Kathleen D. Sanford

At a Glance

To help promote innovation in health care, nursing and finance leaders can:

  • Begin by asking the "why" and "why not" questions  
  • Earmark dollars for experimental care models  
  • Advocate for eliminating legal and regulatory barriers that prevent innovation  

Finance and clinical leaders are acutely aware of the challenges facing health care today. We know that healthcare costs need to be cut and that quality can be improved. This is our reality, even if political maneuvering ultimately changes part, or all, of the Affordable Care Act of 2010. To address this new "normal," nearly every conference speaker on the circuit is urging us to transform our hospitals and health systems through innovation.

The government is also fanning the flames of innovation. For example, the Centers for Medicare & Medicaid Services (CMS) has developed a Center for Medicare & Medicaid Innovation as a result of the Affordable Care Act. CMS describes the center as "a new engine for revitalizing and sustaining Medicare, Medicaid, and the Children's Health Insurance Program (CHIP) and ultimately for improving the healthcare system for all Americans." CMS also notes that the center "has the resources and flexibility to rapidly test innovative care and payment models and encourage widespread adoption of practices that deliver better health care at lower costs."a  

Even before CMS developed this new center, many hospitals and health systems listed innovation as one of their core values. These organizations recognize that change is essential if we are truly going to increase our value to society. This means shifting our product from sick care, in which we are rewarded for doing more for individual patients whether the results are effective or not, to health care, in which payment is based on quality, not quantity, of services.

Innovators and Limiting Assumptions

Who "owns" innovation? Classic marketing theory divides those who adopt new technologies or products into innovators, early adopters, the early majority, the late majority, and laggards. The innovators and early adopters are willing to take risks and embrace transformation. The early majority and the late majority move a bit less quickly because of skepticism about change. The last group, the laggards, are the last to adopt innovation because of their focus on maintaining tradition.b  

If we are to meet our current and forthcoming challenges, our hospitals and health systems require innovators and early adopters at every level of leadership. Nursing and finance leaders can-and should-fill these roles in their organizations to help transform health care.

Why is change often so difficult in health care? One reason is that our limited margins make it difficult to allocate capital and operating dollars to experiments that could fail.

The inertia of the status quo also is abetted by a sea of laws and regulations, professional associations that covertly and overtly fight change, and a cultural history that accepts things the way they are. These forces continue to hold sway even in the wake of major challenges affecting our industry.

Take, for example, the projected shortage physicians, which the Kaiser Commission on Medicaid and the Uninsured predicts will reach 91,000 physicians by 2020. Approximately half of these unfilled slots will be in primary care. Yet there also is evidence that nurse practitioners (NPs) could play a major role in filling this gap. Studies suggest that the quality of primary care provided by NPs is equal to that of physicians. What's more, patients are generally more satisfied with NP care than with physician care and more frequently receive appropriate advice from NPs.c Yet only 11 states allow these practitioners to practice independently, and most limit their ability to prescribe medications.d  

The NP issue is just one example of how our focus on maintaining traditional roles leads us to remain change laggards. To be healthcare innovators, we have to challenge everything about the status quo, which requires asking "Why?" And then we should envision something new and different, which calls for the question, "Why not?"

As an example, consider the following questions addressing the physician shortage:

  • Why continue encouraging medical students to go into primary care if other practitioners could provide this service with the same quality of care and at less expense?
  • Why not focus on educating physicians in other specialties and subspecialties in which there are projected shortages, such as surgery and gastroenterology?e  
  • Why not provide more virtual primary care?

The truth is that many healthcare stakeholders are uncomfortable with these types of "why" and "why not" questions, even when our current system is a relic of outdated assumptions that don't reflect today's realities or technology.

Popular culture provides an example of when "why" should have been asked that, despite the trivial context, aptly illustrates this point. Back in the 1960s, writers of the Star Trek television series equipped the starship's physician, Dr. McCoy, with a device that could diagnose any medical problem when he waved it over an ill or injured crew member. Back then, it was unthinkable for the writers-and the audience-to question why Dr. McCoy alone had ownership of this handheld scanner. Why couldn't Nurse Chapel have wielded the device, or for that matter, why not Mr. Sulu?

Of course, almost 50 years ago, the Enterprise and her crew were science fiction. Today, though, there is a new computer system known as Watson, which is currently being programmed with information from medical textbooks, journals, research, and patient interviews. Watson may soon be able to suggest diagnoses and treatments by reviewing a patient's medical history and current symptoms.f It could even be more valuable when it is programmed to evaluate a patient's genetic makeup and laboratory test results. Given this type of innovation, why should we assume physicians will always be the primary diagnosticians or care providers?

The same type of "why" and "why not" questions apply to other clinical areas, such as nursing and pharmacy. Why not consider the possibility that someone else-armed with technology-could perform at least part of these professionals' jobs? Innovators ask this kind of question, inevitably causing discomfort and protest among those who are predisposed to resist change that could transform their profession or lifestyle. Of course, some resistance to innovation is rooted in reality, given what we know has been best for patients and society so far. Often, those who fight change have years of evidence on their side. However, true innovation often challenges assumptions we may have held for a lifetime. Such change requires a clear-eyed examination of current realities, along with creative minds who can conceive the possibilities for the future. Many organizations have tapped into their own internal innovators and are already piloting change (see the sidebar below).

The bottom line: Innovation means asking why we continue to embrace practices and systems we've had for decades, or even centuries, that not only are expensive, but also fail to produce the highest quality outcomes possible. And nursing and finance leaders should be among the first to raise their hands when it's time to ask why-and why not.

The Finance Leader's Role in Innovation

Senior finance leaders and their teams have an essential role in driving innovation within hospitals and health systems. Working with clinical and strategy leaders, finance leaders can help organizations invest in the future by earmarking dollars for experimental care models. Such projects may not be reimbursed under current payment systems nor meet existing quality and cost goals. Pursuing such models requires the courage and foresight to allocate part of the current budget to innovative projects that may not have an easily identifiable ROI.

The senior finance executive can help the entire executive team think in more innovative ways by sponsoring meetings with futurists who can help the group envision their organization's future and strategize for success in one, two, five, and 10 years. In addition, these finance leaders can promote change by working with their advocacy colleagues to eliminate legal and regulatory barriers that prevent innovation. Such barriers include state laws that restrict the use of technology, such as telemedicine, across state lines and that limit physicians in one state from consulting and prescribing virtually for patients in another state. When addressing such restrictions, finance leaders can help advocate breaking down barriers to such healthcare models as a means to reduce costs while increasing quality of care.

Finally, finance leaders may be in a better position than their clinical colleagues to drive innovation by asking the why and why not questions. Clinical professionals are all too often mired in their traditions and inclined to promote their own agendas when advocating for change. Finance professionals, however, tend to be experts on pushing for explanations. Finance's role in questioning financial assumptions during the budgeting process is one example. By working with their clinical colleagues, finance can help challenge the "way we do things now" so that organizations can move forward with innovations that may decrease costs while providing better health care for all.

Kathleen D. Sanford, RN, MA, DBA, FACHE, is senior vice president and CNO, Catholic Health Initiatives, Denver (kathleensanford@catholichealth.net).


a. The Innovation Center (www.innovations.cms.gov).

b. Rogers, E., Diffusion of Innovations, Glencoe, Ill.: Free Press, 1962, p. 150.

c.  "Improving Access to Adult Primary Care in Medicaid:Exploring the Potential Role of Nurse Practitioners and Physician Assistants," Kaiser Commission on Medicaid and the Uninsured, March 2011 (www.kff.org/kcmu).

d. "Healthcare Reform Memo," Deloitte Center for Health Solutions, Sept. 7, 2010 (www.deloitte.com).

e. Williams, T.E., and Ellison, E.C., "Population Analysis Predicts a Future Critical Shortage of General Surgeons," Surgery, October 2008, pp. 548-54; and "The Impact of Improved Colorectal Cancer Screening Rates on Adequacy of Future Supply of Gastroenterologists," The Lewin Group, Jan. 7, 2009.

f. "Researchers Preparing IBM's Watson Computer for Medical Applications," iHealthBeat and California Healthcare Foundation, May 23, 2011 (www.ihealthbeat.org  [search on Watson Computer]).




Current Innovative Models  

Centura Health, located in Englewood, Colo., uses nurses to perform virtual visits and monitor services for patients in their own homes. The virtual program has helped prevent or decrease emergency department visits, hospitalizations, and hospital readmissions. According to Erin Denholm, CEO of Centura Health at Home, the average hospital readmission rate for patients with congestive heart failure is 20 percent, compared with 3.2 percent for patients in the telehealth program. (For additional information, contact Erin Denholm, erindenholm@centura.org.)

The Global Nursing Network, Sioux Falls, S.D., uses neighborhood health coaches to improve family, neighborhood, and community. Under the supervision of a registered nurse case manager or a university-based practice nurse, lay coaches are trained and supported with web-based tools. Each coach works with 10 local families to address lifestyle choices, weight reduction, stress management, increased activity, and better nutrition. By empowering underserved and uninsured patients to take control of their health, the program has reduced the use of emergency services for nonemergent
illnesses. (For more information, contact JoEllen Koerner, RN, PhD, FAAN, jkoerner@interactivethink.com, or Sheila Ryan, PhD, FAAN, saryan@unmc.edu.)

PharmacistDirect is a telepharmacy program implemented in 2009 as a partnership between North Dakota State University College of Pharmacy, the North Dakota Board of Pharmacy, the North Dakota Pharmacists Association, and Catholic Health Initiatives. With initial funding from a Health Resources and Services Administration (HRSA) grant, the program now provides 10 sites in North Dakota and seven sites in Minnesota with access to virtual pharmacists 24 hours a day, seven days a week. Small hospitals in communities that have had difficulty attracting pharmacists now have
pharmacy service around the clock. (For more information, contact Shelley Johnsen at shelleyjohnsen@catholichealth.net.)

The Center for Healthcare Innovation (CHCI), part of the Institute for Research and Innovation of Catholic Health Initiatives (CHI), was launched in 2010, funded by CHI's Board of Stewardship Trustees. CHCI joined two other centers (the Center for Clinical Trials and the Center for Translational Research) to address impending healthcare challenges across the nation. CHCI helps identify, pilot, and evaluate new healthcare delivery models that can be adopted by CHI's facilities. Among the innovations being studied is a virtual coach model for new inpatient nurses that addresses the growing challenge of attracting and retaining nurses across the country. (For more information, contact Milt Hammerly, MD, at milthammerly@catholichealth.net


Publication Date: Thursday, September 01, 2011

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