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  1. Hader, Richard RN, CHE, CPHQ, NE-BC, PhD, FAAN

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The severe downturn in the economy is beginning to affect how we conduct the business of healthcare. An alarming number of Americans who are unemployed or underemployed and uninsured are filling our EDs because there's no other place for them to receive healthcare that's affordable. This is resulting in rising bad debt and charity care, which are shrinking hospital revenues at an unprecedented pace.

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Declining investment income and the need to allocate money into flailing pension funds have forced healthcare executives to redistribute money from hospital operations to long-term financial venues to ensure that the organization maintains solvency through difficult times. These changes in the economic climate are requiring all leaders to reexamine fiscal and human resources and make unpopular but necessary reallocations.


Nurse-executives are often held accountable for the largest part of the budget. It's unrealistic to believe that you won't be asked to carefully examine all expenditures and begin to develop a plan if it's necessary to make budgetary cuts to produce a responsible, positive, operating margin. There will be no immunity for any program or resource if it isn't an essential component of the strategic mission and plan of the organization.


We've long been taught to advocate for the needs of the nurse and the patient but it must be done in a collaborative, not adversarial, manner. Crucial management decisions will need to be made and nurse leaders should ensure they're at the table during these discussions. It's vital that nurse leaders be viewed by their colleagues as business partners and not perceived to be advocating within a nursing silo. Those who aren't skilled in the process of advocacy may be interpreted as being difficult and won't only lose the battle, but also hamper the appropriate allocation of resources for the entire nursing organization. Too much advocacy with minimal negotiation can be construed as not being a team player and will damage your professional reputation.


Be clear about your role as financial steward not only of your particular area of responsibility, but also of the organization in its entirety. The paradigm you must maintain is one that's inclusive of the entire institution. A team approach to meeting these financial challenges is an essential component for success. You'll need to spend a significant amount of time negotiating with your colleagues to develop strategies that will benefit nursing, as well as other operating departments. The use of management strategies will need to be employed to achieve the overall hospital objective.


In the mid-1990s, many hospitals reengineered their care delivery systems and eliminated the positions of thousands of healthcare providers. In most cases, this process failed because the focus was on the care delivery system (who was doing the work) rather than the model of care (how the care was delivered).


Nurse leaders and their operational colleagues will need to be careful not to repeat the failures of a decade ago by not spending time discussing the major tenets and values of care that can't be compromised. Leaders need to build from the foundation of core values and strategic mission and vision through vigorous negotiation. Do so, and the strategy for success will follow.


Richard Hader

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