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A familiar punch line for a joke about city folk lost on a country road is, "you can't get there from here." This is the line I would like to use for the next few installments of this column. In each one I will describe what I believe the leadership agenda must be for a specific profession or institution to be successful in addressing the tsunami that is about to wash over us all. I will offer these agendas to various parts of the health system not merely as a means of surviving, but of prevailing in the world that will soon enough be about us. The first installment of this series is addressed to the nursing profession and is taken from an address I was honored to give to a meeting of Deans and Directors of Doctoral programs convened by the American Association of Colleges of Nursing (AACN) earlier this year. I take all responsibility for the outrageous nature of these propositions. Transform the hospital- The largest cost center and certainly the nexus for many of the quality problems in health care in the US is the in-patient acute care hospital. If there is to be any hope of arriving where we need to be in health care, the road will go through the hospital. There are a number of substantial and exciting innovations that have developed in this world over the past decade and several colleagues have recently codified these innovations. I don't need to point to the fact that hospitals, both public and private, are the object of every regulator's intense focus. So much so that a recent, personal encounter in a hospital made me wonder if data collection to meet quality standards might imperil health as much as any other misadventure. The nursing leadership agenda in remaking the hospital is a bold one: own it. Hospitals are supposed to be about the integration of nursing and medical service, but it is often the nursing staff that is expected to drive integration without the empowerment, skills or leadership expectations to do so. To make health care better this must end, but it will only happen when nurses take up the challenge and administration responds. Over the past five years The Center for the Health Professions' Integrated Nursing Leadership Program has demonstrated that teams of differently skilled and challenged nurses can bring phenomenal improvement to some of the most critical outcomes in these settings. The expectation of change and the skills to transform the hospital should be in the DNA of every nurse we train. When hospital leadership recognizes nurses as an important resource for driving change, and deploys them for the hard work of remaking the in-patient setting, it will receive praise that is richly deserved. Build community based chronic care management- The disease burden of the nation has radically changed over the past century. Infectious conditions have been, for the most part, routed, basic sanitation and safety is in place and we age to the point that death often occurs after a period of decline characterized by chronic conditions and a series of acute events. This addition of a generation and a half to the life expectancy of the nation is one of the great achievements of the past century. But our health care delivery institutions have not kept apace with this remarkable transformation. While we now suffer from chronicity, we have only the vast array of acute care armamentarium with which to respond. Many efforts at reform today attempt to improve the functioning of our clinics, hospitals, and physician practices, without realizing that these institutions are, at their foundations, the wrong set of tools to get at the problem. But locked away in nursing's closet is just the right tool box. Nurses invented care management and it has only lately come to all other disciplines. Every nurse is provided with the framework and skills to become a public health nurse and understands the value of addressing issues at the population level. At the core of every nurse's training is a psycho-social-behavioral framework that must be the basis of every chronic care management program. Nurses understand community practice, both because they were trained there and because that is where their independent practices were allowed to grow. No chronic care management program will be successful without a team, and it is the nurse that has overtly and covertly knitted the various perspectives of a hundred disciplines into a coherent care plan and found the skills and time to explain it to families. And if this was not enough, it has been nurses that have consistently "made do" with the resources that were available to them, cobbling together low cost innovations to get patient care needs met.
Walk with the customer- To meet these first three leadership challenges will require that the profession of nursing re-imagine itself. Nothing is more difficult. To walk this pathway will require courage and insight. Both of these can be derived from a walk with the patient or consumer. Health care is one of the least consumer responsive institutions in our society, insulated from the market by specialized knowledge. The urgency and anxiety attending the delivery of most health care has prevented the system from understanding just how vital responsiveness to patients is, not just to their satisfaction, but to their health outcomes as well. The focus on patients gives the health care professions a first important step to this understanding, but often it stops at the point where the system begins to fail. Frustrated, the nurse withdraws effort and turns from dedicated clinician to cynic. The challenge here is to give every nurse the anticipation of this frustration, but also the expectation that it is precisely at that point that the profession is called out to lead. But creating expectation is not enough; there must also be skills to successfully meet this challenge. The core skills are what make up the curriculum of the Center's Robert Wood Johnson Executive Nurse Leadership program, but they should be a part of every nursing students program. Make service site the new nursing school- The number of nurses in service is growing and will continue to grow in response to the profession's challenges. But the current system cannot supply enough nurses to meet increasing demand; a wave of retirements looms, and the deficit of about 150,000 nursing students from 1995 and 2005 will continue pull on the reserves. There are not enough faculty to grow programs and potential faculty will be tempted by more lucrative offers in practice. Moreover, the dynamic changes in care delivery models, technology and patient needs mean that there is a growing gulf between education and practice. It is time to reconnect the education and service dimension of nursing
practice. We have had ten years of closer cooperation, but we now need
proposals for deeper integration. Nursing can make great contributions
to the transformations that must occur in the US health care system, but
these will only come with a new set of leadership expectations from nursing
leaders in every sector.
To e-mail Ed O'Neil, please click here. |
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Over the next decade the US health care system will be forced to respond
to a daunting set of challenges which now confront it. These include costs
that are simply not sustainable for the broader society, access that is
uneven and problematic even for the well insured, and service quality
that is a strange gumbo of excellence and mediocrity, beset with faults
attributable to sloppy management, poor system design, and an appalling
lack of customer responsiveness or even awareness. In spite of current
campaign pledges, universal access to this mess is not an answer. It does
not even provide hope. All else remaining equal, universal access will
increase healthcare demand without increasing the supply of health care
services or the efficiency of their delivery. As one seventh of the nation's
productive effort, and indeed the seventh largest economic undertaking
on the face of the globe, health care in America needs more than increased
access to the current system. What is needed is a new model - one that
will not arrive fully developed, but which will provide a framework in
which emerging challenges can be met by innovations that come from existing
health care resources. The most successful of these innovations will be
found in those institutions, organizations, practices, professions and
schools that take the time to understand the new challenges and aggressively
remake themselves in response to them. Those that run to the barricades
to defend every irrational, self-serving feature of the old system will
falter, and might not survive. The stakes are so high and the pent up
demand for change so great, that when changes occur they will blow past
such resistance with unanticipated force.