The Role Of An Advanced Practice Nurse

Description and Analysis of the Healthcare System

Waukesha Memorial Hospital is a community-based not-for-profit hospital located near Downtown Waukesha, Wisconsin. The hospital was originally founded in 1914 and moved to its current location in 1930 after receiving sponsorship through the local Kiwanis Club. The hospital has now grown to over 300 inpatient beds and employs over 2,700 staff members. The hospital is part of a larger healthcare network known as ProHealth Care. ProHealth Care was created in 1998 when the Waukesha Hospital System and Oconomowoc Hospital joined forces. The organization is now comprised of 26 primary care clinics, home health care, inpatient and home hospice services, long-term care, senior residency communities, and a health and fitness center (Waukesha County, 2010).

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ProHealth Care has created a worldview for an optimal healing community which encompasses their mission, vision, and value statement. The mission of the organization is to “promote and deliver extraordinary health care in the communities it serves”. The vision is to “continue to be the provider of choice in the markets they serve as an optimal healing community distinguished by high-quality, cost-effective care and excellent service in an environment of safety, respect, and compassion”. The organization values a response of excellence service, respect, and compassion. The mission, vision, and values influence four strategic keys to the organization’s plan for success: Value Proposition, Physician Development and Relations, Employee Excellence, and Partnership with Patients and the Community (ProHealth Care, 2010). The espoused theory of the organization is that the influences of the mission, vision, and values on the strategic planning will create an optimal healing community. The theory in action appears to be congruent with the espoused theory as Waukesha Memorial Hospital was named one of the top 100 hospitals in the 2009 Thomson Reuters Health System Benchmark Study. Winners of the award had better patient outcomes and fewer complications, fewer safety errors, and higher patient satisfaction rates than their peers (Thomson Reuters, 2010).

The leadership of Waukesha Memorial Hospital is organized into a professional bureaucratic design. A Mintzberg model of the organizational structure can be found on page 4. Within the microsystem of the hospital, there are many subsystems. Subsystems are grouped together in one of specialty areas: Medical Staff Excellence, Clinical Excellence, Operational Excellence, Patient Experience, or Environment. Each of these categories has a Chief Operating Executive who then reports to the President/CEO of the hospital. Skills of professionals are standardized throughout the entire system; however, each subsystem functions relatively independently of the other subsystems within their category. The strength of the support staff in each subsystem creates the core of operating professionals (as demonstrated in the Mintzberg diagram). The techno-structure is present around the outside of the operating core; however, it does not have a strong influence on the core leadership.

The Waukesha Memorial Hospital system is influenced by several regulatory agencies including JCAHO (Joint Commission on Accreditation of Healthcare Organizations), CMS (Centers for Medicare & Medicaid Services), and the Wisconsin DHS (State of Wisconsin Department of Health Services). Accreditation of the system is obtained through JCAHO after an on-site evaluation/survey of the system is completed. Surveys take place every 18-39 months. During the survey, the hospital is evaluated on compliance of specific standards determined by JCAHO for that accreditation year. These standards are determined to ensure that patients

receive care in a safe and secure environment. While accreditation is not required for a hospital to be in operation, there are many benefits to accreditation through JCAHO; mainly it is required by CMS to be eligible for Medicare reimbursement (The Joint Commission, (2010).

CMS influences the system by determining which services provided by the hospital are eligible for reimbursement through Medicare and Medicaid. CMS dictates core patient care measures by which the hospital is expected to perform. If these goals are not met and there is not supporting documentation stating why the goal wasn’t met, CMS may withhold reimbursement for portions of the hospital’s billing. CMS also sets standards of care that will no longer allow reimbursement for certain complications of a hospital stay, i.e. acquisition of a pressure ulcer or hospital-acquired infection. Therefore, all services rendered in these instances must be paid for by the hospital system. This has forced the hospital system to initiate preventative and aggressive measures to ensure a higher level quality of care to all patients.

The State DHS Division of Quality Assurance also influences the system by developing rules and standards for the improvement of quality of patient care. State licensure and federal certification are obtained through the DHS and required for operation of the acute care facility. Like JHACO, the DHS also performs on-site surveys to ensure patient safety and/or investigate any complaints against the facility (Wisconsin Department of Health Services, 2008). The system has also been affected by legislation at the local level. For several years, a competitor system attempted to move into ProHealth’s market area. Local municipalities passed legislation that temporarily kept the competitor out of the area, but eventually, the competitor was allowed to build an acute care hospital within several miles of a ProHealth acute care system.

Waukesha Memorial Hospital is also influenced by other specialty and/or professional organizations. Involvement with an outside organization is generally determined by each category/subsystem within the hospital system. For example, the category Clinical Excellence is influenced by the American Nurses Association and Wisconsin Nurses Association. Nurses within the hospital system may choose to become active members in these societies to join forces in order to influence healthcare related legislation and its effects on patients and nursing staff. Within the subsystems categorized for Clinical Excellence, the ICU is involved with the American Heart Association, the American Association of Critical-Care Nurses, etc, whereas the OR is involved with the Association of Perioperative Nurses. These nursing organizations help create higher standards of care within their specialty area, promote continuing education to nurses, and provide certification for nurses within their area of expertise. Nurses at Waukesha Memorial Hospital are encouraged to become certified in their area of work as the hospital seeks to apply for Magnet Status from the American Nurses Credentialing Center. Achieving Magnet Status testifies that the hospital demonstrates excellence in nursing care. One of the requirements for application for the certification is that a certain percentage of nurses within the organization pass a certification exam within their area of care (med/surg, critical care, etc).

The hospital system has also created partnerships with several community organizations such as the Kiwanis Club, the United Way and the Waukesha Memorial Foundation. These partnerships promote the overall well-being of the community as well as a respectable public image for the hospital. In a now more competitive market, Waukesha Memorial’s continued commitment to the community has helped maintain the public’s loyalty to the organization.

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The community surrounding Waukesha Memorial provides a diverse payer-mix for services rendered, however, exact statistics could not be found. The hospital serves patients with private insurance, no insurance or governmental coverage (Medicare/Medicaid). No person is denied hospital care based on inability to pay. The hospital does budget a substantial amount of funds yearly to help cover costs to those who are uninsured and unable to pay, however, the cost is not able to be deferred for all patients within these circumstances. While this patient group may receive needed care, the cost can be unbearable, forcing these individuals to forego needed therapies. This negatively impacts the community, making it more ill, financially strained, and under duress. As part of the strategic initiatives set by the hospital for 2010, patient education and health promotion plans were initiated to help decrease preventable hospital admissions and continue movement toward an optimal healing community.

Description and Analysis of a Professional Nursing Role within the Healthcare System

In the past year, Waukesha Memorial Hospital has considered adding an Acute Care Nurse Practitioner role in the management of patients in the Intensive Care Unit (ICU). Currently there is one advanced practice nurse (APN) role assigned to the ICU and this individual functions as the unit Nurse Educator. In contrast to the Nurse Educator, the addition of the Acute Care Nurse Practitioner (ACNP) role would place the APN at the bedside. The role of the ACNP within the ICU would focus on direct patient care. This would include but is not limited to daily patient care rounds, interdisciplinary patient rounds, family/patient conferences, ventilator management, and endotracheal tube and vascular catheter placements. The ACNP would also be responsible to ensure that evidenced-based practices are maintained within the unit’s standards of care.

The ACNP in the ICU at Waukesha Memorial would be required to maintain state licensure as a registered nurse, certification in critical care through the American Association of Critical Care Nurses, and certification as an ACNP-BC through the American Nurses Credentialing Center. The ACNP would function within the ICU subsystem of the Clinical Excellence Category of the Leadership Organizational Chart. Key organizational relationships would need to exist between the ACNP and the ICU manager and director, the WMH Intensivist physician group, and the Performance Improvement nursing committees within the ICU. Collaboration with staff nurses, nurse specialists, and interdisciplinary team members would be essential to ensure quality, efficient, and safe patient care. Nursing collaboration would include the Diabetes Nurse Practitioner, the Stroke Nurse Coordinator, the Infection Control Nurse, the Nurse Care Coordinator/Discharge Planner, and the unit Nurse Educator. Collaboration with the Diabetic NP is essential as many patients in the ICU suffer from hyperglycemia which can inhibit healing and promote infection. The Stroke Coordinator is vital to the ICU of a Primary Stroke Center (certified by JCAHO) and with collaboration brings best practice to the patient suffering from stroke. Partnership with the Infection Control Nurse will decrease rates of hospital-acquired infections which are more likely to occur in the ICU. Alliance with the Nursing Care Coordinator allows for improved patient/family satisfaction in the emotional and spiritual aspects of illness. Finally, teamwork with the ICU Nurse Educator ensures improved education of staff nurses and therefore improving care of the patient at the bedside.

Adding an ACNP role to the ICU collaborative team has the potential to greatly improve the ICU environment and patient outcomes. In an article published by Kleinpell, Ely, and Grabenkort in 2008, studies completed on the use of ACNPs in an ICU demonstrate that the ACNP improves collaboration and communication within the unit between medical, nursing, interdisciplinary, and support staff. Patient management by ACNPs within the ICU has shown to decrease overall length stay, days on mechanical ventilation, and total cost of care for the ICU patient. ACNPs are more likely to adhere to best practice guidelines and ensure their implementation at the bedside. The increased autonomy of the ACNP allows for a holistic, patient-centered care approach over a more curative care approach often provided by a physician or physician’s assistant. This approach has been shown to increase patient’s satisfaction with their hospital stay. These studies validate the strengths of the ACNP role within the ICU.

The weakness of the ACNP role within the ICU is the continued lack of understanding of the role by the healthcare team, by patients, and by the community. There continues to be confusion regarding what an ACNP is and what they can do and what an ACNP is not and what they cannot do. It is up to the Advanced Practice Nursing community to continue to educate their peers, patients, and communities about the benefit of their role in the collaborative health team.