Nurse Practitioners: Breaking Down Barriers to Practice Joanne T. Clavelle

DNP, RN, NEA-BC, FACHE Vice President, Patient Care Services Chief Nursing Officer

August 23, 2013 Nurse Practitioners of Idaho 2013 Annual Fall Conference August 20, 2013

Objectives • Understand context for Nurse Practitioner (NP) practice: IOM Future of Nursing Report Elements of the Accountable Care Act (ACA) Regional trends increasing demand • Cite common barriers to NPs practicing to their full scope of practice • Review St. Luke’s case study: Apply a collaborative organizational change model to promote expanded privileges across the care continuum Foster collaborative relationships with medical staff in designing new models of care • Examine service/academic partnerships and impact upon NP supply • Identify resources to lead through assessment and change • Questions

2

Context for Practice

• IOM Future of Nursing Report Blueprint to transform nursing practice, patient care & education Nurse leaders participate in redesign and improvement in full partnership with physicians Ensure that nurses can practice to full extent of their education and training Improve data collection for workforce planning and policy-making

IOM Future of Nursing Report • Messages Nurses should be able to practice to full extent of their education and training Nurses should be full partners with physicians and others in redesigning U.S. health care • Recommendations  Remove scope-of-practice barriers  Expand opportunities for nurses to lead and diffuse collaborative improvement efforts

CNO Context for Practice • Challenges of healthcare reform: Assure safe, high quality, effective patientcentered care Position nurses as integral to design and delivery Design new nursing roles and care models across care continuum Value-based purchasing Align with the Triple Aim Workforce shortages

Positioning for Accountable Care • Group of physicians, hospitals and providers that come together to deliver coordinated, high-quality care to Medicare beneficiaries • St. Luke’s ACO was created to participate in the Medicare Shared Savings Program (MSSP) • Goals Improve quality Improve patient experience Coordinate care Improve patient safety Improve health/manage populations • Full Risk Medicare Advantage Programs • Preparing for state health insurance exchange and expansion of Medicaid 6

Positioning for Accountable Care Primary Care Medical Home • SelectHealth & Clinical Integration Payer partnership Employed and independent providers aligned across the continuum Best practices, clinical guidelines, standard order sets and contracts with SNIFs, LTACHs, Rehab and Behavioral Health Care management & coordination Managing care transitions Medical homes & care of patients at risk (CoPar) • Integrated electronic medical record (EMR) • Healthy U

Accountable Care Organization

7

Why ACA Provisions Will Move Forward

• Republicans and Democrats Agree >80% • Lower cost • Improved quality • Greater access • Focus on prevention and wellness • Patient Centered Medical Home / ACO • Can’t afford not to

What to Expect Nationally ~

State-wide/regionally ~

• ACA is here to stay • Integration and coordination of care • Cost reduction • Quality of care NOT quantity of care • More focus on health and less on health care • Greater focus on primary care • Greater focus on collaborative care

• Health insurance Exchanges • State/Regional Co-Ops • Medicaid expansion • Local primary care • Community health • Improved models of collaborative care • SHIP grant – assists Medicare beneficiaries understand benefits/plans

McGowan Peak, Sawtooth National Recreation Area, Central Idaho

Idaho Workforce Rankings Physicians per Capita Primary Care Physicians per Capita

49th 47th

Nurses per Capita

50th

Nurse Practitioners per Capita

45th

Physician Assistants per Capita

Tied 14th

Idaho Department of Labor, Idaho Primary Care Physicians Workforce Overview, Winter 2012-2013; Idaho Department of Labor, Idaho Nursing Overview, January 2011; Idaho Department of Labor, Idaho Physician Assistants Workforce Overview, Fall 2012

Idaho Workforce Projections

Today Physicians Primary Care Physicians Nurses

2018

1,393 1,580 777

862

13,430 17,050

Nurse Practitioners

441

560

Physician Assistants

539

763

Idaho Department of Labor, Idaho Primary Care Physicians Workforce Overview, Winter 2012-2013; Idaho Department of Labor, Idaho Nursing Overview, January 2011; Idaho Department of Labor, Idaho Physician Assistants Workforce Overview, Fall 2012

Idaho Department of Labor, Idaho Primary Care Physicians Workforce Overview, Winter 2012-2013; Idaho Department of Labor, Idaho Nursing Overview, January 2011; Idaho Department of Labor, Idaho Physician Assistants Workforce Overview, Fall 2012

Primary Care HPSAs

Health Professional Shortage Areas

- (county or service area) (demographic – low income population)

St. Luke’s Treasure Valley • • • • • • • •

Founded as a 6-bed frontier hospital in 1902 Two hospitals (548 beds) 100 provider-based clinics Five regional cancer centers Home care & hospice services Three ambulatory surgery centers 2200 RNs/100 Nurse Practitioners 39th organization to receive Magnet®, 3rd 2011 designation

Professional Practice Model

14

Eight Steps to Creating Change* • Establish a Sense of Urgency • Create the Guiding Coalition • Develop a Vision and Strategy • Communicate the Change vision • Empower Broad-based Action • Generate Short-Term Wins • Consolidate the Gains/Produce More Change • Anchor New Approaches in Culture

*Adapted from: Kotter, J. Leading Change. Boston, MA: Harvard Business School Press; 1996

Establishing a Sense of Urgency • Traditional medical staff philosophy of supervision and restriction Prohibited from admitting and discharging, writing orders, H & Ps, rounding, diagnosing • Clinic expansion, managing populations, primary care provider shortages • Expanding APRN privileges priority for both physician and nursing leadership

August 20, 2013

Outdated Terms: Talking Points* • Limited licensure providers Unique, no “limit” outside of scope of practice as regulated by Idaho Board of Nursing • Dependent care providers  In Idaho, APRNs are independent; physician involvement not required for practice. We support collaborative practice. • Mid-level practitioner Unique body of knowledge/scope, all practicing at highest level under privileges granted from organization • Physician extender Professional nurses practice rooted in nursing body of knowledge, physician provides medical care One profession cannot “extend” another Physician assistants are physician extenders as they practice under the physician’s license and are regulated by the BOM Adapted from J. Clavelle. SBAR on Nursing Practitioner Privileges. Boise, ID. 2010

Creating the Guiding Coalition • CNO catalyst for change • Validate vision: CEO, CMO and MEC Chair agreeing to lead task force • SBAR document for situational briefing • Individual meetings with more than 20 physicians • Selection of a professional facilitator • CNO as nursing practice expert; no NPs

Developing the Vision and Strategy • Nurse Practitioner privileges need to be revised in order to: Align with physician expectations regarding how they collaborate to care for patients across the care continuum Reflect current IBN scope of practice Place St. Luke’s in a better position for accountable care and achieving vision of partnering with providers to achieve patientcentered, quality, integrated care • Nursing strategic plan - Goal

Communicating the Change Vision • SBAR to convey vision and educate on outdated terms • Supervision of practice not aligned with scope • MDs and NPs have separate, but related body of knowledge • CNO as highest level authority and practice expert – DNP • APRNs and physicians work in partnership to care for their patients

Empowering Broad-Based Action • Core privileges • Admission, discharge, H & P, consults, writing orders, prescriptive authority • Specialty privileges at department level • Expedited process and approvals • Significant dialogue on differentiating NPs and PAs • Assessment of privileges in other organizations, review of literature • BON role and rules, nursing practice guidelines, peer review • Sponsoring vs. supervising for shared patients

Generating Short-term Wins • One year process to achieve core privileges • Immediate impact - Nursing strategic goal achieved and celebrated - Addressed IOM report recommendation - Aligned with Magnet® model component of exemplary professional practice - Created new NP Forum - Align with Schools of Nursing plans to expand APRN and DNP programs - Improve physician satisfaction and integration, e.g. hospitalists, across clinics/hospitals

Consolidating the Gains • CNO leadership ~ next steps Continue to engage key stakeholders Create operational framework to support practice, e.g. NP peer review Modify and approve of medical staff bylaws, medical records policies, job descriptions, FPPE and OPPEs Educate staff, leaders, physicians, community Align with Regional Action Coalition Develop service/academic partnerships Emphasize role clarity and consistency of care and practice across settings

Goal is long-term change in health and health care.

Recommendations • CNOs must rise to challenge to lead and transform their organizations, influencing organizational policy to create change • Partnering with physician colleagues integral to achieving outcomes • Task force model effective at removing barriers to nurses practicing at their full scope of practice, improving clarity and meeting physician and nursing expectations • Continue to develop new roles, structures and processes to achieve best outcomes for our patients and community • Access organizational support: AARP, Idaho Regional Action Coalition, Robert Wood Johnson’s Campaign for Action, National Council of State Legislators Scope of Practice Tracking web site

References 1. The future of nursing: the institute of medicine (IOM) issues report. The future of nursing: leading change, advancing health. Nursing News. 2011;35(1):1p. 2. IOM. The Future of Nursing: Leading Change, Advancing Health. 2010; www.iom.edu/Reports/2010/TheFuture-of-Nursing-Leading-Change-Advancing-Health. Accessed July 16, 2011. 3. Bleich MR. IOM report. The future of nursing: leading change, advancing health: milestones and challenges in expanding nursing science. Research in Nursing & Health. 2011;34(3):169-170. 4. IOM future of nursing report recommendations are in: now what? Implications for nursing. New Jersey Nurse. 2011;41(3):10-10. 5. Berwick DM, Nolan TW, Whittington J. The triple aim: care, health, and cost. Health Affairs. 2008;27(3):759769. 6. Tolman DR. Breaking away: the ethical case for nurse practitioner independence. American Journal for Nurse Practitioners. 2011;15(7-8):38. 7. ACNP testifies before IOM hearings on the future of nursing. Journal for Nurse Practitioners. 2010;6(3):229229. 8. Bleich MR. "The Research Imperative and the IOM Future of Nursing: Strengthening Nursing's Contributions to Leading Change and Advancing Health". Communicating Nursing Research. 2011;44:1 11. 9. Kuntz K. "Deadly Spin on Nurse Practitioner Practice". Journal of the American Academy of Nurse Practitioners. 2011;23:573 - 576. 10. Kotter J. Leading Change. Boston: Harvard Business School Press; 1996. 11. Idaho Rules of the Board of Nursing 2012, http://adminrules.idaho.gov/rules/current/23/0101.pdf 12. Leonard M, Graham S, Bonacum D. The human factor: the critical importance of effective teamwork and communication in providing safe care. Quality & Safety in Health Care. 2004;13:i85-90. 13. ANA. Nursing Administration: Scope and Standards of Practice. Silver Spring: Nursesbooks.org; 2009. 14. ANCC, ed Application Manual: Magnet Recognition Program. Silver Spring: American Nurse's Credentialing Center; 2008.

Questions?