1. Hader, Richard PhD, NE-BC, RN, CHE, CPHQ, FAAN

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In an effort to grow a profitable business, some healthcare institutions have structured the table of organization based on service lines or centers of excellence. Often these service lines are led by healthcare administrators evaluated on building a profitable service line by expanding services through the implementation of a business plan. The goals are to generate additional revenue and increase profitability. This structure is strategically valid because the service line leader can devote concentrated time and energy to growing the business. The inherent problem with this structure occurs when nursing reports to the service line leader and there isn't a comprehensive oversight or identified leader of professional nursing practice.

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In extremely decentralized organizations, the table of organization appears to have several companies working independently from one another and there's no overall oversight of nursing practice. Because regulatory agencies require an identified leader of nursing practice, there's typically a senior administrator for nursing; however, he or she may be impotent to ensure the continuity of care and practice because the structure precludes the enforcement of practice standards. This could result in disastrous consequences to the quality of care and service provided.


Operational policies and procedures are often developed and implemented within the confines of the service line, with minimal congruency throughout the continuum of care. This lack of a standardized structure can lead to differences in care delivery that may cause confusion and dissatisfaction among the healthcare provider and the patient. As part of the healthcare reform package recently adopted by Congress, it will become increasingly more important that uninterrupted care throughout the lifespan be practiced. Care that's fragmented will make this task extremely difficult if not impossible without the presence of a strong nursing delivery model.


The goal of growth will likely require that nurse leaders and staff members be active participants in the design and implementation of plans to grow the business. To avoid making decisions that aren't operational, it's incumbent upon the service line leader to actively engage clinical experts in any business decisions that will impact care delivery. If nursing isn't actively engaged in the process, the work done to bring new business to the organization will be negatively impacted if quality suffers.


Although there are many benefits to the business model of service lines, it's vital that nursing oversight and practice aren't fractured as a result. Nursing strategy, standards, and practice must be governed by a nurse who has a proven track record to ensure the delivery of competent, effective, and efficient nursing care. The importance of congruent nursing practice shouldn't be minimized to enhance a bottom line because growth won't be sustained if conducted without a strong nursing presence and engagement in the process.


It's probable that over the next several years, organizations will attempt to operationally restructure to ensure they're well positioned to endure the changing healthcare market brought about by funding sources. Leaders making these decisions must ensure that nursing is well positioned to influence them. Falling victim to making changes based solely on increasing the bottom line will ultimately backfire if nursing practice isn't centrally directed and led.


Richard Hader

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