Week 14: Strategies for increasing consumer participation in the policy process.

The question this week, how do we engage the public in the policy process? Kraft and Furlong suggest that increasing technology will enhance public participation through easier access to relevant information. Public participation in the policy process has declined over the past several decades.₃   However, individual’s access to information has grown significantly over the same time period. Additionally, according to the U.S census bureau 2010 report, only 60% of individuals of voting age in Arizona were registered to vote and of those, only 45% voted http://www.census.gov/compendia/statab/2012/tables/12s0400.pdf.  It seems that apathy for the political process may have taken hold. How can we influence change in an environment of indifference?

This week’s topic directly ties into previous discussions regarding change theory, characteristics of innovators and change agents, and sustaining innovative environments as they relate to APRN consensus. We can again look to Kotter’s change model for guidance. ₁

• Increase urgency
• Build guiding teams
• Get the vision right
• Communicate for buy-in
• Enable action
• Create short-term wins
• Don’t let up
• Make it stick

Let’s take a look at the first step in Kotter’s change model “increase urgency”. ₁ Policy that allows all APRN’s to practice to the full extent of their education and training presents a viable solution to the shortage of healthcare providers. The first step in increasing the urgency should be engaging the APRN. State coalitions such as the Arizona Advanced Practice Registered Nurse Coalition for the Consensus Model http://www.futureofnursingaz.com/practice/aprn-consensus-model/ provide a specific plan to transform nursing to meet the challenge of providing exceptional care in the midst of radical change to healthcare delivery. Additionally, national organizations like the American Nurses Association (ANA) http://www.nursingworld.org/, American Association of Nurse Practitioners (AANP) http://www.aanp.org/. , American Association of Colleges of Nursing (AACN) http://www.aacn.nche.edu/ and the American Association of Retired Persons (AARP) http://www.aarp.org/ have joined the campaign and provided clear vision of APRN’s practicing to the full extent of their education. These organizations provide clear direction and offer opportunities for interested individuals to join a call to action. Therefore, the importance of participating in professional organizations.

Through healthcare policy changes APRN’s could present a resourceful solution to the shortage of health care providers. ₄ Getting the word out to the public is an essential piece to “increasing urgency”. If each APRN were fully engaged in the movement toward APRN consensus, we would have a great force with which to inform the public. A meta-analysis demonstrated a positive causal relationship between social media and participation in civic and political life_{. 2} If each APRN in practice could provide an active voice toward APRN consensus, formats such as Twitter, Facebook, e-mail, web site’s, or even blogging could present a forum to increase urgency and thus support for APRN consensus.

1. Campbell, R. J. (2008). Change management in health care. The Health Care Manager, 27(1), 23-39.
2. Boullianne, S. (2015). Social media use and participation: A meta-analysis of current research. Information, Communication, and Society, 18(5), 524-538. http://dx.doi.org/10.1080/1369118X.2015.1008542
3. Kraft, M. E. & Furlong, S. R. (2015). Public Policy: Politics, Analysis, and Alternatives (5^th). Thousand Oaks, CA: CQ Press.
4. Newhouse, R. P., Weiner, J. P., Stanik-Hutt, J., White, K. M., Johantgen, M., Steinwachs, D., … Bass, E. B. (2014). Policy implications for optimizing advanced practice registered nurse use nationally. In K. A. Goudreau, & M. C. Smolenski (Eds.), Health policy and advanced practice nursing: Impact and implications (pp. 29-40). New York, NY: Springer.

Week 13: Sustaining innovative environments

In week 11 of this blog, we identified characteristics of innovators and change agents in the healthcare sector. Once we begin our quest for innovative change, how can the spirit of innovation and environment of change be sustained? Again, looking to the valuable resource Innovate Like Edison, Gelb offers some concrete strategies to identify and asses strengths and weaknesses of innovative competencies for both individuals and teams.₂ Ongoing assessment and striving to improve effective innovative strategies and competencies is outlined in the innovation literacy blueprint. Following the blueprint is an active way to develop innovation literacy. Using Gelb’s plan, innovation will be cultivated until it becomes second nature.

Next we can look to Kotter’s change management model for sustainable change.₁ Once we are on the trajectory for change we continue using Kotter’s model to sustain gains and encourage future change. In particular, the last three steps of Kotter’s change management model may inspire sustainable change.

• Create short-term wins
• Don’t let up
• Make it stick

The journey for APRN consensus will require “incrementalism”, innovation, and sustainable change. “Incrementalism in policymaking increased the likelihood of reaching compromises among the diverse interests in the political marketplace” _3.  Changes in policy that will allow APRN’s to work to the full extent of their education and training are on the horizon. We must continue to celebrate incremental changes, while sustaining the momentum for further change.

References

1. Campbell, R. J. (2008). Change management in health care. The Health Care Manager, 27(1), 23-39.
2. Gelb, M. J., & Caldicott, S. M. (2007). Innofvat like Edison: The five-step system for breakthrough business success. New York, NY: Penguin Group
3. Longest, B.B. Jr. (2010). Health policymaking in the United States (5th ed.). Chicago, IL:  Health Administration Press

Week 12: Healthcare financing

“The IHI Triple Aim is a framework developed by the Institute for Healthcare Improvement that describes an approach to optimizing health system performance. It is IHI’s belief that new designs must be developed to simultaneously pursue three dimensions, which we call the “Triple Aim” – population health, experience of care, and per capita cost.₂

The U.S. health care is the most expensive in the world; however, more costly does not always mean better care.₂ Not only has spending on national health care doubled in the past 30 years, increased spending is expected to double again by 2035.₃ :Ideally, reducing costs while maintaining or improving quality should be the national goal for health care.₂ Contributors to increased costs include not only the aging population, but also excess cost growth.₃ Increased access to care has contributed to a shortage of primary care providers. Access issues, coupled with increasing age of the population and increasing chronic disease contributes to rising health care costs.

Additionally, physician burnout has been associated with decreased patient satisfaction, reduced health outcomes, and it may contribute to higher costs. ₁ APRN’s could provide a solution to increasing provider shortages. NP’s deliver safe, quality, effective care with outcomes that compare to physicians.₄ Policy that allows all APRN’s to practice to the full extent of their education and training affords a sustainable solution to the shortage of healthcare providers in the U.S. All members of the health care workforce should work to the full extent of their training to contribute to the goal of the Triple Aim.

References

1. Bodenheimer, T., & Sinsky, C. (2014). From triple to quadruple aim: Care of the patient requires care of the provider. Annals of Family Medicine, 12(6), 573-576. http://dx.doi.org/doi: 10.1370/afm.1713
2. Institute of Healthcare Improvement. (2014). The IHI triple aim. Retrieved from http://www.ihi.org/Engage/Initiatives/TripleAim/Pages/default.aspx
3. Longest, B.B. Jr. (2010). Health policymaking in the United States (5th ed.). Chicago, IL:   Health Administration Press
4. Stanik-Hutt et al. (2013). The quality and effectiveness of care provided by nurse practitioners. The Journal for Nurse Practitioners, 9(8), 492-500. doi:10.1016/j.nurpra.2013.07.00

Week 11: Characteristics of innovators and change agents in the healthcare sector.

Garson presents the innovative idea: “The nation may not need as many physicians and nurses if the systems can be changed to promote integration, leveraging every member of the workforce to perform at his or her maximum competency”.₁ The definition of innovation is a new idea, device, or method.₂ Innovation is essential to solve problems, or improve efficiency. Successful innovation is an idea plus implementation of the idea.₃ Issues in health care are presenting significant challenges that may require innovative people and ideas to solve. Perhaps the answers to effective innovation will originate outside of health care; for example, let’s take a look at innovative competencies that originated with the great mind of Thomas Edison.₄   Gelb presents the successful attributes of one of the greatest innovators in history.

Edison’s five competencies of innovation are:

1. Solution-centered mindset
2. Kaleidoscopic Thinking
3. Full spectrum Engagement
4. Master-mind Collaboration
5. Super-value Creation

In a nutshell, this model outlines the actions of a successful innovator necessary to implement innovative ideas. This is accomplished by engaging in the five competencies presented by Gelb₄. First, passionately pursue optimistic goals with a clear vision for success. Second, consider many ideas, and view each idea from various angles. Third, fully engage to promote endurance and effective performance. Fourth, gather a knowledgeable team to create “higher group intelligence”. Finally, creating value for others, or for a target market.

Garson’s innovative idea of decreasing physician and nursing shortages by utilizing each individual to the full extent of their competency could be realized by applying innovative thinkers and doers to provide a realistic solution. In fact, this sounds much like the bases for the APRN consensus model and much of the work that is going on to ensure that APRN’s work to the full extent of their education and training. Edison’s five competencies provide an excellent framework to accomplish innovative change.₄

1. Garson, A. (2013). New systems of care can leverage the health care workforce: How many doctors do we really need? Academic Medicine, 88(12), 1-5.
2. Merriam Webster. (2015). Innovation. In Dictionary. Retrieved from http://www.merriam-webster.com/
3. Kelley, T., & Littman, J. (2005). The ten faces of innovation. New York, NY: Doubleday.
4. Gelb, M. J., & Caldicott, S. M. (2007). Innovate like Edison: The five-step system for breakthrough business success. New York, NY: Penguin Group.

Week 10: Change theory in relation to the APRN consensus model: Kotter’s Change Management Model

In previous weeks this blog presented APRN consensus as a feasible solution to health care issues intensified by the ACA. APRN consensus model will guarantee full practice authority for the APRN, significantly contributing solutions healthcare reform. What does it take to implement effective change that is sustainable? Kotter’s change management model puts forth an 8-step methodology designed to promote lasting change. Let’s take a look at implementing the change of APRN consensus by applying Kotter’s change management model.

• Increase urgency
• Build guiding teams
• Get the vision right
• Communicate for buy-in
• Enable action
• Create short-term wins
• Don’t let up
• Make it stick

Work on the APRN consensus model began with The future of nursing: Leading change, advancing health IOM (2011). Since then, urgency has mounted prompted by the ACA and an increased need for primary care providers, access to quality care. State coalitions such as the Arizona Advanced Practice Registered Nurse Coalition for the Consensus Model http://www.futureofnursingaz.com/practice/aprn-consensus-model/ provide a specific plan to transform nursing to meet the challenge of providing exceptional care in the midst of radical change to healthcare delivery. Additionally, national organizations like the American Nurses Association (ANA) http://www.nursingworld.org/, American Association of Nurse Practitioners (AANP) http://www.aanp.org/. , American Association of Colleges of Nursing (AACN) http://www.aacn.nche.edu/ and the American Association of Retired Persons (AARP) http://www.aarp.org/ have joined the campaign and provided unified vision of APRN’s practicing to the full extent of their education. These organizations provide clear direction and offer opportunities for interested individuals to join a call to action. This may include letters to legislators and participation in lobbying activities at the state or local level. Stakeholders provide ongoing communication and celebrate small victories as APRN’s gain practice authority issue by issue and state by state. Still the progress moves forward with the support of stakeholders and momentum is gained until all APRN’s in the nation can practice to the full extent of their education.

References

Campbell, R. J. (2008). Change management in health care. The Health Care Manager, 27(1), 23-39.

Institute of Medicine. (2011). The future of nursing: Leading change, advancing health. Retrieved from http://books.nap.edu/openbook.php?record_id=12956

Week 9: Policy governing access to data and privacy protection in an electronic and genomic age

The Health insurance Portability and Accountability act (HIPAA) was the first federal legislation to ensure national protection for health insurance information (Erickson & Millar, 2005). In addition to national policy, state policy can also dictate how we manage patient information. While HIPAA is not unfamiliar to the nurse working in a healthcare setting, HIPAA may present new challenges to the APRN.   Prior to the implementation of the HIPAA in 1996, work was initiated by Centers for Medicare and Medicaid Services (CMS) to develop a healthcare provider national identification system with a goal of increased effectiveness and efficiency in both the public and private sectors (Department of Health and Human Services [DHHS], 2004). As a result of this work and the Administrative Simplification provisions of HIPAA, all covered healthcare providers are required to have a unique health identifier. The National Provider Identifier (NPI) was established and is required for each covered health care provider who may electronically transmit health information. Electronic transmission of health information or Electronic Data Interchange (EDI) may include billing claims, coordination of benefits and payments, eligibility, enrollment, dis-enrollment, referrals and authorizations (Department of Health and Human Services [DHHS], 2014). Although the NPI was initially intended for providers billing for CMS, Medicare, and Medicaid, it is now required for any EDI.

Another consideration for the APRN is the meaningful use initiative that was motivated by the American Recovery and Reinvestment Act (ARRA) and introduced the HITech Act. http://www.cdc.gov/ehrmeaningfuluse/introduction.html. This initiative is intended to “reduce medical errors, improve care coordination, eliminate wasteful duplication and engage patients in their care” through meaningful use of the EHR.  APRNs have the ability to participate in meaningful use and receive financial incentives for compliance. By complying with the meaningful use initiative, APRNS can improve quality of care while realizing significant financial incentives. http://www.theamericannurse.org/index.php/2012/10/05/aprns-benefit-from-ehr-incentive-program/

The APRN consensus model encourages APRN’s working to the full extent of their education. Strengthening of the APRN role through consensus will allow all APRN’s to fully engage in improving patient outcomes by complying with initiatives that promote meaningful use in the EHR. Additionally, APRN’s will share in the financial compensation that participation in meaningful use initiatives will deliver.

Department of Health and Human Services. (2004, January 23). Federal Register [Final Rule]. Washington, D.C.: Author. Rules and Regulations, (45 CFR Part 162), National Archives and Records Administration, Washington, D.C.

Department of Health and Human Services. (2014). NPI: What you need to know. Retrieved from http://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/downloads/NPIBooklet.pdf

Erickson, J., Millar, S. (May 31, 2005). “Caring for Patients While Respecting Their Privacy: Renewing Our Commitment”. OJIN: The Online Journal of Issues in Nursing. Vol. 10 No. 2, Manuscript 1. DOI: 10.3912/OJIN.Vol10No02Man01

Week 8: Private sector innovation and policy advancement.

Advanced Practice Registered Nurse (APRN) lobby day was a day spent at the Arizona State Legislature that provided a tangible example of private sector innovation and policy advancement. Private sector innovation by various nursing organizations promote public policy agenda set by the organization. APRN lobby day was hosted by the Arizona Nurses Association (AZNA) with the purpose of familiarizing APRN’s with the legislative process, while introducing the presence of APRN constituents to legislators. This year’s APRN lobby day had a distinct focus on preparation for the 2016 legislative session where the APRN consensus model will be presented. The day consisted of a coming together to rally support for the upcoming APRN consensus model. Additionally, APRN’s had face to face meetings with senators and house representatives from their districts. The brief and pleasant meetings provided an opportunity to engage with legislators prior to the 2016 legislation regarding APRN consensus model. Additionally, APRN participants handed out flyers describing the various positions and role of the APRN, with rolls of lifesavers as a symbol of nurses. The intent of the message is support of APRN’s working to the full extent of their education, the same message that originated with the IOM.

AZNA promotes policy through education regarding relevant policies, active engagement of members, vigorous lobbying, and providing positive visibility to the role of the APRN.

Private sector nursing organizations focus on advancing the nursing profession by providing education and promoting political activism regarding relevant policy. Joining and taking active part in professional organizations like the American Nurses Association (ANA) http://www.nursingworld.org/ or the American Association of Nurse Practitioners (AANP) http://www.aanp.org/. will deliver one, strong, unified, voice to policy makers. Membership in the ANA automatically gives you membership in the state chapter Arizona Nurses Association (AZNA) http://www.aznurse.org/ . And membership in the local chapter of Nurse Practitioners AZNPC (chapter 9) https://arizonanp.enpnetwork.com/

Private sector influence regarding the APRN consensus model could also be influenced by opposing physician groups. The American College of Physicians (ACP) http://www.acponline.org/ and the American Medical Association (AMA) http://www.ama-assn.org/ provides a conflicting message to that of the nursing organizations. They argue that the educational pathway of the APRN is lacking and substandard to the education of the physician. Take a look at the AMA response to the IOM report http://www.ama-assn.org/ama/pub/news/news/nursing-future-workforce.page Physicians have a strong voice through their private sector organizations that lobby against nursing scope of practice issues.

APRN’s can join the discussion and stay informed by visiting http://www.futureofnursingaz.com/practice/aprn-consensus-model/  another private sector organization with influence on public policy. Click on “join” and stay active and informed on upcoming legislation that will allow APRN’s to work to the full extent of their education.

Institute of Medicine. (2011). The future of nursing: Leading change, advancing health. Retrieved from http://books.nap.edu/openbook.php?record_id=12956

Week 7: Medicare, Medicaid, and the Affordable Care Act as examples of public policy implementation.

When we examine the Medicare, Medicaid, and the Affordable Care Act as examples of public policy implementation, it is important to understand why these policies were successfully implemented when many other attempts at major health care reform through policy have failed. Kingdon (2011) points out that presidents since Theodore Roosevelt have attempted to implement broad health care reform. Why some public policies are successful when others fail will offer insight to successful policy implementation in other situations like the APRN consensus model.

As discussed in week five blog the policy cycle is dependent on problem, solution, and political circumstance. The impetus for a major change in public policy is an issue or “problem”. Kingdon (2011) states that a problem exists when there is a mismatch between the current condition and an ideal state. To that point, in the case of the ACA, While 85% of Americans were covered by health insurance, policy makers felt that all Americans should be covered. Political circumstances were right for passage of the ACA due to “the great recession” when unemployment soared and in most cases, loss of job meant loss of health insurance benefits. The ACA was the intended solution to maintain access to health care. Historically, public policy is considered for health care reform because of the major impact it has on the American economy. Policies regarding Medicare and Medicaid were also passed when a problem was identified, and a solution was presented and the political climate was right to ensure access to health care for the elderly, poor, and for other certain special circumstance (Longest, 2010).

Conversely, when the Clinton administration attempted comprehensive health care reform, there was an identified problem that the health care reform may have addressed. However, many critics suggested the solution was too complex; additionally, the political climate was unreceptive to the extensive reform at the time.

As mentioned in week five of this policy blog, the time is right for the APRN consensus model because the problem has been presented with a solution at a time when it is politically feasible to implement. The problem is that APRN’s in the state of Arizona and across the United States have varying degrees of practice authority. The APRN consensus model presents a viable solution that ensures public safety through uniform requirements regarding licensing, accreditation, credentialing and education. Current political circumstances demand reform to health care and the increased need for access to quality health care makes the timing right for drafting and enacting legislation to offer a feasible solution.

References

Kingdon. (2011). Agendas, Alternatives, and Public Policies, Update Edition (2^nd ed.). London: Longman Publishing Group.

Longest, B.B. Jr. (2010). Health policymaking in the United States (5th ed.). Chicago, IL:   Health Administration Press

Week 6: Public sector influence on healthcare policy: Efforts to aid the uninsured, underinsured, disabled, and decrease health disparities

 

With the passage of the Patient Protection and Affordable Care Act (ACA) a major challenge will be the increased need for primary care providers in the United States (U.S.). Additionally, provisions of the ACA necessitate the need for innovative approaches to care delivery (Lathrop & Hodnicki, 2014). Ensuring full practice authority for the APRN can contribute immense value to the solution of healthcare reform.

According to the U.S. Department of Health Resources and Services Administration (HRSA) there is a large shortage of “physicians” with a need of an additional 16,000 across the U.S. in underserved areas http://www.hrsa.gov/shortage/.  Interesting, that the HRSA just names “physicians” while research shows that NP’s deliver safe, quality, effective care with outcomes that compare to physicians (Stanik-Hutt et al., 2013). The current push for healthcare reform strives to provide safe quality healthcare to many uninsured or underinsured. Removing practice barriers to the APRN will help meet the growing healthcare needs of the U.S. by providing safe, quality, and effective healthcare. Additionally, getting the word out that APRN’s are prepared to contribute to the solution is essential for healthcare reform. Getting the word out to the public is the purpose of this AANP campaign. http://www.aanp.org/all-about-nps/awareness-campaign

The APRN consensus model is designed to promote delivery of quality healthcare while providing for public safety by ensuring full practice authoriy. Also, the APRN consensus model is designed to ensure consistent care, while protecting the public, by standardizing licensing, accreditation, certification, and education (LACE) for the APRN. According to the AANP at least two thirds of Americans have visited NP’s when seeking primary healthcare. APRN’s are ready, willing, and able, to serve the public sector when it comes to providing quality healthcare. Removing practice barriers will ensure delivery of quality care for the uninsured, and underinsured. Moreover, the APRN may find innovative ways of delivering healthcare to decrease health disparities in the U.S. Healthcare policy changes will enable APRN’s to present a resourceful solution to the shortage of primary care providers (Newhouse et al., 2014). Policy that allows all APRN’s to practice to the full extent of their education and training affords a sustainable solution to the shortage of healthcare providers in the U.S.

American Association of Nurse Practitioners (2013).  NP public awareness campaign. Retrieved from www.aanp.org/all-about-nps/awareness-campaign

Bryan, R. H., Buzby, M., & O’Sullivan, A. L. (2012). The healthcare reform law and APRN practice. medscape.com.

Lathrop, B., Hodnicki, D., (2014) “The Affordable Care Act: Primary Care and the Doctor of Nursing Practice Nurse”   The Online Journal of Nursing Vol. 19

doi:10.3912/OJIN.Vol198No02PPT02

Newhouse, R. P., Weiner, J. P., Stanik-Hutt, J., White, K. M., Johantgen, M., Steinwachs, D., … Bass, E. B. (2014). Policy implications for optimizing advanced practice registered nurse use nationally. In K. A. Goudreau, & M. C. Smolenski (Eds.), Health policy and advanced practice nursing: Impact and implications (pp. 29-40). New York, NY: Springer.

Stanik-Hutt et al. (2013). The quality and effectiveness of care provided by nurse practitioners. The Journal for Nurse Practitioners, 9(8), 492-500. doi:10.1016/j.nurpra.2013.07.00

Week 5: The process of healthcare policy-making including statutory and regulatory mechanisms.

According to Longest (2010) “Legislation development begins with the origination of ideas for legislation and extends through the enactment of some of those ideas into law or the amendment of existing laws.” Let us begin with the formulation of the idea-or the “policy formation phase”. While Nurse Practitioners in the state of Arizona essentially enjoy full practice authority, other APRN’s in the state of Arizona and across the United States have varying degrees of practice authority (problem). Based on IOM (2011) recommendations previously mentioned in this blog, the NCSBN developed the APRN consensus model (solution). Reform to health care and the increased need for access to quality health care makes the timing right for drafting and enacting legislation to offer a feasible solution to the problem (political circumstances). Work is currently being done in the state of Arizona by the Arizona Coalition of Advanced Practice Registered Nurses to draft the legislation to be presented in 2016. In the meantime, much work is being done to prepare sunrise reports to satisfy the required sunrise review process http://www.azleg.state.az.us/Sunset_Review.pdf

The sunrise review process is regulated pursuant to Arizona Revised Statutes (A.R.S.) Title 32 http://www.azleg.gov/ArizonaRevisedStatutes.asp and in regards to nursing (A.R.S. Title 32 Chapter 15) http://www.azleg.gov/ArizonaRevisedStatutes.asp?Title=32 provides a mechanism for health professions to request regulation to achieve expansion in scope of practice. Once the sunrise review process is complete, legislation would be introduced that would expand the scope of practice of the APRN to better serve the public. Each of the APRN roles including NP, CRNA, CNM, and CNS are cooperatively preparing sunrise reports to make changes to existing scope of practice language to achieve uniformity for the role of APRN. The APRN consensus model provides the framework to inform APRN scope of practice regulation changes they hope to achieve. At this point the bill would be introduced into either house our senate, and follow the process of how a bill becomes a law https://www.youtube.com/watch?v=Otbml6WIQPo

Finally, the law is ready for policy implementation where rules that interpret and prescribe how the law will be implemented are drafted, presented, open to public comment, redrafted, scrutinized by congress and subject to legal challenge, and finally, published. “Rulemaking is a necessary part of policymaking, because enacted laws are seldom explicit enough concerning the steps necessary to guide their implementation adequately” (Longest, 2010).

References

Longest, B.B. Jr. (2010). Health policymaking in the United States (5th ed.). Chicago, IL:   Health Administration Press

Institute of Medicine. (2011). The future of nursing: Leading change, advancing health. Retrieved from http://books.nap.edu/openbook.php?record_id=12956