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Description

For this assessment you will create an 8-12 slide PowerPoint
presentation for one or more stakeholder or leadership groups to
generate interest and buy-in for the plan proposal you developed for the
third assessment.

For this assessment you will create an 8-12 slide PowerPoint presentation for one or more
stakeholder or leadership groups to generate interest and buy-in for the plan proposal you
developed for the third assessment.
As a current or future nurse leader, you may be called upon to present to stakeholders and
leadership about projects that you have been involved in or wish to implement. The ability to
communicate a plan—and potential implications of not pursuing such a plan—to stakeholders
effectively can be critically important in creating awareness and buy-in, as well as building your
personal and professional brand in your organization. It is equally important that you know how
to create compelling presentations for others’ delivery and ensure that they convey the same
content you would deliver if you were the presenter.
You are encouraged to complete the Evidence-Based Practice: Basics and Guidelines activity
before you develop the presentation. This activity consists of six questions that will create the
opportunity to check your understanding of the fundamentals of evidence-based practice as well
as ways to identify EBP in practice. The information gained from completing this formative will
help promote success in the Stakeholder Presentation and demonstrate courseroom
engagement—it requires just a few minutes of your time and is not graded.
Demonstration of Proficiency
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Competency 1: Explain strategies for managing human and financial resources to
promote organizational health.
o Explain how the interdisciplinary plan could be implemented and how the human
and financial resources would be managed.
Competency 2: Explain how interdisciplinary collaboration can be used to achieve
desired patient and systems outcomes.
o Explain an organizational or patient issue for which a collaborative
interdisciplinary team approach would help achieve a specific improvement goal.
Competency 3: Describe ways to incorporate evidence-based practice within an
interdisciplinary team.
o Summarize an evidence-based interdisciplinary plan to address an organizational
or patient issue.
o Propose evidence-based criteria that could be used to evaluate the degree to which
the project was successful in achieving the improvement goal.
Competency 5: Apply professional, scholarly, evidence-based communication strategies
to impact patient, interdisciplinary team, and systems outcomes.
o Slides are easy to read and error free. Detailed speaker notes are provided.
o Organize content with clear purpose/goals and with relevant and evidence-based
sources (published within 5 years) with an APA formatted reference list with few
errors.
Professional Context
This assessment will provide you with an opportunity to sharpen your ability to create a
professional presentation to stakeholders. In this presentation, you will explain the Plan-Do-
Study-Act cycle and how it can be used to introduce the plan (P), implement the plan (D), study
the effectiveness of the plan (S), and act on what is learned (A) to drive continuous
improvement. By using this cycle, the stakeholders will have a tool and a proposal to expand on
these ideas to drive workplace change and create improved processes to solve an
interprofessional collaboration problem.
Scenario
In addition to summarizing the key points of Assessments 2 and 3, you will provide stakeholders
and/or leadership with an overview of project specifics as well as how success would be
evaluated—you will essentially be presenting a discussion of the Plan, Do, and Study parts of the
PDSA cycle. Again, you will not be expected to execute the project, so you will not have any
results to study. However, by carefully examining the ways in which your plan could be carried
out and evaluated, you will get some of the experience of the thinking required for PDSA.
When creating your PowerPoint for this assessment, it is important to keep in mind the target
audience: your interviewee’s organizational leadership. The overall goal of this assessment is to
create a presentation that your interviewee could potentially give in his or her organization.
Instructions
Please follow the Capella Guidelines for Effective PowerPoint Presentations [PPTX]. If you
need technical information on using PowerPoint, refer to Capella University Library: PowerPoint
Presentations.
Be sure that your plan addresses the following, which corresponds to the grading criteria in the
scoring guide. Please study the scoring guide carefully so you understand what is needed for a
distinguished score.
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Explain an organizational or patient issue for which a collaborative interdisciplinary team
approach would help achieve a specific improvement goal.
Summarize an evidence-based interdisciplinary plan to address an organizational or
patient issue.
Explain how the interdisciplinary plan could be implemented and how the human and
financial resources would be managed.
Propose evidence-based criteria that could be used to evaluate the degree to which the
project was successful in achieving the improvement goal.
Communicate the PowerPoint presentation of the interdisciplinary improvement plan to
stakeholders in a professional manner, with writing that is clear, logically organized, and
respectful with correct grammar and spelling using current APA style.
There are various ways to structure your presentation; following is one example:
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Part 1: Organizational or Patient Issue.
o What is the issue that you are trying to solve or improve?
o Why should the audience care about solving it?
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Part 2: Relevance of an Interdisciplinary Team Approach.
o Why is using an interdisciplinary team relevant, or the best approach, to
addressing the issue?
o How will it help to achieve improved outcomes or reach a goal?
Part 3: Interdisciplinary Plan Summary.
o What is the objective?
o How likely is it to work?
o What will the interdisciplinary team do?
Part 4: Implementation and Resource Management.
o How could the plan be implemented to ensure effective use of resources?
o How could the plan be managed to ensure that resources were not wasted?
o How does the plan justify the resource expenditure?
Part 5: Evaluation.
o What would a successful outcome of the project look like?
o What are the criteria that could be used to measure that success?
â–ª How could this be used to show the degree of success?
Again, keep in mind that your audience for this presentation is a specific group (or groups) at
your interviewee’s organization and tailor your language and messaging accordingly. Remember,
also, that another person will ultimately be giving the presentation. Include thorough speaker’s
notes that flesh out the bullet points on each slide.
Additional Requirements
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Number of slides: Plan on using one or two slides for each part of your presentation as
needed, so the content of your presentation will be 8–12 slides in length. Remember that
slides should contain concise talking points, and you will use presenter’s notes to go into
detail. Be sure to include a reference slide as the last slide of your presentation.
Number of references: Cite a minimum of 3 sources of scholarly or professional
evidence that support your central ideas. Resources should be no more than five years
old.
APA formatting: Make sure that in-text citations on your slides and in your notes pages
and reference slide reflect current APA Style and Format.
Leadership
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Grindel, C. G. (2016). Clinical leadership: A call to action. Medsurg Nursing, 25(1), 9–
16.
o This article discusses the characteristics—and importance—of nurses who exhibit
clinical leadership.
Clinical Leadership: A Call to Action
Grindel, Cecelia Gatson. Medsurg Nursing; Pitman Vol. 25, Iss. 1, (Jan/Feb 2016): 9-16.
Headnote
Clinical nurses are expected to assume leadership roles to enhance patient care and assure
efficient work processes. Dimensions of clinical leadership and the essential knowledge and
skills of the clinical leader are described.
The call for nurse leadership at the bedside has been emerging over the last 15 years. Since the
publication of the Institute of Medicine’s (IOM) report, To Err is Human, Building a Safer Health
System (IOM, 1999), the demand has increased for clinical nurses to take the lead in ensuring
quality patient care, patient safety, and healthy practice environments. While clinical nurses are
expected to assume leadership roles to enhance patient outcomes, guarantee patient safety, and
assure efficient work processes, many of them lack the knowledge and skill. To assume
leadership roles at the point of service, nurses must master the essential knowledge and skills of
clinical leaders.
Four landmark IOM reports provide the framework for the development of clinical leaders by
identifying the need for (a) environmental changes in health care to decrease medical errors
(IOM, 1999), (b) redesign of clinical services to assure quality care (IOM, 2001), (c) elimination
of variations in practice (IOM, 2004), and (d) development of clinical leaders to spearhead
change initiatives in the practice environment (IOM, 2011). A significant nursing directive has
evolved from these four IOM reports: Clinical nursing leadership at the point of service now is
recognized as a central professional competency to ensure quality patient care and patient safety.
Nurse leaders at the bedside are clinical experts who provide direct patient care that continually
improves patient outcomes and enhances the practice environment. They are empowered clinical
experts who demonstrate emotional intelligence, challenge ineffective work processes, and
inspire others to act. These nurse leaders recognize their power, professional and ethical
responsibilities, and clinical autonomy to engage in decision-making related to patient care and
nursing practice in an interprofessional practice environment (Benner, 2001; Benner, Sutphen,
Leonard-Kahn, & Day, 2008; Cook, 2001; Downey, Parslow, & Smart, 2011; Kouzes & Posner,
2007; Stanley, 2006; Weston, 2008).
The benefits of being a clinical leader at the bedside are many. Clinical leaders report greater job
satisfaction, increased personal satisfaction in their own accomplishments, and more
opportunities for career advancement. In addition, they take great pride in the accomplishments
of those they have influenced. Clinical leadership at the point of service also has benefits for the
employing agency. The delivery of patient care services is enhanced as patient safety, care,
outcomes, and satisfaction are improved; work processes are more efficient; errors are reduced;
and waste in the workplace is eliminated. These enhancements support a healthy practice
environment (Downey et al., 2011; George et al., 2002).
Regardless of the benefits of being a clinical leader, many nurses do not seek leadership roles in
their practice environments. Many reasons are given for the declining interest in a leadership
role. Nurses indicate they are too busy with patient care, lack the necessary knowledge and skills
for leadership, do not want to take on more work, or do not believe they have the power to lead
in their workplace. Also some nurses do not recognize or acknowledge their professional
responsibility to assume a leadership role in their practice environment. In reality, nurses have
the freedom and authority to make nursing care decisions concerning patient care and work
processes (Weston, 2008).
Determination of Essential Knowledge and Skills
In recognition of the need for clinical leadership at the point of service, the Academy of
MedicalSurgical Nurses (AMSN) assembled a task force of clinical and leadership experts to
develop a curriculum for leadership development for medical-surgical nurses at the point of
service. This task force reviewed the literature and the IOM reports, obtained input from nurse
experts and leaders, and evaluated research findings from AMSN’s Nurses Nurturing Nurses
program. Following a series of discussions, the content was rank-ordered to determine essential
knowledge base and skills for clinical leaders. The curriculum information was compiled into
eight categories, each containing two topics. Ten of the topics were designated as basic
knowledge for clinical leaders at the bedside. Two topics focused on the role, characteristics, and
skills of the clinical leader and the part motivation plays in clinical leadership; these areas are not
presented in this article. The remaining six topics were categorized as advanced knowledge and
skills for the clinical leader at the bedside and will be addressed in the future.
The core knowledge topics are discussed in the next section. The competency skills of clinical
leaders at the bedside follow.
Core Knowledge for Clinical Leadership
The eight core topics of knowledge have been classified into clinical practice and the practice
environment categories (see Table 1). A brief overview of every topic is presented; however, the
author encourages readers to engage in an in-depth inquiry into each topic. After a topic is
reviewed, use the Clinical Leadership Knowledge Assessment Form (see Figure 1) to rate
knowledge of the topic. Reflect on what you know and what you think you would need to do to
strengthen your knowledge about each topic.
Foundations of Quality Care
Clinical leaders have a strong foundation in health care quality so they can take an informed,
active part in quality management initiatives. Quality patient care is grounded in six aims: (a)
keep patients safe from injuries; (b) pro- vide effective patient-centered care based on scientific
knowledge; (c) provide care that is responsive to patient preferences, needs, and values; (d)
deliver timely care; (e) ensure the efficient, cost-effective delivery of services by avoiding waste
of equipment, supplies, ideas, and time; and (f) assure quality care is provided regardless of sex,
ethnicity, geographic location, and socioeconomic status (IOM, 2001).
The knowledge content for quality care begins with an awareness of the many dimensions of
quality as viewed by the patient, nurses, health care professionals, health care organization
leaders, insurers, and national quality organization leaders. An awareness of the responsibilities
and collaborative efforts of quality organizations such as government agencies (e.g., Centers for
Medicare & Medicaid Services [CMS]; Agency for Healthcare Research and Quality [AHRQ]),
independent nonprofit organizations (e.g., The Joint Commission; Institute for Safe Medication
Practices), and professional organizations (e.g., American Nurses Association [ANA]; American
Medical Association) is essential as these organizations assess dimensions of the quality of care,
provide funding for health care, and offer resources to assure quality of care. To participate
effectively in quality initiatives, clinical leaders must be familiar with Donabedian’s structure,
process, outcome (SPO) model (Donabedian, 2005) and other quality improvement models (e.g.,
Plan, Do, Study, Act [PDSA]; Focus, Analyze, Develop, Execute [FADE]) and tools (e.g.,
process maps, fishbone diagrams, surveys) (AHRQ, 2013; Wiseman & Kaprielian, 2014). [Rate
your knowledge about the foundations of quality care.]
National Patient Safety Goals (NPSGs)
Although evidence suggests the effectiveness of many patient safety practices has improved
substantially over the past decade (Shekelle et al., 2013), numerous threats to patient safety
remain in all facets of care delivery. Common obstacles to a safe system include (a) complex and
risk-prone systems; (b) a lack of comprehensive verbal, written, and electronic communication
systems; (c) tolerance of stylistic practices wherein providers do it their way; (d) a lack of
standardization of practices; (e) fear of punishment that inhibits reporting; and (f) a lack of
ownership for patient safety (IOM, 1999). Without an awareness of the sources of these barriers,
nurse leaders at the bedside are less likely to identify safety issues.
Essential knowledge about the NPSGs begins with a brief history of the development of the
NPSGs and Sentinel Event Alerts (The Joint Commission, 2014). With insight about the
configuration of each NPSG, nurses can identify specific directives for patient care. By
recognizing updated NPSGs are published annually and knowing variation exists in the listed
goals from year to year, nurses can be certain they are knowledgeable about current required
health care strategies and universal protocols. [Rate your knowledge about the NPSGs.]
Core Measures and Hospital Consumer Assessment of Healthcare Providers and Systems
(HCAHPS)
Core Measures (The Joint Commission, 2015) and HCAHPS (2015) are quality initiatives
focused on quality patient care and an understanding of what patients really want from providers.
Patients want care that is patient-centered, safe, effective, efficient, timely, and equitable. They
also want providers who listen without interrupting, are truthful, and explain care clearly and
fully. Patients want providers to collaborate with other team members so messages are consistent
between the patient and all providers, thus ensuring care will be coordinated and flow smoothly
(Anderson, Barbara, & Feidman, 2007).
To ensure consumers’ expectations are met, hospitals are ranked on the process of care (Core
Measures) and patient satisfaction (HCAHPS); these rankings are available to consumers. To
foster positive rankings, clinical leaders must understand relationships between (a) the Core
Measures set and evidence-based care, (b) patient-centered care behaviors and consumer
comparisons, and (c) published hospital rankings and financial incentives for hospitals (CMS,
2013). Nurse leaders who are cognizant of HCAHPS patient satisfaction questions will structure
care so patients need are met and patient satisfaction is high. Finally, clinical leaders are very
aware of the Value-Based Purchasing Program (CMS, 2013) and its relationship to hospital
payment for patient care services. [Rate your knowledge about Core Measures and HCAHPS.]
Variations in Practice
Variations in practice, sometimes referred to as fragmented care, can be found at the hospital
systems level. The physical design of the organization and the inaccessibility to updated
technology, such as diagnostic equipment and user-friendly medical records, can be sources of
fragmented care. Variations can occur as a result of ineffective organizational leadership, the
shortage of experienced interprofessional teams, and poor communications among health care
providers. Issues related to medical coverage and services (e.g., access to insurance and medical
services; high deductibles and co-pays) and the research-practice gap (e.g., lack of organizational
culture for research implementation; nurse preparedness and willingness to participate in
research) also contribute to fragmented care. Patients are affected by variations in all these
dimensions. In addition, variations in practice play a significant role in health care cost. Nurse
leaders at the bedside can minimize costs by implementing evidence-based practices and
eradicating fragmented care (IOM, 2001).
Clinical leaders at the bedside recognize sources of fragmented care and use structured
approaches to eliminate them. These leaders implement evidence-based policies, protocols, and
pathways, and share evidence-based and best practices with nurse colleagues. They advo- cate
for the patient’s preferences and values and set the bar high for safe, efficient unit practices (e.g.,
consistency in care via patient assignments; efficient and effective bedside report processes).
Clinical nurses reduce variations beyond the unit by participating in hospital councils,
committees, or projects and becoming nurse champions for interprofessional initiatives. They
also contribute to the refinement of communication technology, such as inefficient patient care
documentation processes (Cook, 2001; Laschinger & Finegan, 2005; Stanley, 2006). [Rate your
knowledge about variations in practice.]
Critical Appraisal of Clinical Evidence
In recent years, clinical experts have emphasized the importance of using evidence to guide
nursing and medical practice. However, the translation of evidence to practice is relatively slow.
Clinical leaders accelerate the process for integrating new clinical evidence into daily practice by
learning how to appraise the literature, determine an intervention’s potential for translating into
practice, and transition the best clinical practices into patient care (IOM, 2011).
Using the evidence-based process to appraise clinical evidence, clinical leaders guide team
members in formulating the research question. They search the literature for current evidence
and begin to appraise the evidence by summarizing important elements of research articles in an
evidence table. The team then decides if the evidence supporting the new procedure is strong
enough to influence clinical practice. If so, members integrate the research evidence with other
types of intangible evidence, such as patients’ preferences and values and clinical expertise. The
new procedure then is applied in clinical practice and evaluated for its effectiveness. Clinical
leaders enhance the translation of evidence into practice by guiding colleagues in use of the
evidence-based process to appraise the literature critically and evaluate the need for a specified
change in the practice environment (Melnyk & Fineout-Overholt, 2010; Melnyk, FineoutOverholt, Stillwell, & Williamson, 2010; Polit & Beck, 2014). [Rate your knowledge about
critical appraisal of the evidence.]
Practice Environment Core Knowledge
Hospital Systems
Nurse leaders’ source of influence lies in their ability to take actions that improve patient care,
enhance patient outcomes, and promote a healthy practice environment. To influence the
delivery of patient care services, clinical leaders must understand their hospitals’ structures and
their relationship to communication within the organizations. Nurse leaders benefit from
knowing about the arrangement of hierarchical management, lines of authority and the chain of
command related to decision-making, and the flow of communication from the top down and the
bottom up. With this information, clinical leaders can contact specific individuals to whom they
can address their concerns or from whom they can seek support for their initiatives (Laschinger
& Finegan, 2005; Rao, 2012).
In most cases, delivery of nursing services is guided by a professional practice model. The model
is selected based on its fit with the organization’s mission, available resources, and the patient
population. Understanding the various practice models fosters selection of the best practice
model for the delivery of patient care or, if needed, gives direction to selecting a new model or
modifying the current model. Most hospitals select a nursing governance model (e.g., shared
governance model) as the framework that empowers clinical leaders to serve on hospital,
nursing, and other leadership committees and participate in decisionmaking related to patient
care and work processes (Barden, Quinn, Donahue, & Fitzpatrick, 2011; Bonsall, 2011). [Rate
your knowledge about your organization’s structure, culture, and professional practice and
governance models.]
Cost Drivers for Nursing Services
Clinical leaders at the point of service are needed around the world to be full partners in
redesigning health care. With a basic understanding of hospital revenues and expenses, these
nurses are knowledgeable about the cost of patient care and sources of revenue that pay for
nursing services. As a result, they can make meaningful suggestions for transforming patient care
(CMS, 2013; Nichols & O’Malley, 2006; Quizlet.com, 2014).
Clinical leaders at the bedside are aware of the major components of a hospital’s budget and can
identify where the cost of nursing services fits. They are also aware of the four key drivers of
nursing care costs: staffing, workload, workflow, and work activities. These leaders can advocate
for safe staffing practices because they know patient volume, acuity, skill mix, practice model,
and productive vs. nonproductive hours should be considered in determining unit staffing and
staffing patterns. They participate in determining workload because they recognize the effect of
nurse workload on service quality. Clinical leaders take action to assure efficiency in workflow
processes so nurse time and energy are saved and the delivery of quality patient care is ensured.
They are also aware of the effect of direct (patient care) and indirect (e.g., change of shift
reports, justification of the scheduled drug count, committee meetings) nurse activities on the
cost of nursing services. Finally, these leaders recognize the importance of the balance between
productivity and quality of services, and its influence on the cost of nursing services. In essence,
nurse leaders can integrate knowledge related to the cost of nursing services into work redesign,
safe staffing projects, and more (ANA, 2014a, 2014b, 2014c). [Rate your knowledge about cost
drivers for nursing services.]
Healthy Practice Environment (HPE)
Optimal patient care does not just happen. Historically, clinical excellence has been credited as
the key to quality patient outcomes. Data indicate the practice environment also plays a
significant part in determining patient outcomes. In its report Keeping Patients Safe:
Transforming the Work Environment of Nurses, the IOM (2004) confirmed the typical nursing
practice environment is characterized by many serious threats to patient safety and the existence
of an HPE. These threats are found within organization management practices, workforce
deployment practices, work design and processes, and the organizational culture. Clinical leaders
at the point of service can assist in creating and maintaining an HPE because they know what it
is, how to recognize threats, and how to initiate strategies to support it (Aiken, Clarke, Sloane,
Lake, & Cheny, 2008).
To create and sustain an HPE, clinical leaders will identify and act to eliminate threats to safety
(e.g., ineffective nurse management, inadequate staffing, lack of nurse knowledge and skills,
inefficient work processes, unhealthy organizational culture). For example, nurse leaders will
approach a colleague who is changing intravenous tubing incorrectly and guide him or her
through the correct method. They will support nurses’ participation in decision making related to
patient care and work processes on the unit. These leaders know the process for evidence-based
change management and will work with the nurse manager and colleagues to ensure the plan for
change reflects this approach. Clinical leaders are empowered to speak to nursing administrators
about inadequate staffing and high nurse turnover, and their relationship to patient safety and
errors. They take action to resolve ineffective work processes, such as inefficient shift reports
and excessive or poor use of resources. In addition, they address issues that arise in a toxic
organizational culture. For example, a clinical leader will intervene in specific incidents of
bullying and work with the nurse manager to eradicate this behavior on the unit. Nurse leaders
cannot control the organization’s culture. However, they can promote positive attitudes among
colleagues and lead change to improve patient care and support a healthy practice environment
(Dearmon et al., 2013; Hall, Doran, & Pink, 2008). [Rate your knowledge about HPEs.]
Leadership Competency Skills
Leadership competency skills for nurse leaders at the bedside are grounded in clinical expertise,
supported by emotional intelligence, and actualized by expert skills in communication,
coordination, and collaboration (the 3Cs).
Clinical Expertise
Clinical expertise is based in education, ongoing professional development, training, and clinical
experiences, and is enhanced by an attitude of positive thinking and professional values. Clinical
leaders approach life with optimism and confidence. Positive thinking is a way of life that is
integrated into all aspects of nurse leaders’ lives, professional and private. These leaders’
professional values center on providing the highest level of patient care. As a result, these nurses
exhibit a high level of professional integrity and accountability for their work. They are
committed to improving nursing practice and patient care. They recognize their professional
responsibility to act when issues or problems arise, and they motivate others to act. These
clinical leaders have respect for self and others, and their colleagues have respect for them
(George et al, 2002; Laschinger & Finegan, 2005).
Emotional Intelligence
Leaders must be able to recognize and regulate their emotions and manage those of others.
Leaders who do so are said to have a high level of emotional intelligence, which is “the capacity
for recognizing our own feelings and those of others, for monitoring ourselves, and for managing
emotions in ourselves and in our relationships with others” (Goleman, 1995, p. 317). To manage
their own emotions, individuals must have a conscious awareness of their emotions
(selfawareness). With this awareness, they can regulate their personal response to the situation
(self-management). Social awareness and relationship management emphasize identifying and
managing the emotions of others while controlling personal emotional responses. Recognizing
and managing the emotions of others allows a nurse leader to handle disruptive or emotional
situations effectively. To do so, the clinical leader keeps calm, speaks appropriately, and most
importantly, separates the emotions from the individuals. In doing so, this leader manages the
group’s relationships by keeping the conversation directed at resolving the issue at hand. In
summary, emotional intelligence requires personal reflection and management of personal
emotions as well as the ability to listen, observe, process, and negotiate with others during an
emotional encounter (Druskat & Wolff, 2001; Goleman, 1995, 1998) (see Table 2 for emotional
intelligence skills assessment).
The 3Cs
In addition to clinical expertise and emotional intelligence, clinical leaders at the point of service
rely on their communication, collaboration, and coordination skills to motivate others to act.
Proficiencies in interpersonal (one-on-one) and group communication are the basis for effective
coordination of activities and collaboration with others. Interpersonal communication is the
critical element for situations, such as coaching/mentoring, educating, managing conflict, and
addressing bullying. Expert group communication skills facilitate good group interactions and
patient care coordination. These skills also foster interprofessional collaboration that enhances
patient care and patient satisfaction. With expertise in the 3Cs, nurse leaders successfully lead
committees and manage difficult group situations. In addition, they identify ineffective work
processes and motivate colleagues to initiate change to manage problems, thus improving the
delivery of patient care services (Druskat & Wolff, 2001).
A great deal of effort goes into assuring the delivery of patient care is efficient and effective.
However, ineffective or inefficient practices can be found in patient care, work processes, and
the unit’s organization (see Table 3). In some cases, inefficient practices have been the norm for
so long nurses do not recognize the inefficiency. Thus, no action is taken. In other cases, nurses
do not want to tackle inefficiencies as they are busy providing patient care; thus they create
workarounds. Rather than addressing the problem with nursing managers, these nurses use
inefficient methods that may increase the incidence of error (Benner et al., 2008).
Clinical leaders are proactive. Their leadership skills extend beyond addressing ineffective work
processes. They can envision a better way to do things. They see the opportunity to improve the
status quo and they motivate colleagues to join in the quest to provide better patient care.
Clinical expertise, emotional intelligence, and expert skills in communication, coordination, and
collaboration serve as the foundation for action by clinical leaders at the point of service. These
nurse leaders mold their skills to fit the situation at hand (Hall et al., 2008; Weston, 2008). [See
Figure 2 to assess your leadership skills proficiency. Then select one skill you would like to
enhance and identify a strategy to do so!]
Conclusion
Clinical leaders at the bedside challenge the process. They identify work inefficiencies, motivate
nurse colleagues to act, and lead change initiatives to correct problems. Whether the inefficiency
relates to poor policies, procedures, or workflow, these nurse leaders recognize their
responsibility to act to improve the delivery of patient care services. They also envision better
ways to deliver patient care services and engage others in testing innovations. The results of their
clinical leadership are enhanced patient care, improved patient outcomes and patient satisfaction,
and the attainment of a healthy practice environment. Take the challenge! Be a clinical leader at
the bedside in your practice environment!
References
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•
Morrison, J. (2016). Nursing leadership in ACO payment reform. Nursing Economic$,
34(5), 230–235.
o The effects of health care finance reform on nursing leadership are explored in
this paper.
Nursing Leadership in ACO Payment Reform
Morrison, Jessica. Nursing Economics; Pitman Vol. 34, Iss. 5, (Sep/Oct 2016): 230-235.
Headnote
Executive Summary
* Accountable Care Organizations (ACOs) are a promising new model for payment reform in the
complex and fragmented health care system in the United States.
* Nursing vision and leadership are essential for the success of an organization participating in
an ACO.
* By understanding the political, financial, and cultural facilitators and barriers to change, as
well as models for helping organizations transition toward change (e.g., Kotter Model of Change
Management), nurses have the potential to be leaders in health care change.
Health care reform has heralded testing of new payment models, yet most nurses have been
largely socialized within a fee-for-service milieu. Accountable Care Organizations (ACOs) are
emerging as a key strategy in payment reform pilots across the country. The professional
literature has begun to address the implications of ACOs for nurses (American Academy of
Ambulatory Care Nursing [AAACN], 2012; Korda & Eldridge, 2011; Mensik, 2013; Swan &
Haas, 2011) and the necessity that nurses come to the table to advocate for their value.
Nevertheless, there is scant literature to guide nurses leading payment reform-driven
organizational change.
In this article, a broad picture will be presented of how payment reform will affect an
organization by outlining the systemic and organizational barriers and facilitators of adopting an
ACO model. Implications for nursing leadership will also be addressed, highlighting how
nursing leadership must adapt to value-based payment models by developing more effective
models of quality assurance and care coordination based on evidence-based practice, showing
their value in patient engagement and chronic disease management, and increasing nursing skills
in data management (Holmes, 2011). To meet the challenge of creating lasting change, the
Kotter Model of Change Management will be provided as a tool for nurses to identify their
organization’s location in the change process and how to fully participate in enabling successful
change.
Background on ACOs
The term ACO was coined by Elliot Fisher at Dartmouth-Hitchcock Health in 2007, who
proposed ACOs as a solution to the fragmented, variable quality, and high-cost care delivered in
the United States (Fisher, Staiger, Bynum, & Gottlieb, 2007). An ACO “is a provider-led
organization whose mission is to manage the full continuum of care and be accountable for the
overall costs and quality of care for a defined population” (Rittenhouse, Shortell, & Fisher, 2009,
para 4). The Medicare Shared Savings Program for ACOs creates financial incentives to keep
costs of care low by allowing participants (providers) to capture shared savings when they keep
costs below those projected for their patient population. The amount of savings they capture is
determined by how well they meet quality objectives, which is designed to ensure the quality of
care remains high. Many gaps in quality are reported to originate from the way the current feefor-service system discourages collaboration, leading to fragmented care coordination and
transitions (Institute of Medicine, 2001). Accordingly, ACOs are also designed to improve
communication between primary care, specialists, and hospitals serving the same patient
population through financial incentives for technology improvements and care coordination.
ACOs build upon pay-for-performance models by improving data analysis, aggregating data not
only from individual practices, but from the entire ACO patient population.
Currently the most prevalent ACO program is the Medicare Shared Savings Program (MSSP),
created by the Patient Protection and Affordable Care Act in 2011. The program has been
growing steadily since its inception; as of January 2016 there are 477 ACOs nationwide serving
nearly 8.9 million Medicare beneficiaries (Centers for Medicare & Medicaid Services [CMS],
2016). Under the MSSP ACO, the percentage of shared savings an ACO captures is determined
by how well 33 quality measures are met in the four domains of patient experience, care
coordination, preventive health, and at-risk population care. Costs must also remain under those
projected for the patient population, calculated from the costs for the Medicare beneficiaries
enrolled in the ACO during the previous 3 years. ACOs under the MSSP have two options for
risk sharing to enable a smooth transition for practices that may not be accustomed to taking on
financial risk. With one-sided risk there is no financial risk to ACOs, and only savings are
shared. This is termed upside risk. Under twosided risk, ACOs share both savings and losses the latter also known as downside risk if they exceed projected costs – but also have a greater
potential for shared savings: up to 60% versus 50% for those not accepting downside risk (CMS,
2012).
Under the Next Generation ACO Model, launched in January 2016, providers assume higher
levels of risks and rewards, with shared savings and losses of 80%100%. This model uses the
same quality measures outlined under the MSSP, but eliminates the electronic health record
(EHR) measure; Next Generation ACOs are expected to have already met this requirement. The
new model also expands payment mechanisms beyond fee-for-service to a variety of populationbased payment options, including capitation, beginning in 2017. ACOs may choose to participate
in benefit enhancements such as a waiver of Medicare’s skilled nursing facility 3day rule (also
available under the MSSP), expansion of telehealth services, and post-discharge home visits
(CMS, 2015).
An aspect of health care reform that is occurring in tandem with the development of ACOs is the
Patient-Centered Medical Home (PCMH) and it is important to draw the distinction between
them. Both have an emphasis on improving quality and coordination of care, but they take
differing yet complementary approaches to meet this goal. While ACOs impact the full spectrum
of health care delivery systems, PCMHs are specifically aimed at strengthening primary care,
which is currently undervalued in the fee-for-service model. Benefits of meeting standards to
become a PCMH for a primary care practice are enhanced reimbursement rates and access to a
Community Health Team, in which practices customize additional staff members for the needs of
their practice. Additionally, PCMHs have an emphasis on integrating mental health access with
primary care and a population focus on treating chronic disease. Together, ACOs and PCMHs
have the potential for a synergistic effect on strengthening primary care and enacting payment
reform that increases quality while decreasing cost (Rittenhouse et al., 2009).
Incentives and Barriers to Change
To lead change, nurses need a broad understanding of the factors influencing the decision to
adopt new payment models. Following are some of the facilitators and barriers to change arising
from regulatory and political, financial, and social spheres.
Regulatory and political. Support for ACO development comes from the federal government
primarily through the creation of the MSSP described previously. A growing number of states
also are turning to ACOs for their Medicaid programs, with several states currently testing pilot
ACO programs. The Affordable Care Act also provides financial incentives for improving EHRs
and for creating Health Information Exchanges (HIEs) to improve the ability to share patient
information among health care providers. Financial incentives are dependent upon EHRs
meeting objectives for meaningful use. Examples of meaningful use criteria include recording an
updated list of active medications and problems and built-in drugdrug interaction checks. A
criterion that is a potential target for ambulatory care nurses is the ability to generate lists of
patients with chronic conditions for use in quality improvement. A proven area of the HIE’s
ability to assist in improving care is in identifying patients who are frequent users of emergency
rooms (Shapiro et al., 2013) so that interventions can be targeted to this population.
While there are many political facilitators to ACO development in the current atmosphere of
payment reform, one notable exception is antitrust laws. There is concern that a particular ACO
may dominate a health care market and increase the cost of care for that region. Accordingly, the
Federal Trade Commission (FTC) and Department of Justice created guidelines for ACOs that
they must not exceed 30% of the market share. There is, however, a “rural excep- tion” in which
an ACO may have one physician or practice from each specialty even if it exceeds the 30% rule
(Sheffler, Shortell, & Wilensky, 2012). The Stark Law also has ramifications for ACOs, as it
states physicians cannot refer patients to services in which they have a financial interest. An
exception to the Stark Law exists for ACO participants for activities “reasonably related” to the
MSSP (Gamble & Walker, 2012). These antitrust laws are intended to protect consumers and
keep costs down, but they also may undermine the collaboration needed for an ACO to provide
continuous care coordination. While this is often more an issue for the broader ACO
organization (Tallia & Howard, 2012), an individual organization may also have hesitation about
the legal ramifications of joining an ACO. Conversely, the FTC issued a statement in March
2014 calling for the lifting of restrictions on advanced practice registered nurse (APRN) practice
and supervision requirements, citing the anticompetitive nature of state laws limiting full practice
authority for APRNs (Gilman & Koslov, 2014).
Financial. The shared savings component is a financial incentive inherent in the design of ACOs
meant to attract practices and incentivize keeping health care costs low. Some ACOs also have
the added financial incentive of group purchasing rates. However, ACOs’ financial incentive to
decrease costs may not be enough to offset losses and there may be increased cost shifting to
private payers (Sheffler et al., 2012). The up-front investment of capital and time to initiate the
change may also be a major barrier, especially for small practices. Additional staff members may
be needed and expensive EHR upgrades will be necessary for interfacing with the HIE, though
there is federal financial support available. There is also uncertainty surrounding reimbursement
for collaborative practice, as the current payment system encourages competing for patients’
business, discouraging the collaboration necessary to ensure seamless care transitions (Tallia &
Howard, 2012).
Social and cultural. Attitudes about health care reform among providers may be an impediment
to change. In writing about their implementation of an ACO in a major medical center in New
Jersey, Tallia and Howard (2012) reported a major barrier in gaining provider support was
skepticism and cynicism about whether the change would improve patient care. There were
misconceptions about ACOs being another version of Health Maintenance Organizations, with
the perception of the PCMH being akin to gatekeeping. The prevalent idea that initiation of case
management should begin in the hospital rather than in primary care also impedes change
towards practices taking on responsibility of case management (Swan & Haas, 2011). Another
barrier is a lack of understanding about nursing knowledge and role in primary care from other
team members, who may not understand the unique set of skills nursing brings to the health care
team. Additionally, nurses may not yet have the skills needed for nursing in the emerging model
of ambulatory care, such as data management.
Nursing Leadership within an ACO
By using this higher-level understanding of the factors affecting payment reform, nurse leaders
can contribute to the vision for how to enact change within an organization adopting an ACO
payment model. This transition is an opportunity for nurses to demonstrate their expertise in care
coordination, prevention and wellness for chronic conditions, and quality improvement through
developing protocols to improve care delivery. These skills can be directly applied to the
measurable outcomes for care built into the ACO and provide increased value and cost savings to
the organization (Swan & Haas, 2011). Many quality metrics within the MSSP can be targeted
by nurses by developing protocols, including the prevention of ambulatory-sensitive conditions
admissions for chronic obstructive pulmonary disease, asthma, and heart failure. Nursing can
also prevent hospital readmission, another MSSP metric, by enhancing post-hospitalization
follow-up. Nurses are also well versed in the team-based care and information exchange
necessary to improve communication among providers in the emerging team model in
ambulatory care (Korda & Eldridge, 2011).
Nursing leadership is needed to advocate for nursing’s skill in these areas and to develop the new
skills and foci necessary to meet the challenges of the new payment models. “Big data” is the
buzzword in payment reform, and learning how to manage data related to quality metrics will be
key for many nursing interventions under value-based care, including generating lists of patients
who can be targeted for enhanced management of chronic diseases. Participating in the
development of the EHR so nursing interventions are represented in documentation will be
essential to reflect nursing value to the organization (AAACN, 2012). Nurses must also begin to
take on responsibility for care coordination at all levels of care (acute and ambulatory) (Swan &
Haas, 2011). Increased adoption of evidence-based practice targeting MSSP quality metrics will
facilitate the development of successful quality improvement projects (Holmes, 2011).
Organizational Readiness for Change
Clearly many changes will be necessary within an organization to achieve the CMS Triple Aim
of increased quality, improved health, and decreased costs (Mensik, 2013). These changes will
require significant cooperation and buy-in from all members of the health care team. Creating
and sustaining organizational change is often a difficult process that can be stalled by
complacency and fear, and easily revert to more comfortable modes of operation. Many change
management models have been developed to identify strategies to avoid these roadblocks. The
Kotter Model has been celebrated as an effective tool for managing change in health care
(Campbell, 2008). The process of organizational change within the Kotter Model and how it can
be applied by nurse leaders to an institution transitioning to an ACO payment model will be
described.
Kotter Model of Change Management
The Kotter Model of Change Management (Kotter, 1995; Kotter & Cohen, 2002) identifies
common reasons why organizations fail when attempting broad changes and outlines a multi-step
process to approach these changes. The model recognizes employees have emotional reactions to
change which can undermine the change process if not addressed, but can be transformed into
positive, change-promoting emotions. This approach requires a change in thinking from an
analytic mindset which speaks to the intellect to one that speaks to the heart, as “emotionally
charged” change behavior is more likely to result in sustained action (Kotter & Cohen, 2002).
The model outlines eight steps to change in which each step is necessary for laying the
foundation for the rest of the change process (Kotter, 1995). These eight steps are organized into
three phases: creating a climate for change, engaging and enabling the whole organization, and
implementing and sustaining change.
Organizational Change within the Kotter Model
The first step in creating a climate for change is to create urgency, an emotional drive towards
change. This step is essential, as some members of an organization are likely to feel complacent
about the status quo or feel anxiety about what changes will bring to their schedule and
responsibilities. Building a cohesive sense of urgency requires an action provoking a strong
emotional response. This can often be achieved by creating a dramatic audio-visual presentation
about the change one wants to target. For instance, if the desired change is to develop an EHR
with an HIE component, increased urgency could be generated by showing a short video about a
family affected by a medical error that could have been prevented with more comprehensive
access to medical records (Campbell, 2008). Kotter also stresses the drive for change can come
from any member of the organization (Kotter & Cohen, 2002).
The second step in creating a climate for change is building a guiding team. Members of the
guiding team are selected to create a combination of capabilities that include relevant knowledge
to create a vision for change, credibility with peers to communicate the vision, valid information
about the inner-workings of the organization, formal authority, and leadership to communicate
and motivate change (Kotter & Cohen, 2002). Nurse leaders must be at the table as part of the
guiding team to demonstrate their knowledge and credibility within their institution.
In the third step, “getting the vision right,” members of the guiding team create a concise vision
statement that considers the options available for change and sample dimensions of each option,
such as how each option will affect support staffing, providers, patients, delivery of care, and
revenue. Nursing scholars stress the importance of registered nurses and APRNs to “be a part of
the vision development, in addition to playing roles in communicating to others the need for
change, gathering support from colleagues, and supporting the change process” (Mensik, 2013,
p. 252). By getting involved early, nurses can advocate for their knowledge and role within the
organization. Coming to the table with an understanding of the organization’s current gaps in
meeting MSSP quality metrics and demonstrating how nursing actions have the potential for cost
savings and quality improvement can have a key role in creating a vision that keeps nursing at
the forefront of improving patient care.
The strengthening of vision and leadership in the first phase sets the groundwork for the second
phase: engaging and enabling the whole organization. The first step of this phase is to
“communicate buy-in,” in which leaders identify who will be affected by the change and how,
address negative feelings about the change, and guide employees to bring thoughts and actions in
line with the change. Thus the guiding team identifies how the changes will influence the
“information needs, concerns, roles, levels of effort, and degrees of communication” for each
group of employees (Campbell, 2008). Nurses information needs will increase about the MSSP
quality guidelines and they may have concerns about an increased level of effort in
documentation. Some ways for nurse leaders to address these concerns and “enable action” (step
two) are with continuous communication, allowing nurses to access educational opportunities,
and connecting them with nurses in similar organizations who have been through the same
change and survived. When change is moving forward, step three is to “create short-term wins”
so that momentum is built forward and change feels achievable. For example, for nurse leaders it
may mean advocating to introduce aspects of the new EHR slowly or focusing on improving a
few quality metrics at a time. Broadcasting and celebrating small wins, such as meeting quality
improvement goals, throughout the organization can increase morale and support for the change.
The final phase for change under the Kotter Model is “implementing and sustaining the change.”
The first step is not to let up on change. This involves maintaining the sense of urgency by
letting short-term wins create ambition for bigger changes. Maintaining support for the change,
such as information technology assistance for EHR issues, is also essential. Finally, “making
change stick” is essential for making lasting changes to organizational culture. This may include
creating new elements of organizational culture, such as check-ins with staff about how they are
adapting to the changes and working to meet quality objectives. Employees must also see that the
change has succeeded, so sharing data about the success of the ACO’s cost savings when it has
been further vetted is also important to maintain buy-in. The phases of the Kotter Model and
nursing actions during each phase of the change process are summarized in Figure 1.
Conclusion
ACOs are a promising new model for payment reform in the complex and fragmented health
care system in the United States. Nursing vision and leadership are essential for the success of an
organization participating in an ACO. By understanding the political, financial, and cultural
facilitators and barriers to change, as well as models for helping organizations transition toward
change, nurses have the potential to be leaders in health care change. In particular, nurse leaders
should:
* Ask questions about changes occurring in their organization and find out how to join or give
input to the guiding team.
* Review the ACO’s quality metrics and answer the question, “How can you improve patient
outcomes?”
* Understand the underlying financial incentives and disincentives, and be prepared to
demonstrate how your work can decrease overall costs.
* Demonstrate and advocate for nursing knowledge in care coordination and quality
improvement.
* Ask how EHR upgrades reflect documentation sensitive to nursing care.
* Seek out additional training in data management and leadership skills and increase your
awareness of community services.
Finally, nursing must also look ahead to developing the future of nursing leadership. Nursing
faculty can guide the upcoming generation of nurse leaders by incorporating modules about
payment reform and organizational change models into courses in health care policy and role
development. $
References
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Advocacy and Policy
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•
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American Nurses Association. (n.d.). Advocacy. Retrieved from
https://www.nursingworld.org/practice-policy/advocacy/
o This Web page provides resources and tools to help nurses become competent
advocates.
American Nurses Association. (n.d.). Health policy. Retrieved from
https://www.nursingworld.org/practice-policy/health-policy/
o This Web page provides links to statements and resources for various health
policies relevant to nursing.
Arms, D., & Stalter, A. M. (2016). Serving on organizational boards: What nurses need
to know. Online Journal of Issues in Nursing, 21(2), D1–D9.
o This article relates an overview of competencies needed by nurses that are
developing policy or serving on organizational boards.
Olson, K. (2016). Influence through policy: Four steps YOU can take. Reflections on
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the direction of health policies.
Financial Resources
•
Welton, J. M., & Harper, E. M. (2015). Nursing care value-based financial models.
Nursing Economics, 33(1), 14–19, 25.
o This article reviews value-based financial models and their potential applications
to nursing care.
Nursing Care Value-Based Financial Models
Welton, John M; Harper, Ellen M. Nursing Economics; Pitman Vol. 33, Iss. 1, (Jan/Feb 2015): 14-19,25.
Headnote
Executive Summary
* Nursing care makes up one of the largest expenditures in the health care system, yet patientlevel nursing intensity and costs are essentially unknown.
* Prior efforts to define nursing care value have been stymied by a lack of available data;
however, emerging information from electronic health records provide an opportunity to measure
nursing care in ways that have not been possible.
* New metrics using these data will allow improved measurement of cost, quality, and intensity
at the level of each nurse and patient across many different settings which can be used to inform
operational and clinical decision making.
* In this article, the initial results and recommendations of an expert panel tasked with defining
and measuring nursing care value as part of a larger effort to address evolving issues related to
big data and nursing knowledge development are described.
IF VALUE IS THE FUNCTION OF quality and cost, what is the contribution of each nurse to
patient care? Existing health care finance metrics hide inherent and intangible characteristics of
nursing care value such as caring, expertise, empathy, intuition, trust, and excellence to name
just a few. Yet progress towards a value-based health care payment system creates an urgent
need to better articulate the nursing product and determine the economic value of nursing care
within the health care system. A key question is how can existing and emerging nursing data in
electronic health records (EHR) be used to measure both the quality as well as the cost of nursing
care?
Background
Nursing labor is one of the largest expenditures of resources and dollars spent within the health
care system. Over half of the three million registered nurses in the United States work in
hospitals, yet inpatient nursing care is billed as a daily per diem charge and there is no direct
relationship between the actual nursing care hours provided to individual patients and the
associated nursing care costs (Thompson & Diers, 1991). In other health care settings, nursing
care is subsumed within procedure codes, bundled payment, or fee-for-service reimbursement.
The variation in nursing resources provided to each patient is essentially unknown and there is
no alignment among nursing direct-care time and costs, billing for nursing services, and payment
for care. This will be increasingly problematic as payers, such as the Centers for Medicare &
Medicaid Services, move toward a value-based payment scheme (CMS, 2014).
For most health care settings, internal inpatient cost-accounting processes related to nursing care
are based on average resource use across many patients. For example, in an inpatient unit, the
monthly sum of nursing hours and nursing labor costs are divided into total patient days to
produce a metric commonly called nursing hours per patient day and nursing costs per patient
day. These are blunt financial instruments that only measure groups of nurses caring for groups
of patients. Every patient is treated as having the same nursing care. This “average” patient
approach lacks face validity as there can be a wide range of demand for nursing care based on
differing levels of patient acuity. Even the same patient will have different nursing care needs
over time (e.g., day 1 or day 3 of a 4-day length of stay). Comparing or benchmarking nursing
care across different settings is difficult because the average does not say anything about the case
mix of patients, their severity of illness, complexity of care, or the characteristics of the nurses
caring for a patient such as education, experience, or wage. Because nursing care makes up a
quarter of all hospital costs (Welton, 2011), small changes in both direct nursing care hours and
wage of nurses can have a large effect on total costs of hospitalization (Kane & Siegrist, 2002).
Better data and information are needed to balance efficiency and productivity with best
performance and effectiveness of the nursing care delivery system across many settings to
achieve high-value nursing care.
Value-Based Nursing Care Financial Models
It is difficult to control costs when those costs are unknown. This is the argument made by
Kaplan and Porter who advocate fundamental changes to costing and billing practices in health
care. They recommend a patientcentric model opposed to the department-level costing models
currently used (Kaplan & Porter, 2011). The patient is the unit of analysis not the cost center,
service, or procedure. This approach highlights the need for greater cost and resource efficiency
and care effectiveness across a specific patient medical condition linked to outcomes of care. A
patientcentric health care finance model would provide new opportunities to measure the value
equation and address the invisibility of nursing care within the health care finance system.
Improving nursing care efficiency, effectiveness, productivity, and performance can lead to
better outcomes of nursing care at reduced costs, satisfying the basic requirements of value-based
care (Welton, 2013).
The growing focus on nursing care value requires development of tangible and measurable
aspects of nursing care (e.g., using nurse scheduling, staffing, and assignment data to link nurses
directly to individual patients). Until recently this has been difficult to achieve as most clinical
and operational records were paper based. In the past, the cost to use these records for such
purposes did not outweigh the benefits (Finkler, 2008). With the advent of EHRs, this problem is
essentially solved and the main focus has shifted toward identifying and extracting relevant
patient care data from the EHR and development of new analytic models to measure nursing care
delivery.
Methods
The impetus for this article dates to a 2013 invitational conference, “Nursing Knowledge: Big
Data Research for Transforming Health Care,” held at the University of Minnesota School of
Nursing in Minneapolis, and comprised of a nationally representative group of nurses,
informaticists, nursing leaders, software vendors, members of nursing professional organizations,
and other health care professionals. The conference identified emerging issues with big data and
nursing knowledge development and how to share and compare nursing data across many
different settings (Clancy et ah, 2014; Delaney & Westra, 2013). A follow-up conference held in
June 2014 synthesized the work to date from the prior year from the 2013 conference attendees
through a series of presentations and interactions within the group. Ten projects were identified
and expert panels were organized at the 2014 conference to guide future work (Delaney &
Westra, 2014).
In this article, the preliminary work of Project 7, tasked to develop strategies to measure the
value of nursing care, is described. The group is made up of members representing chief nursing
executives, nurse informaticists researchers, consultants, software vendors, a health economist,
and nursing faculty. The members come from diverse practice settings including public health,
school-based nursing, acute care, nursing leadership from large health care systems, businesses,
universities, and representatives from two national nursing organizations. The primary objectives
of Project 7 are detailed below.
Objectives
1. Develop a national consensus model to measure patientlevel nursing intensity and costs per
patient in multiple care settings to support the continuum of care and to produce objective
measures of nursing care value.
2. Develop new nursing business intelligence and analytic tools that will utilize the rich clinical,
operational, financial, and quality/safety outcome data currently available to measure and
compare nursing care value.
3. Develop and test new nursing financial models to bring transparency to support risk sharing
within Accountable Care Organizations, valuebased purchasing, and payforperformance models.
The primary work of Project 7 was conducted through several conference calls of 1.5 hours
between August and December 2014, designed to reach consensus on the objectives. The
conversations were guided by the two authors (EH and JW) who were co-leaders for the group.
Materials and relevant articles to support the work were provided between conference calls. The
co-leaders also participated in a monthly conference call among all group leaders to identify
progress and areas of overlap between the groups. The initial results toward the objectives are
presented here.
Results
Several key themes emerged in the early conference calls. First, there was broad agreement that
nursing is a practice discipline and nurses are individual providers of care. This
conceptualization of nurses has not been widely embraced within the health care finance system
except for advanced practice nurses. Viewing all registered nurses as providers of care has
several implications:
1. The measurement of nursing time, costs, and direct-care services provided are based on a
relationship between an individual nurse and patient (or person, family, community) and
identified units of service such as assessments, surveillance, interventions, etc.
2. To meet the specific objective of measuring nursing costs and intensity will require new
methods of collecting data about each nurse-patient encounter (e.g., a home visit, school-based
clinic interaction, or a nurse-patient assignment during a hospital shift).
3. Nursing care should not be viewed in silos, but across the many settings that nursing care
occurs such as hospitals, home health care, hospice, ambulatory care clinics, schools, public
health, etc.
4. The challenge presented to the group was to create a common data model to guide extraction
of existing EHR data that can be applied consistently across many care settings to allow
shareable and comparable information that ultimately will meet the triple aim objectives of better
health, improved patient experience, and lower cost (Berwick, Nolan, & Whittington, 2008).
5. There was also a strong consensus to avoid a dominant acute care focus. This creates a
challenge as much of the ongoing efforts to extract nursing-related data from the EHR are
hospital based.
6. Another key issue was the need to identify all of the “touch points” of nurses caring for
patients across the broad spectrum of health care in conjunction with all other health care
professionals.
A number of concerns were raised within the group. First, in a bundled payment scheme, does
measuring nursing care and individual nurses at the patient level of analysis really matter? Since
nurses usually care for more than one patient at a time, it can be difficult to measure actual time
and costs for each nurse-patient encounter. Second, there is no current billing method for
capturing nursing care in most settings. Advanced practice nurses use existing medical billing
codes such as Current Procedural Terminology (American Medical Association, 2014) but these
are not relevant in most other settings in which nursing care occurs. However, there have been
efforts to incorporate nursing-related data into the Logical Observation Identifier Names and
Codes system (LOINC) which is the basis for facilitating the exchange of results of clinical care,
outcomes management, and research from the EHR (LOINC, 2014). Future work to identify
nursing finance and value elements could be included in LOINC and current efforts are
underway to incorporate the Nursing Management Minimum Data Set elements (Westra et ah,
2010).
Third, the group recognized the opportunity to identify nursing-specific elements in electronic
data sets that could help measure nursing care. These include nursing terminologies to capture
nursing care related problems or diagnoses, interventions, and outcomes of care as well as other
flow-sheet type of data such as basic vital signs, assessment, medication administration, etc.
There was a concern the complexity and evolution of these data sets would require substantial
resource expenditures and dedicated information technology personnel to develop methods to
extract data into reports or other data repositories that could be used to develop patient-level
metrics for nursing finance systems. A final identified issue was the lack of a unique provider
number to identify each nurse similar to that of physicians and other providers who directly bill
for service.
Nursing Intensity vs. Relative Value
The group evaluated different approaches to identify and measure patient-level nursing time and
costs of nursing care. A relatively simple model of using nursing intensity or nursing dose was
considered (Manojlovich, Sidani, Covell, & Antonakos, 2011). Nursing intensity is one of four
elements of the nursing minimum data set (Thompson, 1988). Interestingly, nursing intensity
was proposed in the original diagnosis-related group (DRG) model as a separate nursing cost
center and adjustment to the cost weight used to pay hospitals, but this was not implemented in
the final DRG model (Thompson, Averill, & Fetter, 1979). The appeal of nursing intensity as a
basic component of a patient-level nursing cost model is a relatively straightforward path to
measuring care hours. If direct-care hours can be identified for a specific nurse caring for a
specific patient within a defined unit of time, then either a standard cost or actual hourly wage
can be used to determine direct nursing costs.
Another potential approach is to use a system similar to the resource-based relative value unit
(RBRVU). The RBRVU was developed to capture physician billing and incorporates time, skill,
training required for a physician to provide the service, practice expenses, and professionalliability insurance (Hsiao, Braun, Yntema, & Becker, 1988; Maxwell, Zuckerman, & Berenson,
2007). A nurse RBRVU could be based on nursing care time, nurse skill, as well as patient and
provider risk and underlying severity of illness (see Table 1).
The two approaches to measuring nursing time and associated cost raise some interesting
questions. With intensity or direct-care time measures, the underlying reason for care is unknown
(e.g., what types of nursing care or other procedures consumed that time; or how much activity
was related to surveillance, assessment, or medication administration?) Also not measured are
the complexity of care, acuity of patient, and demand for nursing care.
There are no current methods to create a Nursing Relative Value Unit; however, the group
discussed several alternatives including using nursing terminologies or other procedures
embedded in the EHR. For example, one technique is to use nursing assessment and other flow
sheet data mapped to Nursing Outcomes Classification to identify a patient’s current condition or
status across multiple physiologic, social, and behavioral dimensions to measure the demand for
nursing care (Birmingham, Nell, & Abe, 2010; Harper, 2012). In a recent study, the change in
patient clinical condition was linked to individual nurses to assess both performance and added
value of each nurse (Yakusheva, Lindrooth, & Weiss, 2014).
These research methods are complex and require large amounts of data to be extracted from the
EHR, but are being successfully tested in acute care settings to provide both measures of patientlevel nursing care hours of care and change in patient health status over the course of
hospitalization (Caspers & Pickard, 2013). Additional studies have identified potential candidate
nursing terminologies that could be used to explicate nursing costs and value such as the Omaha
system developed for home health care (Topaz, Golfenshtein, & Bowles, 2014) and the Clinical
Care Classification that can be used in multiple care settings (Dykes, Wantland, Whittenburg,
Lipsitz, & Saba, 2013).
Discussion
As health care reform moves forward, payment for services will increasingly be linked to value.
Where do nurses fit in this value equation and how will nurses improve overall population
health, achieve better patient experience, and lower cost (Pappas, 2013)? The imperative is to
better understand how nursing care is expended for each person and measure the specific costs of
that care as well as outcomes or results. There are ample data in emerging EHRs to quantify
these indicators, but there is paucity of usable and actionable information that can be the basis to
improve the quality and decrease the costs of nursing care delivery systems or to better
understand how to optimize nurse staffing and assignment patterns. Physicians are under
increasing scrutiny to provide evidencebased care and there is a plethora of new and future
metrics designed to measure and compare medical care across physicians and setting (CMS,
2014). It is only a matter of time before nurses are placed under that same microscope.
One pearl of wisdom from the expert panel group activity and interactions is the recognition that
nursing care is a practice discipline and occurs between one nurse and a person, family, or
community. Nurses can be linked to individual patients within the EHR in several ways (e.g., the
nurse-patient assignment or other data that capture touch points such as bar coding for
medication administration or recording an assessment in a patient’s home or clinic
documentation). These data can provide new and unique opportunities to measure nursing care in
several different dimen- sions (e.g., the 1:1 relationship of a nurse caring for a patient, the impact
of many nurses on the outcomes of care for a single patient, or the potential to investigate similar
outcomes across many nurses and many patients across many different settings). This provides a
framework for meeting the second goal of the group: create measures that can lead to new
analytic approaches to nursing finance and explicate nursing care value (see Table 2).
Unanswered Questions and Future Research
One key unresolved question is how to incorporate nursing care into existing and new payment
models such as bundled payment or Accountable Care Organizations. One possibility is to link
the outcomes of each nurse and his or her practice, performance, efficiency, effectiveness, and
costs to payment for nursing care. This could take the form of new performance metrics (e.g.,
using bar code medication administration scanning data to identify delays and omissions or how
often nurses assess and how well they manage a patient’s pain). While there is substantial focus
on nurse staffing and patient outcomes such as infections, falls, and pressure ulcers, future valuebased payment methods may incorporate the efficiency and effectiveness of individual as well as
groups of nurses linked to each patient similar to future performance metrics proposed for
physicians (McGlynn, Schneider, & Kerr, 2014). Using a rich multidisciplinary data source, it
will be possible to measure team interaction, continuity of care, and nursing outcomes across
multiple health care settings.
Conclusion
The preliminary results of an expert panel tasked with measuring tangible products of nursing
care value and finance provide a foundation for further dialog and action. One of the primary
concerns of the expert panel was to identify nursing care value in all settings where nursing care
may occur (e.g., a person’s home, in ambulatory care clinics, etc.) and avoid a hospital-centric
definition of nursing care value. This presents a number of challenges for defining components
of nursing care value (e.g., how to cost nursing care or measure outcomes wherever nursing care
occurs). One key recommendation is to change how nursing care is viewed away from a staffing
model to one where each nurse is viewed as a unique provider of care and the practice of nursing
is examined for best performance and results. $
References
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Human Resources
•
Annis, A. M., Robinson, C. H., Yankey, N., Krein, S. L., Duffy, S. A., Taylor, B., &
Sales, A. (2017). Factors associated with the implementation of a nurse staffing directive.
JONA: The Journal of Nursing Administration, 47(12), 636–644.
o This article may be helpful as you address human resources management in your
presentation.
JONA
Volume 47, Number 12, pp 636-644
Copyright B 2017 Wolters Kluwer Health, Inc. All rights reserved.
THE JOURNAL OF NURSING ADMINISTRATION
Factors Associated With the
Implementation of a Nurse
Staffing Directive
Ann M. Annis, PhD, RN
Claire H. Robinson, MPH
Nicholas Yankey, MPH, MSW
Sarah L. Krein, PhD, RN
Sonia A. Duffy, PhD, RN, FAAN
Beth Taylor, DHA, RN, NEA-BC
Anne Sales, PhD, RN
BACKGROUND: In 2010, the Veterans Health
Administration issued a Staffing Methodology (SM)
Directive to provide a standardized, data-driven method
for determining appropriate inpatient nurse staffing.
OBJECTIVE: We aimed to describe experiences and
factors related to SM implementation.
METHODS: We administered a Web-based survey
to chief nurse executives to obtain their implementation experiences. Structural, process, and outcome
factors and barriers associated with self-reported
implementation success were identified.
RESULTS: Respondents representing 104 of 117
facilities participated. Almost all facilities (96%)
had completed at least 1 cycle of SM, yet only half
(52%) rated their implementation highly successful.
Early implementation date, higher levels of leadership
confidence in SM, and higher frequency in which
nursing staff think in terms of hours per patient day
were associated with higher SM implementation
success. Time, staff training and educational needs,
and engagement were common barriers.
DISCUSSION: Understanding factors that influence
successful implementation of staffing policies is important to ensuring safe staffing.
Author Affiliations: Postdoctoral Fellow (Dr Annis), Research
Health Science Specialist (Ms Robinson and Mr Yankey), Research
Career Scientist (Dr Krein), and Research Scientist (Dr Duffy and
Dr Sales), Center for Clinical Management Research, VA Ann
Arbor Healthcare System, Michigan; Research Professor (Dr Krein),
School of Nursing and Department of Internal Medicine, and
Professor (Dr Sales), Department of Learning Health Sciences,
University of Michigan Medical School, Ann Arbor; Professor
(Dr Duffy), College of Nursing, Ohio State University, Columbus;
and Associate Director for Patient Care Services (Dr Taylor), VA
Southern Arizona Health Care System, Tucson.
The views expressed in this article are those of the authors and
do not necessarily reflect the policy or position of the Department
of Veterans Affairs or the US government. Dr Annis is supported by
a VA Advanced Fellowship in Health Services Research through the
Office of Academic Affiliations. Dr Krein is supported by a VA
Health Services Research and Development Research Career
Scientist Award (RCS 11-222). Funding was provided by the
Department of Veterans Affairs Office of Nursing Services and the
VA Quality Enhancement Research Initiative Program (QuERI).
The authors declare no conflicts of interest.
Correspondence: Dr Annis, Center for Clinical Management
Research, VA Ann Arbor Healthcare System, 3rd Floor, NCRC
Bldg 16, 2800 Plymouth Rd, Ann Arbor, MI 48109 (ann.annis@va.gov).
Supplemental digital content is available for this article. Direct
URL citations appear in the printed text and are provided in the
HTML and PDF versions of this article on the journal_s Web site
(www.jonajournal.com).
DOI: 10.1097/NNA.0000000000000559
636
The importance of adequate nurse staffing in hospitals is widely documented,1-3 and low levels of nurse
staffing have been linked to negative outcomes for
patients, including increased length of stay, hospitalrelated complications, and mortality,4-10 as well as
job dissatisfaction and burnout among nurses.1,2,11
Several models of nurse staffing have been developed
to identify safe and optimal staffing levels. Although
much of the current literature has focused on effects
of staffing models on patient health outcomes, few
studies have described the experiences of hospital
leaders in enacting staffing policies or the factors that
influence implementation of staffing models.
Staffing Methodology in the Veterans Health
Administration
In 2010, the Veterans Health Administration (VHA)
issued a Staffing Methodology (SM) Directive to provide
an evidence-based, standardized method for determining
JONA Vol. 47, No. 12 December 2017
Copyright © 2017 Wolters Kluwer Health, Inc. All rights reserved.
appropriate staffing for nursing personnel on inpatient units.12 This directive resulted from years of
previous work on staffing methods within VHA,13-15
including a pilot initiative in 2009.15 It required
chief nurse executives (CNEs) of all VHA facilities
with inpatient units to implement the SM model by
September 30, 2011, and to complete the SM process at least annually thereafter.
The directive describes a multistep process involving both unit-based and facility-level expert panels.
The unit panels comprised of frontline nursing staff,
systematically collect and analyze core, evidencebased data to project unit staffing requirements and
develop staffing recommendations. These recommendations are presented to the facility expert panel, comprised of facility leadership who evaluate the projected
staffing needs, along with anticipated programmatic
changes and factors that influence staffing adequacy.
These data are used to inform facility budget and
staffing decisions.
Staffing Methodology is a data-driven model,
relying on nursing hours per patient day (NHPPD) as
the measure of staffing. Nursing hours per patient day
is defined as the total number of direct care nursing
hours divided by the number of total patient days for
a particular unit during a given period. Nursing staff
included in these hours are RNs, LPNs, nursing assistants, and technicians. All expert panel staff are
required to complete training modules through a VHA
online employee education program called the Talent
Management System (TMS). Training includes instruction on the use of an electronic staffing tool created
specifically for SM and intended to support standardized
data collection, NHPPD and other staffing calculations,
and projections of staffing needs across VHA facilities.
Conceptual Model
The evaluation was structured in accordance with
a logic model,16 guided by the implementation steps
outlined in the SM Directive. Structural inputs consisting of facility leadership, staff, resources, and
staffing data represent key components necessary for
SM implementation. Process elements include a range
of activities carried out as part of the implementation,
such as staff training, convening of expert panels, and
the collection and use of data. The SM implementation outcomes include the extent and success of
implementation, engagement of leadership and staff,
and incorporation of SM recommendations into the
facility budget. Potentially confounding this structureprocess-outcome model17,18 are underlying contextual factors, such as facility characteristics (eg, facility
size and complexity, number of nursing units) as well
as nursing shortages and staff and leadership turnover,
which may influence implementation.
Methods
An initial assessme…
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