Designing and Delivering Care to Patients

Success in and satisfaction with one’s APN role revolves around the right match between APNs and the work they do and the ability to be flexible and innovative within the scope of that role. APNs’ adaptability to the changing health care marketplace is one of their greatest strengths. As noted, APNs participate in direct and indirect care processes in any practice setting. Indirect processes include the steps taken to market the practice, register a patient, and collect demographics, the process of third-party billing, meeting regulatory, safety, and quality imperatives, and the interaction with medical, pharmaceutical, and office supply vendors. Table 19-1 lists examples of clinical and administrative processes and skills. Direct and indirect processes are essential to the successful management of any health care system, whether it is a small, self-contained APN practice, a physician practice, or a large multihospital network.

It is important to note the differences between the direct and indirect care of patients described in Chapter 7 and the discussion here of direct and indirect processes of practice. For example, in this chapter, quality and risk management are included as direct processes, but the management and reporting of these activities are indirect processes.

Entrepreneurs and Intrapreneurs

Over an APN’s career, the balance between direct and indirect process involvement and the size of the system in which these processes occur may vary. At any given time, such shifts in balance and size of the system may require that APNs adopt an entrepreneurial approach, intrapreneurial approach, or mixture of both (Dayhoff & Moore, 2005; Wilson, Averis, & Walsh (2003). The term entrepreneur refers to someone who plans, organizes, finances, operates, and participates in a new health care delivery organization. Entrepreneurs have control over and responsibility for an increased proportion of indirect processes of care in their roles as compared with intrapreneurs. The term intrapreneur refers to someone who is generally an employee of an existing health care system, in which many of the indirect processes of the care delivery system may be controlled and managed by other employees or departments. The intrapreneur improves, redesigns, or augments an employer’s current direct care processes, with a lesser role in day to day business administrative functions. Entrepreneurs function within the context of the larger, societal health care system. Intrapreneurs function within an institutional health care system—a microcosm of the larger arena. Both entrepreneurs and intrapreneurs are risk takers; however, entrepreneurs are likely to take bigger risks and have a higher tolerance for the accompanying uncertainty. Entrepreneurs and intrapreneurs are individuals who continually search for and are receptive to opportunities and innovation. Innovation comes through the creation of a new process—direct, indirect, or both—or through radical changes to an existing process so that it seems like new.

When embarking on program or practice oversight, the APN needs to understand the balance between direct and indirect processes and the size that the business will have over time. A large portion of time is dedicated to clinical visits and must be financially productive, so there must be a realistic balance between direct and indirect care. The decision about the proportion of one’s role to devote to direct care versus indirect processes is based on the professional and personal values and goals of the APN and the needs and demands of the practice.

A self-assessment may assist the APN in clarifying professional and personal values. Types of questions to consider include the following; these are intended to be illustrative only and are not assumed to be exhaustive.

Inventory of Skills

A skills inventory can serve as a springboard for the clarification of the APN’s professional goals. The extent to which the APN balances the clinical role with administrative demands depends on the APN’s skills and preferences and begins with an inventory of those clinical skills and administrative talents that the APN would like to bring, or acquire, in an ideal advanced practice role. Box 19-1 lists some questions that may refine one’s ideal inventory.

The questions in Box 19-1 are among the many questions to be answered by APNs before deciding how extensive their role will be in the management of their program or practice. Fortunately, several resources help clinicians better understand the indirect processes, or business, of clinical practice. The reader is referred to Buppert (2012a) for an in-depth discussion of nurse practitioner (NP) business and legal concerns. In 2012, the American Medical Association (AMA) launched a new web-based practice management center (AMA, 2012b) to support physicians in the business management of their practices, which is also useful to APNs.

Entrepreneur and other business magazines provide useful information related to business management and administration. The Small Business Administration (SBA; www.sba.gov) provides general and specific information regarding business management and referral to local supports, including the local office of the Service Corps of Retired Executives (SCORE; www.score.org/business_toolbox.html). There are many other online resources related to business management. Specific websites that may be useful to the development of small businesses include the following:

Direct Patient Care

Direct care of patients and families is the central competency for APNs (see Chapters 3 and 7). The direct process of care for a given practice or practice population is defined as those patients who will receive direct clinical care by the APN in a practice environment. High-quality care and patient satisfaction sustain any level or configuration of practice over time. The patient population served, components of care and procedures based on the APN role, scope of practice, and mission must be carefully considered before implementing care. Ongoing evaluation with regard to patient outcomes and patient satisfaction is an important tool to maintain high-quality, safe care over time. The therapeutic relationships that are the trademark of APN direct practice provide opportunities for innovative business opportunities (Person & Finch, 2009; Thomas, Finch, Schoenhofer, et al., 2005).

One way to think about practice environments is that they represent small health care systems based on a patient population with identified needs. This patient population is identified through a variety of means, including individual APN expertise and preference based on the role and scope of practice of the individual APN. For certified nurse-midwives (CNMs) and certified registered nurse anesthetists (CRNAs), the patient population is essentially defined by their roles with childbearing women and their families and with patients undergoing surgical anesthesia, respectively. NPs and clinical nurse specialists (CNSs) have a broader population base (e.g., family NP, psychiatric CNS; see Part III). Sometimes, APNs identify patient populations through other modifiers, such as age, health promotion specialty, or disease state specialty (e.g., CNMs who care for adolescent mothers-to-be, CRNAs who specialize in providing anesthesia in pain management centers, and adult NPs or CNSs who specialize in the management of asthma or diabetes). In other cases, it is the geographic location or organizational setting that differentiates one’s patient population of interest. Examples of these populations are the rural underserved populations cared for by National Health Service Corps providers, veterans cared for in Veterans Affairs Medical Centers, and those in the newly designated accountable care organizations (ACOs; see Chapter 22). APNs must be able to define the patient populations they are serving in their clinical practice clearly and succinctly.

Mission, Vision, and Values

After the patient population has been identified and the patient care processes have been outlined, the APN will need to formalize this information in a mission and vision statement. This is where APNs differentiate their practices from physician practices using the nursing model of care and nursing attributes. The mission and vision statement describe to patients and prospective funding agencies the APN practice’s reason for existence and future direction; this brief statement serves to remind the APN entrepreneur about where the program or practice’s priorities should lie. Professional values include those tenets of nursing practice that provide significance and meaning to the APN’s practice of nursing (American Nurses Association [ANA], 2001; Sellman, 2011). The mission and goal statements of national APN organizations clearly portray these values as well. One’s professional and personal values influence one’s comfort with risk taking and preference about the arena in which care is delivered. The written summary of program or practice values may be combined with the mission and vision statement into one document, such as a brochure or program information sheet. This summary is available for review by any interested party and should be given to every patient at the time of the first practice encounter. These values must be held by all staff, especially those who come into direct contact with patients. As a business owner, it is important for the APN to create a culture of caring and holism throughout the organization.

The mission states the goal of the direct processes of care in one sentence—for example, “comprehensive primary care and wellness care for pediatric and adult individuals and families.” This can be distilled into a tag line, such as “innovative health care” (see Chapter 20). The vision statement describes the ideal 5-year goal (i.e., what the APN envisions the clinical care to be 5 years from inception). The mission and vision statements should enhance transparency and interdisciplinary collaboration as APNs clearly articulate their values, goals, and vision of patient care to existing and potential colleagues, consultants, and third-party payers. If the APN is functioning through an intrapreneurial approach as an employee, the organization’s mission and vision should be carefully examined to ensure that the practice or program fits into the overall goals of the organization and into the APN’s personal goals. If the program’s mission conflicts with that of the organization, problems may take the form of delays in funding, changes to the program’s direct or indirect processes of care, barriers to program implementation, and outright denial of program development. If other providers, individuals, or groups have a stake in the program, the mission and vision statement should be determined through consensus of the group (see Chapter 20 and SCORE [www.score.org/business _toolbox.html]).

The values of a practice or program describe the focus, preferences, and ethical precepts that underlie relationships among the provider, practice, patients, and external groups. They may be related to direct or indirect care processes. Values include core nursing beliefs, that all people have the right to fair and equitable health care within the context of their environment and support system. Some of the ways that these precepts are carried out are described here and are a part of direct and indirect processes of care.

Clinical Relationships with Other Staff and Providers

Although the APN is assumed to be the primary provider in this discussion, attention must be paid to the development of clinical relationships with other APNs, physicians, pharmacists, and allied health colleagues. (In-depth discussions related to clinical mentorship, consultation, and collaboration are found in Part II.) To be successful, the APN must maintain a collegial relationship with other health care providers (Clausen, Strohshein, Farem, et al., 2012; Horns, Czaplijski, Endelke, et al., 2007; Lindeke, 2005; Young, Siegal, McCormick, et al., 2011). An important legal consideration is defining the parameters of the association with a collaborating physician. In states that require medical collaboration, it may be through the development of a collaborative practice or contracting agreement. Even without a state statute, strong collegial relationships that provide support and coverage for time off are essential to the success of the APN practice. Also, in APN-owned practices, impediments to care can occur when referring to out of area facilities for diagnostic testing. Although less common than in the past, some facilities want a Doctor of Medicine (MD; physician) as the referring provider to be identified on patient orders and correspondence. In some states, if APNs’ names are not accepted as the primary provider, patient test results may be sent to the collaborating physician, who is off site and unable to prescribe or otherwise care for patients. APNs must be able to track these results to provide adequate safe care for patients; arrangements in which referral specialists do not communicate directly with the referring APN jeopardize safe and responsible patient care.

APNs need to find consultants and referral sources for patients whose medical problems require additional expertise from a specialist. Locating referrals for indigent or uninsured patients who need specialized medical care or hospitalization may be difficult because of the lack of services or reimbursement for these populations. A list of consultants and referral sources should be generated that outlines the services they offer and their willingness to accept referrals for indigent patients, as well as their participation in third-party payer plans. Consultants are identified through word of mouth recommendations from clinical mentors and colleagues, through the recommendation of lay public support groups who have worked with certain specialty groups, and through direct provider interviews. Over time, the APN develops a referral and consultation base and develops strong relationships with providers who can assist the APN in meeting patients’ needs. Once relationships have been established, acknowledging a consultant’s assistance and support is equally important. This acknowledgment may be as simple as learning from the consulting registration staff what demographic information they need to schedule the patient, providing the most recent office notes to the consultant in time for the patient’s appointment, and sending seasonal cards thanking them for their support.

The numbers and variety of APN providers available in local communities are growing rapidly (see Part III). APN colleagues who can serve as peer consultants to other APNs or serve as potential partners are an added strength that can be fully used to build practice relationships.

APNs must also carefully decide about the support staff that will assist with the direct care of patients. Staff positions include nurses, certified nurse aides, office manager, and clerical staff. Other staff such as respiratory and physical therapists, pharmacists, and nutritionists may be on site on a daily basis. All permanent and part-time staff need to be oriented to the organization and the goals of care, with clear role delineation. Staff should be clearly identified so that the consumer is aware of their role in the provision of care; in particular, non-nursing personnel should not be identified as nurses.

Business Relationships

Day to Day Administrative Support

The organization of day to day administrative support staff services (separate from the services of business advisors) revolves around the processes of care being delivered and the environment in which services are delivered. Once the APN knows what the direct patient care processes will include, and has identified those indirect processes that will support the patient encounter, additional ancillary personnel may be needed. The APN maintains ultimate responsibility for all operations if she or he owns the practice, even if a practice manager is managing daily operations. APN employees must be aware of their specific responsibilities and understand which belong to them and which belong to the owner. In a community-based primary care setting, the practice may require someone to assist in patient registration and scheduling (the first process box in Fig. 19-1), assist the clinician in certain elements of patient care (the second box), and collect or process patient fees (the third box). Any additional administrative roles support these primary roles and may include someone to manage patient medical records and new technologies, such as the electronic health record (EHR) and e-reporting (see Chapter 24), triage acutely ill patients by telephone, and perform office cleaning functions. Those who fill these roles should have skills and qualifications complementary to those of the APN and should be able to meet practice goals for patient care. An organizational chart and job descriptions of the roles required should be developed, placed in a common personnel manual, and shared among staff members so that everyone is aware of his or her role within the successful functioning of the system. At the end of each day, the APN should ensure that all direct and indirect processes of care have been completed. Some practices are now using dashboards to display their practice metrics in a form that is most useful to project quality, cost, and performance (www.dashboards. com). All these factors provide the patient with the most comprehensive health care and the provider with timely and accurate reporting; support services information is completed and insurance companies’ claims for reimbursement are processed.

The administrative structure taken by a particular intrapreneurial program depends on the organization’s overall guidelines for program development. For example, a hospital may wish to open a satellite primary care or oncology clinic staffed partially by APNs. The structure of the new clinic would fall under the business structure and plan of the hospital. In hospital-based settings, CRNAs, CNSs, and CNMs often collaborate with the nurse managers of the area in which they practice to obtain the assistance of the unit’s support staff and ancillary personnel.

Program and Business Structure

An entrepreneurial program structure is often dictated by the requirements of whichever funding agency has provided the startup and operating capital. The APN developing a practice or program that depends on the guidelines of other organizations is referred to the particular organization participating in program sponsorship. Many grant-funding agencies have criteria for funding and program guidelines (available on the Internet).

APNs may adopt one of several business structures, depending on the organizational context in which the practice is set. Practices may be hospital- or community-based. Hospital-based practices may be inpatient or ambulatory in nature. Community-based practices are often primary care settings, free-standing health centers, birthing centers, nurse-managed clinics, or retail clinics. They may also be a part of an ACO, health care home, or other payer-based primary care site. Practices may be established on a for-profit or not- for-profit basis. APNs should consult with business advisors to determine the best business structure to match their values and goals.

The three basic ways to structure the practice are a sole proprietorship, a partnership, or a corporation (www.irs.gov/business/small/article; Buppert, 2012a). The primary differences among these structures lie in differing tax restrictions and liability.

The simplest form of business organization is a sole proprietorship, which involves one owner. It is relatively straightforward and inexpensive to establish, and control remains with the sole owner. For tax purposes, the business income is taxed at the personal tax rate. The major disadvantage of the sole proprietorship is the unlimited liability that accompanies the structure. The owner assumes all liability, including that for any negligent acts of employees. Most medical practices are for-profit partnerships. A general partnership may be advantageous for the APN because partnering with another professional may attract venture capital. The unlimited liability for each individual partner remains, as does the personal tax rate on business income. A disadvantage of this structure is the possibility of personality conflicts and disagreements arising between the partners over control and decision making. As noted, the legality of relationships between different professionals is often dictated by state law. For example, CRNAs can join business arrangements as consultants to hospitals and anesthesia groups; CNMs may contract with hospitals for delivery services.

A corporation is a separate legal entity for tax and liability purposes. Incorporation protects the owners from some, but not all, liability because a corporation’s liability is limited. Consequently, because the medical professional owners retain a portion of any liability incurred, it is strongly advised that APNs and other providers have an individual liability policy. A general corporation, also known as a C corporation, is the most common corporate structure. A general corporation may have unlimited number of stockholders; consequently, it is usually chosen by those companies with more than 30 stockholders or large public stock offerings. Because a corporation is a separate legal entity, a stockholder’s personal liability is usually limited to the amount of investment in the company, and no more. A professional corporation can elect a small business (subchapter S) status, which allows owners to retain the benefit of taxation at the personal rate or, as is sometimes said, to avoid double taxation—first on corporate income and then on shareholder dividends. Other advantages of a corporation include the ability to start pension and profit-sharing plans and the possibility of attracting venture capital investors. The main disadvantage for a corporation not choosing small business status is the higher tax rate incurred by corporations. A corporation may also be more expensive to establish and operate.

A limited liability company (LLC) is not a corporation but offers many of the same advantages. Many small business owners and entrepreneurs prefer an LLC because it combines the limited liability protection of a corporation with pass-through taxations of a sole proprietorship or partnership (www.activefilings.com). See Table 19-2.

External Regulatory Bodies

An interwoven fabric of regulations and guidelines serves as the basis on which APN professional practice is built and developed (see Chapters 21 and 22 and the individual APN chapters in Part III for an in-depth discussion of APN credentialing and regulation). Federal and state regulations, policies of private insurance companies and, in some cases, local politics determine in which business structures and practice environments an APN may work and obtain reimbursement, and whether this practice is independent or collaborative. Although APN students routinely learn about the importance of the rules and regulations established by many different stakeholders within health care systems, the impact on daily practice may not be appreciated until the student becomes a practicing clinician. The major external regulatory vehicles affecting APN practice include the following:

Evaluation Processes That Ensure Quality and Safety

A major component of any APNs practice as an independent APN owner or partner or as part of a larger health care organization requires careful attention to evaluation processes. Chapter 24 offers in-depth guidance and tools that support the skills in which APNs need to have competency as direct care providers or as APN administrators to be able to evaluate care and respond to national and state benchmarks.

The use of electronic dashboards as a way to organize data and track measurable indicators of patient care outcomes have positively changed reporting and evaluation techniques in recent years. New systems and processes, almost all electronically driven, allow APNs and others to discern how “fit” their practices are (Richardson, 2008, see Chapter 24). The use of dashboards and other so-called governance score cards make it possible to improve clinical outcomes and patient safety and thus demonstrate the impact of APN care in the hospital (Griffin, Staebler, Muery, et al., 2007; Chandraharan, 2010). Tools such as the Hedis measures are making similar strides in community-based primary care settings (www.ncqa.org).

An excellent resource for quality is the Nursing Alliance for Quality Care (www.naqc.org). Samples of risk management guidelines may be obtained through the malpractice insurance carriers or as described by Buppert (2012a). Also, Buppert publishes The Gold Sheet, a monthly newsletter on quality for APNs.

TJC (2012) evaluates a health care organization’s system performance in patient-focused (direct) and organizational (indirect) care areas to improve the quality of care provided to the public. Patient-focused functions include patient rights and organizational ethics, assessment of patients, care of patients, education, and continuum of care. Organizational functions include improving organization performance, leadership, management of the environment of care, management of human resources, management of information, and surveillance, prevention, and control of infection. In addition, TJC examines an organization’s governance, management, and functions related to medical and nursing staff. Surveys are conducted every 3 years by TJC-employed provider and nonprovider survey teams. An overall score is determined, along with any recommendations for improving scoring deficiencies. Accreditation is based on the organization’s compliance with TJC guidelines and implementation of any recommendations to resolve deficiencies (TJC, 2012). Health care safety management and hazard control are proven processes that produce results by preventing accidents, reducing injury rates, and increasing organizational efficiency (www.OSHA.gov). Topics include emergency planning and fire safety, general and physical plant safety, managing hazardous materials, managing biologic waste, safety in patient care areas, and health care support area safety. In terms of external regulators, safety management is carefully scrutinized by both TJC and OSHA. APNs functioning as entrepreneurs or employers must be well-versed in the rules, regulations, and implementation of safety programs governing these areas of safety management and hazard control, especially with respect to the management of biologic waste and OSHA guidelines regarding bloodborne pathogens.

Created as part of the Department of Labor, OSHA was charged by the Occupational Safety and Health Act of 1970 to ensure safe and healthful working conditions for U.S. workers. In 2002, Congress amended OSHA to expand research on the “health and safety of workers who are at risk for bioterrorist threats or attacks in the workplace” (OSHA, 2012).