Weighing the Pig Won’t Fatten It

As we inch toward 2014, the year that the Patient Protection and Affordable Care Act, the centerpiece of the healthcare overhaul, takes effect, it has become increasingly clear that the organization of US health care—or its “system”—is not designed to do what we want it to do. Its spiraling costs and uneven quality are certainly problems, but what is at the root of the myriad of delivery system problems is the lack of integration and coordination of care. As $1 trillion is about to be invested in US health care, it must not be used to finance more of the same but rather must provide better care for patients. A study published in the New England Journal of Medicine last November found that almost no progress has been made in one state on patient safety,¹ despite the decade-old publication of the Crossing the Quality Chasm report’s fervent call for a dramatic change and statewide efforts to improve preventable harm to patients in hospitals.² The study found that patient harm remains common in 10 North Carolina hospitals, and there was no significant reduction in harm, suggesting that the ambitious goal set by the Institute of Medicine (IOM) of a 50% reduction in preventable healthcare errors during a 5-year period has not been met and that there is little evidence of widespread improvement in patient safety. Looming workforce shortages present another thorny problem. As 32 million newly insured patients get swept into the system by 2014, a third of current physicians will retire over the next decade, and the physician scarcity will increase to 100,000 with shortages in all specialties, not just primary care.

The IOM Relies on Evidence and Gets Bold

Recall that Clara Barton neither asked for permission nor sought direction before she headed into the front lines of the Civil War. This experience inspired her to campaign fiercely and successfully to create the Red Cross. In the spirit of Clara Barton, 3 years ago, The Robert Wood Johnson Foundation (RWJF) and the IOM launched a 2- year initiative to re-conceptualize and transform the nursing profession. The IOM appointed a Committee on the Initiative on the Future of Nursing, which produced an evidence-based report that decisively recommends an action-oriented blueprint for the future of nursing. The eeport explores how nurses’ roles, responsibilities, and education should change significantly to meet the increased demand for care that will be created by healthcare reform and to advance improvements in America’s increasingly complex health system.

The report offers recommendations for a variety of stakeholders—from state legislators to Centers for Medicare & Medicaid Services (CMS) to the Congress—to ensure that nurses can practice to the full extent of their education and training. The federal government is particularly well suited to promote the reform of states’ scope-of-practice laws by sharing and providing incentives for the adoption of best practices. One sub-recommendation is directed to the Federal Trade Commission, which has long targeted anticompetitive conduct in the healthcare market, including restrictions on the business practices of healthcare providers, as well as policies that could act as a barrier to entry for new competitors in the market.

High turnover rates among new nurses underscore the importance of transition-to-practice residency programs, which help manage the transition from nursing school to practice and help new graduates further develop the skills needed to deliver safe, quality care. While nurse residency programs are sometimes supported in hospitals and large health systems, they focus primarily on acute care. However, residency programs need to be developed and evaluated in community settings.

There are eight big, bold recommendations (see below) that in some form strengthen and improve advanced-practice-registered nurse (APRN) practice and make nursing more central to care delivery. This report had broken every record in the history of the IOM in regard to report sales, and the website has crashed due to such heavy usage. You can read the full evidence-based report at http://thefutureofnursing.org/IOM-Report; see the box for a brief summary of the eight recommendations from the IOM.

Helping Sisyphus: Accelerating the Modernization of the Nation’s Outdated Nurse Practice Acts.

A sub-recommendation that is worthy of close APRN attention is the removal of cope-of-practice barriers. With nearly half of the 50 states needing to modernize their state practice act, it is expected that this process of modernizing and standardizing the state practice acts to comply with our professional standards in the APRN (LACE) Consensus framework (www.nacns.org/LinkClick.aspx?fileticket=P6JBcZlimjM=&tabid=36) may take decades. My experience testifying before a Virginia legislative body on the removal of physician collaboration showed me first-hand the challenges we face, ie, a highly politicized environment, with little to no reliance on science, current realities, public input, or patient-centeredness that is led by a legislative committee that seemed wholly unqualified to adjudicate scope-of-practice challenges. Trying to modernize nurse practice acts in this environment is like Sisyphus rolling his immense boulder up a hill, only to watch it roll back down, and then to repeat the frustrating task over and over again. Imagine the federal government giving favorable funding preferences only to those states that have modernized their nurse practice acts. Just as states have long had highway funds linked to stringent drunk-driving laws and speed limits, those states with outdated practice acts could soon see their funding sources for nursing dry up. This financial loss to those outdated states would significantly expand the pool of stakeholders to advocate for modernization far beyond APRNs. University presidents, the public, hospital administrators, and many others would be joining our efforts. An audacious and compelling idea…

Making It Happen

To implement these recommendations, the RWJF is working with AARP and the states to advance recommendations from the IOM that would give APRNs greater roles and more control in health care. The initiative is encouraging states to partner with them to build regional action coalitions to expand leadership in nursing. If you would like to start or join a coalition or are seeking to modernize your state’s nurse practice act, it would be expedient to work through one of these existing coalitions. For information, email future .(JavaScript must be enabled to view this email address)

Don Berwick’s Message to Nurses

A national summit on advancing these IOM initiatives was held in Washington DC last December. CMS Administrator Don Berwick’s keynote address began with his portrayal of the “majesty of nursing” and his enormous respect for nurse practitioners—he put his own children under their care. He describes the power of nursing as a force that understands patient safety and patient/family-centered care like no other discipline.
Don Berwick heads the largest insurance company in the world, overseeing 4,500 people, and is currently implementing the largest health reform legislation since 1965, when Medicare was enacted. He described the reform legislation passed last March as “stunning” and “vastly under-estimated by the American public.”

He sees it as a turning point for our country because it answers many questions on coverage, access, quality, and security for the chronically ill. A major concept he wants fully developed is “crafting journeys” for patients as they move through the healthcare system. The newly created CMS Center for Innovation is a place for forward-thinking ideas that foster the care integration required to create journeys ofcare. He stressed that this center will go a long way in addressing what works because, if we want different outcomes, we have to develop different systems. He insists that the focus must be on interdependency in order to respect the needs of patients and the traditions of human caring, which have always been core to nursing.

The Critic

The 8 Recommendations

Recommendation 1: Remove scope-of-practice barriers. APRNs should be able to practice to the full extent of their education and training. To achieve this goal, the committee recommends the following action.

For the Congress

For state legislatures

For the CMS 

Management 

For the Federal Trade Commission and the Antitrust Division of the Department of Justice

Recommendation 2: Expand opportunities for nurses to lead and diffuse collaborative improvement efforts. Private and public funders, healthcare organizations, nursing education programs, and nursing associations should expand opportunities for nurses to lead and manage collaborative efforts with physicians and other members of the healthcare team to conduct research and to redesign and improve practice environments and health systems. These entities should also provide opportunities for nurses to diffuse successful practices.

Recommendation 3: Implement nurse residency programs. State boards of nursing, accrediting bodies, the federal government, and healthcare organizations should take actions to support nurses’ completion of a transition-to-practice program (nurse residency) after they have completed a pre-licensure or advanced-practice degree program or when they are transitioning into new clinical practice areas.

Recommendation 4: Increase the proportion of nurses with a baccalaureate degree to 80% by 2020. Academic nurse leaders across all schools of nursing should work together to increase the proportion of nurses with a baccalaureate degree from 50 to 80% by 2020. These leaders should partner with education accrediting bodies, private and public funders, and employers to ensure funding, monitor progress, and increase the diversity of students to create a workforce prepared to meet the demands of diverse populations across the lifespan.

Recommendation 5: Double the number of nurses with a doctorate by 2020. Schools of nursing, with support from private and public funders, academic administrators and university trustees, and accrediting bodies, should double the number of nurses with a doctorate by 2020 to add to the cadre of nurse faculty and researchers, with attention to increasing diversity.

Recommendation 6: Ensure that nurses engage in lifelong learning. Accrediting bodies, schools of nursing, healthcare organizations, and continuing competency educators from multiple health professions should collaborate to ensure that nurses and nursing students and faculty continue their education and engage in lifelong learning to gain the competencies needed to provide care for diverse populations across the lifespan.

Recommendation 7: Prepare and enable nurses to lead change to advance health. Nurses, nursing education programs, and nursing associations should prepare the nursing workforce to assume leadership positions across all levels, while public, private, and governmental healthcare decision makers should ensure that leadership positions are available to and filled by nurses.

Recommendation 8: Build an infrastructure for the collection and analysis of interprofessional healthcare workforce data. The National Health Care Workforce Commission, with oversight from the Government Accountability Office and the Health Resources and Services Administration, should lead a collaborative effort to improve research and the collection and analysis of data on healthcare workforce requirements. The Workforce Commission and the Health Resources and Services Administration should collaborate with state licensing boards, state nursing workforce centers, and the Department of Labor in this effort to ensure that the data are timely and publicly accessible.