Structural Empowerment: Outcomes of Adding Nurse Practitioners to Inpatient Care Teams

Purpose: ACNPs practicing at the top of their license can be a valuable resource in the inpatient setting. Current healthcare initiatives have created the optimal environment for NPs to showcase their abilities and contributions. Creating an information rich environment, identifying outcomes that are directly affected by the NP and quantifying data in terms of dollars can make a powerful statement in the valuation of NP practice. In many practices, value is gleaned in terms of revenue generation and cost-effectiveness of hiring NP providers; however a considerable financial impact can be in cost avoidance and cost savings by means of NP associated outcomes of care.

Two leaders share outcomes of adding nurse practitioners (NPs) to inpatient models of care using structural empowerment theory. Their leadership and work was greatly influenced by their doctoral studies. Both leaders worked together but at different levels of management, one leader is the Chief Nurse Officer (CNO) for a large academic medical hospital and the other is an Advanced Practice Leader. With an organization change initiative grounded in structural empowerment, the CNO created the optimal environment for establishing successful inpatient NP models of care. Under the direction of the CNO, the advanced practice leader was able to deploy teams that proved quite successful in quality improvement and subsequent cost savings to the institution. Both leaders were enrolled in a DNP program during the establishment of the organizational change initiative and NP teams and used much of their work towards their scholarly projects. This presentation will discuss the organizational change initiative utilizing structural empowerment theory, outcomes of adding NPs to inpatient models and in particular, how the DNP influenced their leadership at both levels. 

With optimal organizational structure, NPs can decrease healthcare costs with acute transition management, decreasing length of stay and with adherence to clinical practice guidelines, reducing complications associated with fragmented, unstandardized care. In addition, NPs can generate revenue as billing providers.

We hypothesized that through organizational application of Structural Empowerment theory, we could integrate acute care NPs into interprofessional models of care, with a subsequent increase in revenue and reduction in costs via quality improvement.

Methods: With NPs added to the adult critical care units and hospitalist teams, we tracked revenue and NP associated quality metrics. From July 1, 2011 – June 30, 2012, we tracked NP charges and collections for 4 adult intensive care units (ICU), and 1 hospitalist NP team, utilizing the institution’s billing system. Utilizing our electronic medical record software, we developed practice specific electronic progress note templates to chart daily notes and collect quality data which was then transferred to an electronic dashboard. From January 2011-Dec. 2011, we added NPs to rapid response teams and collected data via a secure electronic data capture tool, REDCap. For a 6-month pilot, Dec.2011 - Feb. 2012, of adding NP hospitalists to a trauma stepdown unit, we collected length of stay data utilizing admission and discharge tracking software and compared to 2 years prior.

Results: The gross collections met 52% (FY11) and 88% (Fy12) of salary and fringe expenses for four ICUs. After addition of NPs to the rapid response teams in 2011, the ratio of rapid response to out of ICU arrest was 18%, as opposed to 35% in 2010. The hospitalists NPs added to a particular hospital unit for 1 year showed high staff satisfaction and a 1.0 reduction in average length of stay to the overall trauma service.

Conclusions: These studies demonstrate the value of adding ACNPs to inpatient models of care. ACNPs as billing providers can generate revenue, avoid costs associated with hospital complications and save costs with decreased length of stay.