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The complexities of race and racism in healthcare


His tattoo read "White Power" in 3-inch calligraphic letters. Emblazoned across his chest for allPAUL LACHINE to see, the ink wasn't something I would normally have missed during my physical exam. In this case, though, his tattoo had been hidden by a bulky neck collar and the array of lines and tubes that come with being a comatose trauma patient.

Only on my third day of being this man's physician did I find myself confronted with the aggressive declaration.

I found myself wondering whether he would want me, a black woman, to be his doctor.

There was no dissatisfaction apparent in many interactions with his family, but they were somewhat distant. Was the distance born of shock over a relative's sudden, life-threatening injury? Or of discomfort with me?

As physicians, we take note of patients' demographics in part because it helps with diagnosis: Black patient with anemia? Think sickle cell. Greek patient with anemia? Think of the blood disorder thalassemia.

The Hippocratic Oath cautions us against refusing to treat patients based on these characteristics.

Doctors aren't supposed to be racist. We tend to think of ourselves not so much as people with specific identities, but more as disembodied brains and skilled hands ready to go about the work of healing.

My patient's tattoo was an unwelcome reminder that the skin I inhabit can't be checked at the hospital door.

Race is sometimes overtly discussed in health-care encounters, but usually because a patient expresses a preference for a clinician of a particular racial or ethnic background.

It is rarer for a patient to say that he or she does not want to be cared for by certain people. A few high-profile cases in the last several years involved white patients refusing care by black nurses.

While these requests are perhaps reprehensible, more controversial was the facilities' responses - in all the cases, the patients' wishes were honored. Some of the affected nurses successfully sued their employers for accommodating the racist requests, which had essentially allowed prejudice to affect their working conditions.

How should health-care providers respond to a racist, sexist, or bigoted patient? Sachin Jain is a physician of Indian descent who wrote about his experience with a patient who yelled at him to go back to India. Jain chose to yell back, a decision he later questioned.

In the New York Times' "Well" blog, Asian physician Pauline Chen revisits the Jain story and describes her own encounter with a combative swastika-decorated patient in the emergency room. She didn't wait for the patient to express his discomfort with her - she instead chose to remove herself from his presence as soon as it was clinically appropriate.

I explored the topic of racist patients in a piece for the Journal of the American Medical Association this month. I argued that I wholeheartedly reject racism and race-based prejudice, but I also recognize that patients have the right to choose their care providers and to have some control over the conditions of their care.

The therapeutic relationship between doctors and nurses and their patients is founded on mutual trust and respect; when these are missing, communication suffers and care plans fall apart. If I care for a patient who does not want me as a doctor, I have done that patient a disservice.

The responses I received to the JAMA piece were mixed. Many people thanked me for tackling a difficult issue for minority clinicians.

A few, though, criticized me for condoning inappropriate behavior. One person suggested that the clinical encounter could become a "teachable moment" in which I could fight prejudicial tendencies.

As much as I want to stamp out racism, I continue to believe that a one-on-one clinical encounter is the wrong venue to address this issue, for at least two reasons.

First, behavior is difficult to change. If I cannot persuade a patient to stop smoking or to eat more healthily, how will I convince them to shed long-held beliefs?

Second, asking for someone's respect when they are not inclined to give it is an exercise in futility. I learned that in high school.

I do think that there is a role for hospitals and other institutions to express that racism is not tolerated in clinical encounters. Similar to the "no smoking" signs that adorn healthcare facilities, I can imagine a "no offensive language or pre-judging" sign.

Health-care providers are under no obligation to treat patients in nonemergency situations, so perhaps instead of merely changing their clinicians, we should be referring bigoted patients to facilities willing to care for them.

That wouldn't have helped my trauma patient, though. He was at the brink of death, unable to declare his preference for care providers one way or the other.

As a result, he received superior care from people that he might have deemed inferior. Maybe the fact that we saved his life will serve as the ultimate teachable moment.



5 Must-Read Reports for Nurses


by Meaghan O'Keeffe, RN, BSN

As the institution of healthcare continues to evolve, nurses across the country are being asked to change with it. It can be easy to lose focus on the larger picture, however, when faced with the day-to-day challenges on the job.

These five reports are an eye-opening look at the healthcare system in crisis, but most importantly, they offer the nursing profession inspiring, actionable plans for how to change it.

Each of these reports is a must-read. They’re engaging and provocative and will help you come to informed opinions about the state of healthcare and your role as a nurse. Consider choosing a report every other month to distribute to your co-workers and then hold semi-formal discussion sessions to explore the themes and how they relate to your experience as a nurse.

5 Must-Read Reports for Nurses

1. Silence Killsdescribe the image

In this ground-breaking study, published by Vital Smarts and the American Association of Critical Care Nurses in 2005, seven areas where communication breakdown occurs in healthcare delivery were identified. They found that fewer than 10 percent of healthcare works speak up when they’ve observed medical errors, incompetency and other potential harmful behaviors. One of the more interesting findings of the study was that the few who do speak up in challenging circumstances have better patient outcomes and are more likely to stay in their jobs.


2. The Silent Treatmentdescribe the image

A follow-up to Silence Kills, The Silent Treatment takes a closer look at the many reasons why nurses fail to speak up during crucial moments in healthcare delivery and what identifies the characteristics shared by nurses who find the courage to say something when it counts.




3. The Future of Nursing: Leading Change, Advancing Health

Published in 2010, The Robert Johnson Wood Foundation, along with the Institute of Medicine, presented a call to action. In The Future of Nursing, the authors present data, and outline constructive ways, in which the nursing profession can become a leading voice in the revolution of the healthcare system.

4. AACN Standards for Establishing and Sustaining Healthy Work Environments: A Journey To Excellencedescribe the image

The American Association of Critical Care Nurses published the AACN Standards for Establishing and Sustaining Healthy Work Environments: A Journey To Excellence in 2005. In it, they identify the factors necessary to create and sustain a work environment that empowers nurses to deliver the best care possible. As you read through it, critically think about which standards your institution or unit meet, and which might be areas for improvement.



5. Keeping Patients Safedescribe the image

The Insitute of Medicine recognizes the relationship between a healthy work environment for nurses and optimal patient care outcomes. In Keeping Patients Safe, the IOM provides recommendations that address adequate staffing, trust in organizations, and other “bundles of change” that will ensure an optimal environment for nurses to do the jobs required of them.


Doctor shortage may not be as bad as feared, study says


Kelly Kennedy, USA TODAY

describe the image

New roles for nurse practitioners and physician assistants may cut a predicted shortage of physicians by about 50%, according to a new study released Monday.

The surge in new patients covered by health insurance that will be sparked by the Affordable Care Act has led to predictions that there will be a shortage of 45,000 primary care physicians by 2025, about 20% less than the predicted demand, said David Auerbach, a policy researcher at the Rand Corp., a non-profit policy think tank that conducted the study published Monday in the journal Health Affairs.

Those studies, Auerbach said, were based on the assumption that health care practices would not change how they operate and ignore provisions in the 2010 law that allow the creation of nurse-managed health centers and medical homes that could relieve physicians of some of their caseload. Technology improvements, also spurred by the law, could also relieve part of the shortage, he said.

"The story has been, 'There's a looming physician shortage, and the Affordable Care Act's going to make it worse, so what are we going to do?" Auerbach said. "But even policy-makers looking at those numbers don't realize they're coming from a static, unchanging way of how we deliver care."

A surplus of 34,000 nurse practitioners, about 48% above demand, and 4,000 surplus physician assistants will help relieve the doctor shortage, Auerbach and his research team found.

Two elements are critical to relieving the shortage, Auerbach said:

• Medical homes. A group of people working together to provide care. A physician, physician assistant or nurse practitioner leads the team of doctors, nurses, pharmacists, nutritionists and social workers using electronic health records and care coordination. Each team can care for larger numbers of patients than a doctor could on his or her own.

• Nurse-managed health centers. These are centers managed by nurses consisting of nurse practitioners. Usually, they are affiliated with academic medical centers, and they often provide specialty care to low-income populations.

"I think these changes can matter quite a lot," Auerbach said. "It's sort of a given: If you use nurse-managed health centers, you're not using a lot of doctors. But patient-centered medical homes, I guess we really didn't know the outcome."

So far, Auerbach said, researchers have seen positive examples of how the changes can work, but they need more analysis.

The new health law promotes these models because they save money, and has provided up to $50 million in direct grants to support nurse-managed health centers. And there are pilot programs for Medicare and Medicaid patient-centered medical homes. The authors said states may need to "liberalize" scope-of-practice laws for nurse practitioners and physician assistants to fill those roles, as well as supply more nurses and aides.

The American Association of Nurse Practitioners is launching a new advertising campaign to try to push for those opportunities, as well as to help people understand what nurse practitioners do.

According to the American Academy of Physician Assistants, 60 new physician assistant programs were waiting for accreditation as of May, and they expect 10,000 new physician assistants by 2020.

Source: USA Today

IOM, RWJF leaders assess progress since 'Future of Nursing' report


Despite “measurable progress” in the three years since the release of the Institute of Medicine’s landmark report on the future of nursing, more work remains “to fully realize the potential of qualified nurses to improve health and provide care to people who need it.”

That assessment is part of a commentary by Harvey V. Fineberg, MD, PhD, president of the IOM, and Risa Lavizzo-Mourey, MD, MBA, president and CEO of the Robert Wood Johnson Foundation, on the aftermath of the report.

“The Future of Nursing: Leading Change, Advancing Health” was released Oct. 5, 2010, by the IOM with the support of RWJF. It provided a blueprint for transforming the nursing profession to “respond effectively to rapidly changing healthcare settings and an evolving healthcare system,” according to a report brief.

The key recommendations: allow nurses to practice to the full scope of their education and training, provide opportunities for nurses to serve as healthcare leaders and increase the proportion of nurses with a BSN to 80% by 2020. Following the report, RWJF and AARP formed the Campaign for Action to implement the report’s recommendations at the state level. 

Regarding scope of practice for advanced practice registered nurses, Fineberg and Lavizzo-Mourey wrote that 43 state action coalitions have prioritized initiatives to remove scope-of-practice regulations that prevent APRNs from delivering care to the full extent of their education and training. Iowa, Kentucky, Maryland , Nevada, North Dakota, Oregon and Rhode Island have removed barriers to APRN practice and care, and 15 states introduced bills this year to remove physician supervision requirements that can hinder APRN care.

Regarding education and training, the proportion of employed nurses with a BSN or higher degree was 49% in 2010 and 50% in 2011. “Progress is likely to accelerate in the years to come,” Fineberg and Lavizzo-Mourey wrote, “because between 2011 and 2012 along there was a 22.2% increase in enrollment in RN-to-BSN programs and a 3.5% increase in enrollment in entry-level BSN programs.” The authors also noted a recent increase in the number of students enrolled in nursing doctorate programs. Of the 51 action coalitions, 48 have worked to enable seamless academic progression in nursing.

The authors noted that the influence of the campaign has paid off with a $200 million Medicare initiative to support the training of APRNs at hospital systems in Arizona, Illinois, North Carolina, Pennsylvania and Texas.

Regarding nurse leadership, Fineberg and Lavizzo-Mourey wrote, the “Campaign for Action has tapped established and emerging nurse leaders across the nation and is working to provide them with opportunities for networking, skills development and mentoring. A key strategy is to advocate for more nurses to serve on hospital boards.” 

Full commentary:

Campaign for Action:

“Future of Nursing” report:

Graduate Nurse Education Demonstration:


Nurse Leaders at the Forefront of Patient Engagement Efforts


By Debra Wood, RN

To achieve the national goal of improved health outcomes, many researchers and health advocates agree that patients must assume a greater role in managing their health

Debi Sampsel: Customized, patient-centered care enhances patient engagement.

care. But how can facilities and health systems accomplish this kind of patient engagement? The answer may rest with nurses and nurse leaders, who have long overseen patient education about how to care for chronic conditions and make lifestyle changes to improve health.

“Promoting patient education has always been a part of our nursing role and obligation to the
patient,” said Debi Sampsel, DNP, MSN, BA, RN, chief officer of innovation and entrepreneurship at the University of Cincinnati’s College of Nursing in Ohio. “It has been a long-standing practice that nurses involve the patient across the life span in their own care.”

Sampsel finds nurses strive to and take great pride in promoting healthy lifestyles. And research has demonstrated that active, engaged individuals have far better health outcomes. The University of Cincinnati includes health promotion in the nursing curriculum and gives students an opportunity gain patient-engagement experience while working with the homeless and elementary and secondary school age youth.

“What’s new is old,” added Patrick R. Coonan, EdD, RN, NEA-BC, FACHE, dean and professor at the College of Nursing and Public Health at Adelphi University in Garden City, N.Y. “I went to nursing school 35, 40 years ago and what did they teach but to be the patient advocate, to teach the patient. But we got away from that in the last few decades.”

Patrick Coonan: Nurses should capitalize on teachable moments for patient engagement.Coonan pointed out that today’s consumers and patients, particularly baby boomers, are better informed. They often turn to the Internet for facts, but he called it a nursing professional’s obligation to verify whether the online information is accurate. Boomers are not going to settle for a paternalistic “Just take this pill” without knowing why and how it will benefit them. And that often falls to the nurse.”

“We have to get away from the patient-doctor or patient–nurse relationship that is almost like a parent–child relationship, in existence for many years, to a more informed and empowered [consumer] who will take responsibility for their health,” said Rosemary Glavan, RN, MPA, CCM, senior vice president of clinical operations at AMC Health, a telehealth provider based in New York. “Baby boomers have been go-getters and always wanted to be in charge. They want to be empowered.”

Advocating with a personal connection

“As patient advocates, nurses and nurse leaders play a key role in promoting patient engagement,” said Cynthia M. Friis, MEd, BSN, RN-BC, associate association executive for SmithBucklin’s healthcare and scientific industry practice in Chicago. “Nurses are privileged withCynthia Friis: Nurse leaders can help nurses achieve patient engagement goals. having the opportunity to spend more time with the patients to assess, plan, implement and then help clarify the plan of care with the patient and his/her family or caregivers. Nurse leaders are key in helping to ensure this role is realized. Nurses can do their jobs better with the full support of our nurse leaders.”

Nurses ask questions, she added, and draw patients into thoughtful discussions about their care, helping them move forward when they feel overwhelmed and understand how to best care for themselves.

Establishing principles of engagement

Patewood Memorial Hospital in Greenville, S.C., participated in a national study by the Agency for Healthcare Research and Quality (AHRQ) and in the development of theGuide to Patient and Family Engagement in Hospital Quality and Safety.

Recommendations in the AHRQ guide include:

Working with patients as advisors;
Communicating effectively; 
Giving bedside shift reports, where nurses do not talk with each other but involve the patient and family members he or she wants to participate; and 
Engaging patients in transitions to home.

The hospital has experienced improvements to its HCAHPS (Hospital Consumer Assessment of Healthcare Providers and Systems) survey since implementing the program.

Kerrie Roberson: Patient engagement required for patient-centered care.“The patients and families are much happier,” said Kerrie Roberson, MBA, MSN, RN-BC, CMS, nurse educator at Patewood. “Patient engagement is a partnership with the patient and families, and they trust you more when they see you are open about their care.”

Nurses at Patewood are leading discussions about patient engagement across the Greenville Health System and have begun sharing their experiences with others.

Other nurses gathered to develop Guiding Principles for Patient Engagement, released last year by the Nursing Alliance for Quality Care (NAQC), which was supported by the Robert Wood Johnson Foundation.

Principles in the NAQC guide include:

• Having a dynamic partnership with patients and their families; 
• Respecting boundaries; 
• Maintaining confidentiality; 
• Adhering to responsibilities and accountabilities; 
• Recognizing patients able to engage; 
• Appreciating patient rights; 
• Sharing information and decision making; and 
• Advocating for the patient.

“Patient-centered care and engaging patients is very important to improving quality outcomes, which includes reducing cost and better health of populations in the community, but also reductions in disparities of care,” said Maureen Dailey, PhD, RN, CWOCN, senior policy fellow for nursing practice and policy at the American Nurses Association (ANA), a member organization of the NAQC. “The patient is at the center of the team and must assume accountability for self-care and part of the outcome. But that evolution has yet to take place.”

Nurses must instill confidence and competence in patients’ self-care, Dailey explained. And patients need nurses to provide knowledge, support and symptom management.

“Nurses hold a central role in patient engagement,” Dailey concluded.

Combing nursing skills with technology

Along with the personal touch, many nurses are finding technology can assist with their patient-engagement efforts.

“As the responsibility of nursing advances to one of building and sustaining patient activation and the role of nursing moves to be more consultative across care settings, technology will play a vital role for both the nurse and the patient,” said Karen Drenkard, PhD, RN, NEA-BC, FAAN.

Drenkard, who has served as executive director of the American Nurses Credentialing Center (ANCC) and past director of the ANCC Magnet Recognition Program, will join GetWellNetwork in January as chief clinical/nursing officer, where she will lead the development of a nursing model of patient engagement. Her responsibilities will include studying and designing new ways to assess and improve patient activation through clinical practice and technology solutions across all care settings.

“Nursing can use interactive patient care technology to proactively engage the patient and shift the responsibility for completing certain care interventions,” said Drenkard, explaining patients can document daily signs and symptoms. Care providers use the network to send reminders about taking medications or the need for follow-up visits to their physician when data and input from the patient indicates the need to do so.

Karen Drenkard: Patient engagement starts with the nurse-patient relationship.

Analytics spot trends, and nurses can intervene at the first sign of trouble with a personal follow-up. The data also helps them identify where the patient is on the readiness scale of change.

“To be most effective in engaging patients and more so activating patients, the nursing role
must evolve and develop,” Drenkard concluded. “The need for change and adaptation is certainly not new to our profession. However, there is a pivotal opportunity today to shift the role of the nurse away from a more task-oriented, episodic care management function to one that more centered on building, sustaining a care management relationship with a population of patients with the effective use of interactive patient care technology.”

© 2013. AMN Healthcare, Inc. All Rights Reserved.

Source: AMN Healthcare

In Healthcare, Diversity Matters


by Crystal Loucel

Because minorities are more likely to receive less and lower-quality health care and suffer higher mortality rates from cancer, heart disease, diabetes, HIV/AIDS and mental health illnesses than their Caucasian counterparts, there have long been calls to increase the number of minority providers to reduce these health disparities. Numerous studies have shown that patients are more likely to receive quality preventive care and treatment when they share race, ethnicity, language and/or religious experience with their providers.

The 2010 Institute of Medicine report The Future of Nursing: Leading Change, Advancing Health found that a diverse workforce – and the diverse perspective it provides – contributes to enhanced communication, health care access, patient satisfaction, decreased health disparities, improved problem solving for complex problems and innovation. Moreover, the Health Resources and Services Administration (HRSA) has found that minorities could improve access to care in underserved areas more than nonminority providers (see The Rationale for Diversity in the Health Professions: A Review of the Evidence [HRSA, 2006]).

Yet minorities are still under-represented in the health care workforce generally and in nursing in particular. In 1908, when Israel Zangwill popularized the term melting pot to describe the American population, it was 89 percent white, 10 percent black and less than 1 percent Indian, Chinese, Japanese and “others.” Today’s melting pot is considerably more diverse, composed of more than one-third racial and ethnic minorities; moreover, the United States Census Bureau expects that portion to be more than half by 2050.

“Today the nursing workforce does not adequately reflect the diversity in the population including gender,” says Beverly Malone, CEO of the National League for Nursing. Latinos, African Americans, American Indians and Native Alaskans compose only 7.6 percent of the nursing workforce, a dismal figure compared to the 25 percent in the general population. UCSF’s nursing student population is doing a bit better – in 2009, the latest year for which data are available, these same groups composed 16 percent of the UCSF nursing student body – but there is certainly room for improvement. When Asian Americans are included, a 2008 HRSA report showed that minorities make up 35 percent of the total population but only 17 percent of the nursing population.

UCSF has been trying to respond to the 2004 Sullivan Commission Report, titled Missing Persons: Minorities in the Health Professions, which recommended that health profession schools hire diversity program managers and develop plans to ensure institutional diversity, including providing educational support, commitment, role modeling and dedicated recruitment. Currently, Judy Martin-Holland serves as associate dean for Academic Programs and Diversity Initiatives at UCSF School of Nursing, a role in which she recruits minority students, seeks to integrate more diversity in the curriculum, and offers support programs for minority students. In addition, after years of medical student advocacy, Renee Navarro, vice chancellor Diversity and Outreach, created the School’s first Multicultural Resource Center. Though the center currently has no budget, its director, Mijiza Sanchez, hopes to advocate for the types of programs that the commission has recommended, such as the mentoring that Sanchez herself offers students.

It’s also important to remember that minorities often face barriers to financing their education and would benefit from scholarships, loan forgiveness and tuition reimbursement programs.

In addition, universities should link to minority professional organizations to promote enhanced admissions policies, cultural competency training and enhanced minority student recruitment. For example, as volunteer past president of the San Francisco Bay Area chapter of the National Association of Hispanic Nurses (NAHN), I am proactively connecting to the UCSF student group Voces Latinas Nursing Student Association (VLNSA) to do just that. VLNSA is open to students of all ethnicities who are interested in working with the Latino community; the ability to speak Spanish is not required. And organizations like NAHN typically offer reduced student membership and benefits such as mentoring, résumé revision, job postings, volunteer opportunities, networking and more for students, without requiring them to be from any particular racial or ethnic background.

That last point is important, because no matter how diverse your workforce, the goal is to create an environment that is inclusive and allows everyone to express themselves. As minorities, we cannot address our specific health issues alone; rather, this is a challenge for all health care providers. Given what we know about diversity and its importance to health care, we must partner to creatively address and embrace an ever more diverse future.



Crystal Loucel is a second-year master’s student at UCSF School of Nursing and past president of the San Francisco Bay Area chapter of the National Association of Hispanic Nurses. She has a master’s in public health, specializing in global health, from Loma Linda University; has served as an AmeriCorps and Peace Corps volunteer in Honduras; was one of eight RNs chosen in 2012 for a General Electric-National Medical Fellowship in primary care; and is a 2012 scholarship recipient from the Deloras Jones Kaiser Foundation. An earlier version of this piece appeared in the UCSF student newspaper, Synapse.

A New Nurse Role for a New Era


Faced with a shift in the healthcare landscape toward outcomes-based practices and quality improvements, the American Association of Colleges of Nursing (AACN) sought to update the scope of nursing practice with a new master's prepared role: the clinical nurse leader (CNL).

The first new nursing role in over 35 years, the CNL grew out of the 1999 Institute of Medicine report "To Err is Human" which challenged care providers to reduce medical errors and focus on patient safety. 

Rising to the challenge, the AACN initiated an investigation into the barriers to improved care delivery and in 2005 introduced the new role as a way to prepare nurses to thrive in the changing healthcare system, according to the AACN website. For many, it couldn't have come at a better moment.

"We are at a pivotal time for the role," said Bob LaPointe, MS, MSN, RN, CNL, president, Clinical Nurse Leader Association (CNLA), and MICU staff nurse at Penn Presbyterian Medical Center, Philadelphia. 

"Healthcare is increasingly complex, and we need leaders who are trained in complexity theory to be able to navigate that and understand it to have better patient outcomes and that's what clinical nurse leaders are uniquely trained to do."


As defined by the CNLA, the CNL is an advanced clinician who serves at the point of care as the lateral integrator, facilitating, coordinating and overseeing care within the unit while also collaborating across the healthcare continuum.1 The CNL is trained to facilitate evidence based care at the bedside and ensure positive outcomes for even the most complex patients. Such training, especially these days, is a great option for nurses of all kinds looking for a way to make a difference at the bedside.

"The role really is about improving clinical outcomes-improving the care of the patient as well as improving financial outcomes," said Tracy Lofty, MSA, CAE, director, Commission on Nurse Certification (CNC), an autonomous agency of AACN, Washington, DC. "Regardless of practice setting, the ultimate goal is to improve outcomes, so really everyone benefits from the role."

When Veronica Rankin, MSN, CNL, Carolinas Medical Center, Charlotte, N.C., decided to go back to school, she chose to do so through a CNL program after her facility's assistant vice president introduced the role at a town hall meeting. Since graduating in 2011, she and her fellow CNLs have been making a huge difference for patients, colleagues and the hospital as a whole.

"We bring that continuity of care back to the bedside, so that even though the nurses may change every shift every day, you are still going to have the same clinical nurse leader Monday through Friday taking care of that patient," Rankin said. 

"It has given me the opportunity to stand back and see the big picture of my patients' journey. I can get in there and see, 'OK, out of everyone that is involved in this patient's care, we have all these hands in this pot, what are we missing and where are the bridges I need to help connect?'"

Rankin's ability to streamline care and improve both patient and hospital outcomes comes directly from her training, and nurses and facilities across the nation are starting to see the difference CNLs can make on a unit-by-unit basis.

"When you take a policy and implement it in your unit, in your hospital, in this city, with the resources you have available, it can be the best evidence based practice out there," LaPointe emphasized. "But we have to apply it to our patients and our staff as well, and that's really where the clinical nurse leader's role really comes into play. How does this make sense for us as a unit, and for our patients."


Since the pilot program that tested in the fall of 2006, more than 2,500 nurses have earned CNL certification from CNC. Part of the success, according to LaPointe, is the fact that anyone inspired to become a CNL can do so.

"Nursing has always had multiple points of entry, which leads to lots of people being able to do it, but it also leads to lots of variability about the training and preparation," LaPointe said. "There is so much more to know and healthcare is so much more complex, that to have training in complexity theory, change management and in the science of outcomes, that's going to be good for anybody."

To make the CNL educational track available to nurses already practicing as well as those looking to get into the field, the AACN created five different models so that regardless of educational background, there is an entry into a CNL education program. The five models are:

  • Model A - Master's degree program designed for BSN graduates
  • Model B - Master's degree program for BSN graduates that includes a post-BSN residency that awards master's credit
  • Model C - Master's degree program designed for individuals with a baccalaureate degree in another discipline
  • Model D - Master's degree program designed for ADN graduates (RN-MSN)
  • Model E - Post-master's certificate program designed for individuals with a master's degree in nursing in another area of study2

Following graduation of a CNL education program, licensure as a registered nurse, and successful completion of the CNL Certification Exam, candidates may be awarded the CNL credential.

With the role gaining momentum, the CNC decided to revamp the certification exam in 2012 to make sure it reflected the basic competencies of a CNL.

"The new exam is based on a CNL job analysis study that was completed in 2011, so the exam reflects the knowledge, skills and abilities of a competent CNL," Lofty said. "It's all about application, so you may be in an educational program, but then you need to be able to apply the knowledge, and that is demonstrated on the exam."



As new CNL graduates start the search for the right clinical setting, they need to keep in mind that some healthcare organizations have yet to fully integrated the clinical nurse leader into their staffing model.

"There are many healthcare institutions specifically recruiting to full clinical nurse leader positions," said Lofty. "For other institutions, it may not be that title, there may be a different title like care coordinator, or they are still looking for someone with the same skill set and they are still hiring individuals with those competencies and perhaps applying them to other positions."

But CNLs need not worry about their job prospects, because their CNL skills are valuable in just about every care setting. According to a 2012 survey conducted by the CNC, 96% of the respondents indicated that they apply their CNL knowledge in their current role, 92% feel they are an important member of their team and 87% said they are valued as an employee because they are a CNL.LaPointe knows from personal experience just how useful being a CNL can be regardless of job title.

"I am not functioning in a job that is called 'CNL' right now, and that is true for many people who currently have the certification," LaPointe said, who was confident he would still use his training despite not being hired specifically as a CNL. "I helped write our successful Beacon Gold application, I was very involved in our hospital's first Magnet designation, I am on the evidence based practice committee for the hospital, and the chair of our unit-based council as part of the shared governance structure of the MICU, so I am using this stuff all the time."

Next Steps

No matter where CNLs end up, they are sure to improve care coordination, communication and hospital-wide outcomes.

"You are basically in there improving care for nurses, patients, and physicians," Rankin said. "You are improving care delivery and the receiving of care for the patient population, so you are in there with your hands so much."

"Bring evidence based practice to your unit to show what the worth of the role is," Rankin advised nurses considering the CNL role. "In the end we are also taught that the clinical nurse leader is the guardian of the nursing profession, so we have to get in there and be the guardian. I would say, go for it, go hard, and be a guardian for the nursing profession."

Source: Advance for Nurses 

DiversityInc Top 10 Hospital Systems Lead HRC Healthcare Equality Index


By Chris Hoenig

DiversityInc Top 10 Hospital Systems lead the HRC's 2013 Healthcare Equality Index.When it comes to understanding the needs of diverse communities, including the LGBT community, not all hospitals are the same. Improving patient outcomes by providing culturally competent care is the focus of a DiversityInc healthcare summit this September, including presentations on equitable care and improved outreach to the LGBT community.

The Human Rights Campaign, which will present at the event, released its 2013 Healthcare Equality Index this month, a measurement of equality in care and employment for LGBT patients and practitioners. Seven of DiversityInc’s Top 10 Hospital Systems earned HRC’s highest rating.

To qualify as an HRC “Leader in LGBT Healthcare Equality,” facilities had to be able to provide documentation proving that they meet guidelines in four core criteria: patient nondiscrimination policy, equal visitation rights, employment nondiscrimination policy and training in LGBT-patient-centered care. The core criteria are further broken down into more specific actions, such as making sure that patient and employee nondiscrimination policies include both the term “sexual orientation” and “gender identity,” and that these policies are communicated to patients and visitors in “at least two readily accessible ways.” A hospital had to comply with every guideline to be designated as a Leader.

The DiversityInc Top 10 Hospital Systems

A total of 24 facilities owned and operated by companies in the DiversityInc Top 10 Hospital Systems achieved Leader status.

University Hospitals (No. 1 in the DiversityInc Top 10 Hospital Systems) has 10 facilities on the list. “We have made it a corporate priority and a strategic business process to nurture and strengthen a culture of diversity and inclusion, both within our system and across our community,” CEO Thomas Zenty III says. The system’s Ohio-based Leader facilities include: UH Ahuja Medical Center, UH Bedford Medical Center, UH Case Medical Center, UH Conneaut Medical Center, UH Geauga Medical Center, UH Geneva Medical Center, UH MacDonald Women’s Hospital, UH Rainbow Babies and Children’s Hospital, UH Richmond Medical Center and UH Seidman Cancer Center.

Henry Ford Health System (No. 2) has six Michigan-based Leader facilities. “Our rich diversity makes us a better company and helps us connect with the healthcare needs of our patients and their families,” CEO Nancy Schlichting says. Henry Ford Behavioral Health Services, Henry Ford Hospital, Henry Ford Macomb Hospital, Henry Ford Medical Group, Henry Ford West Bloomfield Hospital and Henry Ford Wyandotte Hospital all received Leader rankings.

Continuum Health Partners (No. 4) has two New York City hospitals on the list: Beth Israel Medical Center and St. Luke’s–Roosevelt Hospital Center. In addition to site diversity councils and subcommittees, Continuum also has an LGBT communities resource group.

North Shore–LIJ Health System (No. 9) is represented by three New York hospitals. On the DiversityInc rankings for the first time, North Shore–LIJ is known for its outreach to the LGBT community, which has also been recognized by the HRC. Lennox Hill Hospital, Southside Hospital and Staten Island University Hospital all achieved Leader designation in the HEI.

Massachusetts General Hospital (No. 7), Rush University Medical Center (No. 8) and University of New Mexico Hospitals (No. 10), all rated as single facilities, also achieved a perfect four-for-four and are therefore recognized as Leader hospitals by the HEI.

Two Cleveland Clinic (No. 3) facilities—its main campus in Ohio and Cleveland Clinic Florida—narrowly missed the HEI Leader list, gaining approved rankings in three of the four core criteria.

While not included in DiversityInc’s Top 10 Hospital Systems, Kaiser Permanente—a larger healthcare provider that ranks No. 3 in the DiversityInc Top 50—is well represented among HEI Leader facilities. Thirty-eight Kaiser properties in three states—California, Hawaii and Oregon—are recognized in the HEI.

More to Learn

A 2010 Lambda Legal study, quoted by the HEI, noted that 29 percent of lesbian, gay and bisexual patients fear they will be treated differently by medical personnel, while that number rose to 73 percent for transgender patients. More than half of transgender patients (and 9 percent of lesbian, gay and bisexual patients) fear they will be refused care because of their sexual orientation or gender identity.

These statistics highlight the need for improved patient experiences in the LGBT community at the times of greatest need. The Supreme Court’s ruling on the Defense of Marriage Act opens up spousal healthcare benefits for federal employees, but while some financial fears are eased, the care LGBT patients get for the money remains a concern.

The Human Rights Campaign and University Hospitals will offer more detail on the HEI and how to develop successful outreach programs for the LGBT community at Culturally Competent Healthcare: How Diversity Creates Better Outcomes , DiversityInc’s event on Sept.24 in Newark, N.J. Guest presenters include Donnie Perkins, Vice President, Diversity & Inclusion, University Hospitals, and Shane Snowdon, Director, Health and Aging Program, Human Rights Campaign.


Source: DiversityInc

Reflections on diversity


describe the imagedescribe the imageBy Heather Stringer

By 2043, the U.S. is projected to become a majority-minority nation for the first time in its history, according to the U.S. Census Bureau. Both the Hispanic and Asian populations will more than double between 2012 and 2060, and the black population will increase by 50% during the same time period. These statistics illustrate that nurses will be caring for a progressively diverse patient population and the increasing urgency to build a diverse RN workforce. 

“Patients come with an expectation that the caregiver will understand all of their care needs,” Deidre Walton, RN/PHN, MSN, JD, president and CEO of the National Black Nurses Association based in Silver Spring, Md., said. “When you have a diverse workforce, you have people with knowledge and skills to meet the diverse needs of patients. The patient’s cultural identification, spiritual affiliation, language and gender can all affect the care they need, and it is very important that the nurse understands that.” 

Although Walton said the healthcare community is far from reflecting the demographics of the American population, she has hope as she looks into the future because diversity in the nursing workforce is being highlighted as a critical priority by more than minority nursing organizations. 

“I am excited because organizations such as the Robert Wood Johnson Foundation and AARP have a diversity agenda, and that makes me hopeful that there will be change,” she said.

Increasing diversity in the workforce, as illustrated on the following pages, will take individual and group efforts. 

Job titles of minority nurses

According to the 2008 National Sample Survey of Registered Nurses, the largest sample to date, minority nurses were more likely to hold staff nurse positions than white, non-Hispanic nurses.

Black nurses comprise 5.4% of the RN workforce, and 13.8% are in management positions, which is higher than any other ethnic group. Walton, however, said far more black nurses still are needed in leadership positions because this 13.8% is taken from a small pool of nurses. 

“Some organizations have very active programs to promote diversity in leadership, but the diversity gap in leadership continues,” Walton said. “There is a gap between how many minorities are recruited and how many are actually hired. These minorities in leadership roles are able to participate in making changes to improve the practice environment and outcomes, and this is very important.” 

Percentage of RNs in staff nurse positions by race/ethnicity:
White, non-Hispanic: 64.8%
Black: 67.1%
Hispanic: 72%
Asian: 83%

RNs in management, by race/ethnicity:
12.9% of White, non-Hispanic RNs
13.8% of Black RNs 
10.9% of Hispanic RNs
7.2% of Asian RNs 

Distribution of RNs by race/ethnicity vs. national population demographics:
White, non-Hispanic: 83.2% vs. 65.6%
Hispanic, Latino: 
3.6% vs. 15.4%
Black: 5.4% vs. 12.2%
Asian or Native Hawaiian/Pacific Islander: 
5.8 % vs. 4.5%
American Indian/Alaska Native: 
0.3% vs. 0.8%

(Source: 2008 National Sample Survey of Registered Nurses)

Can patient ethnicity affect care?

According to a 2012 report from the Agency for Healthcare Research and Quality, racial and ethnic minorities face more barriers to care and receive poorer quality of care when they can get it. Findings from the report included:

Blacks received worse care than whites, and Hispanics received worse care than non-Hispanic whites for about 40% of quality measures.

American Indians and Alaska Natives received worse care than whites for one-third of quality measures.

Blacks had worse access to care than whites for one-third of measures, and American Indians and Alaska Natives had worse access to care than whites for about 40% of access measures.

Hispanics had worse access to care than non-Hispanic whites for about 70% of measures. 

Would a more diverse RN workforce correct some of these disparities? "Absolutely,” Walton said. “Diversity will improve patient-nurse communication, collaboration and clinical practice for patients of all backgrounds. If an African-American woman comes to the ED with abdominal pain, what is the likelihood that she will be diagnosed with a sexually transmitted disease as the cause of the pain rather than [staff] conducting other tests for a definitive diagnosis? When you have a culturally diverse RN workforce, they may not as easily dismiss symptoms and will advocate for a more intense work-up.” 

According to the 2008 National Sample Survey of Registered Nurses, only 0.3% of the RN workforce is American Indian or Alaska Native. This small percentage who are accepted into nursing school, earn their degree and enter the workforce often have overcome significant challenges, Bev Warne, RN, MSN, one of the founders of the Native American Nurses Association based in Phoenix, Ariz., said. “A survey in 2010 showed that 51% of Native American high school students graduate, so the drop-out rate is very high,” Warne said. “There are complex reasons for this. Studies show that many grow up in families that are poverty-stricken, so they suffer from poor nutrition and difficult family situations, and by the time they are in junior high they are already behind.” 

Warne believes the preparation to attain a formal education begins with good prenatal care, proper nutrition and support for parents. Even after Native Americans are accepted into nursing school, there are other challenges they may face.

“There are differences in values among Native people and Western people,” Warne said. “Generally Native Americans are raised in more of an extended family where there is an emphasis on inclusiveness. When they go into the college setting outside the reservation, they may confront Western values that promote individualism and competition, which is often the opposite of how they were raised. To be successful in this new setting, it is important for educators to get involved with students to discuss this new reality.”

It also can be difficult to transition to the Western medicine paradigm, Warne said. “In the Western hospital setting, caregivers tend to look more toward the physical aspects of illness, but from the Native perspective, they are accustomed to a holistic way of viewing a person.” 

Power to promote

Although it may seem difficult to make time to promote nursing to minorities within the community, here are a few simple strategies that are making a difference. 

Celia Besore, executive director and CEO, National Association of Hispanic Nurses: 
“I believe stories are really what lead people to consider nursing. The personal stories of nurses who were maybe the first to go to college in their families and now are very successful are the ones that inspire people. Our chapter members go into the community and do career fairs and visit schools, and that is when nurses can share their stories. There have been times when people have discouraged Hispanic students from going to nursing school because they think the students will not succeed, and our nurses can give them hope. We also tell young people that 30% of our members are student nurses, so they know they will not be alone.

“During these events, we also explain that now is a good time to be a minority in healthcare,” she continued. “We get calls from places that are desperately looking for Latino nurses. The word is starting to get out that it is an asset to understand the culture and language of minority patients, and hospitals want people with this experience.”

Mildred Crear, RN, MA, MPH, chairwoman for nursing and community education, Bay Area Black Nurses Association:
“Our chapter sponsors community health events like blood pressure drives, and this gives people in the community a chance to see us and ask what it takes to be a nurse. We share this information and then invite them to our meetings. We also do a lot of health fairs with churches and black sororities and fraternities where we do presentations about nursing, and this has been a really effective way of promoting the profession.”

Sharon Smith, RN, MSN, FNP-BC, president of the San Diego Black Nurses Association:
“I think it is critical to connect with people when they are young and try to mentor them. You can meet youth through church, in the community or through the events sponsored by your minority association. Our chapter visits high schools to recruit students, and we will go into the tough neighborhoods where it is harder for students to believe that they can do it. I share my own story that I grew up in North Carolina in one of the poorest counties, and I was told I would never finish high school. I told myself, ‘This is your thought, and not mine,’ and I went on to earn a BSN, a master’s degree and now I am pursuing a doctorate. You can do simple things like take them to work or communicate online, and this will show students the positives of a career in nursing.” 

It starts in the schools

Diversity in the nursing workforce is dependent upon a pipeline of diverse students who graduate from nursing school. This much-needed diversity among students, however, requires focus and resources, Julie Zerwic, RN, PhD, FAHA, FAAN, professor and executive associate dean at the University of Illinois at Chicago, College of Nursing, said. “Our school went through a period of time when there was no staff focused on watching diversity, so the number of underrepresented minorities in the program dropped,” she said. “If no one is paying close attention, you can lose momentum.” 

For example, the school recognized that a number of underrepresented minorities were not finishing their applications and would benefit from having a staff member available to receive phone calls and answer questions. The school also started offering application workshops. 

Although Zerwic hopes to see even more diversity among undergraduate nursing students, her institution has had significant success in recruiting graduate minority students. Zerwic credits a National Institutes of Health-funded program, the Bridges to the Doctorate Program, that helps the school to support potential minority doctoral students through mentoring, funding and coursework. 

University of Illinois at Chicago, College of Nursing, 2012-13
Undergraduate - black students: 10.2%
Undergraduate - Latino students: 9.6%
PhD - black or Latino students: 25%

Like the University of Illinois, diversity became a high priority in the School of Nursing at The University of Texas Health Science Center. “We knew that about 62% of the population in San Antonio was Hispanic, and to provide competent healthcare we needed to increase the number of Hispanic nursing students,” Hilda Mejia Abreu, PhD, MS, BA, associate dean for admissions and student services at UTHSC San Antonio, said. 

During the spring and fall, staff members travel throughout the U.S. to college fairs, schools, nursing association recruitment fairs and other activities to recruit minority students. The local Spanish-language channel also regularly features a 15-minute segment in which Mejia Abreu explains the college preparatory classes needed to apply for nursing school and how to finance an education. 

School of Nursing at the UT Health Science Center 
San Antonio, Spring 2013
Black: 5.2% • Hispanic: 32.3%
Asian: 10.7% • White: 45%

By comparison, below are the national diversity statistics for nursing schools:

Race/Ethnicity of Students Enrolled in Entry-Level 
Baccalaureate Nursing Programs in the U.S. in 2011
White, non-Hispanic: 72%
Black: 10.3%
Hispanic: 7%
Asian, Native Hawaiian or other Pacific Islander: 8.8%
American Indian or Alaskan Native: 0.5%

(Source: American Association of Colleges of Nursing) 

Overcoming the language barrier

For nurses who have arrived in the U.S. as adults and learned English as a second language, there typically are two distinct challenges they will face when communicating: being understood by Americans and understanding Americans, said Victoria Navarro, RN, MSN, MAS, president of the Philippine Nurses Association of America. 

“In the Philippines, we were colonized by Spain for about 400 years, so the Filipino language (Tagalog) that evolved has root words based in Spanish,” Navarro said. “We pronounce every syllable. In English, you have words with silent syllables or letters, so that in itself is something that we need to learn.” 

In addition to pronunciation, healthcare workers use jargon to communicate, and this is even more complicated when English is a second language. Navarro remembers when a physician told a Filipino nurse to get the “lytes.” The nurse turned off the lights, when in fact he had meant electrolytes. Other communication challenges Filipino nurses confront in the U.S. include:

In Tagalog, there are no long vowels, so it takes time and practice to learn to pronounce these sounds. 

There are no pronouns such as ‘he’ and ‘she’ in Tagalog, and there are no singular or plural verbs. It takes time to know when to say the proper pronoun or verb. Many people make mistakes initially.

Mental processing in the native language happens before responding in English. The literal translation from Tagalog to English could change the intent of the sentence.
In the Philippines, people have high respect for elders and do not speak unless they are asked something directly. For this reason, Filipino nurses may be considered passive by peers or patients. 

Navarro and Joseph Mojares, RN, BSN, president of the Philippine Nurses Association of Northern California, say proficiency can come with practice and time and made the following suggestions:

Do not be embarrassed to ask questions to clarify what others mean so you can learn the correct pronunciation and terminology.

Constantly immerse yourself in English-speaking environments and expose yourself to mainstream media at work and at home. 

Challenge yourself by taking classes in communication, leadership and public speaking so you can improve your English. 

Find mentors and preceptors who can encourage you and give you suggestions about how to present yourself and communicate. 

Tips for scholarship success

Jasmine Melendez, the scholarships and grants administrator at the Foundation of the National Student Nurses Association, has an insider’s view into the world of financial assistance. She has seen hundreds of scholarship applications, and said reviewers are looking for three things from applicants: financial need, high academic achievement and involvement in community health activities. 

“It is important to maintain a high GPA, but students who make time for some form of community service really set themselves apart,” Melendez said. 
Another way to stand out from the competition is to turn in well-crafted, accurate essays. “What I’ve been noticing is that students need to learn to write well,” she said. “When you convey a message, you want to make sure you convey it in a clear, concise manner with no spelling errors or grammar mistakes.” 

Here are other tips she suggests:

Get comfortable with the Internet because most scholarships are found on the Web. Websites that can help minority students find scholarships include: 

Check with minority-owned businesses to see whether they offer scholarships, and ask the financial aid office at your school about scholarships and applications.

The hospital association in your state may have access to scholarship information.

Don’t make the mistake of thinking scholarship deadlines are only in the first part of the year. There are scholarships available every quarter of the year.

Don’t disqualify yourself by not applying. Apply for everything and let the committee say no. 


Prescription for change


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AMERICA’S hospitals are the most expensive part of the world’s most expensive health system. They accounted for $851 billion, or 31%, of American health spending in 2011. If they were a country, they would be the world’s 16th-largest economy. And they are in the midst of dramatic change, much of it due to the “Obamacare” health reforms.

The most visible change so far is that big hospital companies are getting bigger. In the latest of a string of recent mergers and takeovers, on June 24th Tenet Healthcare said it would buy Vanguard Health Systems for $4.3 billion including debt. The combined group will have 79 hospitals and 157 outpatient clinics.

Others are going further, turning the industry’s business model on its head. In Massachusetts, Steward Health Care Systems is trying to drive patients out of its hospitals and into cheaper clinics. The pace of change varies from one hospital group to the next. But beneath the shift is an argument—by politicians, insurers, patients and some investors—that the old business ways of hospitals are untenable.

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America has more than 5,700 hospitals, with non-profits outnumbering for-profits by nearly three to one. Most of these share a familiar business model: sell as many services as possible at the highest price. This bodes ill for those who pay, whether employers, the government or patients themselves. Doctors receive a fee for each treatment, so there are few financial incentives to keep patients well. And since the health market has the transparency of a concrete bunker—patients usually do not know the price of treatment until after they have received it—American hospital stays are unusually expensive (see chart). It is little wonder that health spending overall accounts for nearly a fifth of GDP.

This dysfunctional system will welcome millions of new patients next year. Obamacare requires everyone to have some form of health insurance from 2014. To that end it expands Medicaid, the government’s insurance scheme for the poor, and subsidises private insurance policies which will be offered via new exchanges to be set up in each American state. More people with insurance should mean more patients seeking treatment, so the reforms would seem to herald a golden era for hospitals. Indeed, hospital shares have soared since the Supreme Court upheld the health law’s constitutionality a year ago.

Nevertheless, hospitals face mounting pressure to change. In recent years the volume of patients at most hospitals has been flat at best. The recession is partly to blame, since sacked workers lose their insurance. The shifting of some treatments to outpatient clinics has undercut some hospital revenues. And employers have increasingly required their workers to make out-of-pocket contributions towards the cost of their health care, which makes them a bit less likely to seek treatments.

Obamacare itself is not all good news for hospitals. It will bring revenue from newly insured patients. But it will also cut the rates the government pays for Medicare, the health scheme for the old. By 2019 these will cancel each other out, reckon analysts at Bank of America Merrill Lynch. And the Medicare cuts already announced may not be the last. The reforms may create fewer new patients than expected: some people may ignore Obamacare’s “mandate” to buy insurance, since the penalties are small. State and federal officials are scrambling to get the exchanges ready in time. Some Republican governors are refusing to expand Medicaid.

Obamacare also includes incentives for hospitals to provide quality, rather than quantity, of care for publicly insured patients. Medicare will penalise hospitals that discharge patients only for them to return within 30 days. Groups of doctors and hospitals can apply to be designated as accountable-care organisations, or ACOs, which will be rewarded for keeping the cost of Medicare patients’ treatments below a certain level. (They thus have broadly similar aims to health-maintenance organisations, or HMOs, a type of private health plan that pays a fixed fee to doctors and hospitals for the patient’s care).

Last month the Obama administration opened another line of attack on hospital costs by publishing their price lists. These showed huge variations. In practice, insurers negotiate special rates, and these remain mostly hidden. But scrutiny of prices is likely to intensify, as more members of employers’ health schemes are forced to shop around for treatments.

Physician, know thy costs

The reforms, and the other pressures on the hospitals, have prompted them to launch a big efficiency drive. The well-respected Cleveland Clinic is offering shared medical appointments: a doctor tells several patients how to manage diabetes, rather than counselling them individually. Robert Kaplan and his colleagues at Harvard Business School are helping hospitals measure their costs. Many do a poor job of recording how much each type of treatment costs them in terms of doctors’ and nurses’ time, materials consumed and so on.

Hospitals are also seeking economies through dealmaking. All sorts of combinations are being seen, says Martin Arrick of Standard & Poor’s, a credit-rating agency: big, stockmarket-listed chains like Tenet and Vanguard are merging; Catholic hospitals are getting ecumenical with non-Catholic ones; and non-profit outfits are partnering with for-profits. There were more than 200 such deals in 2011-12, according to Irving Levin Associates, a research firm. This does not include many purchases by hospitals of doctors’ clinics.

The combined Tenet and Vanguard will have hospitals and clinics across 16 states. This will make it easier to standardise clinical practice, get discounted supplies and make the most of investment in new medical technology. Most important, a bigger firm will have more clout in negotiating prices with health insurers.

The most seismic shift, however, is the move away from the fee-for-service model. How can a hospital profit from delivering fewer services, when it is organised to deliver more? HCA, a quoted company with 156 hospitals in 20 states, is all but ignoring the question. Vanguard is one of few listed chains to have started looking for answers, including taking part in ACOs.

Steward, which is only three years old, seems to be the most ambitious in embracing change. It was created when Cerberus, a private-equity firm, bought a struggling chain of Catholic hospitals in 2010. Steward does not aspire to have the best hospitals in America—indeed it sends its most complex cases to a rival medical centre in Boston. What it wants to offer is good, convenient, reasonably priced care. Steward has signed up as a Medicare ACO and also has contracts with private insurers that reward it for keeping patients well as opposed to paying it by quantity of treatments. The company has 11 hospitals, up from six in 2010, and a network of 2,900 affiliated doctors, up from 1,100.

Steward is making efforts to ensure that patients do not suffer expensive relapses: nurses scroll through records to confirm that patients have collected their prescriptions and had their check-ups; more home visits are being made to recently discharged inpatients. But it is unclear overall whether such efforts will boost profits, or indeed lower America’s health spending, let alone both. Large hospital chains, thanks to their clout with insurers, are more likely to raise prices than cut them. Steward’s prices are lower than Massachusetts’s most expensive hospitals, but higher than those of some competitors.

As for ACOs, they have had a good start: more than 250 have been formed so far. But their success is difficult to predict. ACOs are responsible for the costs of a given set of patients, but those patients can seek treatments outside the group of providers that form the ACO. This may make it hard to contain their costs.

George Clairmont, who leads a doctors’ group that partners with Steward, is excited by the prospect of a new era. “We are part of a major change in health care that we haven’t seen since the beginning of the 20th century.” But like a novel treatment for a chronic ailment, the cure for America’s bloated hospital industry will need careful monitoring for side-effects.

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