HL20: Robert D. Donaldson, NPC—The Nurse Practitioner-Run ED

In our annual HealthLeaders 20, we profile individuals who are changing healthcare for the better. Some are longtime industry fixtures; others would clearly be considered outsiders. Some are revered; others would not win many popularity contests. All of them are playing a crucial role in making the healthcare industry better. This is the story of Robert D. Donaldson, NPC.

This profile was published in the December, 2011 issue of HealthLeaders magazine.

 "We've gotten past why a nurse practitioner is in charge in this community because I market myself. I am Bob Donaldson, a nurse practitioner."—Robert D. Donaldson, NPC

There are times when patients are ushered into the emergency department in tiny Ellenville Regional Hospital in upstate New York, and they ask: Is there a doc here?

"There are no doctors here in the ED, I'm the one you are going to see," says Robert D. Donaldson, NPC, in his well-worn refrain. And yes, there have been the occasional snickers, or even calls to the C-suite to complain.

Donaldson is no doctor, but he's a nurse practitioner, as is every member of the ED staff at the 25-bed critical access hospital. Not only does he often handle his own shift, he also has clout within the hospital. He's clinical director of emergency medicine and president of the hospital's medical staff, sharing ED leadership responsibilities with a medical director, Norman Chapin, MD. The hospital is in the Catskill Mountains about 40 miles from Kingston, NY.

So is this really working, a nurse practitioner in charge? And do the physicians really like what he's doing? "You'll have to ask them," he says. He pauses. "Yes, there is an answer to that. We are admitting patients, making money for the hospital, and the hospital is in the black year after year. What does that say? The hospital has received an award for its emergency department for patient care. What does that say?"

The 68-year-old Donaldson, who had a long background in emergency nursing, came to Ellenville in 2004 at a time the hospital was ailing financially. In 2009, the hospital was having trouble filling the medical staff president position. Donaldson kept getting notices about the vacancy, and just threw them out. After he received a third notice, he asked if he could run. But first he asked top leadership if they were okay with a nurse practitioner running. "I'm not going to offend the CEO," he says. Eventually, Donaldson won a runoff against two physicians, and garnered 70% of the vote on the final ballot. Donaldson could not even vote for himself; only physicians could vote.

Donaldson believes he was becoming popular with the physicians because he did "the entire workup for them, and essentially managed their patients prior to admission. It goes a long way and makes their job really easy."

After he was named to head the ED, he reshuffled staff, weeding out some providers who weren't meeting hospital standards, and replaced them with nurse practitioners or physician assistants. In the meantime, the patient load within the ED increased from 8,000 patients a year to about 13,000, he says.

Donaldson acknowledges that the nonphysician provider arrangement is unusual, but says that in New York and some other states "nurse practitioners are basically equal to doctors, they can admit patients, manage patients, and discharge patients." New York is currently a collaborative-practice state, which does not require direct physician supervision.

Donaldson laughs easy and says he loves his post, juggling the clinical and administrative worlds. He is thrilled with his working relationship with physicians, and is convinced that under his leadership, the ED, now with four full-time and two-part time nurse practitioners and physician assistants on staff, is doing a standout job.

The hospital staff also has worked hard to reduce the length of stay of patients in the ED with much success, he says. Length of stay was reduced from 2 hours and 12 minutes in 2004 to 92 minutes last year.

Not every patient who walks into the ED is happy that a nurse practitioner is in charge. A patient's family member complained that Donaldson tried to pass himself off as a doctor.  As Donaldson recounts the story, the CEO knew right away it wasn't true. The administrator told the person, "Donaldson is a nurse practitioner. He's proud of that. He would never pass himself off as a doctor."

Not every patient who walks into the ED is happy that a nurse practitioner is in charge. A patient's family member complained that Donaldson tried to pass himself off as a doctor.  As Donaldson recounts the story, the CEO knew right away it wasn't true. The administrator told the person, "Donaldson is a nurse practitioner. He's proud of that. He would never pass himself off as a doctor."

Donaldson laughs.

He recalls in detail the patients who come back to thank him, whether it's the man who was bleeding profusely after a dental procedure and scheduled for cardiac surgery, or the mother of the 3-pound premature baby who had been near death. Donaldson talks haltingly about those cases, and his voice cracks with emotion.

Because Donaldson admits patients to the hospital, the hospital gave him attending status. After he joined the hospital, physicians voted to give equal rights to nurse practitioners on the medical staff, and that means, he says, "you are equal to a doctor as far as privileges at the facility and within the medical staff."

When he's not in the hospital he retreats to his nearby home, with the mountains as scenery and no neighbors nearby. He still thinks about healthcare, though. He is a volunteer pilot for an organization that helps transport patients to hospitals, using his own six-seater Cessna 210.

While Donaldson has certainly made inroads in how nurse practitioners are perceived in Ellenville, it's still a national problem, he says. He's says he's still fighting turf wars. "There's a huge medical lobby out there, and they got a huge amount of dollars; they don't really want to hear that nurse practitioners are doing what docs have done," Donaldson says.

In the meantime, he wants to beat the drum about what Ellenville Regional Hospital has done with its administrative structure; i.e., having a nurse practitioner in charge of the Emergency Department. "The community knows what I'm doing, and I'm on the radio every month with the local disk jockey and talk about what's happening in the emergency room," he says. "We've gotten past why a nurse practitioner is in charge in this community because I market myself. I am Bob Donaldson, a nurse practitioner."

This article appears in the December 2011 issue of HealthLeaders magazine.