Capstone Project: Business Plan

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B USINESS PLANNING IS an essential business tool for entrepreneurs – a best practice approach for

those interested in developing a small business such as an ambula- tory clinical practice. Translating business planning efforts into a properly prepared business plan remains an undisputed, effective necessity in any entrepreneurial endeavor (Sherman, 2016).

For today’s advanced practice nurses (APNs) with an eye toward innovation and independence, a new story is unfolding in an excit- ing era for these expert nurses. Sparked by the Institute of Medicine’s (IOM, 2010) landmark report, The Future of Nursing: Leading Change, Advancing Health, which emphasized the contribu- tion of nurses to “...building a health care system that will meet the demand for safe, quality, patient-centered, accessible, and affordable care” (p. 1). APNs have

begun enjoying a wider practice scope and establishing their own standalone ambulatory practice centers (American Academy of Ambulatory Care Nursing [AAACN], 2017; IOM, 2010; Yee, Boukus, Cross, & Samuel, 2013).

According to the American Association of Colleges of Nursing (AACN, 2017), there are four cate- gories of APNs: nurse practition- ers, certified nurse-midwives, clinical nurse specialists, and cer- tified registered nurse anes- thetists. In at least 45 states, APNs can prescribe medications, while only 16 states have granted APNs authority to practice independent- ly without physician collaboration or supervision. In states where this independent practice is not allowed, APNs must practice under the auspices of a doctor or a medical institution. However, APNs are authorized to receive Medicaid reimbursement. In December 2016, the Department of Veterans Affairs granted three of the four APN roles (nurse practi- tioners, certified nurse-midwives, and clinical nurse specialists) the ability to practice to the full extent of their education and training. While the new policy excluded certified registered nurse anes-

Joyce E. Johnson Wendy S. Garvin

Advanced Practice Nurses: Developing A Business Plan for an Independent

Ambulatory Clinical Practice

JOYCE E. JOHNSON, PhD, RN, NEA-BC, FAAN, is Associate Professor, The Catholic University of America, School of Nursing, Washington, DC.

WENDY S. GARVIN, MSN, APRN-BC, RN, is Nurse Practitioner and Senior Medical Scientific Liaison, Janssen Pharmaceutical Companies of Johnson & Johnson, Raritan, NJ.

NOTE: As a supplement to this article, a summary business plan can be found at www.nursingeconomics.net

EXECUTIVE SUMMARY The driving forces that are moti- vating many advanced practice nurses (APNs) to create new, high-value practices within the ambulatory care setting reflect the need for better, higher quali- ty patient care, a deep commit- ment to spending healthcare dollars wisely, and most impor- tantly, the relentless search for nursing interventions that lead to real improvement in the health of patients. Business planning provides the path through which new APN- run ambulatory practices become a reality and a success. A well-developed and sophisti- cated business plan is an essential first step in setting up a successful APN practice that reinforces APNs’ contributions to health care, and leads to real rewards for patients and fami- lies, APNs, and the healthcare industry.

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thetists, current efforts to include this valuable cohort advances the progressive national trend to enable nurses to practice to the full extent of their education and training.

In addition, population growth and the aging of the U.S. popula- tion have substantially increased demand for primary care pro - viders amidst a growing shortage of primary care physicians (Carrier, Yee, & Stark, 2011; Van Vleet & Paradise, 2015). In this environment, APNs find a fertile terrain rich with opportunities and an invitation to enter the world of small business. While such opportunities can help nurs- es to practice to the full extent of their skills and licensure to improve American health care (Johnson et al., 2012; Wilson, Whitaker, & Whitford, 2012), few APNs understand the regulatory, financial, and general operational business requirements for launch- ing an independent clinical prac- tice. In 2006, AACN recognized this knowledge deficit and de - fined core competencies for the doctorate in nursing practice aca- demic program accreditation.

These core competencies in - clude proficiency in using eco- nomic and financial principles to redesign effective and realistic care delivery strategies and the ability to employ principles of business, finance, and economics to develop effective plans for improving the quality of health care. Many innovative and aspir- ing APNs, including those with and without advanced degrees, who are interested in establishing in dependent ambulatory care prac tices must first understand and appreciate basic business planning principles.

Where does an APN begin to determine if entrepreneurship is right for him or her? The first step is to conduct a serious self-assess- ment to assure the APN has an above-reproach clinical skill set, an exceptional high energy level, and a fiercely independent pro -

pen sity to succeed. If the APN meets these rigorous expectations, the next step is to fully under- stand all the details of what it real- ly means to be an entrepreneur.

Around the beginning of the 19th century, Say coined the term entrepreneur from the French term entreprendre – to “under- take” (Stoy, 1999, p. 231). Say sug- gested change agents seek oppor- tunities for shifting economic resources away from areas of low productivity to those with the potential for higher productivity, higher yield, and greater value. Nurse entrepreneurs seek self- employment by developing di - verse practices and businesses that give them the opportunity to “improve health outcomes with innovative approaches” (Wilson et al., 2012, p. 1). These entrepre- neurs recognize direct accounta- bility to clients regardless of their status as an individual or a pub- lic/private organization that uses their services (Liu & D’Aunno, 2011). Nurse entrepreneurs might have an independent clinical practice, own a business such as a nursing home or pharmaceutical company, or operate a consultan- cy that offers research or educa- tional services, or other businesses that include professional writing, filmmaking, and product develop- ers (Carlson, 2016; Wilson et al., 2012).

As agents of change, APN entrepreneurs seek opportunities to directly address gaps in direct patient care and the healthcare industry. APN entrepreneurs must secure top-notch business skills because they must first convince decision makers and other stake- holders that their views of a new, improved way of doing business via an independent practice offer clear, data-driven advantages for patients and real value for the organization’s bottom line. An entrepreneurial spirit, solid knowledge base, clinical skills, and desire to provide patients with quality healthcare are simply not enough to be successful in an

independent practice. The viabili- ty of nurse-managed practices essentially rests on keen business acumen and financial “know- how” (Barberio, 2010).

To make their case for a new nurse enterprise, ambitious inde- pendent APN entrepreneurs look to the traditional business plan as the vehicle for defining the what, why, who, and where of their nas- cent business venture. For in - stance, what clinical specialty reflects the APN’s clinical expert- ise and services the practice will provide? Who are the competitors and what will differentiate APN practice from the competition? Where will the practice be located to assure sufficient volume and related revenue stream? How many employees are needed to start the business? How much money is needed to get started? What is the potential for getting a loan? How long will it take to make a profit? What are the cur- rent healthcare payer, tax, and related insurance environments? How will the new APN practice be marketed, advertised, and man- aged? It is in a fully developed business plan where nurse entre- preneurs (a) identify specific goals and measurements to assess progress over time; (b) establish the foundation for future practice performance with detailed finan- cial analyses that include cash flow and break-even require- ments; and (c) leverage critical industry intelligence and market- ing information to demonstrate the proposed venture’s viability before decision makers agree to make a significant financial com- mitment.

The Business Plan Framework Although business planning

dates to the 1960s (Taylor, 2016), the essence of business planning has changed very little. A good business plan, with an average length between 10-35 pages, is a well-written, compelling docu- ment that explicitly defines the

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goals of the proposed business and describes in detail the strate- gies that will achieve those goals. Writing a business plan is like telling a story, one that flows logi- cally and step-by-step through a traditional series of key elements (Sherman, 2016) (see Table 1).

These elements are similar to those used in evidence-based practice projects which build on the recommendations from the IOM (2001) and focus on “stan- dardizing healthcare practices to science and best evidence and reducing illogical variation in care, which is known to produce unpredictable health outcomes” (Stevens, 2013, para. 7).

From a writing perspective, business plans must be free of acronyms or colloquial terms that may be unfamiliar to diverse read- ers. The typical plan uses a single- spaced format, with the refer- ences, appendices, tables, and charts included in the body of the plan.

Introduction The introduction sets the

stage for the entire business plan. In the first three sentences of the introduction, the APN entrepre- neur must capture readers’ inter- est, and introduces readers to the author’s area of specialization and envisioned organization. Next comes the description, need, and details of the proposed ambulato- ry practice; this must create a very convincing and compelling case that identifies a significant gap in

patient care. Most importantly, the introduction concludes by describing a practical approach that can close that gap and achieve important data-driven patient out- comes.

Description of the Business This section of a business plan

defines the unique aspects of the proposed ambulatory clinical prac- tice that distinguishes the envi- sioned business from other com- petitors (Barberio, 2010). Centering on a unique area of specialization, discuss how the APN ambulatory practice competes in the healthcare marketplace and drives reimburse- ment – both essential elements for new ventures. Specialization, con- sidered a wise strategy for new business owners, reduces competi- tion and drives compensation – both essential elements for new businesses in the highly competi- tive, consumer-focused healthcare industry.

This section begins with a brief but detailed overview of the APN’s clinical practice history, including current service profi- ciency and offerings, existing cus- tomer base, and economic pro - spects. A complete description of the proposed practice’s essence, evolution, and market follows, as well as the current healthcare and practice trends that support the

need for and sustainability of the new business concept. The sec- tion summary should include a broad and comprehensive per- spective on industry, economic, regulatory, and competitive trends that affect the proposed clinical practice.

Market and Competition Analysis The challenge of this analysis

requires the APN to present suffi- cient data to convince potential investors the proposed clinical practice venture has a substantial market not only for the envisioned practice but also in the larger con- text of the healthcare industry. In this analysis, target populations such as pediatrics or adults are identified, size of the current and potential markets are described, and competition that exists in the market is detailed. The SWOT assessment is the typical frame- work for this analysis (see Table 2).

The strength of the SWOT analysis rests in its analytic frame- work of strengths, weaknesses, opportunities, and threats that can “help your company face its great- est challenges and find its most promising new markets” (Fallon, 2016, para. 1). Strengths and weak nesses are factors internal to the proposed practice and may change over time (Fallon, 2016). Strengths and weaknesses include

Table 1. Key Elements of a Business Plan

• Introduction • Description of the Business • Market and Competition Analysis • Development Plan and Schedule • Operational Plan • Marketing Plan • Organizational Plan • Financial Plan • Executive Summary

Table 2. Sample SWOT Analysis

Strengths Weaknesses • Clinically expert APNs • Location adjacent to target

community • Clinical specialty has few

competitors

• Aging population limits family practice opportunities

• Growing hospital system employs physician practices

• Lack of practice owner experience

Opportunities Threats • Potential to link with practices

interested in specialty referrals • Reconfiguration of practice patterns

may enable significant market penetration

• Growth potential significant based on absence of alternative options

• Aggressive hospital system entry into marketplace

• Insufficient funding support may limit immediate practice expansion

• Practice marketing efforts overshadowed by hospital system market penetration strategy.

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a variety of resources – financial, physical, and human – as well as current processes such as employ- ee programs, department hierar- chies, and software systems.

In contrast, opportunities and threats are external to the practice; these exist in the market and fall beyond the APN’s control. Exam - ples include market and economic trends, funding sources, demo- graphics, relationships with sup- pliers and partners, and political, environmental, and economic reg- ulations in the category of external factors (Fallon, 2016).

Each part of the SWOT analy- sis forces the APN to answer some critical questions. When consider- ing strengths, the APN might answer the following questions: • What is your real strength? • Are you associated with spe-

cialty physicians for referrals? • Do you have competent admi -

nistrative and management personnel?

• Are your personnel trained and educated in ways that dif- ferentiate their expertise from others offering similar servic- es?

• Is your patient flow paradigm preferential? The analysis of weaknesses

might include answers to the fol- lowing questions: • What are the weaknesses in

your skills and experience? • Are there problems in your

facility? • Do you lack business expert-

ise? • Does your business have lim-

ited resources? • Do you lack necessary clinical

expertise to expand your prac- tice?

• Is the management of your patient flow a problem?

• Do you have an unacceptable patient wait time?

• Do you have inadequate sup- plies to meet patient needs?

• Is your business in a poor location? Identification of opportunities

can include answering some dif-

ferent types of questions such as: • Are market trends favorable to

your volume projections? • Are demographics such as age

or gender favorable to your practice?

• Is the payer mix in your loca- tion favorable?

• Can you envision vendor or supplier collaborations and associated cost reduction?

• Can you maximize benefit from economic and financial trends? In contrast, threats require an -

swers to a different set of questions: • Are other nearby practices

expanding? • Have new practices opened in

your area? • Are accountable care organi-

zations affecting your prac- tice’s potential development and growth?

• Are hospital systems aligning market flow to their practices and acute care facilities?

• Are there government regula- tions (such as those focused on the implementation of electronic health records) that are challenges for your pro- posed practice?

• Are there economic projec- tions that could negatively impact the practice you envi- sion?

• Does a new product or tech- nology make your services obsolete? Describing threats from gov-

ernment regulations is an especial- ly critical part of the risk assess- ment. In a national survey conduct- ed by KPMG in 2012, 60% of healthcare executives said regula- tory and legislative pressures were the most significant barriers to their company’s growth projections over the next year (KPMG, 2012). Remem ber the SWOT assess ment only contributes to the foundation of a good strategic plan; it is not the final analysis (Patrishkoff, 2015). As Berry (2016) concluded, “the true value of this exercise is in using the results to maximize the positive influences on your

business and minimize the nega- tive ones” (p. 3).

Development Plan and Schedule In this section, the APN entre-

preneur provides the details of the what, how, and when of develop- ing the new product or service. The services that are planned for the practice are described in pre- cise detail, including the days and hours of operation. Using the development cycle, all the re - sources needed to develop the practice are defined, including equipment, staff, facilities, sup- plies, technology, and finance. This section also includes details of the planning, program, and pol- icy development required for the new enterprise, including the plans for building, marketing, staffing, training, and operating the practice.

The development plan typi- cally includes a step-by-step time- line that details the evolution of the ambulatory practice from planning to completion, as well as an evaluation approach that assures future funding sources. This information requires data- driven metrics and mechanisms for quality control, continuous improvement, and risk abatement. According to Wolters Kluwer (2012), small businesses typically face two primary risks: introduc- ing a product that people will not buy, or not introducing new prod- ucts often enough. The first risk may be reduced by being clear about the target population and including sufficient market re - search at each step of the develop- ment process. The second risk may be lessened by analyzing shifting market conditions and making a strong commitment to continued practice development strategies.

Organizational Plan In this section of the business

plan, the APN provides potential investors with a thorough view of the team and organizational rela- tionships within the proposed

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business. This section includes an organization chart (see Figure 1), which clearly depicts the hierar- chical structure of the practice, defines the chain of command and lines of direct authority and re - porting, and linkages with a larger healthcare system, as appropriate.

The organizational plan also includes detailed descriptions of the key team members who will eventually make the practice a success. These should include succinct qualification profiles that detail key skills, competencies, and prior experience. Position descriptions for all key personnel, along with expected salaries, should be placed in the plan’s appendix. The plan should also identify any external consultants or independent contractors that may be hired, describing their unique practice function and con- tribution (Fontinelle, 2016a). In addition, the organizational plan should include a description of the legal form of ownership that is planned for the business (sole pro- prietorship, partnership, limited liability partners, limited liability company, or corporation), and a statement of the company’s man- agement philosophy, values, and culture.

Marketing Plan According to the U.S. Small

Business Administration (SBA) (2016a), the marketing plan should ensure “you’re not only sticking to your schedule, but that you’re spending your marketing funds wisely and appropriately” (para. 1). The plan, suggests the SBA, includes “everything from understanding your target market and your competitive position in that market, to how you intend to reach that market (your tactics) and differentiate yourself from your competition in order to make a sale” (para. 2). Consideration needs to be given to how the prac- tice will reach potential clients.

Abrams (2015) suggests the entrepreneur consider four fac- tors: 1. Fit. The chosen marketing

vehicles match the profession- al image and can reach the practice’s target customers.

2. Media mix. The plan should incorporate more than one media channel to obtain max- imum exposure, and may in - clude traditional media (bro - chures, on-line advertising, direct or email mailings, and print or broadcast media) as

well as new media (Facebook, other websites, social net- working platforms such as Twitter).

3. Extent of repetition. Planning and paying for many expo- sures to achieve the maximum media saturation needed.

4. Affordability. Since marketing requires a substantial budget, consider where the funds are best spent. Beyond these general guide-

lines, it might also be wise to con- sider some of the tried-and-true principles of diffusion of innova- tion derived from the seminal work of Everett Rogers (2003). Rogers stated five attributes influ- ence the rate of adoption of any innovation: 1. Relative advantage. The de -

gree to which an innovation is perceived as being better than the idea it supersedes; the greater the relative advantage of an innovation, the greater the rate of its adoption. Rogers asserted relative advantage (such as economic profitabili- ty, low initial cost, decrease in discomfort, social prestige, savings of time and effort, or an immediate reward) is one of the strongest predictors of an innovation’s rate of adop- tion.

2. Compatibility. The degree to which an innovation is per- ceived as consistent with the existing values, past experi- ences, and needs of potential adopters. Thus, a nursing in - novation should revolve around a core of caring, healing and holism, dedication to the well-being of patients and families, appreciation of the opportunity to serve others, focus on comfort, and honor for the human spirit.

3. Complexity. Rogers suggested a high degree of complexity is a barrier to adoption; thus, a new nursing innovation should be straightforward, simple, and easy to understand.

Figure 1. Sample Organization Chart

Practice Manager APNs, RNs, LPNs

APN Owner

Reception and Appointment Personnel

Billing, Accounts Payable and Receivable, Insurance Personnel

Clinical Assistants

APNs = advanced practice nurses, LPNs = licensed practical nurses, RN = registered nurses

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4. Trialability. This is “the de - gree to which an innovation may be experimented with on a limited basis” (p. 258). Rogers concluded the triala- bility of an innovation is posi- tively related to its rate of adoption.

5. Observability. Defined by Rogers as “the degree to which the results of the innovation are visible to others” (p. 258); the more easily the results of an innovation can be seen by oth- ers, the greater the rate of adoption. Another critical feature of the

marketing plan is the evaluation metric for the success of the mar- keting initiatives. The SBA calls this “measuring your spend” (2016a, para. 7) (monitoring the effect of specific marketing strate- gies on revenues during a fixed period of time as compared to a previous fixed time period). “The time spent developing your mar- keting plan is time well spent because it defines how you con- nect with your customers, and that’s an investment worth mak- ing” (SBA, 2016a, para. 10).

Financial Plan In this section, the APN will

define the business strategy and goals of the new practice, identify payer priorities, and specify what potential customers value and need. The financial section of a business plan does not equate to traditional accounting (Wasserman, 2016). Although the financial pro- jections – profit and loss, balance sheet, and cash flow – look similar to accounting statements, account- ing looks back in time, while busi- ness planning looks forward (Wasserman, 2016).

A clear understanding of the proposed business, basic knowl- edge of financial planning, and knowledge of financial tools that measure the performance and suc- cess of a business enterprise are essential to writing a business plan. Additional assistance from a financial expert may be required

when writing this section. There are helpful reference texts avail- able (Abrams, 2015; Baker & Baker, 2014; Paterson, 2014) and many on-line resources as well (Fontinelle, 2016b; SBA, 2016b). However, many aspiring nurse entrepreneurs opt for hiring a financial consultant who can assist them in creating a complete, concise, and realistic overview of the proposed business’ financial future. If the APN elects to secure a financial consultant, it is impor- tant to hire an unbiased profes- sional expert who can assure accurate and realistic financial projections. These projections typ- ically include an income state- ment, balance sheet, and cash flow statement with a number of different analyses.

Income statement. This state- ment summarizes the revenue and expenses that are projected for the proposed business. The income statement should list all sources of income, estimate volumes of patients the practice expects to see each day and payer mix, deter- mine expected revenue per unit, and calculate expected total rev- enue per year (Paterson, 2014). Some factors to consider in these calculations include ambulatory payment classifications (which may apply to freestanding prac- tices such as an ambulatory sur- gery center not associated with a hospital), Healthcare Common Procedure Coding System (HCPCS) codes, payer fee schedules, per- cent of charges, relative value units (which are the basis of reim- bursement in ambulatory care), and an allowance for bad debt.

For a new start-up business, the total project expenses are calcu- lated by examining the strategic plan, payer mix information, labor projections for all staff by category including benefits and overtime, expected capital costs, and indirect costs or overhead. Indirect costs, determined by allocation methods acceptable to the funding organiza- tion, recognize the reality all new services require general resources

such as leasing costs for space, fur- nishings, technology support, utili- ties, and administrative or supervi- sory staff. While the income and expense statement provides an estimated organization-wide pool of indirect expenses, new practices or businesses demand the con- struction of de tailed indirect expenses as well as direct expens- es. The total of direct and indirect expenses is then divided by direct expenses to produce the loading factor that shows the excess of total costs over direct costs for the prac- tice (Paterson, 2014).

Balance sheet. The balance sheet simply shows potential investors the expected assets of the new business balance with the pro- jected liabilities. Obviously, these figures will be speculative for a new enterprise although it helps to benchmark the figures with finan- cial figures from similar business- es. Assets may include accounts receivable, cash, inventory, and equipment. Liabilities include accounts payable and loan bal- ances. An easy way to remember the balance sheet is that it describes “what you own vs. what you owe” (Fontinelle, 2016b, para. 8).

Cash flow statement. This statement includes analyses that demonstrate cash flow in a time- frame. The business plan should include a cash flow estimate by month for at least 1 year, and a longer-term, “pro-forma” projec- tion of at least 3 years of business performance. These estimates might include sales forecasts, cash versus credit receipts, the predict- ed time frame for collecting accounts receivable (Fontinelle, 2016b), and any projected variance in the budget. It is critical not only to perform strategic analyses of budget variances that might be due to factors such as lower service vol- ume and higher resource use than expected, but also to identify all potential management strategies that could be implemented to min- imize the budget variances.

Another critical part of the financial plan is the breakeven

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analysis that demonstrates the point at which the patient volume and associated reimbursement may begin to exceed costs and the practice begins to make a profit. The operative question to be answered by this analysis is: At what operational point has a prac- tice earned enough revenue to recoup its costs? At the breakeven point, the new business makes no profit but also does not lose money. The practice has covered the cost of staying in business and building volume.

The breakeven analysis in - volves calculating the total costs (all fixed, variable/semi-variable, and opportunity costs), payer mix, actual revenue per patient, and actual and projected patient vol- umes over a 3 to 5-year period. The figure for actual revenue per patient is multiplied by the patient volume to obtain total rev- enue. Along with total expenses, and current and projected volume for the next 3 to 5 years, there is enough information to perform a simple breakeven analysis that

can demonstrate a profitable prac- tice over the foreseeable future. This is a major step in defining the financial and investment strategy of the new practice, and convinc- ing prospective financiers of the potential profitability of the new ambulatory clinical practice.

Executive Summary Written last but placed at the

beginning of the business plan is the all-important executive sum- mary. “The executive summary is often considered the most impor- tant section of a business plan. This section briefly tells the reader where your company is, where you want to take it, and why your busi- ness idea will be successful. If you are seeking financing, the execu- tive summary is also your first opportunity to grab a potential investor’s interest” (SBA, 2016b, para. 1). In no more than one page of concise and compelling writing, the executive summary has two goals: convince potential funders that the entire business plan is worth reading and that the pro-

posed business is worth funding. Some experts warn that new busi- ness owners should use the upfront executive summary to tell potential funders exactly what they want and to avoid the danger of burying their needs deep inside the busi- ness plan (Entrepreneur, 2016).

Choosing what to include in this critical one-page document is a challenge because every word counts. The executive summary should address every section of the business plan and, at the very least, include: • A brief description of the pro-

posed practice, including a historical overview that in - cludes date of formation, com- pany founders, and projected number of employees.

• A summary of the mission, goals, and objectives.

• Solid description of the target market and the need for the business.

• High-level justification for the viability of the proposed busi- ness along with a quick look at the competition.

3 Projections for 2020 suggest health occupations in ambulatory care will represent 63% of the new 4.2 million jobs in health care (Center for Health Workforce Studies, 2012).

3 Tine Hansen-Turton, CEO of the National Nursing Centers Consortium, estimated in 2014 there were 500 nurse-led clinics in the United States and that the number would grow as healthcare providers look for less costly ways to provide healthcare (Toner, 2014).

3 According to AAACN (2017), ambulatory care nursing occurs across the continuum of care in a variety of settings, which include but are not lim- ited to hospital-based clinic/centers, solo or group medical practices, ambulatory surgery and diagnostic procedure centers, telehealth service environments, university and community hospi- tal clinics, military and Veterans Administration settings, nurse-managed clinics, managed care organizations, colleges and educational institu- tions, freestanding community facilities, care coordination organizations, and patient homes.

Ambulatory care includes those clinical, organi- zational, and professional activities engaged in by registered nurses with and for individuals, groups, and populations who seek assistance with improving health and/or seek care for health-related problems.

3 The Patient Protection and Affordable Care Act (2010) defines a nurse-managed health center as “a nurse practice arrangement, managed by advanced practice nurses, that provides primary care or wellness services to underserved or vul- nerable populations and that is associated with a school, college, university or department of nurs- ing, federally qualified health center, or inde- pendent nonprofit health or social services agency” (p. 24).

3 Nurse-managed clinics have proven benefits. In addition to providing high-quality care with high levels of patient satisfaction, nurse-led clinics decrease urgent care visits, emergency room vis- its, and hospital admissions (Coddington & Sands, 2008).

Ambulatory Care: The Practice Environment of Growth, Good Patient Care, and Patient Satisfaction

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• Growth and service projec- tions.

• Marketing strategies: how the practice will attract patients.

• Financial projections, includ- ing bank references and invest - ors.

• Plans that detail the direction of the business development. (Discover Business, 2016) Two common pitfalls occur

when writing the executive sum- mary (Johnson et al., 1988). First, it is critical to avoid using highly technical, complicated terminolo- gy. Writing with simple, easy-to- understand terms will make it eas- ier for potential investors to under- stand the plan. Second, beware of writing an excessively long execu- tive summary. Investors read many proposals and they value a crisp executive summary that clearly shows the promise and potential of the proposed business. Remember, as with the Introduction, the first three sentences must capture the reader’s interest sufficiently to examine the entire executive sum- mary and assure equal interest in reviewing the contents of the full business plan!

Conclusion In 2015, Health and Human

Services Secretary Sylvia Burwell announced the agency’s goal to shift 50% of payments to value- based models by 2018 (Rappleye, 2015). “Whether you are a patient, a provider, a business, a health plan, or a taxpayer, it is in our com- mon interest to build a healthcare system that delivers better care, spends healthcare dollars more wisely and results in healthier peo- ple,” Burwell said (Rappleye, 2015, para. 31). The driving forces that are motivating to many APNs to create new, high-value practices within the ambulatory care setting reflect the need for better, higher- quality patient care; a deep com- mitment to spending healthcare dollars wisely; and most impor- tantly, the relentless search for nursing interventions that lead to real improvement in the health of

patients. Business planning pro- vides the path through which new APN-run ambulatory practices become a reality and a success. A well-developed and sophisticated business plan is an essential first step in setting up a successful APN practice that reinforces APNs’ con- tribution to health care, and leads to real rewards for patients and families, advanced practice nurses, and the healthcare industry. $

REFERENCES Abrams, R. (2015). Successful business

plans: Secrets & strategies (6th ed.). Palo Alto, CA: Planning Shop.

American Academy of Ambulatory Care Nursing (AAACN). (2017). Scope & standards of practice for professional ambulatory care nursing (9th ed.). Pitman, NJ: Author.

American Association of Colleges of Nursing (AACN). (2017). Expanded roles for advanced practice nurses. Retrieved from http://www.aacn.nche.edu/media- relations/fact-sheets/apn-roles

American Association of Colleges of Nursing (AACN). (2006). The essentials of doc- toral education for advanced nursing practice. Retriev ed from http://www. aacn.nche.edu/ dnp/Essentials.pdf

Baker, J.J., & Baker, R.W. (2014). Health care finance: Basic tools for non-financial managers (4th ed.). Burlington, MA: Jones & Bartlett Learning.

Barberio, J.A. (2010). Establishing an inde- pendent nurse practitioner practice. Retrieved from http://nurse-practition ers-and-physician-assistants.advance web.com/Features/Articles/Establish ing-an-Independent-Nurse-Practitioner- Practice.aspx

Berry, T. (2016). What Is a SWOT Analysis? BPlans. Retrieved from http://articles. bplans.com/how-to-perform-swot- analysis/

Carlson, K. (2016). Nurse entrepreneurs or intrapreneurs? Retrieved from https:// www.nurse.com/blog/2016/02/11/nurs es-entrepreneurs-or-intrapreneurs

Carrier, E., Yee, T., & Stark, L. (2011). Match - ing supply to demand: Addres sing the U.S. primary care workforce shortage. Washington, DC: National Institute for Health Care Reform: Retrieved from http://nihcr. org/ analysis/improving- care-delivery/ prevention-improving- health/ pcp-workforce/

Center for Health Workforce Studies. (2012). Health care employment projections: Analysis of Bureau of Labor Statistics occupational projections, 2010 2020. Retrieved from https:// www.healthit. gov/sites/default/files/chws_bls_report _2012.pdf

Coddington, J.A. & Sands, L. P. (2008). Cost of health care and quality outcomes of patients at nurse-managed clinics. Nursing Economic$, 26(2), 75-83.

Discover Business. (2016). How to write a business plan. Retrieved from http:// www.discoverbusiness.us/business- plans/#7

Entrepreneur. (2016). How to write a busi- ness plan. Retrieved from https:// www.entrepreneur.com/article/247575

Fallon, N. (2016). SWOT analysis: What it is and when to use it. Business News Daily. Retrieved from http:// www. businessnewsdaily.com/ 4245-swot- analysis.html

Fontinelle, A. (2016a). Business plan: Your organizational and operating plan. Retrieved from http://www. investo pedia.com/university/ business-plan/ business-plan6.asp

Fontinelle, A. (2016b). Business plan: Your financial plan. Retrieved from http:// www.investopedia.com/ university/ business-plan/businessplan7.asp

Johnson, J., Veneziano, T., Malasi, T., Mastro, K., Moran, A.L., Mulligan, L., & Smith, A. (2012). Nursing’s future: What’s the message. Nursing Management, 43(7), 36-41.

Institute of Medicine (IOM). (2010). The future of nursing: Leading change, advancing health. Washington, DC: The National Academies Press.

Institute of Medicine (IOM). (2001). Crossing the quality chasm: A new health sys- tem for the 21st century. Washington DC: National Academies Press.

Johnson, J.E. (1988). The nurse executive’s business plan manual. Rockville, MD: Aspen Publishers, Inc.

KPMG. (2012). Pharma execs continue look- ing for growth opportunities in spite of increasing regulatory challenges: KPMG survey. [Press release]. Retrieved from http://www.prnews wire.com/ news-releases/pharma-execs-continue- looking-for-growth-opportunities-in- spite-of-increasing-regulatory-chal lenges-kpmg-survey-159993345.html

Liu, N., & D’Aunno, T. (2011). The produc- tivity and cost-efficiency of models for involving nurse practitioners in pri- mary care: A perspective from queuing analysis. Health Services Research, 7(2), 594-613. doi:10.1111/ j.1475-6773. 2011. 01343.x

Paterson, M.A. (2014). Healthcare finance and financial management: Essen tials for advanced practice nurses and inter- disciplinary care teams. Lancaster, PA: DEStech Publications, Inc.

Patient Protection and Affordable Care Act, 42 U.S.C. § 330A-1 (2010). Retrieved from http://www.oshpd. ca.gov/reform/ PPACA_TitleV.pdf

continued on page 141

141NURSING ECONOMIC$/May-June 2017/Vol. 35/No. 3

Advanced Practice Nurses continued from page 133

Patrishkoff, D. (2015). A SWOT analysis of SWOT analysis. Retrieved from http://insurancethoughtleadership. com/swot-analysis-swot-analysis/

Rappleye, E. (2015). On the record: 50 best healthcare quotes of 2015. Becker’s Hospital Review. Retrieved from http://www.beckershospitalre- view.com/hospital-management- administration/on-the-record-50- best-healthcare-quotes-of-2015.html

Rogers, E.M. (2003). Diffusion of innova- tions. New York, NY: Free Press.

Sherman, A.J. (2016). Business planning: Building an effective business model. Retrieved from http://entrepreneur ship.org/resource-center/business- planning-building-an-effective-busi ness-model.aspx

Stevens, K. R. (2013). The impact of evi- dence-based practice in nursing and the next big ideas. OJIN: The Online Journal of Issues in Nursing, 18(2), Manuscript 4. doi:10.3912/ OJIN. Vol18No02Man04

Stoy, D.B. (1999). The link between entre- preneurial success and advanced skills in organization development. In J. Hommes, P.K. Keizer, M. Pettigrew, & J. Troy (Eds.), Educa - tional innovation and economics and business IV: Learning in a changing environment. Dordrecht, The Netherlands: Kluwer Academic Publications.

Taylor, N.F. (2016, April 1). SWOT Analysis: What it is and when to use it. Business News Daily. Retrieved from http://www.businessnewsdaily. com/4245-swot-analysis.html

Toner, E. (2014). Nurse-led clinics: No doctors required. Retrieved from http://www.marketplace.org/2014/0

3/05/health-care/nurse-led-clinics- no-doctors-required

U.S. Small Business Administration (SBA). (2016a). Developing a market- ing plan. Retrieved from https:// www.sba.gov/managing-business/ growing-your-business/developing- marketing-plan

U.S. Small Business Administration (SBA). (2016b). Executive summary. Retrieved from https://www.sba.gov/ starting-business/write-your-busi ness-plan/executive-summary

Van Vleet, A., & Paradise, J. (2015). Tap - ping nurse practitioners to meet ris- ing demand for primary care. Washington, DC: Kaiser Family Foundation. Retrieved from http:// kff.org/medicaid/issue-brief/tapping- nurse-practitioners-to-meet-rising- demand-for-primary-care/

Wasserman, E. (2016). How to write the financial section of a business plan. Retrieved from http://www.inc.com/ g u i d e s / b u s i n e s s - p l a n - f i n a n c i a l - section.html

Wilson, A., Whitaker, N., & Whitford, D. (2012). Rising to the challenge of health care reform with entrepre- neurial and intrapreneurial nursing initiatives. OJIN: The Online Journal of Issues in Nursing, 17(2). doi:10.3912/OJIN.Vol17No02Man05.

Wolters Kluwer. (2012, May 24). Product development must be an ongoing, intentional process. BizFiling, Retrieved from http://www.bizfil ings.com/toolkit/sbg/marketing/prod uct-development/product-develop ment-an-ongoing-process.aspx

Yee, T., Boukus, E.R., Cross, D. & Samuel, D.R. (2013). Primary care workforce shortages: Nurse practitioner scope- of-practice laws and payment poli- cies. Washington, DC: National Insti - tute of Health Care Reform.

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