Vital Clinical Role in The US Healthcare System Article Analysis
Vital Clinical Role in The US Healthcare System Article AnalysisVital Clinical Role in The US
Healthcare System Article AnalysisRead the Care Redesign ArticleAnswer the following
questions:Which four (4) components does the article point out are needed for the U.S.
healthcare system to succeed?The one recommendation form the ten cited in the Institute of
Medicine Report to improve quality and reduce cost that is described in the article?A recent
factor to be identified of reducing cost is?Name four (4) factors that influence patient
outcomes described in the article.Name the four (4) different nursing care delivery models
and give a short description of each.What is the meaning of the term “lean” as described in
the article.Summarize the method utilized in the study to offer a higher-quality and lower
cost method for acute care in just a few sentences.Your paper should be:Typed according to
APA style for margins, formatting and spacing standards.ORDER NOW FOR CUSTOMIZED,
PLAGIARISM-FREE PAPERSCare Redesign A Higher-Quality, Lower-Cost Model for Acute
Care JONA Volume 44, Number 7/8, pp 388-394 Copyright B 2014 Wolters Kluwer Health |
Lippincott Williams & Wilkins Pamela T. Rudisill, DNP, RN, NEA-BC, FAAN Carlene Callis, BS,
MHA Sonya R. Hardin, PhD, RN, CCRN, NP-C OBJECTIVE: The aims of this study were to
design, pilot, and evaluate a care team model of shared ac- countability on medical-surgical
units. BACKGROUND: American healthcare systems must optimize professional nursing
services and staff due to economic constraints, evolving Federal regulations and increased
nurse capabilities. METHODS: A redesigned model of RN-led teams with shared
accountability was piloted on 3 medical/surgical units in sample hospitals for 6 months.
Nursing staff were trained for all functions within their scope of practice and provided
education and for implementation. RESULTS: Clinical outcomes and patient experience
scores improved with the exception of falls. Nurse satisfaction demonstrated statistically
significant im- provement. Cost outcomes resulted in reduced total salary dollars per day,
and case mixYadjusted length of stay decreased by 0.38. CONCLUSION: Innovative changes
in nursing care delivery can maintain clinical quality and nurse and patient satisfaction
while decreasing costs. Author Affiliations: Senior Vice President and Chief Nursing Officer
(Dr Rudisill), Community Health Systems, Franklin; and Assistant Vice President Strategic
Resource Group, Vice President Strategic Planning American Group (Ms Callis), HCA,
Nashville, Tennessee; Professor (Dr Hardin), College of Nursing, East Carolina University,
Greenville, North Carolina; and Professor Emeritus (Dr Dienemann), School of Nursing, UNC
Charlotte and Nurse Researcher Carolinas Medical Center University, North Carolina; and
Chief Nursing Executive (Dr Samuelson), Poplar Bluff Regional Medical Center, Missouri.

Community Health Systems is a registered trade name of Community Health Systems
Professional Services Corporation. The authors declare no conflicts of interest.
Correspondence: Dr Rudisill, Community Health Systems, 4000 Meridian Blvd, Franklin, TN
37067 (pamela.rudisill@hma.com or pam_rudisill@chs.net). DOI:
10.1097/NNA.0000000000000088 JONA Vol. 44, No. 7/8 July/August 2014 Copyright ©
2014 Wolters Kluwer Health | Lippincott Williams & Wilkins. Unauthorized reproduction of
this article is prohibited. Jacqueline Dienemann, PhD, RN, NEA-BC, FAAN Melissa
Samuelson, DNP, RN, NEA, BC Healthcare systems in the United States must bridge the
transition from volume to value-based models. Components required to succeed include
clinical integration, implementation of technology, and clinical performance 1 improvement
with operational efficiencies to manage financial constraints. Nursing services encompass
the 2 majority of the workforce in today’s acute care hospi- tals. Vital Clinical Role in The US
Healthcare System Article AnalysisHistorically, models of care have been based on a mix of
registered nurses (RNs) and unlicensed assistive personnel (UAP) with occasional reference
to licensed practical nurses (LPNs) and the assignment of work- load. Evidence s that
patient needs are best met by planned skill 3,4 mix and recognition that nurses are
knowledge workers and need to be utilized in that manner. Models-of-care redesign that
embeds im- proving efficiency and increasing accountability to patients’ clinical outcomes
requires a 1 cultural transfor- mation. All major changes in care design should be evaluated
for their evidence-based and desired changes. The purpose of this study was to evaluate a
pilot im- plementation of a shared accountability delivery model for medical-surgical
patients that allowed licensed nurses and UAP to practice at their full authority through
delegation and collaboration in RN-led teams. Background The healthcare system in the
United States is in a state of rapid and unprecedented change with pressures to improve
clinical quality and patient health and increase patient satisfaction, while curtailing costs.
The Institute 5 of Medicine report cites 10 recommendations to ensure better health,
higher-quality care, and lower costs. One recommendation was to optimize operations by
continually improving healthcare operations to reduce waste, streamline care delivery, and
focus on activities that improve patient health. Vital Clinical Role in The US Healthcare
System Article AnalysisThe primary challenge of delivering care in acute settings is
managing increasingly 388 THE JOURNAL OF NURSING ADMINISTRATION complex
patients with shorter lengths of stay (LOSs) while ensuring integration of care upon
discharge and beyond. Recent studies demonstrate that lowering costs is dependent on
increasing patient safety rather than changing 6 nursing salary or staffing expenses. Nurs-
ing factors influencing patient outcomes include num- ber of hours per patient-day (number
of staff), quality of work environment, educational level of nurses, and mix of skills among
7-11 nursing staff. These factors inter- act among each other with varying effects on patient
outcomes. Increasingly, nurse satisfaction is related to recognition that RNs are knowledge
workers whose time should be utilized in 4 decision making regarding patient care and
safety. Nursing Care Delivery Models 12-14 14 Delivery of nursing care has traditionally
been delivered in 1 of 4 ways. Shirey discusses the advantages and disadvantages of various
models. The earliest model is patient allocation or total patient care with groups of patients
assigned to 1 nurse with no UAPs. Because of shortages during and after World War II, task

or func- tional nursing was emphasized, allocating more com- plex care to RNs and routine
care to UAPs. Team nursing evolved with RNs as leaders of UAPs for a group of patients.
Primary nursing identified 1 nurse to assume 24-hour responsibility for a patient with
communica- tion to RNs, LPNs, and UAPs who participated in care throughout the patient
stay. This 12 model of care has been coined relationship-based care. One new, novel ap-
proach is to expand primary care to 14,15 coordinating care after discharge, with the RN
assuming care as the pri- mary nurse for readmissions. model of care fits in the new modes
of accountable care transition coordination. This 16 The recent Institute of Medicine report
on the fu- ture of nursing advocates for RNs to perform to their fullest potential and to
become effective leaders and part- ners in the organization. This parallels the American 17
Organization of Nurse Executives guiding principles for the role of the nurse in future
patient care delivery. These position statements call for new innovative mod- els of nursing
care delivery. In 2005, Partners Healthcare in Boston, Massachusetts, conducted a search of
inno- vative nursing care delivery models for adult, acute care patients that integrated
technology, systems, and new roles to improve quality, efficiency, and cost. They identified
over 40 models that shared common elements of an elevated RN role, sharpened focus on
the patient, smoothed patient transitions and handoffs, leveraged technology, driven by
results that were mea- sured systematically, and 18 19 used for feedback to improve the
innovations.Vital Clinical Role in The US Healthcare System Article AnalysisA few new
models emerged requiring shared accountability. In reviewing these models, our JONA Vol.
44, No. 7/8 July/August 2014 Copyright © 2014 Wolters Kluwer Health | Lippincott
Williams & Wilkins. Unauthorized reproduction of this article is prohibited. team realized
several approaches underutilized RN del- egation, did not utilize LPNs at all, and did not
require RNs, UAPs, or LPNs to practice to their full scope. We did identify 1 computer
simulation model uti- lizing the RN, LPN, and UAP, which incorporated principles of 20 the
lean to enhance the role of the RN, LPN, and UAP in the care delivery of patients. Lean is a
concept adapted from manufacturing to stream- line processes, reduce cost, and improve
care delivery. Each process must add value 21 or be eliminated as waste (or muda in
Japanese) so that ultimately every step adds value to the process. The simulation demon-
strated that teams of RN, LPN, and UAP assigned in a mix to fit patient acuity of a group of
patients wasted less time than patient allocation assignments. Development of Novel
Nursing Care Redesign We decided to develop a shared accountability model utilizing RN-
led teams with LPNs and UAPs, func- tioning to their fullest potential, matching the skill-
mix potential to meet the patient’s needs. We piloted the model on medical-surgical units in
3 community hospitals in 3 states. The goals were to improve clinical quality of care and
nurse job satisfaction through use of accountable teams and balanced caregiver workload
while con- trolling or reducing costs. Methods The pilot was implemented on 1 medical-
surgical unit at each of 3 hospital sites in Alabama, Tennessee, and Mississippi. Each
hospital differed in overall bed size and urban/rural market location. The leadership in
administration (chief executive officer, chief nursing officer) was ive and knowledgeable of
lean principles, the purpose of the nursing care redesign, and the importance of evaluation.
Our 1st step was to review the scope of practice for RNs, LPNs, and UAPs in each state
where we planned to pilot the program (Alabama, Tennessee, and Mississippi). We then

reviewed the job descriptions at the hospitals and found that all legal functions were not
included. Policies, competencies, and job descriptions were revised for the LPN and UAP to
ensure highest level of prac- tice. To ensure patient safety, education was developed and
provided to UAPs and LPNs to achieve competen- cies in all functions. Vital Clinical Role in
The US Healthcare System Article AnalysisExamples of the enhanced compe- tencies for the
UAPs included simple dressing change, oxygen setup, performing blood sugars,
discontinuing Foley catheters, and discontinuing peripheral intrave- nous lines. The LPN-
enhanced competencies varied the most among the selected states. Some included admin-
istering intravenous medications and starting intrave- nous lines. 389 In order to assess
level of patient needs, an acuity tool was needed that was valid, efficient, portable be- tween
units, 22 reliable, and maintainable. Duke Uni- versity Hospital System had designed and
evaluated a tool beginning in 2003 that assesses patient’s acuity based on the complexity of
care or instability of a pa- tient’s health status. Nurses used it with a personal digital device.
In time, it had been modified to reduce input while maintaining validity for multiple
settings. Patients are assessed on 6 patient factors and 4 nursing care demand factors,
resulting in 1 of 4 levels of com- plexity of care. The results are to ensure balance of work-
load with competency level of staff and patient acuity. The tool was used with permission
(e-mail communi- cation, August 2012, November 2012, August 23 24 2013). The Morse
falls risk assessment and Braden skin care assessment were added to the tool. No formal
evalua- tion of the modified tool has been made. New processes adopted were bedside shift
report for all caregivers of the team and formal bed huddles for teams to be done at a
minimum of every 4 hours with new acuity assessment, daily patient goals, and expected
LOS review, as well as any identified patient safety issues (Figure 1).Vital Clinical Role in
The US Healthcare System Article AnalysisThe clinical outcome data chosen for evaluation
were based on existing methodologies and collec- tion practices reported to the Centers for
Medicare & Medicaid Services and other national organizations. These included falls per
1,000 patient-days, falls with injury severity of greater than 1, rate of hospital-acquired
pressure ulcers, medication errors per 10,000 doses, num- ber of sentinel events, and
number of near misses. Unit LOS; rate of readmissions for congestive heart failure (CHF),
myocardial infarction (MI), and pneumonia within 30 days; and core measure scores were
also col- lected. Cost was based on average LOS and cost per patient-day. Patient satisfaction
used the Hospital 25 Con- sumer Assessment of Healthcare Providers and Systems
(HCAHPS) data across the 8 domains. New survey questionnaires on nurse and physician
satisfaction were developed for the specific medical-surgical units that re25 flected key
elements on the model design and based on the hospital-wide surveys performed by Press
Ganey. Preimplementation Institutional review board approval was received from the
University of North Carolina at Charlotte, Charlotte, NC. Materials were prepared, and site
coordinators were trained in data collection of patient outcomes and confidentiality
processes to distribute and collect ques- tionnaires. Upon collection, data and
questionnaires were forwarded to the office of the corporate chief nurse executive for data
entry. Original forms were stored in a locked cabinet. To establish a baseline for all key
metrics prior to implementation, the following were collected: (1) JONA Vol. 44, No. 7/8
July/August 2014 Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins.

Unauthorized reproduction of this article is prohibited. 390 nurse/staff and physician
satisfaction, (2) patient outcomes and patient safety indicators, (3) financial information,
and (4) patient satisfaction. For the clini- cal outcome and financial metrics, data for the
same 6 months of the planned pilot in the previous year were used. Each pilot hospital
assumed responsibility for im- plementing the education in new skills and verifying that all
UAPs and LPNs had mastered the identified competencies prior to initiating the model. Job
descrip- tions were updated. RNs’ job expectations shifted to focus on decision making for
delegation and assurance of quality, patient teaching, patient care coordination, and
collaboration with other health professionals. Vital Clinical Role in The US Healthcare
System Article AnalysisEach team had an RN leader and either 2 UAPs or 1 LPN and 1 UAP.
Patient assignments were for that shift. Each job description was reviewed to ensure clarity
of role function. An 8-hour course for all the nursing staff on the pilot medical-surgical units
at the 3 hospitals was de- signed and led by the research team. The course began with an
overview of the new delivery model and job descriptions for RNs, LPNs, and UAPs. The new
acuity tool was reviewed, and its purpose to share workload fairly discussed. The plan to
assess patient care needs and review in huddles every 4 hours to maintain equity was
reviewed. Delegation and collaboration were then discussed with case examples. Emphasis
was placed on each person working to their enhanced scope of prac- tice and to share
accountability for patient outcomes. This was followed by a simulation exercise where staff
was assigned teams with case scenarios. Nurses left ex- pressing enthusiasm for their new
roles. Implementation and Evaluation The new model was introduced, and all staff was pro-
vided to comply. When turnover occurred dur- ing the 6 months of the study, categories of
new hires were chosen to the model implementation. At the end of the 6-month period, all
metrics were collected and measured against the established baseline. Findings Nurse
satisfaction showed the most statistically signifi- cant improvement in comparison to all
other measures included in the study. Forty-four nurses (86%) com- pleted the presurvey,
and 36 (69%) completed the post- survey. A paired-samples test was performed to identify
any significant change from the implementation of the new care model. While all responses
demonstrated a positive trend, 6 items showed statistically significant improvement:
teamwork among coworkers, appro- priate delegation, sense of accomplishment in their
work, enjoyment coming to work, satisfaction with Figure 1. Bed huddle. workload, and
satisfaction with job (Table 1). Pa- tient satisfaction showed slight improvement accord- ing
to the HCAHPS scores in 3 of the 8 domains. JONA Vol. 44, No. 7/8 July/August 2014
Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins. Unauthorized
reproduction of this article is prohibited. Within the 8 domains, physician communication
re- sulted in a statistically significant improvement at P = 0.013 when an analysis of
variance was performed. 391 Table 1. Paired-Samples Test Nurse Survey Paired Differences
SE Mean 0.21014 0.20845 0.16607 0.18892 0.24860 0.20872 Pre-Post Response Items (n =
36) Pair 1: good teamwork Pair 2: delegation appropriate Pair 3: sense of accomplishment
Pair 7: enjoy coming to work Pair 9: satisfied with workload Pair 11: satisfied with job P e
0.05. Mean Vital Clinical Role in The US Healthcare System Article Analysis