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Like every healthcare system today, the Cleveland Clinic health system is a combination of medical hospitals, institutes, and services in which the implementation of uniform care methodologies faces significant barriers. Although today’s Cleveland Clinic health system (CChs), henceforth called the Cleveland Clinic, has a long heritage of being patient focused, it faces the same challenges that other health systems do in implementing PFCC.
The Stanley Shalom Zielony Institute of Nursing Excellence (the Nursing Institute) is responsible for raising the quality of nursing care at the Cleveland Clinic. There is no universal definition of PFCC because the definition changes with the context in which it’s being used. However, a single, simple description of patient- and family-centered care may not suit the needs of a complex health system. Health systems like the Cleveland Clinic are faced with trying to encourage better patient- and family-centered care while knowing that each decentralized location (and even each unique unit within a location) will have a slightly different view on exactly what PFCC means to their patients.
A health system like the Cleveland Clinic faces at least three major barriers when trying to implement uniform PFCC practices.
Although it may be unnecessary to agree on a detailed definition of patient- and family-centered care, health systems do need to implement uniform best practices as quickly as possible if they're going to deliver consistent PFCC. The Cleveland Clinic is a merged system, consisting of 11 hospitals in northeast Ohio, of which 10 were existing hospitals that joined the original Cleveland Clinic hospital through acquisition or joint operating agreements. Cleveland Clinic currently has numerous technologies and policies that are unique to specific areas, most of which are in the process of being standardized. Nurses perform a variety of roles; yet existing health system practice models are often focused on a single role, namely that of the bedside nurse in a hospital setting. Successful implementation of PFCC requires more than just standardized models, policies, and procedures that tell nurses how to apply their knowledge and skills; it also requires managers to motivate nurses to apply them vigorously. The Cleveland Clinic has recognized that nursing engagement is crucial for successful implementation of PFCC and measures this experience with the Gallup Organization’s Employee Engagement Scores (Gallup®, 2011). Nurses across the system wanted to have their roles better defined and to be more empowered so as to deliver better care. Initially the ACNO of Clinical Practice, (Deborah Small, first author of this article), conducted a comprehensive review of nursing across the system. The first step in development of the model was the establishment of a steering committee that consisted of key stakeholders representing each hospital and service. Inquiries were made of other hospitals and systems regarding their nursing practice models so as to enhance our knowledge base and establish a common understanding for further development of our model. Next the current nursing care delivery process was mapped out, including accepted definitions, expected competencies, practice environments, and levels of care. The nursing and management literature was reviewed to determine the best theoretical framework for the nursing practice model.
The primary objective of a nursing practice model needs to be communicating a shared vision that helps nurses manage changes in their practice and maintain their patient focus.
Understanding the serving leader concept helps nurses guide patients in directing their own care.
Nurses are frequently reminded of the patient’s expectations of their nurses, namely: ‘Don’t hurt me.
Both research and experience have shown that care by nurses and other staff members is an important determinant of patients’ evaluation of overall quality of care, willingness to recommend, and willingness to return (Otani, 2010).
Once the basic content of the models as described above had been identified, the Cleveland Clinic Marketing and Communications Department, along with an outside marketing and program development expert (the second author of this article) were enlisted to help organize and refine the concepts and aid in developing visual representations, tools, and presentations.
The launch materials increased nurse engagement by relating the Nursing Institute’s motto of ‘Delivering on the promise of World Class Care’ back to the reasons people undertake the difficulties, long hours, and extreme stress of a nursing career. The program was launched to 500 Cleveland Clinic Nurse Managers at the annual leadership retreat on October 5, 2010, as the ‘Colleagues in Care Nursing Practice Model’ using a PowerPoint presentation that focused nurses on feeding their passion for nursing through implementation of the model. Nurses are the biggest factor in getting patients to feel that they have received patient- and family-centered care. Patients understand and respond positively when nurses are engaged, understand their role, and are passionate about their career.
The nursing practice model and its supporting materials give a unified approach to nursing at the Cleveland Clinic and help nurses feel like they are part of a unified team delivering the world's best care.
An important part of the Nursing Institute’s efforts is to allow all nurses to fulfill their passion for nursing. Committee on the Robert Wood Johnson Foundation Initiative on the Future of Nursing, at the Institute of Medicine.
Related ArticlesApplication of a Marketing Concept to Patient-Centered Care: Co-Producing Health With Heart Failure PatientsRobert P. The guiding principle of the Cleveland Clinic, ‘Patients First,’ focuses on the principle of patient- and family-centered care (PFCC) but deliberately lacks details due to the wide scope of care delivered by the organization.
Engaging the Hearts and Minds of Nurses with a Patient-Centered Practice Model" OJIN: The Online Journal of Issues in Nursing Vol. The Cleveland Clinic, like every healthcare system today, is a complex combination of medical hospitals, institutes, and services where existing technologies and conflicting priorities can create significant barriers to standardizing care quality. It has adopted the motto ‘Delivering on the promise of World Class Care’ in recognition of its mandate.
Organizational managers who are trying to implement patient- and family-centered care strategies will quickly face the problem of defining PFCC within their organization, the hardest problem for every organization working to implement PFCC. For example, family practice, cancer care, and acute care all have multiple articles with slightly different definitions relevant to their particular research issues. Even the smallest modern health system is a collection of diverse services that can include acute care in urban and rural settings, inpatient care, urgent care, trauma care, home health care, and hospice care. With over 2,000 employed doctors, 11,000 registered nurses (RNs), and more than 800 advanced practice nurses (APNs), plus 30,000 other employees spread over several continents, a restrictive definition of patient- and family-centered care for the entire Cleveland Clinic may prevent some patients from actually receiving PFCC.
Waiting for existing technologies at the different units of a health system to be standardized can significantly slow down the implementation of consistent PFCC policies. In addition, there are many offsite care delivery facilities and support operations in northeast Ohio, such as home health and ambulatory surgery centers. A nursing practice model needs to give guidance that will help nurses perform in a variety of roles, from direct caregiver to central coordinator of care to supporting team member in any of the multiple facilities. This review included a gap analysis, benchmarking of nursing metrics, and interviews with nurses and nurse leaders. An assessment of the existing state of nursing across the system was used to develop ‘guiding principles’ for the model that supported the vision, core values, and guiding principles of the Cleveland Clinic and the Nursing Institute (Figure 1). Physician input was received from the Chair of Patient Safety, the Chair of Regional Quality, and the Chair of the Office of Patient Experience, among others. It was determined that existing nursing care models, even patient-centered ones, were too specific and task-oriented to adequately encompass the issues facing a complex health system. One theorist, Senge (2006), in his 1990 book The Fifth Discipline, The Art & Practice of the Learning Organization, provided an understanding of the purpose of the model from a management viewpoint and explained how the model could be used to build a shared vision with staff nurses. The shared vision of the Cleveland Clinic nursing practice model was based on three concepts, namely serving leader, relationship-based care, and thinking in action. The most important aspect of developing a practice model for nurses was clarifying and simplifying the role of individual caregivers.
The first domain, Quality and Patient Safety, is at the forefront of the Cleveland Clinic’s care delivery. Nurses at Cleveland Clinic have access to a comprehensive ‘dashboard’ showing these quality measures, an important part of the Clinic’s ongoing commitment to excellent outcomes, data transparency, and public reporting. More than 150 years ago Florence Nightingale noted the importance of the environment in her book Notes on Nursing (Nightingale, 1860).
Research and evidence-based practice were combined into one domain as they are integrated and intertwined at the Cleveland Clinic.



The Cleveland Clinic already had in use a number of visual logos, symbols, and themes that the CChs Practice Model Steering Committee wanted to maintain. The Nursing Institute used the Cleveland Clinic Hand Holding a Globe image (Figure 1a) and the theme of ‘Delivering on the promise of World Class Care’ to symbolize the goals of nursing at the Cleveland Clinic. Centering the Patients First guiding principle in the hand holding globe image was unanimously accepted as a starting point for the practice model imagery. To help nurses understand how the practice model works in the real world, a visual image of how care would be delivered using the practice model was developed and titled Colleagues in Care Delivery (Figure 3a). The final piece needed to make the practice model usable in the real world was the development of a tool that would help nurses and nurse managers implement the model.
The completed model and support materials were comprehensive but lacked a ‘hook’ that would encourage world-class performance by engaging the ‘hearts and minds’ of nurses. The main focus of the rollout program consists of mandatory training sessions for every nurse and the assignment of champions to role model execution of the model. This success will be measured by tracking improvements in Hospital Consumer Assessment of Healthcare Providers and System (HCAHPS) scores of patient’s perceptions of care.
Small is the Chief Nursing Officer for Cleveland Clinic health system (CChs), Fairview and Lakewood Hospitals.
Small contributed his marketing and program design expertise in developing the CChs Nursing Practice Model and the related support materials.
The Stanley Shalom Zielony Institute of Nursing Excellence (the Nursing Institute) at the Cleveland Clinic was charged with standardizing nursing practice across a system with 11,000 registered nurses and 800 advanced practice nurses. The leadership of the Nursing Institute recognized the need for a systemwide nursing practice model to guide nurses in achieving the Cleveland Clinic vision and demonstrated the commitment of nursing leadership to PFCC. Since the Institute of Medicine (IOM) identified ‘patient-centered’ care as one of the six keys for quality improvement in health systems in its 2001 report, Crossing the Quality Chasm, there has been a burst of publications trying to clarify what patient-centered care is and how it can be implemented. The Institute for Patient- and Family-Centered Care (2010) has published a simple definition that identifies four core concepts, namely respect and dignity, information sharing, participation, and collaboration, as being essential for PFCC. Robinson, Callister, Berry, and Dearing (2008) identified four distinct definitions of patient-centered care depending on one’s focus, specifically: public policy, economics, clinical practice, and patient care. After completing a large study of patient ratings of their hospital experiences, Otani (2010) concluded that patient ratings of nursing care have the most direct impact on ratings of overall quality of care and services. Hence the Cleveland Clinic has established ‘Patients First’ as a guiding principle designed to communicate the need for patient- and family-centered to every employee.
Because these barriers are not unique to the Cleveland Clinic, a detailed discussion is provided below. Many health systems have grown through mergers and acquisitions and face the cost and delays of standardizing policies across significantly different technologies. There are also hospitals and operations in other states and countries where nursing practice needs to be guided by a nursing practice model.
Implementation must be done via paper and the Internet, supported by onsite training, ongoing education, and role modeling. An Institute of Healthcare Improvement Innovation Series white paper by Balik, Conway, Zipperer, and Watson (2011) identified the engagement of the ‘hearts and minds’ of the staff in the shared values of PFCC as one of five key drivers for exceptional PFCC.
Increases in nursing engagement scores have been shown to have a greater effect on patient outcomes than increases in nurse staffing (measured as the ratio of the number of nurses to total patient days) (Blizzard, 2005). Rather the model needed to reflect the concerns and needs of the nurse and the Institute as well as the patient.
Senge’s work on the learning organization gives significant insight into the operation of a modern health system. Although almost every nurse acts as a leader in some manner, this role is often hard to understand in a patient-centered environment. This required not only defining the relationship between patients, families, and other team members, but also identifying how the nurse should attempt to deliver care and support. The diverse care needs of the patient population at the Cleveland Clinic meant that the nursing practice model could act as no more than a general guide to care delivery. Be nice to me.’ The Framework of Care was a sound foundation for nursing practice but it did not cover all the things that nurses must know and do to be useful and grow in a rapidly changing environment. Today we see a growing body of research that clearly demonstrates the benefits of a healing environment. There is a specific Department of Nursing Research and Innovation reflecting the reality that research is a component that can lead to significant innovation in evidence-based practice (French, 2002). Additionally there are many opportunities for advanced education that will lead to improved patient care, career advancement, and personal satisfaction. Because the nursing practice model is one of the most important tools in focusing efforts on achieving this promise, it had to reinforce this theme as well as the Cleveland Clinic’s guiding principle of Patients First.
Various layouts and wording were developed, reviewed, and revised to clarify the concept of a shared vision for the four domains of the Framework of Care.
This model symbolizes the Cleveland Clinic's shared vision of Patients First by visually centering the RN and care delivery team in the patient. The nursing care delivery process that had been detailed previously (see Figure 2) was simplified into a standard care pathway that included seven major steps in care, along with specific reminders of critical policies (Figure 4a). Such a hook was particularly important in-order-to launch a program requiring active participation because nurses can become actively disengaged or suffer from what is called ‘compassion burnout’ (Douglas, 2011) where they merely go through the motions of delivering care. She has also served as the Associate Chief Nursing Officer for Clinical Practice and Research for the Cleveland Clinic health system.
He has over 30 years of experience in marketing and strategic planning as a brand manager and marketing executive, and is an expert in the design and use of customer surveys.
The serving leader: 5 powerful actions that will transform your team, your business, and your community. Nightingale knew more than she thought - Environment as a phenomenon in nursing: Reflections from nurse theorists.
The challenge involved providing firm direction on delivering PFCC that was appropriate for all clinical disciplines and could be implemented quickly across existing practices and technologies. In this article we will identify the essence of PFCC, consider barriers to PFCC, review the process of developing a PFCC-based nursing practice model, and describe how the Cleveland Clinic health system has implemented a nursing practice model of PFCC. A search of MEDLINE literature shows 7,103 citations of the term ‘patient-centered care’ of which 5,046 (71%) were published after 2001. They concluded that regardless of your specific definition, the basic measuring stick of PFCC is the patient’s perception of whether he or she has received patient-centered care. In this study Otani evaluated the admission process, nursing care, physician care, staff care, food, and room, and concluded that a bad nursing experience had a disproportionate negative result on quality perceptions. This principle guides the thinking of the managers of the institutes, specialized hospitals, and outpatient facilities which are expected to develop appropriate policies and procedures to handle the unique issues within their facility so that they deliver the world-class care that is the Cleveland Clinic’s reason for being. Another key driver was ‘leadership’ defined as demonstrating that “everything (their emphasis) in the culture is focused on PFCC” (p. Finally, the chief nursing officers for each of the 11 hospitals report directly to the ECNO. They were eager to participate in the development of a nursing practice model that would define roles and help guide all nursing activity. Participants in these focus groups included Managers, Assistant Managers, Advanced Practice Nurses, Charge Nurses, Registered Nurses, Licensed Practical Nurses, Nurse Aides, and Clinical Instructors. This recognition prompted us to combine nursing care theories with broader-based management theories to achieve complete coverage of identified issues. While all health systems may appear to be learning organizations, many are being forced to behave in a manner similar to a learning organization because of external influences or events. This descriptor was used because these three attributes together support a patient- and family-centered care model.


Nurses are required to allow patients to direct their own care as much as possible, yet patients and families are unfamiliar with this role and need time and training to accomplish it (Institute for Patient-and Family-Centered Care, 2010).
Because neither the term patient- and family-centered care, nor the Cleveland Clinic’s Patients First guiding principle defined the interactive role of the nurse, we drew upon Manthey’s ‘relationship-based care’ (RBC) theory as described by Koloroutis and colleagues (2004) to provide a roadmap of how a nurse could achieve effective patient- and family-centered care.
While Senge’s (2006) ‘system thinking’ (loosely defined as the ability to understand and utilize or change a system) is important, it is not broad enough of a concept to cover everything that a nurse needs to do to deliver optimal patient care. The many nursing actions needed to achieve the shared vision and execute the Framework of Care for nursing were summarized into four Domains of Nursing Practice. The current concept of a healing environment has expanded from Nightingale’s primary concern about cleanliness and fresh air to also include concerns about the social, psychological, and spiritual environments (Shaner, 2006). Individual nurses or teams of nurses are responsible for identifying potential practice improvements and developing evidence-based research to validate these potential improvements.
The current movement towards higher educational levels for nurses is evident in the endorsement by organizations such as the American Organization of Nurse Executives (AONE) (Thompson, 2005), and the Institute of Medicine (IOM) (Committee on the Robert Wood Johnson Foundation Initiative on the Future of Nursing, at the Institute of Medicine, 2011) for most nurses to be educated at the baccalaureate level. The hand became the representation of the shared vision, the Framework of Care was contained in a circle around the globe, and the four domains were the four quadrants of the globe as shown in the model in Figure 2a. The overlap between the RN and support personnel symbolizes the RN’s role in coordinating care; the overlap between the teams shows the teams that will work most closely together.
This care pathway was produced as a ‘Nursing Unit Care Pathway Form’ that could be customized by nurse managers to include the unique needs of their unit (Figure 6). An online tool kit offering vignettes and examples of how to deliver care using scripting and case studies was developed to ensure easy access to all materials.
The Nursing Institute motto was also linked to the implicit promise of care that nurses make to their patients every day. She has over 30 years of experience as a bedside nurse, nurse educator, and nurse executive. Robert received his BA in economics from the University of North Carolina at Charlotte and his MBA from Columbia University, New York, NY. How patient reactions to hospital care attributes affect the evaluation of overall quality of care, willingness to recommend, and willingness to return. Successful implementation required full engagement in the concept of PFCC by what the Institute for Healthcare Improvement has termed the ‘hearts and minds’ of nurses. Otani recommended that managers should make as their first priority the elimination of poor nursing practice. Specific questions addressed what should be included in the model, as well as daily job tasks and barriers to care. The work of four theorists, Senge, Greenleaf, Manthey, and Benner, were key to the formation of the model as described below.
A rapid evolution in practice, caused by technological growth and abrupt changes due to regulation and payout revisions, has forced modern health systems to react and learn new methods quickly. In 1971, Greenleaf introduced the concept of a servant leader which defines this role for the nurses. Rather than talking only about the patient-family relationship, RBC presents a picture of the three crucial relationships that care providers must navigate to achieve patient-centered care, namely the care provider’s relationships with (a) patients and families, (b) self, and (c) colleagues (Koloroutis, et al., 2004). Because much of the thinking that nurses do occurs in emergent situations, Benner’s descriptor ‘thinking in action’ (Benner, Hooper-Kyriakidis, & Stannard, 1999) was used instead of ‘systems thinking’ in our nursing practice model. The term ‘domain’ which means ‘sphere of activity or control’ was used because these are areas that nurses can control and will decide their personal level of participation. At the Cleveland Clinic, nurses are tasked with maintaining a healing environment that delivers the empathy, care, and compassion that patients and families need to promote healing.
The Department of Nursing Research and Innovation helps to guide nurses through the process of conducting research studies and disseminating these findings, along with other best practices. The Cleveland Clinic nursing leadership is committed to assessing nurses’ competency levels and tailoring their education to their specific learning needs so as to ensure a competent, qualified workforce capable of delivering world class, quality care. Although this form describes bedside nursing, it can be easily modified to show the continuum of care for any patient-oriented nursing activity. This promise to patients has been illustrated through a Cleveland Clinic program called ‘The Patient Experience’ which is summarized by the theme of ‘Cleveland Clinic patients assume world-class care but they experience empathetic care.’ Both of these themes were supported by real-life stories of managers and patients. Deborah received her BSN from the University of North Carolina at Greensboro and her MSN from Duquesne University, Pittsburgh, PA.
The main difference between a health system that acts like a learning organization and one that truly is a learning organization is the practice of ‘building a shared vision’ to which many people are truly committed because it reflects their own personal vision (Senge 2006). A serving leader is a leader who is concerned for the growth of the people he is serving (Greenleaf, 1971). This relationship-based role of the nurse in a modern, collaborative environment requires more than the ‘follower’ role of the traditional, paternalistic care model.
Benner has described ‘thinking in action’ as ‘thinking linked with actions in ongoing situations’ (p. While every nurse will participate in every domain to some extent, individual nurses can select their sphere(s) of focus for their particular role and can identify their own goals for professional and personal growth. Continual emphasis on patient safety is directly rewarded at the Cleveland Clinic as research shows strong improvements with increased professional commitment to patient safety (Teng, 2009).
To aid nurses in achieving this healing environment, we have developed a list of factors that contribute to a healing environment. Practice counsels are also used to spread best practices throughout the organization to provide consistent care across the continuum.
Quantifiable data from on-screen simulations and math assessments round out individual nurse profiles and help develop excellence in patient care. In this article the authors identify the essence of PFCC, consider barriers to PFCC, review their process of developing PFCC, and describe how the Cleveland Clinic health system has implemented a PFCC nursing practice model. The remaining key drivers were respectful partnership, reliable care, and evidence-based care.
Without a shared vision the workforce may feel lost and efforts can be unfocused and less effective when exogenous events, i.e.
Greenleaf’s work and the later development of it by Jennings (Jennings & Stahl-Wert, 2003) comprise a key concept in the Cleveland Clinic Experience, a 16-hour training course that all Cleveland Clinic employees attend. The serving leader training that every Cleveland Clinic nurse receives prepares them for assuming this role.
Interdisciplinary simulations provided in simulation labs and onsite by the Cleveland Clinic Education Institute give care givers the ability to practice and perfect team work, collaboration, and technical skills. In doing so the authors explore how the concept of ‘Passion for Nursing’ was used to stimulate nurse engagement in PFCC. The Cleveland Clinic Experience is a patient-focused program that educates all employees in the concepts of quality, innovation, teamwork, service, integrity, and compassion. It should be noted that this is only a partial listing as a healing environment is in large part a matter of attitude and circumstance.
Serving leadership is the template that all employees are expected to use in interactions with patients, families, and other employees.
The characteristics of the serving leader are: visionary, humility, accountability and drive, leadership, and develops self and others.



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