Good morning and thank you for joining us. The turnout for this early-morning session confirms that the role of the nursing profession in a transformed healthcare system is indeed a “hot topic.” My name is Jack Rowe, and I’m a professor in the department of health policy and management at the Mailman School of Public Health at Columbia University. I’m joined by Tami Minnier, Chief Quality Officer at the University of Pittsburgh Medical Center where she coordinates the activities of over 20 hospitals, 2800 physicians, 1.5 million health plan enrollees, and international hospital sites. (Something tells me she’s used to getting up pretty early in the morning.) Tami is a former chief nursing officer who has held numerous executive and leadership positions in addition to being a fellow in the American College of Healthcare Executives. I am honored to share the stage with her today.You may know that I am a former CEO of Aetna and I was also President and Chief Executive Officer at Mt. Sinai Health in New York City– so both Tami and I come to this topic with years of experience looking at care delivery, quality, cost and outcomes from the perspective of practitioners, professionals responsible for quality and healthcare executives.
We were asked to speak this morning about some of the developments that have occurred since the Institute of Medicine released its landmark report on the future of nursing. Specifically, I am going to provide an overview of the report’s key recommendations and talk about some of the efforts being undertaken to implement them. That will provide a context in which we can talk about the relevance of the report’s nurse education recommendations to leaders like you, the organizations you lead and the patients you serve. Why is it so important that you become engaged on this issue and what are the benefits of doing so?Tami will take the discussion to the operational level – what can you do now, in your position as healthcare executives, to be supportive of advancing nurse education and what might the outcome be?And we will leave a fair amount of time at the end for your questions.
No one knows more than you the challenges face by our healthcare system – the high cost and fragmentation of care, disparities in care among ethnic and racial minorities, and an aging and sicker population that is facing a shortage of primary care providers.So, in 2009 the Robert Wood Johnson Foundation partnered with the Institute of Medicine to launch the Initiative on the Future of Nursing – not only to address many of the issues facing the nursing profession but also to leverage the largest segment of the healthcare workforce to transform the way Americans receive healthcare. As part of the Initiative, the IOM convened a committee of experts to identify the potential for increasing access, improving quality and reducing costs through the involvement of nursing leaders and widespread use of nursing care solutions. The committee was led by Donna E. Shalala from the University of Miami and Linda Burnes Bolton of Cedars-Sinai Medical Center, and I was privileged to serve as a committee member along with 15 others with a wide range of expertise and interests.I am a geriatrician by training, which is one of the reasons I was pleased to have a role. The implications of our aging population for the treatment of patients with chronic diseases and the diseases of aging are profound. And when the committee was charged with examining the capacity of the nursing workforce to meet the demands of a reformed healthcare and public health system, that perspective was critical. It is a factor that impacts and will continue to effect the work that all of you do for the foreseeable future.
The intention was for the committee’s recommendations to be the basis of a report on nursing that would define a clear agenda and blueprint for action, including changes in public and institutional policies at the federal, state and local levels. The committee’s work included: - Examining the capacity of the nursing workforce to meet the demands of a reformed healthcare and public health system and Developing a set of evidence-based recommendations to address the delivery of nursing services in a shortage environment and the capacity of the nursing education system to produce an adequate number of well-prepared nurses able to meet current and future healthcare demands
In October 2010, the Institute of Medicine released The Future of Nursing: Leading Change, Advancing Health , a major report that outlines a blueprint for transforming the nursing profession to enhance the quality and value of U.S. healthcare in ways that meet future needs of diverse populations. This report is a call to action on our nation’s leaders and stakeholders to make changes – regulatory, policy, institutional- based on recommendations in four key areas: practice, education, leadership and a lot of attention to workforce planning.It’s been a best seller at the IOM and was recognized by Department of Health and Human Services Secretary Kathleen Sebelius, who praised the IOM report recommendations in a New England Journal of Medicine interview last year. It is still one and a half years later the most viewed online reports in the history of the IOM. The basis of the report was evidence, as with all IOM reports, and the report also recommended a greater focus on creating and collecting evidence going forward. To that end, the Robert Wood Johnson Foundation, in collaboration with other funders, launched a multi-funder initiative to increase and focus national attention on a common research agenda tied to the IOM recommendations and to facilitate and coordinate funding activity across a range of sources.
The report said a lot that is important about the future of our healthcare system and the role of nurses in helping to meet patient needs. It summarized its overall recommendations as follows:Remove scope-of-practice barriersExpand opportunities for nurses to lead and diffuse collaborative improvement effortsImplement nurse residency programsIncrease the proportion of nurses with a baccalaureate degree to 80 percent by 2020Double the number of nurses with a doctorate by 2020Ensure that nurses engage in lifelong learningPrepare and enable nurses to lead change to advance healthBuild an infrastructure for the collection and analysis of interprofessional healthcare workforce dataI’m going to talk in more depth about the education-related recommendations shortly, but I wanted to provide you with the overall context. You can read more about each of these recommendations in the handout.
To facilitate the implementation of the report’s recommendations, RWJF, in collaboration with AARP and the AARP Foundation, launched the Future of Nursing: Campaign for Action. The campaign’s vision is for all Americans to have access to high quality, patient-centered care in a healthcare system where nurses contribute as essential partners in achieving success.The campaign is coordinated through the Center to Champion Nursing in America, an initiative of AARP, the AARP Foundation and the Robert Wood Johnson Foundation and includes 48 state Action Coalitions anda wide range of healthcare providers, consumer advocates, policy makers, and the business, academic and philanthropic communities.
The campaign is focused on key pillars that correspond to the IOM report’s recommendations. They are: Advancing Education Transformation, which I’ll talk more about later on. Removing Barriers to Practice and Care, not only the laws that create barriers for advanced practice nurses, but removing barriers for nurses at all levels, including institutional and socio-cultural barriers, as well.And,Nursing Leadership - engaging nurses at all levels in decision-making.Interprofessional collaboration and diversity are threads woven through each pillar. We know interprofessionalcollaboration is particularly critical in healthcare systems that take patient-centered care seriously.And the foundation is data.You can read more about the recommendations in the handout and at www.thefutureofnursing.org.
To ensure implementation of these pillars across the country, in all healthcare settings, the campaign is focused on:Mobilizing diverse stakeholders (LIKE THOSE OF YOU IN THE ROOM). Nurses are certainly important, but it will take those in powerful and decision making positions to help ensure adoption of our recommendations. Activating a field strategy Engaging key policy-makers, both at the national level and state levels. Implementing a comprehensive communications program, so that are messages are understood across all sectors Establishing a network of grant makers, in addition to RWJF, to help finance the work that will need to get done Informing a national research agenda. We will also be publicly displaying a dash board of some of our most important indicators of success so that everyone can follow along with our progress.The campaign is guided by a strategic advisory committee – of which I am a member. And the driving force of the campaign is a group of 48 state Action Coalitions, a key component of that field strategy I mentioned.
Each Action Coalition (shaded orange on this map)has two co-leads, one a nursing leader, the other representing another health profession, business or consumer group, hospital or and health system, insurer, or educational institution and association. Some of the diverse co-leads include:Healthcare and hospital associations in Arizona, Colorado, Delaware, Georgia, Idaho, Kansas, Kentucky, Ohio, South Carolina and West Virginia;Blue Foundation for a Healthy Florida;BlueCross BlueShield of Texas;BlueCross BlueShield of Alabama); andOptumHealth (which is part of United Health Group) in ArizonaAARP state offices are co-leads in a number of states, as well.States are working on all priority areas, implementing strategies to engage stakeholders and policy makers, employers of nurses, and payers, among others.
So where is the campaign’s focus and what is happening? I’m going to use the bulk of my time this morning to talk about the first campaign pillar, Education. To ensure that nurses—and healthcare organizations—can continue to provide patients with the best possible care, they will need greater skills and expertise in care management, interprofessional teamwork, prevention and community care, problem solving and more. This makes higher levels of education crucial—through a Bachelor of Science in Nursing or more advanced degree.
Why?Because the advent of value-based payment systems will make a highly educated healthcare workforce an absolute imperative. As payers increasingly focus on hospital readmission rates, “never events,” nurse-sensitive quality measures and care coordination, nurses’ performance will be even more critical to the bottom line. BSN nurses report significantly higher levels of preparation than associate degree nurses, and numerous studies link education to improved patient outcomes including reductions in mortality, failure to rescue and medication errors. [Sources: for levels of preparation - Kovner C, Brewer C, Yingrengreung S, Fairchild S. New nurses’ views of quality improvement education. The Joint Commission Journal on Quality and Patient Safety. 2010; 36(1):29; for outcomes - Estabrooks, Midodzi, Cummings, Ricker & Giovannetti, 2011; Tourangeau, Doran, McGillis Hall, O’Brien Pallas, Pringle, Tu, et. al., 2007.]Because more BSN-prepared nurses will mean a bigger cadre of nurses prepared to fully participate in interprofessional care teams. Nurses with BSNs can ascend to executive leadership roles in a transformed healthcare system. BSN nurses consistently report greater confidence, teamwork and collaboration than nurses with associate and diploma degrees.[Source:Pellico LH, Brewer CS, Kovner CT. What newly licensed registered nurses have to say about their first experiences. Nursing Outlook. 2009;57(4):194-203.]And because a larger pool of advanced-degree nurses will help ameliorate the worsening primary care shortage. In addition, it will expand the ranks of nurse faculty so that nursing schools can admit more students.
The IOM report emphasized that if nurses are to be as effective as possible, they’ll need to be better prepared as care becomes more complex and moves into the community. And we need more nurses with advanced degrees to provide primary care and teach the next generation of students. Today nursing schools are turning away students because they don’t have the capacity.The report also recommends residencies to better prepare new nurses for the workforce and continuing education to help nurses retain clinical skills and to develop leadership abilities.
How did the IOM committee arrive at this? Studies support an association between educational level and patient outcomes in acute care settings, including mortality rates. In addition, only six percent of nurses who graduate with an AD get an advanced degree, enabling them to teach, compared to 20 percent of BSN graduates who get advanced degrees.[Sources : Aiken et al., 2003; Estabrooks et al., 2005; Friese et al., 2008;Tourangeau et al., 2007; Van den Heede et al., 2009;Aiken, 2009.]
Here’s the point, courtesy of hockey great Wayne Gretsky. Change is coming and we can either prepare our organizations to meet it or get left behind.In order to continue running the kind of high-quality, patient-centered health care organizations that new models of care delivery and payment will demand, we have to be in the position to deploy all health care professionals at the very highest level – the top of their game. I’m talking about nurses at every level, physicians and others. On the floors, in the ER and ICU, in outpatient settings. The demand for care and the complexities of delivering that care are such that every one of your employees that has anything to do with a patient will need the skills, training and competencies to score the goal every time.And not only do they have to be competent, they have to be flexible. We need to be in a position to make quick transitions when the marketplace demands it. Nurse leaders in your hospitals and health systems know this works, that this is where the marketplace is headed. And there’s more good news – it doesn’t have to cost more, it could generate savings and the nurses are ready.
JACK’s LAST SLIDEOf course, there’s a lot of work to do. I’m pleased now to turn it over to Tami for a discussion of more of the nuts and bolts – the evidence in favor of the IOM’s call for change and the concrete steps you can take to support system transformation.Following her remarks, we’ll take your questions.
TAMI’s FIRST SLIDE
In the current design, predictable and unpredictable work compete with each other for caregivers’ time, attention and focus…As leaders we need to foster nursing knowledge and systems that can change this and lead us out of this complexity into simple patient-centered answers
Capturing the full economic value of nurses’ contributions across practice settings requires BSN-developed competencies to help bridge the gap between coverage and access, to coordinate increasingly complex care for a wide range of patients and to implement system-wide changes.Employers should also consider that policies that support nurses in attaining higher levels of education may yield savings from lower turnover and vacancies, which cost an estimated $22,000 to $64,000 per position. [Source: Strachota E, Normandin P, O'Brien N, Clary M, Krukow B. Reasons registered nurses leave or change employment status. Journal of Nursing Administration. 2003;33(2):115.]Evidence suggests that organizations earning the Magnet Recognition Program® credential for quality patient care, nursing excellence and innovations in professional nursing practice experience lower turnover among nurses and improved clinical outcomes. [Source:Drenkard K. The business case for Magnet. Journal of Nursing Administration. 2010;40(6):264.]In Magnet-designated organizations, chief nursing officers and 75 percent of nurse managers are required to have a BSN or higher. By next year, all hospitals seeking Magnet designation and re-designation will need to include a plan for how they will attain a nursing workforce comprised of eight percent BSN or higher by 2020.
So why aren’t 80 percent of nurses getting bachelor’s degrees? The Future of Nursing: Campaign for Action worked with the American Organization of Nurse Executives and another nursing groups to conduct member surveys of Chief Nurse Executives that provide hard data on the reasons why. Of the nearly 300 respondents to the survey, just about half said their organization had a policy to preferentially hire BSN-prepared nurses. Yet this is one of the actions that could be revenue neutral to implement (and could generate revenue in the long-term).When respondents who responded in the affirmative here were asked to list the top three reasons their organizations instituted a preferential policy, quality and safety were the chief motivators. About half of the respondents included reasons such as improved patient outcomes, patient safety, or referenced clinical studies showing that patients cared for by BSN nurses had better outcomes[Source: Caramanica L, Thompson PA. AONE survey: Gauging hospitals use of preferential hiring policies for BSN-prepared nurses. Voice of Nursing Leadership. 2012 January.]
So why isn’t it happening more? The reasons cited for not having preferential hiring policies for BSNs were:*Limited access to BSNs – 34% (which takes us back to the doctorate degree issue)Lack of support from other leadership members – 22%Lack of union support – 10%Cost concerns – 10%Lack of evidence related to improved patient safety – 7%Unfair to general nursing staff – 4%[*Respondents could check as many reasons as applied, so percentages do not add up to 100.]From the nurse perspective, we hear anecdotally that lack of pay differential and little reimbursement of tuition costs may be contributing factors, as is lack of support from nurses’ supervisors and reluctance of employers to give time off from work (perhaps given staff shortages). Flexible scheduling and permitting some on-site class work may help overcome these barriers – but we look forward to seeing what the research tells us so that nurse executives such as yourselves can help find solutions within your own organizations to support those staff nurses who wish to continue their education.We also know that transferring credits from community colleges to four year programs has been an issue – and one that many states are working to address with innovative educational models.
Only 32 percent said their organization paid higher salaries to BSNs at the time of hire.And just 27 percent require that associate degree nurses obtain a BSN within a certain timeframe, most frequently 3-4 years (21%) or 5-6 years (23%).
TAMI’S LAST SLIDEWe also know that some of the nation’s most-respected health employers favor advanced-degree nurses:The Johns Hopkins Hospital has a stated preference for hiring BSN nurses, and more than 80 percent of its nurses hold a BSN or higher.The Veteran’s Health Administration links nurse education to career advancement and starts associate-degree nurses and BSNs at different salaries.The U.S. Public Health Service, as well as the Army, Navy and Air Force require that nurses are educated at the BSN level.Tenet Healthcare Corporation prefers to hire BSNs in areas of the country where there is an adequate supply. It has adopted a career ladder for nurses across the entire system.At least 24 states require school nurses to have a BSN, and it is the standard hiring preferential for nurses working in public health.[Source: Pittman P, Horton K, Keeton A, Herrera C. Investing in nurse education: Is there a business case for employers? (project report submitted to the Robert Wood Johnson Foundation) 2011 November.]
JACK RESUMESIn summary, the IOM report on the Future of Nursing discusses the future of our healthcare system and the role of nurses in helping to meet patient needs.The Future of Nursing: Campaign for Action is focused on key pillars that correspond to the IOM report’s recommendations in the areas of education, practice and leadership. As executives, you know and must address the challenges faced by nursing today.After hearing our talk, we think you’ll agree that role of nursing is changing and needs to change in order to transform healthcare.
There are a wealth of resources that the campaign is creating for your background and use. The Robert Wood Johnson Foundation has created a series of data-centered quarterly publications called “Charting Nursing’s Future.” – the recent ones are focusing on the IOM report recommendations. August was on education progression.The United States has the chance to transform its system and culture of health care, but only if nurses are better prepared and able to practice and lead to the full extent of their education and training. Through efforts nationally and locally, the Future of Nursing: Campaign for Action aims to utilize the skills and potential of these women and men to effect sweeping change. We need all of you to join us. Together, let’s create a healthcare system that provides seamless, accessible, affordable and equitable quality care for every American. Thank you.
We’d be happy to take your questions at this time.
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John W. Rowe, MD Tamra E. Minnier, RN, MSN, FACHEProfessor, Mailman School of Public Chief Quality OfficerHealth University of Pittsburgh Medical CenterDepartment of Health Policy andManagementColumbia University, New York
• Review key Institute of Medicine Future of Nursing recommendations• Describe the Future of Nursing: Campaign for Action’s efforts• Discuss the business case of supporting higher levels of nurse education• Share an example of how it all comes together in a new model of care delivery• Q&A
IOM REPORT & FUTURE OFNURSING: CAMPAIGN FOR ACTION
Fragmentation High costs Healthcare disparitiesPrimary care shortage Aging and sicker population
Examining nursing workforce supply and demand Developing evidence-based recommendations to address: Nursing education systemDelivery of nursing services capacity limitations Producing an action-oriented blueprint to transformhealth and healthcare by using nurses more effectively
High-quality, patient-centered healthcare for allwill require atransformation of thehealthcare delivery systemOne of the most-viewed online reports in IOM history
Expand opportunities for Remove scope-of- Implement nurse nurses to lead and practice barriers residency programs diffuse collaborative improvement efforts Increase theproportion of nurses Double the number Ensure that nurseswith a baccalaureate of nurses with a engage in lifelongdegree to 80 percent doctorate by 2020 learning by 2020 Build an infrastructure for the collection and Prepare and enable analysis of nurses to lead change interprofessional to advance health healthcare workforce data
Campaign VisionAll Americans have access to high-quality, patient- centered care in a healthcare system where nurses contribute as essential partners in achieving success
Advancing Education Removing Barriers to Nursing Leadership Transformation Practice and Care Interprofessional Collaboration Diversity DATA
What plans do you have anyway to solve the cost and quality problems in healthcare?
Less than ideal outcomes No more time No more money Clinical outcomes will drive financial bottom Innovative nurse-Have to do more with driven models of care line in our lifetime— less in growing are needed as the the 1-3 percent margin complexity primary care shortage will become the difference looms When we fix nursing…we really will fix healthcare
Nursing staff models Better clinicalEvery 10% increase in with a higher outcomes arethe proportion of BSN BSN/MSN staff ratio achieved with a staff reduces risk of achieve higher higher BSN/MSN staff death by 4% productivity ratio We will no longer be paid for hospital Cases with infections acquired cost 3x more those conditions, mortality without scores and readmissions
FY 2013 2014 2015 2016 2017VBP 1.0% 1.25% 1.5% 1.75% 2.0%HAI Reporting Reporting 1.0% 1.0% 1.0%Readmissions 1.0% 2.0% 3.0% 3.0% 3.0%TOTAL 2.0% 3.25% 5.5% 5.75% 6.0% 1% = $7 million* Total at risk for CMS = $42 million at UPMC What is the impact in your organization?*Includes the overall impact on Medicare managed care revenues21
THE VISION: The right patient gets the right care at the right time… every time THE REALITY:The right patient…gets some of the care they need…some of the time…when we have time
Critical Design Theme:RELIABILITY• Build reliability into the design• Ability of a process to perform the same function in routine circumstances over and over again• Same process Same outcome• Every time When I have time• A good outcome can be due to… – Chance (i.e., “dumb luck”) – Heroic efforts of hardworking diligent staff – The DESIGN of a process (this is Reliability)23
• Predictable work: – Predictable tasks at predictable times – Tasks that can be scheduled – Tasks that should happen at repetitive intervals – Reliable (consistent) work – The work everyone intends to get to – No surprisesNew Role: RELIABLE ROUNDER
• Unpredictable work: − Tasks at unpredictable times − Things you know will come up – you just don’t know when – happens at variable times − The things that get in the way of the work everyone intends to do New Role: VARIABLE ROUNDER
Implementation Implementation Jan 2011 Jan 2011 Implementation Jan 2011Implementation Jan 2011
What can you do now, in your position ashealthcare executives, to be supportive of advancing nurse education ?
Do you know your own BSN mix?Do you pay a BSN differential?With equal candidates, do you hire the BSN first?Are you setting a goal for your nursing staff to achieve BSNs in 5 years?Are you looking at nursing time as the most valuable asset you have toassure quality outcomes?Do you know how much you have at risk in Medicare dollars with yournurse sensitive outcomes?
Have you analyzed where an advanced practice nurse couldextend the productivity of a doc in your area?Are you providing scholarships/tuition for nurses to get thoseadvanced degrees if you can?Have you offered your nursing leadership a chance to beinnovative and creative on care delivery models?Have you looked at your nursing resources as dollarsspent/outcome?Does your state have an Action Coalition you can support?
Workforce Turnover & EmployeeDeployment Retention Point-of-care Sensitivity to humandecision-making resources policies Cost of nurse System-wide turnover and changes vacancies as high as $64,000 per position
Organizations with OtherBSN-supportive Policies Organizations with BSN Pay Organizations with Time Limit Differential for BSN 32% Pay 27% Time limit differential No pay No BSN 68% differential 73% requirement
John’s Hopkins Veteran’s Health• Preference for BSN Administration• 80 percent BSN or • Pay differential higher • Career ladderU.S. Public Health Tenet HealthcareService, Army, Navy, Air CorporationForce • Prefers BSN• BSN requirement • Career ladder
• IOM Report: – Future of our healthcare system – Role of nurses in helping to meet patient needs• The Future of Nursing: Campaign for Action is focused on key pillars that correspond to the IOM report’s recommendations: – Advancing education transformation – Removing barriers to practice and care – Nursing leadership• Understand the challenges faced by nursing today• Agree that role of nursing is changing and needs to change in order to transform healthcare
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