Leadership will need to assure the effective use of practices that (1) balance the tension between production efficiency and reliability (safety), (2) create and sustain trust throughout the organization, (3) actively manage the process of change, (4) involve workers in decision making pertaining to work design and work flow, and (5) use knowledge management practices to establish the organization as a “learning organization.” To this end, the committee makes the following recommendations:

Recommendation 4-1.5 HCOs should acquire nurse leaders for all levels of management (e.g., at the organization-wide and patient care unit levels) who will:

  • Participate in executive decisions within the HCO.

  • Represent nursing staff to organization management and facilitate their mutual trust.

  • Achieve effective communication between nursing and other clinical leadership.

  • Facilitate input of direct-care nursing staff into operational decision making and the design of work processes and work flow.

  • Be provided with organizational resources to support the acquisition, management, and dissemination to nursing staff of the knowledge needed to support their clinical decision making and actions.

Recommendation 4-2. Leaders of HCOs should take action to identify and minimize the potential adverse effects of their decisions on patient safety by:

  • Educating board members and senior, midlevel, and line managers about the link between management practices and safety.

  • Emphasizing safety to the same extent as productivity and financial goals in internal management planning and reports and in public reports to stakeholders.

Recommendation 4-3. HCOs should employ management structures and processes throughout the organization that:

  • Provide ongoing vigilance in balancing efficiency and safety.

  • Demonstrate trust in workers and promote trust by workers.


For ease of reference, the committee’s recommendations are numbered according to the chapter of the main text in which they appear.

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