Department of  Health and Human Services 
OFFICE  OF 
INSPECTOR  GENEML 
I 
ENHANCING  THE  UTILIZATION  OF 
NONPHYSICIAN  HEALTH CARE 
PROVIDERS: 
THREE  CASE STUDIES

MAY  1993  OE141-9042071 
I 
-.  EXECUTIVE  SUMMARY 
This  report  presents  case  studies  on  how three  health  care  organizations  are  working 
to enhance  the  utilization  of nonphysician  health  care  providers.  Evercare,  a managed 
care  delive~  system  in Minneapa@  illustrates  how nurse  practitioners  working  in 
collaboration  with  physicians  can  enhance  the  delivery  of care  to nursing  home 
residents.  St. Josephs  Hospital  of Atlanta  is using professional  and  nonprofessional 
hospital  staff  on  two  units  to del&er  more  patient  care  sexvices directly  at  the  bedside. 
Chicagos  Mercy  Hospital  and  Medical  Center  is training  nonprofessional  workers  to 
perform  technical  tasks  and  to work  in permanent  teams  with  registered  nurses  in a 
hospital-wide  expansion  of the  hospitals  nursing  service. 
Our  companion  report,  Enhancing the Utilization of Nonphyskim  Health  Cure Bovidem 
(OEI-01-90-02070),  synthesizes  our  assessment  of the  potential  for more  effective  use 
of nonphysician  providers.  In that  report  we describe  five significant  barriers  to 
enhancing  the  utilization  of nonphysician  providers.  In this  case  study  repo~  we also 
address  how health  care  organizations  can  overcome  these  barriers. 
~f~nal  Tdria&m  Rather  than  encourage  a teamwork  approach  to  providing 
care,  professional  boundaries  can  inhibit  cross-discipline  sharing  of knowledge  and 
information.  Professional  terntorialism  limits health  care  organizations  abilitv  to take
d 
advantage  of opportunities  to enhance  utilization  of nonphysician  providers. 
To  address  this  barrier,  health  care  organizations  can: 
Clearly  delineate  the  duties  and skills that  are  specific  to a profession.  Allow 
 
members  of the  profession  to maintain  their  professional  identity. 
  Emphasize  each  professions  role  as part  of an overall  health  care  team, 
enhancing  the  role  of the  profession,  rather  than  diminishing  it. 
Hold  in-service  training  and  problem-solving  sessions  that  involve  different 
 
professions,  thus  providing  a broader  viewpoint.  Include  members  of different 
professions  both  as students  and  as teachers  at  the  in-service. 
Re@lx tw u  Licensure  laws are  designed  to protect  the  publics  health, 
safety,  and  economic  well-being  by restricting  entry  into  the  occupations  to  those  with 
the  proper  credentials.  These  regulatory  laws also can  inhibit  flexibility  in how 
nonphysician  providers  may be  utilize~  reduce  access  to semices,  and  impose  higher 
costs. 
To  address  this  barrier,  health  care  organizations  can: 
i  ..   
INTRODUCTION 
BACKGROUND 
This  report  is a companion  to our  inspection  Enhancing the  Utilization  of Nonphysician 
Health  Care Providen  (OEI-01-9042070).  That  report  synthesizes  our  assessment  of 
the  potential  for  more  productive  use of health  care  personnel  and  the  btiers  in the 
health  care  system  that  often  inhi%it such efforts.  Drawing  on a review  of the 
literature,  intemiews  with experts,  and  these  case  studies,  we found  that  health  care 
organizations  in different  settings,  including  hospitals,  nursing  homes,  and  ambulatory 
sites,  are  taking  new  approaches  to organizing  and  staffing  health  care  senkes.  We 
also identified  five significant  barriers  that  constrain  the  widespread  adoption  of these 
approaches: 
Professional  Temtorialtim.  Rather  than  encourage  a teamwork  approach  to 
 
providing  care,  professional  boundaries  can  inhibit  cross-discipline  sharing  of 
knowledge  and  information.  Professional  terntorialism  limits  health  care 
organizations  ability  to take  advantage  of opportunities  to enhance  utilization 
of nonphysician  providers. 
Licenwre  Res~ctions.  Licensure  laws are  designed  to protect  the  publics 
 
health,  safety,  and  economic  well-being  by restricting  entry  into  the  occupations 
to those  with  the  proper  credentials.  These  regulatory  laws also  can  inhibit 
flexibility  in how nonphysician  providers  maybe  utilized,  reduce  access  to 
semices,  and  impose  higher  costs. 
Educational  Isolation.  Health  professions  education  rarely  includes  inter-
 
disciplinary  training.  This  exclusion  divides  the  professions  horn  each  other, 
rather  than  encouraging  cooperative  practice  styles and  team  building. 
Physician Resistance.  Although  some  physicians  are  working  closely with NPs, 
 
PAs,  and  CNMS, other  physicians  resist  broader  scopes  of practice  for these 
providers.  This  resistance  may result  from  physicians  concerns  about  quality  of 
care,  unfamiliarity  with  how to utilize  these  providers  effectively,  and  self-
interest.  This  resistance  can  hinder  access  to care,  since  these  providers  are 
able  to  extend  the  capacity  of individual  physicians  to deliver  care. 
Institutional  lize~a.  Health  care  organizations,  like  most  organizatio~  are 
 
naturally  resistant  to change.  Redefining  organizational  boundaries  requires  a 
significant  change  in how all health  care  staff--both  physician  and  nonphysician 
providers--are  utilized. 
The  case  studies  presented  in this report  ciescni  how three  health  care  organizations 
are  attempting  to make  more  productive  use of nonphysician  health  care  providers. 
EverCare,  a managed  care  delivery  system in Minneapolis,  illustrates  how nurse 
1 
...  -.. 
EXECUTIVE  SUMMARY 
This  report  presents  case  studies  on  how three  health  care  organizations  are  working 
to enhance  the  utilization  of nonphysician  health  care  providers.  EverCare,  a managed 
care  delivery  system  in Minneapoi@  illustrates  how nurse  practitioners  working  in 
collaboration  with  physicians  can  enhance  the  delivery  of care  to nursing  home 
residents.  St. Josephs  Hospital  of Atlanta  is using  professional  and  nonprofessional 
hospital  staff  on  two units  to de&er  more  patient  care  semices  directly  at the  bedside. 
~cagos  Mercy  Hospital  and  Medical  Center  is training  nonprofessional  workers  to 
perform  technical  tasks  and  to work  in permanent  teams  with  registered  nurses  in a 
hospital-wide  expansion  of the  hospitals  nursing  setice. 
Our  companion  report,  Enhancing the Utilization of Nonphysician Health  Care l+ovidens 
(OEI-01-90-02070),  synthesizes  our  assessment  of the  potential  for  more  effective  use 
of nonphysician  providers.  In that  report  we describe  five significant  barriers  to 
enhancing  the  utilization  of nonphysitian  providers.  In this case  study  repo~  we also 
address  how health  care  organizations  can overcome  these  barriers. 
%$~  T* Rather  than  encourage  a teamwork  approach  to  providing 
care,  professional  boundaries  can  inhibit  cross-discipline  sharing  of knowledge  and 
information.  Professional  terntoriaiism  limits health  care  organizations  abilitv  to take
d 
advantage  of opportunities  to enhance  utilization  of nonphysician  providers. 
To  address  this  barrier,  health  care  organizations  can: 
Clearly  delineate  the  duties  and  skills that  are  specific  to a profession.  Allow 
 
members  of the  profession  to maintain  their  professional  identity. 
  Emphasize  each  professions  role  as part  of an overall  health  care  team, 
enhancing  the  role  of the  profession,  rather  than  diminishing  it. 
Hold  in-service  training  and  problem-solving  sessions  that  involve  different 
 
professions,  thus  providing  a broader  viewpoint.  Include  members  of different 
professions  both  as students  and  as teachers  at  the  in-service. 
.  .
Res%m&ow  Licensure  Iaws are  designed  to protect  the  publics  health, 
safety,  and  economic  well-being  by restricting  entry  into  the  occupations  to  those  with 
the  proper  credentials.  These  regulato~  ]aws also  can  inhibit  flexibility  in how 
nonphysician  providers  may be utilize~  reduce  access  to  services,  and  impose  higher 
costs. 
To  address  this  barrier,  health  care  organizations  can: 
1 
  - .-
We  conducted  this study in accordance  with the  Quality Standards for hspection$ 
issued  by the  Presidents  Council  on  Integrity  and  Efficiency. 
ORGANIZATION  OF THE  CASE  SIUIXES 
We  present  each  of the case  studies  using the  same  format.  Fobving  a background 
section  on the  site,  we describe  the  particular  innovation  that  is being  studied.  Next, 
we discuss  our  assessment  of its impact  on quality  of care,  costs,  physicians,  sta&  and 
other  parts  of the  organization.  We  then  discuss  limitations  and  implementation 
impediments,  and  finally, our  conclusions  about  the  innovation. 
3  practitioners  working  in collaboration  with physicians  can  enhance  the  delivery  of care 
to nursing  home  residents.  St. Josephs  Hospital  of Atlanta  is using professional  and 
nonprofessional  hospital  staff  on  two  units  to  deliver  more  patient  care  services 
directly  at the  bedside.  Mercy  Hospital  and  Medical  Center  of Chicago  is training 
nonprofessional  workers  to perform  technical  tasks  and  to work  in permanent  teams 
with registered  nurses  in a hospital-wide  expansion  of the  hospitals  nursing  semice. 
We  did not  intend  for these  organizations  to be representative  or even  typical  of other 
health  care  organizations.  We selected  them,  in fac~ because  of the  atypical  nature  of 
what  they were  doing.  Our  criterion  for selection  was that  each  approach  was 
attempting  to enhance  the  utilization  of nonphysician  providers  by expanding  the 
range  of work  and  services  beyond  what  was typical  in traditional  settings.  We  do not 
endorse  any particular  approac~  and  we make  no claim  that  these  organizations  or 
approaches  represent  best  practices,  either  in outcome  or in implementation.  Each 
of these  organizations  is at  a different  phase  in implementing  its innovation.  Each  has 
encountered  barriers  and  probiems,  but  each  has also  adapted  and  maintained 
flexibility  to overcome  the  barriers.  At the  same  time,  each  organization  has 
maintained  a commitment  to the  basic  goals  and  objectives  of ;he  approach. 
METHODOLOGY 
TO select  organizations  for  case  studies,  we  first  identified  potential  sites  based  on 
interviews  with  professionals  familiar  with  institutional  efforts  to reorganize  work  in 
health  care  settings.  In additio~  we gathered  information  on  potential  sites  horn  our 
review  of policy  and  management  literature  in this field.  We were  particularly 
interested  in organizations  with  recent  experience  in changing  how nonphysician 
providers  are  utiliztx$  thus  leading  us to exclude  from  consideration  organizations 
(such  as long-established  health  maintenance  organizations)  that  may have  been  using 
nonphysician  providers  for  several  years.  In subsequent  intemkws  with personnel 
from  different  health  care  organizations,  we identified  the  length  of time  the  initiative 
had  been  operatin~  the  availability  of data  to assess  its impa~  continuity  of key 
persomel,  and  their  willingness  to participate  in the  study.  To  make  our  final 
selection,  we relied  on our  own  qualiwtfie  judgments  about  whether  the  organization 
was doing  something  innovative  and  had  sufficient  experience  from  which  lessons 
could  be  drawn. 
We  conducted  two-day  visits to  each  site.  During  that  time,  we intemiewed 
administrative  pemonnel,  sexvi~  delivery  staff,  and  physicians,  We  also  obsemed  the 
staff  and  their  interactions  with  other  stfi  members  and  patients.  In addition,  we 
reviewed  documents  horn  the  sites,  including  clinical  protoco~  staffing  and  cost  data, 
patient  satisfaction  sumeys,  training  plans,  and  other  background  materials.  Upon 
completing  a written  draft  of the  report  for  each  site, we shared  it with  the  chief 
executive  officer  and  our  key contact  horn  the  site to review  the  accuracy  of our  facts.
We  did no~  however,  change  our  interpretation  of those  facts 
2   
EVERCARE 
MiImeapol&Minnesota 
BACKGROUND 
Evercare  is a managed  care  delive~  system  that  uses geriatric  nurse  practitioners 
(GNPs)  md  physicians  to provide  acute  care  senkes  to residents  of several  area 
nursing  homes.  A monthly  prem~um  ikom Medicare  covers  all acute  health  care 
services  for enrolled  members--routine  and  urgent  physician  care,  hospitalization, 
laboratory  and  diagnostic  semices.  Chronic  care  services  provided  by a nursing  home, 
such  as routine  nursing  care  and  room  and  boa.rG are  not  part  of the  Evercare 
package  and  are  provided  under  other  funding  sources,  such  as Medicaid  or private 
payment. 
As of November  1~  the  Evercare  membership  in the  Twin  Citiesl  totalled  about 
700 members  in 92 nursing  hornes--4OO in Minneapolis  and  300 in St. Paul.  Although 
Evercare  uses a GNP-physician  team  approach  in both  Minneapolis  and  St. Paul, 
there  are  important  differences  between  the  two  cities  in their  delivery  models: 
In Minneapolis,  EverCare  employs  6 GNPs  directly,  with  physician  sewices 
 
provided  through  individual  physician  contracts.  In St. Paul,  Evercare  contracts  with 
the  Ramsey  County  Medical  Centers  Department  of Geriatric  Medicine,  which 
employs  8 GNPs  and  assigns its physicians  to provide  nursing  home  care. 
In Minneapolis,  the  GNPs  write  prescriptions,  and  they  make  and  sign off on 
 
monitoring  visits required  under  Medicare  regulations;  in St. Paul,  physician  signature 
is required  for those  tasks. 
Because  the  GNPs  in Evercare-Minneapolis  have  a wider  scope  of practice  than  those 
in St. Pa@  this case  study  focuses  primarily  on the  Minneapolis  model. 
WHAT  IS INNOVATIVE  ABOUT  EVERCARE? 
GNP Phuxi&  l%xtxd 
EverCares  protocol  with  the  nursing  homes  in which its members  reside  provides  the 
basis  for GNP  practice.  The  protocol  is a written  agreement  signed  by the  GNP  and 
collaborating  physician  that  specifies  that  the  GNP  functions  collaboratively  with  the 
physician  to manage  the  medical  care.  The  protocol  stipulates  that  the  GNP  may 
undertake  certain  tasks  acting without  consultation  with  the  physician,  including: 
1.  Evercare also operates  in the Chicago metropolitan  area.  This report  addresses only the 
Minneapolis-St. Paul component. 
4  ..  ___ 
GNPs  establish  independent  practices  on a widespread  basis,  nursing  home  care  could 
become  even  less appealing  to many  physicians  than  it is at presen~ 
  Response  of Evexare  to Physician Concerns 
The  EverCare  model  addresses  many  physician  concerns,  since  it is based  on the 
premise  that  the  GNP  operates  as an  extension  of the  physician.  with commensurate 
collaboration  and  coordination.  The  GNP  can  also play an important  role  by 
facilitating  communication  between  physician  and  facility, since  the  GNPs  are  frequent 
visitors  to  the  home. 
One  physician  who works with  EverCare  told  us that  having  GNPs  available  actually 
can  attract  physicians  to nursing  home  care.  According  to this physician,  the  GNP  can 
take  on much  of the  burden  of providing  nursing  home  care--dealing  with  families, 
routinely  monitoring  members  with chronic  conditions,  responding  to questions  from 
and  needs  of nursing  home  staff--leaving  physicians  to practice  w-hat he  referred  to as 
the technical  aspects  of medicine. 
Impact on N&g  Home Stq& 
F  Concerns of Numing Home  Staff 
Some  staff  nurses  initially were  reluctant  to recognize  the  GNPs  authority.  This 
resistance  may  simply  have been  the  result  of confusion  over  the  definition  and 
authority  of the  GNPs  role.  On  another  level, however,  staff  nurses  may  have  viewed 
the  GNP  as another  barrier  between  them  and  the  physician--an  extra  hoop  through 
which  they  would  have  to jump  to get  anything  done.  At  one  home,  the  director  of 
nursing  thought  that  the  Evercare  GNPs  took  too  much  of the  staff  nurses  time, 
always asking  them  questions,  unlike  the  physicians  who  come  into  the  home,  visit 
patients,  and  leave  quickly. 
Other  nursing  home  personnel  were  also confused  over  the  GNP  role.  For  example, 
we learned  that  medical  records  technicians  were  accustomed  to  recording  only 
physicians  orders;  thev balked  at accepting  the  nurse  practitioners  signature  on  a 
medical  order  or pres&iption.  In one  home,  this confusion  carried  over  to the 
director  of nursing,  who simply told  EverCare  not  to let  GNPs  sign prescriptions 
because  medical  records  dwsnt  want  you to.  Only by showing  the  director  of 
nursing  a copy  of the  State  law, her  State  authorization  to write  prescriptions  and  the 
collaborative  agreement  with her  partner  physician  was the  GNP  able  to overcome  the 
objections. 
  Response  of Eveware  to Nwing  Home  Staff Concerns 
Many  of the  initial  problems  associated  with the  nursing  home  staff  have  been 
overcome  as they  build  a level of trust  in the  GNPs.  Once  thev  have  gained 
experience  with  them  nursing  home  staff apparently  like having  the  GNPs  available. 
8 
.   .. 
EVERCARE 
Minneapo& Minnesota 
BACKGROUND 
Evercare  is a managed  care  delivery  system  that  uses geriatric  nurse  practitioners 
(G~s)  and  physicians  to provide  acute  care  services  to residents  of several  area 
nursing  homes.  A monthly  premium  from  Medicare  covers  all acute  health  care 
services  for enrolled  members--routine  and  urgent  physician  care,  hospitalization, 
laborato~  and  diagnostic  services.  Chronic  care  sewices  provided  by a nursing  home, 
such as routine  nursing  care  and  room  and  boar~  are  not  part  of the  Evercare 
package  and  are  provided  under  other  funding  sources,  such  as Medicaid  or private 
payment. 
As of November  l%  the  Evercare  membership  in the  Twin  Citiesl  totalled  about 
700 members  in 92 nursing  homes--4OO in Minneapolis  and  300 in St. Paul.  Although 
EverCare  uses a GNP-physician  team  approach  in both  Minneapolis  and  St. Paul, 
there  are  important  differences  between  the  two cities in their  delivery  models: 
b  Minneapolis,  Evercare  employs  6 GNPs  directly,  with  physician  services 
 
provided  through  individual  physician  contracts.  In St. Paul,  Evercare  contracts  with 
the  Ramsey  County  Mediul  Centers  Depa~ent  of Geriatric  Medicine,  which 
employs  8 GNPs  and  assigns its physicians  to provide  nursing  home  care. 
In Minneapolis,  the  GNPs  write  prescriptions,  and  they  make  and  sign off on 
 
monitoring  visits required  under  Medicare  regulations;  in St. Paul,  physician  signature 
is required  for  those  tasks. 
Because  the  GNPs  in Evercare--eapolis  have  a wider  scope  of practice  than  those 
in St. Paw  this case  study focuses  primarily  on the  Minneapolis  model. 
WHAT  IS INNOVA~  ABOUT EVERCARE? 
EverCares  protocol  with  the  nursing  homes  in which its members  reside  provides  the 
basis  for  GNP  practice.  The  protocol  is a written  agreement  signed  by the  GNP  and 
collaborating  physician  that  specfies  that  the  GNP  functions  collaboratively  with  the 
physician  to manage  the  medical  care.  The  protocol  stipulates  that  the  GNP  may 
undertake  certain  tasks  acting without  consultation  with the  physician,  including: 
1. Evercare also operates  in the Chicago metropolitan area.  This report  addresses only the 
Minneapolis-St. Paul componen~ 
4 
_____  . . 
with  Evercare  and  nursing  home  staff  suggest  that  NPs  can function  in this role 
without  diminishing  the  quality  of care  provided.  III fa~  at Evercare  it appears  that 
effective  utilization  of nurse  practitioners  in this arrangement  can  enhance  the  quality 
of health  care  services. 
Effective  implementation  of a model  such  as EverCare  requires  that  the  GNP  practice 
in a role  that  requires  independent  decisions,  frequently  without  immediate 
collaboration  with  a physician.  Consequently,  that  role  needs  to be  filled by an 
individual  who wants  and  is comfortable  with that  degree  of authority  and 
responsl%iiity.  In addition,  many  physicians  may be uncomfortable  with or  unskilled  in 
utilizing  GNPs  in the  manner  described  here.  It requires  a great  deal  of trust  and 
confidence  in the  GNPs  abilities,  as well as physician  willingness  to let go of many 
aspects  of day-to-day  patient  care.  As one  GNP  told  ~  For this model  to really 
work  you  have  to have  a physician  or medical  group  that  is willing to work with  GNPs 
as primary  providers,  not just  have  them  on staff. 
The  Evercare  model  does  not  rely solely on the  role  of an independent  nurse 
practitioner.  The  financial  incentives  to physicians  and  GNPs  are  important  in making 
the  arrangement  work.  By combining  financial  incentives  for physician  services-
prepayment  for managing  care  and  favorable  rates  for visits to patients--with  the 
availability  of the  GNPs,  an approach  such  as EverCares  also  holds  potential  for 
helping  to  ease  nursing  home  physician  recruitment  problems.  This  approach  may 
work  particularly  well in a nursing  home  setting,  where  so  much  of the  emphasis  is on 
chronic  care  and  on addressing  the  needs  of residents  and  their  families.  These  tasks 
lend  themselves  closely  to the  skills and  training  that  many  NPs receive--assessment, 
psycho-social  skills, interaction,  and  communication. 
10  .. 
As fellow  nurses,  they  feel  more  comfortable  dealing  with  GNPs  than  with  physicians 
since  they talk  our  language  and  have  actually  done  nursing  care. 
Nursing  home  staff have  alSO found  it easier  to contact  the  GNP  than  the  physician  to 
have  orders  change&  medications  approved,  or questions  about  care  answered. 
Evercare  claims  that  its GNPs  always return  nursing  home  staffk phone  calls within  an 
hou~  nursing  home  staff  we met  said  that  most  calls are  returned  within  30 minutes. 
The  staff  nurses  feel  tiee  to call the  GNP.  In addition,  when  a physicians  decision  is 
needed  they believe  that  EverCare  physicians  respond  more  quickly  to the  GNPs  call; 
they realize  it is important  and  a situation  that  the  GNP  feels  requires  a physicians 
expertise. 
Another  benefit  to  the  nursing  home  staff  is informal  continuing  education.  The 
medical  director  at  a nursing  facility  told  us that  the  GNPs  help  the  staff  nurses  by 
increasing  their  nursing  skills, fostering  an environment  for interchange  and  improved 
expectations. 
The  State  regulatory  climate  regarding  the  scope  of practice  of nurse  practitioners 
affects  the  extent  to which  such  a model  can be  replicated.  Obviously,  delivering  care 
through  an approach  such  as this would  be  easier  in those  States  that  permit  NPs  to 
practice  in an  expanded  role,  including  prescriptive  privileges,  than  in States  which 
place  more  restrictions  on NP practice. 
The  start-up  costs associated  with  physician  recruitmen~  member  enrollment,  and 
financial  reseme  requirements  mean  that  financial  feasibility  may  be  difficult  to 
achieve.  The  founders  of Evercare  estimate  that  it took  more  than  three  years  to 
reach  a break-even  financial  point. 
In addition,  the  Evercare  model  is limited  to the  nursing  home  setting.  When  a 
member  is hospitalize&  the  attending  physician  will be  someone  who works  with 
Evercare,  but  may  not  be  the  regular  geriatrician  that  the  resident  had  seen  for 
primary  care  semices  while  in the  nursing  home.  At the  same  time,  the  GNP  would 
have  limited  authority  in the  hospital,  since  her  protocol  agreement  applies  to the 
nursing  home  only. 
Finally,  the  lack  of a clinic setting  in which  the  GNP  can  see  new  patients  also  is a 
limiting  factor.  While  the  EverCare  physicians  offices provide  a potential  location,  the 
GNPs  office is a car.  She must  use-space  either  in a ~ursing  home  or  a hospital 
emergency  department  for the  initial  physical  assessment  and  case  histoq. 
CONCLUSIONS 
Our  study  of Evercare  highlights  the  leading  role  that  nurse  practitioners  can  play  in 
providing  care  through  collaborative  arrangements  with  physicians.  Our  discussions 
9 
.- ST. JOSEPHS  HOSPITAL 
SERVICE  AND  CLXNICAL ASSOCIATES  PROGRAM 
Atkm@Georgia 
BACKGROUND 
St. Josephs  is a 346-bed  hospital  in north  Atlant~  specializing  in cardiac,  oncology, 
and  orthopedic  care.  St. Joseph;s  payer  mix is 35 percent  Medicare,  60 percent 
private  coverage,  and  5 percent  Medicaid.  In 1990, after  examining  hospital 
operations  and  finding  evidence  that  labor  was the  primary  factor  driving  up the  cost 
of health  care,  the  hospital  decided  tO restructure  its inpatient  delivery  system. 
AS part  of its work  redesign  projeq  St. Josephs  created  two  new job  categories-
service  associates  (SAS) and  clinical  associates  (CAs)--that  reconfigure  the  way patient 
care  is provided.4  The  goals  of this project  were  (1)  to promote  efficiency  by 
delivering  more  services  directly  at the  bedside,  and  (2) to respond  to an  emerging 
shortage  of health  care  workers  by training  personnel  to provide  a broad  array  of 
health  care  services. 
k  April  1991, St. Josephs  added  service  associates  and  clinical  associates  to two  units
-a medical/surgical  floor  and  a critical  care  unit.  The  changes  in staff  duties  were 
based  on  two important  assumptions.  Firs\  it was assumed  that  many  technical  tasks 
involved  in treating  patients  could  be performed  under  the  direction  of nurses  by 
workers  who  received  special  trafig+eatig  the  nurses  to  coordinate  and  monitor 
care,  do patient  assessment,  and  use their  professional  judgment.  Second,  it was 
assumed  that  many  patient  care  tasks  could  be shared  by staff  at different  leveIs. 
WHAT  IS INNOVATIVE  ABOUT Sl.JOSEPH%  EFFORT? 
The  hospital  designed  the  position  of selvice  associate  (SA)  to relocate  services 
provided  through  central  hospital  staff onto  the  individual  units.  This  program 
recruited  workers  such  as aides,  food  service  workers,  and  housekeepers,  and  tied 
them  to  expand  their  SWS so that  they could  provide  basic  patient  care.  As of 
October  1992, 43 service  associates  were  working  on two 23-bed  units--the  Critical 
Care  Unit  (CCU)  and  the  MedicaI-Surgical  Unit. 
4.  St. Josephs also created  an Administrative Associate position which incorporated  the roles 
of receptionists, unit department  secretaries, medical record clerks, admitting clerks, and 
utilization reviewers,  as well as some patient mmfort  and transport  duties.  In this repo~  we 
fwus  only on the CA and SA positions 
11    .. 
MERCY  HOSPITAL 
CLXNICAL PARTNERS  PROGRAM 
Chicago,Illinois 
BACKGROUND 
Mercy  Hospital  and  Medical  Center  is a 505-bed  teaching  hospital,  located  on the 
South  side  of Chicago.  Merq?s  payor  mix is 40 percent  Medicare,  37 percent  private 
coverage,  and  23 percent  Medicaid. 
In 1987, Mercy  faced  a severe  nursing  shortage,  compounded  by declining  revenues. 
In a review  of the  hospitals  structures  and  operations,  management  found  that  staff  in 
central  departments--laboratory,  housekeeping,  and  food  setices,  for example-
experienced  a significant  amount  of down-time.  In the  course  of its review,  the 
management  team  also found  that  patients  saw a large  number  of different  hospital 
staff during  their  stays.  In response,  hospital  management  decided  to undertake 
several  projects  in an attempt  to increase  efficiency  and  improve  the  quality  of patient 
care  management.  This  case  study  focuses  on one  of these  initiative%  the  C1inical 
Partners  Program  (CPP). 
Mercy  implemented  its Clinical  Partners  Program  in 1989.  As of November  19%  136 
clinical  partners  worked  in units  throughout  the  hospital. 
WHAT  IS INNOVATIVE  ABOUT  CLINICAL  PARTNERS? 
lWme-Ctial  l%u7ner Tixzms 
A clinical  partner  is a person  trained  to provide  a variety  of nursing  assistant  and 
technical  tasks  essential  to  basic  patient  &re,  working  in a team  witi a registered 
nurse.  Clinical  partners  take  a 6-week  in-house  training  program  tau@  by nursing 
and  central  department  staf&  They  learn  how to  draw  blood;  perform  basic 
respiratory  therap~  retiorce  physi~  and  occupational  therapies;  take  an EKG;  and 
provide  semices  ordinarily  performed  by nursing  assistants.  At the  end  of the  training 
program,  clinical  partners  take  a series  of exams  to ensure  their  competency.  AImost 
ninety  percent  of clinical  partners  have  been  recruited  from  central  hospital 
departments  such  as lab,  environment  services/housekeeping,  EKG,  and  food 
sewices. 
The  CPP  relies  on  a fixed-team  stmcture,  with one  registered  staff nurse  working 
exclusively with  one  clinical  partner.  Nurses  interview  and  hire  their  clinical  partners 
after  they  complete  the  training  program.  Many  of the  teams  have  been  working 
together  since  the  programs  inception.  AS part  of the  CPP,  nurses  who supemise  a 
clinical  partner  must  take  a specia]  workshop  sponsored  by the  hospital  to enhance 
their  management  skills and  develop  their  delegation  principles.  Nurses  also  must  be 
proficient  in all of the  technical  skills that  their  clinical  partners@  be  performing. 
19 
.  educational  and  professional  philosophies.  There  are  overlaps  in much  of the 
technical  education  received  by nurses,  pharmacists,  and  respiratory  therapists.  Major 
differences  emerge,  however,  in underlying  approaches  and  assumptions  that  they 
bring  to their  professions.  Nurses,  for example,  tend  to focus  on managing  the  entire 
spectrum  of care,  where=  respiratory  therapists  perform  primarily  mechanical  tasks 
dealing  with  limited  parts  of the  body  system.  These  educational  underpinnings  are 
evident  within  the  hospiti  where  the  RTs  and  pharmacists  sought  a management 
structure  in which  they were  supetied  by those  in their  own professions.  They  also 
are  evident  in broader  areas  of the  health  care  system,  such  as licensure,  scope  of 
practice,  and  supemisory  responsibilities.  Clearly,  these  concerns  are  major  factors 
that  must  be  considered  in any effort  to change  how the  work  of delivering  health  care 
is performed. 
St. Josephs  experience  demonstrates  the  importance  of flexibility  in changing  the  way 
in which  a hospital  utilizes  personnel.  Despite  some  major  changes  in its initial  plans, 
the  hospital  maintains  a strong  commitment  to the  underlying  principles  behind  its 
work  redesign  effort:  Providing  more  patient  care  directly  on the  unit by using 
workers  who  are  trained  to perform  a broader  range  of services. 
18 
.   .. 
proposed  a wstem  modification  and  further  education  for  the  ciinical  partners  on this 
procedure;  ~  response,  the  lab  and  the  nursing  department  are  developing  a new 
education  program  to remedy  the  problem. 
. Other  advantages  arise  horn  the  additional  time  that  clinical  partners  spend  with 
patients  and  their  families.  The  clinical  partners  are  ffom  diverse  backgrounds  and 
may be  more  attuned  to patients  differing  cultural  needs  and  concerns.  Nurses  told 
us that  on several  occasions  the  clinical  partners  have  recognized  dysfunctional  family 
behavior  and  have  alerted  them  to potential  problems  that  the  patient  might 
encounter  upon  discharge. 
Hospital  management  is still in the  process  of evaluating  the  impact  of the  Clinical 
Partners  Program  on  hospital  finances.  Those  we intenriewed  were  in substantial 
agreement  that  it has  been  expensive,  particularly  for trainin~  however,  they were 
unable  to provide  us with the  actual  costs.  Managers  acknowledge  that  they  probably 
underestimated  the  cost of training  when  they began  this  program.  tie  senior  official 
reporte~  however,  that  the  program  has  added  significant  value  to patient  care, 
despite  its cost. 
With  the  implementation  of the  Clinical  Partners  Pro- Mercy  was  able  to reduce 
the  number  of vacant  RN  positions.  Since  the  program  was adopted  they  have  added 
more  l?TEs to their  payro~  but  these  have  been  in non+mrsing  positions.  By 
transforming  the  unfilled  RN  positions  into  Clinical  Partner  position~  the  hospital 
estimates  that  it has  hired  35 fewer  nurses. 
One  physician  we  spoke  with  said that  the  hospital  has  been  struggling  to figure  out 
how to measure  the  cost-savings  of the  CPP;  he remarked  on the  difficulty  of trying  to 
prove  a negative.  He  nonetheless  thinks  that  the  change  has had  positive  financial 
and  clinical  benefits.  In the  pas~  nobody  was measuring  the  amount  of time  spent 
waiting  for tests  or the  number  of times  a nurse  had  to make  telephone  calls to 
arrange  for care.  Now evelyone  realizes  that  they  have  more  time  for  the  patients, 
but  it is very  difficult  to prove. 
Iinpct  on  Szlf 
Since  CPP  began  over  three  years  ago,  the  nurse  vacancy  rate  has  decreased  horn 
almost  12 percent  to less than  three  percent.  Now the  hospital  reports  a short  waiting 
list of nurses  interested  in working  at Mercy.  All budgeted  positions  were  filled  by 
July  1992-i.ncludhg  traditionauy  d~cult-to-fill  positions  in the  intensive  care  unit. 
Hospital  management  believes  that  the  CPP  has influenced  this trend 
21  .. 
l%w&ii&T&d~  Dmdyonthethit 
In most  hospitals,  when  staff  on a patient  unit  need  sexvices and  tests--EKGs,  blood 
work  x-rays, lab  tests-they  must  wait  for centralized  departments  to  provide  them  and 
communicate  the  resuits.  By training  clinical  partners  to perform  these  semices 
directly  on the  unit,  Mercy  expects  to decrease  waiting  times  for  both  patients  and 
providers.  By bringing  other  services,  such  as physical  and occupational  therapy,  to 
the  patient  on the  unit  rather  than  sending  the  patient  to another  part  of the  facility 
for those  sexvices, the  hospital  hopes  to provide care  more  efficiently  and  reduce  the 
number  of persomel  that  patients  see  during  a hospital  stay. 
QudiYyof Clue 
From  our  discussion  with  staff,  it appears  that  the  CPP  has improved  the  timely 
delivery  of sewices  and  coordination  of patient  care.  Prior  to fiplementing  this 
progrm  unit staff  requested  that  25 percent  of tests  be done  on a stat (immediate) 
basis, in order  to  speed  up  central  processing.  Now, because  many  of the  tests  are 
done  directly  on  the  uni~  the  proportion  of stat  requests  has fallen  to  12 percent.  In 
additio~  by drawing  blood  on the  unit  the  CPs have  helped  the  lab  by expediting 
specimen  delivery,  reducing  the  morning  flood  of lab  orders,  and  shortening 
turnaround  time. 
Mercy  also has  made  some  changes  in its quality  assurance  (QA)  processes  since  the 
implementation  of the  CPP.  The  QA  department  conducts  monthly  assessments  that 
examine  discharge  planning,  patient  falls, medication  and  lab  errors,  and  infection 
rates.  However,  now  that  more  services  are  decentralized,  the  hospital  has  designated 
a QA person  on  each  unit  who reports  to the  hospitals  quality  assurance  office. 
Hospital  management  believes  that  bringing  together  unit  and  central  staff  through 
QA  has opened  up a valuable  dialogue,  contributing  to better  patient  care  and  easing 
the  transition.  to the  CPP.  For  exwp]e,  they  have  noted  a decrease  in the  number  of 
venipunctures  per  patient,  as well as a deche  in the  number  of duplicate  orders  for 
tests. 
Staff from  central  departments  expressed  concern  to us about  the  level  of training  that 
clinical  partners  receive.  They  believe  that  the  hospital  has cut  comers  by providing 
only six weeks  of intensive  training  instead  of the  eight  to ten  weeks  initially  proposed. 
concerns  about  the  competency  of clinical  partners  and  the  effect  on quality  were 
addressed  through  the  hospitals  use  of cross-functional  groups  as a problem-solving 
tool.  These  are  ad  hoc  committees  consisting  of persomel  from  a variety  of 
disciplines  convened  to  address  specfic  systems  and  to create  new  ones.  One  such 
group  w  formed  at  the  request  of the  lab  to examine  the  problem  of an  increase  in 
the  number  of incorrect  specimen  collections.  After  assessing  the  proble~  the  group 
20 
-.  -. 
implementing  this  initiative.  Those  physicians  we interviewed  have  positive  views 
about  this innovation,  but  they are  only a small  part  of the  medical  stafE 
Third,  it is clear  that  an effon  such as this is expensive  and  difficult  to  quanti~. 
Training  staff  to  undertake  new roles  and  new duties,  separate  horn  existing  training 
programs,  carries  a substantial  price  tag. 
2s 
..  .. 
proposed  a svstem  modification  and  further  education  far  the  clinical  partners  on  this 
procedure;  ~  response,  the  lab  and  the  nursing  department  are  developing  a new 
education  program  to  remedy  the  problem. 
Other  advantages  arise  horn  the  additional  time  that  clinical  partners  spend  with 
patients  and  their  families.  The  clinical  partners  are  horn  diverse  backgrounds  and 
may  be more  attuned  to patients  differing  cultural  needs  and  concerns.  Nurses  told 
us that  on several  occasions  the  clinical  partners  have  recognized  dysfunctional  family 
behavior  and  have  alerted  them  to potential  problems  that  the  patient  might 
encounter  upon  discharge. 
Hospital  management  is still in the  process  of evaluating  the  impact  of the  Clinical 
Partners  Program  on  hospital  finances.  Those  we inte&ewed  were  in substantial 
agreement  that  it has  been  expensive,  particularly  for training,  however,  they were 
unable  to provide  us with the  actual  costs.  Managers  acknowledge  that  they  probably 
underestimated  the  cost  of training  when  they began  this  program.  tie  senior  official 
reporte~  however,  that  the  program  has  added  significant  value  to patient  care, 
despite  its cost. 
With  the  ixnpiementation  of the  meal  Partners  Pro- Mercy  was  able  to  reduce 
the  number  of vacant  RN  positions.  Since  the  program  was adopted  they  have  added 
more  FIEs  to their  payro~  but  these  have  been  in non-nursing  positions.  By 
transforming  the  unfilled  RN  positions  into  Clinical  Partner  positions  the  hospital 
estimates  that  it has  hired  35 fewer  nurses. 
One  physician  we  spoke  with  said that  the  hospital  has  been  struggling  to figure  out 
how to measure  the  cost-savings  of the  CPP;  he remarked  on the  difficulty  of t@ng  to 
prove  a negative.  He  nonetheless  thinks  that  the  change  has had  positive  fiancial 
and  clinical  benefits.  III the  past  nobody  was measuring  the  amount  of time  spent 
waiting  for  tests  or  the  number  of times  a nurse  had  to  make  telephone  calls to 
arrange  for care.  Now eve~one  realizes  that  they  have  more  time  for  the  patients, 
but  it is very difficult  to prove. 
Since  CPP  began  over  three  years  ago,  the  nurse  vacanq  rate  has decreased  from 
almost  12 percent  to less than  three  percent.  Now the  hospital  reports  a short  waiting 
list of nurses  interested  in working  at  Mercy.  All budgeted  positions  were  filled  by 
July  1992-includtig  traditionatiy  difficult-to-fill  positions  in the  intensive  care  unit. 
Hospital  management  believes  that  the  CPP  has  influenced  this trend. 
21  .. 
Eiiucational  Isolation 
  Train  staff  in areas  not  covered  in basic  health  professions  curncula--e.g., 
management,  supetision,  delegation. 
e  Establish  career  ladders  for nonprofessional  staff, with clear  expectations, 
requirements,  and  goals.  Involve  different  professions  in providing  training  ~~r 
entry  level  staff. 
  Use  in-semice  education  to expand  knowledge  across  professions. 
Physician Rewktance 
  Involve  physicians  in development  of new  approaches.  This  will help  other 
physicians  buy into  the  organizational  change. 
  Identify,  understand,  and  respond  to major  concerns  of physicians. 
Make  explicit  that  nonphysician  providers,  such  as NPs, PAs,  and  CNMS, must 
 
meet  the  same  quality  assurance  standards  and  processes  as physicians, 
including  service  on  medical  standards  committee. 
  Establish  clear  protocols  to make  explicit  the  lines  of approved  delegation. 
Imtihdond  Inema 
Openly  demonstrate  commitment  by senior  management. 
 
  Designate  a full time  staff  perscm  to be responsible  for implementation.  This 
person  should  report  directly  to  the  organizations  senior  management. 
Spell  out  basic  objectives  of reform.  Make  implications  for patient  care  clear. 
 
hwoive  employees  early  in the  change  process.  Solicit and  respond  to their 
 
concerns. 
27