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leadership resource Ten steps to carrying out a SWOT analysis Chris Pearce offers a guide to help nursing leaders analyse their aotivities A SWOT ANALYSIS is an effecrive way of identifying your strengths and weaknesses, and of examining the opportunities and threats you face. Carrying out an analysis using the SWOT framework will help you and your team focus your activities on where you are strongest, and where your greatest opportunities lie, 7 C0NSIDERTHE USES OF SWOT This technique can be used in various situations includ- ing business planning, team building and away days, as well as when you review the work of your team, during change man- agement processes and even in your personal career planning. 2 PREPARETHE GROUND Draw a box on a flip chart or whiteboard, or even a piece of paper, and divide it into four equal sections. Each section should be labelled as follows: Strengths, Weaknesses, Opportunities and Threats, 3 CONSIDER YOUR STRENGTHS On your own, or with your group or team, decide what your strengths are, what you do well and what other people see as your strengths. Consider this from both your own point of view and from the perspectives of the people with whom you work, lie realistic, not modest. If you have difficulty with this, try listing your characteristics. Some of these will probably be strengths. 4 CONSIDER YOUR WEAKNESSES Ask yourself questions about, for example, what you could improve about yourself, what you do badly or what you should avoid. Consider these questions from different points of view, as other people may perceive weaknesses in you that you do not see. It is best to be realistic now, and to face unpleasant truths about yourself as soon as possible. 5 CONSIDER YOUR OPPORTUNITIES What opportunities are before you? Of what interest- ing trends are you aware? Useful opportunities can arise from changes in technology, government policy and social pattems, or from within your organisation. 6 CONSIDERTHE THREATS What obstacles confront you? Are the specifications of your job, or the service you provide, changing? Is chang- ing technology threatening your position? 7 USE INFORMATION: INTERNAL FACTORS Strengths and weaknesses are intemal faaors. Once you have gathered information on your strengths and weak- nesses, and the opportunities and threats tbat you face, ask yourself first how you can capitalise on your strengths and make greater use of them in work situations. Strengths are the basis on whicb success can be built, so include your strengths into your plans. But also analyse your weaknesses and consider how you can remedy them. Draw up an action plan based on this information, 8 USE INFORMATION; EXTERNAL FACTORS Opportunities and threats are extemal factors. Opportun- ities should be sought, recognised and grasped as they arise, while threats must be acknowledged and steps must be taken to deal with them. 9 USE SWOT IN CAREER PLANNING You can construct your own SWOT analysis to help you with your career .

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leadership resource Ten steps to carrying out a SWOT analysis Chris Pearce offers a guide to help nursing leaders analyse their aotivities A SWOT ANALYSIS is an effecrive way of identifying your strengths and weaknesses, and of examining the opportunities and threats you face. Carrying out an analysis using the SWOT framework will help you and your team focus your activities on where you are strongest, and where your greatest opportunities lie, 7 C0NSIDERTHE USES OF SWOT This technique can be used in various situations includ- ing business planning, team building and away days, as well as when you review the work of your team, during change man- agement processes and even in your personal career planning. 2 PREPARETHE GROUND Draw a box on a flip chart or whiteboard, or even a piece of paper, and divide it into four equal sections. Each section should be labelled as follows: Strengths, Weaknesses, Opportunities and Threats, 3 CONSIDER YOUR STRENGTHS On your own, or with your group or team, decide what your strengths are, what you do well and what other people see as your strengths. Consider this from both your own point of view and from the perspectives of the people with whom you work, lie realistic, not modest. If you have difficulty with this, try listing your
characteristics. Some of these will probably be strengths. 4 CONSIDER YOUR WEAKNESSES Ask yourself questions about, for example, what you could improve about yourself, what you do badly or what you should avoid. Consider these questions from different points of view, as other people may perceive weaknesses in you that you do not see. It is best to be realistic now, and to face unpleasant truths about yourself as soon as possible. 5 CONSIDER YOUR OPPORTUNITIES What opportunities are before you? Of what interest- ing trends are you aware? Useful opportunities can arise from changes in technology, government policy and social pattems, or from within your organisation. 6 CONSIDERTHE THREATS What obstacles confront you? Are the specifications of your job, or the service you provide, changing? Is chang- ing technology threatening your position? 7 USE INFORMATION: INTERNAL FACTORS Strengths and weaknesses are intemal faaors. Once you have gathered information on your strengths and weak- nesses, and the opportunities and threats tbat you face, ask yourself first how you can capitalise on your strengths and make greater use of them in work situations. Strengths are the basis on whicb success can
be built, so include your strengths into your plans. But also analyse your weaknesses and consider how you can remedy them. Draw up an action plan based on this information, 8 USE INFORMATION; EXTERNAL FACTORS Opportunities and threats are extemal factors. Opportun- ities should be sought, recognised and grasped as they arise, while threats must be acknowledged and steps must be taken to deal with them. 9 USE SWOT IN CAREER PLANNING You can construct your own SWOT analysis to help you with your career planning or to examine your current situation. The same rules as above apply to this: how can you capi- talise on your strengths and overcome your weaknesses? What are the external opportunities and threats in your chosen career field? ^ CAUTION A Threats, Opportunities, Weaknesses and Strengths (TOWS) analysis can also be used to plan ahead. This is similar to a SWOT analysis except that it lists negative factors first so that they can be turned into positive factors more readily. It should be remembered however that both SWOT and TOWS analyses can be subjective, and two people rarely come up with the same final version of a SWOT or TOWS. Even though adding and weighting criteria to each SWOT or TOWS factor increase the validity of the analyses, they should be regarded as guides rather
than prescriptions. FINAL POINT A SWOT analysis is a simple tool that can be used in business planning or personal career development. It is an excellent first method for exploring the possibilities for service or personal development, being neither cumbersome nor time consuming, and is effective because of its simplicity Chris Pearce MSc, BA, RN, DipN, RNT, CertHSM is a life coach and freelance trainer with Life Goal Specialists nursing management Vol 14 No 2 May 2007 25 EVALUATION RUBRIC FOR DNP 802 DNP Role Analysis Part 1 and 2 CRITERIA 70-60 POINTS 59-35 POINTS 34-25 POINTS 24-10 POINTS 9-0 POINTS Specific DNP Role, why chosen Complete for part 1 Clear description of the specific DNP role of interest, identifies why this role was chosen. Includes sources identifying why there is a gap related to this role, extrapolates content from references into focused, organized description of the needed role. Â Be sure to differentiate how/why the DNP is more prepared than a MSN educator in addressing these Generally clear description of the DNP role with all components included. Some gaps need more development and explanation as to how they impact the potential new role. Provides some explanation of how the MSN and DNP nurse bringing differing skills and preparation but not well described. Inconsistent description of the specific DNP role chosen, topics addressing why chosen, gaps related to or limited references (or supporting evidence) showing the need for this role, differences b/w MSN and DNP in role Little or no relevant detail or lacks depth - cursory description of role; many areas that could be expanded regarding the specific DNP role and why the role was chosen, along with limited identification of the gaps related to this role. Significantly Limited or no description of the specific role, no discussion of why the role is of interest. Sources minimal to show gaps or need for this role. Unfocused, unorganized description of the needed role
issues What are the differences coming from a DNP perspective? What skills will the DNP have that the MSN RN would not? SWOT Analysis Complete for Part 1 Describes thoroughly the strengths, weaknesses, opportunities and threats for the DNP role. Includes references supporting findings. Describes the SWOT analysis, but some areas could include more content related to the topic, limited references Superficial description of some the SWOT analysis components; areas need more development; some areas unclear, Little or no relevant detail; many areas that could be expanded regarding the SWOT analysis components Limited or no analysis provided of the SWOT components PEST Analysis Complete for Part 2 Describes thoroughly the political, economical, social and technological influences – current and potential, as they impact the DNP role, references as appropriate Describes the PEST analysis, but some areas could include more content related to the topic Superficial or inconsistent description of some the PEST analysis components; areas need more development; some areas unclear Little or no relevant detail; many areas that could be expanded regarding the PEST analysis Limited or no analysis of the PEST components Next steps for this new DNP role Complete for Part 2 Presents implementation strategies addressing stakeholder support for new role, potential funding/costs of new role including savings if they exist, theoretical framework to assist with Describes the implementation plans, but some areas could include more content related to the topic; some of the key ideas are not clearly developed, summary does not tie concepts of the paper Superficial or incomplete description of some the plans for implementation; areas need more development; some areas unclear, summary or conclusion paragraph superficial or Little or no relevant detail pertinent to the implementation of the role; many areas that could be expanded regarding stakeholder support, cost or evaluation methods, limited Limited or no discussion of the next steps to implement this proposed new role in terms of support, expense, or evaluation methods, no summary provided
implementation, and potential evaluation methods to determine effectiveness of new role. Provides a summary of the need for the DNP nurse in the identified role in a short paragraph together well. does not address importance of DNP in this role summary included. All mechanics done for both parts of the role analysis papers, including references- 30 points 6-5 POINTS 4-3 POINTS 2 POINTS 1 POINTS 0 POINTS Thesis / Topic Exceptionally clear; easily identifiable, insightful; introduces the topic for the paper; summary in one or two well-written sentences. Generally clear; is promising; could be a little more inclusive of the content of the paper. Central idea is adequate but not fully developed; may be somewhat unclear (contains vague terms); only gives a vague idea of the content of the paper. Difficult to identify with inadequate illustration of key ideas; does not let the reader know what the paper is going to include. No thesis statement or introduction is identifiable. 6-5 POINTS 4-3 POINTS 2 POINTS 1 POINTS 0 POINTS Content / Development Thesis coherently developed and maintained throughout; thorough explanation of key idea(s) at an appropriate level for the target audience; critical thinking with excellent understanding of Explanation or illustration of key ideas consistent throughout essay; original but may be somewhat lacking in insight; minor topics of the paper could be developed more thoroughly. Explanation or illustration of some of the key ideas; reader is left with some questions due to inadequate development; content may be a little confusing or unclear as to what the author means. Little or no relevant detail; many areas that could be expanded. Paper does not make sense; unclear what the author is trying to say; very little real information presented.
the topic; original in scope (this paper made sense, was easy to understand, and did not leave reader with questions due to incomplete development). 6-5 POINTS 4-3 POINTS 2 POINTS 1 POINTS 0 POINTS Organization Good organization with clear focus and excellent transition between paragraphs; logical order to presentation of information; paragraphs are well-organized; easy to understand and makes sense. Adequate organizational style with logical transition between paragraphs; overall or paragraph organization could be slightly improved. Adequate organizational style, although flow is somewhat choppy and may wander occasionally; somewhat confusing due to organization of paper or paragraphs. Incoherent structure; logic is unclear; paragraph transition is weak; difficult to understand; must re-read parts to figure out what is being said. No order to content; very confusing and difficult to read; makes no sense. 6-5 POINTS 4-3 POINTS 2 POINTS 1 POINTS 0 POINTS Mechanics Skillful use of language; varied, accurate vocabulary; well-developed sentence structure with minimal errors in punctuation, spelling or grammar; appropriate margins, font; correct application of research style format; use of Appropriate use of language with a few errors in grammar, sentence structure, punctuation; fairly accurate interpretation of assignment guidelines, with a few minor errors; readability of paper only slightly affected by mistakes. Some problems with sentence structure, grammar, punctuation, and/or spelling; may have several run-on sentences or comma splices; some errors in citation style; format does not fully comply with assignment guidelines; Many difficulties in sentence structure, grammar, citation style, punctuation, spelling and/or misused words; proper format not used consistently ; many errors in citation style very difficult Not written at a graduate level; many mistakes; proper format not used consistently ; many errors in citation style; difficult to read and understand.
professional active voice; very well- written paper. somewhat difficult to read due to mistakes. to understand. 6-5 POINTS 4-3 POINTS 2 POINTS 1 POINTS 0 POINTS References Uses sources effectively and documents sources accurately with minimal errors; limited use of direct quotes (No more than 2 or 3); meets reference requirements for assignment; reference list is in correct format. Appropriate sources and documentation; may have minimal errors with too few or too many in-text citations; missing no more than one reference as required for the assignment. Some quotes not integrated smoothly into text; several errors with in- text citations or reference list; omitted in-text citations infrequently; missing  2 required references; overuse of direct quotes Quotes are not well integrated into narrative or are significantly overused; paraphrasing is too close to original work. (Minimal errors only; more significant errors will be considered plagiarism – See Plagiarism statement to right.) Plagiarism – source material not adequately paraphrased; direct quotes not identified; source material not referenced. *Plagiarized  papers will be given a grade of zero and could result in failure of the  course WESTERN UNIVERSITY OF HEALTH SCIENCES Pomona, California DNP PROJECT: A FEASIBILITY AND COST ANALYSIS ON A NURSE PRACTITIONER MANAGED ENDOSCOPY SERVICE A dissertation submitted to the College of Graduate Nursing in partial fulfillment of the requirements for the degree Doctor of Nursing Practice Jocylane Mateo Dinsay College of Graduate Nursing
October 2013 All rights reserved INFORMATION TO ALL USERS The quality of this reproduction is dependent upon the quality of the copy submitted. In the unlikely event that the author did not send a complete manuscript and there are missing pages, these will be noted. Also, if material had to be removed, a note will indicate the deletion. Microform Edition © ProQuest LLC. All rights reserved. This work is protected against unauthorized copying under Title 17, United States Code ProQuest LLC. 789 East Eisenhower Parkway P.O. Box 1346 Ann Arbor, MI 48106 - 1346 UMI 3615267 Published by ProQuest LLC (2014). Copyright in the Dissertation held by the Author. UMI Number: 3615267 WESTERN UNIVERSITY OF HEALTH SCIENCES DNP PROJECT: A FEASIBILITY AND COST ANALYSIS ON A NURSE PRACTITIONER MANAGED ENDOSCOPY SERVICE by Jocylane Mateo Dinsay has been approved by the College of Graduate Nursing in partial fulfillment of the requirements for the degree Doctor of Nursing Practice
________________________________________________________ Rod Hicks, PhD, RN, FNP-BC, FAANP, FAAN Assistant Director, DNP Program Committee Chair _______________________________________________________ Kathy A. Baker, PhD, RN, ACNS-BC, FAAN Committee Member ________________________________________________________ Nancy Schlossberg, BSN, RN, CGRN Committee Member ________________________________________________________ Janet (Jan) Boller, Ph.D., R.N. Director, DNP Program ____________________________________________________ Karen Hanford, EdD, FNP, Dean, College of Graduate Nursing iii ACKNOWLEDGEMENTS I would like to express my gratitude to Dr. Rod Hicks, my committee chair, for his unselfish dedication and guidance in the completion of this project. A special thank you to Dr. Kathy Baker and Nancy Schlossberg, my committee members, for their willingness to share their knowledge, expertise, and precious time to assist me. In addition, I want to thank my family for their patience and support throughout this DNP
program. Last but not the least, I am grateful to the LORD above for all the blessings and making all of this possible. iv ABSTRACT DNP PROJECT: A FEASIBILITY AND COST ANALYSIS ON A NURSE PRACTITIONER MANAGED ENDOSCOPY SERVICE By Jocylane Mateo Dinsay, DNP PROBLEM STATEMENT: In spite of multiple studies that demonstrate nurse endoscopists (nurses and nurse practitioners) can perform both sigmoidoscopies and colonoscopies safely, accurately, and effectively, the utilization of nurse practitioners in colonoscopy is very minimal. In Southern California, there remains opposition to nurse practitioners independently performing colonoscopies. PURPOSE: The purpose of this study was to assess the feasibility and cost analysis of a nurse practitioner colonoscopy practice in a Health Maintenance Organization (HMO) setting. SIGNIFICANCE: Assessment of the feasibility and cost analysis of a nurse practitioner colonoscopy practice in a HMO setting identified potential cost savings with the use of a nurse practitioner. Knowledge of the potential cost savings of a NP colonoscopy practice will allow stakeholders to potentially increase the use of a NP. Allowing nurse practitioners to perform colonoscopies will help increase the number of providers, improve capacity and access, as well as address the important public health issue of colorectal cancer (CRC) screening. Allowing nurse practitioners to perform colonoscopies will help solve the problem of capacity. The increase in screening
colonoscopies will potentially allow for early detection of CRC and decrease mortality and morbidity. v METHODS: A modified business plan was used to analyze the feasibility and cost analysis of incorporating a nurse practitioner colonoscopy practice in an HMO setting. The business plan included a financial assessment and a SWOT analysis. FINDINGS: There is a big gap between the number of patients needing colonoscopies and the number of patients having colonoscopies for the last 3 years studied. Less than 10% of the HMO members between the age of 49 to 75 years old were screened. When colonoscopy is done in-house by a nurse practitioner, there is possible cost saving of 59% per case. A loss of $108 per case was projected for cases done outside the facility. Employing a nurse practitioner to perform colonoscopy is a feasible and cost effective way to provide quality and safe colonoscopies. A nurse practitioner working in collaboration with gastroenterologists will improve capacity, increase access for patients, and increase the CRC screening rate. vi TABLE OF CONTENTS Page ACKNOWLEDGEMENTS ………………………………………………. iii ABSTRACT ................................................................................................... iv LIST OF TABLES………………………………………………………… ix LIST OF FIGURES………………………………………………………. .. x CHAPTER I
PROSPECTUS .......................................................................................... 1 Problem Statement ................................................................................ 3 Purpose Statement ……………………………………………………. 3 Significance…………………………………………………………… 3 Methods ………………………………………………………………. 4 Background……………………………………………………………. 4 Factors Influencing Rates of CRC Screening…………………………. 7 Barriers to Colorectal Cancer Screening……………………………… 9 General Barriers to Nurse Practitioner Practice ……………………… 14 Nurse Endoscopist ……………………………………………………. 15 Flexible Sigmoidoscopy......................................................................... 15 Colonoscopy …………………………………………………………... 19 Affordable Care Act and Institute of Medicine Recommendation #1…. 21 Limitations……………………………………………………………… 22 Conclusion……………………………………………………………… 22 vii CHAPTER II BUSINESS DATA.................................................................................... 24 1.0 Overview of the Business Case 1.1 Products and Services…………………………………………… 24 .. 1.2 The Financing ………………………………………………… 24 1.3 Mission Statement ……………………………………………… 24 1.4 Management Team ……………………………………………... 25
1.5 Sales Forecast …………………………………………………... 25 1.6 Expansion Plan …………………………………………………. 25 2.0 Company and Financing Summary 2.1 Required Funds ………………………………………………… 25 2.2 Investor Equity ………………………………………………… . 30 2.3 Management Equity …………………………………………… . 31 2.4 Exit Strategy ……………………………………………………. 31 3.0 Products and Services 3.1 Medical Services ……………………………………………… .. 31 4.0 Strategic and Market Analysis ……………………………………… 31 5.0 Marketing Plan 5.1 Pricing ………………………………………………………… .. 34 6.0 Profit and Loss ……………………………………………………… 38 PEST Analysis ......................................................................................... 42 SWOT Analysis ………………………………………………………… 43 Evaluation ……………………………………………………………… 44 viii CHAPTER III DNP REFLECTION…………………………………………………… . 46 REFERENCES …………………………………………………………….. 50 ix LIST OF TABLES Table Page
1. Advantages of Different Screening Methods ....................................................... 5 2. Disadvantages of Different Screening Methods .................................................. 6 3. Barriers for Colorectal Cancer Screening ............................................................ 11 4. Basic Equipment and Current Prices Needed for a Single Room ........................ 26 5. Cost of Colonoscopy for 4 hour Clinic ................................................................ 27 6. Proposed Staffing with Nurse Practitioner .......................................................... 28 7. Weekend 8 hour Clinic ....................................................................................... 29 8. Total of 20 Colonoscopies = Proposed Staffing with Nurse Practitioner ............ 30 9. Comparison of Colon Cancer Screening Rates ………………………………... 33 10. Medicare Reimbursement ……………………………………………………. 34 11. Number of Colonoscopies Completed Outside………………………………. . 35 12. Cost per Colonoscopy, Reimbursement and Profit…………………………… 39 13. PEST Analysis of Nurse Managed Endoscopy Service………………………. 42 14. SWOT Analysis for Nurse Managed Endoscopy Service……………………. 43 x LIST OF FIGURES Figure Page 1. Basis of Cost Estimates ........................................................................................ 19 2. Members 49-75 years vs Colonoscopies Performed ............................................ 32 3. CRC Screening Rates ........................................................................................... 33 4. Cost Comparison of Colonoscopy Outside Cost vs. In house Cost ..................... 36 5. Cost Comparison of Colonoscopy with NP vs without NP ................................. 37 6. Number of Colonoscopies Completed In house ………………………………. 37
7. Professional Fee Reimbursement ……………………………………………… 38 8. Cost and Profit ………………………………………………………………… 40 9. Loss for Outside Colonoscopy ……………………………………………….. .. 41 1 CHAPTER I PROSPECTUS Colorectal cancer (CRC) is the third most common type of cancer (Anderson, Gilliss, & Yoder, 1996; Jemal et al., 2009) and is the second leading cause of cancer death in the United States (U.S.). The U.S. Preventive Task Force (USPTF) recommends colorectal screening using fecal occult blood testing, sigmoidoscopy, or colonoscopy in adults, beginning at age 50 years and continuing until age 75 years (U.S. Department of Health and Human Services, 2011). Screening for CRC helps promote early detection; screening asymptomatic individuals for precancerous lesions greatly reduces morbidity and mortality (Feeley, Cooper, Foels, & Maoney, (2009). Screening rates for CRC have been increasing; as of 2008, 62.9% of adults aged 50–75 years were screened as recommended compared to only 51.9% of Americans who were screened as recommended in 2002 (Richardson, Rim, & Plescia, 2010). Even with the increased screening rates, there are still more than 22 million people not adequately screened for CRC (Richardson et al., 2010). Dulai et al. (2004) and Guerra et al. (2007) identified several barriers to CRC screening, one of which included limited access to a trained endoscopist. Providing flexible sigmoidoscopies or colonoscopies to the general population for screening would require a considerable increase in the amount of physician time and other health care
resources. Lieberman and Ghormley (1992) and Maule (1994) recommended using nurse endoscopists or physician assistants to perform endoscopic procedures as an alternative to physicians. Several studies have demonstrated that nurse endoscopists can do flexible sigmoidocopies safely and effectively (Horton, Reffel, Rosen, & Farraye, 2001; 2 Lieberman & Ghormley, 1992; Maule, 1994; Wallace et al., 1999). Koornstra, Corporaal, Giezen-Beintema, de Vries, and van Dullemen, (2009) in a study done in the Netherlands concluded that endoscopy trained nurses can safely and effectively perform colonoscopy as proficiently as first year gastrointestinal (GI) fellows. In Davis, California, Limoges- Gonzalez et al. (2011) demonstrated that a properly trained GI nurse practitioner can perform screening colonoscopies as safely and accurately as a GI physician (MD). In San Francisco, California, a safety net hospital increased the endoscopy rate with the use of a nurse practitioner (Day, 2012). In Alaska, a nurse practitioner successfully performs colonoscopy (Christensen & Tealey, 2005). In Baltimore, Maryland, a nurse practitioner has been performing colonoscopies successfully after completion of a one-year GI fellowship-training program (Kalloo, 2011). In Pennsylvania, a nurse practitioner in the Veterans Affairs Medical Center system was credentialed to perform colonoscopies after successful completion of a training base on the American Society for Gastrointestinal Endoscopy (ASGE) colonoscopy curriculum. He was held to the same standard as a gastroenterologist (Hopchik, 2012). With the aging population, there comes an increasing demand for colorectal screening. There is an insufficient quantity of physicians prepared to perform invasive colorectal screening, therefore, training and utilization of more nurse practitioners in
performing screening colonoscopies should be considered. Utilization of nurse practitioners would be helpful in meeting the demands of the aging population. Trained nurse practitioners can also perform screening colonoscopies in safety net hospitals and nurse managed health clinics that primarily serve vulnerable populations. According to 3 Kalloo (2011), nurse practitioners can help decrease the shortage of colonoscopists and continue to provide high quality healthcare. Problem Statement In spite of multiple studies demonstrating that nurse endoscopists (nurses and nurse practitioners) can perform both sigmoidoscopies and colonoscopies safely, accurately, and effectively, the utilization of nurse practitioners in colonoscopy are very minimal. In Southern California, there remains opposition to nurse practitioners independently performing colonoscopies. Purpose Statement The purpose of this study was to assess the feasibility and cost analysis of a nurse practitioner colonoscopy practice in a Health Maintenance Organization (HMO) setting. Significance Assessment of the feasibility and cost analysis of a nurse practitioner colonoscopy practice in a HMO setting identified potential cost savings with the use of a NP. Knowledge of the potential cost savings of a NP colonoscopy practice will allow stakeholders to potentially increase the use of a NP. Allowing nurse practitioners to perform colonoscopies will help increase the number of providers, improve capacity and access as well as address the important public health issue of CRC screening. According
to Hoffman, Espey, and Ryne (2011), there are about 60% of average risk adults 50 years and older (41.8 million individuals) who are not currently screened for CRC. Without an increase in the number of providers, it would take an additional 10 years to complete screening colonoscopy. Hoffman et al. (2011) suggest increasing provider supply to help solve this problem. Allowing NPs to perform colonoscopies will help solve this problem. 4 The increase in screening colonoscopy will potentially allow for early detection of CRC and decrease mortality and morbidity. Methods A modified business plan was used to analyze the feasibility and cost analysis of incorporating a NP colonoscopy practice in an HMO setting. Included in the business plan were a financial assessment and a Strenghts, Weaknesses, Opportunities and Threats (SWOT) analysis. Background Colorectal Cancer Screening Screening for CRC is not new and can be accomplished with fecal occult blood testing, sigmoidoscopy, or colonoscopy. Screening is defined by Allen et al. (2010) as “the testing of individuals for the disease prior to the onset of any symptoms― (p.3). The goal of screening is to detect early-stage cancer and adenomatous polyps and ultimately reduce the mortality of CRC through prevention and early detection (Allen et al., 2010). The presence of treatable precancerous polyps, discovered during screening, falls into the prevention domain. Colorectal cancer has a long asymptomatic phase (Sonnenberg, Delco, & Inadomi, 2000) characterized by polyps (abnormal growths of tissue) or lesions
along the lining of the colon). Most polyps are harmless, but the slow changing common type of polyp, the adenoma, can develop into cancer overtime (Allen et al., 2010). Fecal Occult Blood Test (FOBT) and flexible sigmoidoscopy were the most widely used screening method for the general population before the emergence of colonoscopy. According to Shapiro et al. (2008), colonoscopy has become the most widely use primary screening test in the U.S. In 2001, Medicare initiated financial 5 reimbursement (e.g., coverage) of screening colonoscopies; since then, there has been a decrease in FOBT and flexible sigmoidoscopy use except in the Department of Veterans Affairs and in some healthcare managed organizations (Allen et al., 2010). There are advantages (see Table 1) and disadvantages (see Table 2) of the different screening methods. Table 1 Advantages of Different Screening Methods Adapted from Allen et al. (2010) and Forbes (2008). Screening Method Fecal Occult Blood Test Flexible Sigmoidoscopy Colonoscopy CT Colonography and Barium Enema Level 1 for cancer
mortality benefit Reduction in distal cancer mortality by approximately 2/3 Bowel preparation easier Less time consuming than colonoscopy Procedure relatively safe Greatest ability to detect cancer, greatest ability to detect adenoma Longest screening interval - Every 10 years Examines entire colon Sensitive and specific for polyps > 1 cm Low unit cost No need for follow up testing
after a positive screening test Attractiveness to lay person Simple to perform Safe Low complication rate - no Sedation 6 Table 2 Disadvantages of Different Screening Methods Screening Method Fecal Occult Blood Test Flexible Sigmoidoscopy Colonoscopy Computed Tomographic (CT) Colonography & Barium Enema Poor adenoma detection Missed isolated proximal cancer
and adenomas Missed adenoma and cancer- despite being the Gold Standard Sensitivity less for polyps < 1 cm Compliance with follow up colonoscopy may be poor Patient discomfort Need for rigorous bowel preparation Increase procedural complication Requires sedation High per unit cost Need for rigorous bowel preparation Radiation exposure Need to
comply with annual or biennial screening Every 5 years with high sensitivity FOBT every 3 years Uncertain screening interval Availability of flexible sigmoidoscopy and need for adequate trained sigmoidoscopist Availability of trained colonoscopist Availability of trained personnel Undefined positive
screening test Undefined positive screening test Adapted from Allen et al. (2010) and Forbes (2008). 7 Colonoscopy is perhaps the most important tool in the diagnosis and early detection of CRC. Colonoscopy is recommended following any positive screening test such as FOBT, polyp/mass on sigmoidoscopy, and/or filling defect on CT colonography or double contrast barium enema (Allen et al., 2010; Forbes, 2008; Limoges-Gonzalez, 2012) for CRC. Factors Influencing Rates of CRC Screening There are important patient-related, provider-related, and system-related factors associated with colorectal screening, and each factor, alone or in concert with another, influences the rate of colorectal screening (Allen et al., 2010). Each of these factors influences the screen rate. Patient-related Factors Positive Influencing Factors Patient-related factors, such as patients having insurance and access to a healthcare source, are the two most important factors affecting CRC screening rates. The patient’s socioeconomic characteristics, such as income and educational level, also affect the use of colorectal screening (Allen et al., 2010). As each of these factors increase, there is a corresponding increase in the likelihood to undergo CRC screening. Therefore, these factors are considered positive influencing factors.
According to Allen et al. (2010), older patients (between 60-75 years) are more frequently screened compared to younger patients (age 50-59 years). People with frequent contact with the healthcare provider are more likely to be screened. Equally, people diagnosed with cancer such as breast, prostate, and cervical are more likely to be screened for CRC (Allen et al., 2010). 8 Negative Influencing Factors There are also negative influencing factors influencing the rates of CRC such as ethnicity or geographic region. Patients that are of African-American or Hispanic descent are less likely to be screened. Among Asians, Koreans have the lowest screening rates. Immigrants with shorter stay in the U.S. and non-English speaking are less likely to have CRC screening. Likewise, a lower rate of screening is noted in the Caucasian populations living in Appalachia (Allen et al., 2010). Patient Knowledge and Attitudes Patients with accurate knowledge about the screening test, importance of screening, perceived risk of developing CRC, and a positive attitude about the test in general are most likely to be those who have had CRC screening. Negative attitudes towards the procedure such its invasiveness, anxiety about the test procedure as well as the possible outcome, and a belief that since they do not have a problem, they do not need a procedure, are some of the causes attributed for not being screened (Allen et al., 2010). Healthcare Provider Factors A recommendation from the physician is also the only factor that consistently predicts CRC screening. The relationship between the physicians’ characteristic such as
age, gender, years of training, and specialty and screening rates in populations has not been well documented (Allen et al., 2010). An important gap in the literature is that no study has been done with NP recommendations and the effect on rates of screening. Systems-related Factors Only limited data were available regarding systems-related factors and the subsequent effect on CRC screening. According to Allen et al. (2010), practices with 9 electronic medical records and sufficient ancillary staff for patient follow up lead to higher screening rates. For example, systems with advanced electronic medical records, such as Kaiser Permanente Health System and the Veterans Administration (VA) have screening rates that exceed 75% of the Medicare aged patients (Allen et al., 2010). Barriers to Colorectal Cancer Screening Multiple authors (Dulai et al., 2004; Guerra et al., 2007; Vincent, Hochhalter, Broglio, & Avots-Avotins, 2011) have identified limited access to trained endoscopists as one of the many barriers to CRC screening. Dulai et al. (2004) surveyed 1340 primary care providers in California to determine barriers to and facilitators of colorectal screening in a managed care setting. There was a 67% response rate on the survey. The survey was an 11-pages, 39 questions, 194 individual response items, cross sectional, self reported, mailed questionnaire. The authors demonstrated that only 79% of standard-risk patients were screened for CRC. The four most common recommended CRC screening tests were Fecal Occult Blood test (FOBT), flexible sigmoidoscopy (FS), barium enema, and colonoscopy. The survey showed that the compliance rate for FOBT was only 70 % and FS was only 50 %. The barriers that were found were divided into patient-related
barriers and physician-related barriers which included the absence of an available endoscopist. Following the survey, the authors concluded that CRC screening was underused in the managed care setting. Guerra et al. (2007) conducted a purposive non-probability sampling qualitative study to explore the barriers of and facilitators to physicians’ recommendation of CRC screening. The study consisted of 212 primary care physicians practicing in Pennsylvania, New Jersey, and Delaware. Subjects were chosen because of a specific 10 characteristic such as practice specialty. Interviews and chart reviews were conducted. The authors showed that colonoscopy was the preferred screening method (Guerra et al., 2007). In this study, the barriers were categorized into patient, physicians, and systems. Barriers to physician recommendation included patients’ comorbidities, patient refusal to screening, physician forgetfulness, lack of time, and lack of reminder. One of the system barriers was the long delay of colonoscopy scheduling and lack of direct access to colonoscopy. Between 2003 and 2008, Vincent et al. (2011) performed a survey using 1,234 patients 50 to 80 years old in a HMO to test the difference between male and female barriers to colonoscopy. Analysis of the data indicated that there were no differences in the barriers reported by gender. The most common identified barrier was lack of recommendation for colonoscopy by the primary physician (Vincent et al., 2011). Table 3 is a summary of the barriers for CRC screening. 11 Table 3
Barriers for Colorectal Cancer Screening Barriers Dulai et al. Guerra et al. Vincent et al. Patient-related Comorbidity, more acute care visits * * Distrust/lack of compliance * * * Language barrier, knowledge deficit, pain * * * Physician related Forgetfulness, not recommended by physician * * Concurrent care by a gastroenterologist * System related Inability to track
down prior screening * Lack of time/lack of reminders * * * Lack of insurance coverage, cost * * * Long delay in colonoscopy scheduling/lack of direct access to colonoscopy * * Sources: Dulai, et al., 2004; Guerra, et al., 2007; Vincent, et al., 2011 Note: (*) indicates barrier identified in cited study. 12 Capacity Multiple studies (Ballew, Lloyd, & Miller, 2009; Brown, Klabunde, & Mysliwiec, 2003; Seeff, Richards, et al., 2004; Vijan, Inadomi, Hayward, Hofer, & Fendrick, 2004) have been completed regarding colonoscopy capacity. Ballew, Lloyd and Miller (2009) surveyed all hospitals and ambulatory surgical centers in Montana to assess current and
projected colonoscopy capacity. In 2008, an estimated 19,444 colonoscopies were performed (Ballew et al., 2009). Ballew et al. (2009) concluded that in the state of Montana, the capacity to meet moderate increase in demand for colonoscopy in 2008 was followed by the ability to only meet 17% of the colonoscopy demand in 2009 if all eligible adults were screened. Brown et al. (2003) performed a national survey in 1999 to 2000 to obtain data of endoscopic resources. The authors found primary care providers performed 65% of flexible sigmoidoscopies, gastroenterologists performed another 25%, and general surgeons performed 10%. The authors concluded that with routine screening colonoscopies performed every 10 years, a total of 4.8 million screening and surveillance colonoscopies would be needed, 20% more than the estimated 4 million. Seeff, Manninen et al. (2004) created a forecasting model to estimate the number of unscreened individuals for CRC and the number of procedures needed to screen these people. The test need was compared to the available capacity based on the result done by the Survey of Endoscopic Capacity (Seeff, Manninen, et al., 2004). Seeff, Manninen et al. (2004) found that there are approximately 41.8 million averaged aged Americans, 50 years or older, that have not been screened for CRC. According to Seeff, Manninen et al. (2004), it would take 10 years to screen the unscreened population with flexible 13 sigmoidoscopy or colonoscopy. Seeff, Manninen et al. (2004) concluded that there was ample capacity to screen with fecal occult blood test (FOBT) but not with flexible sigmoidoscopy or colonoscopy. Diagnostic colonoscopy would also be needed if a screening results from the FOBT were positive (Seeff, Manninen, et al., 2004).
Vijan et al. (2004) quantified the demand of colonoscopy and estimated the ability of the current health care system to meet the demand. According to Vijan et al. (2004), the annual demand for colonoscopy ranged from 2.21 to 7.96 million. Colonoscopy demands exceeded the current supply; an estimated increase of 1,360 gastroenterologists would be needed to meet the screening demands of people at age 65 years (Vijan et al., 2004). To perform screening colonoscopy every 10 years, a total of 32,700 gastroenterologists would be needed (Vijan, et al., 2004). Increasing the use of NPs in primary care practice has been proposed as a solution to the lack of access to primary care (Kaiser Family Foundation, 2011; Mundinger, 1994). This solution of increasing the use of NPs can be extended to colonoscopy practice, increasing capacity and thereby providing access. According to Anderson, Gilliss, and Yoder (1996) “the combination of lower cost of nurse practitioners education, the effectiveness and quality of their services, and the lower cost of employment provide compelling reasons for the full use of nurse practitioner in primary care― (p. 209). This would still hold true for a NP in colonoscopy practice even with the extra colonoscopy training. According to the U.S. Department of Health and Human Services Health Resources and Services Administration (2010), in 2008 there were about 158,348 NPs in the United States. California had the largest number of NPs in the nation (Anderson et al., 14 1996) though currently the number of NPs performing colonoscopies in California is unknown. There are only a few known NPs performing colonoscopy on a regular basis in California (Limoges-Gonzalez et al., 2011).
General Barriers to Nurse Practitioner Practice Practice environment barriers for NPs in primary care have been documented and studied (Anderson et al., 1996) as well as barriers for hospital privileges for NPs (Brassard & Smolenski, 2011). According to an old survey, perceived barriers affecting NP practice in California includes lack of prescriptive authority, lack of support from physicians, reimbursement difficulties, and lack of public awareness (Anderson et al., 1996). Brassard and Smolenski (2011) described barriers for NPs in obtaining hospital privileges including Federal and State laws, and ambiguous regulations, as well as hospital bylaws and policies. According to Brassard and Smolenski (2011), removing barriers would reduce cost, increase consumer choice, and improve health quality. These could also be the same barriers that face NPs in colonoscopy practice. Since the 1996 study by Anderson et al., some headway has been made in improving legislations and regulation affecting NP practice. There have been some improvement with regards to physicians’ support (Fairman, Rowe, Hassmiller, & Shalala, 2011). According to Fairman et al. (2011), 16 states have liberalized and improved the scope of nursing practice regulations to allow NPs to practice and prescribe independently. More and more states are reconsidering laws to allow independent practice for NPs (Fairman et al., 2011). California NPs have prescriptive abilities (known as furnishing) and are now allowed to write prescriptions for medications on Schedule II to V (Board of Registered 15 Nursing, 2011). Awareness of the NP role by the public has improved as seen by the endorsement of American Association of Retired Persons (AARP) (Brassard &
Smolenski, 2011). With regards to reimbursement, Medicare reimburses NPs for services to Medicare patients. NPs performing screening colonoscopies on Medicare patients also get reimbursed (American Academy of Nurse Practitioners, 2011) Nurse Endoscopists Numerous studies demonstrate safety, effectiveness, and accuracy when nurse endoscopists perform sigmoidoscopy (Duthie et al., 1998; Horton et al., 2001; Kelly et al., 2008; Lieberman & Ghormley, 1992; Maruthachalam, Stoker, Nicholson, & Horgan, 2006; Maule, 1994; Schoenfeld et al., 1999; Wallace et al., 1999) and colonoscopy exams (Christensen & Tealey, 2005; Kalloo, 2011; Koornstra et al., 2009; Limoges-Gonzalez et al., 2011). Yet, there remains general opposition to the role of nurse endoscopist. At present, the American Society for Gastrointestinal Endoscopy (ASGE) and American College of Gastroenterology (ACG) recommend limiting non-gastroenterologists to performing only sigmoidoscopies (American Society for Gastrointestinal Endoscopy & American College of Gastroenterology, 2009) Flexible Sigmoidoscopy United Kingdom Duthie et al. (1998) did a prospective evaluation of a nurse endoscopy training program in the United Kingdom. The nurse practitioner underwent sigmoidoscopy training that involved observation (n = 35), withdrawals of the scope (n = 35), and then full procedures (n = 35). The nurse practitioner then performed 215 flexible sigmoidocopies independently and 93% of the examination was judged successful with 16 51% having pathology identified. No complications were identified. Duthie et al. (1998)
concluded that with proper training, a nurse endoscopist was able to safely and effectively perform sigmoidoscopy. In another U.K. study, Maruthachalam et al. (2006) studied a nurse led flexible sigmoidoscopy clinic in a primary care setting. In this study, a nurse endoscopist performed 1,002 flexible sigmoidoscopies between March 2004 and July 2005. Results of the screening yielded 22% of patients were diagnosed with colonic pathology and 25% with CRC. No complications were reported. Assessment of patient satisfaction showed high patient satisfaction rate, and 99% of patients were satisfied with the care received (Maruthachalam, et al., 2006). Maruthachalam et al. (2006) concluded that a nurse endoscopist could provide safe and effective flexible sigmoidoscopy service with high levels of patient satisfaction. Another U.K. study done by Kelly et al. (2008) described a nurse specialist who led a flexible sigmoidoscopy clinic in an outpatient setting. The researchers collected data prospectively regarding source of referral, presenting symptoms, the result of flexible sigmoidoscopy, depth of insertion, the follow up plan, and complication. In this study, 3,956 patients had flexible sigmoidoscopy done. The result of the study showed that there were 1,560 normal sigmoidoscopies, 132 with positive cancer detection, and 276 had inflammatory bowel disease, 415 patients with polyps, 584 with diverticulosis, and 926 with hemorrhoids. Kelly et al. (2008) concluded that a nurse specialist led sigmoidoscopy clinic offered a safe and efficient diagnostic service. 17 United States Horton, Reffel, Rosen, and Farraye (2001) described a multispecialty group that
used nurse practitioners (NP) and physician assistants (PA) to perform flexible sigmoidoscopies. These providers had hands on training under the direct supervision of a gastroenterologist whereby the NP or PA provider performed a minimum of 100 successful supervised sigmoidoscopies over a two-to-four month period before being deemed competent. Data were collected on 9,500 sigmoidoscopies; 10% had adenomatous polyps and a 0.32% incidence of CRC. No major complications were observed with the NPs and PAs performing sigmoidoscopies. There was a noted 33% lower cost for a NP or PA to perform sigmoidoscopy compared to a gastroenterologist. Patient satisfaction ratings revealed 90% of patients were very satisfied with the care and were willing to have the procedure done again. The authors concluded that NP and PA- performed flexible sigmoidoscopy had similar accuracy and safety as gastroenterologist performed but at a lower cost (Horton, et al., 2001). Maule (1994) studied two registered nurses and two licensed practical nurses who performed screening flexible sigmoidoscopy in comparison to two gastroenterologists. All four nurses underwent training and gained proficiency with the controls of a 60 cm fiber optic flexible sigmoidoscopy. The nurses performed 1,881 flexible sigmoidoscopy exams while the physicians performed 730 cases. The results indicated that the physicians had greater mean depth of insertion in comparison to the nurses. Adenomas were found on 14% of male and 8% of women. There was no difference in the proportion of positive diagnosis of adenoma or cancer between the nurses and the physicians. No complications were reported. In this study, Maule (1994) concluded that nurses did 18 perform screening sigmoidoscopy safely and as accurately as an experienced
gastroenterologist. Schoenfeld et al. (1999) compared the effectiveness of and patient satisfaction with flexible sigmoidoscopies performed by a registered nurse, general surgeons, and gastroenterology (GI) fellow. Six months prior to the study, the registered nurse (RN) was trained to perform flexible sigmoidoscopies. Prior to the study, the RN completed 100 unsupervised flexible sigmoidoscopies. Patients were assigned to the first available endoscopist for sigmoidoscopy. The depth of insertion, complication, duration of procedure, percentage of patients with adenomas, and patient satisfaction were recorded. The authors demonstrated that the mean depth of insertion was less for a general surgeon compared to both the nurses and the gastroenterology fellow. Duration of the procedure was longer for the nurses compared with the general surgeons and the gastroenterology fellow. Percentage of patient with adenomas was similar between the groups. Patients’ satisfaction was also similar between the groups. The authors concluded that there was no difference in effectiveness or patient satisfaction with flexible sigmoidoscopy performed by the registered nurse, general surgeons, or GI fellows (Schoenfeld et al., 1999). Wallace et al. (1999) studied a NP and two physician assistants who were trained to perform flexible sigmoidoscopy, and prospectively collected data. Between 1995 - 1997, there were 3,701 patients that underwent flexible sigmoidoscopy, and of these, 2,323 (62.7%) had sigmoidoscopy done by non-physicians. The authors demonstrated that there was no difference in depth of insertion after baseline adjustment for age and sex of patients was done. No difference in the rate of detection of polyps was found between the groups. No major complications including perforation, bleeding were 19
reported. Based on the results, the authors concluded that non-physician endoscopists could safely and effectively perform flexible sigmoidoscopy when appropriately trained (Wallace et al., 1999). Furthermore, the authors concluded that an increased use of non- physicians in performing sigmoidoscopies may increase availability and lower cost of the procedure (see Figure 1). Figure 1. Basis of Cost Estimates Source: Wallace et al (1999). Colonoscopy In Alaska, Christensen and Tealy (2005) reported that a trained and experienced NP could perform colonoscopy safely. In this study, the NP provided routine screening colonoscopy for Alaskan natives. The NP filled the critical need for a trained endoscopist in the rural and underserved population of Alaska (Christensen & Tealey, 2005). Limoges-Gonzalez et al. (2011) did a single randomized controlled study comparing screening colonoscopies performed by a NP and a gastroenterologist. The NP performed a total of 1000 colonoscopies within a 2-year period. Limoges-Gonzalez et al. (2011) found that there were no statistically significant differences between the NP and the gastroenterologist with regards to pain, patient satisfaction, cecal intubation, duration of procedure, and withdrawal time. Limoges-Gonzales et al. (2011) concluded that a 20 properly trained NP did perform screening colonoscopy as safely, accurately and satisfactorily as a gastroenterologist. Koornstra et al. (2009) did a feasibility study on colonoscopy training for NPs. In this study, two NPs were trained with the first year gastroenterology (GI) fellow. Each
NP and GI fellow performed 150 colonoscopies. Koornstra et al. (2009) found that NPs cecal intubation rate was 80% for the first 25 procedures and increased up to 96% on the last 25 cases. The patients reported low degree of pain and discomfort and had high satisfaction rates. The complication rate was 0.3% (Koornstra, et al., 2009). Koornstra et al. (2009) concluded that trained NPs did perform colonoscopies as safely and effectively as a GI fellow. At John Hopkins University, a NP attended a1-year fellowship program that included training for colonoscopy. This program included a didactic curriculum as well as clinical experience. Fellows rotated in gastroenterology service, hepatology clinics, and endoscopy procedures. Monica Van Dongen, the first NP GI fellow of John Hopkins University, had an intubation rate of 94.6% and adenoma detection at 0.043 % per colonoscopy (Kalloo, 2011). She exceeded the benchmarks expected of fully trained gastroenterologists with no perforation in 119 cases (Hurtfless & Kalloo, 2013). At San Francisco General Hospital, with the use of NPs, the hospital increased the number of colonoscopy procedures by 40.4% over a 5-year period, an increase of 8.8 % a year. The hospital also reduced the wait time by 65%. A full-time NP was trained for one year to safely and independently perform colonoscopies. The training included didactic education, direct observation, and individual teaching as well as simulation. In this hospital, there were no differences in cecal intubation rates between the NP and the GI 21 physicians nor was there a difference in the percentage of adverse events in colonoscopies done by nurse practitioner versus the GI physician (Day, 2012). In Pennsylvania, a NP in the Veterans Affairs Medical Center system was
credentialed to perform colonoscopy after successful completion of a training based on the ASGE colonoscopy curriculum. He performed 325 colonoscopies and more than 150 polypectomies. He was held to the same standard as a gastroenterologist (Hopchik, 2012). Affordable Care Act and Institute of Medicine Recommendation #1 On March 23, 2010, President Obama signed the Patient Protection and Affordable Care Act (ACA). The law provides comprehensive health insurance reforms. This law is designed to make quality, affordable health care available, guarantees access to health care for all Americans, reduces costs, improves health care quality, enhance disease prevention, and strengthen the health care workforce. One of the provisions of this law includes free preventive care. All new insurance plans will now cover preventive services such as mammogram and colonoscopies without a deductible or copayment (Kocher, Emanuel, & DeParle, 2010). With the historic passing of the ACA in 2010, the Robert Woods Johnson Foundation and Institute of Medicine (IOM) established a two-year initiative on the Future of Nursing (Institute of Medicine, 2010). The Future of Nursing has eight major recommendations. Recommendation #1 is to: “Remove scope-of- practice barriers. Advance Practice Nurses should be allowed to practice to the fullest extent of their education and training. Congress should expand Medicare to include coverage of APRN services within scope-of-practice 22 under applicable state law, just as physicians’ services are now covered. State legislatures should reform scope-of-practice regulations to conform to the
National Council of State Boards of Nursing APRN model rules and regulations― (Institute of Medicine, 2010, p. 7). With more than 45 million Americans who will be getting insurance and needing preventive care including colonoscopy under the ACA provisions, the health care industry will need to increase the number of providers to deliver this care. Allowing NPs to do colonoscopies and to practice to the fullest extent of their education would help in providing much needed health and preventive care. Limitations Studies reviewed in the literature review were very limited to available data. None of the studies reviewed were double blinded randomized studies. The number of nurse endoscopists in the studies was limited in number, and most of the studies only involved 1 or 2 non-physician endoscopist. The nurse endoscopist in the study was selected based on the need of the facility conducting the study. No long-term studies regarding NPs performing colonoscopy were available for review. Most of the study reviewed involved a non physician endoscopist only a few study involved a NP specifically. Conclusion Based on the information to date, nurse endoscopists with proper training can safely perform sigmoidoscopies and colonoscopies as supported by numerous studies from both the United States and United Kingdom. Properly trained NPs are equivalent with gastroenterologists when compared on quality, safety and patient satisfaction outcomes. With the aging population and implementation of the ACA in 2014, allowing 23 NPs to perform colonoscopy will help increase CRC screening by colonoscopy. Allowing
NPs to perform colonoscopies will also help solve the problem of access and capacity. Studies have shown that NPs can perform colonoscopy safely and cost effectively. Yet, there is a need to demonstrate the financial aspect of having a NP endoscopy – led center. This project seeks to determine the outcomes of such a center. 24 CHAPTER II BUSINESS DATA 1.0 Overview of Business Case Numerous studies in both United States and United Kingdom have shown that a properly trained nurse endoscopist can safely perform sigmoidoscopy and colonoscopy. This study assessed the feasibility and cost analysis of having a Nurse Managed Endoscopy Service. 1.1 Products and Services After being trained for colonoscopy, the NP will perform screening colonoscopies on unscreened CRC patients ages 50 to 75 years of age. The ASGE Colonoscopy Core Competency will be used to train and evaluate the NP. The ASGE colonoscopy core curriculum recommends that an endoscopist in training needs to successfully complete 140 colonoscopies to be competent (American Society for Gastrointestinal Endoscopy, 2012). 1.2 The Financing The NP practice will be incorporated into the existing Gastroenterology department, and the same budget would be used. 1.3 Mission Statement
As part of the HMO setting, the NP will adhere to and promote the overall mission of the company which is “ to provide, affordable, high quality health care services to improve the health and well being of our members and the communities it serves.― (Kaiser Permanente, 2013). 25 1.4 Management Team The NPs will be a member of the Department of Gastroenterology. There are 6 gastroenterologist and 2 NPs in the department. The NPs will be under the direct supervision of the Chief of Gastroenterology. 1.5 Sales Forecasts With the increasing number of HMO membership and an aging population as well as an inability to cope with the current demand for colonoscopy as shown by the number of cases being outsourced, the NP will be provide colonoscopy and therefore decrease cost, provide equality care, and meet the demands of the patient population. 1.6 Expansion Plan With the aging population and the passing of the ACA, an anticipated increase in HMO membership would require provision of CRC screening. Having a NP colonoscopist will help fill the gap and provide needed quality care at a lower cost. 2.0 Company and Financing Summary 2.1 Required Funds Since the NP will be incorporated into the existing gastroenterology department, needed equipment is already available. No new equipment will be needed. Below are the basic equipment and current prices needed to run a single room for
colonoscopy. The price quote is from Fujifilm Medical System dated Aug 29, 2012. A total of $158,229.33 for equipment is needed and $23,088.91 for software license, maintenance and training totaling $181,318.24. 26 Table 4 Basic Equipment and Current Prices Needed for a Single Room Description Quantity List price High definition Digital Video processor 1 $17,475 300 Watt Xenon Light Source – automatic Control and light Save function 1 $9,716 Standard Gastroscope with 2.8 mm Channel and 9.3 mmOD, 1100nm Working length 1 $ 26,730 Standard Gastroscope with 4.2 mm Channel and 12.8 mmOD, 1690 nm Working length 1 $29,610 Standard Gastroscope with 3.8 mm Channel and 11.5mmOD, 1690 nm Working length 1 $29,610 NDS Radiane G2 HB Flat Screen LED Monitor with Fujinon Bios 1 $5,860
30 ft Digital video Interconnect Cable 1 $273.60 Endo Gator Jetwash Pump 1 $1,478 Deluxe cart with Dual Scope Holder and Flat Panel Monitor Mount 1 $5,395 Flat screen variable Height Roll Stand 1 $94.5 New air / Water Button 1 $442.80 New Suction Button 1 $442 Hand held leak tester 1 $247 Scope water bottle 1 $148.50 Biopsy valve Cover 6 $130.68 Total $15,8229 27 Below are tables of personnel- payroll cost as well non-payroll cost breakdown with different scenarios. Table 5 and 6 are evening clinics. Table 5 Cost of Colonoscopy for 4 hour clinic = total of 8 colonoscopies Per hour Physician -2 $209 Procedure RN -2 $79 Recovery RN -2 $79 Technician -2 $42
Scope cleaner -1 $22 Receptionist -1 $25 Payroll cost $1,824 Non payroll cost $833 Cost per colonoscopy $332 28 Table 6 Proposed Staffing with Nurse Practitioner Per hour Physician -1 $104.50 Nurse Practitioner -1 $60 Procedure RN -2 $79 Recovery RN -2 $79 Technician -2 $42 Scope cleaner -1 $22 Receptionist -1 $25 Payroll cost $1,646 Non payroll cost $833 Savings on payroll cost $178 Cost per colonoscopy $310 Minimal cost savings are seen with the replacement of one of the gastroenterologists with a NP and keeping the same staff. While savings is only 7%, an addition of a NP will free up a gastroenterologist to do more consultations, endoscopic
retrograde cholangiopancreatography (ERCP), and take hospital calls. 29 Table 7 Weekend 8 hour clinic = total of 10 colonoscopies Per hour Physician -1 $209 Procedure RN -1 $79 Recovery RN -2 $158 Technician -1 $42 Scope cleaner -1 $22 Receptionist -1 $25 Payroll Cost $4,280 Payroll cost per case $428 Non payroll cost $1000 Cost per colonoscopy $528 30 Table 8 Total of 20 Colonoscopies = Proposed Staffing with Nurse Practitioner Per hour Physician -1 $209 Nurse Practitioner -1 $60 Procedure RN -2 $158 Recovery RN -2 $158
Technician -2 $84 Scope cleaner -1 $22 Receptionist -1 $25 Payroll Cost $5,732 Payroll cost per case $286.6 Non payroll cost $2,000 Cost per colonoscopy $386.6 By adding a NP, the number of completed colonoscopies doubles which would help in attaining the goal of a 78% CRC screening rate, and increase patient satisfaction by avoiding the long wait as well as cost savings as seen above. There is a cost saving of 27 % per case. 2.2 Investor Equity The Department of Gastroenterology, which the NP is a part of, is not seeking an investment from a third party at this time. 31 2.3 Management Equity The Department of Gastroenterology will be using its current budget to provide colonoscopy. The NP’s salary is already included in the department’s budget. 2.4 Exit Strategy If a new technology is discovered for CRC screening; then colonoscopy will not be needed, and the NP will have to adapt to the new technology. 3.0 Products and Services Below is a description of the medical services offered under a nurse managed
endoscopy service. 3.1 Medical Services The primary source of revenue for the business will be copayments from insured patients having the procedure completed. Copayment for this procedure varies and ranges from $0 to $250 depending on the patients’ policy. At present, the GI department at this HMO, located in San Fernando Valley, performs 28 to 30 colonoscopies a day. Twice a week, a night clinic is opened for 4 hours to help meet the demand for colonoscopy. A weekend 8 hour clinic is also occasionally offered to help the demand. 4.0 Strategic and Market Analysis With the passing of the ACA and its full implementation in 2014, 32 million uninsured Americans will be having insurance coverage. A projected increase in membership is anticipated from 2014–2016 on top of the expected membership growth over the next 10 years, even without the passing of the ACA. 32 As of February 2012, the HMO cancer screening rate for colon cancer was 74.2 %; the target is 78%. The United States’ CRC rate was 54.1% - 75.2 % as of year 2010. California’s CRC rate was 59.3% to 63% as of year 2010. Below is a graph showing the number of HMO members needing CRC screening versus the number of colonoscopies performed. Less than 10 % of members between the ages 49-75 years of age had colonoscopies. Figure 2. Members 49-75 years of age compared to actual number of colonoscopies performed.
Screen rates vary across the nation. Table 9 is the CRC screening rate of this HMO facility compared to California and the U.S. for the year 2010. This HMO achieved 73.7 % CRC screen rate of all the members that needed screening. 0 10000 20000 30000 40000 50000 60000 2010 2011 2012 Members 49-75 yrs old Colonoscopies Performed 33 Table 9 Comparison of Colon Cancer Screening Rates, 2010 Colon Cancer Screening Rates HMO 73.7 USA (National) 54.1 - 75.2 CA 59.3 - 63 Source: http://kpnet.kp.org/.../docs/Cancer Screenings Update.ppt Figure 3 is the historical trend of screening rates for this HMO facility. The facility’s goal is a 78% CRC screen rate. Using a NP to perform screening colonoscopies
will help attain the goal of a 78% CRC screening rate. 72 73 74 75 76 77 2010 2011 2012 CRC Screening Rates Figure 3. The CRC screening rates of Kaiser for the last 3 years Source: http://kpnet.kp.org/.../docs/Cancer Screenings Update.ppt 5.0 Marketing Plan http://kpnet.kp.org/.../docs/Cancer%20Screenings%20Update.ppt http://kpnet.kp.org/.../docs/Cancer%20Screenings%20Update.ppt 34 The department will inform primary physicians that a NP will be available to perform screening colonoscopy. Patients requesting a physician will be scheduled with a physician. 5.1 Pricing Below is a table with the CPT codes and 2012 Medicare reimbursement Table 10 Medicare reimbursement Procedure Cpt Code *ASC facility fee
Hospital facility fee Physician Fee when procedure performed in Hospital or ASC Physician Fee when procedure performed in office Colonoscopy, flexible, proximal to splenic flexure with biopsy, single or multiple 45380 378 655 264 481 Colonoscopy,
flexible, proximal to splenic flexure with removal of tumors, polyps or other lesions by hot forceps or bipolar cautery 45384 378 655 275 477 35 * Boston Scientific Guidepoint, Simplyfing Reimbursement: Defining Tomorrow, Today in Endoscopy Currently, this HMO contracts to send patients to an outside facility. The fee associated per patient is $475 for the facility fee and $275 for the physician’s fee, a total of $750. Below is a table showing the number of colonoscopies contracted out for 2 years. Table 11 Number of Colonoscopies Completed Outside Year Number of
colonoscopy request for sent out* Number of colonoscopy completed outside Outside Cost Kaiser Cost with NP 2011 2439 600 450000 186000 2012 1866 800 600000 248000 An authorization was requested and granted, but not all referrals had their colonoscopy completed at an outside facility. Patients have an option to still have colonoscopy performed in house as long as patients are willing to wait. Figure 4 is a graph showing the predicted cost savings in 2011 and 2012 if the colonoscopy cases were done at the facility with a NP. 36 Figure 4 Cost of Colonoscopy Performed In-house Versus Outside Referral. Adding two evening clinics a week could accommodate all the cases previously completed outside in a one-year time span. Avoiding cases being outsourced would save the facility 59% per case. It cost $310 per colonoscopy in an evening clinic with the addition of an NP while it cost $750 per case for a colonoscopy to be completed outside. Aside from being cost effective, most patients prefer to be seen within the HMO facility
as noted by the number of referrals compared to cases completed. Having one NP and one gastroenterologist during the night clinic would also free one gastroenterologist for consultation, hospital rounding, ERCP, and other more complex tasks. Below is a graph showing cost savings for 2010, 2011, and 2012 with the use of a NP in house for 4 evening hours. 0 100000 200000 300000 400000 500000 600000 2011 - 600 cases 2012 - 800 cases Outside cost In house cost with NP 37 0 500000 1000000 1500000 2000000 2500000 2010 4842 cases 2011 5299 cases 2012 6295 cases
with NP without NP Figure 5. Cost Comparison of Colonoscopy Below is a chart showing the number of colonoscopy cases completed in-house for 2010, 2011, and 2012. 0 1000 2000 3000 4000 5000 6000 7000 2010 2011 2012 Number of colonoscopies completed in house Figure 6. Number of Colonoscopies Completed in House. 38 6.0. Profit and Loss The data below shows the profit with the different scenarios analyzed. In the calculation of the profit, an assumption of a 100 % physician professional fee will be collected from Medicare and 80% of the physician’s professional fee for the care provided by NP.
830 840 850 860 870 880 890 900 910 920 NP reimbursement - 80 % GI reimbursement Reimbursement Figure 7. Professional Fee Reimbursement The amount of reimbursement doubles for the 8 hours clinic with the addition of a NP. The profit also increases, but the real benefit in the addition of a NP would be decreasing the wait time for colonoscopy as well as usage of space and equipment which would otherwise be unused. An addition of a NP endoscopist is a cost effective way of attaining the facility’s goal of a 78% CRC rate without sacrificing quality care. Table 12 shows the cost of colonoscopy, reimbursement, and profit with the different scenarios. A loss of $108 is seen for each case done outside the facility. For the last 2 years, a total loss of $151,200 is calculated. 39 Table 12.
Cost per Colonoscopy, Reimbursement and Profit Cost per Colonoscopy Reimbursement Profit 1 GI - 8 hour clinic 528 9190 3910 1 GI and 1 NP 8 hour clinic 386.6 17850 10118 2 GI 4 hour clinic 332 7352 4695 1 GI and 1NP 4 hour clinic 310 7140 4661 Outside colonoscopy 750 642 -108 In the graph below, the scenario with one GI physician and an NP working together has the highest reimbursement and profit. This scenario also doubles the number of colonoscopies performed, thereby increasing access. Doubling the number of colonoscopies will increase the CRC screening rate and help attain the HMO’s goal of a 78% CRC screening rate. 40 0 2000 4000 6000 8000 10000 12000 14000 16000 18000
1 GI - 8 hour clinic 1 GI and 1 NP 8 hour clinic 2 GI 4 hour clinic 1 GI and 1NP 4 hour clinic Cost per Colonoscopy Total Cost per clinic Reimbursment Profit Figure 8. Cost and Profit Below is a graph showing the reimbursement rate and outside cost of colonoscopy. A loss is clearly seen when patients are treated outside the HMO. An increase in cost is seen with the increased number of cases contracted outside the facility. Having a NP perform these cases in house will avoid this loss and still be able to provide cost effective and quality endoscopy. 41 -100000 0 100000 200000
300000 400000 500000 600000 2011 - 600 cases 2012 - 800 cases Outside Cost Reimbursement Loss Figure 9. Loss for Outside Colonoscopy Table 13 and 14 highlight the Political, Economic, Social, Technological (PEST) Analysis and |SWOT Analysis of a Nurse Practitioner Managed Endoscopy Service. PEST and SWOT analysis allowed the author to analyze factors affecting the service. External environmental factors, such as the political, economic, social, and technological, which have a critical influence in this project were analyzed as part of the PEST analysis. 42 Table13 PEST Analysis of NP Managed Endoscopy Service Political Passing of the Affordable Care Act Medicare reimbursement of NP Increasing support of NPs nationally such as AARP Increasing number of states allowing NP
independent practice, currently 17 states NP endoscopist has no endorsement from the American Society for Gastrointestinal Endoscopy Economical Increasing demand for colonoscopy Long wait time for colonoscopy Not enough endoscopists NP endoscopists are cheaper than gastroenterologists and provide comparable care and patient satisfaction with regards to colonoscopy Continuity of care Social Increasing population of people ages 50- 75 years old Increasing number of people insured with the passing of the Affordable Care Act Increasing acceptance of NPs e.g. endorsed by AARP Technological Colonoscopy is still the gold standard in
CRC screening 43 Table14 SWOT Analysis for Nurse Managed Endoscopy Service Strengths Availability of NP Trained staff already available (RN, Technicians, and Receptionist) Equipment already available Colonoscopy center already in place Continuity of care for patients Economically cheaper – cost saving Increased number of screening colonoscopy with availability of NP endoscopist Excellent safety and efficacy record The Institute of Medicine’s recommendation for full independent practice for nurse practitioners. Increasing support for NP by the community and other organizations such as AARP Increasing number of states with NP
independent practice, currently 17 states California Senate Passing of SB 491 – Expansion of NP Scope of Practice Reimbursement from Medicare Weaknesses New role for NP Resistance from physicians and other personnel Learning curve for NP in training SB 491- Expansion of NP Scope of Practice did not pass California House Assembly Opportunities Implementation of the Affordable Care Act Aging population Increase in membership Increase demand for quality care as well as cost effective care First NP Managed Endoscopy center in a HMO Threats No support from American Society for Gastrointestinal Endoscopy
No support from administration 44 Evaluation An ongoing evaluation and adjustments will be executed while the program is in progress. Evaluation and adjustments will be performed to ensure patients’ safety and work flow efficiency. At the end of 1 year, an in-depth evaluation will be done. Evaluation on the following criteria will be reviewed. a. patient satisfaction outcomes, waiting period for colonoscopy b. intubation rate, complications, and safety c. work flow efficiency and cost savings d. effect on CRC screening rate After the 1 year evaluation, a continuous evaluation will be carried out every 6 months. Necessary changes and adjustments will be made based on evaluation report. Summary In reviewing data for the NP Managed Colonoscopy Service, a need for a trained NP endoscopist is clearly seen. A well trained NP can fill this need. There is a big gap noted with regards to patients needing colonoscopies and number of colonoscopies performed. It should also be noted that since some patients are contracted outside the HMO, there is a big cost difference for the outside versus in-house cost with a NP performing the colonoscopy. This area is where a potential savings could be appreciated. Currently, reimbursements for NPs are less than a physician. This would affect the income made by a NP when compared to a physician. Even with a lesser reimbursement rate, adding a NP to perform colonoscopies is still a cost effective way to provide quality
endoscopy. NPs working in collaboration with the gastroenterologist would increase the 45 number of screening colonoscopies and help the goal of increased CRC screening rate and positively affect the Healthy People 2020 cancer goal. 46 CHAPTER III DNP REFLECTION The Doctorate in Nursing Practice (DNP) is a terminal degree in nursing. Compared to the PhD, another terminal degree with an emphasis on research, the DNP is a practice doctorate with a focus on translation of research into clinical practice. DNP graduates are prepared to be well equipped to fully implement any research produced by a nurse researcher. DNP graduates focus heavily on innovative and evidence-based practice which reflects the application of credible research findings (American Association of Colleges of Nursing, 2006) Eight essentials in the DNP degree delineate the core foundational competencies needed in all advanced practiced roles. This NP Managed Endoscopy Service Prospectus is the result of the application of the DNP essentials learned in the program. The DNP Essentials Essential I: Scientific Underpinning for Practice. DNP graduates are equipped with a wide array of knowledge needed to be able to adapt and be effective in the ever changing health care delivery system. DNP graduates are prepared to integrate nursing science with knowledge from different sciences and use science - based theories to affect health care outcomes.
Essential II: Organizational and Systems Leadership for Quality Improvement and Systems Thinking. DNP graduates are prepared to be knowledgeable about patients at the individual, population and community level to facilitate improvement of health care outcomes. The DNP graduate’s organizational and leadership skills are necessary to the development, implementation, and evaluation of the NP Managed Endoscopy Service. 47 The NP Managed Endoscopy service affects the individual patients, population, and community health. Essential III: Clinical Scholarship and Analytical Methods for Evidenced – based Practice. DNP graduates have the competency to be able to translate research into practice. DNP graduates focused on translation of new science, application and evaluation. With the NP Manage Endoscopy Service, the DNP’s leadership is needed for implementation and evaluation to improve health care outcomes. The NP DNP graduate will direct, manage, and evaluate the service to ensure safe, efficient, effective, and equitable patient centered care. Essential IV: Information Systems or Technology and Patient Care Technology for the Improvement and Transformation of Health Care. DNP graduates are trained to analyze and use information technology to provide safe, quality, and cost effective patient care. The concept of the NP Managed Endoscopy Service was based on the analysis and evaluation of the existing data available provided by information technology. Essential V: Health Care Policy for Advocacy in Health Care. With the ever changing healthy care policy, DNP graduates are prepared to take a leadership role in health care policy action committees to promote patient care as well as the nursing
profession. The NP Managed Endoscopy Service is an emerging niche for NPs. DNP preparation prepares the graduates with skills for the design, analysis, and future implementation of the a NP Managed Endoscopy Service. Knowledge of evidenced based practice will assist in the influence of other stakeholders to its implementation. Essential VI: Interprofessional Collaboration for Improving patient and Population Health Outcomes. DNP graduates are prepared to work in collaboration with 48 different professional to improve patient care. The NP Managed Endoscopy Service is a collaborative effort of a team, physician, nurses, NPs, and technician to provide safe and quality, cost effective care. Essential VII: Clinical Prevention and Population Health for Improving the Nation’s Health. DNP graduates are expected to provide risk reduction and illness prevention for individuals and families as well as the entire population. Colorectal cancer screening is part of the Healthy People 2020 goal of cancer prevention which supports the nation’s goal of improving the health status of the population of the United States (American Association of Colleges of Nursing, 2006). Implementation of a NP Managed Endoscopy Service will help achieve the goal by providing increased access to train NP endoscopists able to perform safe colonoscopies at a lower cost. Essential VIII: Advanced Nursing Practice. DNP programs provide education to allow specialization. Knowledge learned from the DNP preparation assists in the development and conceptual analysis of a NP Managed Endoscopy Service (American Association of Colleges of Nursing, 2006). Conceptual and analytical skills gained in the DNP program prepared the student for the development of a NP Managed Endoscopy
Service Prospectus. Summary The DNP’s eight essentials were important factors that influenced the development of the NP Managed Endoscopy Service Prospectus. The service is practice based. It is an example of implementation of science done by researchers. The DNP graduate, an advanced practice nurse, was prepared to demonstrate practice expertise, specialized knowledge, and expanded responsibility (American Association of Colleges 49 of Nursing, 2006). All of these characteristics are important in the development of the NP Managed Endoscopy Service Prospectus as well as its implementation, evaluation, and success. 50 REFERENCES Allen, J. D., Barlow, W. E., Duncan, R. P., Egede, L. E., Friedman, L. S., Keating, N. L., . . . Virnig, B. A. (2010). NIH State-of-the-Science Conference Statement: Enhancing Use and Quality of Colorectal Cancer Screening. NIH Consensus and State-of-the-Science Statements, 27(1). American Society for Gastrointestinal Endoscopy. (2012). Colonoscopy core curriculum. Gastrointestinal Endoscopy 76(3), 482- 490. American Society for Gastrointestinal Endoscopy, & American College of Gastroenterology. (2009). Ensuring competence in endoscopy. Retrieved from http://www.asge.org/assets/0/71542/71544/a59d4f7a580e466ab9670ee8b78bc7ec. pdf
American Academy of Nurse Practitioners. (2011). Medicare update. Retrieved from http://www.aanp.org/NR/rdonlyres/5F6EB7ED-F3F1-4E3B-8A8E- 1F847BF7A43C/0/MedicareUpdate911FactSheet.pdf American Association of Colleges of Nursing. (2006). The Essentials of Doctoral Education for Advanced Nursing Practice. Retrieved from http://www.aacn.nche.edu/publications/position/DNPEssentials.pdf Anderson, A. L., Gilliss, C. L., & Yoder, L. (1996). Practice environment for nurse practitioners in California. Identifying barriers. Western Journal of Medicine, 165(4), 209-214. http://www.asge.org/assets/0/71542/71544/a59d4f7a580e466ab9670ee8b78bc7ec.pdf http://www.asge.org/assets/0/71542/71544/a59d4f7a580e466ab9670ee8b78bc7ec.pdf http://www.aanp.org/NR/rdonlyres/5F6EB7ED-F3F1-4E3B-8A8E- 1F847BF7A43C/0/MedicareUpdate911FactSheet.pdf http://www.aanp.org/NR/rdonlyres/5F6EB7ED-F3F1-4E3B-8A8E- 1F847BF7A43C/0/MedicareUpdate911FactSheet.pdf http://www.aacn.nche.edu/publications/position/DNPEssentials.pdf 51 Ballew, C., Lloyd, B. G., & Miller, S. H. (2009). Capacity for colorectal cancer screening by colonoscopy, Montana, 2008. American Journal of Preventive Medicine, 36(4), 329-332. doi:10.1016/j.amepre.2008.11.021 Board of Registered Nursing. (2011). General information: Nurse practitioner practice. Retrieved from http://www.rn.ca.gov/pdfs/regulations/npr-b-23.pdf Brassard, A., & Smolenski, M. (2011). Removing barriers to advanced practice registered nurse care:Hospital priveleges. Washington, DC: AARP Public Policy Institute. Retrieved from http://championnursing.org/sites/default/files/2011-IS- ARPN-Hospital-PrivilegesAARP-branded.pdf.
Brown, M. L., Klabunde, C. N., & Mysliwiec, P. (2003). Current capacity for endoscopic colorectal cancer screening in the United States: Data from the National Cancer Institute Survey of Colorectal Cancer Screening Practices. American Journal of Medicine, 115(2), 129-133. Christensen, C., & Tealey, A. R. (2005). Nurse practitioner performing screening colonoscopy: An update. Paper presented at the Society of Gastroenterology Nurses and Associates Annual Course, Minneapolis, MN. Day, L. (2012). Increasing and advancing gastrointestinal care in the saftey-net: Expanding the role of nurse practitioner. Retrieved from http://www.safetynetinstitute.org/content/upload/AssetMgmt/Site/QLAs/2012%2 0Entries/SNI_application_SFGH.pdf http://www.rn.ca.gov/pdfs/regulations/npr-b-23.pdf http://championnursing.org/sites/default/files/2011-IS-ARPN-Hospital-PrivilegesAARP- branded.pdf http://championnursing.org/sites/default/files/2011-IS-ARPN-Hospital-PrivilegesAARP- branded.pdf http://www.safetynetinstitute.org/content/upload/AssetMgmt/Site/QLAs/2012%20Entries/SNI_a pplication_SFGH.pdf http://www.safetynetinstitute.org/content/upload/AssetMgmt/Site/QLAs/2012%20Entries/SNI_a pplication_SFGH.pdf 52 Dulai, G. S., Farmer, M. M., Ganz, P. A., Bernaards, C. A., Qi, K., Dietrich, A. J., . . . Kahn, K. L. (2004). Primary care provider perceptions of barriers to and facilitators of colorectal cancer screening in a managed care setting. Cancer, 100(9), 1843-1852. doi: 10.1002/cncr.20209 Duthie, G. S., Drew, P. J., Hughes, M. A., Farouk, R., Hodson, R., Wedgwood, K. R., & Monson, J. R. (1998). A UK training programme for nurse practitioner flexible
sigmoidoscopy and a prospective evaluation of the practice of the first UK trained nurse flexible sigmoidoscopist. Gut, 43(5), 711-714. Fairman, J. A., Rowe, J. W., Hassmiller, S., & Shalala, D. E. (2011). Broadening the scope of nursing practice. New England Journal of Medicine, 364(3), 193-196. doi: 10.1056/NEJMp1012121 Feeley, T. H., Cooper, J., Foels, T., & Mahoney, M. C. (2009). Efficacy expectations for colorectal cancer screening in primary care: Identifying barriers and facilitators for patients and clinicians. Journal of Health Communication, 24(4), 304-315. doi: 10.1080/10410230902889241 Forbes, G. M. (2008). Colorectal cancer screening tests: Pros and cons, and for whom? Expert Review of Gastroenterology & Hepatology, 2(2), 197-205. doi: 10.1586/17474124.2.2.197 53 Guerra, C. E., Schwartz, J. S., Armstrong, K., Brown, J. S., Halbert, C. H., & Shea, J. A. (2007). Barriers of and facilitators to physician recommendation of colorectal cancer screening. Journal of General Internal Medicine, 22(12), 1681-1688. doi: 10.1007/s11606-007-0396-9 Hoffman, R. M., Espey, D., & Rhyne, R. L. (2011). A public-health perspective on screening colonoscopy. Expert Reviews 11(4), 561-569. doi: 10.1586/era.11.16 Hopchik, J. (2012). An NP's journey to credentialling for colonoscopy. Retrieved from http://nurse-practitioners-and-physician- assistants.advanceweb.com/Features/Articles/An-NPs-Journey-to-Credentialing- for-Colonoscopy.aspx
Horton, K., Reffel, A., Rosen, K., & Farraye, F. A. (2001). Training of nurse practitioners and physician assistants to perform screening flexible sigmoidoscopy. Journal of American Academy of Nurse Practitioner, 13(10), 455-459. Hurtfless, S., & Kalloo, A. N. (2013). Screening colonoscopy: A new frontier for nurse practitioner. Clinical Gastroenterology and Hepatology, 11, 106-108. Institute of Medicine. (2010). The future of nursing:Leading change,advancing health. Retrieved from http://www.iom.edu/~/media/Files/Report%20Files/2010/The- Future-of-Nursing/Future%20of%20Nursing%202010%20Recommendations.pdf. Jemal, A., Siegel, R., Ward, E., Hao, Y., Xu, J., & Thun, M. J. (2009). Cancer statistics, 2009. CA: A Cancer Journal for Clinicians 59(4), 225-249. doi: 10.3322/caac.20006 http://nurse-practitioners-and-physician-assistants.advanceweb.com/Features/Articles/An-NPs- Journey-to-Credentialing-for-Colonoscopy.aspx http://nurse-practitioners-and-physician-assistants.advanceweb.com/Features/Articles/An-NPs- Journey-to-Credentialing-for-Colonoscopy.aspx http://nurse-practitioners-and-physician-assistants.advanceweb.com/Features/Articles/An-NPs- Journey-to-Credentialing-for-Colonoscopy.aspx http://www.iom.edu/~/media/Files/Report%20Files/2010/The-Future-of- Nursing/Future%20of%20Nursing%202010%20Recommendations.pdf http://www.iom.edu/~/media/Files/Report%20Files/2010/The-Future-of- Nursing/Future%20of%20Nursing%202010%20Recommendations.pdf 54 Kaiser Family Foundation. (2011). Improving access to adult primary care in medicaid: Exploring the potential role of nurse practitioner and physician assistants. Retrieved from http://www.kff.org/medicaid/upload/8167.pdf Kaiser Permanente. (2013). News Center, news and perspectives from Kaiser Permanente. Retrieved from http://xnet.kp.org/newscenter/aboutkp/ Kalloo, A. N. (2011). Who's traversing the tract? A new Hopkins's partnership could
solve one of the GI's chief problem of supply and demand. Inside Tract, Summer. Retrieved from http://www.hopkinsmedicine.org/sebin/w/y/0E9AFE3064666FA8FDDD79E12F5 AEEA8.pdf Kelly, S. B., Murphy, J., Smith, A., Watson, H., Gibb, S., Walker, C., & Reddy, R. (2008). Nurse specialist led flexible sigmoidoscopy in an outpatient setting. Colorectal Disease, 10(4), 390-393. doi: 10.1111/j.1463-1318.2007.01271.x Kocher, R., Emanuel, E. J., & DeParle, N. A. (2010). The Affordable Care Act and the future of clinical medicine: The opportunities and challenges. Annals of Internal Medicine, 153(8), 536-539. doi: 10.1059/0003-4819-153-8-201010190-00274 Koornstra, J. J., Corporaal, S., Giezen-Beintema, W. M., de Vries, S. E., & van Dullemen, H. M. (2009). Colonoscopy training for nurse endoscopists: A feasibility study. Gastrointestinal Endoscopy, 69(3 Pt 2), 688-695. doi: 10.1016/j.gie.2008.09.028 http://www.kff.org/medicaid/upload/8167.pdf http://xnet.kp.org/newscenter/aboutkp/ http://www.hopkinsmedicine.org/sebin/w/y/0E9AFE3064666FA8FDDD79E12F5AEEA8.pdf http://www.hopkinsmedicine.org/sebin/w/y/0E9AFE3064666FA8FDDD79E12F5AEEA8.pdf 55 Lieberman, D. A., & Ghormley, J. M. (1992). Physician assistants in gastroenterology: Should they perform endoscopy? American Journal of Gastroenterology, 87(8), 940-943. Limoges-Gonzalez, M. (2012). Opening doors for nonphysician colonoscopists. Nurse Practitioner, 37(2), 35-40. doi: 10.1097/01.NPR.0000410280.60115.5c 00006205-201202000-00011 [pii]
Limoges-Gonzalez, M., Mann, N. S., Al-Juburi, A., Tseng, D., Inadomi, J., & Rossaro, L. (2011). Comparisons of screening colonoscopy performed by a nurse practitioner and gastroenterologists: A single-center randomized controlled trial. Gastroenterology Nursing, 34(3), 210-216. doi: 10.1097/SGA.0b013e31821ab5e6 Maruthachalam, K., Stoker, E., Nicholson, G., & Horgan, A. F. (2006). Nurse led flexible sigmoidoscopy in primary care--the first thousand patients. Colorectal Disease, 8(7), 557-562. doi: 10.1111/j.1463-1318.2006.00973.x Maule, W. F. (1994). Screening for colorectal cancer by nurse endoscopists. New England Journal of Medicine, 330(3), 183-187. doi: 10.1056/NEJM199401203300307 Mundinger, M. O. (1994). Health care reform: Will nursing respond? Nursing and Health Care, 15(1), 28-33. Richardson, L. C., Rim, S. H., & Plescia, M. (2010). Vital signs: Colorectal cancer screening among adults aged 50--75 Years --- United States, 2008. Retrieved from 56 http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5926a3.htm?s_cid=mm5926a 3_w. Schoenfeld, P. S., Cash, B., Kita, J., Piorkowski, M., Cruess, D., & Ransohoff, D. (1999). Effectiveness and patient satisfaction with screening flexible sigmoidoscopy performed by registered nurses. Gastrointestinal Endoscopy, 49(2), 158-162. Seeff, L. C., Manninen, D. L., Dong, F. B., Chattopadhyay, S. K., Nadel, M. R., Tangka, F. K., & Molinari, N. A. (2004). Is there endoscopic capacity to provide colorectal
cancer screening to the unscreened population in the United States? Gastroenterology, 127(6), 1661-1669. doi: S0016508504016312 [pii] Seeff, L. C., Richards, T. B., Shapiro, J. A., Nadel, M. R., Manninen, D. L., Given, L. S., . . . McKenna, M. T. (2004). How many endoscopies are performed for colorectal cancer screening? Results from CDC's survey of endoscopic capacity. Gastroenterology, 127(6), 1670-1677. doi: S0016508504016300 [pii] Shapiro, J. A., Seeff, L. C., Thompson, T. D., Nadel, M. R., Klabunde, C. N., & Vernon, S. W. (2008). Colorectal cancer test use from the 2005 National Health Interview Survey. Cancer Epidemiology, Biomarkers & Prevention, 17(7), 1623-1630. doi: 10.1158/1055-9965.EPI-07-2838 Sonnenberg, A., Delco, F., & Inadomi, J. M. (2000). Cost-effectiveness of colonoscopy in screening for colorectal cancer. Annals of Internal Medicine, 133(8), 573-584. doi: 200010170-00007 [pii] http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5926a3.htm?s_cid=mm5926a3_w http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5926a3.htm?s_cid=mm5926a3_w 57 U.S. Department of Health and Human Services, Agency for Healthcare Research and Quality,. (2011). Guide to clinical preventive services, 2010-2011. Recommendation of the U.S. Preventive ServiceTask Force. Retrieved from http://www.ahrq.gov/clinic/pocketgd1011/pocketgd1011.pdf. Vijan, S., Inadomi, J., Hayward, R. A., Hofer, T. P., & Fendrick, A. M. (2004). Projections of demand and capacity for colonoscopy related to increasing rates of colorectal cancer screening in the United States. Alimentary Pharmacology & Therapeutics 20(5), 507-515. doi: 10.1111/j.1365-2036.2004.01960.x
Vincent, J., Hochhalter, A. K., Broglio, K., & Avots-Avotins, A. E. (2011). Survey respondents planning to have screening colonoscopy report unique barriers. Permanente Journal, 15(1), 4-11. Wallace, M. B., Kemp, J. A., Meyer, F., Horton, K., Reffel, A., Christiansen, C. L., & Farraye, F. A. (1999). Screening for colorectal cancer with flexible sigmoidoscopy by nonphysician endoscopists. American Journal of Medicine, 107(3), 214-218. http://www.ahrq.gov/clinic/pocketgd1011/pocketgd1011.pdf [removed] WEEK 3 ASSUGNMENT QUESTIONS TOPIC: DNP Role Assignment Paper Part I Title of my Paper: Why DNP/PHD should be a Requirement to be a Faculty Member at a Nursing School The purpose of this assignment is evaluate a current or new role relative to a DNP prepared nurse. The emphasis will be on the skills that a DNP prepared nurse brings to the role. What are the differences coming from a DNP perspective? What skills will a DNP prepared nurse have that a MSN prepared RN would not. The Role Paper will be completed in 2 parts. Part I will focus on a description of the role and what the DNP/MSN nurse will bring to the role. A SWOT analysis will also be done for Part I. Part 2 will consist of a PEST analysis and the next steps in moving the role to a DNP level. References will be completed for both parts of the paper.  The final paper will include both part 1 and part 2. Below is an outline of the items for which you will be responsible throughout the module. 1. Read chapter 8 and 9 from Zaccagnini, M., & Pechacek, J. (2021). The doctor of nursing practice essentials . (4th Ed.). Burlington, MA: Jones & Bartlett Learning. 2. National Academies of Sciences, Engineering, and Medicine. 2021. The Future of Nursing 2020-2030: Charting a Path to Achieve Health Equity . Washington, DC: The National Academies Press. https://doi.org/10.17226/25982 Links to an external site. . Chapter 4- The role of nurses in improving health care access and quality, p. 99-126, Links to an external site.
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leadership resourceTen steps to carrying out a SWOT analysisChris Pear.docx

  • 1. leadership resource Ten steps to carrying out a SWOT analysis Chris Pearce offers a guide to help nursing leaders analyse their aotivities A SWOT ANALYSIS is an effecrive way of identifying your strengths and weaknesses, and of examining the opportunities and threats you face. Carrying out an analysis using the SWOT framework will help you and your team focus your activities on where you are strongest, and where your greatest opportunities lie, 7 C0NSIDERTHE USES OF SWOT This technique can be used in various situations includ- ing business planning, team building and away days, as well as when you review the work of your team, during change man- agement processes and even in your personal career planning. 2 PREPARETHE GROUND Draw a box on a flip chart or whiteboard, or even a piece of paper, and divide it into four equal sections. Each section should be labelled as follows: Strengths, Weaknesses, Opportunities and Threats, 3 CONSIDER YOUR STRENGTHS On your own, or with your group or team, decide what your strengths are, what you do well and what other people see as your strengths. Consider this from both your own point of view and from the perspectives of the people with whom you work, lie realistic, not modest. If you have difficulty with this, try listing your
  • 2. characteristics. Some of these will probably be strengths. 4 CONSIDER YOUR WEAKNESSES Ask yourself questions about, for example, what you could improve about yourself, what you do badly or what you should avoid. Consider these questions from different points of view, as other people may perceive weaknesses in you that you do not see. It is best to be realistic now, and to face unpleasant truths about yourself as soon as possible. 5 CONSIDER YOUR OPPORTUNITIES What opportunities are before you? Of what interest- ing trends are you aware? Useful opportunities can arise from changes in technology, government policy and social pattems, or from within your organisation. 6 CONSIDERTHE THREATS What obstacles confront you? Are the specifications of your job, or the service you provide, changing? Is chang- ing technology threatening your position? 7 USE INFORMATION: INTERNAL FACTORS Strengths and weaknesses are intemal faaors. Once you have gathered information on your strengths and weak- nesses, and the opportunities and threats tbat you face, ask yourself first how you can capitalise on your strengths and make greater use of them in work situations. Strengths are the basis on whicb success can
  • 3. be built, so include your strengths into your plans. But also analyse your weaknesses and consider how you can remedy them. Draw up an action plan based on this information, 8 USE INFORMATION; EXTERNAL FACTORS Opportunities and threats are extemal factors. Opportun- ities should be sought, recognised and grasped as they arise, while threats must be acknowledged and steps must be taken to deal with them. 9 USE SWOT IN CAREER PLANNING You can construct your own SWOT analysis to help you with your career planning or to examine your current situation. The same rules as above apply to this: how can you capi- talise on your strengths and overcome your weaknesses? What are the external opportunities and threats in your chosen career field? ^ CAUTION A Threats, Opportunities, Weaknesses and Strengths (TOWS) analysis can also be used to plan ahead. This is similar to a SWOT analysis except that it lists negative factors first so that they can be turned into positive factors more readily. It should be remembered however that both SWOT and TOWS analyses can be subjective, and two people rarely come up with the same final version of a SWOT or TOWS. Even though adding and weighting criteria to each SWOT or TOWS factor increase the validity of the analyses, they should be regarded as guides rather
  • 4. than prescriptions. FINAL POINT A SWOT analysis is a simple tool that can be used in business planning or personal career development. It is an excellent first method for exploring the possibilities for service or personal development, being neither cumbersome nor time consuming, and is effective because of its simplicity Chris Pearce MSc, BA, RN, DipN, RNT, CertHSM is a life coach and freelance trainer with Life Goal Specialists nursing management Vol 14 No 2 May 2007 25 EVALUATION RUBRIC FOR DNP 802 DNP Role Analysis Part 1 and 2 CRITERIA 70-60 POINTS 59-35 POINTS 34-25 POINTS 24-10 POINTS 9-0 POINTS Specific DNP Role, why chosen Complete for part 1 Clear description of the specific DNP role of interest, identifies why this role was chosen. Includes sources identifying why there is a gap related to this role, extrapolates content from references into focused, organized description of the needed role. Â Be sure to differentiate how/why the DNP is more prepared than a MSN educator in addressing these Generally clear description of the DNP role with all components included. Some gaps need more development and explanation as to how they impact the potential new role. Provides some explanation of how the MSN and DNP nurse bringing differing skills and preparation but not well described. Inconsistent description of the specific DNP role chosen, topics addressing why chosen, gaps related to or limited references (or supporting evidence) showing the need for this role, differences b/w MSN and DNP in role Little or no relevant detail or lacks depth - cursory description of role; many areas that could be expanded regarding the specific DNP role and why the role was chosen, along with limited identification of the gaps related to this role. Significantly Limited or no description of the specific role, no discussion of why the role is of interest. Sources minimal to show gaps or need for this role. Unfocused, unorganized description of the needed role
  • 5. issues What are the differences coming from a DNP perspective? What skills will the DNP have that the MSN RN would not? SWOT Analysis Complete for Part 1 Describes thoroughly the strengths, weaknesses, opportunities and threats for the DNP role. Includes references supporting findings. Describes the SWOT analysis, but some areas could include more content related to the topic, limited references Superficial description of some the SWOT analysis components; areas need more development; some areas unclear, Little or no relevant detail; many areas that could be expanded regarding the SWOT analysis components Limited or no analysis provided of the SWOT components PEST Analysis Complete for Part 2 Describes thoroughly the political, economical, social and technological influences – current and potential, as they impact the DNP role, references as appropriate Describes the PEST analysis, but some areas could include more content related to the topic Superficial or inconsistent description of some the PEST analysis components; areas need more development; some areas unclear Little or no relevant detail; many areas that could be expanded regarding the PEST analysis Limited or no analysis of the PEST components Next steps for this new DNP role Complete for Part 2 Presents implementation strategies addressing stakeholder support for new role, potential funding/costs of new role including savings if they exist, theoretical framework to assist with Describes the implementation plans, but some areas could include more content related to the topic; some of the key ideas are not clearly developed, summary does not tie concepts of the paper Superficial or incomplete description of some the plans for implementation; areas need more development; some areas unclear, summary or conclusion paragraph superficial or Little or no relevant detail pertinent to the implementation of the role; many areas that could be expanded regarding stakeholder support, cost or evaluation methods, limited Limited or no discussion of the next steps to implement this proposed new role in terms of support, expense, or evaluation methods, no summary provided
  • 6. implementation, and potential evaluation methods to determine effectiveness of new role. Provides a summary of the need for the DNP nurse in the identified role in a short paragraph together well. does not address importance of DNP in this role summary included. All mechanics done for both parts of the role analysis papers, including references- 30 points 6-5 POINTS 4-3 POINTS 2 POINTS 1 POINTS 0 POINTS Thesis / Topic Exceptionally clear; easily identifiable, insightful; introduces the topic for the paper; summary in one or two well-written sentences. Generally clear; is promising; could be a little more inclusive of the content of the paper. Central idea is adequate but not fully developed; may be somewhat unclear (contains vague terms); only gives a vague idea of the content of the paper. Difficult to identify with inadequate illustration of key ideas; does not let the reader know what the paper is going to include. No thesis statement or introduction is identifiable. 6-5 POINTS 4-3 POINTS 2 POINTS 1 POINTS 0 POINTS Content / Development Thesis coherently developed and maintained throughout; thorough explanation of key idea(s) at an appropriate level for the target audience; critical thinking with excellent understanding of Explanation or illustration of key ideas consistent throughout essay; original but may be somewhat lacking in insight; minor topics of the paper could be developed more thoroughly. Explanation or illustration of some of the key ideas; reader is left with some questions due to inadequate development; content may be a little confusing or unclear as to what the author means. Little or no relevant detail; many areas that could be expanded. Paper does not make sense; unclear what the author is trying to say; very little real information presented.
  • 7. the topic; original in scope (this paper made sense, was easy to understand, and did not leave reader with questions due to incomplete development). 6-5 POINTS 4-3 POINTS 2 POINTS 1 POINTS 0 POINTS Organization Good organization with clear focus and excellent transition between paragraphs; logical order to presentation of information; paragraphs are well-organized; easy to understand and makes sense. Adequate organizational style with logical transition between paragraphs; overall or paragraph organization could be slightly improved. Adequate organizational style, although flow is somewhat choppy and may wander occasionally; somewhat confusing due to organization of paper or paragraphs. Incoherent structure; logic is unclear; paragraph transition is weak; difficult to understand; must re-read parts to figure out what is being said. No order to content; very confusing and difficult to read; makes no sense. 6-5 POINTS 4-3 POINTS 2 POINTS 1 POINTS 0 POINTS Mechanics Skillful use of language; varied, accurate vocabulary; well-developed sentence structure with minimal errors in punctuation, spelling or grammar; appropriate margins, font; correct application of research style format; use of Appropriate use of language with a few errors in grammar, sentence structure, punctuation; fairly accurate interpretation of assignment guidelines, with a few minor errors; readability of paper only slightly affected by mistakes. Some problems with sentence structure, grammar, punctuation, and/or spelling; may have several run-on sentences or comma splices; some errors in citation style; format does not fully comply with assignment guidelines; Many difficulties in sentence structure, grammar, citation style, punctuation, spelling and/or misused words; proper format not used consistently ; many errors in citation style very difficult Not written at a graduate level; many mistakes; proper format not used consistently ; many errors in citation style; difficult to read and understand.
  • 8. professional active voice; very well- written paper. somewhat difficult to read due to mistakes. to understand. 6-5 POINTS 4-3 POINTS 2 POINTS 1 POINTS 0 POINTS References Uses sources effectively and documents sources accurately with minimal errors; limited use of direct quotes (No more than 2 or 3); meets reference requirements for assignment; reference list is in correct format. Appropriate sources and documentation; may have minimal errors with too few or too many in-text citations; missing no more than one reference as required for the assignment. Some quotes not integrated smoothly into text; several errors with in- text citations or reference list; omitted in-text citations infrequently; missing  2 required references; overuse of direct quotes Quotes are not well integrated into narrative or are significantly overused; paraphrasing is too close to original work. (Minimal errors only; more significant errors will be considered plagiarism – See Plagiarism statement to right.) Plagiarism – source material not adequately paraphrased; direct quotes not identified; source material not referenced. *Plagiarized  papers will be given a grade of zero and could result in failure of the  course WESTERN UNIVERSITY OF HEALTH SCIENCES Pomona, California DNP PROJECT: A FEASIBILITY AND COST ANALYSIS ON A NURSE PRACTITIONER MANAGED ENDOSCOPY SERVICE A dissertation submitted to the College of Graduate Nursing in partial fulfillment of the requirements for the degree Doctor of Nursing Practice Jocylane Mateo Dinsay College of Graduate Nursing
  • 9. October 2013 All rights reserved INFORMATION TO ALL USERS The quality of this reproduction is dependent upon the quality of the copy submitted. In the unlikely event that the author did not send a complete manuscript and there are missing pages, these will be noted. Also, if material had to be removed, a note will indicate the deletion. Microform Edition © ProQuest LLC. All rights reserved. This work is protected against unauthorized copying under Title 17, United States Code ProQuest LLC. 789 East Eisenhower Parkway P.O. Box 1346 Ann Arbor, MI 48106 - 1346 UMI 3615267 Published by ProQuest LLC (2014). Copyright in the Dissertation held by the Author. UMI Number: 3615267 WESTERN UNIVERSITY OF HEALTH SCIENCES DNP PROJECT: A FEASIBILITY AND COST ANALYSIS ON A NURSE PRACTITIONER MANAGED ENDOSCOPY SERVICE by Jocylane Mateo Dinsay has been approved by the College of Graduate Nursing in partial fulfillment of the requirements for the degree Doctor of Nursing Practice
  • 10. ________________________________________________________ Rod Hicks, PhD, RN, FNP-BC, FAANP, FAAN Assistant Director, DNP Program Committee Chair _______________________________________________________ Kathy A. Baker, PhD, RN, ACNS-BC, FAAN Committee Member ________________________________________________________ Nancy Schlossberg, BSN, RN, CGRN Committee Member ________________________________________________________ Janet (Jan) Boller, Ph.D., R.N. Director, DNP Program ____________________________________________________ Karen Hanford, EdD, FNP, Dean, College of Graduate Nursing iii ACKNOWLEDGEMENTS I would like to express my gratitude to Dr. Rod Hicks, my committee chair, for his unselfish dedication and guidance in the completion of this project. A special thank you to Dr. Kathy Baker and Nancy Schlossberg, my committee members, for their willingness to share their knowledge, expertise, and precious time to assist me. In addition, I want to thank my family for their patience and support throughout this DNP
  • 11. program. Last but not the least, I am grateful to the LORD above for all the blessings and making all of this possible. iv ABSTRACT DNP PROJECT: A FEASIBILITY AND COST ANALYSIS ON A NURSE PRACTITIONER MANAGED ENDOSCOPY SERVICE By Jocylane Mateo Dinsay, DNP PROBLEM STATEMENT: In spite of multiple studies that demonstrate nurse endoscopists (nurses and nurse practitioners) can perform both sigmoidoscopies and colonoscopies safely, accurately, and effectively, the utilization of nurse practitioners in colonoscopy is very minimal. In Southern California, there remains opposition to nurse practitioners independently performing colonoscopies. PURPOSE: The purpose of this study was to assess the feasibility and cost analysis of a nurse practitioner colonoscopy practice in a Health Maintenance Organization (HMO) setting. SIGNIFICANCE: Assessment of the feasibility and cost analysis of a nurse practitioner colonoscopy practice in a HMO setting identified potential cost savings with the use of a nurse practitioner. Knowledge of the potential cost savings of a NP colonoscopy practice will allow stakeholders to potentially increase the use of a NP. Allowing nurse practitioners to perform colonoscopies will help increase the number of providers, improve capacity and access, as well as address the important public health issue of colorectal cancer (CRC) screening. Allowing nurse practitioners to perform colonoscopies will help solve the problem of capacity. The increase in screening
  • 12. colonoscopies will potentially allow for early detection of CRC and decrease mortality and morbidity. v METHODS: A modified business plan was used to analyze the feasibility and cost analysis of incorporating a nurse practitioner colonoscopy practice in an HMO setting. The business plan included a financial assessment and a SWOT analysis. FINDINGS: There is a big gap between the number of patients needing colonoscopies and the number of patients having colonoscopies for the last 3 years studied. Less than 10% of the HMO members between the age of 49 to 75 years old were screened. When colonoscopy is done in-house by a nurse practitioner, there is possible cost saving of 59% per case. A loss of $108 per case was projected for cases done outside the facility. Employing a nurse practitioner to perform colonoscopy is a feasible and cost effective way to provide quality and safe colonoscopies. A nurse practitioner working in collaboration with gastroenterologists will improve capacity, increase access for patients, and increase the CRC screening rate. vi TABLE OF CONTENTS Page ACKNOWLEDGEMENTS ………………………………………………. iii ABSTRACT ................................................................................................... iv LIST OF TABLES………………………………………………………… ix LIST OF FIGURES………………………………………………………. .. x CHAPTER I
  • 13. PROSPECTUS .......................................................................................... 1 Problem Statement ................................................................................ 3 Purpose Statement ……………………………………………………. 3 Significance…………………………………………………………… 3 Methods ………………………………………………………………. 4 Background……………………………………………………………. 4 Factors Influencing Rates of CRC Screening…………………………. 7 Barriers to Colorectal Cancer Screening……………………………… 9 General Barriers to Nurse Practitioner Practice ……………………… 14 Nurse Endoscopist ……………………………………………………. 15 Flexible Sigmoidoscopy......................................................................... 15 Colonoscopy …………………………………………………………... 19 Affordable Care Act and Institute of Medicine Recommendation #1…. 21 Limitations……………………………………………………………… 22 Conclusion……………………………………………………………… 22 vii CHAPTER II BUSINESS DATA.................................................................................... 24 1.0 Overview of the Business Case 1.1 Products and Services…………………………………………… 24 .. 1.2 The Financing ………………………………………………… 24 1.3 Mission Statement ……………………………………………… 24 1.4 Management Team ……………………………………………... 25
  • 14. 1.5 Sales Forecast …………………………………………………... 25 1.6 Expansion Plan …………………………………………………. 25 2.0 Company and Financing Summary 2.1 Required Funds ………………………………………………… 25 2.2 Investor Equity ………………………………………………… . 30 2.3 Management Equity …………………………………………… . 31 2.4 Exit Strategy ……………………………………………………. 31 3.0 Products and Services 3.1 Medical Services ……………………………………………… .. 31 4.0 Strategic and Market Analysis ……………………………………… 31 5.0 Marketing Plan 5.1 Pricing ………………………………………………………… .. 34 6.0 Profit and Loss ……………………………………………………… 38 PEST Analysis ......................................................................................... 42 SWOT Analysis ………………………………………………………… 43 Evaluation ……………………………………………………………… 44 viii CHAPTER III DNP REFLECTION…………………………………………………… . 46 REFERENCES …………………………………………………………….. 50 ix LIST OF TABLES Table Page
  • 15. 1. Advantages of Different Screening Methods ....................................................... 5 2. Disadvantages of Different Screening Methods .................................................. 6 3. Barriers for Colorectal Cancer Screening ............................................................ 11 4. Basic Equipment and Current Prices Needed for a Single Room ........................ 26 5. Cost of Colonoscopy for 4 hour Clinic ................................................................ 27 6. Proposed Staffing with Nurse Practitioner .......................................................... 28 7. Weekend 8 hour Clinic ....................................................................................... 29 8. Total of 20 Colonoscopies = Proposed Staffing with Nurse Practitioner ............ 30 9. Comparison of Colon Cancer Screening Rates ………………………………... 33 10. Medicare Reimbursement ……………………………………………………. 34 11. Number of Colonoscopies Completed Outside………………………………. . 35 12. Cost per Colonoscopy, Reimbursement and Profit…………………………… 39 13. PEST Analysis of Nurse Managed Endoscopy Service………………………. 42 14. SWOT Analysis for Nurse Managed Endoscopy Service……………………. 43 x LIST OF FIGURES Figure Page 1. Basis of Cost Estimates ........................................................................................ 19 2. Members 49-75 years vs Colonoscopies Performed ............................................ 32 3. CRC Screening Rates ........................................................................................... 33 4. Cost Comparison of Colonoscopy Outside Cost vs. In house Cost ..................... 36 5. Cost Comparison of Colonoscopy with NP vs without NP ................................. 37 6. Number of Colonoscopies Completed In house ………………………………. 37
  • 16. 7. Professional Fee Reimbursement ……………………………………………… 38 8. Cost and Profit ………………………………………………………………… 40 9. Loss for Outside Colonoscopy ……………………………………………….. .. 41 1 CHAPTER I PROSPECTUS Colorectal cancer (CRC) is the third most common type of cancer (Anderson, Gilliss, & Yoder, 1996; Jemal et al., 2009) and is the second leading cause of cancer death in the United States (U.S.). The U.S. Preventive Task Force (USPTF) recommends colorectal screening using fecal occult blood testing, sigmoidoscopy, or colonoscopy in adults, beginning at age 50 years and continuing until age 75 years (U.S. Department of Health and Human Services, 2011). Screening for CRC helps promote early detection; screening asymptomatic individuals for precancerous lesions greatly reduces morbidity and mortality (Feeley, Cooper, Foels, & Maoney, (2009). Screening rates for CRC have been increasing; as of 2008, 62.9% of adults aged 50–75 years were screened as recommended compared to only 51.9% of Americans who were screened as recommended in 2002 (Richardson, Rim, & Plescia, 2010). Even with the increased screening rates, there are still more than 22 million people not adequately screened for CRC (Richardson et al., 2010). Dulai et al. (2004) and Guerra et al. (2007) identified several barriers to CRC screening, one of which included limited access to a trained endoscopist. Providing flexible sigmoidoscopies or colonoscopies to the general population for screening would require a considerable increase in the amount of physician time and other health care
  • 17. resources. Lieberman and Ghormley (1992) and Maule (1994) recommended using nurse endoscopists or physician assistants to perform endoscopic procedures as an alternative to physicians. Several studies have demonstrated that nurse endoscopists can do flexible sigmoidocopies safely and effectively (Horton, Reffel, Rosen, & Farraye, 2001; 2 Lieberman & Ghormley, 1992; Maule, 1994; Wallace et al., 1999). Koornstra, Corporaal, Giezen-Beintema, de Vries, and van Dullemen, (2009) in a study done in the Netherlands concluded that endoscopy trained nurses can safely and effectively perform colonoscopy as proficiently as first year gastrointestinal (GI) fellows. In Davis, California, Limoges- Gonzalez et al. (2011) demonstrated that a properly trained GI nurse practitioner can perform screening colonoscopies as safely and accurately as a GI physician (MD). In San Francisco, California, a safety net hospital increased the endoscopy rate with the use of a nurse practitioner (Day, 2012). In Alaska, a nurse practitioner successfully performs colonoscopy (Christensen & Tealey, 2005). In Baltimore, Maryland, a nurse practitioner has been performing colonoscopies successfully after completion of a one-year GI fellowship-training program (Kalloo, 2011). In Pennsylvania, a nurse practitioner in the Veterans Affairs Medical Center system was credentialed to perform colonoscopies after successful completion of a training base on the American Society for Gastrointestinal Endoscopy (ASGE) colonoscopy curriculum. He was held to the same standard as a gastroenterologist (Hopchik, 2012). With the aging population, there comes an increasing demand for colorectal screening. There is an insufficient quantity of physicians prepared to perform invasive colorectal screening, therefore, training and utilization of more nurse practitioners in
  • 18. performing screening colonoscopies should be considered. Utilization of nurse practitioners would be helpful in meeting the demands of the aging population. Trained nurse practitioners can also perform screening colonoscopies in safety net hospitals and nurse managed health clinics that primarily serve vulnerable populations. According to 3 Kalloo (2011), nurse practitioners can help decrease the shortage of colonoscopists and continue to provide high quality healthcare. Problem Statement In spite of multiple studies demonstrating that nurse endoscopists (nurses and nurse practitioners) can perform both sigmoidoscopies and colonoscopies safely, accurately, and effectively, the utilization of nurse practitioners in colonoscopy are very minimal. In Southern California, there remains opposition to nurse practitioners independently performing colonoscopies. Purpose Statement The purpose of this study was to assess the feasibility and cost analysis of a nurse practitioner colonoscopy practice in a Health Maintenance Organization (HMO) setting. Significance Assessment of the feasibility and cost analysis of a nurse practitioner colonoscopy practice in a HMO setting identified potential cost savings with the use of a NP. Knowledge of the potential cost savings of a NP colonoscopy practice will allow stakeholders to potentially increase the use of a NP. Allowing nurse practitioners to perform colonoscopies will help increase the number of providers, improve capacity and access as well as address the important public health issue of CRC screening. According
  • 19. to Hoffman, Espey, and Ryne (2011), there are about 60% of average risk adults 50 years and older (41.8 million individuals) who are not currently screened for CRC. Without an increase in the number of providers, it would take an additional 10 years to complete screening colonoscopy. Hoffman et al. (2011) suggest increasing provider supply to help solve this problem. Allowing NPs to perform colonoscopies will help solve this problem. 4 The increase in screening colonoscopy will potentially allow for early detection of CRC and decrease mortality and morbidity. Methods A modified business plan was used to analyze the feasibility and cost analysis of incorporating a NP colonoscopy practice in an HMO setting. Included in the business plan were a financial assessment and a Strenghts, Weaknesses, Opportunities and Threats (SWOT) analysis. Background Colorectal Cancer Screening Screening for CRC is not new and can be accomplished with fecal occult blood testing, sigmoidoscopy, or colonoscopy. Screening is defined by Allen et al. (2010) as “the testing of individuals for the disease prior to the onset of any symptoms― (p.3). The goal of screening is to detect early-stage cancer and adenomatous polyps and ultimately reduce the mortality of CRC through prevention and early detection (Allen et al., 2010). The presence of treatable precancerous polyps, discovered during screening, falls into the prevention domain. Colorectal cancer has a long asymptomatic phase (Sonnenberg, Delco, & Inadomi, 2000) characterized by polyps (abnormal growths of tissue) or lesions
  • 20. along the lining of the colon). Most polyps are harmless, but the slow changing common type of polyp, the adenoma, can develop into cancer overtime (Allen et al., 2010). Fecal Occult Blood Test (FOBT) and flexible sigmoidoscopy were the most widely used screening method for the general population before the emergence of colonoscopy. According to Shapiro et al. (2008), colonoscopy has become the most widely use primary screening test in the U.S. In 2001, Medicare initiated financial 5 reimbursement (e.g., coverage) of screening colonoscopies; since then, there has been a decrease in FOBT and flexible sigmoidoscopy use except in the Department of Veterans Affairs and in some healthcare managed organizations (Allen et al., 2010). There are advantages (see Table 1) and disadvantages (see Table 2) of the different screening methods. Table 1 Advantages of Different Screening Methods Adapted from Allen et al. (2010) and Forbes (2008). Screening Method Fecal Occult Blood Test Flexible Sigmoidoscopy Colonoscopy CT Colonography and Barium Enema Level 1 for cancer
  • 21. mortality benefit Reduction in distal cancer mortality by approximately 2/3 Bowel preparation easier Less time consuming than colonoscopy Procedure relatively safe Greatest ability to detect cancer, greatest ability to detect adenoma Longest screening interval - Every 10 years Examines entire colon Sensitive and specific for polyps > 1 cm Low unit cost No need for follow up testing
  • 22. after a positive screening test Attractiveness to lay person Simple to perform Safe Low complication rate - no Sedation 6 Table 2 Disadvantages of Different Screening Methods Screening Method Fecal Occult Blood Test Flexible Sigmoidoscopy Colonoscopy Computed Tomographic (CT) Colonography & Barium Enema Poor adenoma detection Missed isolated proximal cancer
  • 23. and adenomas Missed adenoma and cancer- despite being the Gold Standard Sensitivity less for polyps < 1 cm Compliance with follow up colonoscopy may be poor Patient discomfort Need for rigorous bowel preparation Increase procedural complication Requires sedation High per unit cost Need for rigorous bowel preparation Radiation exposure Need to
  • 24. comply with annual or biennial screening Every 5 years with high sensitivity FOBT every 3 years Uncertain screening interval Availability of flexible sigmoidoscopy and need for adequate trained sigmoidoscopist Availability of trained colonoscopist Availability of trained personnel Undefined positive
  • 25. screening test Undefined positive screening test Adapted from Allen et al. (2010) and Forbes (2008). 7 Colonoscopy is perhaps the most important tool in the diagnosis and early detection of CRC. Colonoscopy is recommended following any positive screening test such as FOBT, polyp/mass on sigmoidoscopy, and/or filling defect on CT colonography or double contrast barium enema (Allen et al., 2010; Forbes, 2008; Limoges-Gonzalez, 2012) for CRC. Factors Influencing Rates of CRC Screening There are important patient-related, provider-related, and system-related factors associated with colorectal screening, and each factor, alone or in concert with another, influences the rate of colorectal screening (Allen et al., 2010). Each of these factors influences the screen rate. Patient-related Factors Positive Influencing Factors Patient-related factors, such as patients having insurance and access to a healthcare source, are the two most important factors affecting CRC screening rates. The patient’s socioeconomic characteristics, such as income and educational level, also affect the use of colorectal screening (Allen et al., 2010). As each of these factors increase, there is a corresponding increase in the likelihood to undergo CRC screening. Therefore, these factors are considered positive influencing factors.
  • 26. According to Allen et al. (2010), older patients (between 60-75 years) are more frequently screened compared to younger patients (age 50-59 years). People with frequent contact with the healthcare provider are more likely to be screened. Equally, people diagnosed with cancer such as breast, prostate, and cervical are more likely to be screened for CRC (Allen et al., 2010). 8 Negative Influencing Factors There are also negative influencing factors influencing the rates of CRC such as ethnicity or geographic region. Patients that are of African-American or Hispanic descent are less likely to be screened. Among Asians, Koreans have the lowest screening rates. Immigrants with shorter stay in the U.S. and non-English speaking are less likely to have CRC screening. Likewise, a lower rate of screening is noted in the Caucasian populations living in Appalachia (Allen et al., 2010). Patient Knowledge and Attitudes Patients with accurate knowledge about the screening test, importance of screening, perceived risk of developing CRC, and a positive attitude about the test in general are most likely to be those who have had CRC screening. Negative attitudes towards the procedure such its invasiveness, anxiety about the test procedure as well as the possible outcome, and a belief that since they do not have a problem, they do not need a procedure, are some of the causes attributed for not being screened (Allen et al., 2010). Healthcare Provider Factors A recommendation from the physician is also the only factor that consistently predicts CRC screening. The relationship between the physicians’ characteristic such as
  • 27. age, gender, years of training, and specialty and screening rates in populations has not been well documented (Allen et al., 2010). An important gap in the literature is that no study has been done with NP recommendations and the effect on rates of screening. Systems-related Factors Only limited data were available regarding systems-related factors and the subsequent effect on CRC screening. According to Allen et al. (2010), practices with 9 electronic medical records and sufficient ancillary staff for patient follow up lead to higher screening rates. For example, systems with advanced electronic medical records, such as Kaiser Permanente Health System and the Veterans Administration (VA) have screening rates that exceed 75% of the Medicare aged patients (Allen et al., 2010). Barriers to Colorectal Cancer Screening Multiple authors (Dulai et al., 2004; Guerra et al., 2007; Vincent, Hochhalter, Broglio, & Avots-Avotins, 2011) have identified limited access to trained endoscopists as one of the many barriers to CRC screening. Dulai et al. (2004) surveyed 1340 primary care providers in California to determine barriers to and facilitators of colorectal screening in a managed care setting. There was a 67% response rate on the survey. The survey was an 11-pages, 39 questions, 194 individual response items, cross sectional, self reported, mailed questionnaire. The authors demonstrated that only 79% of standard-risk patients were screened for CRC. The four most common recommended CRC screening tests were Fecal Occult Blood test (FOBT), flexible sigmoidoscopy (FS), barium enema, and colonoscopy. The survey showed that the compliance rate for FOBT was only 70 % and FS was only 50 %. The barriers that were found were divided into patient-related
  • 28. barriers and physician-related barriers which included the absence of an available endoscopist. Following the survey, the authors concluded that CRC screening was underused in the managed care setting. Guerra et al. (2007) conducted a purposive non-probability sampling qualitative study to explore the barriers of and facilitators to physicians’ recommendation of CRC screening. The study consisted of 212 primary care physicians practicing in Pennsylvania, New Jersey, and Delaware. Subjects were chosen because of a specific 10 characteristic such as practice specialty. Interviews and chart reviews were conducted. The authors showed that colonoscopy was the preferred screening method (Guerra et al., 2007). In this study, the barriers were categorized into patient, physicians, and systems. Barriers to physician recommendation included patients’ comorbidities, patient refusal to screening, physician forgetfulness, lack of time, and lack of reminder. One of the system barriers was the long delay of colonoscopy scheduling and lack of direct access to colonoscopy. Between 2003 and 2008, Vincent et al. (2011) performed a survey using 1,234 patients 50 to 80 years old in a HMO to test the difference between male and female barriers to colonoscopy. Analysis of the data indicated that there were no differences in the barriers reported by gender. The most common identified barrier was lack of recommendation for colonoscopy by the primary physician (Vincent et al., 2011). Table 3 is a summary of the barriers for CRC screening. 11 Table 3
  • 29. Barriers for Colorectal Cancer Screening Barriers Dulai et al. Guerra et al. Vincent et al. Patient-related Comorbidity, more acute care visits * * Distrust/lack of compliance * * * Language barrier, knowledge deficit, pain * * * Physician related Forgetfulness, not recommended by physician * * Concurrent care by a gastroenterologist * System related Inability to track
  • 30. down prior screening * Lack of time/lack of reminders * * * Lack of insurance coverage, cost * * * Long delay in colonoscopy scheduling/lack of direct access to colonoscopy * * Sources: Dulai, et al., 2004; Guerra, et al., 2007; Vincent, et al., 2011 Note: (*) indicates barrier identified in cited study. 12 Capacity Multiple studies (Ballew, Lloyd, & Miller, 2009; Brown, Klabunde, & Mysliwiec, 2003; Seeff, Richards, et al., 2004; Vijan, Inadomi, Hayward, Hofer, & Fendrick, 2004) have been completed regarding colonoscopy capacity. Ballew, Lloyd and Miller (2009) surveyed all hospitals and ambulatory surgical centers in Montana to assess current and
  • 31. projected colonoscopy capacity. In 2008, an estimated 19,444 colonoscopies were performed (Ballew et al., 2009). Ballew et al. (2009) concluded that in the state of Montana, the capacity to meet moderate increase in demand for colonoscopy in 2008 was followed by the ability to only meet 17% of the colonoscopy demand in 2009 if all eligible adults were screened. Brown et al. (2003) performed a national survey in 1999 to 2000 to obtain data of endoscopic resources. The authors found primary care providers performed 65% of flexible sigmoidoscopies, gastroenterologists performed another 25%, and general surgeons performed 10%. The authors concluded that with routine screening colonoscopies performed every 10 years, a total of 4.8 million screening and surveillance colonoscopies would be needed, 20% more than the estimated 4 million. Seeff, Manninen et al. (2004) created a forecasting model to estimate the number of unscreened individuals for CRC and the number of procedures needed to screen these people. The test need was compared to the available capacity based on the result done by the Survey of Endoscopic Capacity (Seeff, Manninen, et al., 2004). Seeff, Manninen et al. (2004) found that there are approximately 41.8 million averaged aged Americans, 50 years or older, that have not been screened for CRC. According to Seeff, Manninen et al. (2004), it would take 10 years to screen the unscreened population with flexible 13 sigmoidoscopy or colonoscopy. Seeff, Manninen et al. (2004) concluded that there was ample capacity to screen with fecal occult blood test (FOBT) but not with flexible sigmoidoscopy or colonoscopy. Diagnostic colonoscopy would also be needed if a screening results from the FOBT were positive (Seeff, Manninen, et al., 2004).
  • 32. Vijan et al. (2004) quantified the demand of colonoscopy and estimated the ability of the current health care system to meet the demand. According to Vijan et al. (2004), the annual demand for colonoscopy ranged from 2.21 to 7.96 million. Colonoscopy demands exceeded the current supply; an estimated increase of 1,360 gastroenterologists would be needed to meet the screening demands of people at age 65 years (Vijan et al., 2004). To perform screening colonoscopy every 10 years, a total of 32,700 gastroenterologists would be needed (Vijan, et al., 2004). Increasing the use of NPs in primary care practice has been proposed as a solution to the lack of access to primary care (Kaiser Family Foundation, 2011; Mundinger, 1994). This solution of increasing the use of NPs can be extended to colonoscopy practice, increasing capacity and thereby providing access. According to Anderson, Gilliss, and Yoder (1996) “the combination of lower cost of nurse practitioners education, the effectiveness and quality of their services, and the lower cost of employment provide compelling reasons for the full use of nurse practitioner in primary care― (p. 209). This would still hold true for a NP in colonoscopy practice even with the extra colonoscopy training. According to the U.S. Department of Health and Human Services Health Resources and Services Administration (2010), in 2008 there were about 158,348 NPs in the United States. California had the largest number of NPs in the nation (Anderson et al., 14 1996) though currently the number of NPs performing colonoscopies in California is unknown. There are only a few known NPs performing colonoscopy on a regular basis in California (Limoges-Gonzalez et al., 2011).
  • 33. General Barriers to Nurse Practitioner Practice Practice environment barriers for NPs in primary care have been documented and studied (Anderson et al., 1996) as well as barriers for hospital privileges for NPs (Brassard & Smolenski, 2011). According to an old survey, perceived barriers affecting NP practice in California includes lack of prescriptive authority, lack of support from physicians, reimbursement difficulties, and lack of public awareness (Anderson et al., 1996). Brassard and Smolenski (2011) described barriers for NPs in obtaining hospital privileges including Federal and State laws, and ambiguous regulations, as well as hospital bylaws and policies. According to Brassard and Smolenski (2011), removing barriers would reduce cost, increase consumer choice, and improve health quality. These could also be the same barriers that face NPs in colonoscopy practice. Since the 1996 study by Anderson et al., some headway has been made in improving legislations and regulation affecting NP practice. There have been some improvement with regards to physicians’ support (Fairman, Rowe, Hassmiller, & Shalala, 2011). According to Fairman et al. (2011), 16 states have liberalized and improved the scope of nursing practice regulations to allow NPs to practice and prescribe independently. More and more states are reconsidering laws to allow independent practice for NPs (Fairman et al., 2011). California NPs have prescriptive abilities (known as furnishing) and are now allowed to write prescriptions for medications on Schedule II to V (Board of Registered 15 Nursing, 2011). Awareness of the NP role by the public has improved as seen by the endorsement of American Association of Retired Persons (AARP) (Brassard &
  • 34. Smolenski, 2011). With regards to reimbursement, Medicare reimburses NPs for services to Medicare patients. NPs performing screening colonoscopies on Medicare patients also get reimbursed (American Academy of Nurse Practitioners, 2011) Nurse Endoscopists Numerous studies demonstrate safety, effectiveness, and accuracy when nurse endoscopists perform sigmoidoscopy (Duthie et al., 1998; Horton et al., 2001; Kelly et al., 2008; Lieberman & Ghormley, 1992; Maruthachalam, Stoker, Nicholson, & Horgan, 2006; Maule, 1994; Schoenfeld et al., 1999; Wallace et al., 1999) and colonoscopy exams (Christensen & Tealey, 2005; Kalloo, 2011; Koornstra et al., 2009; Limoges-Gonzalez et al., 2011). Yet, there remains general opposition to the role of nurse endoscopist. At present, the American Society for Gastrointestinal Endoscopy (ASGE) and American College of Gastroenterology (ACG) recommend limiting non-gastroenterologists to performing only sigmoidoscopies (American Society for Gastrointestinal Endoscopy & American College of Gastroenterology, 2009) Flexible Sigmoidoscopy United Kingdom Duthie et al. (1998) did a prospective evaluation of a nurse endoscopy training program in the United Kingdom. The nurse practitioner underwent sigmoidoscopy training that involved observation (n = 35), withdrawals of the scope (n = 35), and then full procedures (n = 35). The nurse practitioner then performed 215 flexible sigmoidocopies independently and 93% of the examination was judged successful with 16 51% having pathology identified. No complications were identified. Duthie et al. (1998)
  • 35. concluded that with proper training, a nurse endoscopist was able to safely and effectively perform sigmoidoscopy. In another U.K. study, Maruthachalam et al. (2006) studied a nurse led flexible sigmoidoscopy clinic in a primary care setting. In this study, a nurse endoscopist performed 1,002 flexible sigmoidoscopies between March 2004 and July 2005. Results of the screening yielded 22% of patients were diagnosed with colonic pathology and 25% with CRC. No complications were reported. Assessment of patient satisfaction showed high patient satisfaction rate, and 99% of patients were satisfied with the care received (Maruthachalam, et al., 2006). Maruthachalam et al. (2006) concluded that a nurse endoscopist could provide safe and effective flexible sigmoidoscopy service with high levels of patient satisfaction. Another U.K. study done by Kelly et al. (2008) described a nurse specialist who led a flexible sigmoidoscopy clinic in an outpatient setting. The researchers collected data prospectively regarding source of referral, presenting symptoms, the result of flexible sigmoidoscopy, depth of insertion, the follow up plan, and complication. In this study, 3,956 patients had flexible sigmoidoscopy done. The result of the study showed that there were 1,560 normal sigmoidoscopies, 132 with positive cancer detection, and 276 had inflammatory bowel disease, 415 patients with polyps, 584 with diverticulosis, and 926 with hemorrhoids. Kelly et al. (2008) concluded that a nurse specialist led sigmoidoscopy clinic offered a safe and efficient diagnostic service. 17 United States Horton, Reffel, Rosen, and Farraye (2001) described a multispecialty group that
  • 36. used nurse practitioners (NP) and physician assistants (PA) to perform flexible sigmoidoscopies. These providers had hands on training under the direct supervision of a gastroenterologist whereby the NP or PA provider performed a minimum of 100 successful supervised sigmoidoscopies over a two-to-four month period before being deemed competent. Data were collected on 9,500 sigmoidoscopies; 10% had adenomatous polyps and a 0.32% incidence of CRC. No major complications were observed with the NPs and PAs performing sigmoidoscopies. There was a noted 33% lower cost for a NP or PA to perform sigmoidoscopy compared to a gastroenterologist. Patient satisfaction ratings revealed 90% of patients were very satisfied with the care and were willing to have the procedure done again. The authors concluded that NP and PA- performed flexible sigmoidoscopy had similar accuracy and safety as gastroenterologist performed but at a lower cost (Horton, et al., 2001). Maule (1994) studied two registered nurses and two licensed practical nurses who performed screening flexible sigmoidoscopy in comparison to two gastroenterologists. All four nurses underwent training and gained proficiency with the controls of a 60 cm fiber optic flexible sigmoidoscopy. The nurses performed 1,881 flexible sigmoidoscopy exams while the physicians performed 730 cases. The results indicated that the physicians had greater mean depth of insertion in comparison to the nurses. Adenomas were found on 14% of male and 8% of women. There was no difference in the proportion of positive diagnosis of adenoma or cancer between the nurses and the physicians. No complications were reported. In this study, Maule (1994) concluded that nurses did 18 perform screening sigmoidoscopy safely and as accurately as an experienced
  • 37. gastroenterologist. Schoenfeld et al. (1999) compared the effectiveness of and patient satisfaction with flexible sigmoidoscopies performed by a registered nurse, general surgeons, and gastroenterology (GI) fellow. Six months prior to the study, the registered nurse (RN) was trained to perform flexible sigmoidoscopies. Prior to the study, the RN completed 100 unsupervised flexible sigmoidoscopies. Patients were assigned to the first available endoscopist for sigmoidoscopy. The depth of insertion, complication, duration of procedure, percentage of patients with adenomas, and patient satisfaction were recorded. The authors demonstrated that the mean depth of insertion was less for a general surgeon compared to both the nurses and the gastroenterology fellow. Duration of the procedure was longer for the nurses compared with the general surgeons and the gastroenterology fellow. Percentage of patient with adenomas was similar between the groups. Patients’ satisfaction was also similar between the groups. The authors concluded that there was no difference in effectiveness or patient satisfaction with flexible sigmoidoscopy performed by the registered nurse, general surgeons, or GI fellows (Schoenfeld et al., 1999). Wallace et al. (1999) studied a NP and two physician assistants who were trained to perform flexible sigmoidoscopy, and prospectively collected data. Between 1995 - 1997, there were 3,701 patients that underwent flexible sigmoidoscopy, and of these, 2,323 (62.7%) had sigmoidoscopy done by non-physicians. The authors demonstrated that there was no difference in depth of insertion after baseline adjustment for age and sex of patients was done. No difference in the rate of detection of polyps was found between the groups. No major complications including perforation, bleeding were 19
  • 38. reported. Based on the results, the authors concluded that non-physician endoscopists could safely and effectively perform flexible sigmoidoscopy when appropriately trained (Wallace et al., 1999). Furthermore, the authors concluded that an increased use of non- physicians in performing sigmoidoscopies may increase availability and lower cost of the procedure (see Figure 1). Figure 1. Basis of Cost Estimates Source: Wallace et al (1999). Colonoscopy In Alaska, Christensen and Tealy (2005) reported that a trained and experienced NP could perform colonoscopy safely. In this study, the NP provided routine screening colonoscopy for Alaskan natives. The NP filled the critical need for a trained endoscopist in the rural and underserved population of Alaska (Christensen & Tealey, 2005). Limoges-Gonzalez et al. (2011) did a single randomized controlled study comparing screening colonoscopies performed by a NP and a gastroenterologist. The NP performed a total of 1000 colonoscopies within a 2-year period. Limoges-Gonzalez et al. (2011) found that there were no statistically significant differences between the NP and the gastroenterologist with regards to pain, patient satisfaction, cecal intubation, duration of procedure, and withdrawal time. Limoges-Gonzales et al. (2011) concluded that a 20 properly trained NP did perform screening colonoscopy as safely, accurately and satisfactorily as a gastroenterologist. Koornstra et al. (2009) did a feasibility study on colonoscopy training for NPs. In this study, two NPs were trained with the first year gastroenterology (GI) fellow. Each
  • 39. NP and GI fellow performed 150 colonoscopies. Koornstra et al. (2009) found that NPs cecal intubation rate was 80% for the first 25 procedures and increased up to 96% on the last 25 cases. The patients reported low degree of pain and discomfort and had high satisfaction rates. The complication rate was 0.3% (Koornstra, et al., 2009). Koornstra et al. (2009) concluded that trained NPs did perform colonoscopies as safely and effectively as a GI fellow. At John Hopkins University, a NP attended a1-year fellowship program that included training for colonoscopy. This program included a didactic curriculum as well as clinical experience. Fellows rotated in gastroenterology service, hepatology clinics, and endoscopy procedures. Monica Van Dongen, the first NP GI fellow of John Hopkins University, had an intubation rate of 94.6% and adenoma detection at 0.043 % per colonoscopy (Kalloo, 2011). She exceeded the benchmarks expected of fully trained gastroenterologists with no perforation in 119 cases (Hurtfless & Kalloo, 2013). At San Francisco General Hospital, with the use of NPs, the hospital increased the number of colonoscopy procedures by 40.4% over a 5-year period, an increase of 8.8 % a year. The hospital also reduced the wait time by 65%. A full-time NP was trained for one year to safely and independently perform colonoscopies. The training included didactic education, direct observation, and individual teaching as well as simulation. In this hospital, there were no differences in cecal intubation rates between the NP and the GI 21 physicians nor was there a difference in the percentage of adverse events in colonoscopies done by nurse practitioner versus the GI physician (Day, 2012). In Pennsylvania, a NP in the Veterans Affairs Medical Center system was
  • 40. credentialed to perform colonoscopy after successful completion of a training based on the ASGE colonoscopy curriculum. He performed 325 colonoscopies and more than 150 polypectomies. He was held to the same standard as a gastroenterologist (Hopchik, 2012). Affordable Care Act and Institute of Medicine Recommendation #1 On March 23, 2010, President Obama signed the Patient Protection and Affordable Care Act (ACA). The law provides comprehensive health insurance reforms. This law is designed to make quality, affordable health care available, guarantees access to health care for all Americans, reduces costs, improves health care quality, enhance disease prevention, and strengthen the health care workforce. One of the provisions of this law includes free preventive care. All new insurance plans will now cover preventive services such as mammogram and colonoscopies without a deductible or copayment (Kocher, Emanuel, & DeParle, 2010). With the historic passing of the ACA in 2010, the Robert Woods Johnson Foundation and Institute of Medicine (IOM) established a two-year initiative on the Future of Nursing (Institute of Medicine, 2010). The Future of Nursing has eight major recommendations. Recommendation #1 is to: “Remove scope-of- practice barriers. Advance Practice Nurses should be allowed to practice to the fullest extent of their education and training. Congress should expand Medicare to include coverage of APRN services within scope-of-practice 22 under applicable state law, just as physicians’ services are now covered. State legislatures should reform scope-of-practice regulations to conform to the
  • 41. National Council of State Boards of Nursing APRN model rules and regulations― (Institute of Medicine, 2010, p. 7). With more than 45 million Americans who will be getting insurance and needing preventive care including colonoscopy under the ACA provisions, the health care industry will need to increase the number of providers to deliver this care. Allowing NPs to do colonoscopies and to practice to the fullest extent of their education would help in providing much needed health and preventive care. Limitations Studies reviewed in the literature review were very limited to available data. None of the studies reviewed were double blinded randomized studies. The number of nurse endoscopists in the studies was limited in number, and most of the studies only involved 1 or 2 non-physician endoscopist. The nurse endoscopist in the study was selected based on the need of the facility conducting the study. No long-term studies regarding NPs performing colonoscopy were available for review. Most of the study reviewed involved a non physician endoscopist only a few study involved a NP specifically. Conclusion Based on the information to date, nurse endoscopists with proper training can safely perform sigmoidoscopies and colonoscopies as supported by numerous studies from both the United States and United Kingdom. Properly trained NPs are equivalent with gastroenterologists when compared on quality, safety and patient satisfaction outcomes. With the aging population and implementation of the ACA in 2014, allowing 23 NPs to perform colonoscopy will help increase CRC screening by colonoscopy. Allowing
  • 42. NPs to perform colonoscopies will also help solve the problem of access and capacity. Studies have shown that NPs can perform colonoscopy safely and cost effectively. Yet, there is a need to demonstrate the financial aspect of having a NP endoscopy – led center. This project seeks to determine the outcomes of such a center. 24 CHAPTER II BUSINESS DATA 1.0 Overview of Business Case Numerous studies in both United States and United Kingdom have shown that a properly trained nurse endoscopist can safely perform sigmoidoscopy and colonoscopy. This study assessed the feasibility and cost analysis of having a Nurse Managed Endoscopy Service. 1.1 Products and Services After being trained for colonoscopy, the NP will perform screening colonoscopies on unscreened CRC patients ages 50 to 75 years of age. The ASGE Colonoscopy Core Competency will be used to train and evaluate the NP. The ASGE colonoscopy core curriculum recommends that an endoscopist in training needs to successfully complete 140 colonoscopies to be competent (American Society for Gastrointestinal Endoscopy, 2012). 1.2 The Financing The NP practice will be incorporated into the existing Gastroenterology department, and the same budget would be used. 1.3 Mission Statement
  • 43. As part of the HMO setting, the NP will adhere to and promote the overall mission of the company which is “ to provide, affordable, high quality health care services to improve the health and well being of our members and the communities it serves.― (Kaiser Permanente, 2013). 25 1.4 Management Team The NPs will be a member of the Department of Gastroenterology. There are 6 gastroenterologist and 2 NPs in the department. The NPs will be under the direct supervision of the Chief of Gastroenterology. 1.5 Sales Forecasts With the increasing number of HMO membership and an aging population as well as an inability to cope with the current demand for colonoscopy as shown by the number of cases being outsourced, the NP will be provide colonoscopy and therefore decrease cost, provide equality care, and meet the demands of the patient population. 1.6 Expansion Plan With the aging population and the passing of the ACA, an anticipated increase in HMO membership would require provision of CRC screening. Having a NP colonoscopist will help fill the gap and provide needed quality care at a lower cost. 2.0 Company and Financing Summary 2.1 Required Funds Since the NP will be incorporated into the existing gastroenterology department, needed equipment is already available. No new equipment will be needed. Below are the basic equipment and current prices needed to run a single room for
  • 44. colonoscopy. The price quote is from Fujifilm Medical System dated Aug 29, 2012. A total of $158,229.33 for equipment is needed and $23,088.91 for software license, maintenance and training totaling $181,318.24. 26 Table 4 Basic Equipment and Current Prices Needed for a Single Room Description Quantity List price High definition Digital Video processor 1 $17,475 300 Watt Xenon Light Source – automatic Control and light Save function 1 $9,716 Standard Gastroscope with 2.8 mm Channel and 9.3 mmOD, 1100nm Working length 1 $ 26,730 Standard Gastroscope with 4.2 mm Channel and 12.8 mmOD, 1690 nm Working length 1 $29,610 Standard Gastroscope with 3.8 mm Channel and 11.5mmOD, 1690 nm Working length 1 $29,610 NDS Radiane G2 HB Flat Screen LED Monitor with Fujinon Bios 1 $5,860
  • 45. 30 ft Digital video Interconnect Cable 1 $273.60 Endo Gator Jetwash Pump 1 $1,478 Deluxe cart with Dual Scope Holder and Flat Panel Monitor Mount 1 $5,395 Flat screen variable Height Roll Stand 1 $94.5 New air / Water Button 1 $442.80 New Suction Button 1 $442 Hand held leak tester 1 $247 Scope water bottle 1 $148.50 Biopsy valve Cover 6 $130.68 Total $15,8229 27 Below are tables of personnel- payroll cost as well non-payroll cost breakdown with different scenarios. Table 5 and 6 are evening clinics. Table 5 Cost of Colonoscopy for 4 hour clinic = total of 8 colonoscopies Per hour Physician -2 $209 Procedure RN -2 $79 Recovery RN -2 $79 Technician -2 $42
  • 46. Scope cleaner -1 $22 Receptionist -1 $25 Payroll cost $1,824 Non payroll cost $833 Cost per colonoscopy $332 28 Table 6 Proposed Staffing with Nurse Practitioner Per hour Physician -1 $104.50 Nurse Practitioner -1 $60 Procedure RN -2 $79 Recovery RN -2 $79 Technician -2 $42 Scope cleaner -1 $22 Receptionist -1 $25 Payroll cost $1,646 Non payroll cost $833 Savings on payroll cost $178 Cost per colonoscopy $310 Minimal cost savings are seen with the replacement of one of the gastroenterologists with a NP and keeping the same staff. While savings is only 7%, an addition of a NP will free up a gastroenterologist to do more consultations, endoscopic
  • 47. retrograde cholangiopancreatography (ERCP), and take hospital calls. 29 Table 7 Weekend 8 hour clinic = total of 10 colonoscopies Per hour Physician -1 $209 Procedure RN -1 $79 Recovery RN -2 $158 Technician -1 $42 Scope cleaner -1 $22 Receptionist -1 $25 Payroll Cost $4,280 Payroll cost per case $428 Non payroll cost $1000 Cost per colonoscopy $528 30 Table 8 Total of 20 Colonoscopies = Proposed Staffing with Nurse Practitioner Per hour Physician -1 $209 Nurse Practitioner -1 $60 Procedure RN -2 $158 Recovery RN -2 $158
  • 48. Technician -2 $84 Scope cleaner -1 $22 Receptionist -1 $25 Payroll Cost $5,732 Payroll cost per case $286.6 Non payroll cost $2,000 Cost per colonoscopy $386.6 By adding a NP, the number of completed colonoscopies doubles which would help in attaining the goal of a 78% CRC screening rate, and increase patient satisfaction by avoiding the long wait as well as cost savings as seen above. There is a cost saving of 27 % per case. 2.2 Investor Equity The Department of Gastroenterology, which the NP is a part of, is not seeking an investment from a third party at this time. 31 2.3 Management Equity The Department of Gastroenterology will be using its current budget to provide colonoscopy. The NP’s salary is already included in the department’s budget. 2.4 Exit Strategy If a new technology is discovered for CRC screening; then colonoscopy will not be needed, and the NP will have to adapt to the new technology. 3.0 Products and Services Below is a description of the medical services offered under a nurse managed
  • 49. endoscopy service. 3.1 Medical Services The primary source of revenue for the business will be copayments from insured patients having the procedure completed. Copayment for this procedure varies and ranges from $0 to $250 depending on the patients’ policy. At present, the GI department at this HMO, located in San Fernando Valley, performs 28 to 30 colonoscopies a day. Twice a week, a night clinic is opened for 4 hours to help meet the demand for colonoscopy. A weekend 8 hour clinic is also occasionally offered to help the demand. 4.0 Strategic and Market Analysis With the passing of the ACA and its full implementation in 2014, 32 million uninsured Americans will be having insurance coverage. A projected increase in membership is anticipated from 2014–2016 on top of the expected membership growth over the next 10 years, even without the passing of the ACA. 32 As of February 2012, the HMO cancer screening rate for colon cancer was 74.2 %; the target is 78%. The United States’ CRC rate was 54.1% - 75.2 % as of year 2010. California’s CRC rate was 59.3% to 63% as of year 2010. Below is a graph showing the number of HMO members needing CRC screening versus the number of colonoscopies performed. Less than 10 % of members between the ages 49-75 years of age had colonoscopies. Figure 2. Members 49-75 years of age compared to actual number of colonoscopies performed.
  • 50. Screen rates vary across the nation. Table 9 is the CRC screening rate of this HMO facility compared to California and the U.S. for the year 2010. This HMO achieved 73.7 % CRC screen rate of all the members that needed screening. 0 10000 20000 30000 40000 50000 60000 2010 2011 2012 Members 49-75 yrs old Colonoscopies Performed 33 Table 9 Comparison of Colon Cancer Screening Rates, 2010 Colon Cancer Screening Rates HMO 73.7 USA (National) 54.1 - 75.2 CA 59.3 - 63 Source: http://kpnet.kp.org/.../docs/Cancer Screenings Update.ppt Figure 3 is the historical trend of screening rates for this HMO facility. The facility’s goal is a 78% CRC screen rate. Using a NP to perform screening colonoscopies
  • 51. will help attain the goal of a 78% CRC screening rate. 72 73 74 75 76 77 2010 2011 2012 CRC Screening Rates Figure 3. The CRC screening rates of Kaiser for the last 3 years Source: http://kpnet.kp.org/.../docs/Cancer Screenings Update.ppt 5.0 Marketing Plan http://kpnet.kp.org/.../docs/Cancer%20Screenings%20Update.ppt http://kpnet.kp.org/.../docs/Cancer%20Screenings%20Update.ppt 34 The department will inform primary physicians that a NP will be available to perform screening colonoscopy. Patients requesting a physician will be scheduled with a physician. 5.1 Pricing Below is a table with the CPT codes and 2012 Medicare reimbursement Table 10 Medicare reimbursement Procedure Cpt Code *ASC facility fee
  • 52. Hospital facility fee Physician Fee when procedure performed in Hospital or ASC Physician Fee when procedure performed in office Colonoscopy, flexible, proximal to splenic flexure with biopsy, single or multiple 45380 378 655 264 481 Colonoscopy,
  • 53. flexible, proximal to splenic flexure with removal of tumors, polyps or other lesions by hot forceps or bipolar cautery 45384 378 655 275 477 35 * Boston Scientific Guidepoint, Simplyfing Reimbursement: Defining Tomorrow, Today in Endoscopy Currently, this HMO contracts to send patients to an outside facility. The fee associated per patient is $475 for the facility fee and $275 for the physician’s fee, a total of $750. Below is a table showing the number of colonoscopies contracted out for 2 years. Table 11 Number of Colonoscopies Completed Outside Year Number of
  • 54. colonoscopy request for sent out* Number of colonoscopy completed outside Outside Cost Kaiser Cost with NP 2011 2439 600 450000 186000 2012 1866 800 600000 248000 An authorization was requested and granted, but not all referrals had their colonoscopy completed at an outside facility. Patients have an option to still have colonoscopy performed in house as long as patients are willing to wait. Figure 4 is a graph showing the predicted cost savings in 2011 and 2012 if the colonoscopy cases were done at the facility with a NP. 36 Figure 4 Cost of Colonoscopy Performed In-house Versus Outside Referral. Adding two evening clinics a week could accommodate all the cases previously completed outside in a one-year time span. Avoiding cases being outsourced would save the facility 59% per case. It cost $310 per colonoscopy in an evening clinic with the addition of an NP while it cost $750 per case for a colonoscopy to be completed outside. Aside from being cost effective, most patients prefer to be seen within the HMO facility
  • 55. as noted by the number of referrals compared to cases completed. Having one NP and one gastroenterologist during the night clinic would also free one gastroenterologist for consultation, hospital rounding, ERCP, and other more complex tasks. Below is a graph showing cost savings for 2010, 2011, and 2012 with the use of a NP in house for 4 evening hours. 0 100000 200000 300000 400000 500000 600000 2011 - 600 cases 2012 - 800 cases Outside cost In house cost with NP 37 0 500000 1000000 1500000 2000000 2500000 2010 4842 cases 2011 5299 cases 2012 6295 cases
  • 56. with NP without NP Figure 5. Cost Comparison of Colonoscopy Below is a chart showing the number of colonoscopy cases completed in-house for 2010, 2011, and 2012. 0 1000 2000 3000 4000 5000 6000 7000 2010 2011 2012 Number of colonoscopies completed in house Figure 6. Number of Colonoscopies Completed in House. 38 6.0. Profit and Loss The data below shows the profit with the different scenarios analyzed. In the calculation of the profit, an assumption of a 100 % physician professional fee will be collected from Medicare and 80% of the physician’s professional fee for the care provided by NP.
  • 57. 830 840 850 860 870 880 890 900 910 920 NP reimbursement - 80 % GI reimbursement Reimbursement Figure 7. Professional Fee Reimbursement The amount of reimbursement doubles for the 8 hours clinic with the addition of a NP. The profit also increases, but the real benefit in the addition of a NP would be decreasing the wait time for colonoscopy as well as usage of space and equipment which would otherwise be unused. An addition of a NP endoscopist is a cost effective way of attaining the facility’s goal of a 78% CRC rate without sacrificing quality care. Table 12 shows the cost of colonoscopy, reimbursement, and profit with the different scenarios. A loss of $108 is seen for each case done outside the facility. For the last 2 years, a total loss of $151,200 is calculated. 39 Table 12.
  • 58. Cost per Colonoscopy, Reimbursement and Profit Cost per Colonoscopy Reimbursement Profit 1 GI - 8 hour clinic 528 9190 3910 1 GI and 1 NP 8 hour clinic 386.6 17850 10118 2 GI 4 hour clinic 332 7352 4695 1 GI and 1NP 4 hour clinic 310 7140 4661 Outside colonoscopy 750 642 -108 In the graph below, the scenario with one GI physician and an NP working together has the highest reimbursement and profit. This scenario also doubles the number of colonoscopies performed, thereby increasing access. Doubling the number of colonoscopies will increase the CRC screening rate and help attain the HMO’s goal of a 78% CRC screening rate. 40 0 2000 4000 6000 8000 10000 12000 14000 16000 18000
  • 59. 1 GI - 8 hour clinic 1 GI and 1 NP 8 hour clinic 2 GI 4 hour clinic 1 GI and 1NP 4 hour clinic Cost per Colonoscopy Total Cost per clinic Reimbursment Profit Figure 8. Cost and Profit Below is a graph showing the reimbursement rate and outside cost of colonoscopy. A loss is clearly seen when patients are treated outside the HMO. An increase in cost is seen with the increased number of cases contracted outside the facility. Having a NP perform these cases in house will avoid this loss and still be able to provide cost effective and quality endoscopy. 41 -100000 0 100000 200000
  • 60. 300000 400000 500000 600000 2011 - 600 cases 2012 - 800 cases Outside Cost Reimbursement Loss Figure 9. Loss for Outside Colonoscopy Table 13 and 14 highlight the Political, Economic, Social, Technological (PEST) Analysis and |SWOT Analysis of a Nurse Practitioner Managed Endoscopy Service. PEST and SWOT analysis allowed the author to analyze factors affecting the service. External environmental factors, such as the political, economic, social, and technological, which have a critical influence in this project were analyzed as part of the PEST analysis. 42 Table13 PEST Analysis of NP Managed Endoscopy Service Political Passing of the Affordable Care Act Medicare reimbursement of NP Increasing support of NPs nationally such as AARP Increasing number of states allowing NP
  • 61. independent practice, currently 17 states NP endoscopist has no endorsement from the American Society for Gastrointestinal Endoscopy Economical Increasing demand for colonoscopy Long wait time for colonoscopy Not enough endoscopists NP endoscopists are cheaper than gastroenterologists and provide comparable care and patient satisfaction with regards to colonoscopy Continuity of care Social Increasing population of people ages 50- 75 years old Increasing number of people insured with the passing of the Affordable Care Act Increasing acceptance of NPs e.g. endorsed by AARP Technological Colonoscopy is still the gold standard in
  • 62. CRC screening 43 Table14 SWOT Analysis for Nurse Managed Endoscopy Service Strengths Availability of NP Trained staff already available (RN, Technicians, and Receptionist) Equipment already available Colonoscopy center already in place Continuity of care for patients Economically cheaper – cost saving Increased number of screening colonoscopy with availability of NP endoscopist Excellent safety and efficacy record The Institute of Medicine’s recommendation for full independent practice for nurse practitioners. Increasing support for NP by the community and other organizations such as AARP Increasing number of states with NP
  • 63. independent practice, currently 17 states California Senate Passing of SB 491 – Expansion of NP Scope of Practice Reimbursement from Medicare Weaknesses New role for NP Resistance from physicians and other personnel Learning curve for NP in training SB 491- Expansion of NP Scope of Practice did not pass California House Assembly Opportunities Implementation of the Affordable Care Act Aging population Increase in membership Increase demand for quality care as well as cost effective care First NP Managed Endoscopy center in a HMO Threats No support from American Society for Gastrointestinal Endoscopy
  • 64. No support from administration 44 Evaluation An ongoing evaluation and adjustments will be executed while the program is in progress. Evaluation and adjustments will be performed to ensure patients’ safety and work flow efficiency. At the end of 1 year, an in-depth evaluation will be done. Evaluation on the following criteria will be reviewed. a. patient satisfaction outcomes, waiting period for colonoscopy b. intubation rate, complications, and safety c. work flow efficiency and cost savings d. effect on CRC screening rate After the 1 year evaluation, a continuous evaluation will be carried out every 6 months. Necessary changes and adjustments will be made based on evaluation report. Summary In reviewing data for the NP Managed Colonoscopy Service, a need for a trained NP endoscopist is clearly seen. A well trained NP can fill this need. There is a big gap noted with regards to patients needing colonoscopies and number of colonoscopies performed. It should also be noted that since some patients are contracted outside the HMO, there is a big cost difference for the outside versus in-house cost with a NP performing the colonoscopy. This area is where a potential savings could be appreciated. Currently, reimbursements for NPs are less than a physician. This would affect the income made by a NP when compared to a physician. Even with a lesser reimbursement rate, adding a NP to perform colonoscopies is still a cost effective way to provide quality
  • 65. endoscopy. NPs working in collaboration with the gastroenterologist would increase the 45 number of screening colonoscopies and help the goal of increased CRC screening rate and positively affect the Healthy People 2020 cancer goal. 46 CHAPTER III DNP REFLECTION The Doctorate in Nursing Practice (DNP) is a terminal degree in nursing. Compared to the PhD, another terminal degree with an emphasis on research, the DNP is a practice doctorate with a focus on translation of research into clinical practice. DNP graduates are prepared to be well equipped to fully implement any research produced by a nurse researcher. DNP graduates focus heavily on innovative and evidence-based practice which reflects the application of credible research findings (American Association of Colleges of Nursing, 2006) Eight essentials in the DNP degree delineate the core foundational competencies needed in all advanced practiced roles. This NP Managed Endoscopy Service Prospectus is the result of the application of the DNP essentials learned in the program. The DNP Essentials Essential I: Scientific Underpinning for Practice. DNP graduates are equipped with a wide array of knowledge needed to be able to adapt and be effective in the ever changing health care delivery system. DNP graduates are prepared to integrate nursing science with knowledge from different sciences and use science - based theories to affect health care outcomes.
  • 66. Essential II: Organizational and Systems Leadership for Quality Improvement and Systems Thinking. DNP graduates are prepared to be knowledgeable about patients at the individual, population and community level to facilitate improvement of health care outcomes. The DNP graduate’s organizational and leadership skills are necessary to the development, implementation, and evaluation of the NP Managed Endoscopy Service. 47 The NP Managed Endoscopy service affects the individual patients, population, and community health. Essential III: Clinical Scholarship and Analytical Methods for Evidenced – based Practice. DNP graduates have the competency to be able to translate research into practice. DNP graduates focused on translation of new science, application and evaluation. With the NP Manage Endoscopy Service, the DNP’s leadership is needed for implementation and evaluation to improve health care outcomes. The NP DNP graduate will direct, manage, and evaluate the service to ensure safe, efficient, effective, and equitable patient centered care. Essential IV: Information Systems or Technology and Patient Care Technology for the Improvement and Transformation of Health Care. DNP graduates are trained to analyze and use information technology to provide safe, quality, and cost effective patient care. The concept of the NP Managed Endoscopy Service was based on the analysis and evaluation of the existing data available provided by information technology. Essential V: Health Care Policy for Advocacy in Health Care. With the ever changing healthy care policy, DNP graduates are prepared to take a leadership role in health care policy action committees to promote patient care as well as the nursing
  • 67. profession. The NP Managed Endoscopy Service is an emerging niche for NPs. DNP preparation prepares the graduates with skills for the design, analysis, and future implementation of the a NP Managed Endoscopy Service. Knowledge of evidenced based practice will assist in the influence of other stakeholders to its implementation. Essential VI: Interprofessional Collaboration for Improving patient and Population Health Outcomes. DNP graduates are prepared to work in collaboration with 48 different professional to improve patient care. The NP Managed Endoscopy Service is a collaborative effort of a team, physician, nurses, NPs, and technician to provide safe and quality, cost effective care. Essential VII: Clinical Prevention and Population Health for Improving the Nation’s Health. DNP graduates are expected to provide risk reduction and illness prevention for individuals and families as well as the entire population. Colorectal cancer screening is part of the Healthy People 2020 goal of cancer prevention which supports the nation’s goal of improving the health status of the population of the United States (American Association of Colleges of Nursing, 2006). Implementation of a NP Managed Endoscopy Service will help achieve the goal by providing increased access to train NP endoscopists able to perform safe colonoscopies at a lower cost. Essential VIII: Advanced Nursing Practice. DNP programs provide education to allow specialization. Knowledge learned from the DNP preparation assists in the development and conceptual analysis of a NP Managed Endoscopy Service (American Association of Colleges of Nursing, 2006). Conceptual and analytical skills gained in the DNP program prepared the student for the development of a NP Managed Endoscopy
  • 68. Service Prospectus. Summary The DNP’s eight essentials were important factors that influenced the development of the NP Managed Endoscopy Service Prospectus. The service is practice based. It is an example of implementation of science done by researchers. The DNP graduate, an advanced practice nurse, was prepared to demonstrate practice expertise, specialized knowledge, and expanded responsibility (American Association of Colleges 49 of Nursing, 2006). All of these characteristics are important in the development of the NP Managed Endoscopy Service Prospectus as well as its implementation, evaluation, and success. 50 REFERENCES Allen, J. D., Barlow, W. E., Duncan, R. P., Egede, L. E., Friedman, L. S., Keating, N. L., . . . Virnig, B. A. (2010). NIH State-of-the-Science Conference Statement: Enhancing Use and Quality of Colorectal Cancer Screening. NIH Consensus and State-of-the-Science Statements, 27(1). American Society for Gastrointestinal Endoscopy. (2012). Colonoscopy core curriculum. Gastrointestinal Endoscopy 76(3), 482- 490. American Society for Gastrointestinal Endoscopy, & American College of Gastroenterology. (2009). Ensuring competence in endoscopy. Retrieved from http://www.asge.org/assets/0/71542/71544/a59d4f7a580e466ab9670ee8b78bc7ec. pdf
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  • 75. cancer screening to the unscreened population in the United States? Gastroenterology, 127(6), 1661-1669. doi: S0016508504016312 [pii] Seeff, L. C., Richards, T. B., Shapiro, J. A., Nadel, M. R., Manninen, D. L., Given, L. S., . . . McKenna, M. T. (2004). How many endoscopies are performed for colorectal cancer screening? Results from CDC's survey of endoscopic capacity. Gastroenterology, 127(6), 1670-1677. doi: S0016508504016300 [pii] Shapiro, J. A., Seeff, L. C., Thompson, T. D., Nadel, M. R., Klabunde, C. N., & Vernon, S. W. (2008). Colorectal cancer test use from the 2005 National Health Interview Survey. Cancer Epidemiology, Biomarkers & Prevention, 17(7), 1623-1630. doi: 10.1158/1055-9965.EPI-07-2838 Sonnenberg, A., Delco, F., & Inadomi, J. M. (2000). Cost-effectiveness of colonoscopy in screening for colorectal cancer. Annals of Internal Medicine, 133(8), 573-584. doi: 200010170-00007 [pii] http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5926a3.htm?s_cid=mm5926a3_w http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5926a3.htm?s_cid=mm5926a3_w 57 U.S. Department of Health and Human Services, Agency for Healthcare Research and Quality,. (2011). Guide to clinical preventive services, 2010-2011. Recommendation of the U.S. Preventive ServiceTask Force. Retrieved from http://www.ahrq.gov/clinic/pocketgd1011/pocketgd1011.pdf. Vijan, S., Inadomi, J., Hayward, R. A., Hofer, T. P., & Fendrick, A. M. (2004). Projections of demand and capacity for colonoscopy related to increasing rates of colorectal cancer screening in the United States. Alimentary Pharmacology & Therapeutics 20(5), 507-515. doi: 10.1111/j.1365-2036.2004.01960.x
  • 76. Vincent, J., Hochhalter, A. K., Broglio, K., & Avots-Avotins, A. E. (2011). Survey respondents planning to have screening colonoscopy report unique barriers. Permanente Journal, 15(1), 4-11. Wallace, M. B., Kemp, J. A., Meyer, F., Horton, K., Reffel, A., Christiansen, C. L., & Farraye, F. A. (1999). Screening for colorectal cancer with flexible sigmoidoscopy by nonphysician endoscopists. American Journal of Medicine, 107(3), 214-218. http://www.ahrq.gov/clinic/pocketgd1011/pocketgd1011.pdf [removed] WEEK 3 ASSUGNMENT QUESTIONS TOPIC: DNP Role Assignment Paper Part I Title of my Paper: Why DNP/PHD should be a Requirement to be a Faculty Member at a Nursing School The purpose of this assignment is evaluate a current or new role relative to a DNP prepared nurse. The emphasis will be on the skills that a DNP prepared nurse brings to the role. What are the differences coming from a DNP perspective? What skills will a DNP prepared nurse have that a MSN prepared RN would not. The Role Paper will be completed in 2 parts. Part I will focus on a description of the role and what the DNP/MSN nurse will bring to the role. A SWOT analysis will also be done for Part I. Part 2 will consist of a PEST analysis and the next steps in moving the role to a DNP level. References will be completed for both parts of the paper.  The final paper will include both part 1 and part 2. Below is an outline of the items for which you will be responsible throughout the module. 1. Read chapter 8 and 9 from Zaccagnini, M., & Pechacek, J. (2021). The doctor of nursing practice essentials . (4th Ed.). Burlington, MA: Jones & Bartlett Learning. 2. National Academies of Sciences, Engineering, and Medicine. 2021. The Future of Nursing 2020-2030: Charting a Path to Achieve Health Equity . Washington, DC: The National Academies Press. https://doi.org/10.17226/25982 Links to an external site. . Chapter 4- The role of nurses in improving health care access and quality, p. 99-126, Links to an external site.