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Department of Health and Human Services 

OFFICE OF 

I INSPECTOR GENEML 

ENHANCING THE UTILIZATION OF 

NONPHYSICIAN HEALTH CARE 

PROVIDERS: 

THREE CASE STUDIES


MAY 1993 OE141-9042071° 

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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. Joseph’s Hospital of Atlanta is using professional and nonprofessional 

hospital staff on two units to del&er more patient care sexvices directly at the bedside. 

Chicago’s 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 hospital’s 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 profession’s 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@lxtwu Licensure laws are designed to protect the public’s 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 
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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 Tem”torialtim. 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 public’s 

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 interdisciplinary 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 selfinterest. 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 

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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. Joseph’s Hospital of Atlanta is using professional and nonprofessional 

hospital staff on two units to de&er more patient care semices directly at the bedside. 

~cago’s 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 hospital’s 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 profession’s 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 public’s 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: 

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We conducted this study in accordance with the Quality Standards for hspection$ 

issued by the President’s 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. Joseph’s 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 hospital’s 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 of our facts.

We did no~ however, change our interpretation of 

accuracy 

those facts 

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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 Center’s 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 

EverCare’s 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. 

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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 GNP’s authority. This 

resistance may simply have been the result of confusion over the definition and 

authority of the GNP’s 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 practitioner’s 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 dwsn’t 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. 

experience with them nursing home staff apparently 

Once thev have gained 

like having the GNPs available. 

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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 Center’s 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? 

EverCare’s 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~ 

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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 GNP’s 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 EverCare’s 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 
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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 physician’s decision is 

needed they believe that EverCare physicians respond more quickly to the GNP’s call; 

they realize it is important and a situation that the GNP feels requires a physician’s 

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 

GNP’s office is a car. She must use-space either in a ~ursing 

emergency department for the initial physical assessment and 

home or a hospital 

case histoq. 

CONCLUSIONS 

Our study of Evercare highlights the 

providing care through collaborative 

leading role that nurse practitioners can play in 

arrangements with physicians. Our discussions 

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ST. JOSEPH’S HOSPITAL 

SERVICE AND CLXNICAL ASSOCIATES PROGRAM 

Atkm@Georgia 

BACKGROUND 

St. Joseph’s 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. Joseph’s created two new job categoriesservice 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. Joseph’s 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. Joseph’s 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 

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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 hospital’s 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 

WHAT IS INNOVATIVE ABOUT CLINICAL 

lWme-Ctial l%u7ner Tixzms 

A clinical partner is a person trained to provide 

hospital. 

PARTNERS? 

a variety of nursing assistant and 

technical tasks essential to basic patient &re, working in a team wi”ti 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 program’s 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 

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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. Joseph’s 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 

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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 
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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 hospital’s 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 hospital’s 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 

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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 

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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 

Physician Rewktance 

education to expand knowledge across professions. 

� 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 

Imtihdond Inem”a 

protocols to make explicit the lines of approved delegation. 

� Openly demonstrate commitment by senior management. 

� Designate a full time staff perscm to be responsible for implementation. This 

person should report directly to the organization’s 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 

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