Clustering Excellence for Transformative Change

Change is all around. Healthcare professionals are constantly being urged to do more with less. Nurses are being asked to exert transformational leadership and assume responsibility for the design of caregiving processes and environmental structures [1]. Improving quality isn’t just a preoccupation of nurses working in acute care, but also of those concerned with public health [2]. If you accept the challenge of trying to exert transformational leadership, the question remains: How do you go about doing this? One strategy, I would recommend, is to consider clustering excellence.


Introduction
Change is all around. Healthcare professionals are constantly being urged to do more with less. Nurses are being asked to exert transformational leadership and assume responsibility for the design of caregiving processes and environmental structures [1]. Improving quality isn't just a preoccupation of nurses working in acute care, but also of those concerned with public health [2]. If you accept the challenge of trying to exert transformational leadership, the question remains: How do you go about doing this? One strategy, I would recommend, is to consider clustering excellence.
The business sector was the first to talk about cluster-based development. Porter [3] noted that innovation thrived in a culture of collaboration which featured shared leadership and organizational flexibility. If you have a critical mass of expertise, you can build on existing strengths, create new combinations, play off of each other's ideas, and seize opportunities not available to lone agents.
Silicon Valley computing and Vermont cheese making were put forward as areas that thrived because there was such cross-pollination of efforts. It wasn't a matter of one high-tech company or one dairy doing well, but of similar or related businesses using their collective advantage to accomplish more than any one of them could on its own.
In business, clustering excellence is defined as a geographically close group of interconnected institutions in a particular area that are linked by commonalities. In nursing, I would say that clustering excellence -in practice and academe -means that related or likeminded entities are linked by a shared mission or agenda for the purpose of pooling shared resources so the whole can achieve more than the separate efforts. This might take the form of academe and practice working together to build the leadership capacity of their faculty and staff [4] or to develop a nurse residency program that meets each of their needs [5]. The National Institute of Nursing Research (NINR) has a series of grants -P20, P30 and P01 -that encourage programmatic research whereby individual projects are embedded in the collective power of the group with the expectation that these synergistic efforts will accomplish more over time than a series of separate studies [6].
We are beginning to see examples of the clustering of excellence in nursing education, practice, and research. Using the structure of the Committee on Inter-institutional Cooperation (CIC), otherwise known as the Big 10 +, nurses at several Midwestern universities created a virtual university consortium to pool their graduate nursing informatics courses [7], thus providing graduate students with many more offerings than would otherwise be available at any one university where you are limited in the number of highly specialized faculty that you can afford to recruit. This consortium also functioned as an online research interest group for participants, affording them the collegial support that was not available at their own institutions where they often were the only ones in that specialty.
The nurses at the Massachusetts General Hospital have created interlocking hospital-wide centers that encourage the interface between and among research, evidence-based practice, and innovation at the point of care [8]. The Center for Health Outcomes and Policy Research at the University of Pennsylvania School of Nursing, under the leadership of Dr Linda Aiken [9], has sought to expand research and research training that focuses on healthcare outcomes and workforce policy by gathering likeminded individuals into a structure that provides clear expectations, shared resources, contiguous office space, and opportunities to engage in collaborative research. Behavioral oncology and cancer control are of interdisciplinary interest, and that is why Indiana University School of Nursing developed a transdisciplinary training program to maximize workforce development in those areas [10].
One of the best examples of how nurses have maximized their impact by joining together is the Hartford Geriatric Nursing Institute (HGNI) funded by the John A. Hartford Foundation. The HGNI was a virtual institute that brought together various universities and professional organizations to amplify the effect of multiple endeavors in elder care. The HGNI developed a shared identity, encouraged cross-pollination of efforts, took advantage of the institute's convening function to address opportunities and problems, and launched acrossproject collaborations [11]. The consequences of this intentional collaboration have been profound, particularly in nursing education [12]. What is more, the HGNI expanded its collaboration to other universities as it became self-sustaining under the banner of the National Hartford Center of Gerontological Nursing Excellence [13]. After one decade of existence, one of the programs -Building Academic Geriatric Nursing Capacity (BAGNC) -could lay claim to the publication of 1100 papers in that specialty area, the leveraging of $72 million in additional grant monies, the teaching of 11,000 undergraduates and mentoring of 1000 master's students [14].
If we are going to cluster excellence for transformative change, we as nurses need to change our fundamental professional orientation away from expecting to become Jacks or Jacquelines of all trades, an attitude that is largely responsive, and think more in terms of actively developing programs that can be self-sustaining. We have to move away from thinking that it is enough to hire someone with particular expertise to cover some need, and instead take steps to ensure that every specialist is plugged into some kind of network where that individual's efforts can be amplified to achieve larger goals.
Entities cannot be outstanding in every area, but they should parlay at least one of their assets into developing some area of strength which others seek out for consultation and collaboration. If every practice setting and school was exceptional in some area, you would then know where to go to get partners that would help you handle your organizational vulnerabilities, and overall quality would improve. You would also be less devastated as an organization when individuals retire or are recruited elsewhere because your excellence wasn't contingent on just one person! What is more, I believe that approach would facilitate recruitment because individuals are attracted to places where colleagues are interested in and working on similar things.