4 nurse executives reveal how they are adapting to a challenging healthcare environment.
Until COVID-19 turned healthcare on its head, care models had not changed much since the early 20th century.
But now, nurse executives are finding new and more efficient care models to adapt to the current state of nursing shortages, workforce pipeline challenges, fewer physicians, increased patient acuity, and countless other challenges in today’s healthcare environment.
HealthLeaders talked with four nurse executives and asked each one, “What does practice redesign look like at your organization?”
Their replies have been lightly edited for brevity and clarity.
Associate vice president for advanced practice
Private Diagnostic Clinic at Duke University Health System
We started in 2010 in my practice of cardiology, and along with the cardiologists, we had a group of six NPs and PAs that had about 75 years of combined experience with high-quality training and yet, they were working far below scope, basically doing the work of a nurse.
We had an access issue because our next available appointment for a new patient was a month away, and that's not OK if somebody's calling because they're dizzy or because they have chest pain.
We received funding to hire nurse clinicians to form the hub of an interprofessional team consisting of four physicians, one APP, and the nurse clinician. The model that we chose for our patient population was that the APP would see return patients, acutely triaged patients, and hospital follow-up patients. This freed up the physicians to see complex patients new to our practice and establish a plan of care.
This met our aim of all members of the team working to the top of their scope of practice, while increasing access for our patients.
From there, it was so successful that it spread across our health system in all our ambulatory specialty practices. Each one looks a little bit different because each specialty practice is going to be different. For example, in dermatology, APPs might do general dermatology and the physicians might do the surgical subspecialty part of that.
As we move toward value-based care, we have to take care of lots of people, especially as Medicaid is expanded throughout our country. My mantra is everyone on the team will be working to the top of their scope and that means the top of their license, their board certification, and their training, and that aligns with how we attract and engage and retain the best talent. It’s worked. We have amazing people who come to work with our organization, and they stay.
Chief nursing officer and vice president for patient care
Brigham and Women’s Faulkner Hospital
We started with the fact that we have too many patients and they have to come up from the emergency department when we're overwhelmed and can't provide care. And we started weighing in: Can they go in many different arenas?
And we decided it would be hallway spaces, but what hallways? Can we use conference rooms? Can we use vacant office spaces? We had to look at what was there and what met potential code opportunities for necessary requirements: Can beds fit into them? Can we get suction and oxygen, etc., available to those patients?
Once we said, “No, it has to be in these hallways in these areas,” then we asked, “Will this fit for all of our units?” And the answer even at that was no. We needed to, again, be innovative and go back to redesign.
So, on one unit, we have larger rooms, so we knew we could double up rooms, and we did. We’ve also put potential hallways under certain criteria meeting certain trigger points, so we could bring up beds, put them in halls, and decide which patients are appropriate to be put there.
Executive vice president and chief nurse executive
Indiana University Health
As we are entering in this work, we want to be thoughtful about how this is going to be different. A lot of times we trial things, but then we don't always get good data for what works or what doesn't, or we try to wait for the perfect model before we would implement anything because, quite frankly, the stakes are high and there is that innate fear that you're going to make a mistake that's going to cause you not to give quality care.
So, we created a vision statement for care model redesign, and then associated guiding principles: we wanted to engage our frontline team members, we've encouraged autonomy, rapid testing, and frequent evaluation. We’re trying to get a little more agile and nimble with what works and what does not and spread that so we share the lessons learned across our system.
We have a lot of different pilots going on in the system and we have a research study that's going on with five innovation units across the state, so we're not waiting for perfection on this, but once we communicate the vision and the criteria, we developed some change management tools for our frontline leaders to help with how to go about this.
Part of the mindset shift for this has been to lead more through guiding principles that are not a one-size-fits-all. There were some who were probably waiting for me as the chief nurse executive to say, “This is the care model at IU Health; now everyone go out and implement this and everything will be fine.” I don't think that you can lead this way. I could have done that, but I think it would have failed miserably.
Chief nursing officer
Midland Memorial Hospital
We’ve done some things not considered innovative now, but they were cutting edge at the beginning. We utilize LVNs [licensed vocational nurses], but not in an assistive supportive role; we use LVNs for part of our primary care model, to have them taking patient assignments, taking fuller extent of their capacity here in Texas to evaluate patients and take care of patients.
We’ve implemented and designed an LVN internship, residency, and fellowship program, recognizing that this entry to practice has not really been tapped here locally or in the region, as an opportunity to grow individuals in that space.
We put them on a path where we will pay them to get their RN through a transition program with a local community college partnership here, and that has been very successful. We had 15 individuals in our first cohort that we were able to upskill and get them onto the path to become an RN.
We are looking at our skill mix, as everyone in the country is looking at different skill mixes and how you can have unlicensed assistive personnel in the clinical environment. We redesigned some of our models where we're increasing our UAPs [unlicensed assistive personnel] and having them take on the care, feed, and activity roles where their sole focus is supplementing that aspect.
In addition, we are working further down the pipeline. We recognize that before COVID we were focusing on older adults—high school graduates, adults in the working world, or college kids trying to work toward the healthcare career. We've lowered our hiring limit to age 16. We are working with our local independent school district to create an Explorers program where not only do they get to come into the hospital and experience different areas of healthcare—different roles and disciplines—but also the ability to work as an unlicensed assistive personnel during their downtime that enables them for our employee benefits, such as tuition assistance.
We're getting these individuals plugged in earlier and getting them on a healthcare track so they're not waiting until they graduate to figure out what they want to do, and we as a hospital support them so that gives them a little bit of an edge when it comes to applying for whatever program they want to get into.
*Bredimus is a contributor to the HealthLeaders CNO Exchange Community, an executive community for sharing ideas, solutions, and insights. Please join the community at https://www.linkedin.com/company/healthleaders-exchange/. To inquire about attending a HealthLeaders Exchange, email us at email@example.com
“My mantra is everyone on the team will be working to the top of their scope and that means the top of their license, their board certification, and their training, and that aligns with how we attract and engage and retain the best talent.”
— Allison Dimsdale, associate vice president for advanced practice, Duke University Health System
Carol Davis is the Nursing Editor at HealthLeaders, an HCPro brand.
Practice redesign is never a done deal; it is a constantly changing evolution.
Every care model won't work for every organization with its distinct resources and constraints.
Involving stakeholders in practice redesign is crucial for success.