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If you were to ask 10 people what they believe to be the most significant issue facing healthcare today, you might get 10 different answers. Escalating costs? Regulation? Technology disruption?

These and many other topics are worthy of discussion. Not surprisingly, much has been said in the research, within the profession, and in the news about these topics. Whether they are issues of finance, quality, workload, or outcomes, there is no shortage of changes to be addressed.

In this Discussion, you examine a national healthcare issue and consider how that issue may impact your work setting. You also analyze how your organization has responded to this issue.

To Prepare:

  • Review the Resources and select one current national healthcare issue/stressor to focus on.
  • Reflect on the current national healthcare issue/stressor you selected and think about how this issue/stressor may be addressed in your work setting.

Post a description of the national healthcare issue/stressor you selected for analysis, and explain how the healthcare issue/stressor may impact your work setting. Then, describe how your health system work setting has responded to the healthcare issue/stressor, including a description of what changes may have been implemented. Be specific and provide examples.

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Growing Ranks of Advanced Practice Clinicians

Growing Ranks of Advanced Practice Clinicians — Implications for the Physician Workforce David I. Auerbach, Ph.D., Douglas O. Staiger, Ph.D., and Peter I. Buerhaus, Ph.D., R.N.

Throughout the history of mod-ern American medicine, phy- sicians have made up the vast majority of professionals who di- agnose, treat, and prescribe medi- cation to patients. Although de- mand for medical services has increased markedly over the years (and is projected to grow more rapidly as the population ages), the physician supply has grown relatively slowly. Increased dele- gation of work, new technology, and streamlined care processes can help practices meet patient needs with fewer physicians, but still require an increasing num- ber of health professionals.1

Physician supply is constrained in the short run by long training times and in the longer run by medical school capacity and the number of accredited residency positions. Despite a 16% increase in graduate medical education (GME) slots in recent years, the Association of American Medical Colleges (AAMC) recently project- ed that the supply of physicians will increase by only 0.5% per year between 2016 and 2030.

A growing share of health care services are being provided by ad- vanced practice registered nurses (APRNs), particularly nurse prac- titioners (NPs), who make up the majority of APRNs, and by physi- cian assistants (PAs). NPs and PAs provide care that can overlap with care provided by physicians (both in primary care and increasingly in other specialties), and the AAMC recognizes this overlap in its physician-demand forecasts. The number of NPs and PAs is

growing rapidly, in part because of shorter training times for such providers as compared with phy- sicians and fewer institutional constraints on expanding educa- tional capacity. Residencies aren’t required for APRNs — though organizations are increasingly offering them — and education programs have proliferated: ac- cording to the American Associ- ation of Colleges of Nursing, the number of NP degree programs (master’s or doctorate) grew from 282 to 424 between 2000 and 2016. Baccalaureate-prepared RNs typically require 2 to 3 years of graduate education to become certified NPs. PA programs typi- cally take 2 years and also don’t require residencies. According to the National Center for Education Statistics, the number of PA de- gree programs grew from 135 to 238 between 2000 and 2016.

These dynamics will have last- ing effects on the composition of the health care workforce and on working relationships among health professionals. To take a closer look at these trends, we estimated the number of full-time- equivalent physicians, NPs, and PAs between 2001 and 2016 using data from the U.S. Census Bu- reau’s American Community Sur- vey, which included a roughly 0.4% sample of the U.S. popula- tion between 2001 and 2004 and a 1% sample between 2005 and 2016. Because the Census didn’t identify NPs until 2010, we ob- tained data on NPs from the Na- tional Sample Survey of Regis- tered Nurses from 2000, 2004,

and 2008. Figures were validated using data from health profes- sional associations. The final data set includes 12,887 NPs, 12,801 PAs, and 166,103 physicians.

These data were used to proj- ect the number of NPs, PAs, and physicians through 2030 using methods described in greater de- tail elsewhere.2 Briefly, our model estimates the number of provid- ers of various ages in each year as a function of both workforce- participation patterns associated with age and estimates of differ- ences among birth cohorts in rates of entry into each profession, which reflect institutional con- straints. Our projections assume that age-related workforce-partici- pation patterns will remain stable after 2016 and that the size of the workforce for birth cohorts that have not yet entered the labor force will resemble that of the five most recent cohorts. In the case of physicians, to better cap- ture the expansion in medical ed- ucation and throughput in recent years, we assume that the size of future cohorts will resemble the size of only the most recent (larg- est) cohort. In our prior work, this model has successfully fore- cast health care workforce trends.2

As shown in the table, between 2001 and 2010, workforce supply increased by roughly 150,000 phy- sicians (an increase of 2.2% per year), 27,000 NPs (an increase of 3.9%), and 44,000 PAs (an increase of 7.9%). Between 2010 and 2016, the combined increase in NPs and PAs (79,000) outpaced the increase in physicians (58,000), although

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the NP and PA workforces were roughly one tenth the size of the physician workforce in 2010. Dur- ing this period, growth in the NP supply accelerated to nearly 10% per year, whereas growth in the PA supply slowed to 2.5% and growth in physician supply slowed to 1.1%. The number of NPs and PAs per 100 physicians nearly doubled between 2001 and 2016, from 15.3 to 28.2.

We project that these trends will continue through 2030. The number of full-time-equivalent physicians is expected to continue growing by slightly more than 1% annually, as increased retirement rates are offset by increased en- try, whereas the numbers of NPs and PAs will grow by 6.8% and 4.3% annually, respectively. Rough- ly two thirds (67.3%) of practi- tioners added between 2016 and 2030 will therefore be NPs or PAs, and the combined number of NPs and PAs per 100 physi- cians will nearly double again to 53.9 by 2030. These shifts will probably be even more pro- nounced in primary care, where physician supply has been grow- ing more slowly than in other fields and NPs tend to be more concentrated.

The changing composition of the workforce will have implica- tions for provider teams. Primary care providers, in particular, in- creasingly work in larger groups of professionals with varying back- grounds and types of training. A 2012 national survey of primary care NPs and physicians found that 8 in 10 NPs worked in col- laborative practice arrangements with physicians and 41% of phy- sicians worked with NPs — a percentage that will probably grow over time.3 As more states ex- pand practice authority for NPs, medical practices will have to ad- just. A recent study of working relationships between NPs and physicians on primary care teams in New York and Massachusetts found that physicians, other staff, and patients often confused the roles and skills of various provid- ers and that these misunderstand- ings often led to practices under- mining the productivity and efficiency of NPs.4 Physicians, NPs, and PAs will all need to be trained and prepared for this new reality.

Greater reliance on nonphy- sician clinicians is unlikely to threaten quality of care or increase costs. There is growing evidence

that the primary care provided by NPs and PAs is similar to that provided by physicians, and a re- cent national study of Medicare beneficiaries found that the cost of primary care provided by NPs was significantly lower than the cost of physician-provided care.5

As with other projections, our findings are subject to some de- gree of uncertainty. It is unlike- ly that the physician supply will grow more rapidly than we proj- ect: the AAMC projects even slow- er growth, the number of GME slots is constrained, and even an immediate expansion of medical school capacity and training op- portunities wouldn’t substantial- ly affect the physician supply for many years. Growth in the NP and PA workforces is more un- certain. Although shorter, more flexible training requirements for these providers have facilitated an unprecedented increase in new en- trants, growth rates could fall if demand for nonphysician provid- ers is lower than anticipated and job-market prospects worsen. Major changes are unlikely, how- ever, given the expected increases in demand for care, growing use of team-based and interprofes- sional practice, and the fact that

Provider Group No. of Full-Time Equivalents Average Annual Growth (%)

2001 2010 2016 2030

(projected) 2001–2010 2010–2016 2016–2030 (projected)

Physicians 711,357 862,698 920,397 1,076,360 2.2 1.1 1.1

Nurse practitioners 64,800 91,697 157,025 396,546 3.9 9.4 6.8

Physician assistants 44,282 88,047 102,084 183,991 7.9 2.5 4.3

* Based on data from the American Community Survey (ACS) and the National Sample Survey of Registered Nurses. Estimates for NPs in 2001 are interpolated on the basis of data from the 2000 and 2004 surveys. Full-time equivalents are defined on the basis of reported usual weekly hours worked and a 40-hour workweek for NPs and PAs and a 50-hour workweek for physicians. NPs include a small number of certified nurse midwives who were not separately identified in the ACS because of their small numbers. PAs in the ACS reporting an associate’s degree or less education were excluded. All estimates are based on sample weights provided in each survey.

Historical and Projected Numbers of Physicians, Nurse Practitioners, and Physician Assistants.*

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NPs disproportionately serve ru- ral and underserved populations, whose needs would otherwise go unmet.

Despite these uncertainties, it is clear that patients will continue to encounter more NPs and PAs when they seek care. The shifting composition of the health care workforce will present both chal- lenges and opportunities for med- ical practices as they redesign care pathways to accommodate new payment methods, new in- centives regarding quality of care,

and the demands of an aging population.

Disclosure forms provided by the authors are available at NEJM.org.

From the Center for Interdisciplinary Health Workforce Studies, College of Nursing, Montana State University, Bozeman (D.I.A., P.I.B.); the Department of Economics, Dart- mouth College, Hanover, NH (D.O.S.); and the National Bureau of Economic Research, Cambridge, MA (D.O.S.).

1. Bodenheimer TS, Smith MD. Primary care: proposed solutions to the physician shortage without training more physicians. Health Aff (Millwood) 2013; 32: 1881-6. 2. Staiger DO, Auerbach DI, Buerhaus PI.

Comparison of physician workforce esti- mates and supply projections. JAMA 2009; 302: 1674-80. 3. Donelan K, DesRoches CM, Dittus RS, Buerhaus P. Perspectives of physicians and nurse practitioners on primary care practice. N Engl J Med 2013; 368: 1898-906. 4. Poghosyan L, Norful AA, Martsolf GR. Primary care nurse practitioner practice characteristics: barriers and opportunities for interprofessional teamwork. J Ambul Care Manage 2017; 40: 77-86. 5. Perloff J, DesRoches CM, Buerhaus P. Comparing the cost of care provided to Medicare beneficiaries assigned to primary care nurse practitioners and physicians. Health Serv Res 2016; 51: 1407-23.

DOI: 10.1056/NEJMp1801869 Copyright © 2018 Massachusetts Medical Society.Growing Ranks of Advanced Practice Clinicians

The Graduate Nurse Education Demonstration

The Graduate Nurse Education Demonstration — Implications for Medicare Policy Linda H. Aiken, Ph.D., R.N., Joshua Dahlerbruch, B.S.N., Barbara Todd, D.N.P., and Ge Bai, Ph.D., C.P.A.

Despite decades of public and private investment, the United States continues to have a short- age of primary care capacity. Only 2699 graduating U.S. medi- cal students — about 17% of graduates from allopathic and osteopathic schools — matched with primary care residencies in 2016.1 Studies show that nurse practitioners (NPs) provide high- quality primary care that is satis- factory to patients, improves ac- cess to care in underserved areas, and may reduce costs of care. But although Medicare spends more than $15 billion annually on graduate medical education (GME),2 including training for pri- mary care physicians, it spends very little on clinical training for NPs.

Medicare has contributed to the cost of training nurses since its inception, but NP programs didn’t exist when Medicare was enacted and such funding streams

were established. Modernizing Medicare’s payment policies for nurse training is highly relevant, given the recent success of the Graduate Nurse Education (GNE) Demonstration.3 The $200 million, five-site Centers for Medicare and Medicaid Services (CMS) demon- stration authorized under the Affordable Care Act showed that offering payments to Medicare providers enabled more of them to participate in clinical precept- ing of advanced practice regis- tered nurses (APRNs) and result- ed in a substantial increase in the number of new APRN gradu- ates. More than 60% of training took place in community-based settings, and primary care NPs accounted for most of the growth in the number of new graduates.

The GNE Demonstration doc- umented the success of a new model of organizing and paying for graduate nurse education in- volving consortia of hospitals

and health systems, community partners, and university nursing schools managed by a single Medicare hospital hub. Such con- sortia were originally proposed in 1997 by the Institute of Medi- cine (now the National Academy of Medicine) as a strategy for in- creasing community-based train- ing for physicians, but were not implemented until the GNE Dem- onstration. Of the five demonstra- tion networks, three were state or regional consortia covering greater Philadelphia, the Texas Gulf Coast, and Arizona. In great- er Philadelphia — the largest con- sortium — the Hospital of the University of Pennsylvania served as the designated hub for a re- gional network that included all health systems and hospitals in the area, more than 600 com- munity-based providers, and all 9 local university nursing schools involved in training APRNs. This model has many advantages. For

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Removing restrictions on nurse practitioners’ scope of practice in New York State: Physicians’ and nurse practitioners’ perspectives

Lusine Poghosyan, PhD, RN, FAAN1, Allison A. Norful, PhD, RN, ANP-BC2, & Miriam J. Laugesen, PhD3

ABSTRACT Background and purpose: In 2015, New York State adopted the Nurse Practitioners Modernization Act to remove required written practice agreements between physicians and nurse practitioners (NPs) with at least 3,600 hours of practice experience. We assessed the perspectives of physicians and NPs on the barriers and facilitators of policy implementation. Methods: Qualitative descriptive design and individual face-to-face interviews were used to collect data from physicians and NPs. One researcher conducted interviews, which were audio-taped and transcribed. Twenty-six participants were interviewed. Two researchers analyzed the data. Results: The new law has not yet changed NP practice. Almost all experienced NPs had written practice agreements. Outdated organizational bylaws, administrators’ and physicians’ lack of awareness of NP competencies, and phy- sician resistance and lack of knowledge of the law were barriers. Collegial relationships between NPs and physicians and positive perceptions of the law facilitated policy implementation. Conclusions: Policy makers and administrators should make efforts to remove barriers and promote facilitators to assure the law achieves its maximum impact. Implications for practices: Efforts should be undertaken to implement the law in each organization by engaging leadership, increasing awareness about the positive impact of the law and NP independence, and promoting rela- tionships between NPs and physicians. Keywords: Nurse practitioners; scope of practice; primary care; policy.

Journal of the American Association of Nurse Practitioners 30 (2018) 354–360, © 2018 American Association of Nurse Practitioners

DOI# 10.1097/JXX.0000000000000040

Background Physicians, nurse practitioners (NPs), and physician assistants currently provide the bulk of primary care in the United States (U.S.) to meet the demands of an aging population and expansion of insurance coverage (Agency for Healthcare Research and Quality, 2014; Col- will, Cultice, & Kruse, 2008; DeVol & Bedroussian, 2007; Patient Protection and Affordable Care Act of, 2010). One projection suggests an additional 52,000 physicians will

be needed by 2025 to meet the primary care demand (Petterson et al., 2012); however, the supply of these providers is expected to decrease (Association of Medical Colleges Center for Workforce Studies, 2015). Conversely, NP workforce is expected to grow. In 2013, NPs comprised about 19% of the U.S. primary care provider workforce, and the number of NPs will increase by 93% by 2025 (Health Resources and Services Administration, 2016), potentially expanding the primary care capacity (Auer- bach, et al., 2013; Green, Savin, & Lu, 2013).

However, the ability of NPs to care for patients has been limited by state-level scope of practice (SOP) reg- ulations that determine the services NPs provide. Nurse practitioner state-level scope of practice laws vary across states. In 2017, 22 states and the District of Columbia au- thorize NPs to deliver care according to their competen- cies (Robert Wood Johnson Foundation, 2017). The remaining states impose restrictions, including the re- quirement of NPs to have supervisory or collaborative relationships with physicians. Some states require NPs to

1Columbia University School of Nursing, New York, NY 2Columbia University School of Nursing, Columbia University Medical Center Irving Institute for Clinical and Translational Research 3Department of Health Policy &Management, Columbia University Mailman School of Public Health Correspondence: Lusine Poghosyan, PhD, RN, FAAN, Columbia University School of Nursing, 630 W. 168th Street, Mail Code 6, New York, NY 10032. Tel: 212-305-7081; Fax: 212-305-0722; E-mail: lp2475@ columbia.edu Received: 9 August 2017; revised 30 October 2017; accepted 20 November 2017

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Qualitative Research

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have such relationships both for delivering care and prescribing medication and services, other states impose restrictions only on one aspect. The Federal Trade Com- mission, the National Governors Association, and the National Academy of Medicine have criticized these laws and recommend removal of these restrictions to improve access to care (Federal Trade Commission, 2014; Institute of Medicine, 2010; National Governors Association, 2012). Indeed, states granting NPs greater SOP authority expe- rience expanded health care utilization (Kuo, Loresto, Rounds, & Goodwin, 2013; Xue, Ye, Brewer, & Spetz, 2016).

In 2015, New York State (NYS) implemented the Nurse Practitioners Modernization Act (New York State De- partment of Education, 2015). The law removed the re- quired written practice agreement between NPs and physicians for experienced NPs with more than 3,600 hours of practice. New NPs with less than 3,600 hours of practice still are required to have this agreement. The outdated policy requiring NPs to have a written practice agreement with physicians limited NPs’ ability to in- dependently care for their patients and practice in un- derserved areas with shortage of primary care physicians. This policy change aimed to promote NP independent practice and address the misdistribution of primary care services across NYS by allowing experienced NPs to practice independently in underserved areas (Center for Health Workforce Studies, 2013). In this study, we assessed the perspectives of physicians and NPs on the barriers and facilitators of implementing the NP Mod- ernization Act 18 months after the policy adoption.

Methods We used a qualitative descriptive design as described by Sandelowski (2010) to collect data from physicians and NPs because we know little about the law’s implementa- tion. Participants were recruited through purposive snowball sampling (Sandelowski, 2007). We contacted several practices in NYS, through our professional network in primary care, and informed practice managers or providers about the study and asked for assistance with recruitment. Both managers and providers distributed flyers about the study which included information about study’s risks and benefits, and the contact information of the researchers. Participants were eligible for inclusion if they practiced as a primary careNPor physician and spoke andunderstood English. Interested participants contacted the researchers to schedule a convenient time and place (e.g., primary care office) for the face-to-face interview. Using the snowball sampling method, we also asked par- ticipants to refer colleagues as potential participants.

One researcher (AN), an experienced NP in NYS with expertise in qualitative designs, conducted all interviews using a semistructured interview guide that allowed for probing for additional information. The researcher kept a reflexivity journal prior to and during the interviews to

reduce bias. We developed the questions from existing evidence. Interviews started with questions regarding the practice, participants’ roles, and then about the NP Modernization Act. Table 1 presents key questions.

Each interviewee signed a consent form. Interviews and data analysis were conducted concurrently (DiCicco- Bloom & Crabtree, 2006). As interviews progressed, participants provided information, which was further explored in subsequent interviews. All interviews were conducted in the participant’s practice office with no others present during the interview. Interviews were audio-taped and lasted between 25 and 45 minutes. The interviewer took notes. Demographic and practice char- acteristic information was also collected. Data collection took place in the summer-fall of 2016.

Twenty-three interviews were completed initially (12 NPs and 11 physicians) and analyzed to identify codes and themes (Miles & Huberman, 1984). To further explore the codes and themes and develop an exhaustive de- scription, we conducted three additional interviews with two NPs and one physician. In alignment with qualitative research principles (Sandelowski, 2007), data collection ended when interviews were not producing new in- formation. This was reached after the 26th interview.

Interview audio-recordings were transcribed verbatim by a transcriptionist. We imported the data into the qualitative software package, Atlas, and using iterative content analysis (Bradley, Curry, & Devers, 2007), we an- alyzed the data. Two researchers independently read and reread transcripts for overall understanding and in- ductively coded the data (Hsieh & Shannon, 2005). We reviewed data line-by-line and when a concept became apparent, we assigned a code. We used constant com- parison to refine codes and had regular in-person meetings to review discrepancies and achieve consensus. After identifying all concepts, we linked them to develop themes relating to barriers and facilitators of the law’s implementation. We also conducted a comparative analysis in two groups (physicians and NPs) by retrieving data coded with both conceptual and participant codes. This comparison showed whether certain concepts were

Table 1. Examples of interview questions Key Questions

•Can you describe the Nurse Practitioners Modernization Act? What does it state?

•Can you talk about how your organization has adopted the Nurse Practitioners Modernization Act?

•How has the Nurse Practitioners Modernization Act impacted your practice?

•What organizational barriers exist to adopt the Nurse Practitioners Modernization Act?

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reported differently between two groups. Findings were shared with participants to obtain feedback. De- mographic data were analyzed using SPSS v24.

Results Table 2 includes information about the 14 NP and 12 physician participants. Themean age was 41 years for NPs and 45 years for physicians. Themean years of experience for NPs was about 7 years and for physicians was 13 years. Twelve of 14 NPs (85.7%) were experienced NPs with at least 3,600 hours of clinical practice. The majority of NPs and physicians worked in practices affiliated with

hospitals or medical centers. We identified four barriers and two facilitators toward the law’s implementation (Table 3), which emerged both in NP and physician interviews; thus, findings are combined.

Barriers The following barriers emerged: stagnant organizational policy; lack of awareness of NP competencies; lack of knowledge about the NP Modernization Act; and physi- cian autonomy and resistance to change.

Stagnant organizational policy. Almost all NPs reported that the law change did not affect their practice because

Table 2. Nurse practitioner (NP) and physician characteristics Characteristics NPs (N = 14) Physicians (N = 12)

Age, mean (SD), years 41.36 (3.4) 45.78 (2.7)

Female, No. (%) 13 (93) 7 (58)

Highest degree, No. (%)

Master’s 5 (36) —

Post-Master’s 3 (21) —

MD — 11 (92)

Doctorate (PhD; DNP; PhD/MD) 6 (43) 1 (8)

Years of experience, mean (SD) 7.21 (1.8) 13 (2.4)

Main practice site, No. (%)

Private practice 2 (14) 3 (25)

Academic medical center-affiliated practice

5 (36) 6 (50)

Hospital-affiliated practice 7 (50) 2 (17)

Community health center — 1 (8)

Geographical location, No. (%)

Urban 9 (64) 8 (67)

Suburban 5 (36) 3 (25)

Rural — 1 (8)

Table 3. Barriers and facilitators for implementing the nurse practitioners modernization act Barriers

•Stagnant Organizational Policy

•Lack of Awareness of NP Competencies

•Lack of Knowledge about the NP Modernization Act

•Physician Autonomy and Resistance to Change

Facilitators

•NP and Physician Collegiality

•Positive Perceptions of the benefits of NP Independence and the Law

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Removing restrictions on NPs’ scope of practiceQualitative Research

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the organizational bylaws were not reformed to accom- modate the change, particularly in practices affiliated with hospitals or medical centers. Eighty-six percent of NPs (12 out of 14), regardless of experience, had a written practice agreement with physicians. One NP employed in a hospital-affiliated practice for seven years described, “The bylaws…state that you have to have a collaborating physician…I still have a collaborating physician.” She continued, “They (administrators) have not kind of come with the times yet…my collaborating physician in particular totally agrees with the Modernization Act and does not feel that she needs to oversee me in any way, shape, or form.” Most NPs reported that their organizations do not plan to change their bylaws because of lack of advocates in the leadership to encourage change.

Practices sold to hospitals found that new owners were less supportive of expanding NP SOP. Hospitals not only did not promote NP independent practice, but they even restricted the practice of those NPs who had a broader SOP in a standalone practice prior to the hos- pital acquiring their practice. One NP with 15 years of experience provided an example:

Before (hospital) took over, I was comfortable, and the physician that owned the practice was very comfortable with me doing initial physical examinations, doing med- ical clearances, doing worker’s compensation. All that has gone away since (hospital) bought the practice.

Physicians also confirmed that their organizations did not conform to the law. They saw this as a reflection of their organizations, which they perceived as out of touch with new policies. One physician practicing with NPs for 20 years stated, “I really think that the organization that I’m working for is just not up with the times. I don’t think they’re astute enough to… know what’s out there.”

Lack of awareness of NP competencies. Most participants, both NPs and physicians, perceived that some physicians and administrators are not familiar with NP competen- cies or the care NPs can deliver. One NP said, “I also don’t think that all providers, like physicians, know what nurse practitioners can do and the extent we can do it, too.” Physicians’ comments confirmed NPs’ concerns. One physician said, “I’m not really sure what their (NPs’) training entails.”

Physicians had conflicting views about NPs’ abilities when speaking about NPs more generally compared with NPs they workedwith directly. Most physicians viewed the quality of care of NPs in their practices positively, “The nurse practitioner that works here I feel is exceptional. So, if she went out on her own independently, I would have no hesitation about it.” However, viewed as a group, the same physician’s perception of NPs was not as positive, “I don’t feel that way across the board for most NPs.” Awareness of NP competencies and support for NP in- dependent practice was higher among physicians who

worked with NPs; however, that awareness and support was individualized to the NPs they worked with. Physi- cians often perceived that these NPs are uniquely skilled and their competencies are not generalizable to the overall NP workforce.

Lack of knowledge about the NP Modernization Act. Awareness of the policy change varied across the two groups. Although most NPs were familiar with the law, only a few physicians had heard about it. One physician stated, “I heard it is’ something like they (NPs) can practice individually? Without any presence of any doctors?” Another physician said, “I don’t know about NPs going independent. I have not seen that in any of my practices.”

Even though most NPs knew the law had passed, they were not well informed about its details. One NP sum- marized as, “It is (NP Modernization Act is) basically pro- moting NP autonomy”. Also, both physicians and NPs reported that their organizations are unfamiliar with the law or they do not keep informed about the state policy changes.

Physician autonomy and resistance to change. Two physicians reported resistance toward surrendering some of their rights despite recognizing that the law’s implementation would reduce delays for patients by allowing NPs to bypass physician signing off on forms. One physician provided an example, “Ideally, I would hope that we (NPs and physicians) would be completely equal. But I know that after being in, like, 20 years of practice where I am sort of the final say, I might have a hard time giving up that.” The same physician said, “Then you would have to sort of negotiate between the two providers.” Another physician said, “not that they (NPs) don’t know and they don’t have any experience, but I feel still that I think there has to be some kind of com- munication with the doctor…”

Facilitators Two factors emerged as facilitators: NP and physician collegiality and positive perceptions of the benefits of NP independence and the law.

Nurse practitioner and physician collegiality. Both NPs and physicians identified favorable collegial relations as facilitating the law’s implementation. In practices where NPs and physicians had positive relationships, NPs were more likely to practice independently. Furthermore, in these practices, NPs were key members of the team. One NP said, “A lot of our physician colleagues…see me as a warrior with them…” Similarly, some physicians spoke about NPs being equal team members and in- dependently delivering care to patients. One physician said, “the NP certainly is seeing patients on her own… she has her own panel.” Other physicians emphasized the importance of having collegial relationships with NPs because it would benefit patients.

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Positive perceptions of the benefits of NP independence and the law. Physicians were supportive of the law when they perceived that NP independence benefitted their practice by expanding its capacity. Nurse Practitioners could help practices meet the increased care demand and attract more patients. One physician with over 20 years of ex- perience owning his practice said:

Expansion (NP SOP) is like if I have two “me’s…because the NP is going to be doing the same thing that I do, it is’ just that we are able to get asmany patients as possible…I just want to make the office bigger.”

Physicians who found the NP collaboration re- quirement burdensome were also more likely to support the law’s implementation. One physician said, “I’ve asked thatmany times, ‘Why am I signing for a nurse practitioner who has a Ph.D. and has been working with me since 1998?’ I have absolutely no clue.” Similarly, NPs perceived that environments where physicians and administrators had positive attitudes toward NP independence were more likely to adopt the law.

Discussion Our study represents one of the first comprehensive assessments of the NYS NP SOP policy change imple- mentation. Despite the attention on the NPworkforce and the regulatory trend of loosening NP SOP restrictions nationwide (Robert Wood Johnson Foundation, 2017), no study has assessed how these laws are implemented. The response to policy change is important to understand because translation from policy into practice is a neces- sary step in realizing the law’s goals. Our study reveals some important barriers toward the law’s implementa- tion, which should be addressed by policy makers and administrators to assure NPs in NYS practice according to the law. Despite that NP SOP is different in NYS, our findings may inform policy makers in other states con- sidering reform of NP SOP laws. New York State has had a slow response to SOP law change compared with other policies. Research on other state policy changes has shown immediate and measurable responses (Gresenz, Edgington, Laugesen, & Escarce, 2012; Gresenz, Laugesen, Yesus, & Escarce, 2011; Laugesen et al., 2014; Sabik & Laugesen, 2012). Both NPs and physicians believe that their organizations lack the ability to embrace policy innovations and no efforts are undertaken to implement the law. These findings are consistent with previous re- search showing how implementation is frequently over- looked after legislation is passed (Pressman &Wildavsky, 1984).

Most practices had not changed their bylaws in ac- cordance with the law. These findings contribute to new knowledge that legislative change alone is not adequate to maximize the contributions of the NP workforce to our health care system. For the NP Modernization Act to achieve maximum impact, many stakeholders, including

physicians and administrators, should get involved in efforts to embrace the law at the organizational level. With more NPs employed in practices associated with hospitals or medical centers, it is particularly important to work with leadership because these organizations seem to be more resistant to expanding NP SOP. Cur- rently, about 32% of NPs in NYS practice in such settings (Poghosyan, Boyd, & Knutson, 2014). Supporting NP practice according to the state laws promotes patient safety (O’Grady, 2008).

Although NPs gained legal SOP in NYS in 1988 (Elwell & Ferrara, 2014), there remains a lack of awareness among some physicians about NP competencies. Evidence is clear that NPs deliver high-quality care (Kurtzman & Barnow, 2017; Newhouse et al., 2011). Therefore, increasing awareness about NP competencies could promote the implementation of the NP Modernization Act. Also, al- though the law affects both NPs and physicians, many physicians are unfamiliar with it. Raising awareness about the law, particularly how it can positively affect the practice of NPs and physicians, patient care, and the overall health care system may motivate its implementation.

Nurse practitioner and physician collegiality and leadership’s positive perceptions of NP independence and the law facilitate the law’s implementation. Physi- cians speak favorably about the NPs they work with and support NP independent practice if they already have favorable relationships. Our findings suggest that physi- cians’ greater familiarity with NPs increases support for NPs. These findings are consistent with research showing that physicians practicing with NPs have positive atti- tudes toward them (Street & Cossman, 2010). As the number of NPs grows, it may lead to improved relation- ships between NPs and physicians and subsequently to a better implementation of laws aimed at loosening restrictions on NP SOP.

Our findings reinforce existing research showing that support for NPs depends on organizational leadership (Poghosyan et al., 2013). In organizations where leader- ship does not share resources with NPs and/or do not communicate with NPs, teamwork between NPs and physicians suffers, thereby inhibiting state policy adoption (Poghosyan & Liu, 2016). Efforts should pro- mote the relationship between NPs and leadership to aid the implementation of the policy at the practice level.

The study has limitations. The study was conducted in NYS and the findings might not be applicable to other states. A purposive sample of participants was inter- viewed. Other NPs and physicians, especially from dif- ferent geographic areas, might have different perspectives. Participants might not be truthful during the interviews. Future large-scale studies are needed. Studies might track how the law affects the supply of NPs

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Removing restrictions on NPs’ scope of practiceQualitative Research

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in underserved areas over time. Also, it is important to collect data from leadership.

Conclusion The NP Modernization Act is a major policy accomplish- ment in NYS. Policy makers and administrators should make efforts to remove the barriers and promote facili- tators of the law’s implementation to assure the law achieves its maximum impact.

Presentation: The study was presented as a poster at Annual Research Meeting at AcademyHealth in June 2017.

Authors’ contributions: Lusine Poghosyan (data analysis; manuscript writing; editing and revisions); Allison A. Norful (interviewer; data analysis; manuscript writing; editing and revisions); Miriam J. Laugesen (manuscript writing; editing and revisions).

Competing interests: The authors report no conflict of interests.

Funding: The study was funded by the Robert Wood Johnson Foundation, the National Institute of Nursing Research (T32NR014205), and the National Institute of Health (TL1TR001875).

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Original Article

Predictors of Evidence-Based Practice Implementation, Job Satisfaction, and Group Cohesion Among Regional Fellowship Program Participants Son Chae Kim, RN, PhD • Jaynelle F. Stichler, DNS, RN, NEA-BC, FACHE, FAAN • Laurie Ecoff, RN, PhD, NEA-BC • Caroline E. Brown, DEd, CNS • Ana-Maria Gallo, PhD, CNS, RNC-OB • Judy E. Davidson, DNP, RN, FCCM

Keywords

evidence-based practice,

fellowship, EBP beliefs,

EBP implementation, job satisfaction,

group cohesion, group attractiveness

ABSTRACT Background: A regional, collaborative evidence-based practice (EBP) fellowship program utiliz- ing institution-matched mentors was offered to a targeted group of nurses from multiple local hospitals to implement unit-based EBP projects. The Advancing Research and Clinical Practice through Close Collaboration (ARCC) model postulates that strong EBP beliefs result in high EBP implementation, which in turn causes high job satisfaction and group cohesion among nurses.

Aims: This study examined the relationships among EBP beliefs, EBP implementation, job satis- faction, group cohesion, and group attractiveness among the fellowship program participants.

Methods: A total of 175 participants from three annual cohorts between 2012 and 2014 com- pleted the questionnaires at the beginning of each annual session. The questionnaires included the EBP beliefs, EBP implementation, job satisfaction, group cohesion, and group attractiveness scales.

Results: There were positive correlations between EBP beliefs and EBP implementation (r = 0.47; p <.001), as well as EBP implementation and job satisfaction (r = 0.17; p = .029). However, no statistically significant correlations were found between EBP implementation and group cohesion, or group attractiveness. Hierarchical multiple regression models showed that EBP beliefs was a significant predictor of both EBP implementation (β = 0.33; p <.001) and job satisfaction (β = 0.25; p = .011). However, EBP implementation was not a significant predictor of job satisfaction, group cohesion, or group attractiveness.

Linking Evidence to Action: In multivariate analyses where demographic variables were taken into account, although EBP beliefs predicted job satisfaction, no significant relationship was found between EBP implementation and job satisfaction or group cohesion. Further studies are needed to confirm these unexpected study findings.

BACKGROUND The adoption and implementation of evidence-based practice (EBP) in nursing and other healthcare disciplines are recog- nized as essential in ensuring optimal patient outcomes and quality of care (Aarons, Ehrhart, & Farahnak, 2014). Although EBP is considered to be the gold standard in nursing practice, the actual implementation of EBP has been inconsistent due to barriers related to nursing workload, lack of organizational support, lack of EBP knowledge and skills, and poor attitudes toward EBP (Brown et al., 2010; Ramos-Morcillo, Fernandez- Salazar, Ruzafa-Martinez, & Del-Pino-Casado, 2015; Squires, Estabrooks, Gustavsson, & Wallin, 2011). Although many hos- pitals have used professional development courses individually

to encourage nurses’ implementation of EBP through im- proved nurses’ knowledge and attitudes about EBP, successful outcomes have been elusive (Melnyk, Gallagher-Ford, Long, & Fineout-Overholt, 2014; Pryse, McDaniel, & Schafer, 2014; Underhill, Roper, Siefert, Boucher, & Berry, 2015).

A regional, collaborative EBP fellowship program, the EBP Institute, was founded in 2006 by nurse leaders from multi- ple hospitals and academia in San Diego County, California, to promote implementation of EBP by hospital nurses. The fel- lowship program utilized institution-matched mentors to assist in executing unit-based EBP projects, and included didactic as well as interactive learning experiences in six daylong educa- tional sessions over a 9-month period. A formal graduation day

340 Worldviews on Evidence-Based Nursing, 2016; 13:5, 340–348. C© 2016 Sigma Theta Tau International

Original Article completed the learning experience, with the fellows present- ing their EBP projects in poster and podium presentations. A previous report on this program showed improvements in the participants’ knowledge, attitudes, and practice associated with EBP, as well as a reduction in barriers to EBP implementation (Kim et al., 2013).

LITERATURE REVIEW The literature is replete with evidence and opinions that ef- forts to educate nurses regarding EBP have improved nurses’ knowledge and attitudes. However, these efforts have not nec- essarily resulted in actual improvements in EBP implementa- tion, nor have they changed clinical practices (Aarons et al., 2014; Melnyk et al., 2014; Pryse et al., 2014). Although barri- ers to EBP implementation have been well-documented, some authors have also cited the importance of organizational cul- ture and leadership in reducing barriers and fostering EBP implementation.

Organizational Culture and Leadership for EBP An organizational culture that emphasizes making clinical de- cisions based on evidence is critical for improving and sus- taining safe and high-quality patient care (Melnyk, Fineout- Overholt, Giggleman, & Cruz, 2010; Wallen et al., 2010). Al- though leaders influence the organizational culture, they also play an important role in supporting implementation of EBP and other innovative practices. Supportive leaders obtain fund- ing, provide resources, allow the time necessary for nurses to engage in EBP implementation, and reward those nurses who participate in evidence-based change projects in perfor- mance evaluations (Aarons et al., 2014; Ehrhart, Aarons, & Farahnak, 2015). Ehrhart, Aarons, and Farahnak (2015) have reported that clinical nurses with the greatest clinical exper- tise and EBP knowledge were most helpful in advancing EBP skills and positive EBP attitudes among their coworkers. This finding supports the importance of mentorship in improving nurses’ knowledge, attitudes, and practice of EBP (Abdullah et al., 2014; Green et al., 2014; Magers, 2014).

Furthermore, organizations that engage in the Magnet Recognition Program have been recognized for nurse engage- ment in EBP and implementation of clinical practice changes. The Magnet journey transforms organizational cultures, and ensures leadership support and resources necessary to facili- tate nurses’ engagement in EBP (American Nurses Credential- ing Center, 2014; Black, Balneaves, Garossino, Puyat, & Qian, 2015; Wilson et al., 2015).

Educational Processes to Enhance EBP in Healthcare Settings A number of studies have described the structures, processes, and outcomes of programs to enhance nurses’ appreciation, knowledge, competencies, and practice of EBP (Kim et al., 2013; Magers, 2014; Mollon et al., 2012; Ramos-Morcillo et al., 2015; Underhill et al., 2015; Wong & Myers, 2015). Although

most EBP educational programs emphasize EBP contents re- lated to asking relevant clinical questions, and searching for and appraising forms of evidence, less emphasis is put on actual EBP implementation (Wyer, Umscheid, Wright, Silva, & Lang, 2015). The Advancing Research and Clinical Practice through Close Collaboration (ARCC) model emphasizes EBP implementation as the final focal point of the entire model, through which all of the beneficial outcomes of EBP diffusion flow (Melnyk et al., 2010). These outcomes include benefits to patients with improved patient outcomes as well as bene- fits to nurses such as higher job satisfaction and group cohe- sion, along with lower nurse turnover, with the ultimate out- come of decreased hospital costs. Using the ARCC model to educate nurses, previous studies have reported that partici- pants’ beliefs about EBP were significantly correlated with perceived organizational culture for EBP, implementation of EBP, group cohesion, and job satisfaction (Melnyk et al., 2010; Wallen et al., 2010). However, there has not been a full ex- amination of the strength of relationships among EBP beliefs, EBP implementation, job satisfaction, and group cohesion that takes the demographic variables into account.

The purpose of the study was to examine the relation- ships among EBP beliefs, EBP implementation, job satisfac- tion, group cohesion, and group attractiveness among nurses participating in a regional, collaborative EBP fellowship pro- gram. The specific aims were to examine: (a) EBP beliefs as a predictor of EBP implementation; and (b) EBP beliefs and EBP implementation as predictors of job satisfaction, group cohe- sion, and group attractiveness above and beyond the influence of demographic variables.

METHODS Design and Participants Three annual cohorts of nurses attending the 9-month re- gional, collaborative EBP fellowship program in San Diego, California, from 2012 to 2014 were invited to participate in the study. The program attendees were selected nurses repre- senting each participating institution as a dyad of mentor and fellow. The fellows, in general, were staff nurses who would be implementing unit-based EBP projects under the mentorship of advanced practice nurses, nurse educators, or other nurses with experience in implementing EBP projects.

Instruments EBP beliefs scale. This 16-item scale measures respondents’ beliefs about the importance of EBP and their EBP competence in a five-point Likert response format, ranging from strongly disagree ( = 1) to strongly agree ( = 5). Possible total scores range from 16 to 80, with higher scores indicating stronger EBP beliefs. The internal consistency reliability was reported as Cronbach’s alpha of 0.90, and validity testing has also been reported in the previous study (Melnyk, Fineout-Overholt, & Mays, 2008). The Cronbach’s alpha for the instrument in this study was 0.87.

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Predictors of EBP Implementation, Job Satisfaction, and Group Cohesion

EBP implementation scale. This 18-item scale assesses the frequency of performing EBP-related activities in the past 8 weeks (Melnyk et al., 2008). Examples of items include gener- ating a PICO question, critically appraising research evidence, and collecting data, as well as sharing EBP guidelines with oth- ers. Response options range from 0 times ( = 0) to greater than or equal to 8 times ( = 4), and the total summation score ranges from 0 to 72, with a higher score indicating greater participa- tion in EBP-related activities. The internal consistency reliabil- ity was Cronbach’s alpha of 0.96, and validity testing was also reported. The Cronbach’s alpha in this study was 0.96.

Job satisfaction scale. Respondents are asked to rate their perception of job satisfaction in a five-point Likert response format, ranging from strongly disagree ( = 1) to strongly agree ( = 5). This scale contains four items and the total summation score ranges from 4 to 20, with a higher score indicating higher job satisfaction (Mueller, Boyer, Price, & Iverson, 1994). The Cronbach’s alpha was reported as 0.88 in the previous study and it was 0.89 in this study.

Group cohesion and attractiveness scales. These are two scales that measure group cohesion and group attractiveness in a seven-point Likert response format (Good & Nelson, 1973). The four-item Group Cohesion scale rates respondents’ percep- tion about their work group’s productivity, efficiency, feeling of belongingness, and morale from very much above average ( = 1) to very much below average ( = 7). The two-item Group Attractiveness scale assesses respondents’ perception of their enjoyment in working with the group. Responses range from like/enjoy very much ( = 1) to dislike very much ( = 7). In this study, the scores were reversed so that higher scores indicate positive perceptions. The reported split-half reliabilities were 0.77 and 0.82, whereas the Cronbach’s alphas in this study were 0.90 and 0.85, respectively.

Demographic data form. General demographic information, such as age, educational background, ethnicity, years of RN experience, and nursing position, was obtained.

Data Collection Procedures This study was approved by the institutional review boards of the participating academic and healthcare institutions. A consent letter was provided to and reviewed by all potential participants. Written documentation of consent was waived, because minimal risk was involved in this study and partici- pants’ anonymity was protected. Completion of the study ques- tionnaires indicated consent to participate in the study. The participants completed the study questionnaires at the begin- ning of each 9-month program.

Data Analyses Descriptive statistics, including mean, standard deviation, fre- quency, and percentage, were calculated. Independent t-tests were performed to compare the mean scores of EBP be- liefs, EBP implementation, job satisfaction, group cohesion,

and group attractiveness between the mentors and the fel- lows. Bivariate Pearson’s correlations were performed to exam- ine the relationships among demographic variables and other variables. To examine EBP beliefs as a predictor of EBP im- plementation, the demographic variables that had significant correlations with EBP implementation were entered in the first step of the hierarchical multiple regression model. The EBP be- liefs was then entered in the second step as a predictor of EBP implementation above and beyond the demographic variables.

To examine EBP beliefs and EBP implementation as pre- dictors of job satisfaction, group cohesion, and group attrac- tiveness, the demographic variables that correlated with job satisfaction, group cohesion, or group attractiveness were en- tered in the first step of the hierarchical multiple regression models. This was followed by entry of the EBP beliefs and EBP implementation in the second step as predictors above and beyond the demographic variables. The assumptions of normality, linearity, and homoscedasticity in the hierarchical multiple regression models were met. SPSS version 21.0 (IBM SPSS Statistics, Armonk, NY) was used for data analyses and the level of significance was set at p < .05.

RESULTS Sample Characteristics A total of 175 participants (101 fellows and 74 mentors) from the three annual cohorts between 2012 and 2014 completed the questionnaires at the beginning of the program. The fellows comprised 57.7% of all participants. A majority of the partic- ipants were white (69.7%) and had graduate degrees (52%). The mean age was 42 years and average RN experience was 15 years (Table 1).

The mentors had statistically significant higher scores for EBP beliefs (66.6 vs. 59.3; p < .001) and EBP implementation (24.2 vs. 11.0; p < .001) in comparison with the fellows. How- ever, there were no statistically significant differences in job satisfaction, group cohesion, or group attractiveness between the mentors and the fellows (Table 2).

Bivariate Correlations among Demographics and Other Variables Table 3 shows that the demographic variables of being a mentor, clinical nurse specialist, nurse educator, or nurse practitioner, as well as having a graduate-level education, had statistically significant positive correlations with both EBP beliefs and EBP implementation. Length of RN experience also correlated with EBP implementation and having a graduate- level education was the only demographic variable that corre- lated with job satisfaction. None of the demographic variables had positive correlations with either group cohesion or group attractiveness.

For EBP implementation, positive correlations were ob- served with EBP beliefs (r = 0.47; p < .001) and job satisfaction (r = 0.17; p = .029). However, no statistically significant cor- relations were found between EBP implementation and group

342 Worldviews on Evidence-Based Nursing, 2016; 13:5, 340–348. C© 2016 Sigma Theta Tau International

Original Article Table 1. Demographic Characteristics (N = 175)

Total Fellows Mentors

Variables (N= 175) (n= 101) (n= 74) Cohorts

2012 cohort 42 (24.0) 20 (19.8) 22 (29.7)

2013 cohort 60 (34.3) 40 (39.6) 20 (27.0)

2014 cohort 73 (41.7) 41 (40.6) 32 (43.2)

Age, mean (year), range 42 (23-68) 39 (23-68) 46 (27-67)

Ethnicity

White (non-Hispanic) 122 (69.7) 66 (65.3) 56 (75.7)

Black 5 (2.9) 3 (3.0) 2 (2.7)

Hispanic 11 (6.3) 6 (5.9) 5 (6.8)

Asian/Pacific Islanders 29 (16.6) 19 (18.8) 10 (13.5)

Other 8 (4.5) 7 (6.9) 1 (1.4)

Educational level

Diploma/associate 8 (4.6) 8 (7.9) 0 (0.0)

Baccalaureate 76 (43.4) 70 (69.3) 6 (8.1)

Master/doctorate 91 (52.0) 23 (22.8) 68 (91.9)

Nursing position

Clinical nurse 73 (41.7) 67 (66.3) 6 (8.1)

Lead nurse 20 (11.4) 13 (12.9) 7 (9.5)

Nurse manager 12 (6.9) 1 (1.0) 11 (14.9)

CNS/nurse educator/NP 64 (36.6) 15 (14.9) 49 (66.2)

Non-nursing 6 (3.4) 5 (5.0) 1 (1.4)

RN experience, mean (year), range 15 (1, 42) 12 (1, 35) 20 (2, 42)

ANCC certification in specialty 94 (53.7) 48 (47.5) 46 (62.2)

Note. Values are expressed as n (%) unless otherwise indicated. Percentages may not add up to 100% because of missing data or rounding. ANCC = American Nurses Credentialing Center; CNS= clinical nurse specialist; NP= nurse practitioner; RN= registered nurse.

cohesion or group attractiveness. For job satisfaction, there were positive correlations with EBP beliefs (r = 0.26; p = .01) and group attractiveness (r = 0.23; p = .003). There was also a positive correlation between group cohesion and group attrac- tiveness (r = 0.49; p < .001; Table 3).

Multivariate Analysis: EBP Beliefs as a Predictor of EBP Implementation In the first step of a hierarchical multiple regression model, the demographic variables, including being a mentor, edu- cational level, years of RN experience, and nursing position accounted for 22.5% of the variance in EBP implementation

(R2 = 0.225; Table 4). The entry of the EBP beliefs in the second step increased the R2 by .075, indicating that the EBP beliefs explained a small fraction of the variance in the EBP implementation above and beyond the demographic variables (7.5%). Being a mentor (β = 0.27; p = .012) and EBP beliefs (β = 0.33; p < .001) were statistically significant predictors of EBP implementation.

Multivariate Analyses: Predictors of Job Satisfac- tion, Group Cohesion, and Group Attractiveness Table 5 shows that demographic variables in the first step of a hierarchical multiple regression model accounted for 6.2%

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Table 2. Comparison of Mean (± SD) of Variables Between Mentors and Fellows (N = 170)

P value

Fellows Mentors independent

(n= 98) (n= 72) (t test) EBP beliefs 59.3 (6.38) 66.6 (6.91) < .001***

EBP implementation 11.0 (10.6) 24.2 (16.9) < .001***

Job satisfaction 16.6 (2.18) 17.0 (2.34) .215

Group cohesion 20.1 (4.39) 20.6 (4.67) .479

Group attractiveness 11.7 (1.67) 11.8 (1.83) .653

Note. ***p < 0.001. SD = standard deviation. The higher the scores, the higher the EBP beliefs, EBP implementation, job satisfaction, group cohesion, and group attractiveness.

of the variance in job satisfaction (R2 = 0.062). The entry of EBP beliefs and EBP implementation in the second step in- creased the R2 by 0.050, indicating that these two variables ex- plained a small fraction of the variance in job satisfaction above and beyond demographic variables (5.0%). EBP beliefs was a statistically significant positive predictor of job satisfaction (β = 0.25; p = .011), but EBP implementation was not a predictor of job satisfaction.

For group cohesion, the demographic variables in the first step explained 1.8% of the variance of group cohesion (R2 = 0.018). The EBP beliefs and EBP implementation in the second step explained 0.2% of the variance of group cohesion (R2 = 0.002), indicating that these two variables explained only a minimal fraction of variance in group cohesion above and beyond the demographic variables.

For group attractiveness, the first entry of demographic variables accounted for 1.0% of the variance of the group at- tractiveness (R2 = 0.010). The entry of EBP beliefs and EBP implementation in the second step changed the R2 by 0.038, indicating that they explained a minimal fraction of the vari- ance in group attractiveness (3.8%). EBP implementation was a statistically significant negative predictor for group attractive- ness (β = -0.22; p = .021; Table 5).

Table 3. Bivariate Correlations Among Variables

EBP beliefs

EBP implementation

Job satisfaction

Group cohesion

Group attractiveness

Mentors 0.48*** 0.43*** 0.10 0.06 0.04

Educational level

Diploma/associate −0.19* −0.03 −0.02 −0.19* 0.01 Baccalaureate −0.43*** −0.37*** −0.15* −0.002 −0.06 Master/doctorate 0.51*** 0.38*** 0.16* 0.01 0.07

Years of RN experience 0.13 0.16* 0.02 0.04 0.04

Nursing position

Clinical nurse −0.33*** −0.28*** 0.04 −0.01 −0.07 Lead nurse −0.02 −0.001 −0.19* −0.04 −0.02 Nurse manager 0.07 −0.02 −0.07 0.11 0.04 CNS/nurse educator/NP 0.34*** 0.32*** 0.09 −0.02 0.01

EBP beliefs 1 0.47*** 0.26** −0.02 0.09 EBP implementation 0.47*** 1 0.17* −0.02 −0.11 Job satisfaction 0.26** 0.17* 1 0.09 0.23**

Group cohesion −0.02 −0.02 0.09 1 0.49***

Group attractiveness 0.09 −0.11 0.23** 0.49*** 1 Note. *p< .05; ** p< .01; *** p< .001 by Pearson’s correlations.

344 Worldviews on Evidence-Based Nursing, 2016; 13:5, 340–348. C© 2016 Sigma Theta Tau International

Original Article Table 4. Multivariate Analysis: Predictors of EBP Im- plementation

EBP implementation

Predictors B β

Step 1

Constant demographic variables a 15.4

R2 = 0.225***

Step 2

Constant −27.0 Mentor 8.25* 0.27*

EBP beliefs 0.66*** 0.33***

R2 � = 0.075***

F� (1, 160) = 17.22***

Note. *p < 0.05; *** p < 0.001. aDemographic variables of being a men- tor, educational level, years of RN experience, and nursing position were entered.

DISCUSSION The study findings indicate that EBP beliefs had a signifi- cant correlation with EBP implementation in bivariate anal- ysis, and was a positive predictor of EBP implementation in multivariate analysis. In addition, EBP beliefs showed a signif-

icant correlation with job satisfaction in bivariate analysis and was also a positive predictor of job satisfaction in multivariate analysis. These results are consistent with previous findings and support the ARCC model, which postulates that strong EBP beliefs result in high levels of EBP implementation (Melnyk et al., 2010).

Although these study findings indicate that EBP implemen- tation has some correlation with job satisfaction in a bivariate analysis, the multivariate analysis showed a surprising finding that EBP implementation was not a predictor of job satisfac- tion. In addition, EBP implementation was not a significant predictor of group cohesion or group attractiveness in mul- tivariate analyses. Furthermore, EBP implementation was a significant negative predictor of group attractiveness, indicat- ing that high levels of EBP implementation are associated with lower group attractiveness. These unexpected findings from multivariate analyses appear to conflict with the ARCC model, which postulates that high levels of EBP implementation re- sult in high job satisfaction as well as high group cohesion (Melnyk et al., 2010). However, these findings are consistent with a previous report showing no statistically significant cor- relations between EBP implementation and job satisfaction or group cohesion (Melnyk et al., 2010). Also, an interventional study of implementing the ARCC model showed no signifi- cant effect on job satisfaction, in spite of improvements in EBP implementation (Levin, Fineout-Overholt, Melnyk, Barnes, & Vetter, 2011). It is possible that these findings showing no significant relationship between EBP implementation and job satisfaction or group cohesion are due to small sample sizes, which could have prevented detection of small effects. Further studies are needed to confirm this study findings.

Table 5. Multivariate Analyses: Predictors of Job Satisfaction, Group Cohesion, and Group Attractiveness

Job satisfaction Group cohesion Group attractiveness

Predictors B β B β B β

Step 1

Constant 17.0 19.3 12.1

demographic variables a

R2 = 0.062 R2 = 0.018 R2 = 0.010 Step 2

Constant 12.2 20.9 10.2

EBP implementation 0.01 0.06 −0.01 −0.03 −0.03* −0.22 EBP beliefs 0.07* 0.25* −0.02 −0.04 0.04 0.16

R2 � = 0.050* R2 � = 0.002 R2 � = 0.038*

F� (2, 157) = 4.47* F� (2, 162) = 0.16 F� (2, 157) = 3.12*

Note. *p< 0.05. aDemographic variables of being a mentor, educational level, years of RN experience, and nursing position were entered.

Worldviews on Evidence-Based Nursing, 2016; 13:5, 340–348. 345 C© 2016 Sigma Theta Tau International

Predictors of EBP Implementation, Job Satisfaction, and Group Cohesion

It was not surprising that mentors, given their longer years of RN experience, higher levels of education, and nursing positions as advanced practice nurses (clinical nurse special- ists, nurse educators, or nurse practitioners), had significantly stronger EBP beliefs and greater EBP implementation. These findings are consistent with previous reports showing that higher levels of education correlated with higher EBP be- liefs and EBP implementation (Underhill et al., 2015). It is interesting that the mentors did not have higher job satis- faction, group cohesion, or group attractiveness, in spite of having higher EBP implementation. This is consistent with the aforementioned findings from this study, as well as previ- ous reports that EBP implementation is not necessarily asso- ciated with higher job satisfaction or group cohesion (Melnyk et al., 2010).

Since its inception in 2006, our regional collaborative EBP fellowship program has been in continuous operation, and has successfully educated more than 400 nurses and nurse lead- ers from 12 local hospitals to date. With solid and consistent organizational support from local hospitals and academic insti- tutions, the fellowship program has been able to pool resources and expertise from these organizations to empower participat- ing nurses to execute unit-based EBP projects (Kim et al., 2013). The fellows and mentors, equipped with EBP knowledge and skills, along with strong EBP beliefs, become EBP champi- ons in their own hospital units and serve as role models for their colleagues (Melnyk, 2007). We believe that our regional EBP fellowship program in Southern California can serve as a template for other regional organizations to come together and collaborate in fostering EBP implementation across mul- tiple hospitals in their own regions, with the ultimate aim of improving quality of care and patient outcomes.

Limitations There are several limitations to this study. First, the study find- ings of EBP beliefs as a significant predictor of EBP implemen- tation and job satisfaction should not be taken as cause-and- effect relationships in this descriptive cross-sectional study. Second, the subjective self-reporting methods of the study questionnaire may have overestimated respondents’ percep- tions about their beliefs in the value of EBP, EBP implemen- tation, and job satisfaction. Third, the fellowship participants were selected from a group of staff nurses who had already demonstrated high motivation for EBP adoption. Due to the potential sample selection bias, the study findings may not be generalizable to other nursing staff. Fourth, although the in- struments used in this study have been validated previously, the items may not have fully captured the intended concepts. Further refinements of the instruments could show differ- ent results. Finally, even though the study population came from multiple institutions, the findings are from one region in Southern California and may not be generalizable to other regions.

Future studies are needed to conduct an interventional study to evaluate the beneficial effects of regional fellowship

programs on EBP beliefs, EBP implementation, job satisfac- tion, and group cohesion. There is a need for further empir- ical research evidence to support relationships in the ARCC model.

CONCLUSIONS The baseline data collected from the participants of a regional collaborative fellowship program involving multiple local hos- pitals and academic institutions over a 3-year period indicated that strong EBP beliefs was a positive predictor of EBP imple- mentation and job satisfaction. However, no significant rela- tionships were found between EBP implementation and job satisfaction or group cohesion when demographic variables were taken into account. Further studies are needed to evalu- ate the impact of regional collaborative fellowship programs on EBP beliefs, EBP implementation, job satisfaction, and group cohesion among the participants, as well as to generate addi- tional evidence for the ARCC model. WVN

LINKING EVIDENCE TO ACTION

� A regional, collaborative EBP fellowship program utilizing institution-matched mentors should be encouraged to advance EBP because such pro- grams may be effective in improving EBP beliefs, EBP implementation, and job satisfaction.

� Support from participating institutions is essential for the success of a regional, collaborative EBP fellowship program.

� Strong beliefs in the value of EBP appear to be associated with high levels of EBP implementation and job satisfaction among the fellowship program participants.

� No significant relationship was found between EBP implementation and job satisfaction or group cohesion when demographic variables were taken into account; further studies are needed to confirm these unexpected study findings.

Author information

Son Chae Kim, Professor, St. David’s School of Nursing, Texas State University, Round Rock, TX; Jaynelle F. Stichler, Pro- fessor Emerita, San Diego State University; Consultant, Re- search and Professional Development, Sharp Memorial Hos- pital and Sharp Mary Birch Hospital for Women & Infants, San Diego, CA; Laurie Ecoff, Director of Research, Education, and Professional Practice, Sharp Memorial Hospital, San Diego, CA; Caroline E. Brown, Research Consultant, Bonita Springs, FL; Ana-Maria Gallo, Director of Nursing Education, Research and Professional Practice, La Mesa, CA; Judy E. Davidson,

346 Worldviews on Evidence-Based Nursing, 2016; 13:5, 340–348. C© 2016 Sigma Theta Tau International

Original Article EBP/Research Nurse Liaison, University of California San Diego Health System, San Diego, CA

Address correspondence to Dr. Son Chae Kim, Professor, St. David’s School of Nursing, Texas State University, 1555 Univer- sity Blvd., Round Rock, TX 78665; sck30@txstate.edu

Accepted 14 November 2015 Copyright C© 2016, Sigma Theta Tau International

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Engaging Employees in Well-Being Moving From the Triple Aim to the Quadruple Aim

Barbara Jacobs, MSN, NEA-BC, RN-BC, CCRN-K; Julie McGovern, MA, SPHR, SHRM-SCP; Jamie Heinmiller, BS; Karen Drenkard, PhD, RN, NEA-BC, FAAN

Anne Arundel Medical Center has been on a 3-year journey to improve employee well-being with the assumption that employee well-being and employee engagement are interconnected. Improvements in employee well-being will result in increased employee engagement and will be a pivotal driver to assist the health system meet its goals. Historically, Anne Arundel Medical Center successfully differentiated itself in the market by being the region’s high-quality, low-cost provider of health services delivered through intense collaboration with patients and families. The financial, quality, and patient satisfaction results are in the top percentiles nationwide. However, as the pace of change accelerates and the organization faces increased pressure to improve outcomes, keeping employees from becoming burned out and disengaged becomes an increasing concern. The WellBeing framework was developed on the basis of the work of Tom Rath and Jim Harter as the model to support Anne Arundel’s WellBeing work. The efforts around well- being are comprehensive and impact all aspects of how work is conducted. Employee well- being has been elevated to an equal third prong along with providing high-quality low-cost care in a patient-centered environment. This focus on leading an employee WellBeing Program has resulted in improved engagement scores at Anne Arundel Medical Center. Key words: employee engagement, leadership, quadruple aim, WellBeing Program

WHEN ANNE ARUNDEL MEDICAL CEN-TER (“AAMC”) adopted its 10-year strategic plan, “Vision 2020” in 2009, it was developed around 5 strategic pillars: Qual- ity, Community, Workforce, Growth, and Fi- nance. The initial strategies tied heavily to the Triple Aim of improving the health of populations, improving the patient experi-

Author Affiliations: Anne Arundel Medical Center, Annapolis, Maryland (Mss Jacobs, McGovern, and Heinmiller and Dr Drenkard); and GetWellNetwork, Inc, Bethesda, Maryland (Dr Drenkard).

The authors declare no conflict of interest.

Correspondence: Karen Drenkard, PhD, RN, NEA-BC, FAAN, GetWellNetwork, Inc, 7700 Old Georgetown Rd, Bethesda, MD 20814 (kndrenkard@gmail.com).

DOI: 10.1097/NAQ.0000000000000303

ence, and lowering the cost of care.1 Anne Arundel Medical Center had and continues to have excellent outcomes, regularly receiv- ing statewide recognition for high patient ex- perience scores as compared with the state of Maryland, better than average turnover scores, and being the first organization in the country to be awarded the Organiza- tion Patient Safety Certification by the Mary- land Patient Safety Center and the Courte- manche & Associates. The system continues to grow and be a financially strong, indepen- dent health system. In the early years of Vi- sion 2020, AAMC strove to differentiate it- self in the market by being the high-quality, low-cost provider of health services delivered through intense collaboration with patients and families. Anne Arundel Medical Center

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231mailto:kndrenkard@gmail.com

232 NURSING ADMINISTRATION QUARTERLY/JULY–SEPTEMBER 2018

adopted a culture of continuous performance improvement by following Lean2 principles. In addition, AAMC began to include patients and families in all aspects of care delivery. By 2015, AAMC had 100 patient advisors actively participating on system committees at every level, including on the Board Quality Commit- tee and Physician Peer Review Committee.

As the pace of change accelerated, and AAMC faced increasing financial pressure along with ever-changing reporting mandates, concerns about staff fatigue and burnout sur- faced. Goals associated with the workforce pillar of the strategic plan focused on in- creasing employee engagement and decreas- ing turnover. Both were important goals but neither did enough to address employee stress and burnout. In 2014, Thomas Bodenheimer, MD, and Christine Sinsky, MD,3 published an article reporting that staff burnout and dissat- isfaction are associated with lower patient sat- isfaction, reduced health outcomes, and po- tentially increased costs. They recommended that organizations adopt the quadruple aim, citing that the fourth aim, improving the work life of health care clinicians and staff, is nec- essary to achieve the triple aim.1

In this same time period, Gallup (2013) published the State of the American Workplace,4 reporting that overall, in all cat- egories and all industry sectors, employee en- gagement continues to remain at 30% across the US workforce. They noted that the work environment has a significant impact on em- ployee well-being, and employees with poor

well-being were less engaged and more neg- ative about the workplace. The Gallup study reported that employees who had high well- being were more likely to be agile and re- silient, experience better health, and report higher job performance. It was suggested that making well-being an organizational strategy could be a way to improve employee’s lives while achieving organizational outcomes. Fur- ther research about well-being led to the work of Rath and Harter, published in the book Wellbeing: The Five Essential Elements.5

Rath and Harter define well-being as “the com- bination of our love for what we do each day, the quality of our relationships, the security of our finances, the vibrancy of our physi- cal health, and the pride we take in what we have contributed to our communities.”5 The core concepts of well-being transcend coun- tries, culture, and generations. For the pur- poses of this article, definitions spelled out in Table 1 are used to describe WellBeing at Anne Arundel Medical Center. Rath and Harter posture that organizations that invest in their employee well-being will gain an emotional, financial, and competitive advantage.5

The stressors at work were not the only stresses facing AAMC employees in 2014. The economy was improving, but in a national study that year, 76% of Americans surveyed cited personal finances as a leading cause of their stress.6 The survey revealed that many physician visits are related to financial stress while resulting in increased health care costs, prescription costs, and absenteeism.6

Table 1. Definitions of Well-Being at Anne Arundel Medical Center

Purpose WellBeing: Having something to do every day that is challenging and enjoyable. For most people, it is their jobs that contribute to their purpose.

Social WellBeing: Having strong relationships and love in your life. Having a supportive work environment with people who care about you and who you care about is critical for thriving social well-being.

Financial WellBeing: This element is about managing your finances in a way that provides long-term economic security.

Physical WellBeing: Employees with thriving physical well-being experience good health and have enough energy to get things done on a daily basis.

Community WellBeing: Being engaged with the community where they live and work enhances an employee’s overall well-being.

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Engaging Employees in Well-Being 233

In addition, 69% of 2014 college graduates left college with student loan debt. Between 2004 and 2014, students’ average debt had increased 56%, from $18 550 to $28 950.7

Other research showed that people were more isolated and not connecting enough. This resulted in increased loneliness and poor social well-being.8 One comment from a survey participant was:

At one time, work was a major source of friend- ships. We took our families to company picnics and invited our colleagues over for dinner. Now, work is a more transactional place. We go to the office to be efficient, not to form bonds.8

By every measure, American workers were less healthy than at any other period in our history.9

It appeared that by focusing on WellBeing there could be improvement in the lives of employees while AAMC continued to meet the goals expressed in the triple aim.

There was early concern that focusing on employee well-being was getting the organi- zation too involved in employees’ personal lives. Questions were raised about what could actually be done to improve employee well- being. From the outset, AAMC leaders were determined to take demonstrable action to im- prove employee well-being as part of meeting the hospital mission: “To enhance the health of the people we serve.” Hospital employees are part of the community being served, and all stakeholders could see the direct correla- tion between employee well-being and the Vision 2020, “Living Healthier Together.” It was recognized that adoption of a WellBeing program would take careful thought and preparation. To get started, executive leaders participated in a retreat to immerse them- selves in the WellBeing model. The retreat’s objective was to help leaders understand what it means to commit to employee well- being and what outcomes they could expect from a formal program. There was honest dialogue about how work was impacting each executive’s well-being. The discussion centered on how individuals own their per- sonal well-being and the need to make small

shifts to improve work-life balance. Each executive committed to a personal action plan. A significant outcome of the retreat was recognition of the importance of executive role modeling. As a team, executives adopted several strategies to help with their own work-life balance, knowing full well that the changes they made would impact the larger leadership team. These strategies were to

• reduce many meetings from an hour to 45 minutes in order to allow time for bio- breaks, checking e-mail, and getting from one meeting to the next;

• stop sending e-mails between 7PM and 7 AM and on weekends, unless it was ab- solutely required;

• use texts and calls to reach a colleague (if necessary) in the “off hours.” This would reduce everyone’s need to constantly check e-mail. It was acknowledged that this was already a practice and which dif- ferentiated routine contact from urgent communication;

• role model well-being, while speaking openly at meetings about individual commitments to improve personal well- being.

The rollout of the WellBeing program to the employees was gradual, giving AAMC time to test the model, build infrastructure, and ensure support. Leaders monitored and rec- ognized the model’s swift adoption by staff and management as people saw relevance to their lives. All management staff received the book, Wellbeing: The Five Essential Ele- ments by Tom Rath and Jim Harter.5 A com- mittee was formed to conduct a needs as- sessment to identify the organization’s well- being strengths and opportunities for im- provement. The human resources (HR) de- partment reviewed its programs to determine how they could be redesigned to support well-being.

METRICS FOR SUCCESS

A key foundational strategy was to deter- mine, in advance of the rollout, how well- being would be measured and where the

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234 NURSING ADMINISTRATION QUARTERLY/JULY–SEPTEMBER 2018

results would be reported. Ten initial work- force aims were identified. Each month a re- port is shared at the quality committee of the board of trustees. Each aim supports 1 or more WellBeing element. For instance, there is an aim to increase employee Financial WellBeing by increasing participation in the 401k plan. Another metric is to increase Physical Well- Being through increased sales of healthy food at all organization cafeterias and coffee shops. Purpose WellBeing has aims to increase the number of BSN-prepared nurses and to in- crease staff skills in Lean quality concepts. The Community WellBeing aim is developed around support for community service. Over time, the workforce aims have evolved. For example, feedback from employees who vo- calized concerns about employee safety has resulted in additional aims targeted at reduc- ing injuries to employees caused by patients.

To get a baseline on employee engagement and well-being, AAMC implemented a WellBe- ing survey that included the Gallup Q12 and Gallup’s Well-Being 5 View assessment.10 As of 2018, AAMC has 3 years’ worth of data. Each year, goals are set at the system level as well as the department level to increase employee well-being and engagement. In ad- dition, HR has built the concepts of WellBe- ing into the core structural practices of re- cruitment, staff and leadership development, and goal setting. Some examples include the following:

• WellBeing is integrated into the leader- ship framework. Leadership behaviors at AAMC are guided by the leadership frame- work of “Team, Change, Business.” To be a leader, each manager must excel at managing his or her team by serving as a coach, serving as a mentor, assuring staff well-being, and encouraging team diver- sity. Leaders are expected to demonstrate changes in a transformational and inno- vative way. The framework’s reference to business means that leaders need to understand the business of health care, their role in it, and the basic skills of man- agement. WellBeing concepts have been woven into the “Team, Change, Business”

framework, making the commitment ex- plicit.

• The electronic performance appraisal and goal-setting system is used to have all employees develop personal well-being goals. By doing this, leaders have the op- portunity to learn more about their teams. They can better determine whether there are ways to support staff members with their goals. Employees determine how much they want to share. Many have found it beneficial and are getting sup- port from their teams, as they seek to improve their own well-being. Develop- ment of personal well-being goals is vol- untary and not part of the weighted per- formance appraisal.

• The WellBeing concepts are woven into orientation and into the leadership devel- opment curriculum.

• Interviews for new leaders highlight the importance of well-being for both them- selves and their staff members. When new leaders are onboarded, they receive training on the well-being principles along with an introduction to their role in promoting employee well-being.

• Organizational goals to improve well- being outcomes were set in year 2 and have been applied to all leaders.

COMMITTEE FORMATION AND PARTICIPATION

Once the commitment was made by the or- ganization to embrace employee well-being as a core differentiator, education was done with key constituents. These included the nursing leadership team and the Nurse Professional Practice Council. Each presentation was well received and resulted in volunteers to help roll out the strategies. A structure was devel- oped that supports well-being across the or- ganization and includes staff at all levels. The structure includes a steering committee and 5 subcommittees, 1 for each of the 5 Well- Being elements. The steering committee is led by the VP of HR, and there is an iden- tified executive champion for each of the 55

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Engaging Employees in Well-Being 235

committees. In addition, there are 3 additional staff committees to represent night shift as well as off-site stakeholders. Membership ap- plications are taken through an intranet ap- plication system in which employees can ex- press their interest to serve on a committee of their choice. Employees are asked, but not required, to attend the meetings in person or virtually. Conference line numbers are pro- vided for meeting times. Members have be- come champions within their departments, constantly communicating efforts. Commit- tee participation started at about 40 employ- ees and has surged to more than 160 partici- pants organization-wide during a 3-year time period. There has been consistent participa- tion due to expressed employee passion for the work. Some participants like to work at the organizational level while others focus at the department level. The committees have developed strategic objectives to guide the committee work and set priorities. This step has been pivotal in ensuring that work is measurable and tied to the overall well-being objectives. These objectives are shared in Table 2.

Each year, the committees reevaluate goals and develop actions for the coming year. Suc- cessful programs are continued and unsuc- cessful programs are revisited, either to revise objectives or to develop new ones.

A big challenge for this work is prioritiz- ing the interventions so that goals can be met. The employees on these committees drive the work and take ownership for the initiatives. Because all stakeholders are involved in the process, well-being actions have been imple- mented for all shifts and sites. The commit- tee members supporting the Eastern Shore (approximately 25 miles from the main cam- pus and part of the organization consisting of physician practices and small ambulatory sites) focused on Purpose, Social, and Physi- cal WellBeing. They increased the amount of education available to staff and held a fun, competitive Field Day. They provide tips and ideas about what individuals could do to im- prove personal well-being.

The other regional committee serves a larger population in 1 locale. Over the course of 6 months, this group flourished. There is consistent committee participation from 15 team members. The committee has planned social gatherings, hosted a farmer’s market over the summer months, implemented morn- ing stretching sessions, reinstituted a popular weight loss program, and planned a yearlong Financial WellBeing series for employees. A significant accomplishment was the addition of food trucks to compensate for the lack of a cafeteria. Staff members regularly comment about the commitment to increase their well- being and how they do not have to leave the site to achieve it. The well-being scores in one department at this site increased by 7% over the course of 3 years.

The smaller number of staff on the night shift creates challenges for bringing events and programming to employees. The night shift committee has developed creative ways for programs designed for the day shift to be successfully replicated for the night shift, in- cluding specially designed physical challenges and a stress reduction fair. The night shift WellBeing champions have encouraged an increase in social activities. They are coordi- nating the financial series for this staff as well. The committee challenges the organization to include them in activities and has taken ac- countability to help increase night shift mem- ber participation at programs. The success of the committees is driven by interested and engaged leaders who can facilitate a philo- sophical conversation, understand the limita- tions of what can actually be achieved, and encourage the committee to follow through on planned actions. Employees do not have to wait for someone else to make a change. Changes can be made at the organization level or department level through committee work or by the individual. The steering com- mittee, executive champions, and the VP of HR are available to remove obstacles or to guide actions so that they are aligned with the overarching strategy and plans for the organization.

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236 NURSING ADMINISTRATION QUARTERLY/JULY–SEPTEMBER 2018

Table 2. AAMC WellBeing Strategic Objectives and Tactics, 2015-2018

WellBeing Element Strategic Objectives Completed Tactics over the last 3 y

Purpose Evaluate opportunities to increase reward and recognition for individuals and departments

Provide additional opportunities at all levels to participate in career development opportunities

Expand coaching and mentoring throughout the organization

Promote empowerment philosophy

$250 000 scholarship program for nonclinical employees; career exploration fair for internal applicants looking to explore opportunities or transfer to new jobs; 100% e-mail access for all employees; increased number of employee classes; monthly newsletter to all employees with education offerings; leadership essentials program for new leaders; panel sessions focused on balancing work/life; national speakers on WellBeing topics

Social Provide increased opportunities for employees to participate in system-sponsored social events

Develop strategies to increase social WB at unit level

Provide education and support to employees to learn impact of others on their social WB

Thank You Card program; NYC Bus Trips; Baseball Game; Book Club; Movie Nights; Increased recognition training; Best Friend at Work campaign; Art in the Café; free tickets to local baseball and lacrosse games; guidance to departments for how to host their own department events focused on Social WB; EAP hosted a class on toxic people

Financial Increase participation in retirement program

Increase financial education for all staff

Financial education series; auto enrollment for retirement plan; home buying course; enhanced pharmacy benefits; partnership with financial planners that offer complimentary introduction and reduced fee; financial fitness fair; vendor fair to explore discounts; additional vendors added to employee discounts; promotion for EAP; combined leave benefit revision

Physical Promote healthy eating/ healthy food choices

Provide stress-reduction programming

Promote health/opportunities to stay active

Develop executive-level/ leadership involvement

Fresh fruit tastings with recipes in cafeteria; cancer screenings and education for employees; Wellness Wednesdays and Fitness Fridays; Walk with an Executive series; reduced soda and unhealthy snacks; enhanced signage; healthy cooking classes; New Year’s resolution events; WellBeing+ (a wellness portal to track challenges and overall health); free seated chair massages; fryerless Fridays; whole fruit at cafeteria registers; stress reduction fair; stress reduction baskets to departments

(continues)

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Engaging Employees in Well-Being 237

Table 2. AAMC WellBeing Strategic Objectives and Tactics, 2015-2018 (Continued)

WellBeing Element Strategic Objectives Completed Tactics over the last 3 y

Community Increase communication about current AAMC community activities

Create additional opportunities for employees to participate in community service

Recognize and support employees for community service

Food collection for local women’s shelter; backpack collection and delivery for foster children transitioning to homes; sock drive; United Way campaign; cultural diversity series; partnership with project clean stream; CEUs for community education; employee hardship assistance fund; community events at other well-being fairs (such as packing lunches or can drives); more than 200 000 h in community benefit hours

Abbreviations: AAMC, Anne Arundel Medical Center; CEUs, continuing education; EAP, employee assistance program; WB, WellBeing.

INVESTMENTS, ACTIONS, AND OUTCOMES

The initial investment in WellBeing was the implementation costs of adding the WellBeing survey to the employee engage- ment survey and the training of leaders on WellBeing. A WellBeing manager was hired to help facilitate the work of the committees, conduct training, and oversee the survey and action planning. The AAMC WellBeing budget is small but it pays for 1 national external pre- sentation a year as well as the supplies needed to support committee activities. Significant changes, such as alterations to the retirement program, are funded through the annual ben- efits budget. The majority of activities are low cost and free. Whenever possible, WellBeing concepts are interwoven into existing activ- ities such as Nurses Week. Each WellBeing element (Purpose, Social, Financial, Physical, and Community) had specific activities that have been implemented across the organiza- tion. Each is described in more detail later:

Purpose WellBeing

There is a direct correlation to Purpose WellBeing and high employee engagement.11

Anne Arundel Medical Center internal data show that departments with high levels of

well-being are 12 times more likely to have engaged employees. The Purpose WellBeing committee has embraced career development and has implemented an annual career de- velopment fair. In addition, the committee has raised awareness of the needs of entry- level employees. As a result, an “Expanding Horizons” program has been created in collaboration with the Purpose WellBeing committee to provide opportunities for career exploration, career paths, and advancement for entry-level staff within AAMC. Resources have been invested to ensure that all staff have e-mail access along with basic computer skills. Entry-level staff now have access to career coaching, basic skills assessment, and devel- opment activities. Service department lead- ers support and encourage their staff to take advantage of these opportunities, which in- crease promotion potential. The focus on Pur- pose has resulted in the development of a ca- reer ladder for patient care technicians in the hospital. As a result, there are currently 35 patient care technicians on the ladder, and several ancillary support service employees have been promoted. System benefits include reducing turnover and improving retention.

Data from the annual WellBeing survey in- dicated the need to invest more in the de- velopment of leaders. Programs have been

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238 NURSING ADMINISTRATION QUARTERLY/JULY–SEPTEMBER 2018

expanded to support leaders through the en- tire life cycle of leadership. The AAMC “Lead Academy,” an emerging leaders program, was started in Nursing and was then expanded to all leaders throughout the organization. In ad- dition to learning basic leadership skills, Lead Academy participants must complete a year- long project. Several projects tie directly to the WellBeing work, such as one study in- troducing mindfulness to AAMC, and another that researched the impact of sleep depriva- tion on patient care.

Social WellBeing

This element has been widely embraced at all levels of the organization. Under So- cial WellBeing, the focus of the work is on bringing employees together socially. It also focuses on reducing stress, increasing em- ployee safety, and reducing bullying. There is overlap between Physical WellBeing and Social WellBeing in developing and execut- ing programs. Examples of activities include well-loved programs such as bus trips to local attractions, family movie nights, sports out- ings, book clubs, and art nights. Employees of all backgrounds help organize the events, and participation is consistently high. Depart- ments have worked hard to conduct and sup- port social activities. Some combine social activities with community support, such as volunteering together at the local homeless shelter.

One area of concern to AAMC team members is that health care workers today feel more threatened and less safe in the workplace.12 Anne Arundel Medical Center is able to leverage the WellBeing strategy to address employee safety concerns. The workplace safety committee has been rein- vigorated. Members connect their work to improving employee well-being. The most recent AAMC Patient Safety Culture Survey experienced a 16% increase in participation, and 11 of the 12 composite areas went up significantly. The composite score for Handoffs and Transitions went from 43% to 77% and the composite score for Nonpunitive

Response to Errors increased from 41% to 72%. This is an example of how employees are beginning to see the connection of well-being to all facets of their work life.

Nationally, it has been well documented that relentless change and ongoing pressure to improve quality and reduce cost have led to increased stress and dissatisfaction for clinicians.13 The AAMC WellBeing Steering committee has spearheaded more efforts to- ward reducing stress within the organization. The committee sponsored a speaker who came to the organization to talk about burnout and techniques to combat it. A stress reduc- tion fair is hosted each year to give employ- ees the opportunity to explore offerings such as acupuncture, zero balancing, and mindful- ness. Anne Arundel Medical Center also con- tracts with local providers to offer employees a discount on these services. One of the most successful, yet simplistic, tactics has been to create a stress reduction basket that contains a plethora of stress reduction massage tools along with tips for stretching. These baskets rotate around the organization, and many de- partments take matters into their own hands by purchasing their own supplies for a “relax- ation station.”

The medical staff has also championed physician well-being. An annual physician WellBeing conference attracts approximately 100 to 200 physicians. A physician well-being survey is currently being implemented to identify areas for improving provider well- being. The physician lead for this work and the manager of WellBeing are working to- gether to create synergy between efforts.

Financial WellBeing

Financial WellBeing is the most difficult ele- ment for leaders to address. Leaders across the organization express discomfort when deal- ing with this subject. There is not an expec- tation that leaders need to discuss personal financial planning with their staff. Rather, leaders need to be aware of how financial worries impact employee well-being and, po- tentially, job performance. Leaders can be the

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Engaging Employees in Well-Being 239

conduit to the growing library of information the organization has to offer. The Financial WellBeing committee arranged for a financial series that offers opportunities for employ- ees to learn about topics ranging from retire- ment, home buying, credit card theft, improv- ing credit scores, simple budgeting practices, and loan forgiveness programs for health care workers. Programs are offered in person and online. The goal is to encourage individuals to manage their financial resources (rather than the misconception that the organization fo- cusing on Financial WellBeing was going to give everyone a raise). At the system level, AAMC has taken significant steps to increase employee Financial WellBeing. The Expand- ing Horizon program was developed to en- courage a career path for entry-level employ- ees. As part of the evaluation of the Expanding Horizon program, the minimum starting wage was strategically increased by almost $3.00 an hour over 2 years, with plans to continue to invest as resources allow.

Gallup data indicate that individuals who take steps to increase their long-term eco- nomic security enjoy higher well-being over- all. This information led to the system increas- ing the retirement match an additional 1% and automatically enrolling employees in the re- tirement program with an auto escalation. To- day there is a 95% participation in the retire- ment program. This investment in Purpose and Financial WellBeing for entry-level staff has resulted in a 24% decrease in first-year turnover.

A source of huge pride at AAMC is the im- plementation of the Auxiliary Scholarship pro- gram for entry-level staff. The volunteer aux- ilians were educated about the principles of WellBeing and then decided to build a pro- gram for staff with the greatest need. The Auxiliary donated $250 000 to start the pro- gram. This competitive, scholarship program is helping to build the pipeline for career progression in the organization. Scholarship winners are paid for full-time work but are scheduled only 20 hours per week, allowing them to enroll in school full time. All recipi- ents are assigned a coach and a mentor. They

take classes that lead directly to a degree or a certification for a job at AAMC. Once an individual is close to successfully completing his or her program, the desired department works to hold a position for the employee. On average, there has been an increase of 25% to the employee’s base rate of pay in the schol- arship group. Twenty-three employees have successfully completed the scholarship in 7 fields. Currently, through the Foundation, 20 nursing scholarships are offered annually that go beyond regular tuition reimbursement.

Physical WellBeing

Prior to the adoption of the WellBeing framework, AAMC had a wellness initiative called “Energize.” This successful program provided on-site exercise classes and offered weight loss reduction programs along with healthy challenges. Since the adoption of WellBeing as a program, participation in En- ergize programs has increased by 75%, with 4300 employees participating in the program. The Physical WellBeing committee expanded the scope of Energize. Members work directly with the dietary department to decrease the sale of unhealthy food in the cafeteria. Sale of healthy food now contributes 66% of all revenue in system eateries. Soda has been eliminated from the conference center, and the sale of sweetened beverages has been re- duced by 24%. In addition, a cooking class is being hosted for employees. They can come to the organization’s kitchen to learn how to cook simple, easy, and healthy dishes at home. They get to taste the food, too! Many departments have developed programs and challenges to promote a healthy lifestyle. The benefits of these programs cross over to in- creased Social WellBeing. A number of em- ployees have made significant gains in improv- ing their health. Their accomplishments are celebrated on the internal AAMC WellBeing Web site.

Community WellBeing

A few of the actions that were taken early on were about building and expanding what

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240 NURSING ADMINISTRATION QUARTERLY/JULY–SEPTEMBER 2018

was already successful in the organization. Two examples came directly from the nursing division. Long before Community WellBeing was being planned, the nursing staff had organized a committee called the Community Service Initiative. This group planned sponsored community drives and collections for local shelters and schools. The Community WellBeing committee built upon the nursing structure and expanded it throughout the organization, thus allowing more collections and drives. For many years, the nursing staff did community outreach to the local homeless shelter by providing a health clinic twice a month. The Community WellBeing committee expanded that support by formally agreeing to support 2 families annually as they transition from the shelter to a home. Anne Arundel Medical Center employees collect both new and used goods that could outfit an entire house, including furniture, kitchen supplies, and the hundreds of basics it takes to make a home for a family. A future challenge for the Community WellBeing committee is to develop ways to encourage employees to get involved in their own communities and help leaders recognize staff who do. The efforts around Community WellBeing have increased employee pride in working for AAMC. The Community WellBe- ing score has experienced the largest increase over the 3 surveys, with a 5% improvement.

NURSING LEADERSHIP AND WELLBEING INITIATIVES

As the manager of the largest employee base in the health system, the chief nursing officer’s (CNO’s) involvement and passion for this work are essential for the system’s success in deployment. The AAMC National Database of Nursing Quality Indicators (NDNQI) nurs- ing satisfaction results were above benchmark in all major categories, but it was clear from employee feedback that the radical changes occurring in health care and the stresses of the workplace today have strained the staff. The CNO must take an active role in educat- ing nurse leaders on the positive impact of in-

creased employee well-being. He or she must support the training and education needed to properly support this type of change. One of the core principles of a nursing Magnet hospi- tal is to create a work environment supportive of nursing professional practice and develop- ment. The CNO should act as a role mode or executive leader in this work by clearly demonstrating to a large employee base that the well-being of our staff is a priority for the organization.

The development of the WellBeing initia- tives, with the strong involvement of frontline staff, has complemented work being done to enhance Magnet performance and to maintain a supportive work environment. In addition to initiatives developed by the staff, national experts were invited to provide educational programs for frontline and leadership staff to add to the WellBeing work. One, particularly focused in Nursing, was centered on bullying and incivility. Another was to provide tech- niques for helping staff develop resiliency in these times of change. Both courses were received very positively by the staff and augmented work being done through the WellBeing committees.

An example of frontline nursing staff contributions toward the development of a project for one of our committees is the “Petals of Purpose.” Discussions at the pro- fessional practice committee have included conversations about the personal impact of remembering why individual nurses chose the profession. These thoughts were shared through the Purpose WellBeing committee and resulted in a systemwide “petals of pur- pose” project, which has resonated strongly with the nursing staff. Employees were given paper petals on which they wrote their pur- pose, and each unit created a poster in which these are mounted in their unit (see Figure 1).

Overall, this work supports the joy of practice14 and is in line with the latest white paper released by the Institute for Healthcare Improvement13 on bringing joy back to the workplace. This joy optimizes performance, reduces turnover, and improves quality of care. The 2017 IHI Framework for Improving

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Engaging Employees in Well-Being 241

Figure 1. Emergency department “petals of purpose.” Used with permission from Anne Arundel Medical Center.

Joy in Work summarizes the importance of leaders by stating that “the leadership and management practices designed to improve joy in work are some of the most high-leverage changes an organization can undertake since a focus on joy in work simultaneously impacts so many goals embedded within the Triple Aim.”13 At AAMC, the success of this work in each department was made a part of in- dividual nurse leaders’ performance evalua- tion. Regular pulse surveys are done to give snapshot views of progress. Combining in- formation from the employee engagement survey and the NDNQI survey, nurse leaders worked to develop action plans that tie the work together in order to prevent duplica- tion of plans. The pulse surveys ask 5 or 6

questions and allow monitoring the success of work occurring on different units.

It is very important for staff to see the CNO and all executive leaders as promoters of this work. Discussing these initiatives with large groups of nurses provides an excellent opportunity to allow employees to see that the organization is supportive of this work to benefit them. The success of major cul- tural change initiatives like this is dependent on executive leaders actively demonstrating their support. In partnership with the VP of HR, nurse leaders can customize some of this work for Nursing and then develop appropri- ate training. Frontline leaders need to receive excellent coaching so that they can support changes in their individual departments.

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242 NURSING ADMINISTRATION QUARTERLY/JULY–SEPTEMBER 2018

IMPLICATIONS FOR BOARD MEMBERS

The CNO has an active role with HR to underscore the importance and then the success of the WellBeing work to the board of trustees. When quality efforts and initiatives emerge for health systems, the role of the board of trustees is critical. Board member engagement at the right level and at the right time is essential for large-scale change efforts to be successful. Appropriate board-level engagements in understanding the strategic priority, the expected outcomes, and the necessary resources are all areas that board members should be attuned to. “For the not for profit hospital, the highest order stake- holders are the patient and community”15(p59)

and by extension the community of care- givers who provide that care. Board members

need to understand the impact of a healthy employee population on the care of patients. They should take the employees’ needs for well-being into account when considering resource allocation and strategy decisions. Board roles in this work include activities such as approving high-level organizational goals and policies, overseeing project perfor- mance at a strategic level through review of performance metrics and results, and acting as an advocate within the community for im- portant initiatives.16 The management team of AAMC has created “True North” metrics of operational measures that include the Well- Being efforts to improve workforce health. Table 3 shares the extended well-being goals and measures. Metrics are tracked monthly and quarterly and are presented at each meet- ing to both the quality and safety committee

Table 3. Workforce Goals and WellBeing Framework

AAMC Workforce Aims WellBeing

Framework Last Year

Result (2017) This Year

Goal (2018)

Reduce year 1 turnover Purpose WellBeing

38% staff turnover 33% staff turnover

Increase number of diverse candidates for leadership positions

Purpose WellBeing

Community WellBeing

New 80%

Increase participation in defined contribution plan

Financial WellBeing

87% of staff participating

92% of staff participating

Increase employees participating in fitness challenges

Physical WellBeing

Social WellBeing

4306 employees participating

4737 employees participating

Increase sales of healthy foods in cafeteria

Physical WellBeing

65% 67%

Reduce number of products offering sugar by 65%

Physical WellBeing

168 products in cafeterias

59 products in cafeterias

Reduce number of injuries from combative patients

Physical WellBeing

17 employee injuries

14 employee injuries

Financial WellBeing

Maintain contributions level to United Way

Community WellBeing

$123 000 in contributions

$120 000 in contributions

Implement pulse surveys and track improvement in Great Places to Work survey

All WellBeing and Engagement

Dimensions

New TBD

Abbreviations: AAMC, Anne Arundel Medical Center; TBD, To be determined.

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Engaging Employees in Well-Being 243

of the board and the entire board of trustees. The review and directional progress toward annual goals are discussed in subcommittee and committee meetings. Board members are expected to ask knowledgeable and appro- priate questions of management16 in order to exercise the decision-making function and the oversight function. The board members serve as excellent external advocates for the initiative. They realize that the approximately 4800 employees at the health system are also members of the community, and that their well-being has an impact on the ability of the system to have a robust workforce to provide high-quality, consistent care. Annually, progress toward goals is reviewed, and board approval is sought when setting new targets. In addition, top leadership and executive performance reviews are tied to achievement of annual operating goals. In this way, alignment occurs throughout the organization, and the management team can be rewarded for reaching goals.

EVALUATION AND NEXT STEPS

Anne Arundel Medical Center surveys for both engagement and well-being at the same time. The organization uses the Gallup Q12 for staff engagement and the Gallup- Healthways Well-Being 5 View to measure staff well-being. Survey results show that work groups that are high in engagement also tend to have higher well-being scores. Thirty-eight percent of employees are highly engaged at AAMC, while 14% are disengaged. Employees who are thriving in well-being tend to be more highly engaged. The latest survey results show that

• 74% of employees who are thriving in all 5 WellBeing elements are engaged;

• 48% of employees who are thriving in 3 of the 5 WellBeing elements are engaged; and

• engagement drops to 10% for employees thriving in zero WellBeing elements.

In addition, metrics for the WellBeing pro- gram measure specific criteria reported to the board of trustees (Table 3). Anne Arundel has

seen the following improvement since the program began:

• Physical WellBeing: There has been an im- provement in participation in physical ac- tivity programs (called “Energize”) from 2466 participants in 2014 to 4298 partic- ipants in 2017. This represents a nearly 75% increase. In addition, the system had a 65% reduction in cafeteria prod- uct offerings of sugared beverages. This resulted in the elimination of 68 sugar products.

There was an improvement in staff percep- tion of feeling active and productive and hav- ing physical health near perfect.

• Purpose WellBeing: Twenty-three em- ployees enrolled in the “Expanding Hori- zons” program that resulted in promo- tions and pay increases. There was an improvement in staff rating of “liking what I do every day,” and learning and doing something interesting every day.

• Social WellBeing: Because of all of the ac- tivities and social events that have been conducted, there has been an improve- ment in employee perception of receiv- ing positive energy every day.

• Financial WellBeing: Over 3 years, par- ticipation in defined contribution plans rose from 75% to 95%. There was a de- crease in employee perception of “being worried about money in last seven days” as well as an increase in employee per- ception of “having enough money to do everything.”

• Community WellBeing: Contributions to United Way increased. An employee hard- ship fund was launched as part of the AAMC Foundation Annual Giving Cam- paign, which gave employees the oppor- tunity to designate funds to help fellow employees during a financial emergency. Employee perception was highest in “re- ceiving recognition for helping to im- prove the city where I live.”

Next steps for AAMC include a program evaluation and further analysis of data. For ex- ample, the organization will evaluate different

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244 NURSING ADMINISTRATION QUARTERLY/JULY–SEPTEMBER 2018

workforce strategies and stratify them by gen- eration. Data will be analyzed to see whether there are differences in perception based on age category. Another step will be to further enhance the opportunities for employees to more completely develop their own personal well-being plan, along with individual mile- stones that are easily tracked at the individual level. Determination of the most valuable elements of the WellBeing program from the employee perspective will allow the leader- ship team to further develop the most valuable components of the program. In addition, linking the WellBeing program outcomes to employee engagement scores will ultimately lead to reduced turnover and improved employee satisfaction.17 Ultimately, these metrics will be linked to organizational patient satisfaction and quality-of-care outcomes.

CONCLUSION

As the work in WellBeing at AAMC has evolved, one lesson learned has been that the success of this initiative is dependent on working with employees to own their own WellBeing journey. The organization is providing resources that employees can choose to utilize as they desire. In this way, employees are truly engaged in their health and well-being. There is an expectation that there will be an increase in the emotional commitment that the employee has to the or- ganization and to the “community we serve.” The program will continue to be expanded. It will include more frontline employee par-

ticipation, stronger frontline leadership, and enhanced education about the importance of whole-person well-being for employees. On- going evaluation of progress will continue. Opportunities for research in this space exist, and data evaluation and linkages can continue to be made by linking well-being to employee engagement. Ultimately, this improvement in employee well-being will lead to better outcomes, as demonstrated by documented studies that show that engaged employees lead to better service, quality, and productivity.6 Anne Arundel Medical Center is well on its way to reaching the quadruple aim through well-being of employees.

Engaged employees who feel cared for by their employer through initiatives like our WellBeing programs positively influence an organization’s performance. The work done at AAMC provides a framework, and gives suggestions to others, around the process of developing a robust employee WellBeing program.

Many health care organizations have exclu- sively focused on Physical WellBeing, under the moniker, Wellness, and are now contem- plating moving toward a more comprehensive well-being strategy. Anne Arundel Medical Center started out with a broader WellBeing platform. Our wellness initiatives were placed under Physical WellBeing as just one com- ponent. This has allowed us to communicate with our staff members in a direct way. We have embraced the quadruple aim not just in theory but through demonstrable actions, actions that any leadership team can embrace.

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14. Gergen Barnett K. In pursuit of the fourth aim in health care: the joy of practice. Med Clin North Am. 2017;101(5):1031–1040.

15. Bader BS. Distinguishing governance from manage- ment, great boards, trustee services. Am Hosp Assoc Publ. 2008;8(3):58–62.

16. Callender AN, Hastings DA, Hemsley MC, Morris L, Peregrine MW. US Department of Health and Human Services Officer of the Inspector General, American Health Lawyers Association. https:// oig.hhs.gov/fraud/docs/complianceguidance/ corporateresponsibilityfinal%209-4-07.pdf. Pub- lished 2007. Accessed February 14, 2018.

17. Kruse K. What is employee engagement? Forbes. https://www.forbes.com/sites/kevinkruse/2012/ 06/22/employee-engagement-what-and-why/ #68d84b697f37. Published 2012. Accessed February 14, 2018.

Copyright © 2018 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.https://q12.gallup.com/public/en-us/Featureshttp://www.healthways.com/well-being5http://www.healthways.com/well-being5http://www.ihi.org/resources/Pages/IHIWhitePapers/Framework-Improving-Joy-in-Work.aspxhttps://oig.hhs.gov/fraud/docs/complianceguidance/corporateresponsibilityfinal%209-4-07.pdfhttps://oig.hhs.gov/fraud/docs/complianceguidance/corporateresponsibilityfinal%209-4-07.pdfhttps://oig.hhs.gov/fraud/docs/complianceguidance/corporateresponsibilityfinal%209-4-07.pdfhttps://www.forbes.com/sites/kevinkruse/2012/06/22/employee-engagement-what-and-why/#68d84b697f37https://www.forbes.com/sites/kevinkruse/2012/06/22/employee-engagement-what-and-why/#68d84b697f37https://www.forbes.com/sites/kevinkruse/2012/06/22/employee-engagement-what-and-why/#68d84b697f37

Do you ever wonder whynurses engage in practicesthat aren’t supported by evidence, while not implementing practices substantiated by a lot of evidence? In the past, nurses changed hospitalized patients’ IV dressings daily, even though no solid evidence supported this prac- tice. When clinical trials finally explored how often to change IV dressings, results indicated that daily changes led to higher rates of phlebitis than did less frequent changes.1 In many hospital EDs across the country, children with asthma are treated with albuterol delivered with a nebulizer, even though substantial evidence shows that when albuterol is delivered with a metered-dose inhaler plus a spacer, children spend less time in the ED and have fewer adverse effects.2 Nurses even disrupt patients’ sleep, which is important for restorative healing, to docu- ment blood pressure and pulse rate because it’s hospital policy to

take vital signs every two or four hours, even though no evidence supports that doing so improves the identification of potential complications. In fact, clinicians often follow outdated policies and procedures without questioning their current relevance or accu- racy, or the evidence for them.

When a spirit of inquiry—an ongoing curiosity about the best evidence to guide clinical decision making—and a culture that sup- ports it are lacking, clinicians are unlikely to embrace evidence-based practice (EBP). Every day, nurses

across the care continuum perform a multitude of interventions (for example, administering medica- tion, positioning, suctioning) that should stimulate questions about the evidence supporting their use. When a nurse possesses a spirit of inquiry within a sup- portive EBP culture, she or he

can routinely ask questions about clinical practice while care is being delivered. For example, in patients with endotracheal tubes, how does use of saline with suctioning compared with suctioning without saline affect oxygen saturation?

ajn@wolterskluwer.com AJN � November 2009 � Vol. 109, No. 11 49

By Bernadette Mazurek Melnyk, PhD, RN, CPNP/PMHNP, FNAP, FAAN, Ellen Fineout-Overholt, PhD, RN,

FNAP, FAAN, Susan B. Stillwell, DNP, RN, CNE, and Kathleen M.

Williamson, PhD, RN

Igniting a Spirit of Inquiry: An Essential Foundation for Evidence-Based Practice

How nurses can build the knowledge and skills they need to implement EBP.

Every day, nurses perform interventions (for

example, administering medication, positioning,

suctioning) that should stimulate questions

about the evidence supporting their use.

This is the first article in a new series from the Arizona State University College of Nursing and Health Innovation’s Center for the Advancement of Evidence-Based Practice. Evidence-based practice (EBP) is a problem-solving approach to the delivery of health care that integrates the best evidence from studies and patient care data with clinician expertise and patient preferences and values. When delivered in a context of caring and in a supportive organiza- tional culture, the highest quality of care and best patient outcomes can be achieved.

The purpose of this new series is to give nurses the knowledge and skills they need to implement EBP consistently, one step at a time. Articles will appear every two months to allow you time to incorporate information as you work toward implementing EBP at your institution. Also, we’ll schedule “Ask the Authors” call-ins every few months to provide a direct line to the experts to help you resolve questions. Details about how to participate in the calls will be published with January’s Evidence-Based Practice: Step by Step.

50 AJN � November 2009 � Vol. 109, No. 11 ajnonline.com

In patients with head injury, how does elevating the head of the bed compared with keeping a patient in a supine position affect intracra- nial pressure? In postoperative surgical patients, how does the use of music compared with no use of music affect the frequency of pain medication administration?

The Institute of Medicine has set a goal that by 2020, 90% of all health care decisions in the United States will be evidence based,3 but the majority of nurses are still not consistently imple- menting EBP in their clinical set- tings.4 To foster outcomes-driven health care in which decisions are based on evidence, providers and health care systems need a

To accelerate the use of EBP by nurses and other health care providers, some insurers have instituted pay-for-performance programs that offer clinicians incentives to follow evidence- based guidelines. And Medicare no longer reimburses hospitals for treating preventable hospital- acquired injuries or infections (such as falls, pressure ulcers, or ventilator-associated pneumonia). Although these measures should improve the overall quality of care in our hospitals, it’s well known that extrinsic motivators are typically not more successful in facilitating a change in behavior than intrinsic motivators. There- fore, for EBP to accelerate and

comprehensive approach to ensure that their results are measured.5

Without EBP, patients don’t receive the highest quality of care, health outcomes are seriously jeopar- dized, and health care costs soar.6

Findings from recent studies also indicate that when nurses and other health care providers engage in EBP, they experience greater autonomy in their practices and a higher level of job satisfaction.7 At a time when this country is facing the most serious nursing shortage in its history, empowering nurses to routinely engage in EBP may lead to less turnover and lower vacancy rates, in addition to im- proving the quality of health care and patient outcomes.

Figure 1. The EBP Paradigm: the merging of science and art. EBP within a context of caring and an EBP culture results in the highest quality of health care and patient outcomes. © Melnyk and Fineout-Overholt, 2003.

EBP Organizational Culture

Research evidence and evidence-based

theories

High-quality patient

outcomes

Clinical decision making

Patient preferences and values

Clinical expertise (for example, evidence from patient assessment

as well as use of health care resources)

Context of Caring

ajn@wolterskluwer.com AJN � November 2009 � Vol. 109, No. 11 51

with amoxicillin. However, if the child dislikes the taste and it’s likely that the medication won’t be taken, patient preference should outweigh the best practice guide- line and an alternative antibiotic should be prescribed.

Although EBP may be re- ferred to as evidence-based medi- cine, evidence-based nursing, or evidence-based physical therapy within various disciplines, we advocate referring to all of these as evidence-based practice, in order to stimulate transdiscipli- nary evidence-based care and avoid the specialized terminology that can isolate the various health professions.

When nurses implement EBP within a context of caring and a supportive organizational cul- ture, the highest quality of care is delivered and the best patient, provider, and system outcomes are achieved (see Figure 1).10 Despite outcomes being substantially

better when patients receive evidence-based care, nurses and other health care providers often cite barriers that prevent its deliv- ery, including10, 11

• inadequate EBP knowledge and skills.

• a lack of EBP mentors to work with providers at the point of care.

• inadequate resources and support from higher admin- istration.

• insufficient time, especially when there are demanding patient caseloads and staffing shortages. Conversely, a number of factors

facilitate the implementation of EBP, including8, 12, 13

• EBP knowledge and skills. • belief in the value of EBP and the ability to implement it.

• a culture that supports EBP and provides the necessary tools to sustain evidence-based care (for example, access to computer databases at the point of care and time to search for evidence).

• EBP mentors (advanced prac- tice clinicians with expertise in EBP and organizational and individual behavior-change strategies) who work directly with clinicians at the point of care in implementing EBP. Once nurses gain EBP knowl-

edge and skills, they realize it’s not only feasible within the con- text of their practice setting, but that it reignites their passion for

thrive in the U.S. health care sys- tem, nurses must have • a never-ending spirit of inquiry and consistently question cur- rent clinical practices.

• strong beliefs in the value of EBP.

• knowledge of and skills in EBP along with the confidence to use it.

• a commitment to deliver the highest quality evidence-based care to patients and their fam- ilies.

In addition, health care institu- tions must sustain a culture that embraces EBP, including providing clinicians the support and tools they need to engage in evidence- based care.

EBP is a problem-solving ap- proach to the delivery of health care that integrates the best evi- dence from well-designed studies and patient care data, and com- bines it with patient preferences and values and nurse expertise.8, 9

However, there’s no magic for- mula for what percentage of a clinical decision should be based on evidence or patient preferences or nurse expertise. The weight given to each of these three EBP components varies according to the clinical situation. For exam- ple, evidence-based guidelines might indicate that a young child with an ear infection receive amox- icillin and clavulanate (Augmentin) if the infection hasn’t resolved

Questions that Spark a Spirit of Inquiry • Who can I seek out to assist me in enhancing my evidence-based practice (EBP) knowledge and skills and serve as my EBP mentor?

• Which of my practices are currently evidence based and which don’t have any evidence to support them?

• When is the best time to question my current clinical practices and with whom? • Where can I find the best evidence to answer my clinical questions? • Why am I doing what I do with my patients? • How can I become more skilled in EBP and mentor others to implement evidence-based care?

Strategies for Building a Spirit of Inquiry

Write “WHY?” on a poster and place it in the staff lounge orrestroom to inspire questions from nurses about why they’re engaging in certain practices with their patients. Gather the responses in an answer box. After one month, take the responses and arrange them according to common themes. Address the themes in a staff meeting.

Review and answer the Questions that Spark a Spirit of Inquiry. Create a poster with these questions and post them where your colleagues will see them. Think about these clinical questions when caring for your patients.

52 AJN � November 2009 � Vol. 109, No. 11 ajnonline.com

We’ll use this case in each column to focus on successive steps of the EBP process. In the meantime, we encourage you to answer the

Questions that Spark a Spirit of Inquiry and implement two Strategies for Building a Spirit of Inquiry in order to start your own EBP journey and begin build- ing a spirit of inquiry with your colleagues at work. �

Bernadette Mazurek Melnyk is dean and distinguished foundation professor of nursing at Arizona State University in Phoenix, where Ellen Fineout-Overholt is clinical professor and director of the Center for the Advancement of Evidence- Based Practice, Susan B. Stillwell is clinical associate professor and program coordi- nator of the Nurse Educator Evidence- Based Practice Mentorship Program, and Kathleen M. Williamson is associate direc- tor of the Center for the Advancement of Evidence-Based Practice. Contact author: Bernadette Mazurek Melnyk, bernadette.melnyk@asu.edu.

REFERENCES 1.Gantz NM, et al. Effects of dressing

type and change interval on intra- venous therapy complication rates. Diagn Microbiol Infect Dis 1984;2(4): 325-32.

2.Cates CJ, et al. Holding chambers (spacers) versus nebulisers for beta- agonist treatment of acute asthma. Cochrane Database Syst Rev 2006(2): CD000052.

3.Olsen L, et al. The learning health- care system: workshop summary. Washington, DC: National Academies Press; 2007. http://www.nap.edu/ catalog.php?record_id=11903.

4.Pravikoff DS, et al. Evidence-based practice readiness study supported by academy nursing informatics expert panel. Nurs Outlook 2005;53(1): 49-50.

5.Piper K. Results-driven health care: the five steps to higher quality, lower costs. Washington, DC: Health Results Group LLC; 2008.

6.Health Research Institute, Pricewater- houseCoopers. What works: healing the healthcare staffing shortage. Dal- las: PricewaterhouseCoopers; 2007. http://www.pwc.com/us/en/healthcare/ publications/what-works-healing- the-healthcare-staffing-shortage. jhtml.

7.Maljanian R, et al. Evidence-based nursing practice, Part 2: building skills through research roundtables. J Nurs Adm 2002;32(2):85-90.

8.Melnyk BM, et al. The evidence-based practice beliefs and implementation scales: psychometric properties of two new instruments. Worldviews Evid Based Nurs 2008;5(4):208-16.

9. Sackett DL, et al. Evidence-based medicine: how to practice and teach EBM. 2nd ed. Edinburgh; New York: Churchill Livingstone; 2000.

10.Melnyk BM, Fineout-Overholt E. Evidence-based practice in nursing and healthcare: a guide to best practice. Philadelphia: Lippincott Williams and Wilkins; 2005.

11.Melnyk BM. Strategies for overcoming barriers in implementing evidence- based practice. Pediatr Nurs 2002; 28(2):159-61.

12.French B. Contextual factors influenc- ing research use in nursing. Worldviews Evid Based Nurs 2005;2(4):172-83.

13.Melnyk BM. The evidence-based practice mentor: a promising strategy for implementing and sustaining EBP in healthcare systems. Worldviews Evid Based Nurs 2007;4(3):123-5.

14.Dacey MJ, et al. The effect of a rapid response team on major clinical out- come measures in a community hos- pital. Crit Care Med 2007;35(9): 2076-82.

their roles and assists them in delivering a higher quality of care with improved patient outcomes. We use the term Step Zero to refer

to the continual cultivation of a spirit of inquiry as an essential foundation for EBP, and we rec- ommend the routine use of a standard set of questions in prac- tice (see Questions that Spark a Spirit of Inquiry) and the use of the strategies in Strategies for Building a Spirit of Inquiry.

Remember, EBP starts with a spirit of inquiry (Step Zero). As you embark on this wonderful journey to promote the highest quality of care and the best out- comes for your patients, reflect upon Step Zero, the EBP para- digm, and how you practice care. The Case Scenario for EBP: Rapid Response Teams will provide a context for learning EBP through- out the next several columns.

Case Scenario for EBP: Rapid Response Teams

You’re a staff nurse on a busy medical–surgical unit. Overthe past three months, you’ve noticed that the patients on your unit seem to have a higher acuity level than usual, with at least three cardiac arrests per month, and of those patients who arrested, four died. Today you saw a report about a recently published study in Critical Care Medicine on the use of rapid response teams to decrease rates of in-hospital car- diac arrests and unplanned ICU admissions. The study found a significant decrease in both outcomes after implementation of a rapid response team led by physician assistants with spe- cialized skills.14 You’re so impressed with these findings that you bring the report to your nurse manager, believing that a rapid response team would be a great idea for your hospital. The nurse manager is excited that you’ve come to her with these findings and encourages you to search for more evi- dence to support this practice and for research on whether rapid response teams are valid and reliable.

Step Zero refers to the continual cultivation

of a spirit of inquiry.

SPECIAL COMMUNICATION

How Evolving United States Payment Models Influence Primary Care and Its Impact on the Quadruple Aim Brian Park, MD, MPH, Stephanie B. Gold, MD, Andrew Bazemore, MD, MPH, and Winston Liaw, MD, MPH

Introduction: Prior research has demonstrated the associations between a strong primary care founda- tion with improved Quadruple Aim outcomes. The prevailing fee-for-service payment system in the United States reinforces the volume of services over value-based care, thereby devaluing primary care, and obstructing the health care system from attaining the Quadruple Aim. By supporting a shift from volume-based to value-based payment models, the Medicare Access and Children’s Health Insurance Program Reauthorization Act may help fortify the role of primary care. This narrative review proposes a taxonomy of the major health care payment models, reviewing their ability to uphold the functions of primary care, and their impacts across the Quadruple Aim.

Methods: An Ovid MEDLINE search and expert opinion from members of the Family Medicine for America’s Health payment and research tactic teams were used. Titles and abstracts were reviewed for relevance to the topic, and expert opinion further narrowed the literature for inclusion to timely and relevant articles.

Findings: No payment model demonstrates consistent benefits across the Quadruple Aim across a limited evidence base. Several cross-cutting lessons from available payment models several recommen- dations for primary care payment models, including the following: implementing per member per month–based models, validating risk-adjustment tools, increasing investments in integrated behavioral health and social services, and connecting payments to patient-oriented and primary care-oriented met- rics. Along with ongoing research in emerging payment models, data systems integrated across health care and social services settings using metrics that can capture the ideal functions of primary care will be critical to the development of future payment models that most optimally enhance the role of pri- mary care in the United States.

Conclusions: Although the ideal payment model for primary care remains to be determined, lessons learned from existing payment models can help guide the shift from volume-based to value-based care. To most effectively pay for primary care, future payment models should invest in a primary care infra- structure, one that supports team-based, community-oriented care, and measures the delivery of the functions of primary care. (J Am Board Fam Med 2018;31:588–604.)

Keywords: Delivery of Health Care, Family Medicine, Health Expenditures, Primary Health Care

Forty years ago, in the milestone “Declaration of Alma Ata,” all member nations of the World Health Organization declared that achieving health for all was dependent on a foundation of primary

care.1 A quarter century later, Dr. Barbara Starfield added to the evidence base, demonstrating that primary care produces higher quality of care, im-

This article was externally peer reviewed. Submitted 26 September 2017; revised 11 March 2018;

accepted 13 March 2018. From the Department of Family Medicine, Oregon

Health & Science University, Portland, OR (BP); Eugene S. Farley, Jr. Health Policy Center, University of Colorado School of Medicine, Denver, CO (SBG); Robert Graham

Center for Policy Studies in Family Medicine and Primary Care, Washington, D.C. (AB, WL).

Funding: none. Conflict of interest: none declared. Corresponding author: Brian Park, MD MPH, Department

of Family Medicine, Oregon Health & Science University, 3181 SW Sam Jackson Pk Rd, Mailcode FM, Portland, OR 97239 �E-mail: parbr@ohsu.edu).

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proves health outcomes, increases access, lowers costs, and attenuates disparities.2,3,4 She attributed the positive impact of primary care on health sys- tems to the “4 Cs,” which define its function: first contact, continuity, comprehensiveness, and coor- dination (Figure 1).4 Subsequent research has dem- onstrated that supporting these 4 Cs are the ele- ments of primary care that help health systems achieve the Quadruple Aim of improving patients’ experience of care, population health, and physi- cian satisfaction, while reducing costs.5,6,7,8

Starfield’s work and the healthcare system’s longstanding inattention to primary care may ex- plain the ongoing failure of the United States to achieve its Quadruple Aims, given the inadequate system level support for primary care.9,10,11,12,13,14

Its predominant fee-for-service (FFS) payment model has long been thought to undermine or insufficiently support the 4 Cs that explain primary care’s positive effects.15,16,17 Under pure FFS pay- ment models, clinicians are reimbursed retroac- tively for services, incentivizing higher volume, treatment rather than prevention, and fragmenta- tion of care without regard for quality or cost. Such models reward greater numbers of services ren- dered (ie, volume) rather than the quality and cost of care provided to patients (ie, value).18,19

Payers, public and private, are experimenting with shifting from paying for volume to paying for

value. The Affordable Care Act included provisions that advance primary care and value-based pay- ment, including the creation of the Center for Medicare and Medicaid Innovation (CMMI), which has tested innovative payment and delivery system models aimed at improving value.20,21,22 Five years after the Affordable Care Act, the Medicare Access and Children’s Health Insurance Program CHIP Re- authorization Act (MACRA) passed. Under MACRA, providers1 will select 1 of 2 incentive tracks: the al- ternative payment model (APM; see Table 1) or the Merit-Based Incentive Payment System (see Table 2).23 Both programs provide incentives for improving quality and reducing costs.

As value-based payment spreads, better under- standing of existing models can guide which ap- proaches deserve ongoing implementation and re- search efforts. This narrative review of the literature proposes a taxonomy of the major health care pay- ment models, highlights their distinguishing charac- teristics (Table 3), and reviews their impacts across the Quadruple Aim (Table 4). We also discuss the impact of each payment model in supporting the 4 Cs of primary care; given the lack of widespread use and standardized metrics in measuring these pri-

1Eligible clinicians provide care for at least 100 Medicare patients and bill for greater than $30,000 of Medicare Part B services.

Table 1. Scheduled Adjustments in APM Eligibility Criteria under Medicare Access and Children’s Health Insurance Program Reauthorization Act

Year Eligibility

2019 and 2020 �25% of total Medicare revenue is from a qualified, eligible APM 2021 and 2022 �50% of total Medicare revenue OR

�25% of total Medicare revenue and 50% of all-payer revenue (eg, Medicaid, private insurers) is from a qualified, eligible APM

2023 and beyond �75% of total Medicare revenue OR �25% of total Medicare revenue and 75% of all-payer revenue is from a qualified, eligible APM

APM, alternative payment model; OR, odd ratio.

Figure 1. The 4 Cs of Primary Care.

• Contact: Accessibility as the first contact with the health care system • Comprehensiveness: Accountability for addressing a vast majority of personal health

care needs, • Coordination: Coordination of care across settings, and integration of care for acute

and (often comorbid) chronic illnesses, mental health, and prevention, guiding access to more narrowly focused care when needed,

• Continuity: Sustained partnership and personal relationships over time with patients known in the context of family and community.

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mary care attributes24, when relevant, we consider the hypothetical impacts of each model when for- mal metrics were not used. Based on these findings, we provide policy and research recommendations for payment reform to best advance primary care.

Methods Starfield Summit I: Advancing Primary Care Research, Policy, and Patient Care The first iteration of this narrative review was con- ducted before the inaugural Starfield Summit (http://www.starfieldsummit.com) on April 24 to 26, 2016, in Washington, D.C. It was intended to inform and capture informant input from the Sum- mit’s nearly 150 invited primary care leaders (PCPs), researchers, and health care leaders to dis- cuss and enable research and policy agenda-setting around primary care payment, measurement, and teams.25

Literature Review We first conducted a literature search26 on primary care payment, enriched through expert consulta- tion before, during, and after the Summit. In March 2016, an Ovid MEDLINE search was con- ducted using the search terms “payment” and “pri- mary care.” The search was limited to articles pub- lished in English since 2010, yielding a total of 391 results2, with 97 articles ultimately included in the review. Exclusion criteria included the following: inclusion in a subsequent systematic review, up- dated evidence available (ie, more recent article from the same demonstration), not focused on pay- ment models, not focused on Quadruple Aim and/or the 4 Cs, and non-US evaluations that were subnational. Additional articles and gray literature were identified from the expert opinions of mem- bers of the Family Medicine for America’s Health payment and research tactic teams and a “snowball”

method of reviewing the references of the search results. The literature was summarized for each model, and key demonstrations or projects were selected, with agreement from at least 2 authors from the writing group, to highlight examples.

Results Fee-For-Service Under FFS, a provider is retrospectively paid a predefined amount for each service. Consequently, providers are incentivized to increase volume with- out bearing financial risk for quality or costs; in- surers bear high financial risk in this arrangement. In 1992, the Centers for Medicare and Medicaid Services (CMS) began using the Resource-Based Relative Value Scale to set a fee schedule for dif- ferent services, which has been criticized for dis- proportionately weighing specialist care and proce- dures over primary care.27,28 Despite concerns over the limitations of FFS, its inclusion in a payment model may enhance the use of services that are low-cost and underutilized29, such as vaccines in low immunization areas, where increased volume is desirable for population health.

Traditional (Or Full-Risk) Capitation In response to rising costs from FFS, health main- tenance organizations (HMOs)3 emerged in the 1980s to coordinate care and reduce use30 by capi- tating payments.26 In traditional capitation, provid- ers are paid a prospective amount to cover all ser- vices within a specific period of time, most often as a per member per month (PMPM) fee. Payments vary by age-group and sex and are determined based on prior average costs of care under FFS.31,32

A capitated fee can cover all primary care services, all outpatient services, or all health care services,

2In the case that a more recent report on a demonstration project was published between the time of the initial litera- ture search and submission of this manuscript, we replaced the prior report with the most up-to-date evidence.

3HMOs and other managed care models also include other mechanisms for cost control (e.g., narrow provider networks and pre-authorization of services). For the pur- poses of this paper, we have examined this model as a surrogate for capitated payment, though we acknowledge other mechanisms were in place to contribute to outcomes.

Table 2. Scheduled Payment Adjustments in Merit-Based Incentive Payment System

Adjustment 2019 2020 2021 2022 and beyond

Baseline payment adjustment �4% �5% �7% �9% Maximum payment adjustment for high performers �12% �15% �21% �27%

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pa ym

en t

m od

el

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en tia

lly M

ed ic

ar e

P hy

si ci

an G

ro up

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ct ic

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em on

st ra

tio n

P ro

je ct

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m ar

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re pr

ac tic

es ,i

f ta

rg et

s no

t m

et B

un dl

ed pa

ym en

t (e

pi so

de –

of -c

ar e)

P ai

d fo

r al

ls er

vi ce

s re

nd er

ed fo

r a

gi ve

n ep

is od

e of

ca re

M ix

ed (g

en er

al ly

re tr

os pe

ct iv

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tr ig

ge re

d an

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os pe

ct iv

el y

pa id

)

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(b ut

do es

no t

di sc

ou ra

ge vo

lu m

e of

ep is

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)

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ex ce

pt fo

r ou

tc om

es re

la te

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za tio

n

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m ar

y ca

re pr

ac tic

es ,

or ga

ni za

tio ns

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C M

M I’

s B

un dl

ed P

ay m

en ts

fo r

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e Im

pr ov

em en

t

Sh ar

ed sa

vi ng

s P

ai d

ba se

d on

sp en

di ng

be lo

w a

pr ed

et er

m in

ed be

nc hm

ar k

ov er

a pe

ri od

of tim

e (c

on tin

ge nt

on m

ee tin

g ce

rt ai

n qu

al ity

ta rg

et s)

M ix

ed (p

ro sp

ec tiv

e at

le ve

lo f

th e

A C

O ,b

ut pr

ov id

er s

of te

n st

ill pa

id vi

a FF

S)

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O s

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en tia

lly M

ed ic

ar e

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ed Sa

vi ng

s P

ro gr

am A

C O

s

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nd ed

FF S

an d

ca pi

ta tio

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ai d

a pr

ed et

er m

in ed

am ou

nt in

te nd

ed to

co ve

r m

ed ic

al ho

m e

se rv

ic es

fo r

a sp

ec ifi

c pe

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of tim

e in

ad di

tio n

to FF

S

M ix

ed N

o (t

o th

e ex

te nt

th at

FF S

is th

e pr

ed om

in an

t pa

ym en

t m

ec ha

ni sm

)

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D ep

en ds

on un

de rl

yi ng

pa ym

en t

m od

el

P ot

en tia

lly M

ed ic

ar e

C om

pr eh

en si

ve P

ri m

ar y

C ar

e In

iti at

iv e

C om

pr eh

en si

ve (p

ri m

ar y)

ca re

pa ym

en t

P ai

d a

ri sk

-a dj

us te

d am

ou nt

to co

ve r

al l

pr im

ar y

ca re

se rv

ic es

fo r

a sp

ec ifi

c pe

ri od

of tim

e; in

cl ud

es co

m po

ne nt

of P

4P

P ro

sp ec

tiv e

Y es

Y es

P ri

m ar

y ca

re pr

ac tic

es Y

es Io

ra H

ea lth

C on

tin ue

d

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including inpatient and outpatient. In contrast to FFS, capitation incentivizes cost control. Capita- tion may also exist as part of blended models with mixed PMPM payments and FFS, or in a further risk-adjusted form mixed with pay-for-perfor- mance in comprehensive primary care payment; these models are discussed in a later section. In contrast to FFS, capitation shifts financial risk to the provider, while the payer has lower risk.

One study examined the impact of capitation on one of the 4 Cs and finding capitated models was associated with decreased first contact (access).33

This may reflect the incentive for providers to avoid sicker patients (termed adverse selection or “cherry-picking”) to reduce costs. Another possible negative impact on the 4 Cs is a financial incentive to inappropriately underdeliver services, leading to decreased comprehensiveness.34 The prospective element of capitation could benefit primary care by enabling upfront investments in practice compo- nents that enhance the 4 Cs (eg, care coordination) and providing flexibility for practices to determine how finances are spent.

Traditional capitation has demonstrated mixed effects on cost and quality35,36,37, although most evidence suggests a decreased use of hospitals and other expensive resources and worse patient satis- faction, consistent with the backlash toward HMOs in the 1990s.38

Pay-For-Performance (P4P) P4P supplements an underlying payment model, most often as a bonus on top of FFS. P4P refers to payment based on the achievement of a quality target (eg, hemoglobin A1c [HbA1c] level �8 for diabetic patients or delivery of cancer screening) or improvement in performance (eg, change from baseline for HbA1c); the latter approach may at- tenuate variation in quality across providers, and provide incentives for both high-performing and low-performing practices.39

Limited evidence exists for the impact of P4P on the 4 Cs. The United Kingdom’s Quality and Out- comes Framework (QOF) found decreased conti- nuity rates and no differences in patient-reported perception of coordination, when compared with preintervention periods.40 Incentivized metrics tended to improve, whereas nonincentivized met- rics demonstrated unchanged or worsened rates of improvement; a limited set of targeted metrics could thus inhibit the comprehensive function ofTa

bl e

3. Co

nt in

ue d

D es

cr ip

tio n

P ro

sp ec

tiv e

vs re

tr os

pe ct

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nc ia

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sc ou

ra ge

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lu m

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se rv

ic es

?

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nc ia

lly en

co ur

ag es

hi gh

qu al

ity of

ca re

?

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ty th

at pr

im ar

ily be

ar s

th e

fin an

ci al

ri sk

?

R is

k ad

ju st

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r pa

tie nt

co m

pl ex

ity ?

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m pl

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D ir

ec t

pr im

ar y

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P ai

d ou

ts id

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th ir

d- pa

rt y

in su

re rs

(o ft

en di

re ct

ly fr

om pa

tie nt

s) a

pr ed

et er

m in

ed am

ou nt

to co

ve r

al l

pr im

ar y

ca re

se rv

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fo r

a sp

ec ifi

c pe

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e

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tiv e

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m ar

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re pr

ac tic

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r pr

im ar

y ca

re ex

pe ns

es

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Q lia

nc e

P at

ie nt

s fo

r ot

he r

as pe

ct s

of ca

re (a

nd in

su re

rs if

pa tie

nt s

ha ve

th ir

d pa

rt y

in su

ra nc

e)

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cc ou

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le ca

re or

ga ni

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,h ea

lth m

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M M

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ed ic

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ic ai

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no va

tio n.

592 JABFM July–August 2018 Vol. 31 No. 4 http://www.jabfm.org

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Ta bl

e 4.

Im pa

ct of

Pr im

ar y

Ca re

Pa ym

en tM

od el

s on

th e

Q ua

dr up

le Ai

m an

d Te

ne ts

of Pr

im ar

y Ca

re

P ay

m en

t M

od el

Q ua

dr up

le A

im A

llo w

s P

ro ac

tiv e

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st m

en t

in P

ri m

ar y

C ar

e

T he

4 C

s of

P ri

m ar

y C

ar e

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m en

ts A

ss oc

ia te

d w

ith Su

cc es

sf ul

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gr am

s H

ea lth

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co m

es E

xp er

ie nc

e of

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e C

os t

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tr ol

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vi de

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tis fa

ct io

n C

on ta

ct (A

cc es

s) C

on tin

ui ty

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rd in

at io

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om pr

eh en

si ve

ne ss

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fo r-

se rv

ic e

(F FS

) 2

2 2

2 ✕

2 4 3

2 1 2

* B

ill in

g m

ec ha

ni sm

s av

ai la

bl e

th at

re co

gn iz

e pr

im ar

y ca

re te

ne ts

an d

no n-

fa ce

-t o-

fa ce

se rv

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di tio

na l

(f ul

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sk )

ca pi

ta tio

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tly 2

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ff .e

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k lim

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-f or

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4P )

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pr ia

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in pr

im ar

y ca

re *

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dl ed

pa ym

en t

(e pi

so de

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ca re

)

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k) In

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su ff

. ev

id en

ce In

su ff

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de nc

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/✕ (r et

ro ac

tiv el

y tr

ig ge

re d)

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ff .

ev id

en ce

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ff .e

vi de

nc e

1 (w

ea k)

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ff .e

vi de

nc e

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,m ay

no t

ap pl

y to

pr im

ar y

ca re

gi ve

n di

ffi cu

lty de

fin in

g an

d as

si gn

in g

bu nd

le s

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ed sa

vi ng

s 1

1 2 1

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ff .e

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✔ /✕

(p ro

vi de

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ff .

ev id

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ff .e

vi de

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ds pa

tie nt

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dd re

ss ps

yc ho

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C on

tin ue

d

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Ta bl

e 4.

Co nt

in ue

d

P ay

m en

t M

od el

Q ua

dr up

le A

im A

llo w

s P

ro ac

tiv e

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st m

en t

in P

ri m

ar y

C ar

e

T he

4 C

s of

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m ar

y C

ar e

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m en

ts A

ss oc

ia te

d w

ith Su

cc es

sf ul

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gr am

s H

ea lth

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co m

es E

xp er

ie nc

e of

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e C

os t

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tr ol

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vi de

r Sa

tis fa

ct io

n C

on ta

ct (A

cc es

s) C

on tin

ui ty

C oo

rd in

at io

n C

om pr

eh en

si ve

ne ss

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nd ed

FF S

an d

ca pi

ta tio

n

2 1

2 1

2 1

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ff .e

vi de

nc e

✔ /✕

1 1

1 In

su ff

.e vi

de nc

e T

ar ge

t hi

gh -n

ee ds

pa tie

nt s

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ro pr

ia te

ri sk

– ad

ju st

m en

t M

ul tip

ay er

al ig

nm en

t R

ea l-

tim e

da ta

sh ar

in g

O pt

im al

FF S/

ca pi

ta tio

n bl

en d

(m or

e re

se ar

ch ne

ed ed

) C

om pr

eh en

– si

ve pr

im ar

y ca

re pa

ym en

t

1 (w

ea k)

1 (w

ea k)

1 (w

ea k) 1

(w ea

k) ✔

1 (w

ea k)

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ff .

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de nc

e In

su ff

.e vi

de nc

e 1

(w ea

k) A

pp ro

pr ia

te ri

sk ad

ju st

m en

t P

ay m

en ts

ba se

d on

10 %

to ta

lc os

t of

ca re

ra th

er th

an pr

io r

FF S

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ec t

pr im

ar y

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ff .e

vi de

nc e 1

(w ea

k) 1

(w ea

k) 1

(w ea

k) ✔

2 1

* (b

et te

r in

di v.

ac ce

ss ,b

ut af

fo rd

ab ili

ty an

d w

or kf

or ce

co nc

er ns

)

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ff .e

vi de

nc e

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ff .e

vi de

nc e

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ff .e

vi de

nc e

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pl in

g w

ith ap

pr op

ri at

e w

ra pa

ro un

d in

su ra

nc e

to av

oi d

hi gh

pa tie

nt co

st s

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no n-

pr im

ar y

ca re

se rv

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*

1 ,e

vi de

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of po

si tiv

e ou

tc om

es .

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vi de

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of ne

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es .

2 1

,e vi

de nc

e of

m ix

ed ef

fe ct

s. 4 3

,n o

si gn

ifi ca

nt ef

fe ct

or ch

an ge

. ✔

,a llo

w s

pr oa

ct iv

e in

ve st

m en

t in

pr im

ar y

ca re

. ✕

,d oe

s no

t al

lo w

pr oa

ct iv

e in

ve st

m en

t in

pr im

ar y

ca re

. ✔

/✕ ,s

om e

co m

po ne

nt s

al lo

w pr

oa ct

iv e

in ve

st m

en t

in pr

im ar

y ca

re ,w

hi le

ot he

rs do

no t.

In su

ff .e

vi de

nc e,

no av

ai la

bl e

ev id

en ce

;( w

ea k)

,l im

ite d

or po

or qu

al ity

ev id

en ce

(ie ,�

1 st

ud y

ex am

in ed

an d/

or no

t a

co m

pa ri

so n

st ud

y) .

*N o

or lim

ite d

ev id

en ce

,b ut

a st

ro ng

th eo

re tic

al lik

el ih

oo d

of ef

fe ct

. P

ro ac

tiv e

in ve

st m

en t

in pr

im ar

y ca

re ca

n su

pp or

t al

lo f

th e

4 C

s. A

C O

,a cc

ou nt

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or ga

ni za

tio n;

P M

P M

,p er

m em

be r

pe r

m on

th .

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primary care.41,42 P4P targeted to the 4 Cs could hypothetically support primary care; however, cur- rent metrics focus predominantly on disease-fo- cused and process-oriented outcomes (eg, HbA1c) outcomes, rather than patient-centered outcomes (eg, quality of life) or primary care attributes (eg, continuity).41,43 Metrics for the latter remain un- derdeveloped and under used,42 despite growing recognition of the importance of measuring the 4 Cs.45 As P4P is a bonus payment, the shortcomings of the underlying payment model often prevail.

Overall, the evidence supporting P4P has been mixed, with inconsistent impacts across the Qua- druple Aim.41,45,46,47,48,49,50 In 2 large systematic reviews, 1 from QOF and 1 from the United States, some modest yet positive impacts on rate of im- provement for targeted quality and patient out- comes were observed initially, but these benefits stagnated over time, if not regressed to preinter- vention rates.41,51 Providers reported decreased pa- tient-centered care and continuity41, which are im- portant predictors of provider satisfaction.52 The return on investment of P4P may be low, given significant time and financial costs of implementa- tion.53

Bundled Payment/Episode-of-Care Payment Under bundled payment, providers receive a pre- determined payment for all services rendered for an episode-of-care; this payment may be provided prospectively or retrospectively. This model has been used in hospitals (ie, Diagnosis Related Groups), which receive a set fee for services (ie, labor and delivery). As with capitation, providers are at financial risk if their costs exceed the fee but profit from cost savings. Bundled payments may be optimal for high-cost, low-frequency conditions or episodes (eg, hip fractures), as there is incentive to limit the costs for the given episode, but not to limit future episodes.30

Limited evidence exists of the impact of bundled payment on the 4 Cs. As reimbursements for an episode of care are bundled for multiple providers, coordination across specialties is encouraged54, with improvements demonstrated in a Netherlands bundled-payment initiative.55 Like capitation, global payment could support the 4 Cs by enabling investment in a strong primary care infrastructure. Unfortunately, bundled payments can be difficult to implement in primary care due to issues around defining episodes of care. Although acute condi-

tions like fractures and pregnancy have clearer be- ginning and end points, defining what constitutes a chronic condition episode is more challenging, a problem amplified in patients with multiple chronic conditions. Furthermore, as a retrospectively trig- gered but prospectively defined fee, bundled pay- ment shares some of the disadvantages of both FFS and capitation. Though costs may be saved within episodes, there is a financial incentive to increase episodes, similar to FFS. Because financial incen- tives are predicated on savings, there may be a disincentive to care for sicker patients.

Although Diagnosis Related Groups decrease overall health care expenditures56, evidence for the use of bundled payments in primary care is limited. This was evaluated in a 2006 pilot, where none of the primary care sites were able to implement the model over 3 years due to challenges in defining an episode and identifying and tracking included ser- vices based on FFS claims.57 Data from the Neth- erlands suggest no significant impact on quality58; otherwise there is a paucity of evidence for bundled payment outside of an acute care setting.59 In sum- mary, there is a lack of evidence on the impact of bundled payments in primary care on the Quadru- ple Aim, possibly because the model may not be applicable to that setting.

Shared Savings Under shared savings, providers or an accountable care organization (ACO) are responsible for the costs and quality of care for a defined population through the provision of a global budget.60 Most often, the global budgets are calculated based on expenditures from prior years and supplied by in- surers as a risk-adjusted PMPM.61 Expenditures at the end of 1 year are compared against a bench- mark, which are also often calculated from expen- ditures from prior years. Risk arrangements can be 1-sided, where the ACO or equivalent group is eligible for shared savings if their costs are below the benchmark and they meet predetermined qual- ity targets; or they can be 2-sided, where they are also at risk of penalty if they exceed the bench- mark.62 As with other global budget arrangements (eg, capitation, bundled payment), the 2-sided ar- rangement shifts some financial risk from payers to the ACO.

Our review of shared savings models found few evaluations offering insights into their impact on the 4 Cs. Like other models using global payments,

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shared savings theoretically allows ACOs to invest upfront in a primary care infrastructure. Like bun- dled payment, because cost savings are shared across provider groups, shared savings could im- prove coordination.63 Shared savings, as it has been operationalized thus far, may present limitations for primary care. First, because benchmarks are often calculated from expenditures from previous time periods, inefficient, high-spending providers could be rewarded, while high-functioning, coor- dinated practices delivering comprehensive care could receive comparably lower payments. Second, due to the payment lag from distributing cost sav- ings retrospectively at the end of the year, practices may not be able to invest this money upfront in services that deliver on primary care functions. Fi- nally, despite being paid by a global budget, many ACOs continue to reimburse their providers based on FFS64,65, limiting both the effectiveness of the model and the benefits reaped at the provider level.

The most significant data examining shared sav- ings are the preliminary results of 2 CMMI initia- tives: the Medicare Shared Savings Program (MSSP; with results currently available for its third performance year) and the Pioneer ACO (with re- sults currently available for its fourth performance year).

In 2015, 392 organizations participated in MSSP; there were 12 participating organizations in the Pioneer ACO program. Although 31% of MSSP and Pioneer ACO practices earned shared savings, the programs operated at a net loss of $216 million to CMS after accounting for bonus pay- ments.66 The majority of quality measures im- proved in 2015.67 There was no significant corre- lation between quality performance and cost savings in the MSSP.68 Cost savings were more likely in ACOs that were smaller and physician-led or integrated (physician-hospital partnership), had been participating in the program longer, and had higher benchmarks. As with many other programs, although the ACO is paid through a global budget, many providers continue to be paid via FFS.69,65

Hennepin Health, a safety-net ACO serving Medicaid enrollees in Minnesota, is a partnership between federally-qualified health centers, the county hospital, the county health department, and a nonprofit HMO.63 The ACO’s model centers around interdisciplinary primary care teams, and the flexibility of PMPM funds under the global budget has been used to address a broader set of

patients’ needs, including behavioral health care and social services. Early results demonstrate de- creased emergency department (ED) visits im- proved quality of chronic disease care and high patient satisfaction.63 Approximately $3 million in savings over 3 years has been reinvested in inter- ventions to meet social needs.63

Across the Quadruple Aim, shared savings seems to have positive impacts on quality of care and mixed results on costs; cost savings have been ob- served in particular when there is physician leader- ship in the ACO, the ACO has been in existence for a longer period of time, and care coordination and inclusion of nonmedical services are emphasized. Continued FFS payments at the provider level may limit benefits.

Blended FFS and Capitation Capitated PMPM payments are given in addition to FFS in the form of care management fees, care coordination fees, or patient-centered medical home (PCMH) payments in blended payment models. These fees are intended to finance PCMH infrastructure, staffing, and services not covered by reimbursement for traditional office visits, particu- larly activities that coordinate care across the health care system. These fees may be adjusted to dimin- ish the risk of cherry-picking. By adjusting payment systems that are already in place, blended FFS and capitation may present fewer barriers to widespread implementation than models that require systemic overhaul.

The largest source of emerging evidence regard- ing impact of blended FFS and capitation in the primary care setting comes from 2 large Medicare demonstration projects: the Comprehensive Pri- mary Care Initiative (CPCI) and the Multi-Payer Advanced Primary Care Practice (MAPCP). In the third year of CPCI, improvements in care access and continuity were observed.70 The capitated PMPM payments could allow practices to proac- tively invest in an infrastructure that supports pri- mary care, and practices implementing risk-adjust- ment could guard against cherry-picking. As capitation and FFS often have opposite effects, blending the 2 models could mitigate the short- comings of each; however, as the PMPMs support- ing PCMH services are often disproportionately smaller than FFS payments71, the incentive for higher volumes of services may predominate.

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Results from the first 3 years of CPCI, encom- passing 445 primary care practices, over 2100 pro- viders, and nearly 2.9 million patients in 7 regions, show practices have not yet achieved cost savings.72

Statistically significant reductions were noted in expenditures for skilled nursing facilities (5%), pri- mary care services (2%), and outpatient services (2%). ED visits were significantly reduced in the CPCI group, but decreases in hospitalization did not reach statistical significance. However, after including care management fees, Medicare expen- ditures increased by $7 PMPM more for CPCI than comparison practices. Most quality of care measures did not change, with the exception of small improvements in some measures of diabetes care quality and likelihood of ED revisit.

The MAPCP demonstration project started in 2011, involving 8 states, approximately 850 primary care practices, over 6300 providers, and about 712,000 Medicare beneficiaries.70 In all 8 states, Medicare, Medicaid, and private health plans are participating. Preliminary results from the second (with cost saving estimates) and third year are avail- able for MAPCP. Only Michigan demonstrated significant net savings after accounting for demon- stration fees paid out to each state for MAPCP participation. Significant heterogeneity in PMPM payments exists among the MAPCP group, ranging from $1.20 to $60.81.70

Quality outcomes and utilization for MAPCP have been mixed. In the second year evaluation, 5 out of 8 states had some improvement in guideline- recommended services for diabetes, while in 2 states these measures declined.70 Similarly, in 6 out of 8 states, there were no significant differences found in preventable hospitalizations; in 2 states, there were increases observed.70 In the third year, some commercial payers and Medicaid in New York and Vermont reported reductions in hospi- talizations and ED visits, with some payers finding a decrease in total PMPM costs.

Other studies in our review found similarly mixed Quadruple Aim outcomes for blended FFS and capitation models.73,74,75,76 Commonalities across more effective programs include being in place for a longer period of time, multipayer align- ment77, focusing on high-cost patients78,79,80,81, and investing in population health data systems that provide real-time information on health care use.80,81,82 Some experts have suggested blended

FFS and capitation as a transition to fully global budgets.83,84

Comprehensive Primary Care Payment Like traditional capitation, under comprehensive primary care payment, insurers provide a prospec- tive payment to cover all primary care services within a specific period of time (eg, PMPM). Rather than basing capitated payments on historic FFS reimbursements, these payments are calcu- lated to account for the delivery of primary care services and costs necessary to support medical homes. To address cherry-picking, comprehen- sive primary care payments are risk-adjusted based on patient complexity and include a com- ponent of P4P to address concerns about poten- tial inappropriate under use of services. Further- more, PCPs are financially responsible for primary care expenditures rather than total costs, relieving some of the financial risk seen in traditional capi- tation and transferring part of the risk to payers30; however, providers continue to maintain some fi- nancial accountability.

Relatively little evidence exists for the impact of comprehensive primary care payment on the Qua- druple Aim or the 4 Cs. Like other prospective models, the model allows for flexible, proactive investments in a primary care infrastructure that could support the 4 Cs. Unlike traditional capita- tion, however, the risk-adjustment of compre- hensive primary care payment may guard against cherry-picking and continue to facilitate access for high-complexity patients. Although the capi- tated model could hinder comprehensive care by incentivizing underdelivery of services, linkages to quality of care in this model through P4P, if ap- propriate measures for primary care are employed, could hypothetically guard against inappropriate underdelivery of care.

Most of the evidence on comprehensive primary care payment comes from Iora Health4, a national network of primary care practices, which receives a fixed, risk-adjusted PMPM from large self-insured employers, unions, or insurers, and incorporates additional payments for meeting quality or use tar- gets.85,86 Ten percent of the total cost of care is invested in primary care services, roughly doubling

4Iora Health has also opened one DPC practice; a second DPC practice, Turntable Health, closed in January 2017.

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the percentage the US health care system spends on primary care.87 These primary care investments enable Iora to redesign care delivery, such as in- creasing access (eg, same-day appointments, e-mail contacts) and comprehensiveness (eg, personal health coaches).90 Furthermore, the group devel- oped its own electronic health record to enhance quality monitoring and performance feedback. There have not been independent evaluations of outcomes, but Iora reports increased patient and provider satisfaction, improvements in blood pres- sure and HbA1c, a 12.3% decrease in health care expenditures, a 48% reduction in ER visits, and a 41% reduction in inpatient admissions.85,88

Direct Primary Care (DPC) DPC has emerged as a model outside of the insur- ance system attempting to reorganize both the de- livery and payment of health care to enable the primary care function.4 In DPC, patients pay the provider directly, without third-party billing; defi- nitions vary on whether or not employers paying providers directly also fall under this model. Pa- tients are charged a fixed, age-adjusted monthly fee for all their primary care, independent of preexist- ing medical conditions.89 Common ancillary ser- vices are generally provided as part of the monthly fee, including on-site lab tests, x-rays, and electro- cardiograms.

There is limited evidence on the potential im- pact of DPC on specific primary care functions. DPC providers have increased visit lengths (typi- cally 30 minutes to 60 minutes per visit), which could support coordination of care and allow for greater comprehensiveness.90 Decreased volume of face-to-face visits has increased time for access via e-mail and telephone communications.91 As with other prospective payment models not linked to volume, DPC grants practices the flexibility to in- vest revenue in nonvisit-based services that support primary care.

Some concerns have emerged about the ways DPC could inhibit the 4 Cs. First, there is the potential for high cost-sharing90, as the DPC fee covers only outpatient primary care services. Sec- ond, DPC may limit access for individuals of lower

socioeconomic status, although DPC groups have explored arrangements with Medicaid to cover these patients (by definition, however, this would no longer constitute a DPC payment arrange- ment).89 Because DPC panels are one-fifth the size of non-DPC providers, there are concerns that expanding the model would decrease access by compounding the PCP shortage.90

Like comprehensive primary care, few studies exist that examine the impact of DPC on the Quadruple Aim. Most of the available evidence comes from Qliance, a Seattle-based DPC net- work. Qliance reported 35% fewer hospitaliza- tions, 65% fewer ED visits, and 66% fewer spe- cialist visits.92 In addition, they estimated cost savings of 19.6% per patient per year and scored at the 95th percentile for patient experience.93

Qliance recently closed its doors due to financial difficulties, raising concerns about the financial sus- tainability of DPC, although this may be related to efforts to rapidly scale the model.

Discussion Our review identified 8 distinct payment models which differentially shape primary care delivery in the United States: FFS, traditional capitation, P4P, bundled payment, shared savings, blended FFS and capitation, comprehensive primary care payment, and DPC; many payers use combinations of these models. Each model is currently in various stages of implementation, with significantly less evidence available for newer models.

Few studies examined the impact of payment models on the 4 Cs of primary care. Nonetheless, several key characteristics were consistently noted. First, payment models can be viewed along a spec- trum from FFS (retrospective) to capitated (pro- spective) payment. Whereas retrospective payment may incentivize the delivery of services, prospective payments offer flexibility for primary care practices to invest in services and infrastructure that can enhance the 4 Cs, such as nursing follow-up calls to enhance coordination, same-day appointments to improve access, and integrated behavioral health for more comprehensive care. Second, because capitated models may encourage adverse selection and underdelivery of appropriate services, risk-ad- justment may be used to preserve the primary care attributes of access and comprehensive care, re- spectively. Third, P4P has been used as a bonus to

5DPC differs from concierge medicine in that concierge practices continue to bill insurance for services, but also charge a retainer (usually annually, and significantly higher than DPC payments) to patients.

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incentivize quality; however, measures are largely disease-oriented and generally do not assess the tenets of primary care or patient-centered out- comes. Finally, newer payment models have prior- itized sufficient funds to support primary care ser- vices that uphold the 4 Cs, but inpatient and specialty services are paid for separately. Although in a prospective payment model this may reduce the financial risk to providers, ongoing research will be needed to assess whether doing so limits coordination (eg, incentives not aligned across pri- mary care and specialty care, or inpatient and out- patient settings). Studies that examine the role of and optimal payment for PCMHs within ACOs may be particularly useful.94

These principles, and the evidence available for payment models, provide cross-cutting lessons that guide the following recommendations for the fu- ture of primary care payment.

Implement and Research Payment Models Based in PMPMs for Primary Care Despite the shift from volume to value, FFS re- mains the dominant model95 As the United States transitions away from FFS, more primary care pay- ment models based in prospective payment should be implemented. The most promising evidence across the Quadruple Aim came from comprehen- sive primary care payment and DPC. Both models use prospective fees that allow practices to tailor services to the needs of their communities and proactively implement a primary care infrastruc- ture supporting the 4 Cs. However, evidence for both models is generally lacking, so ongoing re- search is critical. Recently, the Physician-Focused Payment Model Technical Advisory Committee recommended testing the American Academy of Family Physicians’ proposed Advanced Primary Care APM. This primary care payment model in- cludes a risk-adjusted PMPM along with P4P (es- sentially, comprehensive primary care payment) that could impact 30 million Medicare patients.96

Risk-Adjusted Payments to Ensure Access for All Populations to Primary Care Risk-adjusted payments can protect against cherry- picking healthier patients that negatively impacts access and also decreases financial risk to providers, which could improve satisfaction. It is difficult to assess the impact of risk-adjustment alone however, as it is a single component of a more complex

model, and significant heterogeneity exists in how payments are risk-adjusted. Nonetheless, several risk-adjusted payment models in our review found decreased health care costs/use for high- needs, high-using populations.97,98,99,80,100 More research is needed to validate risk-adjustment tools.101

Broaden Investments in Primary Care to Include Behavioral Health and Social Services One safety-net ACO in our review supporting comprehensive care inclusive of social and behav- ioral needs demonstrated significant promise. CMS’s Accountable Health Communities demon- stration project provides another opportunity to research the effect of varying levels of medical- social services partnerships on costs and use.102

This initiative aims to connect medical and social services by creating a community-based system that identifies social barriers to health in the clinical setting and enables referrals to appropriate com- munity services.103 More research of similar mod- els is needed to understand how data, costs, and risks can be shared across a truly integrated medi- cal-social neighborhood.

Connect Payments to Performance on Patient- Centered and Primary Care-Centered Metrics P4P studies in our review demonstrated inconsis- tent and mixed results on the Quadruple Aim and the 4 Cs. The overwhelming majority of quality metrics are disease-oriented measures, and the remaining measures largely focused on process measures and adherence to evidence-based guidelines104, rather than health outcomes.105

We recommend, as Dr. Starfield did in response to the QOF, connecting payments to metrics that capture how well a practice delivers the 4 Cs and improve patient-centered outcomes, to better ac- count for multimorbidity and the contexts of pa- tients’ lives.106

Both the complexity of primary care and the administrative burden of measurement stand as barriers to adequately evaluating the 4 Cs.107 Al- ready, the health care system pays $15.4 billion annually to measure quality metrics.108 Early brightspots exist in evaluating some of the attri- butes of primary care, such as continuity109, com- prehensiveness110, and contact111, as well as pa- tient-centered outcomes19, but much more work remains in developing those measures and confirm-

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ing their validity across various populations.112 We support the recommendations of others for more research to create metrics that effectively measure primary care113, health information technology to capture those metrics114, and a national organiza- tion that validates, disseminates, and implements these measures.115

Rapid Dissemination and Research is Necessary in Emerging Primary Care Payment Models Our review revealed several remaining areas for research in primary care payment. Evidence is par- ticularly limited regarding provider satisfaction and comprehensiveness, and the emerging primary care payment models (eg, comprehensive primary care, DPC) lack independent evaluation of their impact on the Quadruple Aim. Furthermore, the majority of models in our review demonstrated mixed re- sults, pointing to the need for ongoing research in variation of Quadruple Aim outcomes within each model that could elucidate which factors (eg, clin- ical characteristics/settings, payer characteristics, variations in payment amounts) most impact out- comes, and accounting for how payment impacts delivery of care.

Limitations As a narrative review, our search may not have captured all the relevant evidence. Similarly, a qual- ity assessment was not conducted, although articles with higher levels of evidence (eg, systematic re- views) were prioritized. Furthermore, our recom- mendations were guided by seminal examples of these models of the main payment models repre- sented in US health care, rather than strictly through randomized control trials, which do not exist for the majority of the models reviewed. Given this, as well as significant heterogeneity in study design, populations, delivery settings, and metrics evaluated, standard quantitative summary methods were not possible. Finally, although our review focused on payment models, significant het- erogeneity in the delivery and services stemming from the payment structure is a possible con- founder to interpreting our results; however, changes in payment enable changes in delivery, and in many instances, it may be difficult to separate their effects.

Conclusion Evidence from Starfield and others2–15 supports the central role of primary care in high-performing health systems and the achievement of population health goals. Effective payment for primary care delivery, supportive of the 4 Cs, can lead to achiev- ing the Quadruple Aim. Findings from this review can help guide future implementation and research efforts to successfully shift away from a FFS model that has inhibited primary care. MACRA, through its support of APMs, as well as a host of multipayer initiatives such as the CMMI’s Comprehensive Pri- mary Care Plus demonstration project and the American Academy of Family Physicians’s Ad- vanced Primary Care APM, signal an opportunity for the US health care system to continue the transition from volume-based to value-based care. Increasing investments into primary care is necessary but not sufficient for improving health care; how we invest in a comprehensive primary care infrastructure—spanning health care deliv- ery, research, practice transformation support, and HIT—to evolve how care is both delivered and measured will be critical.

The authors gratefully acknowledge the support of Family Med- icine for America’s Health, along with the additional sponsors of the Starfield Summit, the Pisacano Leadership Foundation, and the American Board of Family Medicine.

To see this article online, please go to: http://jabfm.org/content/ 31/4/588.full.

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Shared Decision-Making in Intensive Care Units Executive Summary of the American College of Critical Care Medicine and American Thoracic Society Policy Statement

Shared decision-making is a central component of patient-centered care in the intensive care unit (ICU) (1–4); however, there remains confusion about what shared decision-making is and when shared decision-making ought to be used. Further, failure to employ appropriate decision-making techniques can lead to significant problems. For example, if clinicians leave decisions largely to the discretion of surrogates without providing adequate support, surrogates may struggle to make patient-centered decisions and may experience psychological distress (5). Conversely, if clinicians make treatment decisions without attempting to understand the patient’s values, goals, and preferences, decisions will likely be predominantly based on the clinicians’ values, rather than the patient’s, and patients or surrogates may feel they have been unfairly excluded from decision-making (1, 2). Finding the right balance is therefore essential. To clarify these issues and provide guidance, the American College of Critical Care Medicine (ACCM) and American Thoracic Society (ATS) recently released a policy statement that provides a definition of shared decision-making in the ICU environment, clarification regarding the range of appropriate models for decision-making in the ICU, a set of skills to help clinicians create genuine partnerships in decision-making with patients/surrogates, and ethical analysis supporting the findings (6).

To develop a unified policy statement, the Ethics Committee of the ACCM and the Ethics and Conflict of Interest Committee of the ATS convened a writing group composed of members of these committees. The writing group reviewed pertinent literature published in a broad array of journals, including those with a focus in medicine, surgery, critical care, pediatrics, and bioethics, and discussed findings with the full ACCM and ATS ethics committees throughout the writing process. Recommendations were generated after review of empirical research and normative analyses published in peer-reviewed journals. The policy statement was reviewed, edited, and approved by consensus of the full Ethics Committee of the ACCM and the full Ethics and Conflict of Interest Committee of the ATS. The statement was subsequently reviewed and approved by the ATS, ACCM, and Society of Critical Care Medicine leadership, through the organizations’ standard review and approval processes.

ACCM and ATS endorse the following definition: Shared decision-making is a collaborative process that allows patients, or their surrogates, and clinicians to make health care decisions together, taking into account the best scientific evidence available, as well as the patient’s values, goals, and preferences.

Clinicians and patients/surrogates should use a shared decision-making process to define overall goals of care (including decisions regarding limiting or withdrawing life-prolonging interventions) and when making major treatment decisions that may be affected by personal values, goals, and preferences (7, 8). Once clinicians and the patient/surrogate agree on general goals of care, clinicians confront many routine decisions (e.g., choice of vasoactive drips and rates, laboratory testing, fluid rate). It is

logistically impractical to involve patients/surrogates in each of these decisions. Partnerships in decision-making require that the overall goals of care and major preference-sensitive decisions be made using a shared decision-making approach. The clinician then has a fiduciary responsibility to use experience and evidence-based practice when making day-to-day treatment decisions that are consistent with the patient’s values, goals, and preferences. Throughout the ICU stay, important, preference-sensitive choices often arise. When they do, clinicians should employ shared decision-making.

Clinicians should generally start with a default shared decision- making approach that includes the following three main elements: information exchange, deliberation, and making a treatment decision. This model should be considered the default approach to shared decision-making, and should be modified according to the needs and preferences of the patient/surrogate. Using such a model, the patient or surrogate shares information about the patient’s values, goals, and preferences that are relevant to the decision at hand. Clinicians share information about the relevant treatment options and their risks and benefits, including the option of palliative care without life-prolonging interventions. Clinicians and the patient/surrogate then deliberate together to determine which option is most appropriate for the patient, and together they agree on a care plan. In such a model, the authority and burden of decision-making is shared relatively equally (9). Although data suggest that a preponderance of patients/surrogates prefer to share responsibility for decision-making relatively equally with clinicians, many patients/surrogates prefer to exercise greater authority in decision-making, and many other patients/surrogates prefer to defer even highly value-laden choices to clinicians (10–13). Ethically justifiable models of decision-making include a broad range to accommodate such differences in needs and preferences.

In some cases, the patient/surrogate may wish to exercise significant authority in decision-making. In such cases, the clinician should understand the patient’s values, goals, and preferences to a sufficient degree to ensure the medical decisions are congruent with these values. The clinician then determines and presents the range of medically appropriate options, and the patient/surrogate chooses from among these options. In such a model, the patient/surrogate bears the majority of the responsibility and burden of decision-making. In cases in which the patient/surrogate demands interventions the clinician believes are potentially inappropriate, clinicians should follow the recommendations presented in the recently published multiorganization policy statement on this topic (14).

In other cases, the patient/surrogate may prefer that clinicians bear the primary burden in making even difficult, value-laden choices. Research suggests that nearly half of surrogates of critically ill patients prefer that physicians independently make some types of treatment decisions (10–13). Further, data suggest that approximately 5–20% of surrogates of ICU patients want clinicians to make highly value-laden choices, including decisions to limit or

1334 American Journal of Respiratory and Critical Care Medicine Volume 193 Number 12 | June 15 2016

EDITORIALS

withdraw life-prolonging interventions (12, 13). In such cases, using a clinician-directed decision-making model is ethically justifiable (15–24).

Employing a clinician-directed decision-making model requires great care. The clinician should ensure that the surrogate’s preference for such a model is not based on inadequate information, insufficient support from clinicians, or other remediable causes. Further, when the surrogate prefers to defer a specific decision to the clinician, the clinician should not assume that all subsequent decisions are also deferred. The surrogate should therefore understand what specific choice is at hand and should be given as much (or as little) information as the surrogate wishes. Under such a model, the surrogate cedes decision-making authority to the clinician and does not need to explicitly agree to (and thereby take responsibility for) the decision that is made. The clinician should explain not only what decision the clinician is making but also the rationale for the decision, and must then explicitly give the surrogate the opportunity to disagree. If the surrogate does not disagree, it is reasonable to implement the care decision (19–24). Readers may review references 19–24 for detailed descriptions and ethical analyses of clinician-directed decision-making.

The statement was intended for use in all ICU environments. Patients and surrogate decision-makers have similar rights both to participate in decision-making when appropriate and to rely more heavily on providers when they wish to do so, regardless of the type of ICU. Similarly, the statement is equally applicable in pediatric and neonatal settings, where decision-making partnerships between parents and the ICU team are equally important. As noted in the statement, including children in some decisions can often be appropriate as well. The statement is also intended to be applicable internationally. Although patient and surrogate decision-making preferences may differ globally, the default approach presented and the recommendation to adjust the decision-making model to fit the preferences of the patient or surrogate are universal. Both ACCM and ATS are international organizations, and the literature review included publications from many countries. The statement focuses on the ICU environment because critically ill patients are often, but not always, unable to participate in decision-making themselves, and because many decisions in the ICU are value- sensitive. The recommendations in the statement, however, could be equally applicable in all patient care settings.

To optimize shared decision-making, clinicians should be trained in specific communication skills. Core categories of skills include establishing a trusting relationship with the patient/surrogate; providing emotional support; assessing patients’/surrogates’ understanding of the situation; explaining the patient’s condition and prognosis; highlighting that there are options to choose from; explaining principles of surrogate decision-making; explaining treatment options; eliciting patient’s values, goals, and preferences; deliberating together; and making a decision. The full policy statement provides significant guidance and examples in these areas (6).

Finally, ACCM and ATS recommend further research to assess the use of various approaches to decision-making in the ICU. The use of decision aids, communication skills training, implementation of patient navigator or decision support counselor programs, and other interventions should be subjected to randomized controlled trials to assess efficacy. Considerations regarding the cost and time burdens should be weighed against

anticipated benefits from such interventions when determining which efforts to implement. n

Author disclosures are available with the text of this article at www.atsjournals.org.

Acknowledgment: The views expressed in this article represent the official position of the American College of Critical Care Medicine, the Society of Critical Care Medicine, and the American Thoracic Society. These views do not necessarily reflect the official policy or position of the U.S. Department of the Navy, U.S. Department of Defense, U.S. National Institutes of Health, U.S. Department of Veterans Affairs, U.S. Food and Drug Administration, or U.S. Government.

Alexander A. Kon, M.D. Naval Medical Center San Diego San Diego, California

and

University of California San Diego San Diego, California

Judy E. Davidson, D.N.P., R.N. University of California Health System San Diego, California

Wynne Morrison, M.D. Children’s Hospital of Philadelphia Philadelphia, Pennsylvania

Marion Danis, M.D. National Institutes of Health Bethesda, Maryland

Douglas B. White, M.D., M.A.S. University of Pittsburgh School of Medicine Pittsburgh, Pennsylvania

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Copyright © 2016 by the American Thoracic Society

1336 American Journal of Respiratory and Critical Care Medicine Volume 193 Number 12 | June 15 2016

EDITORIALS

Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.

RESEARCH Open Access

Workforce planning and development in times of delivery system transformation Patricia Pittman1* and Ellen Scully-Russ2

Abstract

Background: As implementation of the US Affordable Care Act (ACA) advances, many domestic health systems are considering major changes in how the healthcare workforce is organized. The purpose of this study is to explore the dynamic processes and interactions by which workforce planning and development (WFPD) is evolving in this new environment.

Methods: Informed by the theory of loosely coupled systems (LCS), we use a case study design to examine how workforce changes are being managed in Kaiser Permanente and Montefiore Health System. We conducted site visits with in-depth interviews with 8 to 10 stakeholders in each organization.

Results: Both systems demonstrate a concern for the impact of change on their workforce and have made commitments to avoid outsourcing and layoffs. Central workforce planning mechanisms have been replaced with strategies to integrate various stakeholders and units in alignment with strategic growth plans. Features of this new approach include early and continuous engagement of labor in innovation; the development of intermediary sense-making structures to garner resources, facilitate plans, and build consensus; and a whole system perspective, rather than a focus on single professions. We also identify seven principles underlying the WFPD processes in these two cases that can aid in development of a new and more adaptive workforce strategy in healthcare.

Conclusions: Since passage of the ACA, healthcare systems are becoming larger and more complex. Insights from these case studies suggest that while organizational history and structure determined different areas of emphasis, our results indicate that large-scale system transformations in healthcare can be managed in ways that enhance the skills and capacities of the workforce. Our findings merit attention, not just by healthcare administrators and union leaders, but by policymakers and scholars interested in making WFPD policies at a state and national level more responsive.

Keywords: Workforce planning and development, Human resources in health, Healthcare delivery reform, System change, Loosely coupled systems, Labor-management partnerships, US Affordable Care Act

Background As the implementation of the 2010 Affordable Care Act (ACA) advances in the United States, many healthcare organizations are taking bold measures to reorganize their delivery systems and finding that in order to do so, changes must be made to the healthcare workforce [1]. While different healthcare organizations in the United States, be they public or private, are at very different points in this process, commonly popular concepts in- clude moving staff to new ambulatory and home care

settings [2]; creating new jobs relating to care coordin- ation and outreach to the sickest patients [3]; designing new modes of delivering care in response to consumer- ism [4]; adopting team-based care and task shifting based on the principal of practicing at the top of license and education [5]; requiring new roles and skills as part of the adoption of health information technologies (HIT); and the use of data for decision-making [6]. Understanding what workforce changes are occur-

ring and how they are being managed is key not just for healthcare leaders but for policymakers as well. Traditional methods of projecting provider shortages and justifying the allocation of public funding to expand various professional pipelines are giving way

* Correspondence: ppittman@gwu.edu 1Milken Institute School of Public Health, The George Washington University, 2175 K Street, NW, Suite 500, Washington, DC 20037, United States of America Full list of author information is available at the end of the article

© 2016 The Author(s). Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.

Pittman and Scully-Russ Human Resources for Health (2016) 14:56 DOI 10.1186/s12960-016-0154-3http://crossmark.crossref.org/dialog/?doi=10.1186/s12960-016-0154-3&domain=pdfmailto:ppittman@gwu.eduhttp://creativecommons.org/licenses/by/4.0/http://creativecommons.org/publicdomain/zero/1.0/

to the notion that there are many models of care delivery and that they have vastly different staffing configurations. For example, several studies have demonstrated that including advanced practitioners in primary care medical homes allows practices to expand panel sizes [7, 8]. Choices about staffing, therefore, can have enormous im- plications for productivity, making assumption about the demand for certain health professions a moving target. The policy question then becomes not just how will

these changes alter the national demand for certain types of health workers at an aggregate level but how are organizations making choices about ways to recon- figure their workforce and, ultimately, what kinds of local, state, and federal policies are most supportive of workforce transformations that advance both workers’ well-being and the value of their services. We know from the literature reviewing the hospital re-

structuring of the 1990s that workforce change manage- ment faces many challenges. The critiques of this era were many, but chief among them, according to Walston and colleagues, were the following: goals for change were not clear, too many changes were implemented too quickly, there was a lack of communication with em- ployees, a lack of engagement with physicians and unions, there was a poor understanding of the local site differences by management leading to a one-size- fits-all approach, and, lastly, that training needs were not anticipated [9]. In a review of the international literature on workforce

planning and development (WFPD), Curson and col- leagues suggest that the problem goes deeper. They argue that workforce policies lack the capacity to re- spond to new demands for system change [10]. The reason, they point out, is that most workforce planning do not take account of political dynamics among the range of stakeholders outside the control of human re- source administrators, be they at the organizational or the policy level. It is with these critiques in mind that we are interested

in understanding how two leading health systems in the United States, with a historic commitment to developing and retaining their workforce and to managing change through labor-management partnerships, are responding to the demands of the post-ACA environment. The aim is to explore how they are determining what changes are needed and how they are implementing those changes in practice. Their experiences may provide insights for other organizations, as well as for policymakers charged with ensuring that the healthcare workforce is able to meet population needs. Our first case focuses on Kaiser Permanente (KP), an

integrated system that has historically served the em- ployer market on the West Coast. It has been at the forefront of systems that emphasize value over volume

and among the organizations most advanced in the use of HIT to improve the patient care process. In addition, KP has one of the most successful models of labor- management partnerships (LMP) in the nation. The second system is the Montefiore Health System,

headquartered in the Bronx, NY, an organization with al- most 20 years of experience with shared risk contracts with payers. Like KP, they have extensive experience with care coordination, they are in the process of expanding to new markets, and they have a LMP. They differ from KP in that their patient population is predominantly poor and Spanish speaking, and an extraordinary 80 % of their revenue is coming from Medicaid and Medicare.

Conceptual framework The objective of this study is to go beyond descriptive groupings of health workforce changes to explore the dy- namic processes and interactions by which staffing models emerge. To frame our inquiry, we draw on the literature on health workforce planning and development and the theory of loosely coupled systems (LCS) [11]. For the purposes of this paper, we define WFPD as the

macro level processes and practices that enable the sys- tem to change and adopt new staffing arrangements and respond with timely and appropriate education, training, and certification programs. Schrock has suggested that WFPD policies span the continuum of skill formation, employment networks, and career advancement [12]. This means not simply examining the supply and distribu- tion of personnel in different categories but also under- standing educational and training pathways, management of performance, and the regulation of working conditions. Dussault and Dubois argue that the traditional ap-

proach to WFPD is a linear, sequential, and protracted skill formation process through which healthcare pro- viders hand off demand projections to education institu- tions and certifying bodies that in turn, supply the requisite workforce [13]. Weick reasons that this form of sequential task interdependence induces rule-based action and cognitive processes that are not equipped to tackle ambiguous problems like providing a skilled workforce for care models that are in a constant state of flux [14]. This and other complex, non-routine problems require controlled cognition or slow, deliberative, and explicit thinking that is more often associated with reciprocal interdependence coordinated by an iterative process of negotiation and mutual adjustment among relatively autonomous units and subsystems. [14] Dussault and Dubois describe an alternative approach

that is emerging in healthcare that coordinates the efforts of a diverse range of institutional actors through adaptive processes that respond to specific, local polit- ical, economic, cultural, and social contexts where healthcare is delivered [13]. This approach is understood

Pittman and Scully-Russ Human Resources for Health (2016) 14:56 Page 2 of 15

as a political exercise in which values and differences are made explicit, compromises are made, and actions are justified. Orton and Weick further suggest that there is a need to move beyond the traditional focus on static organizational elements, like structure, resource alloca- tion, and technology, and turn instead to a focus on the dynamic relationship among them [15]. Organizational scholars developed the concept of

“loose and tight coupling” as one way to examine com- plex organizational structures and relationships [16–19]. The focus of this approach is on hierarchy and inter- dependence among elements within and between organi- zations and how variability in these features enables different operational strategies and responses to shifts in the external environment [17]. In tightly coupled sys- tems, individual units and organizations are linked to- gether through formal structures and procedures and they respond to change through centralized control mechanisms that reduce variation and close the system off from the effects of external forces. In loosely coupled systems, on the other hand, the links among the compo- nents are weak and a high level of autonomy exists among the interdependent parts of the system [20]. While the variation in the way similar functions are or- ganized and managed may make it difficult to integrate activities, theorists argue that it enables flexibility and openness to change in the environment [15]. According to the theory of LCS, all systems are both

tightly and loosely coupled because there is variation in how subunits are linked and rely on each other (couple- d)—as well as in the number and strength of their con- nections (lose or tight) [15, 17, 21]. Therefore, any subsystem may be closed to outside forces to ensure for stability (tight), while another subsystem may remain open to outside forces to enable flexibility (loose) [15]. This paradoxical nature of LCS makes it difficult for

researchers to conceptualize and study [16], yet we would suggest that its application to the US healthcare system during this period of intense transformation holds explanatory potential. Healthcare systems are sim- ultaneously being asked to expand coverage and access, while being financially incentivized to extend the con- tinuum of care to address the social determinants and provide ongoing care management. As a result, there are significant pressures on traditional care models and staffing arrangements, leading in turn to the emer- gences of new patterns of “coupling,” both within and across healthcare organizations. Further, we submit that the effectiveness of the transformation occurring in healthcare today may hinge on new, more adaptive methods to prepare the healthcare workforce to perform in a more complex system of care, where job tasks, team interactions, and work locations are con- tinuously changing.

To analyze changes in WFPD, we borrow from Weick’s typology of strategies for changing LCS [11] and from the descriptions on a new approach to WFPD in healthcare put forth by Curson et al. [10] and Dussault and Dubois [13] to identify a set of principles that together, may serve as a new adaptive WFPD framework aligned with the needs of a rapidly changing deliver system.

Methods We use a case study design to explore how two major health systems undergoing significant system transform- ation are managing the process of workforce change. We selected Kaiser Permanente (KP) and Montefiore because they are well known for their innovative approaches to in- tegrating healthcare yet they are significantly different from each other with regard to their organizational histor- ies, structures, and patient populations. We conducted site visits to both organizations in the

spring and summer of 2015, conducting interviews with 8–10 people at each site including executives, human re- source managers, the heads of innovation and care coord- ination programs, and union and LMP representatives. Some interviews were held in group settings, while others were individual. We also conducted planning and follow- up phone calls with some of the participants. Interviews were taped and transcribed. We also reviewed current organizational documents, including training plans, re- ports, and collective bargaining agreements, as well as prior studies on each system [9, 22, 23]. Data analysis proceeded through several steps. First,

the research team conducted a review of each case, including the historic development of the system and significant drivers of change, as well as the strategies, structures, and resources informants reported as being central to the competiveness of the system and the sustainability of the workforce in the post-ACA environ- ment. To support this analysis, the research team devel- oped a series of inductive and deductive codes, which we used to extract relevant data from the case docu- ments and interview transcripts. Next, the researchers jointly analyzed the coded data to developed individual case profiles. These profiles were validated by key infor- mants from each case. Finally, we conducted a constant comparative method to identify cross-cutting themes and principles to explain the workforce planning and de- velopment strategy emerging within the two systems.

Results Case study 1: Kaiser Permanente Kaiser Permanente (KP) was established in 1938 as a comprehensive medical system for the workers and their families at Kaiser steel mills and shipbuilding facilities across California and in Portland, OR. In 1945, after WWII ended and many shipyards closed, KP opened

Pittman and Scully-Russ Human Resources for Health (2016) 14:56 Page 3 of 15

membership to the general public. The KP unions played an instrumental role in this expansion by helping KP market to unionized employers in areas where the com- pany had a presence. Today, it operates as a Health Maintenance Organization (HMO) with 8.3 million health plan members in seven regions: Northern and Southern California, Colorado, Georgia, Hawaii, Mid- Atlantic, and the Northwest. Each region is made up of two separate entities, the Kaiser Foundation Health Plans and the Permanente Medical Group (PMG), a physician- owned corporation that owns and operates KP’s medical facilities. The PMG contracts with the Foundation to serve KP health plan members. A key feature in this model is that physicians are employed by KP. The na- tional program office includes a variety of support func- tions, including human resources, labor relations, information technologies (IT), finance, and patient care services (nursing). The KP Labor-Management Partnership (LMP) was

formed in 1997. At the time, KP faced competitive pressures leading executives to demand deep union concessions. In response, many of the KP unions of- fered the company a choice: continued harsh labor- saving tactics and escalating labor strife, including a strike, or a partnership to address the fiscal crisis and improve the quality of care at KP. The company agreed to the partnership [24]. The governance struc- ture consists of the LMP Strategy Group, with one representative from each of three sectors: Physicians, Management and Labor, and each region maintains its own tripartite LMP council. By 2015, the LMP included 12 international and 28

local unions representing 105 000 KP employees or about half of the total KP workforce, across six of the seven regions. Hawaii is not part of the partnership, and not all KP unions are involved in the partnership, most notably absent is the California Nurses Association. KP also has a network of functional units to support

the design and management of change and WFPD strategies. The LMP staff is integrated into these units, and labor representatives are highly engaged in their activities. These units include the following:

� National Workforce Planning and Development (housed in national human resources (HR)) provides opportunities to the KP workforce to optimize skills and competencies and manages two LMP education trusts: the Ben Hudnall Memorial Trust and SEIU/UHW Joint Employer Education Fund.

� National Innovations Network including patient care services, workforce planning, and IT functions as a loosely coupled “future-sensing” group that examines technology trends, creates proof of

concepts and proof of technology, and develops pilots.

� Unit-based teams (UBT) are natural work groups of frontline workers, physicians, and managers who solve problems and enhance quality.

Drivers of change KP’s history of pre-paid, member-based service is critical to understanding the company’s current competitive situation. KP is well positioned to grow in a post-ACA era in which policies to advance integration has prolifer- ated. Growth has been especially dramatic in the South- ern California Region, where new individuals that joined via the Health Exchange grew by 4 % per year (from 2 to 6 %). This rapid influx of new members has been most pronounced among younger and healthier individuals as compared to members in KP’s traditional employer- based plans. KP leadership knew that they needed to understand

the implications of this shift in demand and have held focus groups with their newest members. Results have led the company to reorient business strategy around three priorities, as follows:

1. Convenience. Millennials are demanding “care anywhere and how we want it.” Increased access, convenience, and enhanced experience of healthcare are therefore major priorities for the organizations.

2. Affordability. Because the individual market is more price sensitive than the group market, there is a heightened awareness that they must reduce the cost of care in order to continue to expand in this market.

3. Value. At the same time, new healthcare consumers expect more value or increased and enhanced services, and this is driving a number of efforts focused on the care experience.

Change strategies Three strategic initiatives have emerged in response to these drivers. The LMP and the national innovation units are integrated into all three, as are KP members’ views, as represented through surveys, focus groups, and ethnographic studies.

� Perform, Grow, Lead is KP’s strategic plan. It emphasizes affordability targets, meeting rising customer expectations, and transforming care. Guiding principles include the following: One KP, which calls for a common care experience across all regions, and the KP people strategy, which articulates the desired characteristics of the KP workforce as “innovative, engaged, change ready, healthy, and accountable.”

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� Vision 2025 is an ongoing initiative to understand what healthcare consumers will look like and how KP can position itself to meet needs in a rapidly changing healthcare market. It develops care models and offers strategic road maps to guide planning and change. Health information technologies are central to this strategy, including the use of social media to keep its members informed and healthy and new mobile technologies to enhance staff communication and reporting. Remote diagnostic tools will also be more available to patients for common ailments like strep throat, to allow self-testing and more rapid recoveries. In the next 5 to 7 years, they see increased use of remote monitoring technology, sensors, and virtual care, as well as health analytics to enhance the nurse role in triage and care management [23]. As one interviewee put it, “…if it can be automated, it will be.”

� Reimagining Ambulatory Design (RAD) is an initiative of the Southern California Region that may spread across KP. Its goal is to design a new ambulatory care delivery model aligned to the principles of consumerism. In extensive research with members, the leads of this effort discovered that “…people wanted access to care in a much more radically different way… It has to do with much more embedding of services into the community, into the home, into work…and much more local access for simple things.” This “life- integration vision” has sparked several experiments to redesign and relocate KP clinical operations in Southern California.

Workforce planning and development strategies Human resource (HR) leaders and the Coalition of Kaiser Permanente Unions (CKPU) staff report that early on the focus of WFPD was on creating consistent work- force metrics and analytics to help the regions forecast future staff and skill needs. They now view these tools as necessary but insufficient. A regional HR leader described the change:

So, at first…we forecasted membership growth, utilization, supply, turnover, retirement, we looked at the local labor markets, we connected with a university for economic analysis of the projected nursing workforce, and the fluctuations around the economy. And then we realized that most forecasting is based on the previous year, or the previous three, or the previous five years, projecting forward. But if you’re in the midst of complete transformation of how you’re providing care, how accurate are those numbers? …We need to understand what kinds of jobs (are coming); we need to understand how work is

transforming. So, it really started in 2012 to 2013, (we have been) trying to get a movement towards a kind of qualitative approach to understanding change.

Key to this new approach is that it is integrated with KP’s strategic growth initiatives. As one HR leader ex- plained, “workforce development is being driven by the business need.” Part of this emanates from the “affordabil- ity” imperative, which both HR and labor representatives agree has given finance a larger role in the company. At the same time, HR leaders describe the emerging WFPD approach as “maturing,” by which they mean that finance is one important player but that they also take into ac- count other interests. Indeed, HR leaders view themselves as “intermediaries” who help senior leaders understand the strategic value of the workforce in the context of the drive toward labor-cost-saving solutions. The LMP, which was further strengthened in the 2015

National Agreement, has several mechanisms that inte- grate labor and innovative WFPD strategies into the strategic change processes. First, for collective bargain- ing, they use an “interest-based approach,” rather than traditional, positional bargaining. Both sides emphasize that there is full transparency in this process—manage- ment shares information on the company’s financial situ- ation, competitive standing, and other data related to the subjects of bargaining and labor provides insight into the affect of change on the workforce. This open ex- change results in accommodation, as illustrated by the Employment and Income Security Agreement (EISA), which stipulates that any innovation or change at KP must include a plan for retaining the effected employees. A second LMP mechanism consists of the negotiated

programs to support innovation and the implication of change for the workforce. The national agreement delin- eates the mission and values of joint programs, sets aside funds, and directs LMP staff and company to consist- ently integrate the programs across all KP regions. Examples of these national efforts include Total Health, which advances wellness, health, and safety in the work- place; unit-based teams, which identify quality improve- ment and cost containment solutions at the ground level; and the National Taft-Hartley Education and Training Trusts, described above. Lastly, an important characteristic of the LMP govern-

ance and planning structures is that it is holistic and aims to permeate every level of the system. In theory, every manager has a designated labor partner with whom they are encouraged to engage in strategic and operational de- cisions that affect the workforce. Both sides report that this works better in some regions than others, but where it does work, they say that the engagement is ongoing and includes strategic decisions that affect not only the work- force but also the future direction of the company.

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Jobs for the Future, an initiative in the Southern California region, illustrates how these mechanisms work together to integrate labor and WFPD strategies into the strategic change processes at KP. The project grew from the HR leader’s intermediary strategy of showing up and intently listening at meetings related to the RAD project, a strategic change initiative aimed at redesigning ambulatory care. According to this leader, he quickly convinced the VP overseeing the project of the value of labors’ early involvement, and soon after, a LM committee was formed to explore the proposed innovation and its impact on the jobs and workers. Rather than focus on the contentious questions of

workforce impacts, the committee first set out to de- velop a holistic view of the redesign (new care models, technologies, facilities, etc.) in order to target the oper- ational initiatives that would have significant impact on jobs. Though the HR lead reported that some labor and management participants fell into traditional roles and knee-jerk reactions, he observed that these positions quickly gave way as the committee became more en- gaged in the processes to redesign the care models and workflows. Next, the committee developed a rigorous method-

ology to assess the impact on jobs and formed LM sub- committees to apply the method to the redesign of specific work areas. In the end, the committee proposed three new jobs: a roving receptionist of the future that would take on multiple roles of patient greeter/way finder/educator, a multifunctional healthcare worker that would staff new small walk in clinics and perform patent care and diagnostic functions, and a patient navigator who would facilitate the extension of care into the arena of social determinants by helping to coordinate commu- nity resources. Each of these new roles transgresses existing occupational, as well union boundaries and jurisdictions. The difference between the new with the old approach

to labor relations managing change at KP are explained by the HR leader as he reflected on this project:

The traditional way of doing it is you’re assigning labor relations people who don’t understand the operations and all the technology and innovations. They’re not included in those conversations. So they go to the bargaining table, and the labor person has only been told that there is either going to be a layoff, or a change in jobs, and we are doing this because of the need for affordability, or because we need to cater to the customer. They are like, what!!??? So it is just kind of set up for an antagonistic type of relationship…because there hasn’t been this pre-work, conversations and joint learnings about why this change is really happening, how it will improve care.

There is a big disconnect between the innovators planning this change and the bargaining with unions to implement downstream workforce implications.

Interestingly, a union representative also sees her role as an intermediary in the broader change pro- cesses at KP:

What I’m trying to do is to help facilitate the conversation. It’s really hard to make management own what they want… What classifications do you need? Where are you going to lay-off people? And where do you want to grow, right? Put it on the table, take the consequences…. And you will get (union) members that say, I am not changing… Kaiser has a lot of money; they do not need to do this… And they’re wrong, but they are human; they are afraid. (So I say) basically you’re stuck: either you learn this, or you won’t have a job… So, that’s the conversation I’m trying to facilitate. I try to get everyone to put their issues on the table and work it out…

Challenges While there are many success stories in the transform- ation of WFPD at KP, informants also expressed concerns. Several informants talked about the continued resist-

ance of some business units and regional operations to the new WFPD approach. As one person explained, “the C-Suite is on board with a human capital strategy and there is a fair amount of engagement of line employees in unit-based teams, but the middle management is not fully engaged”. While informants view the LMP as a powerful mech-

anism for managing the impacts of change, involving workers who are represented by unions outside the LMP and the large number of exempt employees in KP (al- most half of the workforce) is challenging. As one in- formant put it, “So what is the governance for this work with the other half? Who sets the priorities, allocates the resources, and oversees the initiatives?” The fluid fiscal environment and constant innovation

are expanding the role of finance in strategic change and workforce decisions. Informants did not challenge the need for more fiscal control; their concern was over the episodic nature and the short-term time horizon of the financial decision-making process. As one person put it, “it does not matter if the company and the LMP have invested in a long-term strategy to fill a skills gap, fi- nance can insist on a last minute reduction in force or a redeployment to meet fiscal targets.” Several informants expressed the need to figure out how

to bring workforce initiatives to scale and spread innova- tions, like the Jobs of the Future, to other regions. They believe that a deeper understanding of the knowledge,

Pittman and Scully-Russ Human Resources for Health (2016) 14:56 Page 6 of 15

skills, and methods that underlie the emerging WFPD model might help spread innovation in KP.

Case study 2: Montefiore Health System The Montefiore Health System is headquartered in the Bronx, NY, and currently covers approximately 350 000 lives through a variety of value-based reimbursement re- lationships with commercial and government payers. Over 80 % of Montefiore’s revenue is derived from the Medicare and Medicaid programs. Its leaders describe it as an “open ecosystem” with long-standing partnerships with the community, its labor unions, community-based organizations (CBO), and local high schools and com- munity colleges. This, we shall see, is a critical character- istic of Montefiore’s approach to workforce changes. The organization has a long history of seeking out

capitation and other forms of risk-sharing agreements. Twenty years ago, Montefiore executives formed an Integrated Provider Association (IPA), which encompassed its salaried physicians, as well as community-based, volun- tary (private-practice) physicians, and approached private payers with a request to develop risk-sharing contracts. While Montefiore experienced some losses during the early days of managing these agreements, they pushed ahead, understanding that the change would take time and that returns would be realized only when there were higher volumes of covered lives. The passage of the ACA, and in particular the launching of Medicare’s Pioneer Accountable Care Organization (ACO) program, in which Montefiore was selected to be one of the original participants, opened new opportunities for value-based contracts. From the beginning, this active pursuit of value-based

contracts has been supported by a subsidiary called a Care Management Organization (CMO), which developed a ro- bust care management infrastructure with the explicit ob- jective of understanding and addressing the upstream determinants of health. The CMO’s approach to care co- ordination includes health education, linkages with social services and government benefits, health system navigation, provider communication, chronic care management and care transition management, and medication review and reconciliation. A focus on patients with high medical ex- pense and high risk of hospital and emergency department utilization by interdisciplinary care management teams has generated savings that that are reinvested in the delivery system. Care coordination is extended beyond Montefiore’s facilities through active partnerships with community- based, voluntary physicians as well as a wide range of com- munity service organizations. The CMO supports this care model with a robust

WFPD infrastructure that includes a comprehensive competency map for all key CMO workflows supported by a wide range of training programs to ensure em- ployees are prepared with the required skills.

In addition to the CMO WFPD capabilities, Montefiore Human Resources (HR) and Labor and Employee Relations functions have structures and mechanisms to integrate HR as well as labor into unit-based change. For example, HR stations a HR person in every department whose role is to understand the local culture and help HR anticipate and support change. This sensing function also enables HR to ensure the engagement of labor in planned changes. Regionally, Montefiore also has a long history of labor-

management partnership through its participation and leadership in the 1199SEIU Training and Employment Fund. The fund, which was established in 1969 to pro- vide education and job training programs for healthcare workers, is the largest joint labor-management training organization in the United States. It covers 250 000 workers (190 000 in New York City) and more than 600 employers, including hospitals, nursing homes, regis- tered nurses (RN), and home care workers. 1199SEIU and healthcare employers jointly govern the fund and Montefiore’s Executive Vice President is on the Board of Trustees. Since its formation in 1969, 1199SEIU has established

a total of nine funded initiatives, of which Montefiore contributes to five, that cover three main areas:

� Training and upgrading: There are two training and upgrading funds (one specific to RN and one general) that work with Montefiore and union leaders to identify high-demand skills and occupations and develop training programs in response. It includes counseling and tutoring, adult basic education and pre-college preparation programs, and an array of college education benefits to support workers in attaining college degrees in healthcare-related occupations.

� Job security: An additional fund provides a safety net and rapid re-employment services for laid-off workers, who receive priority employment from hundreds of healthcare institutions in the NYC area. They also support job counseling, placement, training programs, and benefits to assist workers’ transition into a new job in healthcare.

� Labor-management initiatives: This fund seeks to increase worker voice in the planning and implementation of efforts to increase quality care, patient satisfaction, and operational effectiveness. It supports technical assistance on the development of joint governing structures and training in joint problem solving around quality and performance issues.

The funds are financed by collective bargaining contri- butions, with employers contributing 0.5 % of gross

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payroll to the Training and Upgrading Fund and smaller amounts to the other funds. The funds have also re- ceived over $300 million in grants to open their pro- grams to community members and other healthcare workers who are not members of the 1199SEIU.

Drivers of change The ACA’s payment reforms allowed Montefiore to le- verage its experience with value-based purchasing and deepen its commitment to population health. However, New York state health policy, in particular the ambitious Delivery System Reform Incentive Payment (DSRIP) Program, a product of New York’s Medicaid Redesign Team (MRT) Waiver Amendment, is likely the greatest driver of change at Montefiore. DSRIP will fundamentally restructure the healthcare

delivery system by reinvesting in the Medicaid program, with the primary goal of reducing avoidable hospital use by 25 % over 5 years. Up to $6.42 billion dollars are allo- cated to this program with payouts based upon achiev- ing predefined results in system transformation, clinical management, and population health. The entities that are responsible for creating and implementing DSRIP are Performing Provider Systems (PPS). PPS are pro- viders that form partnerships among major public hospi- tals and safety net providers, with a designated lead organization for the group. There are 25 PPS across the state, with Montefiore leading one in the Hudson Valley and participating in a second PPS in the Bronx (Bronx Partners for Healthy Communities) led by St. Barnabas Hospital (SBH). A major focus of DSRIP is to develop strategies to re-

align, redeploy, and retrain the healthcare workforce across the provider networks within broad regions throughout the state. DSRIP has also merged the Office of Mental Health, Office Alcoholism and Substance Abuse, and Department of Health (DOH), so there is a single regulatory structure with payment aligned. This means all community-based organizations (CBO) will begin to receive their funding from this single payer/ regulator at the state level. Montefiore executives de- scribe the program as “right-sizing” Medicaid. All care will be managed, and the number of contracts with HMOs will be dramatically reduced from 17 to 7–10 plans. Ultimately, the program’s goal is to achieve 90 % value-based payment in 5 years.

Change strategies Over time, Montefiore’s leaders have realized that to make their value-based contract model work, they needed to create economies of scale. The strategy has so far resulted in the outright acquisition or other partnership arrange- ments with nine hospitals, several of which are in the Hudson Valley, a region that is largely exurban, dominated

by solo practices, and radically different from the Bronx in terms of patient demographics. In addition, Montefiore views its engagement in DSRIP as an opportunity to ex- pand its model to a broader continuum of care in the Bronx as well as in the Hudson Valley. Finally, it has begun to expand into new lines of business with the estab- lishment of the Managed Long Term Care Plan (MLTCP), which may transform Montefiore into a fully integrated delivery system. The implication of these expansions is significant, both for the workforce and more broadly in terms of testing the feasibility of Montefiore’s population health model in new environments.

Workforce planning and development strategies The central workforce dynamic resulting from the DSRIP rollout and Montefiore’s policy of acquisitions is that Montefiore is rapidly blurring its traditional work- force boundaries. This has multiple implications for its approach to WFPD. First, the inclusion of new facilities and regions requires HR to integrate the workforce into Montefiore’s culture, often in the context of downsizing and redeployment of staff. Second, the merging of the various social service payment schemes into one payer/ regulator under DSRIP will mean that Montefiore has a direct financial interest in strengthening CBO services and, therefore, the capabilities of its workforce. Third, early discussions among partners in the PPS suggest a commitment to relocate any displaced workers from partner organizations in the PPS to avoid unemploy- ment. This will not only intensify the imperative to ex- pand care coordination across providers and CBO, but now extend WFPD outside the traditional boundaries of Montefiore’s employees. An HR leader described the change:

Whereas in years past we focused on our own employees and attracting top talent, now we are (also) interested in folks in the community and their future, and how to get them interested in a health care profession…We are partnering with schools, and building health care curriculums…And we have a greater focus on development and education of our community partners. We are doing more with internships and externships and volunteerism…It’s really about building the health of the community.

Montefiore’s WFPD strategies are emerging within three loosely coupled and well-resourced efforts: expan- sion of the CMO’s competency and training map, lever- aging regional ties through its LMP, and embracing DSRIP aims to build a strong provider network. Each is closely tied to Montefiore’s strategy to build economies of scale and improve population health.

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The first strategy involves the expansion of the CMO comprehensive training program to support Montefiore’s efforts to bring its care management model to scale. A core feature of this effort is a competency map that specifies what each worker needs to know and do and identifies curriculum pathways for each of the 80 clinical and non-clinical roles in the CMO. One in- formant shared that the map enables the CMO to scale up training and target delivery throughout the growing continuum of care.

It’s not scalable to create an education program that trains every single person here on how to arrange transportation or how to find a pharmacy that delivers. We want that to be role specific and matched to the right skill set so the training that goes with each role is then matched to what we expect people in that role to do… If we hadn’t gone to a model like that, it’s just not scalable.

The CMO model has both loose and tight elements. The loose characteristics include the placement of facili- tators in the CMO units to listen and support people in developing the skills and knowledge required to continu- ously improve the model. There is also an educational council comprised of representatives from throughout the system that helps ensure frontline input into learn- ing needs and evaluation of training programs. Its tight- ening mechanisms include standardizing some elements of training to help spread the care coordination model to the new Montefiore and the PPS partners. The second WFPD strategy involves leveraging

Montefiore’s affiliation with the 1199SEIU League Train- ing Fund to intervene into the regional healthcare labor market to address broad workforce challenges facing the industry as a whole. For example, Montefiore, in partner- ship the Training and Upgrading Fund, agreed to provide a clinical site for a RN-to-BSN bridge program being of- fered by the City University’s Lehman College in the Bronx. This partnership brought to light Montefiore’s con- cerns about nursing school curricula, which are largely fo- cused on training nurses for acute care roles and lack preparation around care coordination and population health. The partners addressed this gap in this one-time bridge program with the inclusion of a care management module. Since then, the parties have worked together to revamp the curricula to better prepare nurses for care management and care coordination careers—which in- clude courses on the broader institutional changes in healthcare and changing care models. Montefiore and the training fund’s involvement in two regional DSRIP PPS will likely afford them an opportunity to replicate this kind of partnership with other schools of nursing and programs to train workers for other high-demand occupations.

On the internal front, though labor union relations were described as being “very collaborative” and “very well integrated into the facilities,” the degree to which the LMP is involved in Montefiore’s innovation and growth strategies is unclear. The nature of labor rela- tions at Montefiore maybe best illustrated by the way in which CMO managers described problems redefining jobs and job titles. They essentially work hard to respect the union, but efforts to engage unions in the redefin- ition of jobs, as occurred in KP’s Southern California region, have not taken place.

In the union contract you have certain titles and those titles really still largely crosswalk to functions that you would have seen in a hospital or maybe in a physician’s office. But to get a new title is hard. It has to be negotiated… So what we’ve tried to do is take our functions and crosswalk them to existing titles. Our titles don’t always completely (crosswalk to the new duties)…It would be nice to have more flexibility, because it takes too long (to negotiate change).

Despite these challenges, HR leaders described their relationship with labor as being based on mutual trust and collaboration. For example, Montefiore developed training for hospital staff on Hospital-Acquired Condi- tions for which CMS will no longer reimburse. They partnered with 1199SEIU to roll out the program, which they believe greatly facilitated workers’ confidence that the program would be beneficial and not harmful to their interests. The third workforce strategy involves embracing the

DSRIP aims to build a strong provider network. With reduction of potentially avoidable emergency room (ER) visits and hospital admissions as end goals, the NY DSRIP stipulates that an immediate task is to “re- train the workforce for care continuum and redeploy them to ambulatory and home care.” Executives describe this challenge on several fronts. First, they report “We work across health care settings and CBO’s in the PPSs to standardize titles and compe- tencies, and to establish criteria for determining how care will be coordinated.” They point out that this process is made particularly challenging by the vast array of ways that organizations across the PPS network have organized jobs. “Some organizations re- quire care managers to be RNs, while others employ individuals with … a high school diploma or a GED as care managers. There is a lot of cross cutting (comparison) that we need to do.” CMO leaders say a key challenge is ensuring that its

standards are maintained as the number of organizations involved in the continuum of care expands through the DSRIP process.

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There are a myriad of organizations out there that provide all kinds of services… peer groups, housing groups, mental health, substance abuse, transportation… They’re not going to be our employees… (but) we’re going to have to make decisions about (whether) we are comfortable actually turning over the responsibility for case management in a particular case.

The second area of work required by DSRIP will be to manage the relocation process. DSRIP anticipates that, over time, hospitals will reduce the number of beds or close shrink and that ambulatory-, home-, and community-based care will grow. Workers will need to be retrained to move into these new settings within PPS. The 1199SEIU League Training and Employment Fund, which spans multiple em- ployers, will likely play a role in managing these transitions through its Job Security Fund.

Challenges Despite what is largely a story of successful relationships, Montefiore informants were frank about the challenges ahead that concern them. The first is a reflection of the need for continued mat-

uration of the labor partnership. In particular, the lack of flexibility in renaming and redefining jobs has been an impediment to change and expansion plans. “It would be nice to have more flexibility.” Another challenge is related to the design and use of

community health workers (CHW) across the new DSRIP PPS networks. Currently, these jobs are different in their design and function, based on where the work is performed in a very broad spectrum of care coordin- ation. Historic interests and political dynamics have in part shaped these varied roles. There are deep differ- ences over how to integrate CHW, e.g., whether they should be hired directly into the organization, and of course, there are divergent views on which union might claim this growing cadre of workers. The question is whether the CMO’s data-driven innovation strategy will work in this highly politicalized context or whether new consultative mechanisms are also needed to successfully integrate diverse occupational roles and cultures. The third challenge regards the spread of the model to

the Hudson Valley. Currently, Montefiore’s relationship with its newly acquired facilities in the region is largely financial—but ensuring institutional stability will require Montefiore to transport its care coordination and community-based approach. This model is in part reliant on a large system that can move workers affected by change in one facility to new roles and locations in the expanding continuum of care. It remains to be seen whether there are the workforce relationships and mech- anisms that will facilitate such processes in this subur- ban and exurban area of the state.

Discussion Though KP and Montefiore are very different systems, each mounting a different strategic response to the ACA, they share a common understanding of the cen- trality of the workforce in any delivery system change process. This is reflected in a series of common themes that emerged in relation to our central study questions: how are these systems determining what changes are needed, and how they are implementing change in prac- tice? Below, we identify five broad themes present in both systems and discuss in the context of the theory of LCS. We then extrapolate the principles in each that may be relevant to other health systems and to broader issues of workforce policy and practice.

Core values and a centralized vision The first theme common to these case studies is that both organizations have a set of strong core values and a centralized vision with regard to their goals. At KP, the history of pre-paid, member-based service has instilled a core value for health prevention, while its roots as an innovator in the delivery of comprehensive medical services to workers and their families contributed to KP’s vision for continuous innovation and healthy work- places. These values and vision appear to be one explan- ation for KP’s extensive investment in the LMP and the many LM programs aimed at improving working condi- tions and making KP an employer of choice. Extensive engagement of labor in change decisions, coupled with the integration of innovation units into the change pro- jects, helps to ensure that these values and vision are key factors in determining the needed change in KP. More recently, participation in the Health Exchanges has led to the adoption of additional values centered on the ideas of consumer convenience and affordability. These new values are also informing the current cycle of innovation and change in the company. At Montefiore, the core value of population health not

only directs internal change, it underlies its efforts to build extensive external partnerships aimed at improving the entire continuum of care in the region. Regardless of whether WFPD is focused on current employees or the external pipeline of people who need jobs, Montefiore informants view these investments as part and parcel of a population health strategy. An HR leader summarized the viewpoint: “…we believe [these external WFPD pro- grams] are good for us as an organization.” In addition, Montefiore’s centralized vision of socially oriented care links and integrates many locally driven innovations and care models to the overall system. “…Every facility [in the Montefiore Health System] has its own culture, but the core is… our vision and our values.” These values and vision are embedded in the formal and informal processes that drive care and change at Montefiore. “If

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they (a newly acquired facility) are following the process, the culture starts changing; there is no other way.” Weick [11] and Burke [17] argue that large-scale, insti-

tutional change, like that occurring in healthcare today, requires a high degree of cooperation that is difficult to achieve among the many semi-autonomous subunits and organizations in LCS. Burke suggests that shared values help remind people why the system exists in the first place, while a centralized vision contributes focus within the dynamic complexity of LCS. In both cases, we see that their historical and cultural

context is key to understanding how they integrate WFPD activities into ongoing change processes. The emerging principle, then, is that the situation determines what type of adaptive WFPD is possible in the first place. This means that WFPD is not just a technical exercise; it must also appraise the political, economic, cultural, and social dynamics within specific contexts in which health- care takes place [13]. To be effective, the process must consider the multiplicity of values that drive healthcare and WFPD decisions [13].

Transparency and early dialogue The second theme that emerged in both cases is the com- mitment to transparency with regard to the goals and cri- teria for making decisions about changes and to an early dialogue with stakeholders, in particular labor, around the best way to organize the change. In both systems, we see an institutional commitment to early collaboration with labor and other key partners throughout the change process. In KP, the national agreement and the investment in

the LMP have resulted in a highly integrated system of corporate governance that involves labor in strategic decisions on every level of the company, from the UBT to national strategic planning efforts. The sharing of sensitive corporate information and performance data is essential to making these efforts work. The extent to which labor is involved in determining

internal change in Montefiore is unclear, though HR leaders did talk about the importance of early dialogue with labor about planned changes: “…we contact them early so that they do not hear about things late.” Accord- ing to an HR lead, this early consultation results in labor buy-in, which in turn provides employees with the assur- ances they need to engage in change. Greater emphasis on transparency and early dialogue

between Montefiore and 1199SEIU, its largest union, was observed in external efforts to close gaps in the labor market and in their mutual engagement in the DSRIP planning process. The expansion of the one-time nurse bridge program to create a new curriculum to prepare nurses for care coordination roles is an example of how joint leadership resulted in improvements to the WFPD infrastructure in the region.

The theory of LCS suggests that transparency and early dialogue are highly functional change mechanisms, because they open the process to many different inter- ests and vantage points required for sense making [25]. In addition, these mechanisms create shared leadership, which is more effective than hierarchical leadership when seeking to tighten connections within a LCS [17]. An emerging principle then is that WFPD is integrated

with strategic and operational planning processes. Beekun and Glick [16] define integration as a process for achieving unity of effort among various subsystems in the accomplishment of the organization’s tasks and goals. Moreover, from a change perspective, efforts to in- tegrate are seen as boundary defining and boundary spanning, which is a political process that requires on- going negotiation and mutual adjustment [17]. With these concepts in mind, this principle suggests that WFPD is a dynamic process of negotiation and mutual adjustment among semi-autonomous subunits in a LCS that seeks to integrate the workforce into the change processes within firms, as well as, as we shall discuss below, to align internal change with the system-wide skill formation goals and activities of WFPD institutions.

Innovations to workflow The third theme is changes often emanates from innova- tions to workflow that emerge from an analysis at the unit level and then take into account competing inter- ests across the system. This is in contrast to change de- fined based on existing jobs and organizational structure or simply an analysis of who currently does what. For example, KP’s UBT engage in the process on an

ongoing basis. In Southern California, efforts to mas- sively revamp ambulatory care based on the principles of consumerism began at a central level with a complete rethink of consumers’ wants and then engaged stake- holders in a discussion about how and where work is carried out, as well as who does what. The innovation model in Montefiore also starts with

an analysis of the optimum work design at the unit level, as opposed to the current workflows and job structures. The CMO competency map then uses the local analysis to build a whole-system approach to WFPD. It identifies the range of knowledge and skills that are required for coordination across the con- tinuum of care, and it delineates what every occupa- tion group needs to know and do to support the care model. This tool ensures that the required expertise is available across the entire system, while it also en- ables the customization of curriculum pathways for each role and individual in the CMO. There are several emerging principles here. The first

related once again to integration, as discussed above. But in addition, we see principles of both a holistic

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approach and an approach that is adaptive to chan- ging demand. The holistic principle implies the consideration of the

whole system of professions and occupations, as op- posed to each profession having its own distinct role, training structure, and regulatory mechanisms. Dussault and Dubois posit that a traditional siloed approach in healthcare hinders the implementation of policy and complicates the change process, particularly when new, multidisciplinary models that require a high degree of interdependence among many different professions are required [13]. A related principle is that adaptive WFPD must be

responsive to changing demand. Both systems have con- cluded that the traditional linear approach to WFPD is necessary but not sufficient. Their adaptive approaches begin with a focus on the demand for healthcare and try to account for the macro shifts and trends as well as the internal political dynamics affecting the health system and its workforce [13]. In the complex setting of health- care today, this requires a highly participative decision approach that accounts for many perspectives that is also supported by accurate, robust, and accessible data that can account for the large and growing number of variables that affect the demand for care and the supply of the workforce [10, 13]. New methods are also re- quired that can utilize the new so-called big data systems to model the efficacy of possible care models and WFPD scenarios [10].

New patterns of coupling The fourth theme is the new patterns of coupling, in- cluding both tightening and loosening of the alignment of each company’s component parts. These changes are consistent with the proposition of Bechun and Glick, who argue that institutional changes can set into motion new patterns of coupling within organizations as they re- spond to the changing environment. They also claim that the strategies used to foster new patterns of coup- ling will reflect the organizations’ traditional approach to implementing change. We have seen that, historically, KP grew as a loosely

coupled network of providers (Permanente Group) and an insurer (Kaiser Foundation Health Plan), across seven semi-autonomous regions. Recent efforts to streamline administrative systems through “One KP,” as well as HR’s work to create centralized skill standards and train- ing, reflect an attempt to cut costs and to create a com- mon corporate identity by tightening connections. In addition, the influx of new individual members is pushing KP to both loosen and realign their historic workflows and communication patterns by relocating care and con- solidating roles to improve care and make it more access- ible. Lastly, we see how technology continues to play an

important role in meeting long-held objectives to tighten the connection between KP and its members, as well as, they hope, to improve the quality of care. Similarly, Montefiore’s historic strategy to promote

value-based contracting led them to extend their care model by tightening their connections throughout a loosely coupled network of providers, and this approach continues to grow as they expand into new regions. Once connections are made, CMO takes the lead in tightening efforts by identifying the parts of the system where outcomes are weak and costs are high and then turns the focus to the redesign of work, followed by training, both initial and continuous. Now, with the expansion of the system into new regions, and the new relationships with external providers and community- based organizations that are being formalized through DSRIP, the CMO is poised to integrate its approach with external partners. The emerging principle here is again integration, not just

with regard to internal realignment but with external rela- tionships as well. This is particularly striking in the case of Montefiore, where their new patterns of integration are aligning internal change with external partnerships.

Maturing the WFPD model through intermediary functions Both systems work hard to continuously mature their approach to WFPD. Indeed, Burke anticipated that as LCS grew more commonplace in business and society, change agents would need deeper knowledge of the dynamics of LCS and more complex change strategies to enable both the tightening as well as the loosing of ties throughout the system. Change agents know how to tighten, according to Burke, but few can discern the need to loosen and then effectively intervene. Informants in both cases were quite articulate about

their WFPD model and the need to improve and expand it beyond the traditional approach. Intermediary struc- tures form the structural basis for the WFPD model in both cases. Intermediaries, according to Giloth, broker and integrate a variety of interests and resources to en- act WFPD in local settings [26]. As seen in both cases, these intermediaries devote a great amount of “face time and linguistic work” to help people make sense of the ambiguity brought about by the unpredictable structures within LCS [25]. The intermediary partnership in KP is made up of a

loosely coupled network of staff housed in a variety of support units who “show up” at important corpor- ate innovation meetings and establish a presence in the change process. In addition to showing up, infor- mants talked about a variety of intermediary strat- egies, such as aggressive engagement, deep listening, and accommodation, that they utilize to help HR and

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the LM to “translate the workforce and labor piece” of the change. Thus, in KP, the intermediary strategies provide a valuable sense-making function that help the parties respond to change. One informant claimed that this intermediary, sense-making approach “…is core to how you transform workforce planning.” Intermediary partnerships also provide sense-making

functions throughout Montefiore. The HR Business Partners also show up at business meetings and they link HR processes to change occurring in operational units. The CMO’s Education Council and frontline fa- cilitators are listening mechanisms that align training with change occurring in the system. Lastly, in the context of DSRIP, Montefiore participates in work- force planning in the Bronx and the Hudson Valley PPS. In the Hudson Valley, they are engaging provider HR and operations staff in a preliminarily needs as- sessment to help make sense of future staffing needs and to identify gaps and resources. This was de- scribed as an analytical process to develop a strategy to close the gaps required to make each new role successful. A major emerging principle regarding this theme is

that decisions are being made through a process of consensus building that includes workers and are ac- commodative of the needs, interests, and preferences of participating groups. Again, WFPD is both a political and technical exercise [13], and as such, it calls for a process of exchange, negotiation, and mutual adjust- ment [11] among a diverse range of stakeholders. Consensus is necessarily achieved through processes of accommodation to the needs, interests, and preferences of the client. According to Burke [17] change agents must accept that they cannot fully understand and appreciate the client’s deep situational knowledge and approach each setting with curiosity. This openness promotes learning and shared ownership of WFPD problems, activities, and programs. In addition, we see that WFPD is a process that is

continuous and iterative. Dussault and Dubois suggest that the historic system of professional dominance in healthcare calls for an ongoing process (continuous) of adjustment (iterative design) that can attend to popula- tion needs as well as the changing expectations and roles of the healthcare workforce [13]. Further, Weick and Burke suggest the ambiguous and complex inter- relationships in LCS require an improvisational change process that connects past experience and knowledge (continuity) to present novelty through tinkering (incremental change) [17, 27]. Achieving this approach requires an eclectic mix of listening, practice, modeling, the ability to recognize the partial relevance of previous experience, and a high confidence in skill to deal with non-routine events [11].

Finally, WFPD is generative, resulting in new resources and capacity for innovation. We see in both cases that WFPD requires institutional capacity and the investment of time and money in sense making and structuring ac- tivities [13]. Both cases demonstrate how the interest in listening and accommodation has implications for inter- mediary WFPD structures and resources. And resource allocation for these functions is significant, in particu- lar for the LMP at KP. Both organizations are also recruiting top talent in workforce development and place a high value on the expertise of their employees in this area.

An emerging framework The seven principles emerging from these case studies, when considered synergistically, help provide a frame- work for thinking about adaptive WFPD in specific con- texts. Table 1 synthesizes our findings for this purpose. This emerging framework is consistent with the theory

of LCS and resonate strongly with the critique offered by Dussault and Dubois of human resource planning in the healthcare sector. We would suggest that others could adopt these propositions to think about WFPD in new and innovative ways

Conclusions This comparative case study analysis suggests that the old way of doing WFPD by estimating the workforce needs within the confines of an institutional setting is giving way to new adaptive approaches. Institutional set- tings in the context of a post-ACA landscape are simply too complex and fast paced for the old approach to work. Both KP and Montefiore understand that the only way to do WFPD in periods of rapid transformation is to engage—to listen and interpret what is happening from a workforce perspective. This process requires

Table 1 Emerging themes and their related principles

Common themes in case studies Related theoretical principles

1. Strong core values and vision 1. Historically and culturally situated

2. Transparency and early dialogue with labor and other stakeholders

2. Integrated, internally and externally, with strategic and operational process

3. Innovations in workflow (2) Integrated 3. Changes are holistic 4. Changes are adaptive and based on data about changing demand

4. New patterns of coupling (2) Integrated

5. Maturing the WFPD model through intermediary functions

5. A process on ongoing consensus building

6. Continuous and iterative 7. Generative of new investment in the function

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developing an institutional capacity for sense making [11] across the organization, achieved through a con- tinuous process of engaging, listening, and organizing. WFPD is therefore no longer a centralized function at

KP and Montefiore. Control mechanisms have been re- placed with strategies to integrate various stakeholders and units across a broad continuum of WFPD activities and programs. The new approach to WFPD is aligned with strategic growth plans and is integrated with labor, employment relations, innovations teams, and local change initiatives. Both systems demonstrate a concern for the impact of change on their workforce and have made large political as well as financial commitments to avoid outsourcing and layoffs. We find that a series of new change principles defined

by theorists as suitable for improving the functioning of LCS [11, 17] and aligned with the adaptive WFPD model [10, 13] are present in both organizations. The principles include WFPD that is (1) situated in a set of core values that have emerged from specific historic and cultural contexts; (2) integrated, both internally and externally; 3) focused on a whole-system perspective; 4) responsive to changing demand; 5) based on consensus building, that is (6) continuous; and (7) generative and requires real and continued investment. The effective implementation of these principles in

these two major health systems has given rise to a pat- tern of reciprocal interdependence and mutual adjust- ment among the diverse range of actors across the WFPD ecosystem. This new form of coordinating WFPD across the system is both enabled by and helps to foster a form of knowledge-based action and a pattern of thinking that is slow, deliberate, and explicit—and is more aligned with the complexity of health workforce changes in a post-ACA environment. These findings may be relevant to a range of other

healthcare organizations. While the payment reforms that are spurring workforce transformations may be different for public systems, like the Veterans Health Administration in the United States, to the extent that they are embracing any major system changes, these WFPD principles would be applicable. In other words, the principles are about managing change in complex organizations, not about the specifics of the changes. The findings may also hold meaning for macro-level

workforce policies at the state and federal governments. Technocratic WFPD at these levels is also likely to be insufficient during periods of large-scale system trans- formation. Traditional policy levers, such as scope of practice regulation, education and training curriculum and degrees, and professional codes, have not been re- sponsive to the needs of LCS, because they are designed to ensure uniformity in roles and job structures across the broader healthcare system.

If today, we are likely to see less uniformity in our dis- tributed, free-market healthcare system as it continues to innovate and multiply new models of care, then WFPD at both the organizational and the public policy levels must also go beyond data analysis and engage in a political process of spanning traditional boundaries, listening to diverse interests, and building consensus. It requires new intermediary structures, and it must be generative of new resources and new talent. It also re- quires building the political and technical skills of WFPD professionals and empowering them to challenge old practices and ways of thinking about workforce issues and problems [13] and address the structural and financial gaps in the skills formation continuum.

Abbreviations ACA: Affordable Care Act; ACO: Accountable Care Organization; CBO: Community-based organizations; CHW: Community health workers; CKPU: Coalition of Kaiser Permanente Unions; CMO: Care Management Organization; DOH: Department of Health; DSRIP: Delivery System Reform Incentive Payment Program; EISA: Employment and Income Security Agreement; ER: Emergency room; HIT: Health information technologies; HMO: Health Maintenance Organization; HR: Human resources; IT: Information technologies; KP: Kaiser Permanente; LCS: Loosely coupled systems; LMP: Labor-management partnerships; MRT Waiver Amendment: Medicaid Redesign Team Waiver Amendment; PMG: Permanente Medical Group; PPS: Performing Provider Systems; RAD: Reimagining Ambulatory Design; RN: Registered nurse; UBT: Unit-based teams; WFPD: Workforce planning and development

Acknowledgements No applicable.

Funding This article was supported by a cooperative agreement with the National Center for Health Workforce Analysis, Health Resources and Services Administration. The funder did not have a role in the design of the study nor collection, analysis, and interpretation of the data or in writing the manuscript.

Availability of data and materials All interview recordings and notes are available upon request.

Authors’ contributions Both authors made substantial contributions to conception and design, acquisition of the data, and analysis and interpretation of the data. They were both involved in drafting the manuscript and revising it and approving the final version for publication.

Authors’ information PP is the Director of the George Washington University Health Workforce Research Center and the Co-Director of the George Washington University Health Workforce Institute. PP teaches and focuses her research on health workforce policy. Her recent focus is on workforce innovations in the context of system change. ES is a Professor of Human and Organizational Learning. She is an expert in qualitative research methods and has more than 25 years of experience as a workplace learning and workforce development practitioner in a wide range of industries including healthcare, telecommunications, manufacturing, hospitality, and the public sector. She has worked with dozens union- management partnerships on the firm, regional, and industrial levels to develop policies and programs to meet the dual goals of supporting individual learning and development and improving industry and firm performance.

Competing interests The authors declare that they have no competing interests.

Pittman and Scully-Russ Human Resources for Health (2016) 14:56 Page 14 of 15

Consent for publication Not applicable

Ethics approval and consent to participate Not applicable

Author details 1Milken Institute School of Public Health, The George Washington University, 2175 K Street, NW, Suite 500, Washington, DC 20037, United States of America. 2Graduate School of Education and Human Development, The George Washington University, 2136 G Street, NW, Washington, DC 20052, United States of America.

Received: 15 April 2016 Accepted: 12 September 2016

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4. Quan X, Joseph A, Keller A, Taylor E. Designing safety-net clinics for innovative care delivery models. California Healthcare Foundation: Oakland, CA; 2011. http://www.chcf.org/~/media/MEDIA%20LIBRARY%20Files/PDF/ PDF%20D/PDF%20DesigningClinicsInnovativeCareDeliveryModels.pdf. Accessed 3 Sept 2015.

5. Dougherty R, Crowley R. Principles supporting dynamic clinical care teams: an American College of Physicians position paper. Ann Fam Med. 2013; 159(9):620–6.

6. Hein R. 7 healthcare IT roles that are transforming tech careers. CIO Web site. http://www.cio.com/article/2385786/it-strategy/7-healthcare-it-roles- that-are-transforming-tech-careers.html. Published May 16, 2013. Accessed 10 Aug 2015.

7. Altschuler J, Margolius D, Bodenheimer T, Grumbach K. Estimating a reasonable patient panel size for primary care physicians with team-based task delegation. Ann Fam Med. 2012;10:396–400.

8. Auerbach DI, Chen PG, Friedberg MW, Reid RO, Lau C, Mehrotra A. Nurse- managed health centers and patient-centered medical homes could mitigate expected primary care physician shortage. Health Aff. 2013;32(11):1933–41.

9. Walston S, Lazes P, Sullivan P. Improving hospital restructuring: lessons learned. Health Care Manage Rev. 2004;29(4):309–19.

10. Curson JA, Dell ME, Wilson RA, Bosworkth DL, Balduf B. Who does workforce planning well? Workforce review team rapid review summary. Int J Health Care Qual Assur. 2010;23(1):110–9.

11. Weick KE. Management of organizational change among loosely coupled elements. In: Weick K, editor. Making sense of the organization. Malden, MA: Blackwell; 2001.

12. Schrock G. Connecting people and place prosperity: workforce development and urban planning in scholarship and practice. J Plan Lit. 2014;29(3):257–71.

13. Dussault G, Dubois CA. Human resources for health policies: a critical component in health policy. Hum Resour Health. 2003;1(1). doi:10.1186/ 1478-4491-1-1.

14. Weick KE. Making sense of the organization: the impermanent organization (V2). West Sussex: John Wiley & Sons; 2009.

15. Orton JD, Weick KE. Loosely coupled systems: a reconceptualization. Acad Manage Rev. 1990;15(2):203–23.

16. Beekun RI, Glick WH. Organization structure from a loose coupling perspective: a multidimensional approach. Decis Sci. 2001;32(2):227–50.

17. Burke WW. Changing loosely coupled systems. J Appl Behav Sci. 2014;50(4): 423–44.

18. Thompson JD. Organization in action. New York, NY: McGraw-Hill; 1967. 19. Weick KE. Educational organizations as loosely coupled systems. Adm Sci Q.

1976;21:1–16.

20. Heldal F. Multidisciplinary collaboration as a loosely coupled system: integrating and blocking professional boundaries with objects. J Interprof Care. 2010;24(1):19–30.

21. Thompson JD. Organizations in action: social science bases of administrative theory. 7th ed. New Brunswick, New Jersey: Transaction Publishers; 2010.

22. Chase D. Montefiore Medical Center: integrated care delivery for vulnerable populations. New York, NY: The Commonwealth Fund; 2010. http://www. commonwealthfund.org/~/media/Files/Publications/Case%20Study/2010/Oct/ 1448_Chase_Montefiore_Med_Ctr_case_study_v2.pdf. Accessed 10 Aug 2015.

23. Permanente K. Jobs of the Future: workforce planning for 21st century care. Oakland, CA: Kaiser Permanente; 2014. http://www.seiu-uhw.org/files/2015/ 10/JobsoftheFuture-FinalReport-Nov2014.pdf. Accessed 13 Aug 2015.

24. Kochan T, Eaton A, McKersie R, Adler P. Health together: the labor management partnership at Kaiser Permanente. Ithaca, NY: Cornell University Press; 2009.

25. Weick KE. Social psychology of organizing. 2nd ed. New, NY: McGraw-Hill; 1979. 26. Giloth RP. Workforce intermediaries for the 21st century. Philadelphia, PA:

The American Assembly, Columbia University; 2004. 27. Weick KE. Organizational redesign as improvisation. In: Huber G, Glick W,

editors. Organizational change and redesign. New York, NY: Oxford University Press; 1993.

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Pittman and Scully-Russ Human Resources for Health (2016) 14:56 Page 15 of 15http://www.hhnmag.com/Magazine/2014/Mar/cover-story-great-migrationhttp://www.pcdc.org/resources/publications/carecoordinationreportfinal2.pdfhttp://www.pcdc.org/resources/publications/carecoordinationreportfinal2.pdfhttp://www.chcf.org/~/media/MEDIA%20LIBRARY%20Files/PDF/PDF%20D/PDF%20DesigningClinicsInnovativeCareDeliveryModels.pdfhttp://www.chcf.org/~/media/MEDIA%20LIBRARY%20Files/PDF/PDF%20D/PDF%20DesigningClinicsInnovativeCareDeliveryModels.pdfhttp://www.cio.com/article/2385786/it-strategy/7-healthcare-it-roles-that-are-transforming-tech-careers.htmlhttp://www.cio.com/article/2385786/it-strategy/7-healthcare-it-roles-that-are-transforming-tech-careers.htmlhttp://dx.doi.org/10.1186/1478-4491-1-1http://dx.doi.org/10.1186/1478-4491-1-1http://www.commonwealthfund.org/~/media/Files/Publications/Case%20Study/2010/Oct/1448_Chase_Montefiore_Med_Ctr_case_study_v2.pdfhttp://www.commonwealthfund.org/~/media/Files/Publications/Case%20Study/2010/Oct/1448_Chase_Montefiore_Med_Ctr_case_study_v2.pdfhttp://www.commonwealthfund.org/~/media/Files/Publications/Case%20Study/2010/Oct/1448_Chase_Montefiore_Med_Ctr_case_study_v2.pdfhttp://www.seiu-uhw.org/files/2015/10/JobsoftheFuture-FinalReport-Nov2014.pdfhttp://www.seiu-uhw.org/files/2015/10/JobsoftheFuture-FinalReport-Nov2014.pdf

  • Abstract
    • Background
    • Methods
    • Results
    • Conclusions
  • Background
    • Conceptual framework
  • Methods
  • Results
    • Case study 1: Kaiser Permanente
      • Drivers of change
      • Change strategies
      • Workforce planning and development strategies
      • Challenges
    • Case study 2: Montefiore Health System
      • Drivers of change
      • Change strategies
      • Workforce planning and development strategies
      • Challenges
  • Discussion
    • Core values and a centralized vision
    • Transparency and early dialogue
    • Innovations to workflow
    • New patterns of coupling
    • Maturing the WFPD model through intermediary functions
    • An emerging framework
  • Conclusions
  • show [a]
  • Acknowledgements
  • Funding
  • Availability of data and materials
  • Authors’ contributions
  • Authors’ information
  • Competing interests
  • Consent for publication
  • Ethics approval and consent to participate
  • Author details
  • References

ajn@wolterskluwer.com AJN ▼ February 2018 ▼ Vol. 118, No. 2 43

strategies for creating a more highly educated nurs- ing workforce.

APIN GRANTEES The National Advisory Committee for the APIN NPO selected nine states—California, Hawaii, Massachu- setts, Montana, New Mexico, New York, North Car- olina, Texas, and Washington—to design and test potential models of academic progression. All nine states were already engaged in some aspect of aca- demic progression, and each received a two-year, $300,000 grant with the possibility of a second. The RWJF and the NPO considered this a laboratory in which results could be obtained, evaluated, and shared within that four-year time frame; all grants concluded by the end of 2016.

APIN funded efforts on two fronts: initiatives that remove obstacles that keep nursing students from get- ting their BSN—such as support for partnerships be- tween universities and community colleges to allow seamless progression from the associate’s degree (AD) to the baccalaureate—and employment-focused part- nerships between schools and health care facilities that provide students with practice experience, pro- mote greater use of the BSN, and create employment opportunities.

APIN OUTCOME HIGHLIGHTS All of the states involved in the program developed strategies for removing obstacles that keep nursing students from getting their BSN. Massachusetts, Mon- tana, Texas, and Washington, for instance, developed

Moving Closer to the 2020 BSN-Prepared Workforce Goal

In 2010, the Institute of Medicine (IOM) released its groundbreaking report The Future of Nurs­ing: Leading Change, Advancing Health. One of the report’s recommendations was to increase the proportion of the nursing workforce with a bachelor of science in nursing (BSN) or higher degree to 80% by 2020.1 When the report was released, approxi- mately 50% of nurses in the United States had a BSN or higher.2

Better use of the nursing workforce is one goal of the Campaign for Action, a joint initiative of the Rob- ert Wood Johnson Foundation (RWJF) and AARP, created to transform health care nationally.3 Through work conducted by the Center to Champion Nursing in America, possible models for addressing the need for more nurses to obtain a BSN were identified,4 and the RWJF built on that structure in developing and evaluating opportunities to accelerate change within the nursing education system.

In 2012, the American Organization of Nurse Executives (AONE)—one of the four members of the Tri-Council for Nursing—was selected by the RWJF as the National Program Office (NPO) for a new ini- tiative, the Academic Progression in Nursing (APIN) program, which was created to study the topic of higher degrees and employment for nurses and de- velop solutions. (Along with AONE, the Tri-Council member organizations are the American Association of Colleges of Nursing, the American Nurses Associ- ation, and the National League for Nursing.)

Now, APIN has concluded a four-year project de- signed to identify and develop the most promising

ABSTRACT One of the recommendations of the landmark Future of Nursing: Leading Change, Advancing Health report was to increase the proportion of nurses with a bachelor of science in nursing or higher degree to 80% by 2020. In 2012, the American Organization of Nurse Executives was selected by the Robert Wood Johnson Foundation as the National Program Office for a new initiative—the Academic Progression in Nursing (APIN) program—with the goal of identifying and developing the most promising strategies for creating a more highly educated nursing workforce. This article discusses the findings of APIN’s four-year project.

Keywords: bachelor of science in nursing, nursing students, nursing workforce

SPECIAL FEATURE By Tina Gerardi, MS, RN, CAE,

Pat Farmer, DNP, RN, FNP, APIN, and Bryan Hoffman, MA

44 AJN ▼ February 2018 ▼ Vol. 118, No. 2 ajnonline.com

transfer agreements outlining the courses and credits that will transfer between community colleges and universities, which facilitates a smooth progression from AD to baccalaureate.

The program in Massachusetts is known as the Nursing Education Transfer Compact (NETC). It simplifies the transfer of credits earned in an AD pro- gram to an RN–BSN program. Prerequisites, general education, and core curriculum courses are accepted by participating programs statewide. Students apply- ing to any public school and many private schools are under the umbrella of the NETC after obtaining their AD and passing the National Council Licensure Ex- amination (NCLEX), assuming they have completed the general education requirements defined in the state’s credit-transfer policy, known as MassTransfer. Students who have completed the AD with a grade point average of 2.75 or higher receive additional ben- efits through the NETC: the fee for admission to an RN–BSN program is waived, no admission essay is required, and preferential admission is offered.

Washington created a state-approved program, the Direct Transfer Agreement/Major Ready Program (DTA/MRP), an optional standardized curriculum for AD programs that makes the transfer of credits easy. Students at participating community colleges complete coursework and receive a DTA/MRP AD. Having met all criteria for entry into a baccalaureate nursing pro- gram, as well as all general education requirements, they are eligible for licensure and can apply to any in- state institution that grants RN–BSN degrees. Students must select institutions for both their AD and BSN that participate in the DTA/MRP curricular pathway. Once admitted, students can complete their BSN in one year. The DTA degree program has been initiated in 43% of Washington State’s community college RN programs and in all in-state public and private RN– BSN programs. In 2015–2016, approximately 600 AD nursing students were enrolled in these programs, with about 300 expected to graduate in June 2017. To date, 11 students have attained their BSN through the DTA.

California, Hawaii, New Mexico, New York, and North Carolina replicated successful arrangements between community colleges and universities for use in other areas of the state.

For example, California State University, Los Angeles, initially developed partnerships with seven

community colleges, providing a pathway for AD students to complete the baccalaureate within four years through coenrollment. Students apply and are selected by their AD faculty prior to the second se- mester of coursework at the community college. Stu- dents complete the first three years at the community college, taking baccalaureate-level classes offered dur- ing the summer sessions. The AD is awarded at the end of year 3 and students must pass the NCLEX to continue.

Similar programs were subsequently developed across other areas of California. All programs feature five core elements: dual admission, integrated curricu- lum, shared faculty, the availability of a BSN one year after attainment of the AD, and a plan for program sustainability. The program currently involves 19 uni- versity campuses and more than 50 community col- leges. Known as the California Collaborative Model for Nursing Education, the program is on track to add nearly 1,200 new BSNs a year to the California work- force. Eighteen percent of AD students in California

are dually enrolled. In addition, employment part- nerships between schools of nursing and health fa- cilities were an important part of the process for the development of academic-progression strategies.

The Queen’s Medical Center on the island of Oahu in Hawaii worked with the University of Hawaii at Manoa to develop an on-site executive RN–BSN program for its nurse managers. The on-site pro- gram allowed managers to achieve their BSN and subsequently become mentors for staff nurses, help- ing them go back to school to obtain their BSN.

North Carolina’s Regionally Increasing Baccalaure- ate Nurses program and New York’s Dual Degree Partnership in Nursing (DDPN) program both em- phasize the need for strong academic practice part- nerships to ensure that students complete their BSN courses after passing their NCLEX.

In New York, a striking example of the positive impact a strong partnership between academic insti- tutions and employers can have on student success was seen at St. Joseph’s College of Nursing in Syra- cuse. When AD students shared with their dean that the part-time work requirements for health benefits at St. Joseph’s Hospital Health Center hindered their ability to complete their courses, the dean contacted the chief nursing officer (CNO) at the facility to share the students’ concerns. The CNO formed a focus

A commitment to the work and to one another represents

transformative change in the nursing-education community.

ajn@wolterskluwer.com AJN ▼ February 2018 ▼ Vol. 118, No. 2 45

group and asked the students what a realistic part- time work schedule that allowed them to complete their studies might be. Through the focus group, it was determined that 16 hours per week would give these new RNs the time they needed to meet the ac- ademic requirements of the DDPN program.

The CNO worked to change hospital policy to allow any employee enrolled in the final year of the DDPN program to receive part-time benefits while working a minimum of 16 hours per week. This proved to be a win–win for the students and the employer.

The NPO and the APIN learning collabora- tive (among the grant states and other academic- progression leaders) determined that the community college–university partnership model showed great potential. New Mexico provided visionary leadership through its New Mexico Nursing Education Consor- tium model, pilot testing a statewide curriculum to increase the number of BSN-educated nurses in New Mexico and mentoring many other programs as they implemented the model. All participants recognized that close collaboration and support from practice partners are critical to success, and many worked to develop mechanisms to foster these relationships.

Updated information on the increase in the per- centage of nurses with a baccalaureate or higher de- gree is available from the Campaign for Action, at https://campaignforaction.org/issue/transforming- nursing-education. Here are highlights of the posi- tive changes that have taken place as a result of these efforts: • The percentage of the RN workforce with at least

a BSN increased from 49% in 2010 to 53.2% in 2015.

• The percentage of first-time NCLEX takers with a BSN or higher increased from 39.3% in 2010 to 47.2% in 2015.

• The proportion of RN–BSN graduates, in relation to all BSN graduates, increased from 30.6% in 2010 to 47.4% in 2016. More information on APIN and the outcomes of

the grant can be found at www.academicprogression. org.

COMMUNITY DEVELOPMENT The creation of a national community of nursing ed- ucators dedicated to smoothing the path from com- munity colleges to universities is having a profound impact. The collegial spirit of this community has created a climate that invites frank discussion of model strengths, weaknesses, and challenges. Prom- ising practices from all areas have been shared and consolidated. Working toward a common goal has resulted in a fellowship and camaraderie that gener- ate a commitment not only to the work but to one another. This represents transformative change in the

nursing-education community. The addition of local employers into the development, implementation, and evaluation of these models has added to the strength of the partnerships, while providing incen- tives for the incumbent workforce to achieve their BSNs.

NEXT STEPS With the closing of the NPO on June 30, 2017, the work toward national academic progression continues through a new initiative called the Na- tional Education Progression in Nursing Collabora- tive (NEPIN). The collaborative evolved from a series of meetings with Tri-Council members and other in- terested parties, including the Organization for Asso- ciate Degree Nursing (OADN), HealthImpact, the Washington Center for Nursing, Western Governors University College of Health Professions, the Univer- sity of Phoenix, the University of Kansas School of Nursing, the Center to Champion Nursing in Amer- ica, and the Philip R. Lee Institute for Health Policy Studies. The OADN Foundation will serve as the fi- duciary and convener for the collaborative in part- nership with the National Forum of State Nursing Workforce Centers.

For additional information on NEPIN, contact Tina Lear, NEPIN national program director, at tina. lear@nepincollaborative.org. ▼

Tina Gerardi is executive director of the Tennessee Nurses As­ sociation in Nashville. Pat Farmer is a research professor at George Washington University School of Nursing in Ashburn, VA. Bryan Hoffman is deputy director of the Organization for Associate Degree Nursing in Seattle. The authors received com­ pensation from the Robert Wood Johnson Foundation through the APIN grant discussed in this article. Contact author: Tina Gerardi, gerarditina@gmail.com. The authors have disclosed no potential conflicts of interest, financial or otherwise.

REFERENCES 1. Committee on the Robert Wood Johnson Foundation Initia-

tive on the Future of Nursing, at the Institute of Medicine, ed- itor. The future of nursing: leading change, advancing health. Washington, DC: National Academies Press; 2011. https:// www.nap.edu/catalog/12956/the-future-of-nursing-leading- change-advancing-health.

2. Health Resources and Services Administration. The registered nurse population: findings from the 2008 National Sample Survey of Registered Nurses. Washington, DC: U.S. Depart- ment of Health and Human Services; 2010 Sep. https://bhw. hrsa.gov/sites/default/files/bhw/nchwa/rnsurveyfinal.pdf.

3. Robert Wood Johnson Foundation. The case for academic progression: why nurses should advance their education and the strategies that make this feasible. Washington, DC; 2013 Sep. Charting nursing’s future.

4. Future of Nursing: Campaign for Action. Four models show­ ing promise for educational transformation. Washington, DC: Robert Wood Johnson Foundation, AARP; 2012 May 15. https://campaignforaction.org/wp-content/uploads/2012/05/ Early_Findings_Education_Learning_Collaborative_May2012. pdf.https://campaignforaction.org/issue/transforming-nursing-educationhttps://campaignforaction.org/issue/transforming-nursing-educationhttp://www.academicprogression.orghttp://www.academicprogression.orgmailto: tina.lear@nepincollaborative.orgmailto: tina.lear@nepincollaborative.orgmailto: gerarditina@gmail.comhttps://www.nap.edu/catalog/12956/the-future-of-nursing-leading-change-advancing-healthhttps://www.nap.edu/catalog/12956/the-future-of-nursing-leading-change-advancing-healthhttps://www.nap.edu/catalog/12956/the-future-of-nursing-leading-change-advancing-healthhttps://bhw.hrsa.gov/sites/default/files/bhw/nchwa/rnsurveyfinal.pdfhttps://bhw.hrsa.gov/sites/default/files/bhw/nchwa/rnsurveyfinal.pdfhttps://campaignforaction.org/wp-content/uploads/2012/05/Early_Findings_Education_Learning_Collaborative_May2012.pdfhttps://campaignforaction.org/wp-content/uploads/2012/05/Early_Findings_Education_Learning_Collaborative_May2012.pdfhttps://campaignforaction.org/wp-content/uploads/2012/05/Early_Findings_Education_Learning_Collaborative_May2012.pdf