Parkland Health & Hospital System's CNO shares practical ways to help staff cope after a major event such as the recent mass shooting of police officers in Dallas.
After high-profile tragedies, the following quote from Mr. Rogers often makes the rounds on social media: "When I was a boy and I would see scary things in the news, my mother would say to me, 'Look for the helpers. You will always find people who are helping.'"
Yes, the acts of selflessness, compassion, and dedication by these "helpers" comfort others in times of trouble but, I always wonder, who helps the helpers after a tragic event? What can be done to comfort them and help them cope?
In July, after being shot by a sniper at a Dallas Black Lives Matters protest, seven police officers were taken to Parkland for treatment. Unfortunately, three of those officers died. [Others, including civilians, were taken to other hospitals.]
"That was a struggle for the staff, and for the physicians, who were there and who did their best to try to save everybody that they could," Watts told me when we spoke in late August. "What we want to do is save lives. It's very hard when you can't."
Though the immediacy of the situation is over, the effects of the tragedy are not.
"I think they're [the staff] doing better than they were early on, but I think there are still moments in time when it comes back to them or something triggers it," she told me.
"Maybe after a very difficult trauma scenario, there are tears at the end of the shift. Or if you lose someone, it brings back the memories of, 'Well, I wasn't able to save this person or save this police officer.'"
So what can a nurse leader do help the helpers recover after a tragedy? Watts suggests:
Set Up Mandatory Counseling
Stoic ED and critical nurses won't always seek out help on their own, which is why Watts advocates for mandatory counseling after tragic events.
"We have psychologists that work with our staff," she says. "So we provide that and generally [make it] mandatory in cases like this where the challenges are so great and there are so many emotions around it."
She also recommends group debriefings and input from the organization's pastoral care services.
Ask Staff What They Need
Parkland's vice president of emergency services meets frequently with the ED staff to get feedback about resources they think will help them cope, Watts says.
"One of the things they talked about was pet therapy," she says. "We do pet therapy typically with patients, but the staff benefits as much as the patients do."
Express Empathy
"I would say one of the things that has helped tremendously is the amount of support in this community," Watts says. "As a leader, that's something you really like to see because when you go through difficult times, people can band together or they can splinter."
Expressions of empathy, like when a local restaurant sent food for the staff [as did people in Orlando who experienced the Pulse nightclub shooting in June], are encouraging and help bring people together, says Watts.
Offer Recognition
Celebrating the good work the staff has done during trying situations can help with healing, Watts says.
Together with The Daisy Foundation, Parkland has planned an event to recognize and acknowledge the trauma team for its efforts during the shooting. Watts says. "I think that's a good way to celebrate the good things that happen," she says.
CNOs must also remember to take care of themselves because it's difficult to care for others if you are running on empty. Watts recommends self-care activities like exercise, eating healthfully, and reaching out to others for support.
"Fortunately, CNOs are a good, strong network," she says. "You could pick up the phone and call anyone around the country and talk to them and that's very helpful."
How can an organization get its arms around something as massive and variable as the patient experience? By listening to the experts—the patients.
This article first appeared in the September 2016 issue of HealthLeaders magazine.
Carol Raimondi, RN, knows what it's like to be a patient. Born with congenital heart defects, the 40-year-old's life has been entwined with the healthcare system for decades. Raimondi had her first open-heart surgery when she was 6 years old, and has since had multiple surgeries and hospitalizations both at well-known academic medical centers and at her local community hospital, 259-bed Elmhurst (Illinois) Hospital.
In her time as a patient and a provider, Raimondi has noticed changes in the way healthcare is delivered. What was once a very patient-focused experience has morphed into something less personal and more procedural, she says.
"Over the years, everybody just became busier. There was more charting and more things to do," says Raimondi, who worked as a nurse for eight years, but stepped away from clinical practice in 2006 due to health issues. "Healthcare has become so big, with all these pharmaceutical and insurance companies and all these different regulations. Patient experience has become focused on HCAHPS scores, and what are we going to do to get our scores higher?"
For healthcare executives, attention to results of the Centers for Medicare & Medicaid Services' Hospital Consumer Assessment of Healthcare Providers and Systems survey— the organization's tool for measuring patients' perceptions of care—has become a necessity due to reimbursement changes, public reporting of scores, and the shift to value-based care. But a single-minded focus on HCAHPS scores is a missed opportunity to improve quality, safety, and patient engagement through a broader, more multifaceted approach to patient experience. The Beryl Institute, an independent nonprofit thought leadership organization focused on improving patient experience, defines this approach as "the sum of all interactions, shaped by an organization's culture, that influence patient perceptions across a continuum of care."
"Patient experience is about building a relationship-centered culture that delivers an exceptional experience every time," says Adrienne Boissy, MD, MA, chief experience officer at Cleveland Clinic. "Here at the Cleveland Clinic, we define it as safe care, high-quality care in the context of satisfaction and high value."
Cleveland Clinic is considered an early adopter in the realm of patient experience, with the organization creating its first Office of Patient Experience in 2008.
Today more hospitals and health systems across the country are following its lead and moving beyond the silo of patient satisfaction in an attempt to improve patient experience through a variety of ways.
Patient satisfaction vs. patient experience
While the terms patient satisfaction and patient experience are often used interchangeably, they are in fact different—albeit related—concepts.
"Patient satisfaction is just that: Are you satisfied or aren't you satisfied?" says Kristin Baird, RN, BSN, MHA, president and CEO of the consulting firm the Baird Group in Fort Atkinson, Wisconsin. "It's kind of a yes or no, and it's on a continuum where you can say how satisfied you are. It's pretty quantitative."
The HCAHPS survey is one tool to help organizations gauge patients' sentiments in this area.
"Satisfaction is really, are they happy?" says Shawn R. Smith, vice president of patient experience at Wilmington, Delaware–based Christiana Care Health System, a not-for-profit health system that had $1.6 billion in total patient revenue in fiscal year 2015. "To some degree, the CMS platform for HCAHPS is an indicator of how well they like you, how well they're into you as an organization."
Patient experience, on-the-other-hand, is all encompassing.
"It's clinical. It's operational. It's behavioral. It's cultural. It's everything," says Sandra Myerson, RN, BSN, MBA, MS, chief patient experience officer at New York's Mount Sinai Health System, an integrated system that sees 152,576 annual inpatient admissions. "It's every interaction patients have with anything within our healthcare system, whether it's someone on the telephone, whether it's a document they're reading, whether it's our website, whether it's the building—everything matters."
It is also personal.
"Patient experience gets into more of the qualitative, where you're saying what's important to you. It's all about the individual," Baird explains. "If you and I were both being admitted to the hospital right now, hopefully somebody would say, 'During your stay with us, what is going to be most important to you?' You're going to have an answer for that, and chances are it's not going to be the same as mine."
This variability in patient preferences can create a challenge in determining how to provide an excellent patient experience, Boissy says.
"If you asked every patient what the patient experience meant to them, they would say something different, just as if you were to ask clinicians, they would say something different," she says. "It's very difficult to get your arms around it if we can't agree on a definition."
Which is why Boissy suggests organizational leaders ask individual business units or service lines to develop their own vision and measurements to assess patient experience.
"HCAHPS can be one of the metrics but not the metric," she says. "We've gone through an exercise over the last year or so … to drive every department, every unit within the office of patient experience to articulate what their own goals are for patient experience and then, to come up with goals and metrics around those."
For example, volunteer services and the center for excellence for healthcare communications are both part of Cleveland Clinic's office of patient experience. Boissy says each group asked questions such as ...
How do they feel they've touched patient experience?
What are they expecting out of themselves for the next year?
What would success look like?
Different groups may come up with different answers, but teasing out those variables is essential to understanding how to affect patient experience.
"We believe that listening to patients is not only the right thing to do, but it's absolutely one of the best ways we can spend time."
"I think HCAHPS is one of what can be a more richly defined experience and metrics to track whether or not we're moving the needle," Boissy says. "But that's individualized."
A multipronged approach
Christiana Care's Smith agrees that there is a richness to patient experience that can't be measured just through HCAHPS scores.
"Patient experience created a conversation to broaden the context of how we connect with people," he says. "If you start looking at what health systems are really focused on, it's really about the quality of communication."
Smith points out that communication isn't just pushing information out to patients; it's actively listening to feedback from them as well.
"Whether we're rounding virtually from a phone call, calling and connecting with the patient postcare, or we're in the moment having a conversation about safety and quality and about their overall healthcare experience, we're collecting that data in real time to look at matters that we can address."
"We believe that listening to patients is not only the right thing to do, but it's absolutely one of the best ways we can spend time," he says.
Christiana Care takes a multipronged approach to patient experience. In addition to HCAHPS scores, the organization uses feedback from patient advisors along with real-time information gathered through conversations with patients to improve patient experience.
"Whether we're rounding virtually from a phone call, calling and connecting with the patient postcare, or we're in the moment having a conversation about safety and quality and about their overall healthcare experience, we're collecting that data in real time to look at matters that we can address," Smith says.
Another way the organization is trying to understand the patient experience is through sentiment analysis. "You have two different ways—qualitatively and quantitatively—to get data out of a survey," he explains.
"You actually get your metrics, but you also get a great story when you start looking at the feedback. We take the sentiment from all of our surveys, and we take all of our sentiment from our mobile applications, all the sentiment inside social media chatter—think #ChristianaCare or Facebook—and we actually push that into an engine that does natural language processing on that." This allows Christiana Care to notice themes in that information.
"Those themes can be as simple as, 'Close the door on the unit for quiet,' or something more significant like as a concern about the medication side effects," Smith says.
Smith stresses that just focusing on one data set, whether it be HCAHPS or patient sentiment, isn't enough to fully comprehend that patient experience.
"It's not necessarily a true indicator of quality," he says. "You really need to look at the quality, safety—those outcomes—as well as experience."
Providers' discomfort zone
Because they are involved in direct patient care, the two groups most visibly involved in a patient's experience are nurses and physicians. They're specifically called out on the HCAHPS survey where patients are asked to rate the degree to which they think these providers showed them courtesy and respect, listened to them, and responded to their needs during their hospital stay.
And it's no secret that feedback to such questions has caused discomfort for some providers.
"I've been a nurse for 24 years, and more than any time in my career, we are asking providers to do more with less. In addition, they're being judged almost every day on how they're doing, whether it's a point-of-care survey or patient satisfaction. I would imagine it's very hard for them not to take it personally," says Jennifer Strickland, RN, BAN, customer experience director at Lakewood Health System, an independent, integrated, rural healthcare system based in Staples, Minnesota, with a 25-staffed-bed critical access hospital and primary care clinics.
Strickland saw this uneasiness occur when the organization began sharing scores of provider's Clinician and Group Consumer Assessment of Healthcare Providers and Systems (CG-CAHPS)—CMS' standardized survey tool to measure perception of physician's care in an office setting. Originally, the providers said they were on board with—even looking forward to—this transparency of scores.
"The first time, we put their scores up during a provider meeting, we listed each provider from best to worst, with those at or above the practice average listed in green and those below in red. There was immediate silence, and literally no discussion. No one wanted to see their name on that list, unless they were one of the top-ranking providers. They immediately asked us to change the process," she recalls. One provider even came to Strickland following the meeting, visibly upset about being ranked in the red zone.
"I explained, 'Well, you are actually doing fairly well; the red just means you're slightly below the practice average,' " Strickland says. "The provider replied, 'I can't be below average. If there's something red, it means there is something I haven't done or haven't done right.' "
While listening to clinicians' concerns is essential, the key to making progress in providers delivering a positive patient experience is support, says Craig Wolhowe, vice president of clinics and hospital services at Lakewood.
"We see the providers' side of the story, but they also have to understand our side. This is important. This is how we get reimbursed," he says. "We need to make sure we're all working together and ask providers, how can we make you better? How can we make you successful?"
The power of thank-you
Finding ways to help providers improve patient experience, including one-to-one work if needed, is a major part of Strickland's role. This philosophy of support was successful with a physician who was unhappy about having some of the practice's lower CG-CAHPS top box scores regarding the CG-CAHPS question "Would you recommend this provider's office?" and in the provider communication domain.
Strickland acknowledged that by virtue of being new to the practice and therefore seeing patients who couldn't get appointments with their usual providers, this provider was "already behind the eight ball" when it came to patient satisfaction. So Strickland created an assignment. For the next 30 days, the provider simply was to look each patient in the eye at some point during the visit and thank him or her for coming.
"A genuine 'Thank you so much for seeing me today. Thank you for coming in,' " Strickland says. "That was the only thing, the eye contact and that genuine thank-you."
Next she asked the provider, and the rest of the practice, to intentionally open the patient's visit with the thank-you.
"I said, 'Think about where the patients are coming from. They have higher deductibles than they have ever had. People are paying a lot more out of pocket. So, where people used to just go to the doctor without much thought, you need to know that the mom of that small child or that gentleman who is already missing work, they're wondering if they even made the right choice to come to the doctor," says Strickland.
And questions like, "Am I wasting the physician's time? Am I wasting my time? Am I wasting my money?" are likely running through most patients' heads.
"Many patients are having those thoughts. So what if you started the visit with, 'Thank you so much for coming in today.' They're going to take a deep breath. They're going to relax. You're affirming that they made the right choice in seeing you, and you're connecting with them," Strickland says.
Since the one-on-one work with Strickland, the provider's top box scores on the "would you recommend" question improved by 20 percentage points, and the provider communication scores improved by 16 percentage points.
First impressions matter
Just as it's wise to expand the concept of patient experience beyond patient satisfaction or CG-CAHPS and HCAHPS scores, it's also important to recognize physicians and nurses are not the only individuals who can influence patient experience.
"What if you started the visit with, 'Thank you so much for coming in today.' They're going to take a deep breath. They're going to relax. You're affirming that they made the right choice in seeing you and you're connecting with them."
"You could talk about how the nurses impact experience and miss the phlebotomist, miss the physical therapist that comes into the room, miss the dietitian, miss the environmental services. The industry created that broad context of patient experience to cover everybody for it to be an inclusive measure," Smith says.
Detroit's Henry Ford Health System is one organization that recognizes improving the patient experience means including employees beyond physicians and nurses.
"I think it's been helpful to break down the workforce into different components and take different approaches to each of the components," says William Conway, MD, executive vice president at Henry Ford Health System and CEO for Henry Ford Medical Group. "Our receptionists operated around 65% to 68% of positive comments" just three years ago.
As of March 2016, the receptionists were ranking at 95% on the CG-CAHPS question "How often did the clerks and receptionists treat you with courtesy and respect?"
The results are impressive, but as Conway points out, it did not happen easily.
"There has been an intense education," he explains. "That component of the workforce, they're entry-level jobs. I think in the past we didn't pay a lot of attention to it. We inservice that group about as intensively as we do anybody in this organization right now."
Providing continuous and consistent feedback has played a role in improvement as well. Each week, the clinic service representatives get reports on their performance measures, and the organization has put more resources into supervising this group than it did in the past, says Conway.
"I meet with the managers of the clinic services representatives across the medical group, and we review how well behavior standards and clinic appearance standards are being applied," says Kelley Dillon, director of care experience at Henry Ford Hospital and Health Network.
Henry Ford's behavior standards are based on AIDET, the Studer Group consulting firm's acronym for its five fundamentals of patient communication. It stands for acknowledge, introduce, duration, explanation, and thank-you. These, along with clinic standards like cleanliness and noise levels, are measured through CG-CAHPS scores, Press Ganey surveys, and mystery shopping feedback.
In addition to the managers, with whom she meets monthly, Dillon meets quarterly with clinic service representatives, whom she refers to as chief first impression officers, to provide feedback and recognition. From Dillon's perspective, continued follow-up with and development of this group of employees is necessary to improving patient experience.
Helping this group understand the importance of their interactions and recognizing them for a job well done is also important.
"It's finding ways to constantly talk about it that make them feel proud, too."
Dillon is now using some of the same techniques, including the AIDET model of communication, with medical assistants at the organization. "For example, the A is acknowledge. Instead of just acknowledging someone as mister-or-miss-last-name, we also want to find an opportunity to ask or to say some things that acknowledge their backstory as a human being," Dillon explains. "And then making notes in our electronic medical record that remind us of things that are important to the patient.
"Any time we teach any audience—nurses, doctors, medical assistants, clinic service representatives—we focus on this model so that way we're not reinventing a bunch of new behaviors," she says. "It's not that this is the be-all and end-all, but my strong opinion is, you've got to get consistent and decide what are the main behaviors of your organization's behavioral model and keep centering around that."
Listen to the experts
For all of the experts, tools, and solutions available to assess and improve the patient experience, sometimes it's easy to overlook the people whose opinions matter most—the patients. For this reason, many hospitals and health systems have created patient advisory boards to help ensure actions and interventions are on target.
"We can try to anticipate the patients' needs, but what we realized is—while we might get it 80% or 90% correct—how much more important it is to bring the patient's voice in earlier in those decisions," Strickland says. "If we have X number of dollars to spend on a certain area, how best do we use those dollars? We can come up with a good plan, but by asking patients to give their input earlier in the process, we can come up with a great plan."
Patients have insights on everything, both large and small. "We might think that our patient experience is about what the building looks like or that it's about the care that the doctor's giving," she points out. "But sometimes, it's as simple as, 'I'm on hold for too long when I'm trying to call,' or it might be, 'I really think waiting an X number of minutes is way too long.'"
At Lakewood, there are a variety of ways for patients to become involved in shaping the patient experience. There's an experience council that consists of 20 different people including Lakewood's CEO, a number of vice presidents including Wolhowe, directors, managers, frontline staff, a board member, and two patients who have used Lakewood's services. Strickland says the group's mission is to be proactive in looking at the patient experience from the first time patients call to access the health system to the moment they get their final bill.
The experience council discusses trends in patient complaints or concerns and develops action plans for areas across the system it would like to improve. For example, the group wanted patient experience scores to be easily available to all employees, Strickland says. To do this, it held a contest where the various business units created a themed dashboard where the scores could be posted. One of the assisted living facilities designed theirs as a bowl of popcorn in a nod to the movie nights they have with their residents. The higher the satisfaction scores, the more popcorn in the bowl. And if scores drop, so does the number of popcorn pieces, she says.
There is also a patient and family advisory council made up of 11 patients and one Lakewood staff member who takes minutes. These are patients who have used Lakewood's services, including primary care, acute care, and critical care. Members have come to the council in a variety of ways, including recommendations from their physicians, and, in one case, a recommendation from the financial services department, says Strickland.
In addition, there is an online patient advisory group of 88 patients, which Strickland hopes to grow to 100 patients by the end of the year, called VOICE—Valuable Opinions Innovating Customer Experience. Through this program, patients, family members, employees, and community members share their thoughts and opinions about Lakewood Health System through anonymous online surveys. This group will be giving feedback on changes that have been made to the organization's care coordination call tree, Strickland says.
There also are what Strickland describes as "flash mob" groups, which, much like a focus group, meet in person one time for one hour to discuss a specific topic or issue on which Lakewood is seeking feedback.
"It's just myself and one person taking minutes and asking really open-ended questions, making sure they know we're not really looking for a right or wrong answer and not leading them in any way," Strickland says about the flash mobs.
This approach was used when developing new resources for patients with memory care issues. Strickland placed an ad in the local paper inviting caregivers of patients with dementia, Alzheimer's, or other memory care issues to share their ideas during a flash mob session. Though the group was small—there were about nine people in the room, representing four patients—what they had to say was very powerful.
While they expressed a need for a support group for their loved ones, Strickland noticed that the caregivers developed a bond with each other during the hour-long session.
This feedback led Lakewood to not only launch a new support system for patients with dementia, Alzheimer's disease, and memory issues, but also to create a separate support group for the caregivers.
"We started a support group for people with memory issues but simultaneously acknowledged the need to develop a support group for caregivers as well," Strickland says. "In that hour they can have coffee. They can share. It is very unstructured, and it works great because it's one time they can let their guard down."
Embracing the processes
At Elmhurst Hospital, patient experience is a driving factor in how the organization functions. At the hospital, which received Planetree designation in 2012, processes are designed to support patient-centered care and deliver high-quality patient experience.
"It's really about patient-centered care, or the patient experience, and making sure all of your policies and processes, et cetera, are really from the patient perspective," says Pamela L. Dunley, RN, MS, MBA, CENP, chief nursing officer and chief operating officer at Elmhurst Hospital, about the Planetree philosophy. "You think about the patient when you're developing anything. It's about demystifying the healthcare experience for patients and involving the patient in their care and taking into account the patient's cultural values, the patient's choices, how they learn, making sure that they and their families are part of the experience."
Even before it received the Planetree designation, Elmhurst had been listening to patients.
In 2009, it created its approximately 15-member patient advisory committee and asked Raimondi, who is now the volunteer co-chair, to join the group.
"I was instantly all over it. I really felt like I could be that voice for myself, for my family, and for my community because I have so many different hospital stays in different facilities," she says. "I felt like I could survive those experiences to give a lot of feedback, both negative and positive, what works and what doesn't work."
This includes the feedback the group gave when the organization was developing a new hospital building that opened in 2011.
"Everything was thought of from the patient perspective, which is really what patient experience is about," says Dunley. "We have a patient family advisory council that is very, very active, and they helped us design everything, and continue to help us."
During the design of the new building, the advisory committee helped develop expectations for what an acceptable response time should be if a patient needed pain medications or assistance to the restroom, says Raimondi. But the group's pride and joy is the glass communication boards in each patient room. The boards in the previous hospital were not very aesthetically pleasing, so the organization considered getting rid of them completely.
"Everybody on the patient advisory committee said, 'No, we want to keep those. We want to know who our nurse is and how to reach them or what we have scheduled for the day.' It was a unanimous decision," Raimondi says.
When the new building opened, what was included in every patient room?
"They came up with these beautiful glass boards that are etched and have your nurse, your caretaker, any scheduled tests—it's all written on there," says Raimondi. "So they kept it based on our response."
Another important point that Dunley makes is that to provide an excellent patient experience, processes also need to support staff members. For nurses, this means following what Dunley calls the 90-5 rule.
"Ninety percent of what you need is within 5 seconds of you," she says. "If for whatever reason something wasn't stocked right or they didn't have the right mix at that moment, then it starts getting stressful. As long as the nurses have what they need to do their job, then they want to make sure the patient has the best experience."
The 90-5 rule was put to the test after a merger with Edward Hospital in 2013, which created the current Edward-Elmhurst Health system of three hospitals and more than 50 outpatient locations that reports total revenues of more than $1 billion annually.
"I started hearing from the nurses that we didn't have enough staff," says Dunley, who knew that staffing numbers had not changed. While trying to uncover what had caused this shift in the nurses' perceptions of their workload, she discovered there had been a change, of which Elmhurst executives were unaware, in the way the stock room was maintained.
"The nurses only know that it's harder to do their work, so they're just assuming it's staffing, but we tracked it down to they didn't have the supplies they needed when they needed it. Once we fixed that, which took a while to get to, it went right back to, 'We are fine again,' " Dunley says. "It's a matter of really making sure you understand everything that competes for the nurses' time so that they can focus on taking care of that patient the way the patient needs to be taken care of."
Solving the mystery
Another way to evaluate the patient experience is through the use of mystery shoppers. A mystery shopper is someone who poses as a patient or patient's family member to assess what type of patient experience an organization provides.
"One of the toughest things for an organization to do is to look at the absolute truth," says Dwight W. McBee, RN, BSN, MBA, director of customer experience at AtlantiCare, a member of Geisinger Health System, in Egg Harbor Township, New Jersey. "Mystery shopping, in my eyes, is looking at the absolute truth. It's a truly unique and innovative way to assess whether the tactics that you put into play are really working. So we're engaging with our mystery shoppers to get a completely neutral assessment of the work that we provide."
A mystery shopping evaluation can be done by phone or in person. McBee says mystery shoppers were used in late 2015 to assess patients' experiences with various access points throughout the organization.
"We wanted to make sure that when people were reaching out to AtlantiCare for service, we truly understood what they were experiencing," he says. "Everything from the way they were greeted on the phone to the way that the interaction flowed from the person who asked them for their insurance information."
To understand the patient experience from soup to nuts, McBee says the organization used mystery shoppers in three different ways—by phone, by posing as patients, and by shadowing actual patients.
"Those three different methods really helped us get a perspective that we would not have gotten any other way," he says. "Sometimes you can start this patient experience work and think that you've trained a group and they understand the concepts that you're training and they're all doing it consistently everywhere that you provide service. But with the randomness that comes with mystery shopping … it was really an authentic assessment of our organization and we learned quite a bit."
One thing that came to light was the need for some standardization in communication.
"Some of the things that we say and the ways that we respond to our patients, or essentially our future patients or future customers in various care locations, we need to get that right in order for them to effectively access care. So we needed to standardize the way we were holding those conversations," McBee says.
This ensures that all patients have the basic information they need to make informed decisions about their care.
"We really want to make sure that it's easy, seamless, and things work in concert when you've made that very difficult decision to choose a healthcare provider. We want to make the process easy for you once you've made that decision," he says.
Standardization may sound counterintuitive because providing an excellent patient experience is so personal and variable. To understand this, it helps to remember something taught to most healthcare professionals—Maslow's Hierarchy of Needs. In order for people to reach their highest potential, they must first have the basic needs of food, water, warmth, and rest met; similarly, to have an outstanding experience with a healthcare organization, the patient must first have basic needs—appointment times, insurance coverage, test locations—met.
Healthcare providers can then build off this solid base to customize a patient's experience and make it meaningful to him or her and create what McBee calls, "a starfish experience."
The concept is based loosely on the short story "The Star Thrower" by Loren Eiseley. In it, a man sees a young man on the beach throwing starfish into the ocean. When he asks why, the young man explains that if he does not throw the starfish back into the water, they will die. The man tells him that with miles of beach and starfish, the young man surely won't be able to make a difference. After hearing this, the young man picks up another starfish, throws it into the ocean and replies, "It made a difference for that one."
"It's the story of making a difference one person at a time," McBee says. "Everything that we do focuses on everything working together to build an exceptional patient experience. So when we say 'starfish experience,' we're really talking about making the human connection at every moment during a patient's journey."
Feeling like the focus is on you is what takes a patient's experience from good to great. This is why Raimondi says she would receive all her care at Elmhurst, rather than a big academic medical facility if she could.
"I feel like when I'm there at Elmhurst, they really focus on you," she says. "Everything that they're doing is putting you first. I see that it's getting back to where the patient is a priority, despite whatever might be going on outside that room. That nurse is focusing on me when she's there."
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Have you ever felt like a patient was "off," but didn't have the data to justify that gut feeling?
At Connecticut's Yale-New Haven Hospital, nurses can use predictive data to identify subtle changes in a patient's condition and intervene before deterioration occurs.
Thanks to a nursing SWAT team's monitoring of predictive data, YNHH saw a 30% drop in patient mortality over a 15-month period.
It's possible to improve patient outcomes without hiring an army of staff members.
Patients enrolled in Wooster (OH) Community Hospital's Community Care Network, a program that trains and uses college students as community health workers, reduced ED usage by 26%, and their readmission rates dropped by 51%.
"You don't need to have a whole bunch of RNs out there," says AlexSandra Davis, RN, BSN, manager of the Community Care Network.
Holy Name Medical Center in Teaneck, NJ, has had great success using the NP Care Model to improve patient outcomes.
In 2012, Judith Kutzleb, RN, DNP, CCRN, CCA, APN-C, vice president of advanced practice professionals at Holy Name, helped launch the program, which originally focused on heart failure patients. Over a 12-month period, 30-day readmission rates dropped to 8% from 26%.
Healthcare costs for the group of 312 patients receiving care via The NP Care Model totaled $311,818 during the 30 days after discharge. The 30-day post-discharge cost of care for this patient population prior to the model's implementation was $1,019,405.
The results have spurred Holy Name to add advanced practice providers to more of the medical center's service lines including cardiology, chronic care management, oncology, and genetics.
For more on how nurse practitioners can improve clinical outcomes, join Judith Kutzleb, RN, DNP, CCRN, CCA, APN-C, Vice President of Advanced Practice Professionals at Holy Name Medical Center in Teaneck, NJ, for the HealthLeaders Media webcast, "Improving Clinical Outcomes through Advanced Practice Nurses," on August 31 from 1:00 to 2:00 pm ET.
A technique used in comedy clubs is helping nurses develop vital communication skills—but without the laughs.
In the emerging practice of medical improv, humor isn't the end goal.
When people hear the word "improv," they usually˙ think of the type of comedy made famous by The Second City, Chicago's comedy club, theater and school of improvisation. But improv doesn't always have to lead to a joke.
"We take teaching strategies and activities from improvisational theater and we use them to build soft skills that we need for communication, teamwork, and leadership," says Beth Boynton, RN, MS, organizational development consultant at Beth Boynton Consulting Services, in Portsmouth, NH.
"Instead of worrying about entertaining or being funny, we're going to focus on how medical improv helps us build skills and solve these big problems in healthcare," she says.
Medical Errors are No Laughing Matter
Major issues such as patient safety, patient experience, job satisfaction, and horizontal and vertical violence are all effected by communication, interpersonal interactions, and teamwork, says Boynton.
Likewise, The Joint Commission cites failure of communication, lack of empowerment, and distraction as contributing factors to sentinel events like wrong-site surgery, patient falls, and unintended retained foreign objects.
The beauty of medical improv is that it helps participants move from intellectually knowing a problem exists to experientially understanding the problem, says Boynton.
Take, for instance, nurse distraction and medical errors. The impact that distractions can have on a nurse's cognition becomes very clear in this video of the medical improv activity "Overload," where one person counts to 100 by fours and mirrors another person's hand motions while being asked simple math and personal questions by the rest of the group.
As the activity goes on, the participant becomes increasingly frustrated and has more difficulty completing the task. Replace the group with call lights, questions from patients' family members, and beeping IV pumps, and it becomes clear why medication errors continue to happen.
A Framework for Medical Improv
Boynton uses six principles to create a framework for a successful medical improv experience:
Yes, and… A group participant says "Yes" to what another person says and then follows that with an "And…" statement.
Support your partner. The primary responsibility in an improv relationship is to want your partner to be successful.
Celebrate risk taking. In medical improv, it's okay to do something that's uncomfortable, like being assertive or speaking up.
Avoid questions. Participants are encouraged to make statements rather than asking questions because that means they are bringing something to the table rather than asking someone else to do so, Boynton says.
You have everything you need. This principle helps participants relax and understand that, while they may not be trained actors, whatever they do in that moment is enough and the group is there to support them.
It's okay to make things up. Obviously this wouldn't fly in a clinical situation, but in medical improv, participants sometimes need to make things up to continue the flow of an improv exercise, says Boynton.
These concepts can be applied to hundreds of different improv activities, like Dr. Know-It-All or Yes, and…/Yes, but…
In the Yes, and…/Yes, but… activity, a group breaks into pairs to talk about a simple topic such as pets. Boynton asks them to have a Yes…and conversation. One person may say, "I love golden retrievers and my dog is going to have puppies." His or her partner could say, "Yes, I like dogs and puppies are adorable."
During a Yes, but… conversation, the partner would respond, "Yes, I like dogs, but puppies are a lot of work."
"What happens is those two conversations have completely different tones," Boynton explains. "You have one conversation that's collaborative and cooperative and builds a relationship. And you have this other conversation that's a little bit antagonistic."
During Yes, and…, participants learn how to listen and be assertive, Boynton says.
"The 'Yes' part is you listening to your partner. The 'and' part is you being assertive. You're bringing something of yourself into this picture," she explains. "If you learn how to play some of these basic improv games, you can learn to have respectful conversations. From that, we will have better teamwork."
Adding an NP with a background in psychiatric nursing was just one tactic a Chicago nursing director used to dramatically improve care among unfunded behavioral health patients in the ED.
Around 2012, Ajimol Lukose, DNP, RN-BC, nursing director at Swedish Covenant Hospital in Chicago, noticed a trend—more patients with behavioral health issues were seeking treatment in the emergency department. This development came on the heels of the state cutting $113.7 million in general funds from its mental health budget, and Chicago closing of six of its 12 city-run mental health clinics.
"There was a reduction in mental health clinics, so the follow-up or outpatient programs were limited. That resulted in patients showing up in the emergency department," Lukose told me.
On any given day, there could be as many as six or seven behavioral health patients in the ED.
"Our emergency department was struggling with patients with mental health issues staying there for three and four days and waiting for state transfer, especially unfunded patients," she said.
At the same time, Lukose needed to implement a project for the doctorate of nursing practice degree she was working toward. She has a background in psychiatric nursing and thought she could help address some of the issues around caring for this patient population by developing a safe care delivery model to improve care quality and reduce length of stay in the ED.
Her results were even better than expected.
The Best-Laid Plan
Lukose developed a number of goals for the project. Short-term, she wanted the initial behavioral health assessment in the ED to occur within one hour of its order time and to have behavioral health interventions initiated within two hours of the consultation order time.
Long-term, she wanted to decrease behavioral health patients' ED length of stay, the use of sitters and behavioral restraints, elopement events, and labor costs.
Through a literature review, she identified three best practices to support these goals:
Place a psychiatric liaison in the ED
Designate a dedicated area in the ED for behavioral health patients, separate from the general patient population
Create guidelines, protocols, and policies to direct ED staff on how to care for behavioral health patients
Lukose hired a family nurse practitioner with a background in psychiatric nursing as the psychiatric liaison. The NP worked eight-hour shifts, Monday through Friday. She rounded on behavioral health patients in the ED, completed the psychiatric evaluation, initiated appropriate interventions, and coordinated discharge planning.
"The interesting thing that we found was many of them did not need to be in an inpatient psych unit," says Lukose. "Because the ED physicians were not comfortable, they would keep them" until the patients could be transferred to a psych unit.
The NP also facilitated a 30-day medication supply program for underinsured patients and established a "bridge" program for patients who needed temporary support until they connected with a behavioral health follow-up provider.
"If they get discharged from the ED, they don't always get an appointment for follow-up right away. It might take a month or three weeks," Lukose says. "She provided three follow-up visits while [a patient] was waiting for the post-discharge follow-up with the mental health provider. They could walk into her small program, which is a room in the ED."
Location, Location, Location
Creating a dedicated space in the ED for behavioral health patients may sound costly, but Lukose says it wasn't not the project highest ticket item. The largest expense in the entire project was hiring the NP.
"Doing the facility enhancement is not a costly program," she says. "We weren't buying equipment. We just removed items to make the room simple."
Working with the ED director, they were able to identify a section of the ED where five beds could be dedicated to behavioral health patients. The crisis department, which had previously been located outside the ED, was moved inside the department to help improve collaboration.
"There was a big disconnect between the crisis staff and the ED staff so we moved their office to this particular area so they are available constantly," she says.
Clustering the behavioral health beds in one area also facilitated a decrease in sitter use.
"We had them in the general ED, but here and there, we had to provide a sitter for each patient," Lukose says. "In reality, they don't always need one-to-one care. Because we have this one separate area, you can have one sitter for three patients."
Lukose and the ED director developed policies, procedures, and guidelines using the Four S Model, which calls for focus on "safety, support, structure, and symptom management." For example, giving behavioral health patients a different color gown so they can be easily identified if they are trying to elope, placing all patient belongings into a locked cabinet, and ensuring metal objects like soda cans or silverware are not brought into the room.
In addition to training to help boost the staff's comfort and compliance with the new polices, a checklist was created.
"If you give a nurse a three-page or four-page policy, they're not going to sit down and read the policy all the time," she says. "So we made a one-page checklist, which is a summary of the entire policy, so the nurse can make sure everything is done."
Impressive Outcomes
After these changes were implemented in April 2013, Lukose collected three months of post-implementation data in October, November, and December of 2013. The results of the project? Behavioral health consultations were completed an hour after being ordered 93% of the time and interventions were initiated two hours after the consultation was ordered 92% of the time. Sitter use decreased by 46% as did sitter costs. Labor costs decreased by 49%.
At first glance, it may seem like length of stay didn't budge much—average length of stay for all behavioral health patients in the ED was 12. 3 hours prior to the project and 8.8 hours after its implementation. But when Lukose looked at insured behavioral health patients' length of stay in the ED compared to uninsured behavioral health patients, there was a definitive improvement for the second group whose pre-project average length of stay was 24.1 hours and post-implementation average was of 16.3 hours.
Lukose took the analysis of length of stay a bit further after her DNP-project was completed. She found that in fiscal year 2014 the average length of stay for all behavioral health patients in the ED decreased to 12.5 hours from 17.9 in fiscal year 2013—a 30% reduction. For all uninsured behavioral health patients in the ED, the length of stay dropped to 29.1 hours in fiscal year 2014 from 48.5 hours in 2013—a 40% reduction.
And, for uninsured patients waiting to be transferred to a different facility, average length of stay was 36.2 hours in fiscal year 2014, down from 74.7 hours in fiscal year 2013.
"That was a great accomplishment for our hospital," she says. "I didn't want to start something and see that the project ended. It shows that the changes that were made have been sustainable and that the project was continuing."
The Office of Management and Budget has again classified CNSs as general RNs rather than advanced practice nurses. One CNS explains why this is a cause for concern.
If you head over to the Bureau of Labor Statistics website and search "advanced practice nurses" function here are the results you'll get—nurse anesthetists, nurse midwives, and nurse practitioners.
Where's the fourth category of APRNs—clinical nurse specialists?
The U.S government's Office of Management and Budget does not recognize CNSs as APRNs. Instead, it classifies CNSs as general registered nurses.
The system is now up for revision (to be published in 2018), and on July 22, much to the dissatisfaction of CNSs, the Standard Occupational Classification Policy Committee again categorized CNSs as general RNs.
"Yet again, we are incredibly disappointed that the Standard Occupational Classification (SOC) Policy Committee is erecting barriers to full scope of practice for the more than 72,000 clinical nurse specialists across the United States who work in hospitals and other health care settings," said Sharon Horner, PhD, RN, MC-CNS, FAAN in a news release.
Horner is president of the 2016-2017 National Association of Clinical Nurse Specialists Board of Directors. "Clinical nurse specialists are advanced practice registered nurses who have education and training in advanced nursing care, physiology, pharmacology, and physical assessment. The demand for CNS's science-based expertise is rising as our nation's health care needs multiply and become more complex."
An Out-of-touch Policy
This certainly is out of step with the policies of other groups.
The National Council of State Boards of Nursing recognizes CNSs in its APRN Consensus Model, the VA included CNSs in its recent proposal to give its APRNS full-scope of practice, and Congress recognized CNSs as APRNs in the Balanced Budget Act of 1997.
These groups have more sway over ARPNs' practice and reimbursement than OMB, but this incorrect classification of CNSs is still significant says Ann M. Mayo, RN, DNSc, FAAN, a professor at the Hahn School of Nursing & Health Science and Beyster Institute for Nursing Research at University of San Diego and member of the NACNS.
"The Bureau of Labor statistics accesses this data to look at nursing workforce issues, and I believe other federal agencies access the data too, which is the worrisome part," she says.
"Policy positions are made based on this data that various agencies are accessing. For example, if someone decided they wanted to make some decisions about educational funding and accessed this data, the CNS would not be evident as part of that."
Mixed Data Skews Outcomes
Mayo represents NACNS at the Interagency Collaborative on Nursing Statistics, an organization that promotes generation and research of data on the nursing workforce, so she understands the importance of data and how it drives decisions.
"Organizations across the United States want to know what's driving certain healthcare outcomes," she says.
By lumping CNSs together with general RNs, researchers won't be able to accurately collect the data and statistics that represent the CNS workforce or general RNs.
"The CNS data is embedded within the RN data, so it's never really clear what contribution the CNS makes independently nor is it clear what contribution the RN makes independently," she says. "So if you're looking at fall rates or pressure ulcer prevention or any of these outcomes that we're concerned about then that data isn't valid."
It also makes it difficult to compare outcomes between CNSs and the other ARPNs categories, she says.
The NACNS, its members, and other nursing organizations will submit comments on the recommendations for revising the 2010 Standard Occupational Classification for 2018 during the second comment period, which closes Sept. 20.
Delivering excellent patient experience starts with leaders creating and supporting environments conducive to achieving good experiences between RNs and patients.
Donald Trump and Hillary Clinton may be grabbing all the headlines, but in healthcare circles, patient experience is the topic on everyone's mind.
"I can tell you that even though I have the title, everybody in our organization is talking about it, asking how to do it better, [and] wanting to know what they need to do differently to really get us to that next level," Sandra Myerson, MBA, MS, BSN, RN, chief patient experience officer at Mt. Sinai Health System in New York told me recently.
So what's the secret to achieving high-level patient experience? There's no one-size-fits all answer, but here are some of my favorite insights on patient experience from Myerson and other leaders I've talked with recently.
1. Acknowledge Patients' Suffering
With illness there is suffering—on many levels.
"Even if you're sitting in the waiting room for 30 minutes waiting to be seen and you're just there for your annual physical, there's some level of suffering going on," says Kelley Dillon, director of care experience at Henry Ford Hospital and Health Network in Detroit.
"You have to sit there and wait. You're doing it because it's the right thing to do. But you'd much rather be having lunch with a friend."
This calls for creating a culture where all employees communicate with compassion "because that's the way our customers will always come to us," Dillon says.
2. Create 'Radical Convenience'
"The things the customer really cares about, and you see [this] in focus groups—it's convenience and affordability. They're the top two things at the top of mind with the consumer today," says William Conway, MD, executive vice president at Henry Ford Health System, chief executive officer for Henry Ford Medical Group in Detroit.
To meet the consumers' needs, organizations should become "radically convenient," a term Conway coined. This means giving patients multiple options to connect with your organization. At Henry Ford, patients can, "click, call, and come-in," Conway says.
Use "whatever approach you would like to solve your problem," he explains. "You can go to a walk-in clinic, you can use My Chart form of communication with staff, or use the traditional telephone."
3. Apply the '90/5' Rule
Nurses often say they feel like they don't have time to spend with their patients the way they used to. The '90/5' rule can help put them back at the bedside where both they and their patients want them to be.
"90% of what you [nurses] need is within five seconds of you," explains Pamela L. Dunley, MS, MBA, RN, vice-president, chief operating officer and chief nursing officer at Elmhurst (IL) Hospital.
"If, for whatever reason, something wasn't stocked right, or they didn't have the right mix at that moment, then it starts getting stressful. As long as they have what they need to do their job, then they want to make sure the patient has the best experience."
4. Appreciate Your Staff
Letting staff know they're valued is more than something that's just nice to do, it's essential to moving an organization toward a culture that focuses on patient experience.
"If [staff] don't feel appreciated, they're not going to step up. They'll be very resistant to change," Myerson says. "If they're coming in and just trying to slog through the day so they get a paycheck and go home, when it comes time to implement a change, they're unlikely to jump on board."
This connection can be made through leadership rounds and by publicly rewarding and recognizing staff who display behaviors that are compassionate, warm, and team-based, she says.
Eye contact and authentic conversation can do more to improve patient satisfaction than following a checklist, says a patient who is an RN.
Let's cut right to the chase. We all know there's a lot of grumbling about patient satisfaction from the very people who deliver it—nurses.
Just last week, this meme popped up on a nurse friend's Facebook feed, "The only patient satisfaction score that matters… Did you die??"
I'm used to hearing fellow nurses complain about patient satisfaction scores. How its measurement is an insult to their professionalism. That it encourages patients to treat them like waitresses. That it doesn't improve care.
But more so than most complaints, this meme bothered me.
Perhaps because its sentiment is so harsh. Perhaps because I've heard this friend express frustration that nurses don't get to spend enough time with their patients. Perhaps because so many nurses became nurses to help people, not to check off boxes and get people Diet Cokes.
As both a nurse and a patient, Carol Raimondi, RN, of Elmhurst, IL, can understand some of the frustration my friend has expressed. Born with congenital heart defects, Raimondi has had multiple surgeries and hospitalizations over her lifetime.
"It was initially very patient-focused," Raimondi, who is now 40, says.
"Over the years, I feel like nurses became busier. More charting. More things to do. I knew from my own experience as a nurse. You could just see in their faces that when they came into the room. They're there physically, but you can tell they're already thinking about the next three or four things that they're doing as a result of higher acuity."
But, Raimondi says that despite the frenetic pace of today's hospital environment, nurses, and patients can cultivate the authentic connections for which both groups are longing. She offers three suggestions:
1. Know the Patient's Story
"Find out about who that patient is, not just their disease," Raimondi says.
She suggests asking patients questions such as, "What works for you?" or "What's something that, in the past, has helped?"
Don't just assume that doing something "because that's the way it's done" will help each and every patient.
"It's definitely just listening to the patient," she says. "You could have all the best technologies, the best doctors, but if you lose that focus, none of those other things really matter."
2. Make Eye Contact
Raimondi understands the realities of nursing. There is charting to do and phone calls to be answered, but pausing for a minute to connect with a patient goes a long way.
"Stop for a minute and just look me in the eyes," she says. "Ask me what you can do to help."
Raimondi says she'd rather have a short, authentic conversation where she feels listened to rather than having a nurse go down a checklist to make sure they've covered everything that will be evaluated on a patient satisfaction survey.
3. Remember Why You're There
Eye contact and a quick conversation may not seem like much, but they can be just as important as high-tech treatments or lifesaving heroics.
"Those extra little things go a long way for us as patients, but also for nurses," she says.
Once nurses realize that these small things make a huge difference to patients, Raimondi believes they'll begin to feel reconnected to the reason they became nurses—to help others.
"I feel like I got into nursing because [nurses are] compassionate and caring and a lot of that gets pulled away with all of that extra pressure of keeping all these scores high," she says.
"If they can really relate back to the patient and get back to that original reason why they went into it, I think eventually the other things don't seem as overwhelming."
One nurse with firsthand knowledge about medical errors is a calling on RNs and other healthcare professionals to exercise their voices and vigilance to protect patients.
We've all heard harrowing stories about medical errors.
They are the third leading cause of death in the U.S., estimated to be responsible for more than 250,000 deaths per year.
Donna Helen Crisp, JD, MSN, RN, PMHCNS-BC, knows about medical errors firsthand. She has experienced more than one and has lived to write about them.
Crisp's story, or "debacle," as she describes it, began in 2007. After undergoing a laparoscopic hysterectomy for uterine cancer, medical errors left her fighting for her life on a ventilator in the surgical intensive care unit.
Pressure from the two surgical graspers applied by the surgeons left Crisp with a perforated small intestine that was undiagnosed for more than 36 hours.
Her severe post-op abdominal pain, a tell-tale sign of a perforated bowel, was instead chalked up to gas pain. When she was finally taken for emergency surgery where, because of improper intubation technique, she aspirated the radiopaque contrast dye she drank for a CT scan.
As a result, she experienced acute respiratory distress syndrome, sepsis, more surgeries, and was on a ventilator in SICU for three weeks—of which she has no recollection.
"My memory stops in the little room where I changed my clothes," she told me.
It took Crisp years, with the help of a lawyer, to piece together what happened. The hospital and physicians offered very little in the way of explanations and no apology for what happened.
'Nurses Can Do So Much More'
I asked Crisp what she thinks nurses can do regarding medical errors. She slept on the question and the next day, emailed me her answer, which has been lightly edited:
"The power for changing the paradigm in hospitals involves hospital administrators and leaders, healthcare insurance companies, physicians, nurses, and the patient-consumers.
Nurses can do so much more, if they are capable of becoming empowered to truly put the patient first. Even if nurses meet resistance, they can do more, if they try, than if they remain silent and therefore complicit in things that are wrong."
She encourages nurses at all levels to be vigilant, to ask questions, and to think critically.
"Let curiosity or confusion lead to knowledge, conversation, and professional growth," she advises. "Always ask why, and why not."
Lastly, she advocates for bravery and moral courage. Nurses should never be content to keep silent if they see something that could lead to an error or if they encounter a situation that caused an error. They must keep pressing others to help them do what's right for the patient.
"If you have to, pick up the hospital phone, dial "0," and ask to speak with the administrator on call," she says.
"Silence," she says, "creates further victimization."
Nursing and veterans' organizations have united to advocate for adoption of the VA's proposal to allow its advanced practice registered nurses full practice authority.
It's time to put egos and hyperbole aside and start focusing on improving U.S veterans' access to timely, high-quality healthcare, nursing and veterans' organizations say.
A recent news conference addressed the Department of Veterans Affairs' proposal to amend its medical regulations and permit "full practice authority of all VA advanced practice registered nurses when they are acting within the scope of their VA employment."
"It's time for evidence to trump politics when it comes to the health of our veterans. And there's no evidence for the arguments of the groups opposing the rule [it's] all baseless rhetoric," said Juan Quintana, DNP, MHS, CRNA, president, American Association of Nurse Anesthetists, during the June 28 news conference at the National Press Club in Washington, DC.
In addition to the AANA, the American Association of Nurse Practitioners, the American Nurses Association, the American Association of Colleges of Nursing, the Air Force Sergeants Association, and the Military Officers Association of America, voiced their support for the rule during the event.
Unacceptable Wait Times
Par for the course, the American Medical Association and other physician's organizations are against the proposal.
They claim that allowing APRNs full-practice authority "will significantly undermine the delivery of care within the VA," and that veterans' deserve access to physician expertise.
What these physicians' groups don't seem to understand is that access to care has already been compromised.
Despite the 2014 high-profile scandal regarding VA wait-times, a U.S. Government Accountability Office review released in April 2016 found that many of the veterans it surveyed "waited from 22 days to 71 days from their requests that VA contact them to schedule appointments to when they were seen."
"The waiting is unacceptable," says CMSGT Robert L. Frank, USAF (Ret), chief executive officer of the AFSA. "We're excited about this rule to allow the 6,000 APRNs currently employed by the VHA to be used to their full potential. Let them serve our veterans."
APRNs Can Improve Access
A move to full-practice authority would help address the access issue says, CAPT (Ret) Kathryn Beasley, USN, PhD, FACHE, a retired Navy nurse and deputy director of government relations for MOAA.
"In the Navy, we would never train a sailor ten skills, then limit them to using only three. It makes no sense. No one would do that," she says.
"But that's what illogical and wasteful practice limitations on highly skilled advanced practice nurses do. Our veterans need all the skills advanced practice registered nurses can provide them."
Since APRNs are already in place at the VA and have the training and education necessary to provide veterans with healthcare, moving to a full-practice environment is a cost-effective and timely solution to barriers in access to care, says Cindy Cooke, DNP, FNP-C, FAANP, president of the AANP.
"The proposed rule is [a] zero-risk, zero-delay, and a zero-cost solution to ensuring veterans have access to needed health care," she says. "We applaud the VA for taking this important action, which will immediately improve veterans' access to care. And we are doing everything we can to support its proposal."
This includes providing and encouraging public comments on the rule, which can be submitted until July 25. In fact, the number of public comments on this rule—over 46,000 at half-way into the comment period—is the largest number of comments for a VA rule since online submission began in 2006.
Some echo the fears of physicians' groups, including the concern that the change would "force the best trained physicians out of the operating room." Others support the move and take issue with those in opposition to full-practice.
The AANA's Quintana, who also served in the Air Force Reserves, says a review of comments thus far shows that about two-thirds of respondents support the rule.