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Chapter 11

MANAGING HEALTH CARE PROFESSIONALS

Learning Objectives

  • Distinguish between the education, training, and credentialing of physicians, nurses, nurses’ aides, midlevel practitioners, and allied health professionals.
  • Identify 5 factors impacting supply of and demand for healthcare professionals.
  • Analyze reasons for and costs of healthcare professional turnover.

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Learning Objectives

  • Propose strategies for increasing retention, preventing turnover of healthcare professionals.
  • Define and provide examples of conflict of interest.
  • Discuss issues associated with management of the worklife of MDs, RNs, nurses’ aides, midlevel practitioners, and allied health professionals.

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Healthcare Industry

  • Over 14.3 million jobs in 2008.
  • Registered nurses = 2.6 million jobs, 60% of which are in hospitals
  • Physicians = 661,000 majority working in metropolitan areas
  • Physician assistants = 74,800 jobs, about 50% in physician practices, 25% in hospitals, and the rest in outpatient care.

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Physicians

  • Pre-medical students can obtain a degree in any subject.
  • Must graduate with a strong foundation in mathematics, biology, chemistry and physics.
  • Entry into medical school is competitive; applicants must have high grade point averages and high scores on the Medical College Admission Test (MCAT).

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Residency Training

  • National Residency Matching Program (NRMP) matching process for graduating medical students for Graduate Medical Education (GME).
  • Length of the residency training program from three years (for family practice) to ten years (for cardio-thoracic surgery or neurosurgery).
  • After completion of residency, physicians are eligible to take their board certification examinations and practice independently.

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Residency Work Hours

  • Effective July 1, 2011, all specialty and subspecialty residency training programs required to limit resident work hours to no more than 80 hours per week, and in-house continuous duty can’t exceed 24 hours. No moonlighting allowed for PGY-1s.
  • Work restrictions mean increased use of contract physicians or mid-level practitioners, physician assistants and nurse practitioners.
  • Healthcare organization may need to hire ancillary staff and allied health professionals, to do tasks previously covered by resident physicians.

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Physician Licensure

  • Most physicians are eligible to obtain a license to practice medicine after one year of post-graduate training.
  • Licensure is granted by the state, required for physicians, nurses and others to practice, and demonstrates competency to perform a scope of practice. State Boards of Physician Quality Assurance (BPQA) establish requirements for medical licenses.

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Criminal Background Checks

  • Majority of states now have authority to require criminal background checks (CBCs) for physician licensure.
  • Reasons: increasing societal concerns about: alcohol and drug abusers, sexual predators, and child and elder abusers.
  • If CBC shows convictions, boards review the application, looking for level and frequency of criminal behavior, basing their decision on that, along with other materials submitted by the applicant, such as proof of alcohol and drug rehabilitation.

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Board Certification

  • Physicians may voluntarily submit documentation of education, training, and practice to an American Board of Medical Specialists (ABMS) Member Board for review.
  • Upon approval of the medical specialty board and successful completion of examinations, the physician is designated as board certified in that specialty.

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Board Certification (cont’d)

  • Certificates are time-limited. Physicians must demonstrate continued competency and re-take the exam every six to ten years, depending on the specialty.
  • Board certification is a form of credentialing a physician’s competency in a specific area.

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Board Certified/Board Eligible

  • For staff privileges and hiring purposes, most hospitals, HMOs, and other healthcare organizations require a physician to be board certified or board eligible, i.e., preparing to sit for the exams.
  • Board certification is used as a proxy for determining the quality of health professional’s services.
  • Assumption of quality is based on research that more education and training leads to a higher quality of service.

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Continuing Medical Education

  • Most States require physicians to complete a certain number of continuing medical education (CME) credits to maintain state licensure and to demonstrate continued competency.
  • Hospitals may require CME credits for their physicians to remain credentialed.
  • Accreditation Council for Continuing Medical Education (ACCME) establishes criteria for determining which educational providers are quality CME providers and gives its seal of approval only to those organizations meeting their standards.

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Physician Credentialing

  • Physician credentialing is the process of verifying information that a physician supplies on an application for staff privileges at a hospital, HMO, or other healthcare organization.
  • Physician credentialing is a time consuming, labor intensive, costly process that must be repeated every two years. When physicians apply for privileges at a hospital, they must specify what they want, not only by specialty, but in the surgical specialties, by procedure.

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Core and Specific Privileges

  • Core privileges cover a multitude of activities that a physician is allowed to do in a healthcare services organization.
  • Specific privileges would be those activities outside the core privileges and would require documentation of required additional training and expertise in a procedure.

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Physician Credentialing

  • The hospital must conduct diligent research on that surgeon before granting privileges, or it can be held liable in a court of law for allowing an incompetent physician on its staff, should there be a bad outcome.
  • It is preferable to obtain primary verification and documentation, i.e., to contact each place individually by phone and obtain original documents, such as transcripts with raised seals.

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Healthcare Manager’s Role

  • As a healthcare manager, you may find yourself working in the physician relations and credentialing department and you may be responsible for determining whether the credentials offered by a physician are legitimate.
  • Physician credentialing requires excellent interpersonal skills, organizational skills, persistence, an eye for details, and the ability to identify inconsistencies in data.
  • VA (2010) study underscores need for diligence.

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No Gaps in Resumes

  • Since physicians are tracked from the moment they graduate from medical school, the first thing you want to verify is that there are no gaps in their resumes.
  • Physicians rarely take time off “to find themselves.”
  • A significant gap between educational or employment placements is a red flag and you need to question it.
  • You will be responsible for safe, effective patient care, and you must be mindful about who is providing that care.

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Physician Imposters

  • Physician imposters, rare, potentially dangerous individuals, can obtain fraudulent credentials from medical schools in other countries, or even in the US.
  • You must have direct contact with the authorities at the institution where the person claims to have been educated or employed.

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Physician Imposters

  • You will be required to handle telephone inquiries with tact, to ensure that you obtain verification. If no one at an institution knows the individual, or if the medical school has “burned down, leaving no records,” alarm bells should be ringing and you must notify your manager.

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National Practitioner Data Bank

  • The National Practitioner Data Bank (NPDB) was created to have a system, to identify, discipline, and report those who engage in unprofessional behavior.
  • The intent of the NPDB is to restrict the movement of incompetent physicians and dentists from state to state without disclosure.
  • “The information contained in the NPDB should be considered together with other relevant data in evaluating a practitioner's credentials; it is intended to augment, not replace, traditional forms of credentials review”(NPDB, 2010).

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Physician Review of Credentials

  • After the physician credentialing department does due diligence, the materials are submitted to a department credentialing committee, made up of physicians.
  • Upon approval of that committee, documents are forwarded to a Medical Executive Committee, a subcommittee of the hospital Board of Directors (BOD).
  • The subcommittee makes a recommendation to the BOD, which approves or disapproves the application.
  • Time from submission of the application to final approval can take 3 to 6 months. Problems with the application can make the process even longer.

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International Medical Graduates

  • International Medical Graduates (IMGs), can be US citizens who attend school abroad, or foreign-born nationals who come to the US.
  • IMGs represent 26 percent of the US physician workforce.
  • 60% of IMGs are in Primary Care; 75% are in direct patient care.
  • The top three countries for sending foreign-born physicians to the US are India, the Philippines, and Cuba.

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IMGs Serve Poor & Inner City

  • IMGs provide services where US medical graduates won’t go.
  • Must pass English language, clinical skills assessment and written exams before being allowed to apply for residencies.
  • Future US physician workforce will have more US-born IMGs.

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IMGs and Quality of Care

  • A study examining quality of care provided by IMGs in Pennsylvania found the quality of care provided to be as good as care or better than that given by those who graduated from US medical schools (Norcini, Boulet, Dauphinee, Opalek, Krantz & Anderson, 2010).

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Physician Workforce

  • Demographic shifts now seen as forces contributing to future shortage of physicians in the US.
  • Experts agree that the physician workforce will continue to be smaller, younger and to work fewer hours per week regardless of gender (Steiger, Auerbach, & Buerhaus, 2009; 2010).

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Future Physician Shortage

  • Will continue to see controversy of US medical graduates vs. IMGs over the next decades.
  • Role of HCMN manager will be to ensure credentials of IMGs are verified and that they are legally allowed to work in the US.

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Employed PCPs and Turnover

  • Increasing numbers of employed MDs means they will no longer be independent contractors, but employees of healthcare organizations.
  • One recruiter reported that in some communities as many as 90% of the physicians may be employees (Butcher, 2008).
  • Turnover of employed MDs is of concern.

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Direct Costs of PCP Turnover

  • Estimates of recruitment and replacement costs for individual PCPs for three specialties (in 2001):
  • $236,383 for Family Practice (FP);
  • $245,128 for Internal Medicine (IM); and,
  • $264,645 for Pediatrics (Peds).

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Indirect Costs of PCP Turnover

  • Burden of workload on remaining PCPs;
  • Decreased morale;
  • Decreased productivity;
  • Loss of continuity of care; and
  • Loss of clients and revenue stream.

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MD Retention Strategies

  • Women and older male MDs are more likely to opt for part-time employment.
  • One of the more effective retention strategies found in a national survey was the use of mentoring.
  • “Setting clear expectations” for new hires was also cited as another useful retention strategy (Cejka & AMGA, 2007, p.8).

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Job Satisfaction and Burnout

  • Employee turnover has been clearly linked to job dissatisfaction and job burnout.
  • Job satisfaction is the pleasurable or positive emotional state resulting from the appraisal of one’s job or job experiences.
  • Job burnout is a prolonged response to chronic emotional and interpersonal stressors on the job.
  • The organization is the primary cause of job dissatisfaction and burnout. It is the healthcare manager’s role to address these issues.

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Employed MDs and
Conflict of Interest

  • Fears about the influence of gifts and other financial incentives on MD prescribing practices and purchasing behaviors.
  • Some states enacted laws earlier than others to prohibit pharmaceutical or medical device companies from giving more than $100 in gifts to a physician organizations.

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Conflict of Interest

  • Conflict of interest (COI) is a term used to describe when an individual can be influenced by money or other considerations to act in a way that is contrary to the good of the organization for whom he or she works or the patient for whom he or she should be advocating in their best interests.

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COI Policies

  • Many health care organizations have specific policies for physicians and executives regarding COI.
  • Employees must disclose any COIs for themselves or their family members, including spouses. COI documents must be updated annually.
  • HCMN manager responsible for COI documentation and policy enforcement.

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Registered Nurses (RNs)

  • RNs used to be trained in hospital-based programs and received diplomas upon graduation, essentially an apprenticeship, without a set curriculum. In 2010, there were only 68 diploma nursing schools left in the US.
  • The majority of nursing education is now provided in degree-based settings: community colleges, earning an associate degree in two to three years, or university and college baccalaureate programs for professional nursing practice, earning a Bachelors of Science in Nursing (BSN) in four years.

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Baccalaureate Nurses (BSNs)

  • The undergraduate nursing school curriculum (BSN) is rigorous, requiring a good understanding of the biological sciences.
  • Students are eligible to apply for admission to the major only after completing a minimum of 42 undergraduate credits, including at least four laboratory sciences and an English composition course.
  • Admission is based on GPA.

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Nursing Faculty Shortage

  • Fewer nursing faculty mean fewer slots for nursing students.
  • Nursing students must be supervised closely in clinical settings. Faculty supervisor can only have set number of students.
  • Otherwise, patient safety and faculty license are jeopardized.

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NCLEX

  • National Council Licensure Examination (NCLEX) must be passed by nursing students to obtain nursing license.
  • Pass rates on NCLEX act as proxy for quality of nursing school curriculum and the graduating nurse.
  • Some states now require CBCs for RN licensure, for the same reasons as MDs.

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Transition to Nursing Practice

  • In the past, hospitals (the major employer of RNs) have thrown RNs into nursing units after a minimal orientation period.
  • Nursing turnover has resulted, leading to massive costs to the organization, with up to $65K per lost nurse.
  • This becomes millions of dollars when multiplied by the numbers of RNs quitting.

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New Nursing Graduates

  • New graduates worry about communication with MDs, and about hurting patients.
  • Nurse residency programs (NRPs) are one year programs for ICUs, CCUs, and trauma centers that give new grads more education and training.
  • Model NRPs have increased confidence in abilities, increased retention, and reduced RN turnover.

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CCNE Standards for NRPs

  • In 2008, the Commission on Collegiate Nursing Education (CCNE) promulgated standards for the accreditation of NRPs to be implemented in 2009 (Dracup & Morris, 2007; CCNE, 2008).
  • NRPs desiring CCNE accreditation must go through a number of procedures, including a self-study and a site visit (CCNE, 2009).

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Why Nurses Leave

  • RNs quit jobs where they feel overworked, underpaid, and disrespected.
  • RNs are concerned about:
  • being unable to physically continue to do the work;
  • increases in their daily workloads; and,
  • the lack of ancillary staff to support them.

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RNs and Patient Mortality

  • Overwork of nurses and high patient-to-nurse ratios lead to patient mortality, nurse burnout and job dissatisfaction.
  • The difference from 4 to 6 and from 4 to 8 patients per nurse was accompanied by 14% and 31% increases in mortality, respectively (Aiken, Clarke, Sloane, Sochalski, & Silber, 2002)

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More Education, Better Care

  • More nurse education and training leads to a higher quality of service and lower patient mortality.
  • It makes financial sense to employ more RNs per patient, and to hire RNs with a baccalaureate level degree or higher.

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Nurse-Physician Relations

  • In the past, physicians had at least twenty more years of formal education than the RNs they worked with.
  • The educational gap between the two healthcare professional groups has diminished dramatically.
  • Women have also “come of age” since the women’s rights’ movement in the 1970’s. Nurses are no longer the doctor’s handmaiden.

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Physicians and Teamwork

  • MD resistance to acknowledge RNs as professionals and colleagues leads to:
  • poor teamwork;
  • interpersonal conflict; and,
  • potentially poor patient outcomes.
  • Teamwork is essential to a culture of safety.

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Disruptive Behaviors

  • Intimidating and disruptive behaviors include “overt actions such as verbal outbursts and physical threats as well as passive activities such as refusing to perform assigned tasks or quietly exhibiting uncooperative attitudes during routine activities” (The Joint Commission, 2008).

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Sentinel Event

  • Disruptive behavior (either MD or RN) is considered a “sentinel event, i.e., an unexpected occurrence involving death or serious physical or psychological injury, or the risk thereof” (The Joint Commission, 2010).
  • Trust and good communication are central to excellence in healthcare delivery and a culture of safety.

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Organizational Climate

  • Organizational climate is critical to promoting job satisfaction and retention of nursing staff.
  • Nurses who perceive that they have access to opportunity, honest relationships, open communication with peers, co-workers, and managers, and trust their managers are more likely to be retained and to have higher job satisfaction.

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Hallmarks of the Professional Nursing Practice Environment

  • The American Association of Colleges of Nursing white paper identifies attributes of hospitals with work environments that support professional nursing practice, and provides a list of questions a new graduate should ask.
  • The questions posed by the AACN challenge healthcare organizations to rise to higher standards.

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Certification for Nurses

  • Nurses can specialize in practice areas and take examinations that credential their competency.
  • Some examples of certification areas: Ambulatory Care, Cardiac Rehabilitation, Cardiac Vascular, Case Management, Critical Care, and Gerontological.
  • Must demonstrate continuing competency and renew certification on a periodic basis.

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RN Continuing Education Units

  • In many states, nurses are required to obtain nursing continuing education units (CEUs) to renew and maintain their nursing license.
  • Hundreds of providers of nursing CEUs and multiple ways to obtain nursing CEUs, are available. It is the responsibility of the RN to maintain her license.
  • The role of the healthcare manager: ensure that resources, i.e., money and time, are available for nurses to participate in these educational opportunities.

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Foreign Educated Nurses

  • In 2004, about 3.5% percent (100,791) of the RNs practicing in the US received their basic nursing education outside the US. Over 50% come from the Philippines. About half have a baccalaureate degree or higher.
  • Most US state nursing boards have stringent requirements for foreign-educated nurses, including completion of the Commission on Graduates of Foreign Nursing Schools (CGFNS) certification program (CGFNS, 2006).

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Foreign RNs and HCMN Manager

  • The CGFNS Certification Program removes a major burden, however, the healthcare manager must ensure that foreign-educated nurses have fulfilled all the requirements of the State Board of Nursing, and that they are legally allowed to work in the US.
  • Different cultures bring varying expectations to the work setting. Excellent interpersonal skills, conflict management, cultural competency and sensitivity to diversity issues are critical for you to be able to be an effective healthcare manager for these employees.

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LPNs/LVNs

  • In 2008, about 753,600 Licensed Practical Nurses (LPNs) or Licensed Vocational Nurses (LVNs) worked under the supervision of physicians and nurses in the US. About 25% employed in hospitals, 25% in nursing care facilities, and 12% in physician’s offices.
  • After graduation from high school, LPNs are trained in one year, state-approved programs, then must pass the LPN licensing exam, the NCLEX-PN.

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LPNs/LVNs (cont’d)

  • LPNs do basic nursing functions, such as vital signs, and observing patients, assisting patients with activities of daily living (ADLs), like bathing, dressing, and feeding. With additional training, where state laws allow, they can also administer medications.

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LTC and LPNs

  • LPN’s are the backbone of the long-term care (LTC) sector of the healthcare industry, providing around the clock care and supervision of certified nurse’s aides (CNAs) in nursing homes and convalescent centers.
  • Many LPNs go on to earn their RN, and in some states, LPNs can take challenge examinations to earn their RN licensure.
  • LPNs are important members of the healthcare team, and should be included in the healthcare manager’s tuition assistance plans.

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Nurses’ Aides (NAs)

  • In 2008, there were about 1.5 million nursing and psychiatric aides employed in nursing and residential care facilities, hospitals, psychiatric and substance abuse facilities (BLS, 2010).
  • Nursing aides, nursing assistants, certified nursing assistants (CNAs), orderlies, and other unlicensed patient attendants work under the supervision of physicians and nurses, answering call bells, and assisting patients with ADLs.
  • Regardless of employment setting, aides are front line healthcare personnel.

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CBCs and NAs

  • In the past, CNAs were not required to have criminal background checks (CBCs), and elder abusers, sexual predators, and thieves preyed upon the elderly. Now the majority of states and employers require CBCs.
  • A clean CBC doesn’t guarantee that the person hasn’t or won’t abuse a patient.
  • The healthcare organization must have policies about neglect and abuse prevention in place, and the healthcare manager must be vigilant and enforce them.

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CNAs and Turnover

  • CNAs are trained on-the-job in 75 hours of mandatory training, and required to pass a competency examination. CNAs provide direct care to patients over long periods of time.
  • Estimates of CNA turnover from LTC facilities ranged from 40% to 166%, with indirect and direct costs per lost worker ranging from $951 to $6,368, with a minimum direct cost of $2,500 per lost worker.
  • The job of the healthcare manager is to improve retention to slow down or stop turnover by addressing the quality of worklife.

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Home Health Aides

  • In 2008, there were 1.7 million home health and personal care aides employed in the US (BLS, 2010).
  • Hospitals are discharging patients quicker and sicker, which means more and more health care that used to be provided strictly in hospital settings is now given at home (Landers, 2010).

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Home Health Growth

  • In addition, due to the demographic tsunami of aging baby-boomers who wish to age in place (i.e., at home) and due to the increasing longevity of individuals with chronic diseases and disability, this area of employment is expected to grow dramatically over the next decade—and hospitals will be in this business, too.

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Assessing Quality of Worklife

  • The healthcare manager needs to assess the quality of the work environment, including employee job burnout and satisfaction. Some of the items to be included are:
  • Job autonomy, variety and significance;
  • Fairness of pay and benefits;
  • Opportunities for promotion and advancement;
  • Relationships with supervisors;
  • Relationships with co-workers;
  • Level of job burnout; and,
  • Overall job satisfaction.

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Midlevel Practitioners

  • Midlevel practitioners work mid-way between the level of an RN and that of an MD.
  • Advanced Practice Nurses (APNs), such as Nurse Practitioners (NPs), Clinical Nurse Specialists (CNS), and Nurse Anesthetists, Nurse Midwives.
  • Physician Assistants (PAs).

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Midlevel Practitioners (cont’d)

  • Serve in a variety of settings: hospital emergency rooms or departments, covering hospital floors for physicians, community health clinics, physician offices and health maintenance organizations.
  • Are usually less expensive than physicians, often replacing MDs at a 2:1 ratio.
  • Are much sought after by healthcare organizations because they can provide many of the same services as physicians, at a lower cost.

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Advanced Practice Nurses (APNs)

  • In 2008, an estimated 250,527 RNs reported that they were prepared as an advanced practice nurse in one or more advanced specialties or fields, an increase of 4.2 percent from 2004, when there were 240,460 prepared for advanced practice” (HRSA, 2010, p. 19)

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Advanced Practice Nurses

  • Nurse Practitioners (NPs) prepared in either an NP MSN program or in a post-master certificate and must graduate from an accredited program that includes both didactic and clinical components and a minimum number of hours (specified by the specialty) of supervised clinical practice in the specialty area.
  • Can become certified in specific areas of care.
  • Must pass a certification exam and maintain their competency through continuing nursing education, and/or re-certification exams.

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NPs and Independent Practice

  • Only eleven states permit nurse practitioners to practice independently, i.e., without physician supervision.
  • However, in light of looming physician shortages, these laws may soon change (Christian, Dower, & O’Neil, 2007).

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Clinical Nurse Specialist (CNS)

  • Has in-depth education in the clinical specialty area at a Master’s degree level and must have all of the same educational qualifications as an NP, but in their area of focus, plus a minimum number of specified hours of supervised clinical practice in their specialty area.
  • Can become certified in specific areas of care.
  • Must pass a certification exam and maintain their competency through continuing nursing education, and/or re-certification exams.

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Certified Registered Nurse Anesthetists (CRNAs)

  • Specialize in providing anesthesia, working in cooperation with anesthesiologists, surgeons, dentists, and other healthcare professionals.
  • To become a CRNA, in addition to having a BSN and an RN, and having worked at least one year as an RN in an acute care setting, the nurse must graduate from an accredited master’s degree nurse anesthesia program.
  • CRNAs must also pass a national certification examination.

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Nurse Anesthetists’
Quality of Care

  • A review of six years of data from the Centers for Medicare & Medicaid Services (CMS) found no adverse outcomes in states where nurse anesthetists were allowed to practice solo, i.e., without the supervision of physicians (Dulisse & Cromwell, 2010).
  • Cheaper, more available than MDs and equally safe—who would you hire?

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Certified Nurse Midwives (CNMs)

  • Licensed as independent practitioners in all 50 states.
  • Must be RNs, with at least 1-2 years of nursing experience, and graduate from a nurse-midwifery education program accredited by the American College of Nurse-Midwives (ACNM) Division of Accreditation (DOA) and pass a national certification examination.
  • Over 80% of all nurse midwives have master’s degrees; another 7% have doctoral degrees.

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Physician Assistants (PAs)

  • In 2008, there were 74,800 PAs employed in the US (BLS, 2010).
  • Over 140 accredited educational programs as varied as certificate programs, associate degrees, baccalaureate degrees, and masters’ degrees.
  • Take the Physician Assistant National Certifying Examination and must demonstrate competency, to be recertified every six years, and earn 100 CME hours every two years
  • PAs are versatile, valuable members of the healthcare team and are highly sought after by physician practices, hospitals, and other employers.

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Allied Health Professionals

  • More than 2000 programs in over twenty health science occupations.
  • Assist physicians and nurses in providing care to in a variety of settings.
  • Many of the occupations have grown from the unmet demand for help in the highly specialized operating room environment. Others have grown out of the technological boom and the need for people to operate highly specific equipment.

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Allied Health Shortages

  • Respiratory therapy is particularly affected, along with radiology technologists and certified nursing assistants.
  • One survey found all three groups were dissatisfied with current worklife, and claimed inadequate staffing was the “number one problem they face.” They felt healthcare professional shortages compromised patient care, and that turnover was impacting retention and recruitment.

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Allied Health Shortages (cont’d)

  • Recommendations included: increased salaries, improved staffing ratios, better health benefits, more input into decisions, flexible schedules, increased support staff, and continuing education
  • These are all under the control of the health care manager.

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