Concepts in Program Design and Development

Ann L. Cupp Curley

Graduates of doctoral education for advanced nursing practice are expected to integrate nursing science with knowledge from other fields in order to provide the highest level of nursing care. They are also expected to develop and provide effective plans for “practice level and/or system-wide practice initiatives that will improve the quality of care delivery” (American Association of Colleges of Nursing, 2006, p. 11). In this chapter, the advanced practice registered nurse (APRN) will learn how to design new programs by addressing factors related to planning and organizational decision making.

Nurse leaders are instrumental in using data to make decisions that lead to program development, implementation, and evaluation. Data used to drive decision making must be accurate, pertinent, and timely in order to be applied appropriately when designing a program. It is critical that a program be constructed in a way that takes into consideration all components that impact that program, both internally and externally. Determining measures of success or desired outcomes when designing a program provides continuous checkpoints for evaluation throughout program implementation. Program development, implementation, and evaluation will vary across geographic and practice settings because of the unique and varied characteristics of an APRN’s practice.

CONSUMER AND SOCIETAL TRENDS AND DEMANDS

Justification

Justification for a program helps determine whether it is reasonable or necessary. Information gained from investigating consumer and societal trends and demands contributes to this justification. If a program makes sense, nurse leaders have ammunition to argue their case. Justifying a program requires an understanding of and quantification of the planned scope of the program. Producing a well-defined set of expectations and value propositions will make key stakeholders feel confident about approving and funding a program. The identification of a trend (such as increasing readmission rates for a particular population) is one justification for a program, especially when the trend leads to increasing costs or morbidity/mortality. By conducting a literature search, an APRN might reveal evidence that transitional programs for patients with heart failure are successful in preventing readmissions. Transitional programs that already exist may be adapted to fit an APRN’s own patient population rather than designing a new program from scratch. Using evidence from the literature may reinforce the value or justification of such programs, especially those programs that are successful in reducing readmission rates and reducing overall healthcare costs.

Once a program is conceived and a literature review is completed, it is important to consider whether the program is feasible. A feasibility study helps to frame the program structure and identify potential risks associated with the program. Basic questions need to be addressed and answered, such as:

Designing a program is different from implementing it; therefore, nurse leaders must determine whether or not the program can be effectively operated and supported. Critical issues such as operational and support issues must be considered. The following is a nonexhaustive list of examples.

Programs that are seen as having the potential to save money and improve patient outcomes will also often prove to be feasible. The Centers for Medicare & Medicaid Services (CMS) has tied reimbursement to certain key quality indicators. The readmission rate within 30 days for heart failure is one such indicator. Heart failure is the most costly diagnosis in the 65-year-old and older Medicare population (Sherwood et al., 2011). The Affordable Care Act (ACA) established the Hospital Readmissions Reduction Program, which requires CMS to reduce payments to inpatient prospective payment system (IPPS) hospitals with excess readmissions. The ACA went into effect on October 1, 2012, and hospitals that were above the national average for 30-day readmission rates saw decreased reimbursement rates (Centers for Medicare & Medicaid Services, 2014). Improving readmission rates makes good financial sense.

The APRN should assess the community to determine whether other, similar programs exist that would compete with the proposed program, or whether the proposed program could be built into an existing program. If a hospital has an existing community outreach department, the APRN could use the existing structure to house a new program.

In summary, justification of a program can be strengthened significantly by providing sound evidence, such as a thorough review of the literature, to establish the background of the problem and by examining currently successful programs that may be applicable to the APRN’s population of interest. Additionally, by following trends, APRNs can compare outcome measures to national quality indicators (benchmarks) and follow these measures over time with a goal to improve patient outcomes and reduce costs. And finally, determining whether the program is feasible will further strengthen the justification, as feasibility studies provide a systematic framework in which a program can be assessed and thoughtfully implemented or integrated into current practice.

Identification of Key Stakeholders and Players

Stakeholders

A list of questions can guide identification of key stakeholders:

There are many stakeholders in healthcare, but there are five important and powerful stakeholders who should not be ignored: patients or clients, medical staff, agency management, professional staff, and the board of directors or trustees. Think broadly when determining key stakeholders and also consider government agencies, professional groups or associations, present and prospective employees, local communities, the national community, the public at large, suppliers, competitors, the media, and future generations.

There may be considerable overlap of stakeholders’ expectations, including healthcare quality, support or adequacy of resources, and costs in terms of cost reduction and profitability. Publicly reported indicators may impact consumers’ image of a hospital’s quality of care. The board of trustees is also invested in the organization’s image, which can directly impact a consumer’s decision about where to seek care—or a physician’s decision about where to admit patients.

The power or influence of stakeholders can vary as a result of the organizational makeup and the stakeholders’ philosophy and values. Values drive needs, and when a needs assessment is performed to justify a program, values should be addressed because expectations often arise from values. Understanding expectations of stakeholders and considering expectations when designing a program can result in stakeholder satisfaction and program success. The identification of program outcomes that stakeholders value can help win their support. Healthcare organizations have mission statements that reflect organizational values, and, in many cases, these statements reflect the value placed on the development of community programs.

Key Players

Who are the key players in the program? The lead key player is the program administrator or manager. This role involves common responsibilities, regardless of industry or setting, which include the following:

Regardless of the number and type of team members, the program manager or administrator plays a critical role in building a successful team. A team that is effective and focused contributes to the success of the program. A useful framework for building successful teams is described best by the acronym “together (T) everyone (E) achieves (A) more (M).” The origins of the model are difficult to trace, but its concepts are sound and used by many. Successful teambuilding requires attention to the following:

Stakeholders, team leaders, and team players all play a critical role in the success and/or failure of a program. Each member has a role and an expectation based on the anticipated outcome of a new program. Values sometimes play a role, and it is important to share these values and address them early on to ensure success. Ultimately, commitment, communication, and collaboration are some of the most important characteristics a team requires for a successful program.

Structure

Program structure can be as simple or complex as desired as long as specific outcome measures and sustainability are considered in the planning phase. APRNs must be careful when employing complex approaches to program structure, as complex designs can lead to failure if discrete outcomes are not easily measured or if too many measures or variables are being studied. For example, a simple approach might structure the program around the following six areas: