What healthcare leaders need to know now

 

One in a series of interviews with Modern Healthcare's Top 25 Women in Healthcare for 2015.

 

As the healthcare industry begins to shift to value-based care, Pam Cipriano is utterly convinced that nurses are prepared to lead that transformation in many ways.

 

“I believe nurses are continuing to be the key providers in this transition of care,” says Cipriano, president of the American Nurses Association, which represents the interests of 3.4 million registered nurses. “Nurses have been the owners of care coordination for decades – they have this skill as a core competency. They tend to be the most holistic members of the team regardless of settings.”

 

Care coordination, says Cipriano, is a linchpin for quality, and the industry is taking notice of the pivotal role nurses can bring to the entire equation.
“That may come under many different names: care coordinator, case manager, outcomes manager,” she notes. “The major insurance companies have already seen the enormous value of having nurses in these roles.”

 

In every quality-improvement initiative, it is nurses who play a crucial role in determining if that patient experience will succeed or fail, adds Cipriano, who has served on boards and committees for a variety of respected industry organizations, including the Joint Commission and the National Quality Forum.

 

“When providers say, ‘We’re going to prevent readmissions, we’re going to prevent hospital-acquired conditions, or we’re going to make sure that people with chronic conditions don’t come back to the emergency room for their care and that they’re taking their medications’ – it’s nurses who are driving all of these activities.”

 

Cipriano herself has been driving the agenda for the ANA since her election in 2014. Yet she took a non-traditional path to nursing, beginning in a med tech program at a state college in rural Pennsylvania. Dissatisfied, she began looking for a parallel course of study to which she could apply her chemistry and biology courses and ended up at the Hospital of the University of Pennsylvania School of Nursing. She became heavily involved in the National Student Nurses Association and her career took off. She eventually earned a Ph.D. and has served in a variety of leadership and teaching roles for the University of Virginia, including chief clinical officer and chief nursing officer.

 

Her first year leading the ANA was a whirlwind, including a very visible role as the nation dealt with a number of cases of Ebola.

 

“What was most important was not only protecting the nurses, but also making sure we played a role in reducing the fear and anxiety of the public,” she says. “There was so much bad information that was being propagated and people were unable to focus on the science in the height of emotion.”

 

The ANA worked with the AMA, AHA, CDC, HRSA and many nursing associations to provide information and a reasoned response to the situation. Cipriano even did a media tour with Rich Umbdenstock, retiring CEO of the AHA, guesting on numerous morning radio shows across the country to assuage the public’s concerns.

 

That’s the kind of leadership that many nurses demonstrate, Cipriano shrugs. But she is not sure they receive adequate credit for their executive acumen.

 

“First and foremost, I believe there is a myth that nurses don’t understand finance, and so I believe there is a bias against placing nurses in positions that would oversee an organization’s financial position and budgets,” she says. “Yet if you think about a typical hospital, over half of the personnel and usually more than half of the budget is under the leadership of the chief nursing officer.”

 

That’s a lot of responsibility. And so Cipriano admits one of her pet peeves is when chief nursing officers or executives don’t report to the chief executive officer of the organization.

 

“It is absolutely critical that the chief nursing officer not only report to the highest level executive but also has access to and regular interactions with the governing body of the organization,” she says. “We now have pretty solid data linking outcomes of care and patient satisfaction and engagement scores with direct relationships to not only the nurses but also other employees directly involved in care. So why would you relegate that CNO to a role that is viewed as less important?”

 

Cipriano says many nurses don’t seek out a CNO role not only because they prefer to manage at the point of care but also because of the politics that can derail a career at that level.

 

“If you talk to nurse executives across the country, there are many who have left their jobs or been removed from their jobs because they didn’t get along with the CEO or they didn’t go along with the CEO,” she says. “And so, being in a CNO job is really tough work advocating for person-centered care and those who provide that care.”

 

If you get the impression that Cipriano is a fierce advocate for nurses, you’re right. As she continues her term as ANA president through 2016, she’s also helping nurses adjust to possible shifts in the setting of patient care as it moves from primarily hospitals to all sorts of venues, including the home, along the continuum of care. She’s also testified at briefings on Capitol Hill championing the installation of lifting equipment because nurses and so many others are injured trying to lift patients.

 

“Nurses are fifth in line among occupations for the most musculoskeletal injuries, ahead of many manufacturing jobs. It’s scary,” she says. “The turnover cost for a nurse can be huge --- it can be over $100,000 for an organization.”

 

Ultimately, she says, she wants to see nurses recognized by consumers and policy makers as intelligent, highly skilled and resourceful healthcare leaders.
“I want nurses at every level to be recognized as individuals who bring a lot of underrepresented knowledge to the conversation.”

 

 

One in a series of profiles of Modern Healthcare’s Top 25 Women in Healthcare (sponsored by Furst Group)

 

Karen Daley loved being a nurse, and she was a good one. But all that changed one day in 1998 when she was stuck by a needle while treating a patient. From that one needle stick, she contracted HIV and hepatitis C.

 

Her clinical nursing days were over. Over the next couple of years, she would undergo exhausting treatment regimens. But she was determined that the incident would not end her healthcare career.

 

“I learned how resilient I was physically and emotionally,” says Daley today, now president of the American Nurses Association and one of the 2013 Top 25 Women in Healthcare as chosen by Modern Healthcare. “It was a grueling time. I was constantly worried about fatigue, falling and exposing others to my blood, and I had little appetite because of the drugs. I looked sick.”

 

Yet while she underwent treatment, she plunged into advocacy, petitioning the U.S. Congress to change laws to reduce the odds that other nurses would have to face what she was going through. The laws were eventually changed to mandate use of safety-engineered sharps devices that could prevent similar injuries. Now, more than a decade later, compliance isn’t where it could or should be.

 

“We had to educate the healthcare system that these injuries and associated bloodborne pathogen exposures were preventable,” Daley explains. “Not only were they losing workers to these injuries, they were risking the goodwill of workers who learned over time that these were injuries that should not have occurred.”

 

In hospitals, she says, “prevention often is not seen as a viable strategy because it often costs money on the front end versus money you may or may not have to pay on the back end.”

 

While more safety needles are on the market and in greater use, Daley says the price drop that was promised by the medical device industry for the costlier devices as market penetration increased has not occurred. She also says federal enforcement of OSHA requirements is now a priority issue because “we know there are employers who are still not compliant with the requirements under the law.”

 

Beyond the institutional level and despite evidence that the overall number of these injuries has declined since the law was enacted, Daley says operating rooms remain a very high-risk area because surgeons control the kits and sharps that are used in each procedure, and are often resistant to changing their instruments or sharps devices. That has to change, she says. “Everyone’s health and safety is at risk with these injuries. It really is about what’s right across the board for a safer work environment.”

 

And medical device companies haven’t stopped making conventional or less effective early-generation safety needles and devices , nor have hospitals stopped buying them, she laments. “Today, despite the fact that the technology has improved significantly, we have some of the same devices on the market as when the law was passed.”

 

In the process of advocating around this issue, she says she’s learned that change is never simple, and that it’s important to get all stakeholders to the table, even congressional leaders who are feeling pressure from constituents and lobbying groups.

 

“For any movement, persistence is necessary,” she says. “It’s seeing the change through. We are still not where we need to be on needlestick injury prevention, so the need for persistence is another lesson learned.”

 

That’s a lesson she’s taken to heart in her own life, where she has gone back to the classroom numerous times to earn advanced degrees. Beyond her bachelor’s degree in nursing, she has earned a master’s in public health from Boston University School of Public Health, and a master’s in science and a PhD in nursing from Boston College.

 

To keep up with technological advances, the growing complexity of the healthcare system and patient healthcare needs, and to help combat the shortage of providers in healthcare, nurses need more education, she says.

 

“We need to make sure we’re helping nurses go back to school to advance their education. It’s an expensive proposition and that investment doesn’t always get recouped when they go back into the workforce,” Daley adds. “We also need to continue to grow the number of advanced practice registered nurses to provide care that is not going to be met by primary-care physician workforce, just based on numbers and geography.”

 

But shortages of all kinds are facing the practice of nursing, Daley says. There is an impending shortage of nurses, of nursing faculty, of chief nursing officers, and nursing-school deans – due to age, experienced nurses are retiring in large numbers. But the lack of adequate numbers of qualified nursing faculty is particularly vexing, she says.

 

“The faculty shortage represents a huge barrier for educating enough nurses. In fact, over the past several years, we’ve turned away more than 70,000 qualified applicants from nursing programs each year in this country because we don’t have enough faculty or clinical sites to accommodate them.”

 

Taken together, those numbers mean Daley will often be headed back to Capitol Hill to ask for more government funding to help to ease the crunch, exacerbated by the prospect of 2 to 3 million Baby Boomers aging into Medicare every year for the foreseeable future.

 

“We have to make sure the supply of care providers meets the demand,” she adds. “That care is largely going to be nursing care. So we have to feed the pipeline, and I’m concerned when I see so much reticence in Congress around the budget regardless of the issue, that we might not be able to keep up with what is going to be a very unusual shortage and critical demand over the next decade.”

 

Part of the issue, she suggests, is a lack of understanding of the value the nursing profession brings to patient care.
“What has to happen,” she adds, “is nurses need to be better understood as not simply compassionate caregivers, but as knowledgeable and skilled providers who impact patient outcomes and are licensed and accountable as part of their societal contract to assure patients of safe, quality care.”

 

She notes the case of two nurses in Texas’ Winkler County who anonymously reported a physician for unsafe practices (their allegations were proven to be true). But a law-enforcement official who was friends with the doctor uncovered the nurses’ identities and they were fired, prosecuted and indicted. Though they were later vindicated and won a settlement, the entire episode gives other nurses pause about speaking up, Daley says.

 

She is no less candid in describing the state of women in the C-suite, noting the paucity of female leaders in healthcare. “If I were to characterize it in one sentence, I would say we’re not doing very well at all in shattering the glass ceiling. We need to make a lot of progress to raze that ceiling.”

 

Daley hopes she can play a small role in changing that view of the ceiling.

 

“As I go out and speak with nurses and other leaders around the country, my job is to inspire and empower them to find their own voice, and to encourage them to take the risks that are necessary for making change. I want to help them continue in their own journey to be effective change agents within a larger system.”

 

Undaunted by the setback that ended her nursing career, Daley is taking her own advice to heart.