.
Excerpted from The Chief Medical Officer’s Essential Guidebook, by Mark Olszyk, MD, MBA, CPE.