Quality and economics have been topics in several issues, since the inception of Nursing Administration Quarterly (NAQ), more than 35 years ago. After all, what is the overriding responsibility of every nurse executive in every patient care setting from acute care to multisystems to out of hospital care, including schools, work places, public health, and every community, nationally and internationally? In anticipation of the many changes and challenges that nurse leaders will face in overcoming the complexity of organizational response to health care reform, it was decided to dedicate 2 sequential issues to Economics and Quality. Nurse leaders have had many challenges, obstacles to overcome, and politically mandated reforms, such as DRG's (Diagnosis Related Groups for reimbursement or The Revenue is Gone), in my era of administrative practice. Following the money has been the "battle cry" for me and other nurse executives throughout the years, as attempts to bill for direct nursing care, nurse midwives, and advanced practice nurses were initiated in the 1970s and 1980s. "Overall strategies to cope with the changing economics of acute care facilities include sophistication of information systems to integrate clinical/financial cost accounting and provide computerized decision support systems, enhancement of services offered, prudent application of new technology, reduction of costs, improvement of communication and education, and monitoring of performance with risk identification and analysis.-Nursing's responsibility is to identify its product clearly and its program output relative to its mission." Barbara J. Brown, 1984. In 1983, the American Academy of Nursing discussed the Economics of Health Care and Nursing at the annual meeting and published outcome results in an interesting, now historical, document.1
Most pertinent, in response to today's health care reform legislation, is the continuous effort of nurse leaders to seek direct reimbursement for advanced practice nurses and other possible nursing revenue sources. As we address the political changes affecting health care and "new" initiatives proposed by government-sponsored health directives and impacts on monetary operations and revenues in health care services, nurse leaders face many challenges.
Leading this issue of NAQ, as guest coeditors, are Rhonda Anderson and Kathy Sanford, both exemplary nurse leaders. Rhonda Anderson, RN, DNSc(h), FACHE, FAAN, is the Chief Executive Officer at Cardon Children's Medical Center in Mesa, Arizona, and is a member of the adjunct faculty at Grand Canyon University, College of Nursing and W. P. Carey School at Arizona State University. Rhonda served as a commissioner for 9 years on the TJC Board, Data Use Oversight Committee, chair of the Accreditation Committee, Nursing Advisory Council, chair of the Ernest A. Codman Awards Evaluation Committee, and chair of the Performance Measurement Committee. She has served as a member of the American Hospital Association Quality Task Force and the Quality Awards Committee. She served as Chair of Joint Commission International Accreditation Committee and on the JCR Board and Global Tourism Committee.
Rhonda chaired the Patient Safety Committee for the Arizona Hospital and Healthcare Association, is on the Advisory Committee of W. P. Carey School of Health Management and Policy, is a member of NACHRI Quality Council, NQF Expert Panel, and American Hospital Association Board of Trustees. She has extensive and progressive experience in staff nursing, education, hospital and health care organization management roles, performance measurement, and patient safety. This diverse experience has given her a wide range of challenges because the practice of health care varies from region to region.
Kathleen Sanford, DBA, RN, CENP, FACHE, senior vice president and chief nursing officer, Catholic Health Initiatives, has over 33 years experience in health care, including staff nursing, middle management, chief nurse executive, and hospital administrator roles. Her current appointments include the following: member, Coordinating Committee of the Nursing Organizations Alliance; member, Centura Health Corporation Board of Trustees; and member, American Hospital Association Board of Trustees, 2009-2011.
A former army nurse, she retired as chief nurse of the Washington Army National Guard. She served as the 2006 President of the American Organization of Nurse Executives, and has been on the American Hospital Association Long-Term Planning Committee. She has served in leadership positions for numerous community and charitable organizations and has been an adjunct faculty for The University of Washington and Pacific Lutheran University. She was selected by the American Business Women's Association as the American Business Woman of 1994. She currently writes a monthly column for HFMA's Business of Caring publication. As a former newspaper health care columnist and author for multiple publications, she has more than 100 published articles and the management book Leading With Love. Research studies for her ACHE thesis and her doctoral dissertation were in the area of health care leadership.
Both Rhonda Anderson and Kathleen Sanford have been responsible for quality and cost of patient care for several years. They have led their organizations through value-based purchasing and are on the leading edge to assure that nursing care is a major influence on hospital reimbursement and generation of revenue. We are certainly in the era of value-driven leadership. The Patient Protection and Affordable Care Act (PL 111-148) finally recognizes, acknowledges, and rewards certified registered nurse practitioners. I say "finally," as nurse leaders have been advocating for APRN reimbursement since 1970s and to do so without the requirement for a physician to oversee. Admission privileges for APN's to secure reimbursement in long-term care, home care, transitional care, clinics, school-based health care centers, and rural health centers is absolutely essential for cost savings and quality health care.
The shortage of primary care physicians, along with more than 4000 family nurse practitioners, opens the door to respond to health care reform challenges without resorting to physician referral or consultation for primary care in all settings mentioned previously. Additional cost/quality federal mandates have opened the door for the adoption and use of Health Information Technology.
Hospitals are required to achieve "Meaningful Use" (MU) of a certified electronic health record to receive financial incentives from the federal government beginning in 2011. While Roy Simpson's Informatics Column is addressing MU, there are 5 National health Policy Goals that are pertinent to this issue of NAQ:
1. Improve quality, safety, efficiency, and reduce health disparities.
2. Engage patients and families.
3. Improve care coordination.
4. Ensure adequate privacy and security protections for personal health information.
5. Improve population and public health.
Achieving MU is another challenge for nurse executives requiring significant changes to provide better patient care outcomes. Health care systems will continue to make successful transitions, which balance quality patient care and financial considerations in an MU way. You will need an entrepreneurial spirit to develop and sustain a culture of safety for patients and the workforce. Will health care reform create a health care leviathan? Will health care be overmanaged and overcontrolled by the federal government? We have many lessons to learn:
1. One size does not fit all, as we see the differences in rural health care settings as compared to major urban medical centers. Bigger is not necessarily better.
2. Proactive decision making based on evidence is overwhelmingly preferred over reactive defensive management decision making.
3. Flexibility and anticipation of challenging changes are keys to assuring the most positive administrative outcomes.
4. The nursing shortage is here to stay and will worsen. Measuring the work of nursing, financially, is critical.
At times, I want to be in the mainstream of nursing administration and be able to address these wonderful opportunities for initiating change. Hopefully, through NAQ, you will benefit from many mentors sharing theirexperiences. We need strong, dedicated nursing leaders to keep and sustain patient/family-centered values at the forefront of decision making while exercising evidence-based testimony with unified voice and power for the profession of nursing.
Nursing Administration Quarterly
-Barbara J. Brown, EdD, RN, CNAA, FNAP, FAAN
Editor-in-Chief
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