APRNS AND MEDICAL EXECUTIVE COMMITTEE MEMBERSHIP 1
Advanced Practice Registered Nurses and Medical Executive Committee Membership:
A Quality Improvement Proposal
Amy Louise Vaflor
Kent State University
College of Nursing
Chair: Dr. Lynn Gaddis
Mentor: Dr. M. Shah
Date of Submission: July 31, 2020
APRNS AND MEDICAL EXECUTIVE COMMITTEE MEMBERSHIP 2
APRNS and Medical Executive Committee Membership:
A Quality Improvement Proposal
Introduction
The title of “advanced practice registered nurse” or “APRN” has originated as nurse practitioners (NPs) began to expand access for quality patient care and offset physician workloads (Chan, 2014). The growing entity of providers demanded a name that suited the educational differences and clinical training. Advanced practice registered nurse (APRN) includes the following practitioners: Certified Nurse Midwife (CNM), Certified Nurse
Practitioner (CNP), Certified Nurse Specialist (CNS), and Certified Registered Nurse Anesthetist
(CRNA). As more advanced practice nurses provide healthcare within the confines of a hospital, the areas of their influence continue to grow. This valuable growth has brought questions involving the APRN community and their relationship to the medical staff, hospital committees, and administration.
Healthcare systems are filled with APRNs and today's patient is well aware of non-physician care providers. Between 2013 and 2015, the Center for Advancing Provider Practices (CAP2) provided data showing 61% APRN growth in 37 organizations (Anen & McElroy, 2017).
However, few hospitals have positioned APRNs within the medical executive committee (MEC).
The scarcity of APRN roles on hospital medical committees is puzzling as the national growth of the advanced practice nurse continues at a rapid pace. Multiple advanced practitioner journals, professional practice organizations, and textbooks direct APRNs toward positions in leadership as part of our professional responsibilities. As for the APRN provider, the author was unable to find statistics reporting advanced practice nurses on hospital medical executive committees.
APRNS AND MEDICAL EXECUTIVE COMMITTEE MEMBERSHIP 3
Quality Improvement
Quality improvement (QI) is now a common and permanent quest for healthcare systems.
According to a 2016 study, each year, American medical practices spend 15.4 billion and 15.1 hours per physician per week for quality measurement issues (Casalino et al., 2016). Quality management encourages the use of QI methods, yet the effectiveness of QI influencing problematic health care issues have varied as well as yielding disappointing results (Dixon-
Woods & Martin, 2016). The inconsistency of quality improvement efforts has initiated providers to contemplate multiple elements addressing quality measurement (Health Catalyst,
2018).
Triple Aim (IHI, 2020) has provided areas for QI in population health, cost containment, and patient experiences. However, to achieve the Triple Aim, clinician empowerment and engagement was found to be a necessary component; this is now known as the Quadruple Aim
(Bodenheimer & Sinsky, 2014). The need for a healthcare system to adapt quickly to provide quality and effective patient care can be addressed with the APRN force (Younger, 2020). An
APRN membership on the MEC brings to discussion not only advanced practice empowerment but also, the opportunity to support the QI process. The expertise and input from an advanced practice nurse within executive teams promotes the translation of QI measures. This increased buy-in from an APRN practitioner, who is at the forefront of patient support, understands clinically relevant practice issues to address better care and outcomes (Melnyk, 2016; Health
Catalyst, 2018).
However, the placement of an APRN into medical executive committees is not an easy or quick undertaking. There needs to be an understanding and education of the current thinking from both the APRN community and physician teams to move forward in a MEC collaborative
APRNS AND MEDICAL EXECUTIVE COMMITTEE MEMBERSHIP 4 direction. The project is a QI proposal to assess the readiness and understanding of the APRN practitioners towards MEC membership.
The chosen tool for framing the quality improvement process and documenting a test of change was the Plan-Do-Study-Act (PDSA) model (Institute for Healthcare Improvement
[IHI], 2020). This model provided a foundation for the DNP QI proposal to address current topics involving APRNs and MEC membership positions. The PDSA process guided the task of evaluating APRN value, recent trends of APRN confidence, and engagement beyond the bedside. Each cycle of the PDSA illuminated the current progress and barriers of APRN membership and assisted in establishing future plans for APRN executive positions.
THE PLAN PHASE
Background
Hospital leadership has evolved from a physician-led, hierarchical authority to a diverse collection of individuals overseeing top strategy, financial, IT, and population health issues
(Dyrda, 2017). Additional persons in hospital committees can include the chief executive, business, experience, research, quality, and legal officers (Dyrda, 2017). However, despite the increase and various expansion of the advanced practice providers, few APRN memberships on medical executive committees have occurred.
Four significant trends driving APRN prominence and autonomy include national physician shortages, increased demands on physician workloads, tremendous APRN growth, and an increase of the aging patient population (Bean, 2018). Advanced practice nurses are continuing to ensure safe and accessible patient care. Medical credential committees endorse
APRN privilege applications thus furthering alignment within medical staff departments. The application is then sent for final review and approval by a MEC or governing committee.
APRNS AND MEDICAL EXECUTIVE COMMITTEE MEMBERSHIP 5
Therefore, MEC memberships should be reflective of advance practice presence within healthcare systems. The mixture of providers signifies diversity in the current day of healthcare delivery and advocates for a transformation of the traditional medical executive committee.
The clinical integration of APRNs and physicians is well documented with collaborative relationships at the bedside benefitting patients. As the growth and continued utilization of the advanced practice provider is indispensable, the lack of their membership on hospital medical executive committees is perplexing.
Purpose and Aim
The initial DNP proposal aimed to discover the potential membership of advance practice nurses on medical executive committees. The purpose was twofold: to collect information related to APRN MEC membership potential and to address the current literature findings of
APRN clinical value and the lack APRN presence beyond the bedside.
Environmental and Validation Plan
For the planning phase, a local opportunity was identified for assessing APRNs and their views towards medical committee membership. The prospect of advancing interprofessional connections within executive medical teams is a positive realism for complementing the clinical aspects of collaboration between APRNs and medical staff. The DNP proposal designed an electronic survey as a strategic method to collect information in relationship to APRN leadership readiness and their believed value beyond the bedside. The results will aid in constructing a plan to progress APRNs into leadership positions within the medical staff.
An environmental scan will utilize the Ohio Hospital Association (OHA) information. OHA represents 236 hospitals and 14 health systems (OHA, 2020). OHA membership hospitals, in
2019, was 188 acute care hospitals; 21 long-term acute care; 27 psychiatric, rehabilitation and
APRNS AND MEDICAL EXECUTIVE COMMITTEE MEMBERSHIP 6
specialty surgical hospitals; and 10 children's hospitals (OHA, 2020). The DNP student will
focus on acute short-term care, critical access, and children’s hospitals medical executive
committees and advance practice departments.
Lastly, a validation group will be assembled to conduct a root cause analysis. The group will
be asked to identify possible reasons APRNs are rarely present on MECs. The findings will be
placed within a fish bone diagram to visually display potential causes and effects of the proposal
problem question. The validation group will consist of two APRNs; a nurse practitioner and a
certified registered nurse anesthetist, and a physician. The nurse practitioner is a current voting
member of the MEC within their healthcare system. The selected physician has held positions in
all areas of medical staff leadership.
The root cause analysis was formed through conversations with the validation group. The
diagram is shown below:
PEOPLE ENVIRONMENT *Lack of Ownership. (no vote = no participation) *Value of APRN from CEO perspective
* Impact or concern on hospital leadership team * Inconsistent educational perceptions *Barriers of stakeholders * Capable clinical provider Why are there few APRNs
on MECs?
*No consistent educational *Financial Issues perception *Political Agendas
*No standard MEC governance MATERIALS MACHINE
METHOD
APRNS AND MEDICAL EXECUTIVE COMMITTEE MEMBERSHIP 7
In this period of healthcare transformation, the exploratory QI proposal would create awareness and data regarding APRN readiness and progress towards memberships on hospital
MECs. The DNP proposal can assess and disclose APRN attitudes of a positive, neutral, or negative direction towards APRN memberships on hospital medical executive committees. This tangible example is sorely needed as the literature does not clearly address a presence or examples of advance practice providers incorporated into hospital medical executive committees.
Search Strategies
To investigate memberships of the APRN on hospital medical executive committees search terms included: APP, advanced practice providers, PA, CRNA, CNM, CNS, CNP, attitudes, physicians, hospital, boards, leadership, trust, governance, interprofessional collaboration, MEC, and medical staff integration. Databases included Cochrane collection, CINAHL, Medline, and
PsycINFO. The inclusion criteria were hospital and clinic care sites who employed APRNs and physicians. Exclusion criteria included hospitals or clinics that only used APRNs or physicians.
For the OHA membership hospitals, search terms within the healthcare websites were: APP,
APRN, advance practice providers, administration, leadership, governance, MEC, and executive staff.
Significance
The changing healthcare system has created the need for a diverse membership among medical committees. A variety of clinicians provide comprehensive quality care. Memberships on MECs and leadership boards, reflecting a modern-day care template, should mirror all providers caring for the hospital patient (Burroughs, 2015). Multiple views, i.e., nursing, medicine, and now, advance practice providers, are necessary to navigate the rapid changes in patient care. The absence of an APRN brings a delay to policy conversations. However, the APRNS AND MEDICAL EXECUTIVE COMMITTEE MEMBERSHIP 8 presence of an advanced practice provider would provide expertise in areas that involve discussions of education, EBP, clinical abilities, scopes of practice, and prescriptive issues.
Contribution from the APRN would reduce the time of "finding that answer" to inform the executive team for developing hospital policies. In representing the advanced practice provider,
APRN membership should be viewed as a knowledgeable, professional able to contribute to executive decisions and policy development. The reorganizing of the MEC aligns with a contemporary approach in navigating the views and perspectives of non-physician clinicians on the medical staff (Burroughs, 2015).
Medical Executive Committees
The MEC was designed to manage the large and complex nature of hospital departments
(Burroughs, 2015). Credentialing, privileging, peer review, and quality issues were review among a large group of medical staff officers, department chairs, and ex-officio members of senior management, including the CNO.
Synthesis of Literature
The literature review revealed the national recommendations for advanced practice providers presence in leadership. APRN involvement in patient care settings is noted along with the current medical acknowledgment to the benefit of the clinical role. The review of trust in management literature authenticated characteristics that have been longstanding despite the domain of focus. Articles found APRN leadership language to include collaboration, comanagement, and interprofessional terms.
This review did not address the economic contributions of APRN or the scope of practice variance within the United States or other countries. The search did not include the development nor the history of medical staff or hospital leadership development. APRNS AND MEDICAL EXECUTIVE COMMITTEE MEMBERSHIP 9
APRN and Medical Staff Expansion
Improvements for healthcare have acknowledged the need for expansion in the nursing discipline. The increase in patient numbers, complex health needs, and limited access has burdened the traditional models of healthcare. This expansion has led to the promotion of the
APRN role. The Institute of Medicine (IOM, 2011) committee formulated four key messages with one recommending a full partnership with physicians and other health professionals. The
IOM’s recommendation stated, “bedside to boardroom” (IOM, 2011, p. 7) for nurses being full partners in leadership, serving actively where policy decisions are created for improved care.
Hospitals have governing bodies to direct policies, conduct, and management of both nurses and physicians. In 2012, the Center for Medicare/Medicaid Services (CMS) expanded the medical staff definition to include non-physician practitioners. This regulation change included advanced practice registered nurses and physician assistants. The Code of
Federal Regulation (C.F.R, 2011) is the primary source for federal regulations and includes codification for CMS and the Department of Health and Human services. Title 42 C.F.R 482.22 allows hospitals and their medical staffs to take advantage of the expertise and skills of all types of practitioners who practice at the hospital when making decisions concerning medical staff privileges and membership. In 2014, Title 42 C.F.R. 482.22 (a) Medicare Conditions of
Participation clarified state laws would determine the eligibility for appointments by the governing body. The document does state the membership to the governing body is not a requirement but optional. (CMS, 2012).
Trust
The social construct of trust is deeply embedded in nursing and medicine. A recent Gallup poll finds Americans trusting nurses first, followed by doctors and pharmacists. (Brenan, 2018).
APRNS AND MEDICAL EXECUTIVE COMMITTEE MEMBERSHIP 10
Organization science reflects the importance of trust between the employer, workplace performance, and the employee (Brown, Gray, McHardy, & Taylor, 2015). The influx of advanced practice into the hospital system has created change not only in numbers of practitioners but also the increased patient care areas in which an APRN is utilized. The change in practitioner mix affects trust within a system. The various perspectives, roles, and culture of clinicians and management can diminish trust between clinicians and organizations (Kornacki,
Silversin, & Chokshi, 2019). Morgan and Zeffane (2003) found change to be a positive influence on trust, but overall, an organizational structure change had the most negative impact on trust.
The authors contended that trust was a relational phenomenon. The membership of APRN on a
MEC would be a result of the relational trust first developed at the bedside and acknowledgment of provider combinations.
Outcomes in Patient Care
Bedside integration of APRN and physicians is well documented. From the emergency room
to surgery, intensive care units to primary care, the utilization of an advanced practitioner is respected as a health team member. Emergency rooms are utilizing nurse practitioners (NPs) to offset shortages of emergency room physicians. Tucker and Bernard (2015) highlighted a model of using NPs in the triage and fast-track areas. They decreased door-to-provider times by 27.17 min, decreased the overall length of stay an average of 18.3 min with daily visits increasing by
2.25 patients per day. The nurse practitioners contributed care resulting in patient satisfaction at more than 90% during the two-year trial.
With the need for quick assessment and intervention, the APRN enhances the care given to trauma patients. (Messing, J. et al., 2017) The ICU patient can benefit from APRN and physician interactions to receive high-quality care. Donovan et al., (2018) noted interprofessional patient
APRNS AND MEDICAL EXECUTIVE COMMITTEE MEMBERSHIP 11 care involving APRNs and teamwork was vital in providing clinical support. The increased complexity and diverse needs of the ICU patient support this relationship for better care. In surgery, resident physicians work closely with APRNs. In Clark et al., (2018), the impact of
APPs was positive, with 44.1% residents noting the importance of the APP. Interestingly, this study revealed that 42.4% of the participants indicated the role of the advanced practice practitioner was not well-defined.
APRNs address complex patient care situations and improve the value of care. Harr et al.,
(2015) demonstrated the importance of APNs in radiation oncology. This APRN-led clinic improved outcomes with patients having head and neck cancer. The patients in the APN group had a 16.7% rate of adverse events versus the 60% in the standard management group. ER visits were also lower for the APN-led care at 24%, versus 50% in the control group. The literature supports not only the involvement of the APRNs but also their positive outcomes in patient care.
Integration of APRNs
The language of integration brought terms of collaboration, comanagement, and interprofessional words. This expression was applied to the APRN and physician relationship when working together, whether at the bedside or within a leadership context. In family medicine, Norful et al., (2018) discussed a co-management approach. This model of nurse practitioner-physician comanagement had three elements: effective communication; mutual respect and trust; and clinical alignment/shared philosophy of care. This systematic review revealed twenty-six interviews, with nurse practitioners and physicians, having the elements of integration. However, the process had been inhibited due to undefined barriers from legal and organization areas, recommending further research to measure the comanagement. The article
APRNS AND MEDICAL EXECUTIVE COMMITTEE MEMBERSHIP 12 did not address integration within the medical committee sphere.
A collaborative management model was discussed in 2013, with Matthews and Brown. The article addressed bringing both nurse and physician into an interprofessional/collaborative practice. They asserted that APRNs need to strengthen their practice environment to maximize their potential while enhancing collaboration (Matthews and Brown, p.3). Again, they stressed collaboration with physicians but spoke to the inadequacy of a working strategy even at the point of direct clinical care. They stated organizational support needed but did not define the levels, nor address medical staff integration as a component of this process.
Current Integration Barriers
Interprofessional relationships will bring some degree of interpersonal conflict. Good collaborative practices will encounter disagreement and dispute. In DiCiccoo-Bloom and
Cunningham, (2015) the ability to function independently and engage in reciprocal consultations with physicians, within their practice group, brought highly collaborative relationships. Yet when working with physicians, in other departments (i.e., radiology, billing, or specialists) within the same hospital system, physicians were disruptive to the practice. The disruption included undermining morale, poor patient assignments, and counter-productive means of communicating patient test results. Interprofessional role perception varied among these physicians, creating barriers but did not address what was being attempted to change the culture. The conclusion of the article stated the American Medical Association (AMA) and outside organizations might be creating systematic barriers for optimal use of APRNs.
Hain and Fleck (2014) discussed that the American Medical Association believe that their training and education are more rigorous, and therefore, nurse practitioners are incapable of delivering better care. However, American College of Physicians has identified the importance of the APRN, publishing a policy paper to recognize the position and value of the NP (American APRNS AND MEDICAL EXECUTIVE COMMITTEE MEMBERSHIP 13
Colleges of Physicians, 2009). These differing opinions may be promoting confusion among the various physician organizations concerning APRN roles and leadership positions.
Full practice barriers are often cited as a limit of APRN practice. The willingness of physician counterparts to collaborate, whether clinically or administratively, reflects institutional and state limitations. Wolf et al. (2017) found barriers related to hospital administration, restrictive hospital policies and physician-led decisions in the practice area. The writers reported that practice settings can have both supportive and uncooperative attitudes towards APRN contributions. Positive physician-nurse collaboration, supportive institutional culture, and strong nursing leadership facilitates APRNs. The most serious consequence of practice limitation was APRNs exiting as physicians, or hospital policies would not allow advance practice nurses to do procedures despite the education and training of the APRNs.
Wide variations in APRN practice opportunities continue to complicate APP positions in hospital leadership committees.
The challenges of APRN integration include full practice issues, receptivity, and relationships with physicians. The barriers have extended into leadership and boardroom areas. Dubree,
Kapu, & Parmley (2015) authored difficulties of practice in relation to the full extent of the
APRN’s education. Despite requests for organizations to expand opportunities for interprofessional collaboration, the expansion has not gone much beyond the clinical area. In
2015, Dubree, Jones, Kapu, and Parmley discussed the receptivity of physician partners in the community and organization. The issue of potential competition with APRNs can thwart collaboration thus hinder integration within the medical staff.
Advanced Practice Leadership Progress
The American Association of Colleges of Nursing (AACN) indicates all levels of nursing
APRNS AND MEDICAL EXECUTIVE COMMITTEE MEMBERSHIP 14 education have foundational programs in leadership (AACN, 2019). The APRN position within clinical care identifies practitioners as frontline leaders in healthcare due to managing and navigating patient care issues (Lamb, Martin-Misener, Bryant-Lukosius, & Latimer, 2018).
Advanced practice, a modern term, has evolved to describe an age-old approach for patient treatment and now is pushing the boundaries of patient care beyond the bedside (Dunphy, 2018).
Transformation leadership, per Kapu and Jones, (2016) was a result of building and developing APRN practitioners. The authors discuss integration through transformational leadership. However, they acknowledged APRN roles are relatively new, and the leaders who are knowledgeable about APRN roles will be effective in utilizing their skills. Despite the understanding of a contemporary practitioner, working with medical directors and physician leaders, there was not a description in the “how” this is accomplished with medical staff and hospital leadership.
Advanced practitioners themselves indicate a capacity to lead both at the bedside, and organizational levels (Lamb, Martin-Misener, Bryant-Lukosius, & Latimer, 2018). In exploring the advanced practitioners’ perceptions of their leadership capabilities, Lamb et al. (2018) found two main themes, “patient-focused leadership” and “organizational system-focused leadership” as contributions of the APRN. The qualitative study continued with understanding one’s audience in order to break physician barriers, being mindful of how to communicate, as the intended messages could be political in nature (Lamb et al., 2018).
Advance practice providers are being employed in key leadership positions. In 2016,
Beresford noted three PAs and three APRNS had been selected for key leadership roles in healthcare systems. The practitioners functioned not only as clinicians, but also as facility medical directors, system APP directors, and chief clinical operations officers with voting
APRNS AND MEDICAL EXECUTIVE COMMITTEE MEMBERSHIP 15 privileges (Beresford, 2016).
Theoretical Framework
The selected theoretical model for the DNP project is Transformational Leadership. In using this framework, scientific underpinnings are supported by allowing integration of nursing science and the evaluation of practice outcomes and changes. (AACN, 2006). Leadership styles have experienced change from an autocratic, bureaucratic approach to more creative and participatory blends (Khan, et. al., 2015). The modern styles of leadership foster the process of aligning people towards common goals and empowering for decision making. (Khan, et.al.,
2015). The theory chosen for the project is the Transformational Leadership theory as it provides a foundation for advanced practice nurses aligning and expanding their roles within medical staff committees.
Transformational Leadership, first theorized by Burns (1978), was developed into four characteristics by Bass (Choi, Goh, Adam, & Tan, 2016). The four attributes of transformational leadership are individualized consideration, intellectual stimulation, inspirational motivation, and idealized influence. (Bass & Avolio, 1994). This contemporary model of leadership focuses on the relationship between leaders and followers to achieve shared objectives and goals (Gallagher-Ford, Buck, & Melynk, 2019).
The first characteristic, individualized consideration, provides support and encouragement for followers. APRN leaders appreciate their colleagues' unique talents, education, and positions within current healthcare areas. The leader understands the necessity to provide a supportive climate for other nurse practitioners within the medical community and staff. Collaboration, listening, and engaging of other APRNs is vital as it promotes growth and achievement with each
APP and their participation in medical staff integration. (Carlton, Holsinger, Riddell, & Bush,
APRNS AND MEDICAL EXECUTIVE COMMITTEE MEMBERSHIP 16
2015). Second, intellectual stimulation is an attribute of transformational leaders that encourage a culture for intelligence and rational thinking (Choi, Goh, Adam, & Tan, 2016). The APRN leaders are exploring new platforms, means, and ideas for problem-solving among both APRN and physician colleagues beyond the bedside (Bass & Avolio, 1994).
Inspirational motivation is the third element of transformational leadership. An APRN leader fosters a “team spirit” among other advance practitioners for greater achievements and goals. In this, encouraging the attendance of advance practice nurses to other medical staff events allows for connection and communication for relationship building among other practitioners. Actions that boost and support the APRN community, rather than individual interests, benefit the medical staff and overall healthcare organization.
Lastly, the trait of idealized influence calls the APRN leaders to be positive role-models for followers (Riggio, 2014). This ethical behavior is noted as the leader is not asking followers to do something they themselves would not do, thus building respect and trust from followers
(Riggio, 2014). The leader considers the needs of followers over their own personal needs and avoids using power for personal gain (Bass & Avolio, 1993). An APRN member on medical committees translate action from the advanced practice community as a template for professionalism beyond expectations (Rykrsmith, 2013). The MEC membership position for
APRNs could provide followers with a role model and vision for their identity in medical staff committees.
Transformational leadership states that environments of shared responsibilities influence new ways of knowing are created. (Doody & Doody, 2012). The care of patients is now shared among a variety of healthcare providers. The ability of an APRN leader sharing information
(idealized influence) and important representation on the MEC (intellectual stimulation) could be
APRNS AND MEDICAL EXECUTIVE COMMITTEE MEMBERSHIP 17 attained with membership on the MEC. (Poghosyan & Bernhardt, 2018).
Transformational leadership is most difficult to imitate as a transformational leader combines professional maturity, excellent communication skill, trust, and a sincere belief in the others and the organization (Steinhauer, 2016). However, this role is not limited to only APRNs, but applies to all care providers, being transformational leaders within the confines of one’s practice, hospital committees, and systems.
With the growth of APRNs within hospital systems, transformational leadership will motivate to change organizations, groups, and individuals. Navigation towards shared visions and goals of future healthcare systems is complicated, but is attainable as a unified entity, planned partnering with physicians, nursing, and advance practice providers.
The Do Phase
Environmental Scan
The OHA classifies hospitals into certain types: children’s, critical access, for-profit, non- profit, short- or long-term care, public, psychiatric, rehabilitation, and teaching (OHA, 2020).
The total number of hospital membership is 188 hospitals (OHA, 2020). An environmental scan of twenty-two hospital websites that registered as a children’s, critical access, or short-term care was to be reviewed. The other hospital classifications were not reviewed. In the search for hospital MEC roster or administration, the goal is to confirm an APRN membership within the hospital medical executive committee. An additional objective is to assess for a visible presence of the APRN community as a separate tab within the website.
The validation group participants were asked for their perceptions of APRNs and the potential membership on a MEC. The discussion included each one to speak to causes and problems relating to APRNs and executive medical leadership. The component of trust, and whether
APRNS AND MEDICAL EXECUTIVE COMMITTEE MEMBERSHIP 18
APRNs would add value beyond the bedside was also deliberated. The root cause analysis was
formed through conversations with the validation group. The diagram is shown below:
PEOPLE ENVIRONMENT *Lack of Ownership (no vote = no participation). * Impact or concern on hospital leadership team * Inconsistent educational perceptions
*Barriers and culture of stakeholders * Capable clinical provider
*Value of APRN from CEO perspective *Current MEC membership
Why are there few APRNs
on MECs?
*Pollical Agendas *Financial Issues *On-line program vs clinical time
*No consistent educational perception MATERIALS
*No standard governance MACHINE METHOD
The Study Phase
The national APRN force is outpacing physician practitioners. Auerbach, Staiger, and
Buerhaus (2018) indicated that two-thirds of practitioners between 2016 and 2030 will be APPs
according to their projections. This increase was reflected in the literature due to the overall
need for patient access to care, the Affordable Care Act, and a reduction in physician providers
(Corley, 2017). The rapid growth of advanced practice has brought a variety of integration
definitions, overall hospital inclusion, and the need to quantify the APRN growth. Anen and
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McElroy (2015) expressed the importance of leadership in supporting the introduction and integration of advanced practice nursing roles with the chief nursing officer and chief medical officer advocating for the APRNs.
In answering the need to quantify APRN growth, the Center for Advancing Provider Practices
(CAP2) was established in 2012. The view through data highlighted the growth and need for APRN organization within healthcare systems. Between 2013 and 2015, this group provided data showing 61% APRN growth in 37 organizations. (Anen & McElroy, 2017). CAP2 (as cited in Anen & McElroy, 2017) is the first comprehensive national database designed to help providers nationwide optimize the use of advanced practice registered nurses and PAs.
(https://www.cap2.net).
The Chief Nurse Officer (CNO) has oversight of all nursing practice of the APRN via state licensure and nursing boards, yet APRNs do not exclusively report to the chief nurse. APRNs report to the collaborating physician, thus indirectly to the Chief Medical Officer (CMO).
However, numerous competencies, rapid growth, varied medical levels of care, and practice nuances of the APRN are often expansive and particularized for clinical practice. The traditional hierarchical model is inefficient in dealing with the large APP volume and practice issues. The benefit of having an APRN leader who innately understands that advanced practice is an asset to the organization (Kapu & Jones, 2016). The must-have qualities of advance practice leaders have been identified as clinical experience, management experience, strong facilitation, consensus – building, and negotiation skills. (Mahler, 2014). The benefit of having a single contact on all issues related to APPs allows for engagement, utilization, and expertise on practice regulations.
In Swensen and Robel’s leadership survey (2018) one clinician says, “Nurses, especially those with advanced degrees and experience, make skilled leaders because they have more
APRNS AND MEDICAL EXECUTIVE COMMITTEE MEMBERSHIP 20 experience at the bedside and can often see issues with a variety of solutions that may not be seen by someone who has less time available with the patients and the health system as a whole." (Charts and commentary section, para. 2).
The combination of true progress, utilization, and personal relationships with the medical staff will continue to advocate for the APRN community into hospital MECs. The reality of
APRNs leading collaboration is observed by Goldsberry (2018). The author understood the barriers from hierarchical factors, male-dominated medical physicians, and territorial concerns.
The knowledge of these barriers makes the process complex, but education is a continuing solution to this integration. APRN integration into the medical staff questions the balance between older, territorial archaic and newer, broad collaborative healthcare models. Elliot and
Walden (2015) echo the truth: APRNs are relied upon to provide leadership in cost-effective healthcare. Why, then, are APRNs rarely present among the medical executive committees?
Validation Group Input
The remarks provided by the validation participants did mirror the literature review and all acknowledged the valued care by APRNs at the bedside. However, the perception of an APRN value and voice at MEC is determined by the hospital leadership. Not the APRN group itself.
And when APRNs are invited to medical committees, yet do not have voting privileges, they will often not continue to participant in the committee.
The question of “Why are there few APRNs on MECs?” was found to be of a political nature from the validation group. The traditional membership of MECs consists of physicians and the CNO. The committee understands the role of the physician and the CNO. The members within the hospital MEC have been given the authority for decision-making as well as formulate hospital bylaws. The MEC is not quite sure or ready for cultural changes regarding APRN membership as well as not wanting to fully understand the advanced practitioner. APRNS AND MEDICAL EXECUTIVE COMMITTEE MEMBERSHIP 21
An additional answer was related to the financial clout of the physician. The MEC is composed of physicians who are often surgeons creating revenue for the hospital. Due to this concept, the members will have the attention of the CEO. One comment directly addressed a financial (material) why: “Politics alone will not make a way, but when money is brought into the hospital, it will pave the way for change”. The APRN director, a voting member of a MEC, also stated data knowledge of APRN cost savings is reviewed within medical executive committees. The ability to talk to this point will be challenged from other disciplines, so it is important to understand economic issues within advanced practice. All agreed the MEC membership is one of power and someone is always contending for more.
The findings brought consideration to the perceived educational differences (i.e. on-line studies versus clinical hours) between APRNs themselves and physicians. One practitioner stated “It used to be MD versus DO, now, its physicians versus APRNs”. On-line programs are difficult for a CEO to fully appreciate as it relates to clinical capability. The CEO asks, “Are you capable?” as it is hard to witness from an executive leadership position. This is factored into the view of APRN value within the hospital. However, some believed the education augment will never be won, therefore the focus should be on changing the culture towards APRN leadership.
The MEC APRN member stated “building on the fact that APRNs are part of medical staff via the credentialing process” is a start in the process of MEC representation. And all members of the validation group believed an APRN would have membership on a MEC, adding value, yet it will be a long process over time.
The Act Phase
The goal of the QI proposal is to create an awareness and understanding for the APRN community to progress towards an APRN membership within a MEC. There is a need to APRNS AND MEDICAL EXECUTIVE COMMITTEE MEMBERSHIP 22
establish initial information from the APRN community to view their position beyond the bedside. For this, the student developed a fourteenth-item questionnaire to assist in the process of discovery. The group that would be questioned is advanced practice registered nurses. The inquiry would provide a baseline in understanding the current culture for APRN leadership desire, involvement, and potential for membership within a MEC. The last item will allow additional comments from the participants.
The search for a previous survey with established reliability and validity addressing APRN attitudes towards medical committee membership was not found. The extensive review of other tools included Collaborative Practice Assess Tool, Role Perceptions Questionnaire, Index of
Interdisciplinary Collaboration, Assess of Interprofessional Team Collaboration Scale, and
Interprofessional Collaboration Scale. Two resourceful tools were the Jefferson Scale of
Attitudes Towards Physician-Nurse Collaboration (JSATPNC) and Attitudes towards Health
Care Teams Scale (ATHCTS). JSATPNC and ATHCTS are designed for assessing collaboration among nursing, health care teams and physicians (Heinemann, Schmitt, Farrell, &
Brallier, 1999; Hojat, Fields, Veloski, Griffiths, Cohen, & Plumb, 1999).
The questionnaire designed by the student consists of fourteen items regarding inter- professionalism, advanced practitioner degrees, APRN membership on MEC, and trust
(Appendix A). In writing the questionnaire, the student tailored questions based upon the subject matter, types of individuals completing the survey, resources, and the time frame for tabulating results. (Dillman, Smyth, & Christian, 2014). The questionnaire length and items were designed for simplistic ease and relevance for enhancing response rates.
For convenient sampling, participants would be APRN practitioners that are employees, or partners within the hospital systems. The email addresses would be obtained after permission APRNS AND MEDICAL EXECUTIVE COMMITTEE MEMBERSHIP 23
from the organization and selection will originate from identifying the practitioner’s terminal degree as listed as CNS, CNP, CNM, or CRNA. The total number of APRN responses would be determined by the size of the hospital APRN community. The author recommends a goal of two to five percent survey return.
In review of the data, interpretation would assist in answering the following questions: Does the APRN provider believe there is need for MEC membership? Will there be a consensus on involvement and trust concepts? If APRNs provide value at the bedside, does this position the
APRN for hospital MEC membership? How many clinical years of advance practice determine eligibility for MEC positions? Do APRNS trust one another in the handling high-level executive decisions within medical staff committees? Does the APRN community desire membership within a MEC?
The summary evaluation results are best utilized by the Advance Practice Provider councils or
APRN departments. The purpose of collecting APRN attitudes towards their membership on a
MEC aids in determining if the APRN group believes of their value towards non-clinical positions of hospital executive leadership. The proposal would also assist in evaluating if there is a movement towards APRN readiness within MEC leadership.
The assessment of APRN attitudes are important as the results can determine the path of advance practice nurses and their willingness to invest in organizational change. Is there an office within hospital for Advanced Practice Providers? Does the hospital have an Advanced
Practice council or a group of APRNS that meet collectively? Is there unity or support among the practitioners within the system? The QI proposal can generate unity and direction for future APRN MEC leadership roles. As APRNs address their value beyond the bedside, MEC membership potential for an APRN should be established. The reality of moving APRNs into APRNS AND MEDICAL EXECUTIVE COMMITTEE MEMBERSHIP 24
medical executive leadership has been recognized in one Ohio care system.
APRNs are credentialed through the medical staff committees due to organizational requirements. This knowledge should prompt APRNs to understand their practice is linked with the medical staff and thus, their involvement within medical executive leadership should be examined. Consequently, the advancement of APRNs should be developed by the advance practice nurses within that environment. The medical staff and hospital administration are less likely to extend an invitation to executive committees for practitioners who are not interested in their professional leadership presence. If the value of the APRN is being assessed by the CEO and executive leadership teams, it provides opportunities to educate APRNs of the need to develop purposeful relationships beyond the bedside. The process of moving APRNs into MECs is different for each care system and requires a specific plan of action for all hospital cultures.
A PDSA cycle, developed by the site APRNs, should be implemented to determine a specific model for advancing their MEC representation. The APRN survey should be completed on an annual basis to evaluate progress of APRN leadership, address future goals, and review of their value within the hospital culture. The components of the cycle could vary each year due to the frequent changes known to occur within our healthcare climate of today.
Essential Foundations
DNP Essentials II, III, V, and VI provide support for the DNP proposal and recommendations (AACN, 2006). Essential II highlights that organizational and systems leadership is improved with a DNP graduate (AACN, 2006). The doctoral level of knowledge, coupled with an advanced practice education promotes quality and safety in patient care. The
APRN membership on MECs fosters the use of communication skills, systems thinking, policy development, and practice initiatives from the perspective of an advanced practitioner. APRNS AND MEDICAL EXECUTIVE COMMITTEE MEMBERSHIP 25
As modern patient care is addressed through many avenues, advanced practitioners address issues of patient care from a "hands-on" approach as they bridge gaps between physicians, pharmacy, and nursing staff.
The third Essential tackles clinical scholarship and analytical methods for evidence-based practice (AACN, 2006). The APRN integration into medical executive committees promote discussion between evidence-based practice (EBP) guidelines and the actual EBP hospital routines. The DNP graduate, expert in nursing practice, is trained to evaluate clinical practice effectiveness. The ability to solve care issues and facilitate, or challenge, is within the DNP scholarly training. EBP can flourish within our hospitals but needs frequent conversations with stakeholders who are also fellow collaborating colleagues. All must work together to focus on
EBP initial principles and work through the robotic protocols, administrative directives, and practice traditions (Greenhalgh, Howick, & Maskrey, 2014). The DNP-educated APRN voice represented on a MEC team can employ research methods to help translate new science, assist in the evaluation of outcomes and use findings to improve healthcare results.
The opportunity to review, develop, and implement healthcare policies occurs within the medical executive committees. Essential V reflects the importance of health care policy engagement as a requirement of a DNP graduate (AACN, 2006). The clinical bedside presence of the APRN offers a unique view towards enhanced policy evaluation and development at all organization levels, including MEC committees. Exploring the possibilities of APRN membership on MEC and medical committees could determine the level of readiness of the
APRNs and for committee memberships.
Lastly, Essential VI is upheld within the DNP proposal. Interprofessional collaboration is observed with the collection of individuals from a variety of disciplines (AACN, 2006). The APRNS AND MEDICAL EXECUTIVE COMMITTEE MEMBERSHIP 26
DNP proposal is an exploratory report viewing the readiness and attitudes of the APRN towards a membership on MECs. The delivery of modern healthcare is accomplished with diverse practitioners. The mix of practitioners should be reflected within hospital committees to facilitate collaborative leadership in practice guidelines, peer review, policies, and organizational issues. The foundational competencies substantiate the DNP proposal, as organizational leadership, EBP, health care policy reviews and interprofessional collaboration are addressed within the examination of APRN attitudes towards membership in executive medical committees.
Summary
Despite the IOM (2011) and CMS (2012) recommendations for APRN involvement with our medical colleagues, the literature was lacking in describing APRN integration into medical executive committees. Current practice barriers reflect the hierarchy of medical education, perceived clinical capability, financial inputs, regulatory bodies, system responsiveness, and political power. This influence has been present in both interprofessional practice and hospital governing committees. The lack of literature documented the limited partnership between medical staff committees and APRNs.
The literature review did disclose APRNs working alongside physicians in hospitals, in a variety of care arenas. Collaboration is present in clinical capacities and discussed in management terms. APRN growth has promoted quality patient care but has also brought questions related to the APRN membership on medical staff committees, including the hospital
MEC. APRN memberships into hospital MEC is essential for advanced practice nursing representation.
The noted literature gap is reflective of the actual medical, nursing, and hospital leadership APRNS AND MEDICAL EXECUTIVE COMMITTEE MEMBERSHIP 27
responses. Hospital healthcare systems lack examples of APRN positions in their MEC structures. The perception gained from concept analysis, literature synthesis, and background is that APRNs have value in caring for the patient. However, in executive hospital committees, the membership of an APRN is uncommon. Perhaps, again, the barrier of physician versus non- physician status continues in executive committees. Or the “other clinical” membership position is filled with optometrists or chiropractors. Also, a conclusion was drawn that due to the rapid increase of APRNs, the community itself has expended energies in education and presence at the bedside, but not in hospital executive medical committees.
The APRN QI proposal was developed as the local hospital had inquired how to bring advanced practice into medical staff alignment. The pursuit of the DNP degree has brought an academic lens to answer these questions. Yet the author has encountered much difficulty in assessing APRN readiness due to true practice cultures. The author attempted to complete the
PDSA QI proposal within her own healthcare system, but the project was rejected from the system’s gatekeeper for research. And despite willingness of the VPMA to allow the survey proposal, it was unable to be executed due to organizational regulations and gatekeepers. The barriers the student experienced included system willingness, poor or lack of returned inquiries, and the re-assignment of research personnel during the COVID pandemic. The rejection of the local hospital proposal drove the student into looking into other healthcare sites through the
OHA classifications.
The OHA Vice President of Member Services did return my email request for assistance. He suggested becoming a member might provide networking opportunities to learn from nursing leaders and other hospital systems. The OHA site would not allow the student to use their organization for the APRN survey deployment or a connection to hospital medical leadership. APRNS AND MEDICAL EXECUTIVE COMMITTEE MEMBERSHIP 28
The possibility of using the Ohio Association of Advanced Practice Providers (OAAPP) site, and their Facebook page for questionnaire delivery was also rejected. The organization informed the author that they have had a “large volume” of similar DNP student requests, and that OAAPN cannot post surveys to social media or send via email (OAAPN, personal communication, June
6, 2020).
In this period of healthcare transformation, this exploratory proposal would contribute data regarding APRN readiness on hospital MECs as a means of integrating advanced practice nurses into hospital executive teams and medical staff. The DNP proposal would help to assess and disclose attitudes of a positive, neutral, or negative trend towards APRN memberships on hospital medical executive committees. The proposal also complements the pursuit of the
Quadruple Aim, through the APRN MEC position, contributing to all levels of hospital medical decision-making and leadership.
The QI proposal discovered the unknown dynamics between APRNs and hospital leadership.
Internal politics, financial contribution, and perceived educational differences continue to impede
APRN leadership progress. The APRN has the clinical training and education yet needs to continue mitigating perception issues of the APRN within the executive leadership teams. The
APRN community needs to engage, connect, and organize themselves in order to advance within the local hospitals and sustain practice progress. It is a slow yet achievable position within the
MEC. The tangible QI proposal is sorely needed as the literature does not clearly address a presence or examples of advance practice providers incorporated into hospital medical executive committees.
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Appendix A APRNS AND MEDICAL EXECUTIVE COMMITTEE MEMBERSHIP 37
Submission/completion of the questionnaire will be interpreted as your implied/informed consent. You are free to discontinue participation at any time without prejudice.
APRN Readiness Towards Membership on Medical Executive Committees Questionnaire
Please select a response: 1. Strongly disagree 2. Disagree 3. Neutral 4. Agree 5. Strongly agree
1. As an APRN, are you: (select all that apply) a. CNM (Certified Nurse Midwife) b. CNP (Certified Nurse Practitioner) c. CNS (Certified Nurse Specialist) d. CRNA (Certified Registered Nurse Anesthetist)
2. Do you believe an APRN provides value to clinical patient bedside decisions?
1----2----3----4----5
3. APRNs should be involved in policy development influencing their hospital practice.
1----2----3----4----5
4. Is there a Medical Executive Committee (MEC) or medical governance team in your institution?
Yes------No
5. Does the type of APRN’s degree influence one’s leadership ability on a MEC?
1----2----3----4----5
6. The length of an APRNs clinical practice years determines one’s leadership ability.
1----2----3----4----5
7. How many years of clinical practice, as an APRN, is believed to be beneficial for Medical Executive Committee (MEC) membership? (please select)
0-5 yrs., 6-10 yrs., 11-15 yrs., 15 yrs.+
8. I could trust an APRN’s decision making abilities within the hospital MEC.
1----2----3----4----5
APRNS AND MEDICAL EXECUTIVE COMMITTEE MEMBERSHIP 38
9. I believe APRNs would provide value to hospital MEC decisions.
1----2----3----4----5
10. In the past year, did you work in the clinical area, with an APRN?
Yes ------No
11. In the past year, did you work outside the clinical area, (i.e., leadership, policy, QI, or executive teams), with an APRN?
Yes ------No
12. I believe APRNs should have membership on medical executive committees.
1----2----3----4----5
13. For additional comments, place in box:
Key: APRN = CNM, CNP, CNS, CRNA,
MEC = medical executive committee
QI = quality improvement
5-point Likert scale:
1. Strongly disagree 2. Disagree 3. Neutral 4. Agree 5. Strongly agree