Case Analyses Submission Guidelines & Rubric Case an.docx

Case Analyses Submission Guidelines & Rubric
Case analyses should be approached as though you are a
marketing manager
whose responsibility it is to assess the situation and present
three long-term
strategies to the board of directors. Based on your
understanding of the case
and external research on the CURRENT situation, what are the
three best
strategies to revitalize and/or improve public perception to the
same target
market and/or alternative markets? Please do not limit yourself
to the
specifics of the case when formulating your strategies. Think
‘BIG
PICTURE’ (ethical objectives, internal/external factors,
complementary
products/industries, sustainability, alternative products/services,
cultural

assessment, pricing changes, etc.).
Your strategic recommendations should be 1) measurable and 2)
broad
enough to encompass the direction of the brand for at least 5
years. At the
same time, analyses should explain IN DETAIL the logic and
process
behind implementing such initiatives. Please do not provide
vague
recommendations. Please use the critical thinking rubric below
as a
guideline and checklist for your submissions.

Not Proficient
Some Proficiency
Proficient
Highly Proficient
Points Received
(10 x 5)
Identified and
Explained Issues
Fails to identify,
summarize, or explain
the main problem or
question, or represents
the issues inaccurately

or inappropriately.
Identifies main
issues but does not
summarize or
explain them
clearly or
sufficiently.
Successfully
identifies and
summarizes the
main issues, but
does not explain
why/how they
are problems or
create questions.
Clearly identifies

and summarizes
main issues and
successfully and
identifies implicit
issues, addressing
their relationship to
each other.
Recognizes
Stakeholders and
Contexts
Fails to accurately
identify and explain any
context for the issues or
presents problems as
having no connections
to other contexts.

Shows some
understanding of
the influences of
theoretical
contexts on
stakeholders, but
does not identify
any specific ones
relevant to
situation at hand.
Correctly
identified all the
empirical and
most of the
theoretical
contexts
relevant to all
the main

stakeholders in
the situation.
Not only correctly
identifies all the
contexts relevant to
stakeholders, but
also finds minor
stakeholders and
contexts and shows
conflicts of interests
among them.
Takes
Intellectual
Risks
Stays strictly within the
guidelines of the

assignment.
Considers new
directions or
approaches
without going
beyond the
guidelines of the
assignment.
Incorporates
new directions
or approaches to
the assignment
in the final
product.
Actively seeks out
and follows through

on untested and
potentially risky
directions or
approaches to the
assignment in the
final product.
Evaluates
Assumptions
Fails to identify and
evaluate any of the
important assumptions
behind the
recommendations
made.
Identifies some of

the most important
assumptions, but
does not evaluate
them for
plausibility or
clarity.
Identifies and
evaluates all the
important
assumptions, but
not the ones
deeper in the
background–the
more abstract
ones.
Not only identifies
and evaluates all the

important
assumptions, but
also some the more
hidden, more
abstract ones.
Innovative
Thinking
Merely restates existing
ideas.
Experiments with
creating a novel or
unique idea,
format, or product.
Actually creates
a novel or

unique idea,
identifies a new
void, or
proposes a new
product
Extends a novel or
unique idea,
question, format, or
product to create
new knowledge or
knowledge that
crosses boundaries.
Evolving Role of the Nursing Informatics

Specialist
Lynn M. NAGLEa, Walter SERMEUS b, Alain JUNGERc
a
Lawrence S. Bloomberg, Faculty of Nursing, University of
Toronto, Toronto, Ontario,
Canada
b
Leuven Institute for Healthcare Policy, University of Leuven,
Belgium
cUniversity Hospital of Lausanne, Lausanne, Switzerland
Abstract. The scope of nursing informatics practice has been
evolving over the
course of the last 5 decades, expanding to address the needs of
health care
organizations and in response to the evolution of technology. In
parallel, the
educational preparation of nursing informatics specialists has
become more
formalized and shaped by the requisite competencies of the role.
In this chapter,
the authors describe the evolution of nursing informatics roles,
scope and focus of
practice, and anticipated role responsibilities and opportunities
for the future.

Further, implications and considerations for the future are
presented.
Keywords. Nursing informatics specialist, role function,
connected health, data
science, big data, personalized medicine, clinical intelligence,
virtual care
1. Introduction
By 2018, 22 million households will use virtual care solutions,
up from less than a
million in 2013. Average (healthcare) visits among these
adopter households will
increase from 2 per year in 2013 to 6 per year in 2018, which
include both acute care
and preventive follow-up services in a variety of care settings—
at home, at retail kiosk
or at work. [1]
Nursing informatics roles have taken many forms in focus and
function over the
last decades; suffice it to say that they have not been
consistently described or defined
in terms of scope of practice. At the time of this writing it is
clear that role of nursing
informatics specialists will continue to evolve at an increasingly

rapid rate in the
coming years. The unfolding of new health care paradigms will
bring greater
connectivity between care providers and patients, include a
wide array of emerging
technologies and an increasing emphasis on data analytics will
make the integration of
informatics competencies into every area of nursing an
imperative.
2. Brief history of roles of the past and present
The earliest and most common types of informatics work
assumed by nurses has
included: oversight of organizational workload measurement
systems, project
leadership, systems educator, and nursing unit or departmental
information technology
resource. In many instances, these roles were enacted on the
basis of a specific
identified organizational need and were often secondments to
the Information
Technology Department. It was not unusual for these roles to
have the designation of
Forecasting Informatics Competencies for Nurses in the Future
of Connected Health

J. Murphy et al. (Eds.)
© 2017 IMIA and IOS Press.
This article is published online with Open Access by IOS Press
and distributed under the terms
of the Creative Commons Attribution Non-Commercial License
4.0 (CC BY-NC 4.0).
doi:10.3233/978-1-61499-738-2-212
212
“IT nurse” [2]. As role responsibilities and job titles have been
widely varied, so have
the qualifications for each. The need for more specificity and
consistency in nursing
informatics roles has been recognized for several years [3, 4, 5].
The advent of formal education programs for nurses interested
in specializing in
informatics has occurred in conjunction with increasing
sophistication in the use of
information and communication technologies (ICT) in clinical
practice settings. Today,
nurses have the option to pursue specialization and credentials
at a variety of levels
including graduate specialization and specialty certification.
Advanced credentials and

certification (e.g., Certified Professional in Healthcare
Information and Management
Systems - CPHIMS) have afforded nurses the opportunity to
achieve credibility and
legitimacy regarding the specialty informatics knowledge and
skills they bring to bear
in nursing practice and academia and healthcare in general [6].
This credibility has
been recognized with the development of executive level
positions such as the “Chief
Nursing Informatics Officer” (CNIO) in some countries. The
position of the “Chief
Medical Informatics Officer” (CMIO) is much more prevalent
and deemed essential in
medium and large health care organizations while the C-level
nursing counterpart
remains less common. Several authors [7-11] have described the
role and competencies
for these senior informatics positions, yet the valuing of these
positions remains limited
among health care provider organizations.
In addition to the evolution of formalized training programs for
nurses interested in

informatics, the specialty of nursing informatics has continued
to evolve and has
become recognized in local jurisdictions, nationally and
internationally. Groups of like-
minded nurses have organized into special interest groups
affiliated with larger
interdisciplinary organizations (e.g., International Medical
Informatics Association -
Special Interest Group on Nursing Informatics (IMIA-NI-SIG)).
Organizations such as
the Canadian Nursing Informatics Association (CNIA), the
American Nursing
Informatics Association (ANIA), the Nursing Informatics
Working Group of the
European Federation for Medical Informatics (EFMI-NURSIE)
are examples of forums
for nurses to network, collaborate and profile their work in
informatics. The existence
of these specialty organizations has served to further legitimize
the work of nurse
informaticians and provided a venue for advancing regional,
national and international
efforts in nursing informatics. Through conferences, meetings
and the offering of

educational sessions, virtually and face to face, these networks
of nurse informaticists
have collectively advanced the practice and science of nursing
informatics. A case in
point is the International Nursing Informatics Congress and
post-conference, now held
bi-annually and hosted by countries across the globe. Outputs of
these meetings include
publications such as this one; benefitting nursing informatics
specialists and the nursing
profession worldwide.
At the time of this writing, we find nursing informatics
specialists in virtually
every clinical practice setting. The roles and focus of their work
endeavors are wide
and varied. The titles of “informatics nurse”, “nurse
informatician”, and “nursing
informatics specialist” are but a few of the titles applied to
nurses working in the field.
Many of the roles of the past and present have been more
extensively described
elsewhere [2,12]. For the purpose of this chapter, the authors
use the title of nursing
informatics specialist to provide illustrations of the potential

focus of these roles
current and future.
Roles to date have largely focused on supporting acquisition,
implementation and
evaluation of clinical information systems in health care
organizations. As noted by
McLane and Turley [4], “informaticians are prepared to
influence, contribute to, and
mold the realization of an organization’s vision for knowledge
management” (p.30).
L.M. Nagle et al. / Evolving Role of the Nursing Informatics
Specialist 213
Nurses have been in pivotal roles at every step of the systems
life cycle and
instrumental in the success of deployments at every level of an
organization. From the
provision of executive oversight, project management, systems
education and training,
and analytics, nurses in clinical settings have become core to
organizations’
information management infrastructure and support.
In addition to health care provider organizations, nursing

informatics specialists
can be found in the employ of technology vendors, retail
outlets, and consulting firms
while many others have created their own entrepreneurial
enterprise. Over the last few
decades, technology vendors, hardware and software, have come
to appreciate the
invaluable contribution of nurses to the development, sales and
deployment of their
solutions. Throughout the world, nurses are also engaged in
academic pursuits to
advance the knowledge base of nursing informatics through the
conduct of research.
Efforts are underway in many countries to advance the adoption
and integration of
entry-to-practice informatics competencies into undergraduate
nursing programs.
Notwithstanding some of the ongoing gaps in the provision of
informatics content in
undergraduate nursing education, many courses and programs
have been taught in a
variety of post-secondary education institutions over several
years by nursing
informatics specialists. In fact it is not unusual for many nurses

to develop an interest
in informatics through a single course and subsequently pursue
further studies and
employment opportunities.
Since the early 90’s many graduate level courses and degrees,
certificate and
certification programs have been developed and offered world-
wide. Nurses have
pursued these opportunities recognizing the necessity of
informatics knowledge and
skills now and particularly into the future, as they face an
increasingly connected world
of digital healthcare. To a large extent, the core competencies
of the nursing
informatics specialist have become essential for all nurses and
expectations of the
specialist role will continue to evolve even further.
3. Emerging roles for nursing informatics specialists
The healthcare sector continues to evolve in the application and
use of technologies to
support the delivery of care. Factors including: a) rising health
care expenditures, b) the
increasing incidence of chronic disease, c) the ubiquity of

technology, d) an aging
demographic, e) personalized medicine, f) mobile and virtual
healthcare delivery, g) the
emergence of consumer informatics, h) genomics, i) big data
science, and connected
health are and will continue informing the evolution of nursing
informatics roles.
One of the main challenges we have to cope with is the
difference in growth rate
that is exponential for the new technology and knowledge yet is
still linear for
changing human behavior, learning, organizations, legislation,
ethics, etc, A linear
growth rate is mostly represented by a function in a form like
y(x) = ax+b. An
exponential growth rate is mostly represented by a function in a
form like f(x) = kax.
For example: In an exponential world where the information is
doubling every year, 5
exponential years would equal to 25 or 32 linear years which
has a massive impact on
the management of professional knowledge. In reality, we
estimate that knowledge
development in healthcare, which has doubled every century

until 1900, is now
estimated to double every 18 months. And the pace is getting
faster. This means that
when nurses finish their education, the knowledge they gained
might be already
outdated. The traditional way of developing procedures,
protocols and care pathways,
sometimes requiring a year to develop, are outdated when they
are finalized and are
Specialist214
insufficient to guide future practice. The only way forward is to
integrate and embed
the new knowledge in electronic patient records using
algorithms and decision support
systems so that practice remains aligned with new knowledge
and insights. The impact
might be that best practices can change very quickly and what is
viewed as best
practice before your holiday leave might be different upon your
return to work. Making
the connection between these different dimensions of time will
be a key-role of the

evolving role of the NI specialist.
A second challenge is that clinical practice in the future will be
largely team based.
The nature of teams will include interprofessional teams,
patients and their relatives
and a wide range of virtual devices (internet of things - IoT)
that are all connected.
Teams will work across boundaries of organizations and will be
organized around a
particular patient. We still have to come up with new labels for
naming these temporary
virtual interprofessional patient teams. Practically it will mean
that nurses will be
(temporary) members of different teams at the same time. This
notion of teamwork is
in contrast with what we normally see as teams organized in
organizations, departments
and units. It will challenge how teams will be managed, led, and
evaluated. But it will
also challenge the communication within teams and the
exchange of information.
3.1 Virtual and connected care
The delivery of health services virtually is becoming

commonplace in many places
around the globe. Virtual care has been defined as: “any
interaction between patients
and/or members of their circle of care, occurring remotely,
using any forms of
communication or information technologies, with the aim of
facilitating or maximizing
the quality and effectiveness of patient care” [13, p 4].
The most common modalities of virtual care are currently in use
in telemedicine.
Telemedicine has been largely used to conduct remote medical
consultations,
assessments and diagnosis (e.g., teledermatology, telestroke,
telepsychiatry) through
the use of computer technology and associated peripheral
devices including digital
cameras, stethoscopes and opthalmoscopes, and diagnostic
imaging. More recently, the
tools of telemedicine have been extended to the provision of
remote nursing monitoring
and assessment particularly for individuals with chronic
diseases such as congestive
heart failure (CHF) and chronic obstructive pulmonary disease
(COPD). The nurses

providing these tele-homecare services are not necessarily
informatics specialists but
the design and management of the monitoring tools,
infrastructure and support services
may be provided by them in the future.
Another emerging area of nursing informatics practice will
likely focus on the use
of remote monitoring technologies such as sensors and alerts
embedded in structures
(e.g., flooring, lighting, furniture, fixtures) and appliances (e.g.,
stove, refrigerator) in
the homes of citizens. These tools offer the promise of
supporting seniors to maintain a
level of independence in their own homes longer, particularly
those with cognitive or
sensory impairments. Such devices might trigger direct
messaging to providers, lay and
professional, flagging potentially harmful situations and
affording early intervention as
necessary. Different types of sensors (e.g., sleep, activity,
falls, ambulation,
continence, fluid and electrolyte) will also contribute new
supplementary data to health

information repositories, offering the possibility of linking to
other data sets and
provide new insights to the well-being of individuals in the
community especially the
aged and those living with chronic illness.
With the increasing use of consumer health solutions such as
patient portals and
smartphone apps for self-monitoring and management of health
and disease, nurse
Specialist 215
informatics specialists will likely play a key role in their
support and development.
From the perspective of application design and usability, and
training, nursing input
and informatics expertise will be important to ensure
appropriate and safe use of these
tools. As individuals and their families become more active
participants in their care
through the use of applications and devices to connect with
providers, they will likely
also need expertise and support from the nursing informatics
specialist.

3.2 Knowledge generation and innovation
The traditional ways of new knowledge generation is through
research and the
dissemination of findings in research journals. Knowledge is
consumed by researchers
and clinicians who transform it into relevant guidelines and care
pathways. The time
between the generation of research findings and application in
the real clinical work
can take several years. It is generally estimated that it takes an
average of 17 years for
research evidence to reach clinical practice [14]. Therefore
clinicians are not always
aware of existing evidence. In a landmark study, McGlynn et al.
[15] evaluated the use
of evidence-based guidelines in 30 conditions and 439
indicators for the use of the
same. They showed that clinicians (doctors, nurses) only apply
50% of them in their
daily practice. The use varied from 80% for structured
conditions such as cataract to
10% for unstructured conditions such as alcohol addiction.
There is also a lot of

research demonstrating that nurses lack knowledge related to
common procedures.
Dilles study illustrated [16] that nurses lack sufficient
pharmacological knowledge and
calculation skills. Baccalaureate prepared nurses’
pharmacological knowledge averaged
between 60% and 65% of the level expected. Segal et al. [17]
analyzed the use of hip
arthroplasty care pathways in 19 Belgian hospitals finding a
high variability in
providing evidence-based interventions. While post-op pain
monitoring is in 100% of
the care pathways, pre-op physiotherapy was only present in
25% of the care pathways.
In the future of connected health, there will be direct links to
knowledge generated
by specialists from around the world. New knowledge will be
automatically integrated
and embedded into electronic patient records, and include new
algorithms for decision
support systems. It is interesting to note that Hearst Health
Network, one of the largest
media and communication groups in the world, is taking a
leading role in healthcare.

They started an intensive collaboration among strong health
knowledge companies
such as First Databank (FDB), Map of Medicine, Zynx Health
and Milliman Care
Guidelines (MCG). FDB is a United Kingdom company
specialized in integrated drug
knowledge to prescribe medication, follow-up drug interactions,
improve clinical
decision making and patient outcomes. Map of Medicine was
created in the UK for
clinicians by clinicians. It offers a web-based visual
representation of evidence-based
patient journeys covering 28 medical specialties and 390
pathways. Zynx Health offers
a similar story from the US to provide evidence-based clinical
decision support system
solutions at the point of care through electronic patient records.
MCG produces
evidence-based clinical guidelines and software and is widely
used in the US, UK and
Middle East. Other examples of health information networks are
CPIC (Clinical
Pharmacogenetics Implementation Consortium) to help
clinicians understand how

available genetic test results could be used to optimize drug
therapy, the International
Cancer Genome Consortium (ICGC) which facilitates data
sharing to describe genomic
sequences in tumor types among research groups all over the
world. In the information
models, such as archetypes and Detailed Clinical Models (see
section C chapter 1) offer
summaries of evidence for specific clinical concepts.
Specialist216
Likely one of the most significant areas of focus for nursing
in the near term is data science and the use of “big data”. Big
data has been defined as:
“large amounts of data emerging from sensors, novel research
techniques, and
ubiquitous information technologies” [18, p. 478]. Access to big
data unveils a whole
new sphere of informatics opportunities related to health and
nursing analytics.
According to Masys [19], big data is “that which exceeds the
capacity of unaided

human cognition and strains the computer processing units,
bandwidth, and storage
capabilities of modern computers”. The future development of
nursing capabilities in
data science will essentially lead to an entirely new cadre of
nursing informatics
specialists whose work will focus on deriving new nursing
knowledge from not only
electronic health record data, but also the data from sensor and
remote monitoring
technologies, patient portals and mobile apps described above.
The implications of -
omics data such as genomics, metabolomics, and proteomics,
being included as part of
the electronic health record in the near future, should be taken
into account. Nurse
informatics specialists will be pivotal in assisting to identify
potential ethical and
practice implications in the use of these data.
Using big data, the knowledge generating process might be
reversed into practice-
based evidence where data from electronic health records,
patient portals, sensors etc.

are uploaded into large databases that identify patterns and
clinical interesting
correlations. An example of the power of analyzing large
datasets is the Vioxx-case
(rofecoxib). Although a clinical trial initially showed no
increased risk of adverse
cardiovascular events for the first 18 months of Vioxx use, a
joint analysis of the US
FDA and Kaiser Permanente’s Healthconnect database of more
than 2 million person-
years of follow-up, the NSAID arthritis and pain drug was
found shown to have an
increased risk for heart attacks and sudden cardiac death. [20]
After the findings were
confirmed in a large meta-analysis, Merck decided to withdraw
the drug from the
market worldwide in 2004.
With the proliferation of these emerging data sources and
databases, the nursing
informatics specialist will play a key role in the use of these
data to inform quality and
safety improvements in every practice setting.
3.3 Sharing knowledge and communication

In the realm of the new normal of connected health, nurses will
work in temporary
teams around patients. Within these teams it will be essential
that goals are clear and
shared, that roles are defined and accepted and that the way of
working is clear to
everyone. It requires systems for coordination and
communication to ensure the
continuity of care. Reid et al. [21] defined continuity of care as:
"how one patient
experiences care over time as coherent and linked; this is the
result of good
information flow, good interpersonal skills, and good
coordination of care". They
make a distinction between information continuity, relational
continuity and
management continuity. Information continuity consists on one
hand in the exchange
and transfer of information among health care providers and to
patients and on the
other hand how the knowledge of the patient is accumulated. It
is about their specific
knowledge, preferences, expectations, social network. With the
existence of the new

technology of the quantified self, it is important that these new
data are effectively
integrated and connected. Relational continuity consists of the
trusted relationship
between patient and healthcare provider. Increasingly advanced
practice nurses are
assuming this pivotal role within the health team. Management
continuity is referring
to a consistent and coherent approach to the health problem
across organizations and
Specialist 217
boundaries. The Belgian healthcare system offers an interesting
example of this:
General Practitioners are stimulated (financially) to prescribe
generic drugs. Hospitals
are stimulated to negotiate discounts with pharmaceutical
companies leading to brand
named drug choices. Although they might chemically be
identical, for the patient they
often are not as they have different names. Like drugs may be
different in size and
color leading to more medication errors as patients may take

two pills without being
aware that they are the same drug.
Although nurses spend a lot of time documenting care, the
accuracy of nursing
documentation has been found to be poor. In a study within 10
Dutch hospitals, Paans
et al. [22] found that within 341 patient records the accuracy of
documentation of
diagnoses was poor or moderate in 76% of the records. The
accuracy of the
intervention documentation was poor or moderate in 95% of the
patient records. Only
the accuracy for admission, progress notes and outcomes
evaluation and the legibility
were acceptable. The work of Connected Health should support
the documentation
systems of nurses and other health professionals. The use of
structured documentation
methodologies and standardized terminologies should improve
the quality of the
patient record and improve the capacity for comparability of
care processes and
outcomes across the care continuum and within patient care
groups.

3.4 Impact of connected health on the Scope of Practice of
Nurses and Advanced
Practice Nurses (APN)
In Connected Health, the scope of practice of nurses will
change. For example, based
on time and motion studies, it has been shown that nurses spend
5-7% of their time [23,
24] collecting vital sign data. In the future this work will be
assimilated by sensors and
other devices. However, nurses’ work will be more focused on
analyzing the data and
evaluating thresholds for action (e.g., alerting rapid response
teams). Another example
is the use of sensors for pressure ulcer monitoring [25]. The
used sensors will provide
information about patient temperature, skin humidity, pressure
points and position.
These data will generate a whole new set of information for
review and action
including pressure intensity map and humidity intensity maps.
These data would lead to
more precise management of pressure sores. Other examples of
data gathering that will

change the focus and processes of nurses’ work include:
barcode scanning for checking
identity of patients, patient and device tracking systems, and
robotic dispensing of
medication.
Patient access to their own records and partnering in their own
health will change
the roles of physicians, nurses and hospitals drastically. The
work of nurses will
increasingly shift from a direct care provision to the role of
knowledge broker in
helping patients to understand care alternatives, manage their
health, and navigate
information access.
4. Impact of connected health on the evolving role of the
Nursing Informatics
Specialist
Connected health will alter the future role of the nursing
informatics specialist and
require a new set of competencies. To a large extent these
competencies will build
upon existing competencies but have an increasing emphasis on
information use rather

than technology use. Table 1 provides a summary of the
anticipated new competencies
Specialist218
and role responsibilities that are likely to be necessary for
Nursing Informatics
Specialists in the emerging world of connected health and the
IoT.
Table 1. New competencies related to the future role of nursing
New Competencies New Roles
Knowledge Innovation and
Generation
• Provide guidance and support to others (nurses, patients) in
the
application and use of emerging knowledge (e.g., clinical
decision
support, Practice-Based Evidence (PBE), genomics, expert and
patient/citizen knowledge)
• Inform-teach others (clinicians, teams, patients) about new

knowledge and knowledge innovations relevant to specific
situations
• Provide direction and support to others in the use of
international
guidelines and knowledge
• Contribute internationally to new knowledge generation and
innovations ensuring the inclusion of relevant team member and
patient perspectives and expertise
Monitoring the use of new
technology
• Monitor and maintain vigilance over data/technologies to
identify
those that add value to a given health situation.
• Recognize that nurses, other clinicians and patients may
engage and
assume responsibility independently and or interdependently for
specific data (e.g., remote monitoring, self-monitoring,
wearables,
appliances).
• Recognize the emergence of patient self-service and relevance
of

patient expertise in specific situations.
Value judgement & quality
assessment
• Provide guidance as to the value and relevance of specific data
and
information as derived from single or multiple sources for any
given
set of circumstances, or health situations.
Change Management • Identify the broader scope and
considerations for change
management in the context of connected health (e.g., virtual and
physical participants/partners)
• Recognize the extended complexities of technology adoption
in the
context of connected health.
Communication &
Documentation
With increasingly complex and personalized approaches to
health care,
participate in the identification and/or development of new:

• models of clinical documentation
• methods of communication
• data standards
• terminology standards
• data sources
• data models
• data repositories
Data Analytics In addition to traditional quantitative and
qualitative analyses, support
and participate in the development and use of new approaches
and
methods of data analytics for:
• knowledge generation (e.g., natural language processing,
experiential data)
• reporting outcomes
• demonstrations of value (e.g., patient-caregiver perspectives,
health
and financial outcomes)
• predictive and retrospective analyses

Specialist 219
5. Conclusion
The future Nursing Informatics Specialist will function in the
context of virtual care
delivery, be informed by data aggregated from a multiplicity of
sources and real-time
knowledge generation that will inform individualized care. In
addition to the
competencies required to date, they will be required to support
other clinicians and
patients and families as they assume new roles and use data
analytics to interpret and
appropriately apply new knowledge. With the IoT, connected
care will pose as yet
unknown challenges for the Nursing Informatics Specialist in
the future; what is certain
is that the role will continue to evolve from the role scope and
responsibilities known
today.
References:
[1] Wang H. (2014). Virtual Health Care Will Revolutionize

The Industry, If We Let It. April 3, 2014.
Forbes.
[2] Nagle LM. (2015). Role of informatics nurse. In K.J.
Hannah, P. Hussey, M.A. Kennedy, & M.J. Ball
(Eds.), Introduction to nursing informatics (pp. 251-270).
London: Springer-Verlag.
[3] Hersh W. (2006). Who are the informaticians? What we
know and should know. J Am Med Inform
Assoc 13(2):166-170
[4] McLane S & Turley J. (2011). Informaticians: how they
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Nurs Adm 41(1):29-35.
[5] Smith SE, Drake LE, Harris JG, Watson K & Pohlner PG
(2011). Clinical informatics: a workforce
priority for 21st century healthcare. Aust Health Rev 35(2):130-
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[6] Health Information Management Systems Society(HIMSS)
(2016). Health IT certifications. Retrieved
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certification
[7] Harrington L. (2012). AONE Creates New Position Paper:
Nursing Informatics Executive. Nurse
Leader 10(3): 17-21.

[8] Remus S & Kennedy M (2012). Innovation in
transformative nursing leadership : nursing informatics
competencies and roles. Nurs Leadership 25(4):14-26.
[9] Kirby SB. (2015). Informatics leadership: The role of the
CNIO. Nursing 2015 (Apr):21-22.
[10] Cooper A. & Harmer S (2012). Strategic leadership skills
for nursing informatics. Nurs Times
108(20): 25-6.
[11] Simpson R. (2013). Chief nurse executives need
contemporary informatics competencies. Nurs Econ
3(6) 277-87.
[12] Murphy J. (2011). The nursing informatics workforce:
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29(3), 150-3.
[13] Women’s College Hospital Institute for Health Systems
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Virtual Care: A Framework for a Patient-Centric System.
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http://www.womenscollegehospital.ca/assets/pdf/wihv/WIHV_V
irtualHealth Symposium.pdf on April
14, 2016.
[14] Morris ZS, Wooding S, Grant J. (2011). The answer is 17
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[15] McGlynn EA, Asch SM, Adams J, Keesey J, Hicks J,
DeCristofaro A, Kerr EA. The quality of health
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[16] Dilles T, Vander Stichele RR, Van Bortel L, Elseviers
MM. (2011) Nursing students' pharmacological
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[17] Segal O, Bellemans J, Van Gerven E, Deneckere S,

Panella M, Sermeus W, Vanhaecht K. (2011)
Important variations in the content of care pathway documents
for total knee arthroplasty may lead to
quality and patient safety problems. J Eval Clin Pract., Aug 23,
p.11-5
[18] Brennan P. & Bakken S. (2015). Nursing Needs Big Data
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Scholarship 47(5):477–484.
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[20] Graham DJ, Campen D, Hui R, Spence M, Cheetham C,
Levy G, Shoor S, Ray WA. (2005). Risk of
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selective and non-selective non-steroidal anti-inflammatory
drugs: nested case-control study. Lancet
365(9458):475-81.
[21] Reid R., Haggerty J., McKendry R. (2002). Defusing the
Confusion: Concepts and Measures of
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documentation in patient records. J Adv Nurs. Aug 23, p. 1365-
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[23] Mendonck K., Meulemans H., Defourny J. (2000), Tijd

voor zorg: een analyse van de zorgverlening in
de gezondheids- en welzijnssector, VUB Press, 126pp.
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medical-surgical nurses spend their time? Perm J. 12(3):25-34.
[25] Marchione FG, et al., (2015). Approaches that use
software to support the prevention of pressure ulcer:
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Specialist 221
OnlineJournal of NursingInformatics: Volume 21, Winter 2017
Contents
1. Featuring the work of:
2. Manuscripts
3. Fact-Finding Survey on the Operational Status of Electronic
Medical Record Systems in Japan

4. A Comparison of Professional Informatics-Related
Competencies and Certifications
5. Student Manuscripts
6. Healthcare Informatics
7. Policy Statement: Texting in Health Care
8. Using an Electronic Health Record to Standardize
Documentation in an Emergency Observation Unit
9. Needs Assessment of an Electronic Health Record at an
Inpatient Psychiatric Hospital
10. Nursing Informatics and the Metaparadigms of Nursing
11. Do Clinical Decision Support Systems Reduce Inappropriate
Antibiotic Prescribing for Acute Bronchitis?
12. Editorial Columns
13. Successful submissions: Helpful Editor Tips
14. Senior Editor Columns
15. National Efforts in 2016 to Improve Health IT Usability
16. Training Beyond Task: Organizational Policy Implications
for Competency Development
17. Making Advance Care Planning Information Interoperable at
the Point of Care: The Next Step to Genuinely Promoting
Dignified Dying
Full Text
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Volume 21 Winter 2017

OnlineJournal of NursingInformatics (OJNI) Winter 2017
ISSN # 1089-9758 Indexed in CINAHL © 1996 - 2017
Featuring the work of:
Kuroda, Y., Fukuda, K., Yamase, H., Seto, R., Ito, M.,
Shimomai , K., Furukawa, H., Tatsuno, J., Tado, A.,
McCormick, K., Gugerty, B., Sensmeier, J., Sweeney, J., Terry,
A., Noal, C., Thomas, L., Francis, I., Lipford, K., Jones, S.,
Johnson, K, Storck, L., Kaminski, J., Staggers, N., Makar, E.,
Keenan, G., Kennedy, M.
OJNI is transitioning to Guest Access in which you must either
login or create an account to view content from OJNI. Creating
an account is free and HIMSS membership is not required.
Please help us obtain readership demographics and create your
account today.
Manuscripts
Fact-Finding Survey on the Operational Status of Electronic
Medical Record Systems in Japan
Using a quantitative descriptive study design, the present
operational status of Japanese electronic medical record (EMR)
systems and the extent of computerized nursing record adoption
in nursing departments are identified. [Yuko Kuroda, Mitsumi
Masuda, Kazuaki Fukuda, Hiroaki Yamase, Ryoma Seto, Misae
Ito, Kimiyo Shimomai, Hidetoshi Furukawa, Junko Tatsuno,
Asami Tado].
Feb 2017

A Comparison of Professional Informatics-Related
Competencies and Certifications
This paper describes various types of professional informatics
competencies that are measured by certification standards.
[Kathleen A. McCormick, Brian Gugerty, Joyce Sensmeier].
Student Manuscripts
Feb 2017
Healthcare Informatics
This paper explores the implications that are most notable in
today's healthcare world within healthcare and
nursinginformatics fields [Julianne Sweeney].
Feb 2017
Policy Statement: Texting in Health Care
The purpose of this policy is to establish guidance on short
message service (SMS) text messaging by members of the
health care workforce, and address security risks presented by
SMS text messaging [Lisa Storck].
Feb 2017
Using an Electronic Health Record to Standardize
Documentation in an Emergency Observation Unit
This workflow redesign project identified ways to improve and
optimize patient care and reduce inefficiencies by developing a
standardized EHR documentation template for observation
patients using social, technical, and regulatory requirements
[Christina Noah, Laura Thomas].

Needs Assessment of an Electronic Health Record at an
Inpatient Psychiatric Hospital
Studies have examined different healthcare organizations' quest
to adopt a meaningful use electronic health record (EHR), but
there is a significant lack of studies conducted for inpatient
psychiatric hospital settings. The purpose of this mixed design
descriptive study was to explore one particular inpatient
psychiatric hospital's EHR and identify facilitators and barriers
to the current EHR's use [Stacey Jones, Kelly Johnson, Karen
Lipford].
Feb 2017
Nursing Informatics and the Metaparadigms of Nursing
The nursing metaparadigm is a conceptual framework that
demonstrates the interconnected nature of nursing, person
(patient), environment and health. This paper will present three
different viewpoints of technology and nursing practice; nurse
perceptions and utilization of technology within an inpatient
acute care setting, an over-arching examination of the ethicality
of the use of technology in the science of caring, and nurse and
patient perceptions of utilizing health-enabling technology in an
outpatient community setting [Isabel Francis].
Feb 2017
Do Clinical Decision Support Systems Reduce Inappropriate
Antibiotic Prescribing for Acute Bronchitis?
Clinical Decision Support (CDS) systems are tools that utilize

either electronic medical records (EMR) or paper methods to
guide the evidence-basis- for specific treatment during patient
encounters as nurse practitioners are increasingly utilizing CDS
systems as part of the care team. This integrative review of the
literature demonstrates that, when implemented correctly, CDS's
can help reduce inappropriate antibiotic prescribing by nurse
practitioners for acute bronchitis [Angela Terry].
Editorial Columns
Feb 2017
Successful submissions: Helpful Editor Tips
Since the OnlineJournal of NursingInformatics (OJNI) began 21
years ago, nurses have been encouraged to submit manuscripts
for double blind peer review. June Kaminski, RN MSN PhD(c),
Editor in Chief, OJNI, provides helpful tips and tricks for
writers who are interested in submitting a manuscript for the
OJNI.
Senior Editor Columns
Feb 2017
National Efforts in 2016 to Improve Health IT Usability
With the widespread deployment of electronic health records
(EHRs) and other electronic devices, poor health IT usability
has become a critical issue across disciplines and health
organizations. Read the insights from Nancy Staggers, PhD, RN,
FAAN, President, Summit Health Informatics and Adjunct
Professor, University of Utah and Ellen Makar, MSN, RN-BC,

CCM, CPHIMS, CENP, Senior Research Scientist, Battelle and
their discussion on the importance of nurses in informatics to
harmonize efforts to build traction in providing solutions for
nursing pain points with health IT.
Feb 2017
Training Beyond Task: Organizational Policy Implications for
Competency Development
Read how Margie Kennedy, PhD, RN, CPHIMS-CA, Chief
NursingInformatics Officer and Managing Partner, Clinical
Informatics, Gevity Consulting Inc. discusses the challenges of
change management and the implications to understand where
new solutions fits into the overall strategy of the organization,
the kinds of comparable applications and functionality used, as
well as the scope of policies governing practice use within a
new application environment.
Feb 2017
Making Advance Care Planning Information Interoperable at the
Point of Care: The Next Step to Genuinely Promoting Dignified
Dying
In the absence of preference identification for end-of-life care,
many unnecessary and costly procedures may be performed that
severely compromise the dignity of the dying patient. Senior
Editor, Gail M. Keenan, PhD, RN, FAAN, Professor and the
Annabel Davis Jenks Endowed Chair of the College of Nursing,
University of Florida, discusses the new CMS (2016)

reimbursement policy of advanced care planning visits for
Medicare patients as an important step toward implementing
care that honors the dignity of all dying patients.
American Accent
How To Make An Infographic In PowerPoint
JANUARY 18, 2018
24SLIDES
Contents
· Why Use Infographics?
· How To Make An Infographic In PowerPoint
· How To Resize Your Slides For Your Infographic
· How To Format The Background For Your Infographic
· How To Use SmartArt For Your PowerPoint Infographic
· More Tips On How To Create And Design Infographics In
PowerPoint
· Final Words
· You might also find this interesting: Executives, Powerpoint
& Time – Set Your Priorities
The first thing people think about when they hear the word
infographic is probably Photoshop, not PowerPoint. You can do
a lot of graphics pretty quickly in Photoshop if you’re quite
handy with that software, or any other graphics software, for

that matter. PowerPoint is not a well-known graphics creator,
but you can make one just fine! If you’re curious how to go
about doing this, then you’re in luck because, in today’s article,
I’m going to show you how to make an infographic in
PowerPoint.
Why Use Infographics?
Infographics are all the rage nowadays. Everywhere you look,
you see infographics of basically any topic you can think of.
And it’s really not surprising why. Humans are visual creatures,
and as such we prefer a visual illustration as opposed to reading
10 pages of the same stuff. The old saying, “A picture paints a
thousand words,” holds true even to this day. Even on social
media, you’ll notice people sharing memes, infographics, and
other forms of graphics, because these are far easier to consume
and understand.
Infographics allow you to present information in a succinct and
efficient manner. If you’ve got information, you can turn it into
an infographic. You just need to have a plan in place on how
you’re going to lay out your information into something that
can be easily consumed by your audience.
For bloggers, digital marketers and other website owners who
care about optimizing their website rankings on search engines
(SEO), infographics can be a useful tool to gain additional
backlinks and traffic to their sites. Often, an infographic
presentation gets more shares on social media rather than

lengthy blog posts themselves.
Not too many content creators use infographics to complement
their written content because creating infographics in
PowerPoint, or any other software, take time and, in most cases,
money. But if you know how to use PowerPoint, and you’ve got
some spare time, then you can create infographics yourself.
How To Make An Infographic In PowerPoint
There’s no standard design or even sizes for infographics. Plain
and simple, you’re only limited by your creativity and
imagination. But, for starters, the first thing normally have to
do when making an infographic in PowerPoint is to resize the
slides to a size commonly used for infographics. Different
platforms have different recommended sizes, so you have to
consider as well where you’re going to be posting or sharing
your PowerPoint infographic.
How To Resize Your Slides For Your Infographic
1. Go to Design > Slide Size > Custom Slide Size.
(Caption: How to resize your PowerPoint slide for your
infographic)
2. In the Slide Size dialog box that pops-up,
select Custom in the drop-down for Slides sized for. Then type
in the width and height (in inches) and select
the orientation (portrait or landscape). Normally for
infographics, the orientation used is portrait.
You’re free to set your own size, but as you can see in the

screenshot, I set the width to 10 inches and the height to 25
inches.
(Caption: Use a custom slide size for your PowerPoint
infographic)
3. This is my new slide size for my infographic:
(Caption: The new slide size for our PowerPoint infographic
example)
How To Format The Background For Your Infographic
Your infographic can retain its original white background. But
if you’d like to add some color and style, you should consider
changing the background to something that will catch the eye of
your intended audience.
To change the background, right click on a blank spot on your
infographic slide and select Format Background. The Format
Background pane will then appear on your screen.
(Caption: How to format the background for your PowerPoint
infographic)
You can decide whether you want to use a solid fill, a gradient
fill, a picture or texture fill, or a pattern fill. Choose the most
appropriate background that’s going to fit in with the
infographic as well as the message you’re trying to convey to
your audience.
How To Use SmartArt For Your PowerPoint Infographic
You can easily use custom shapes and vector graphics, but for
beginners, SmartArt is one of the easiest ways to get started

with an infographic on PowerPoint as it provides responsive
graphics (there’s a reason it’s called SmartArt).
Go to Insert > SmartArt and choose a graphic that will look
good for your infographic. Hit OK when you’re done choosing.
(Caption: How to use SmartArt graphics for your PowerPoint
infographic)
To format and design your SmartArt, simply click on the
graphic first so that the SmartArt Tools pane will appear.
Choose from either the Design or Format tab.
(Caption: Use SmartArt Tools to format and design your
PowerPoint infographic)
Play around with the different options until you get your
infographic design just right.
At this point, you can decide how you want to design your
infographic. You can use a combination of SmartArt graphics
and other elements like vector graphics, some nice fonts that
complement your message, etc.
More Tips On How To Create And Design Infographics In
PowerPoint
There’s more to creating infographics than just resizing the
slide, creating nice backgrounds, and using SmartArt or custom
graphics. If you’ll remember the reason why you’re creating an
infographic, then you’ll realize that you need to actually put a
lot of thought into creating one. Depending on your industry,
you may have lots of competition so you’d have to think of a

way to create an infographic that will catch your audience’s
attention. Here are a few more tips:
· Get inspiration from other outstanding infographics.
You can get plenty of ideas by browsing sites
like Pinterest, Visual.ly, or even Google Images. See what your
competitors are doing and check if you can do a much better
infographic.
· Keep it focused.
Don’t talk about everything in your infographic. Rather, you
should only focus on one topic. If your topic has a lot of sub-
topics, then you can try using only the main points so as not to
put too much information on your infographic.
· Keep it simple.
If you keep your infographic focused, then it’s easier to keep it
simple as well. You don’t need to worry about overloading your
audience with too much information. Likewise, use simple
colors and a simple layout. Don’t try to overcomplicate things.
· Think of an attention-grabbing headline.
Your headline should accurately describe what your infographic
is all about. You don’t have to make it clickbait-y, but if it gets
you more views, then I don’t see any problem with it.
· Make sure your story flows.
You don’t want your audience to get lost in your infographic.
Having a storyline or a timeline in place is great, so your
audience knows the sequence of your story.

Final Words
Creating an infographic in PowerPoint is not easy, but it’s
certainly doable. It will take time and an eye for good design
(or at least some good research skills). Now that you’ve got an
idea on how to make an infographic in PowerPoint, it’s time to
plan how you’re going to be making yours from scratch.
At 24slides, we create world-class presentation designs,
animations, and infographics. Take a look at some of
our examples and get an instant quotefor your professional
infographic.
You might also find this interesting: Executives, Powerpoint &
Time – Set Your Priorities
PREVNEXT
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Rubric Detail
Select Grid View or List View to change the rubric's layout.

Name: NURS_5051_Module01_Week02_Assignment_Rubric
· Grid View
· List View
Excellent
Good
Fair
Poor
Develop a 5- to 6-slide PowerPoint presentation that addresses
the following:
· Explain the concept of a knowledge worker.
· Define and explain nursing informatics and highlight the role
of a nurse leader as a knowledge worker.
32 (32%) - 35 (35%)
The presentation clearly and accurately explains the concept of
a knowledge worker.
The presentation clearly and accurately defines and explains
nursing informatics with a detailed explanation of the role of
the nurse leader as a knowledge worker.
28 (28%) - 31 (31%)
The presentation explains the concept of a knowledge worker.

The presentation defines and explains nursing informatics with
an explanation of the role of the nurse leader as a knowledge
worker.
25 (25%) - 27 (27%)
The presentation inaccurately or vaguely explains the concept
of a knowledge worker.
The presentation inaccurately or vaguely defines and explains
nursing informatics with an inaccurate or vague explanation of
the role of the nurse leader as a knowledge worker.
0 (0%) - 24 (24%)
The presentation inaccurately and vaguely explains the concept
of a knowledge worker, or is missing.
The presentation inaccurately and vaguely defines and explains
nursing informatics with an inaccurate and vague explanation of
the role of the nurse leader as a knowledge worker, or is
missing.
· Develop a simple infographic to help explain these concepts.
14 (14%) - 15 (15%)
The presentation provides an accurate and detailed infographic
that helps explain the concepts related to the presentation.
12 (12%) - 13 (13%)
The presentation provides an infographic that helps explain the
concepts related to the presentation.

11 (11%) - 11 (11%)
The presentation provides an infographic related to the concepts
of the presentation that is inaccurate or vague.
0 (0%) - 10 (10%)
The infographic provided in the presentation related to the
concepts of the presentation is inaccurate and vague, or is
missing.
· Present the hypothetical scenario you originally shared in the
Discussion Forum. Include your examination of the data you
could use, how the data might be accessed/collected, and what
knowledge might be derived from the data. Be sure to
incorporate feedback received from your colleagues' replies.
32 (32%) - 35 (35%)
The presentation clearly and thoroughly includes the
hypothetical scenario originally shared in the Discussion
Forum, including a detailed and accurate examination of the
data used, how the data might be accessed/collected, and the
knowledge that could be derived from the data.
28 (28%) - 31 (31%)
The presentation includes the hypothetical scenario originally
shared in the Discussion Forum, including an accurate
examination of the data used, how the data might be
accessed/collected, and the knowledge that could be derived
from the data.
25 (25%) - 27 (27%)

shared in the Discussion Forum, including an examination of the
knowledge that could be derived from the data that is vague or
inaccurate.
0 (0%) - 24 (24%)
shared in the Discussion Forum, including an examination of the
knowledge that could be derived from the data that is vague and
inaccurate, or is missing.
Written Expression and Formatting - Paragraph Development
and Organization:
Paragraphs make clear points that support well developed ideas,
flow logically, and demonstrate continuity of ideas. Sentences
are carefully focused--neither long and rambling nor short and
lacking substance.
5 (5%) - 5 (5%)
Paragraphs and sentences follow writing standards for flow,
continuity, and clarity.
4 (4%) - 4 (4%)
continuity, and clarity 80% of the time.
3.5 (3.5%) - 3.5 (3.5%)

continuity, and clarity 60%- 79% of the time.
0 (0%) - 3 (3%)
continuity, and clarity < 60% of the time.
Written Expression and Formatting - English writing standards:
Correct grammar, mechanics, and proper punctuation
5 (5%) - 5 (5%)
Uses correct grammar, spelling, and punctuation with no errors.
4 (4%) - 4 (4%)
Contains a few (1-2) grammar, spelling, and punctuation errors.
3.5 (3.5%) - 3.5 (3.5%)
Contains several (3-4) grammar, spelling, and punctuation
errors.
0 (0%) - 3 (3%)
Contains many (≥ 5) grammar, spelling, and punctuation errors
that interfere with the reader’s understanding.
Written Expression and Formatting - The paper follows correct
APA format for title page, headings, font, spacing, margins,
indentations, page numbers, running head, parenthetical/in-text
citations, and reference list.
5 (5%) - 5 (5%)
Uses correct APA format with no errors.
4 (4%) - 4 (4%)

Contains a few (1-2) APA format errors.
3.5 (3.5%) - 3.5 (3.5%)
Contains several (3-4) APA format errors.
0 (0%) - 3 (3%)
Contains many (≥ 5) APA format errors.
Total Points: 100
Name: NURS_5051_Module01_Week02_Assignment_Rubric
Exit
Running head: HEALTHCARE INFORMATICS
1
HEALTHCARE INFORMATICS
4
Discussion: The Application of Data to Problem-Solving
In the modern era, there are few professions that do not to some
extent rely on data. Stockbrokers rely on market data to advise
clients on financial matters. Meteorologists rely on weather data
to forecast weather conditions, while realtors rely on data to
advise on the purchase and sale of property. In these and other
cases, data not only helps solve problems, but adds to the
practitioner’s and the discipline’s body of knowledge.
Of course, the nursing profession also relies heavily on data.

The field of nursing informatics aims to make sure nurses have
access to the appropriate date to solve healthcare problems,
make decisions in the interest of patients, and add to
knowledge.
In this Discussion, you will consider a scenario that would
benefit from access to data and how such access could facilitate
both problem-solving and knowledge formation.
To Prepare:
Reflect on the concepts of informatics and knowledge work as
presented in the Resources.
Consider a hypothetical scenario based on your own healthcare
practice or organization that would require or benefit from the
access/collection and application of data. Your scenario may
involve a patient, staff, or management problem or gap.
Post a description of the focus of your scenario. Describe the
data that could be used and how the data might be collected and
accessed. What knowledge might be derived from that data?
How would a nurse leader use clinical reasoning and judgment
in the formation of knowledge from this experience?

ANSWER OF THE DSCUSSION
QUESTION
The scenario that would rely on informatics within the
healthcare system involves patient care management. The
scenario involves a patient is undergoing a diagnostic and
screening process such as prostate specific antigen test (PSA)
for prostate cancer in one hospital. The current hospital doctor
is able to establish that the patient had already undergone a
similar process in another hospital after interviewing the
patient. This prompts the current doctor to seek records of the
patient from the other hospital indicating the results of the last
screening tests for further review and guide the current
screening process. In this case, the type of data required
involved those produced from the diagnostic and screening tests
the patient underwent in the last hospital. The data includes the
PSA tests results and underlying conditions such as medications
or infections that might affect the test. The doctor in this case
accesses the patient’s data from the other hospital’s electronic
health records which consist of lab tests, clinical notes and
other patient data.
In practical terms the doctor can receive a fax of the
patient data such as blood tests, and other details such as
weight, age, blood pressure and blood sugar levels. The doctor
can also use text messaging which also promotes equitable care
(Storck, 2017).The fax can also contain previous or current

medical conditions and medications of the patient which will
guide the current doctor’s diagnosis and treatment plan.
Overall, the doctor will learn about the policies and procedures
that the other hospital has established in its diagnostic and
treatment processes. It will also show the doctor the
authorization and authentication process of processing patient
records including his intentional purposes for the data.
A nursing leader, in this regard, will rely on clinical
reasoning and judgment by diligently collecting and processing
information regarding the patient’s condition before
implementing any treatment plan. At the managerial level it
requires the interpretation and modification of information and
data for better decision making processes within the information
system (Sweeney, 2017). After all, virtual health services are
the coming trend globally (Nagle et al., 2017). This effort will
ensure the patient in this scenario gets the proper diagnosis and
treatment and thus obtain the best health outcomes based on
evidence-based practices.
References
Nagle,L.M., Sermeus,W., & Junger,A.(2017). Evolving role of
the nursing informatics specialist. Open Access, 212-221.
Sweeney, J.92017). Healthcare Informatics. Online Journal of
Nursing Informatics, 21(1).
Storck, L. (2017). Policy Statement: Texting in Healthcare.
OJNI,21(1).

IN1473
Gaga for Wawa:
Blue Ocean Retailing
06/2018-6421
This case was written by Michael Olenick, Institute Executive
Fellow of the INSEAD Blue Ocean Strategy Institute, with
W. Chan Kim and Renee Mauborgne, Professors at INSEAD. It
is intended to be used as a basis for class discussion

rather than to illustrate either effective or ineffective handling
of an administrative situation.
Special thanks to Jason Hunter, Senior Blue Ocean Strategy
Specialist.
Additional material about INSEAD case studies (e.g., videos,
spreadsheets, links) can be accessed at cases.insead.edu.
Copyright © 2018 INSEAD
COPIES MAY NOT BE MADE WITHOUT PERMISSION. NO
PART OF THIS PUBLICATION MAY BE COPIED, STORED,
TRANSMITTED, REPRODUCED OR DISTRIBUTED IN
ANY FORM OR MEDIUM WHATSOEVER WITHOUT THE
PERMISSION OF THE COPYRIGHT OWNER
This document is authorized for use only by Mahmoud Darrat
([email protected]). Copying or posting is an infringement of
copyright. Please contact [email protected] or
800-988-0886 for additional copies.

“We don’t take success for granted. We’ve seen too many
retailers disappear from

this landscape. I grew up in the department store industry and
many of the
department stores that I worked with don’t exist today. That’s a
very humbling type
of situation. We just don’t take it for granted. So, we’re
paranoid when it comes to
success and we’re always reinventing ourselves. We want to be
around for another
hundred or two hundred years as the company goes back about
two hundred years
at this stage of the game. The Blue Ocean approach and tools
have been pivotal in
helping us realize this aim.”
Howard Stoeckel, Former CEO & current Vice-Chairman, Wawa
Wawa is always on the move. Founded in 1803, the fabled
American firm began as an iron
foundry producing cast iron stove plates and fire backs. Over

the next 200 years the company
with a funny name outpaced its competitors to continuously
create new markets. From the early
days as an iron foundry, Wawa evolved from cast iron stove
plates, railings and pipes to textiles,
to dairy, to groceries, to gas stations, to its current form: a
$10.5 billion sensation whose fan
base is the envy of the convenience retail and quick service
restaurant industries.
The modern incarnation of Wawa began in 1902, when family
patriarch George Wood opened
a dairy farm in Wawa, Pennsylvania. Most dairies were family
farms, and levels of cleanliness
were inconsistent. Wood’s goal was to sell “doctor certified”
milk, a system created by
pediatricians and veterinarians that reduced the likelihood of
milk passing on tuberculosis and
other bacteria. Twenty years before pasteurization was common
practice, Wood wanted a
modern dairy that sold safe milk. He constructed a dairy
processing facility and a distribution
service that would control every step of production from the
animal, to bottling to home
delivery, ensuring sanitary conditions and temperature control.

Before pasteurization, Wood’s milk (and its other dairy
products such as cream, cottage cheese,
etc.) was as healthy and safe as was possible, delivered directly
to customer’s homes1 using
horse-drawn carriages, then stylish trucks. Wawa built a blue
ocean of dairy products based on
trust, delighting his customers and always doing things right.
The Wawa brand, tied to fresh,
Doctors examined the cows, followed strict guidelines to
determine the herds were tuberculin-tested and
disease free. They also inspected the milking barns, procedures,
bottling, storage, and other facilities. Similar
practices are followed today in places where “certified raw
milk” may be sold.
Copyright © INSEAD
1
1

wholesome and trustworthy dairy products, grew along with the
company. As a 1905 Wawa
brochure claimed, “Man cannot improve Nature’s product, so all
we do is keep it clean.”2
Scientific advancements in food safety posed a threat to Wood’s
growing business. In 1856,
French scientist Louis Pasteur had discovered a process to
eliminate microbes – his early work
focused on wine, destroying a microbe that transforms grape
juice to vinegar rather than wine.
He patented the process and called it “pasteurization”. Three
decades later, Robert Koch
discovered that tainted milk carried bacteria that caused
tuberculosis – that pasteurization killed,
rendering milk safe.3 Its adoption was nonetheless slow;
farmers rejected the additional cost
and consumers thought pasteurization destroyed taste.4 In 1899,
another new process,
homogenization, eliminated much of the variability in the taste
of milk, regardless of its source.
Gradually, municipalities started to mandate both milk
pasteurization and homogenization, with
Chicago being the first US municipality to require milk

pasteurization, in 1908. Eventually,
Wawa’s “doctor certified” unpasteurized milk no longer stood
apart.5
In 1929, 24 years after Wawa introduced its safe milk and dairy,
Pennsylvania enacted laws
governing the processing and storage of milk that required all
bulk sale milk be pasteurized. In
response, the Wood family invested $250,000 ($3.5 million,
adjusted for inflation to 2016) in
a modern dairy processing plant (still in operation today) to
pasteurize their milk.
However, thanks to the trust it had earned over the years,
customers to continue buying Wawa
milk and other dairy products,6 either from dairy stores or the
Wawa home delivery service.
2 Thompson, M. M., & Price, D. H. (2004). Wawa. Arcadia
Publishing.
3 This discovery won Koch the 1905 Nobel Prize in physiology.
4 This debate carries on to modern day with 28 US states
allowing strictly controlled sales of unpasteurized
milk under limited specific conditions. However, the

overwhelming majority of milk, including all mass
market milk, is pasteurized.
5 To this day pasteurization laws vary state-by-state. Some
states entirely outlaw unpasteurized milk whereas
others allow the sale, often only from farmers directly to
consumers.
6 The dairy sold pasteurized products from about 1913 while
continuing to sell a full line of certified products.
Homogenization, a process to make milk similar, did not enter
the marketplace on a wide scale until after
WWII. What made the 1920 plant special was that it was really
two plants in one: a certified processing
facility and a pasteurized facility. There had been two separate
plants before but this new “ultra-modern”
plant was designed to comply with health board requirements.
The plant was featured in the June 1933 issue
of Milk Plant Monthly.
Copyright © INSEAD 2

Although the functional features of certified safe milk no longer
mattered (by the 1940’s all
milk was safe) the emotional appeal of the brand and the trust
Wawa had earned carried the
business in an era when consumers bought meat from the
butchers, bread at bakeries, and non-

perishables at small stores.
In post-war America, suburbs blossomed outside of city centres,
allowing more space for
retailers to build “super markets” that brought all products
under the same roof. Besides the
added convenience, they enjoyed economies of scale that
allowed them to offer comparably
high quality at lower cost. Wawa’s dairy delivery slumped in
the 1960s as consumers preferred
to purchase dairy products along with other groceries at
supermarkets. Wawa’s milkmen were
overtaken by progress.
Wawa Food Markets
Faced with the simultaneous collapse of the milk production and
delivery business and also the
remaining industrial businesses,7 Grahame Wood (George
Wood’s grandson), President of
Wawa Dairy Farms, convinced the board of directors to try
something new: retail stores.
Struggling in a red ocean of milk, Wood took out a $50,000 loan
to finance three new grocery

stores.8 Wawa sought to differentiate their little grocery stores
from larger ones by offering
own-brand products which buyers knew and trusted, sold by
friendly and authentic employees
who cared about their customers. Early advertisements
promoted them as an alternative channel
(besides delivery) to purchase fresh Wawa products.
Wood opened the first Wawa Food Market, on April 16, 1964,
in Folsom, PA.9 Wawa
advertisements from this era included milk, chocolate milk,
skim milk, cottage cheese, coffee
cream, whipping cream, sour cream, eggs, butter, orange juice,
bacon. Only two of the 16 items
advertised were non-perishables: syrup and a steak knife.
7 Wawa, at this time, remained a wholly owned subsidiary of
the Millville Manufacturing Company, which
continued to operate textile mills until the 1950s. Here, the
name Wawa describes the corporate entity.
8 At this point in time, the business was financially frail enough
they could not self-finance their stores.
9 This store remained open until June 2016, when the company
moved to a substantially larger building nearby.

Wawa’s commercial outlets leveraged the trust and emotional
connection earned by the milk
and dairy business. The public went wild for Wawa. In 1972 it
opened the 100th store. In 1978
– a dozen years after opening the first store – the firm opened
its 200th store.
Wawa’s strategy was counterintuitive – to deliberately position
stores sub-optimally close to
one another. Traditional grocery stores and branded franchises
positioned stores with ample
space in between to avoid cannibalization and reduce same-store
sales. Wawa flipped the
narrative. In Wawa’s thinking, dense grouping – referred to as
“clustering” – unlocked strategic
benefits. It gave the appearance that the stores were

everywhere, and that Wawa was a much
larger company, creating enhanced credibility.10 At a time
when big companies engendered
trust, this was important. Additionally, clustered stores could
restock one another, share
employees and managers, work from one central distribution
facility to lower logistical costs,
and share best practices. Clustering increased total revenue and
market share, even when
individual stores poached each other’s sales.
Over time, supermarkets grew in size and scope as automation
allowed an ever-increasing
number of items. On 26 June 1974, the first Universal Product
Code (UPC) barcode was
scanned at Troy’s March Supermarket in Troy, Ohio.
Supermarket automation evolved, with
front-end barcode scanning systems connected to back-end
ordering systems to ensure a
constant supply of fresh food delivered to stores on-time with
minimal spoilage. These new
technologies were expensive to implement and the systems
required a high sales volume to
operate effectively. As a result, many small stores, including
smaller supermarkets, were

consolidated or forced out of business.11
Wawa’s early food marts were popular but the company once
again found itself in a red ocean.
Unable to compete on price or selection against new-entrant
automated supermarkets, Wawa
upended the strategic logic. Instead of scaling up to copy their
competitors, Wawa traded down
from small grocery stores to convenience stores. Henceforth,
whereas supermarkets would
carry a full line of fruits and vegetables, Wawa now had a
limited produce offering, often grown
on the dairy farm. Whereas grocery stores had a full line of
meat and fish, Wawa featured a
small delicatessen that sold sliced sandwich meat.12 With the
transition to a convenience store,
Wawa dropped “Food Market” from the firm’s name.
Wawa did not invent the convenience store. In 1927, 7-Eleven
opened its first store in Dallas,
Texas. 7-Eleven stores were small and offered a limited
selection of (oftentimes lower quality)
products but with longer hours than traditional stores (from 7am
to 11pm). However, unlike 7-
Eleven stores, which were franchised, Wawa’s were entirely

company owned and operated.
Centralized ownership enabled a focus on the stores as a whole,
rather than on each individual
store as a profit centre competing with the others. Both sold
milk, but Wawa sold its own brand
milk. Both had clerks, but Wawa’s staff were friendly members
of the community serving other
members of the community. Still, there was some copying: in
1972, Wawa expanded its hours
to remain open 24/7.
10 A strategy Starbucks would later use with great success.
11 On May 9, 2017, Marsh Supermarkets – owner of Troy’s
where the barcode was first used – declared
bankruptcy. Troy’s was sold.
12 The Evolution of the Supermarket Industry: From A&P to
Walmart. Paul B. Ellickson, University of
Rochester (2015). http://paulellickson.com/SMEvolution.pdf

“When we entered the convenience industry, 7-Eleven was
already a national chain, but we
found an advantage by making all our stores company owned
and company operated. Other
convenience store chains use a franchise model. That means
they’re not nearly as consistent as
we are and have a much different corporate culture; and their
corporate business has always
been about selling franchises first, convenience second. Our
business is about running each and
every store on our own and maintaining consistency throughout
the chain,” said Howard
Stoeckel.13
Whereas many convenience stores offered a tepid “Thank you –
come again”, Wawa’s customer
service stood apart. With its long history in the Delaware Valley
community, friendly
atmosphere and high-quality products, locals fell in love with
Wawa. Unlike anonymous
conglomerates, the company was emotionally invested in the
community. Its ubiquitous stores,

high-quality private-label brands and friendly atmosphere set
Wawa apart from traditional
convenience stores. Wawa employees would, for example, check
up on an elderly regular
customer who failed to show up, and always served customers
with a smile. Prompted by the
friendly atmosphere, Wawa customers routinely hold doors open
for one another.
This cycle of creation, recreation, and eventual imitation by
competitors continued, with Wawa
moving back and forth between a red and blue ocean business.
“Around 1990 business was
slow and very sluggish,” explained Stoeckel. “Convenience
stores at that point went through a
very difficult period because supermarkets were expanding
hours, discounters were more
aggressive, our pricing was out of line, and we didn’t have
many proprietary brands.” Still, at
Wawa there was an ongoing focus on speed and friendliness
joined with an unwillingness to
nickel-and-dime customers through, for example, upcharges for
credit-cards.
Over time, Wawa retained an ongoing advantage over both

grocery and convenience stores
thanks to clustering, refusing to enlarge stores into full-size
supermarkets or expand its national
footprint, leaving their ever-increasing number of stores near
one another. Clustering reduced
marketing costs and simplified logistics while allowing the
company to focus on the specific
communities it served. “Our desire is to be better than to be a
national brand,” said Stoeckel.
“We may wake up someday, in 50 years, and find ourselves a
national brand. But that probably
would take 50 to 100 years, but that’s never been our desire. We
want to be the best we can be.
We want to fulfil our customers’ daily lives. We want to be part
of their daily routine. We want
to be top-of-mind every single morning when they wake up.
And we want greater frequency
than any other retailer.”
In 1994, Wawa opened a first “superstore”, featuring
considerably more parking and space,
4,780 square feet (444 square meters). Most older Wawa stores
at this time were small, with
cramped parking lots.

In 1996, the firm expanded into an entirely new market, adding
high-quality, high-efficiency
fuelling stations with its own private label: Wawa gas. As
Wawa’s gas was not a well-known
brand, its innovation was to guarantee the gasoline would not
damage cars – the same promise
it had for milk three generations earlier. Wawa installed high-
speed pumps to make the task of
13 Stoeckel, Howard. The Wawa Way: How a Funny Name and
Six Core Values Revolutionized Convenience
(p. 42). Running Press. Note: all other Stoeckel quotes are from
first hand interviews.

filling the tank faster for customers14 and eliminated charges

for credit-cards so people would
always get a good price whether they had cash or not. It was
usually the lowest cost fuel
retailer.15 The firm also ensured there were many pumps so
people wouldn’t have to wait to
refuel.
Fuel is a low-margin business, but Wawa’s offering inspired
customers to come to Wawa for
fuel, which also brought people into the stores, where it
installed automated teller machines
(ATMs) that did not charge fees.16 So, fuel brought customers
and free ATMs made stores more
appealing – people rewarded Wawa by spending a good portion
of the money they withdrew at
Wawa.
Like many convenience stores, Wawa offered an underwhelming
selection of largely unhealthy
pre-packaged snacks. The firm had been selling sliced deli meat
and coffee since 1975, but the
offering was limited.17 In the mid-1990s, Wawa experimented
by partnering with third-party
quick-serve food chains. This move alienated staff (who wanted
to work on Wawa brand

products) and underwhelmed customers. The branded
restaurants were quickly removed.
Convenience goods, fuel, and roadside food are all cut-throat
red ocean industries, competing
on marketing and price. The US Bureau of Labor Statistics puts
gas stations and small grocery
stores in the top-ten businesses most likely to fail. Restaurants
tend to do better but are still a
high-risk industry. “There are so many strong competitors in
each of these industries,” said
Stoeckel. “It’s not like McDonald’s against Burger King. It’s
not like Costco against Sam’s
Club. You had Subway expanding dramatically. You had the
fast casual (food) business: Panera
and companies of that nature coming into the marketplace.
There were just so many competitors
and we recognized at that point, as we have at other times in our
history, the need to distance
ourselves from other players and stay true to who we are.”
As the financial crisis of 2008 unfolded, Wawa, along with
almost all retailers, felt the pinch of
constrained consumer spending. In response to the recession,
companies began to aggressively

copy the Wawa offering. Faster pumps, lower wait times, and no
credit-card surcharges became
more common. “The marketplace became more and more
competitive (in 2009) and we’re in
three businesses,” said Stoeckel. “We’re in the fuel business,
we’re in the convenience business
and we’re in the food service business. There are players in all
three businesses that have deeper
pockets. McDonald’s has deeper pockets than we do; Exxon-
Mobile has deeper pockets than
we do. You had the hypermarkets and supermarkets going into
the gasoline business. So, as we
looked at the future, particularly 2010 to 2014, we saw things
converging. We very consciously
14 In at least one market, New Jersey, people are prohibited
from filling their own cars: only fuel station
attendants may fill cars. Although customers wait more
comfortably inside their cars the faster fill-ups still
add value.
15 Besides low cost and high quality the firm also has a
commitment to honesty that serves as a differentiating
factor. For example, in the Orlando market – where they have
recently been expanding in – they effectively

drove two sham gas stations positioned out of business. Those
gas stations were positioned to sell tourists
fuel at outlandish prices; Wawa created a third station and made
it clear, to foreign tourists unaccustomed to
the US’s low fuel prices, what normal pricing should be.
16 Wawa does not impose the upfront surcharge fees often
imposed by retailers. However, customers’ banks
may impose fees.
17 Hoagies are sandwiches on a large baguette like bread. In
other geographic regions they are called subs,
heroes, grinders, or Italian sandwich.

said that we needed to distance ourselves from this highly
competitive marketplace and create
this wave of innovation that would create value for both the
company and our customers.”

Before the competitors caught up, Stoeckel convened senior
management to study the business
strategy in 2009. As he looked at the marketplace, it became
clear that its competitors were
converging with Wawa. In response, Stoeckel handed out
popular business books and asked
executives to read them with an open mind. “The more leading
business books we read, it
became clear to us that the tenets of Chan Kim and Renée
Mauborgne’s book Blue Ocean
Strategy fundamentally spoke to who we were and what we
aspire. We realized that we are
absolutely Blue Ocean,” said Chief Operating Officer Cathy
Pulos. “We really are Blue Ocean,
and it's really about value innovation – pursuing differentiation
and low costs, not one or the
other - as we looked at the activities and milestones in our
history.”
Rather than try to compete head-to-head with the industry,
Wawa reconstructed the market
boundaries to break away from the competition and open new
value-cost frontiers. “After team
discussions, top management saw that we risked sinking into the

red ocean if we didn’t rethink
Wawa’s strategy. That was when the team agreed to move
forward and to consciously apply
the Blue Ocean approach and its tools to the rising red ocean
challenge we confronted,” said
Pulos.
As Stoeckel explained, “The Blue Ocean approach and tools
gave us a systematic way to
address the challenge we confronted to open a blue ocean of
new growth for the company. As
we set out to rethink of our strategic plan, we applied the Blue
Ocean tools and process as the
backdrop for our strategic planning process,” explained
Stoecke, “and referred to it as our ‘Blue
Ocean Strategic Plan.’”
Blue Ocean Shift
Senior executives drew as-is strategy canvases, a key analytic
of Blue Ocean Strategy, to study
their current business.18 They concluded the food service
business was the weakest of their
three offerings – food, fuel, and convenience – but also the one
with the highest potential for

growth. Buyers did not believe that a convenience store or gas
station could offer high-quality
food, but with the blue ocean tools and process, Wawa saw a
way to change that. To make a
blue ocean shift, Wawa would redefine itself from a
convenience store with gas that also sold
food, to a quick service restaurant that also sold convenience
items and gas.
The company had been serving sliced meat and hoagies, but the
bread wasn’t baked fresh on
the premises and the ingredients were limited and hadn’t been
creatively rethought to reflect an
array of healthy fresh toppings. In the old offering, food
counters were stacked high with upsell
items: salty snacks and other packaged unhealthy items. This
created the impression that cheap-
quality products like hotdogs, that been rolling around on an
electric cooker for hours, existed
only for people with no other options. Checkout counters
featured cigarettes and aisles were a
maze, designed to route shoppers past impulse buys. Wawa
looked like a convenience store that
also sold uninspiring food (like the rest of the industry).

18 See W. Chan Kim and Renée Mauborgne, Blue Ocean
Strategy (Harvard Business Review Press, 2005, 2015)
and Blue Ocean Shift (Hachette, 2017).

Transitioning to a quick service restaurant that also sold a
limited selection of goods and fuel
required a major shift – in the look and feel of stores, the food,
and the store layout. To succeed,
Wawa eliminated certain amenities that seemed expensive yet
added little value: its quick-
service restaurants had neither tables nor servers.
Food
The Blue Ocean shift revealed that food freshness and
healthfulness had to be created and
quality raised. But to offer a quantum leap in buyer value,
Wawa did not stop there. It aimed to
couple the new food offering with significantly lower prices –
thereby establishing a new value-
cost frontier that made traditional quick service restaurants
essentially irrelevant.

Americans love comfort food but management appreciated that
to do right by customers, and
the trend toward healthy alternatives, Wawa had to offer an
array of fresh ready-to-go salads,
wraps and crudities (not the type that people pick up in sealed
containers and scrutinize to
determine just how long they’ve been lying around, or whether
they actually contain quality
ingredients). The aim was to break the stereotype by creating
delicious fresh salads – think kale
and quinoa, original customized salads that would surprise, and
classics like fresh Caesar salad
with grilled chicken breast – made every day with only the
highest quality ingredients.
Wawa also needed to create healthy delicious hot alternatives.
Breakfast choices not found in
many restaurants, much less convenience stores, include egg
whites, turkey sausage, and
gourmet items like Applewood Smoked Bacon. Lunch choices
would be their famous hoagies
–but with a fresh, high-quality twist – bread baked on the
premises, top-quality meats, and fresh
vegetable and cheese accompaniments – plus roast chicken,

paninis, flatbreads, quesadillas, and
burritos made to order. Dinner items were geared towards
complimenting main courses people
cook at home, with a variety of soups and traditional side
dishes.
Wawa also focused on coffee – up to 12 types, from dark brew
to French roast or hazelnut – all
at Starbucks quality but far lower price and faster delivery.
Almost all were walk up, pour a
cup, and leave. Offerings include limited reserve coffee – like
Kenyan AA beans – all at $1 per
cup regardless of size. At the centre of this effort was a large
number of high-quality self-serve
coffees kept hot by thermal carafes, accompanied by additional
flavourings and other amenities.
The new carafes kept coffee fresh, enabling higher quality
coffee at lower cost due to less
spoilage, and the self-service offering freed staff to focus on
customized hot drinks, speeding
up that process as well. “If you’re a coffee drinker, welcome to
Nirvana,” wrote one travel
blogger.19
19 “I Wawa, Wawa, Wonder.” Excessive Excursionist, 29 Mar.

2011,
excessiveexcursionist.wordpress.com/tag/wawa/

Speed
Ordering food in a quick service restaurant was recognized as a
perennial pain-point even for
restaurants with limited menu choices. Wawa’s highly
customizable offerings could create
mayhem as customers struggled to explain their choices to a
person transcribing the order into
a computer system. To increase speed while reducing
complexity and cost, Wawa was an early
pioneer in ordering kiosks that efficiently and accurately
accepted orders directly from
customers. “Want bacon on that breakfast burrito? How about
extra lettuce? Even add a hot
soup or side to round off your meal. Most of their food
offerings are available Built-to-Order at
the touchscreen...”20 Quoting Stoeckel: “It’s a friendly,
efficient experience.”
Store Look
To create an atmosphere that inspired people, Wawa set out to
change the look and layout of its

stores. Old stores received an interior overhaul and new stores
would be built with food at the
core. Gone were the aisles that blocked a near-hidden food
counter, the processed snacks and
Slim Jim’s piled high at the food counter. New Wawa stores
looked like takeout restaurants that
sell other items (rather than convenience stores that sell food).
Stores were airy and uncluttered,
with a modern feel. General purpose goods, including
cigarettes, were on sale but not the
centrepiece. Aisles were spacious and parking abundant. As you
walked into the stores, the food
counter was straight in front, immediately visible and inviting
with modern clear signage with
the fast, easy-to-use ordering kiosks so the need to stand in line
was significantly reduced.
The Friendliest, Authentic Service
When it comes to service, whether in a quick service restaurant
or any place else what most
people want is warm authentic service that genuinely feels like
people care about you, want to
make you happy, and bring joy to your day. Wawa management
had long taken great pride that

that type of service was precisely what Wawa was known for
when it came to its convenience
stores. Its 30,000 store Associates take pride in working at
Wawa and getting to know and bring
20 Wawa was a pioneer in self-serve touch-screen kiosks. Since
that time the technology has become more
common in quick serve restaurants.

joy to their customers. What the blue ocean process made clear
was that Wawa management
could leverage this capability as they coupled it their new food
offering, creating a level of
authentic service and customer stewardship that would further
set its new value proposition in
food apart.
Building a Compelling Profit Proposition for its Shift
With the parameters for its new offering defined, the question
was to how to build a compelling

profit proposition to make the Blue Ocean shift. Wawa was,
after all, aiming for the freshest,
high-quality, delicious food, reasonably priced, yet knew little
about sourcing fresh ingredients
or making the range of foods daily, at the lowest cost, that its
new value proposition demanded.
Rather than compromise or attempt a costly and risky effort to
build these capabilities in-house,
it challenged the key assumptions behind the business model of
quick service restaurants. And
as it did so, new ideas came into focus.
Executives understood the value of strategic partnering from
prior work with McLane, a $50
billion grocery logistics company owned by Berkshire
Hathaway, which had been delivering
its convenience store goods for years. Wawa’s clustering of
stores made it possible for McLane
to efficiently supply Wawa’s stores, allowing McLane to keep
its costs low, while Wawa
achieved steep economies of scale for convenience items.
Couldn’t Wawa’s clustering be
leveraged again - in this case to deliver healthy, fresh, high-
quality salads and all other food

items on a daily basis?
Wawa management partnered with Taylor Farms – tagline
“America’s Favorite Salad Maker”
– to provide fresh salads to Wawa daily. Its expertise in
sourcing the freshest produce at low
cost (due to their high volumes as well as facilities and
expertise in fresh food preparation)
allowed Wawa to achieve salad expertise overnight without the
costs of adding purchasing
agents or food prep staff to its payroll, not to mention kitchen
facilities.
Wawa turned to the Safeway Group, a family-owned leader in
pre-made foods like roast
chicken, for its premium fresh food delivered daily. The food
items from both Taylor Farms
and the Safeway Group were delivered every day to all of its
stores by the shipping giant
Penske, ensuring everything was delivered at the correct
temperature.21 Penske coordinated
bundling and delivery from the various food logistics providers
to Wawa’s clustered stores, a
process called “cross-docking”.

In Wawa’s early days as a food mart, bread was sourced from
Philadelphia’s acclaimed
Amoroso bakery. To replicate the quality and freshness of
Amoroso’s at scale Wawa now
installed bread ovens in every store and delivered ready-to-bake
dough supplied by Amoroso,
so that sandwich bread was the freshest possible. These
companies were willing to work with
Wawa due to the fact that its stores were clustered near one
another, enabling large scale in a
tight geography.
“To shift and break away from the competition, the blue ocean
tools and process effectively
channelled our efforts to challenge how we could offer a leap in
value for our customers while
21 Case Study. “Wawa: A Fresh Look at the Northeast’s Most
Recognized Convenience Store.” Penske
Logistics, Penske, 2015,
www.penskelogistics.com/pdfs/08_wawa_case_study.pdf

pushing for a radical drop in the costs and speed of making this
happen. The idea of partnering
with Taylor Farms and the Safeway Group had a tremendous
impact on the economics of our
business model. It allowed us to eliminate the cost of building
and staffing a full-scale restaurant
kitchen in every store which also means far less real estate is
needed than at other quick-service
restaurants,” said Stoeckel.
Despite that the stores are large the kitchens are small because
almost all food is prepared
freshly at centralized facilities. Wawa kitchens, feeding
thousands of people per day, are no
larger than many home kitchens. The hot food is flash-frozen to
lock in freshness at the Safeway
Group and delivered daily. “To ensure freshness, our kitchens
have thermal heating machines,
with each about the size of a large dishwasher,” explained
Stoeckel. “The thermal heaters use
hot water – not microwaves. And as demand for a food item
grows in the day, a flash-frozen
pack is placed in the heater. To ensure freshness, each item has

a specified amount of time the
food can remain in the heater before serving. Any food that
passes that time is not allowed to
be served as a guarantee of freshness.” In this way, sanitation of
food was also maximized,
freshness ensured, and minimal kitchen equipment called for.
Making a strategic shift, and creating effective partnerships was
vital but Wawa had to also
physically overhaul the look and layout of its stores, oftentimes
opting to close older small
stores and replace them with larger new one’s nearby. Some
older convenience stores were not
large enough to offer the higher value/low cost throughput of
the new strategic offering, and
their parking lots were too small. During the Blue Ocean shift,
Wawa closed old stores,
replacing them with newer ones nearby – but not in one fell
swoop. To manage risk and build
buy-in, the firm tested its new strategy in select stores to allow
kinks to be ironed out, confirm
its market appeal, and share customer testimonies with its
30,000 associates of the shift’s
appeal. When store managers and staff saw and heard testimony
of how customers loved the

shift, Wawa management appreciated that the new strategy
would be more rapidly embraced in
the roll-out and that people would embrace the new strategy
with ‘pushback’ minimal.
Involvement
Wawa utilized fair process to include the tens of thousands of
employees needed for a
successful strategic shift. Thanks to an Employee Stock
Ownership Plan (ESOP), where
employees own about 40 percent of the company and close to
200 cousins own the majority of
the remainder, employees were already invested in the long-
term success of the company. But
Stoeckel also made sure employees were engaged and involved,
creating custom videos
explaining the transformation, oftentimes visiting stores, and
always listening to feedback.
“When you think about it when we come to work each and every
day we see our shareholders,”
said Stoeckel. “Our shareholders are in the stores. They’re in
the main office. They’re our
friends. They’re the people that we work with each and every
day. Their lives go as Wawa’s

success goes.”
This use of fair process, combined with the core shift, aligned
value, people and profits not only
within the stores but also between senior management and store
associates. “Most CEO’s, most
leaders, don’t see their shareholders, don’t live with their
shareholders, don’t work with their
shareholders,’ said Stoekel, “they’re mutual funds, they’re
investors throughout the world. They
have no emotional attachment to the business.”

Senior management also follows a longstanding tradition of
spending time in stores. Each
executive spends a minimum of one full day every month
visiting 12 to 15 stores to talk with
associates and managers. At Christmas, executives visit stores
and thank associates for
outstandingly serving customers 365 days per year. On every
visit, management is there to

listen, thank, learn about associates’ concerns, and ask them to
share ideas for improving
operations.
Blue Ocean Success
The primary benchmark of a blue ocean business is that it does
not compete head-to-head but,
rather, makes the competition irrelevant. True to form, industry
analysts and competitors see
Wawa as an irrelevant player in the quick serve restaurant
industry despite their size.
QSR 50, the industry standard ranking of convenience stores
and fast-casual restaurants, does
not classify Wawa in their top 50 brands. “Wawa is not on the
list because it is a convenience
store, and we only include quick-serve restaurants,” explained a
QSR magazine analyst.
“Generally, if a store offers gasoline and/or packaged goods it’s
a convenience store.” If Wawa
was included, it would be ranked first, ahead of industry leaders
Chick-fil-A, Panera, and
McDonald’s in per-store sales and fifteenth in overall revenues,
despite a more limited

footprint.22
Similarly, an executive from fast casual competitor Panera also
referred to Wawa as a niche
player, dismissing the company outright. Panera has a national
footprint but their overall sales
are about one-third of Wawa’s; Wawa’s per store sales are
significantly higher.
“If you sell gas, people have traditionally assumed you can’t be
a high-quality food restaurant,”
said Stoeckel. “So, we set out to redefine the space by
completely changing that very perception.
We aimed to create a leap in value, in the quality, freshness and
overall health of the food we
sold at the best possible price. The result was that we recast
Wawa from a convenience store
and gas station that also sells food, to a leading quick-service
restaurant and leader in the fast-
casual-to-go space that also sells gas and convenience items.”
While industry associations and
fast casual players like Panera might not get it, customers
certainly do.
Conversely, Wawa’s search for noncustomers is central to its

Blue Ocean shift. “We wanted
customers that shop Starbucks, that shop Panera, that shop
Chipotle – along with all those
customers who shop McDonald’s and Burger King and Wendy’s
– to feel very comfortable in
a Wawa store,” said Stoeckel. “People who rarely ate at quick-
service restaurants not only
became customers of Wawa’s new offering, many became
frequent customers.” (In fact, in
writing this case, numerous people volunteered how they, their
children, or their friends loved
Wawa’s food – without prompting).
As prominent Florida restaurant critic Jean Le Boeuf put it,
“Kale and quinoa, from a gas
station, and it’s actually good.”23 Besides its quick-service
restaurant offering, Wawa’s ever-
22 “The QSR 50.” QSR Magazine, 3 Aug. 2015,
www.qsrmagazine.com/reports/qsr50-2015-top-50-chart
23 Le Boeuf, Jean. “Jean Le Boeuf: I Binged on Wawa Food.”
News-Press, USA Today, 23 Apr. 2015,
newspr.es/1mygwqT

growing selection of high-quality private label products –
especially their line of teas – have an
almost cult-like following. Private label goods are also created
by outsourced companies.
With the success of its Blue Ocean shift and the worst of the
global financial crisis behind it,
by 2012 Wawa was ready to lengthen, widen and deepen its blue
ocean by expanding into
Florida. Today the firm has over 800 stores, including more
than 150 in Florida, with more in
the pipeline. All Florida stores are quick-service restaurant-first
Wawa’s and have been wildly
successful.
As of 2017 Wawa is estimated to be the 34th largest private
company in America, serving 625

million customers in 2017, with $10.5 billion in revenue from
789 stores in six states. In the
territories they serve, Wawa leads in coffee sales (222 million
cups a year), sandwich sales (105
million a year), and its gasoline sales are considerably higher an
average station. An average 7-
Eleven convenience store brings in $30,000 to $35,000 per
week; Wawa averages $116,000.24
Wawa’s Blue Ocean aligned value, profit, and people. Its food,
non-food items, and fuel are all
high-quality and low cost. The company is exceptionally
profitable. Wawa’s people not only
write glowing reports about their work environment, even on
anonymous internet bulletin-
boards, but can retire with six- and even seven-figure savings
due to the employee profit-sharing
plan, which keeps going up in value with Wawa’s passion to
break out of red oceans and keep
sailing toward open, blue waters.
Epilogue
A decade after the successful Blue Ocean shift Wawa’s growth
remains strong, with record

sales and profits year-after-year. The company continues to
open new stores based on the new
Blue Ocean model. But, as is usually the case, the red ocean
marketers have noticed and are
now, a decade later, beginning to copy. Convenience fare food,
led by Wawa, is rapidly
improving. “When it comes to food offerings, convenience
stores can no longer afford to stick
to the basics. Leading on fresh, natural food trends will be
essential going forward, particularly
as other channels have diversified into everything from sushi to
gourmet sandwiches—offerings
a step above from what they can make easily at home. Being
transparent and health conscious—
and displaying these attributes—will also be critical,” said US
analyst firm Nielsen.25
So, as they always have, Wawa continues to innovate and has
set out to make a new Blue Ocean
shift. A December 2017 expansion into Washington, DC,
brought a new look and enormous
crowds. At over 9,000 square feet (835 square meters) the DC
store is the largest Wawa to date.
There is ample indoor and outdoor seating, free Wi-Fi, and no
fuel pumps. Ordering kiosks still

exist but they’re joined by mobile phone apps and interactive
digital wall panels.
Reviewing the new store the Washington Post wrote, “Fans of
Wawa – whose logo and mascot
Wally the Goose serves as a beacon in the night for famished
road trippers and hoagie fans alike
– love it for its convenience, variety, food and, likely, the tug of
nostalgia. This Jersey girl can’t
24 Steinberg, Don. “It’s a Wawa World.” Philadelphia,
Philadelphia Magazine, 27 July 2011,
www.phillymag.com/articles/wawa-world/
25 “How U.S. Convenience Stores Can Stay Ahead of the Retail
Pack.” N Insights, Nielsen, 17 May 2017,
www.nielsen.com/us/en/insights/news/2017/how-us-
convenience-stores-can-stay-ahead-of-the-retail-
pack.html

look at a Wawa chocolate-glazed doughnut without
remembering how, as a child, she would
beg her father to buy her one any time they stopped in.”26
Questions
• What can struggling retailers learn from Wawa’s Blue Ocean
shift?

• As they developed their Blue Ocean shift, how might the
traditional red ocean practice of
benchmarking against competition help or hurt Wawa? Why?
• Restaurants, convenience stores, and gas stations are some of
the lowest margin, highest
risk business types. Wawa is all three, but the company is
thriving, with record revenue and
profits year after year. Why?
• If you were a Wawa executive how would you continue to
protect and expand your Blue
Ocean?
• How does each Wawa business line build upon and reinforce
the prior components?
26 Simmons, Holley. “The Largest-Ever Wawa Just Opened in
D.C. Here’s Why It’s a Big Deal.” The
Washington Post, 14 Dec. 2017,
www.washingtonpost.com/news/going-out-
guide/wp/2017/12/14/the-
largest-wawa-ever-just-opened-in-d-c-heres-why-its-such-a-big-
deal/

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