Patient Outcomes and Sustainable Change

Patient Outcomes and Sustainable Change: Identifying Leadership Roles for Doctors of Nursing Practice
Today, the United States spends more taxpayer monies on healthcare services than virtually any other industrialized country in the world, yet Americans still pay more out-of-pocket expenses and receive fewer physician visits per year compared to nations that spend less. Moreover, the demand for already scarce healthcare services is expected to increase concomitantly with the rapid growth being experienced in the elderly demographic, and these demands will likely continue to expand as the baby boomer generation retires in greater numbers and lives longer lives compared to past generations. Against this backdrop, determining how and why the United States ranks alone among dozens of other countries – many of them still in their developmental stages – in terms of the lack of universal healthcare. To determine the facts, the purpose of this paper is to provide a review of the relevant literature concerning the provision of universal healthcare services in Canada, including its health outcomes and how they compare to the U.S. In addition, an assessment concerning whether universal health care should be a concept supported by a doctor of nursing practice (DNP) and supporting rationale is followed by the results of a health care quiz and an analysis of its implications for the U.S. health care system. Finally, a review of selected articles and the DNP’s leadership role in promoting optimal health care outcomes is followed by a summary of the foregoing research and relevant findings in the conclusion.
1. Explore a country that provides universal health care. What are its health outcomes? How do these outcomes compare to those in the United States? Should universal health care be a concept that the DNP should support? Why or why not?
Today, the United States is the only major industrialized nation that treats access to health care services as a privilege rather than a fundamental human right. One country that is routinely cited as being superior to the U.S. in terms of health care coverage is Canada, which has offered some level of government-subsidized health care services to all of its population since the mid-20th century (The birth of Canadian Medicare, 2018). This trend was reinforced by the passage of the Canada Health Act of 1984 which transformed the disparate components of the provincial health care system into a true nationwide resource that are currently free to all Canadian consumers at the point of care (Martin & Miller, 2018).
Although the universal health care coverage offered in Canada is a laudable objective, the services that are offered are limited compared to other countries including the United States and lengthy wait times for elective care are the norm (Martin & Miller, 2018). In addition, access to universal health care services in Canada is restricted by geographic proximity to available clinicians, and access for the country’s large rural population, including most especially its diverse indigenous peoples, is especially limited. In this regard, Martin and Miller (2018) emphasize that, “Profound health inequities experienced by Indigenous populations and some vulnerable groups require coordinated action on the social determinants of health if these inequities are to be effectively addressed” (p. 1719). In addition, the health care system in Canada has limited access to new medical technologies (Roy, 2015)
Notwithstanding these constraints, though, the outcomes achieved by Canada’s universal health care system are enviable, with an infant mortality rate ranked 180th lowest and the 21st highest longevity rate in the world today (Canadian people, 2018). Nevertheless, Canadian health care consumers still suffer from some of the same levels of health care problems as their U.S. counterparts, including obesity levels that are ranked the 26th highest in the world (Canadian people, 2018). In order to improve these suboptimal health care outcomes, Martin and Miller (2018) advise that, “Expansion of the publicly funded basket of services and coordinated effort to reduce variation in outcomes will hinge on more engaged roles for the federal government and the physician community than have existed in previous decades” (p. 1720). Taken together, it is reasonable to conclude that the Canadian universal health care system remains a work in progress, but the treatment of the access to health care services as a right rather than a privilege is a concept that all DNPs should support for the United States given its potential to extend the lifespan and improve the quality of life for consumers.
2. The Commonwealth Fund provides an international review of health care systems. Read the Commonwealth Fund report, International Profiles of Health Care Systems, 2014, and take the associated quiz. Discuss what knowledge you gained from the quiz and describe any changes you would apply to the U.S. health care system.
The results of the administration of this quiz are presented in Table 1 below, followed by a summary of the knowledge gain and how it should be applied to the U.S. health care system.
Table 1
Results of International Profiles of Health Care Systems quizs (selected answers are BOLDED)
Question
Results
Description
In which two countries are adults least likely to get a doctor’s appointment for the same or next day when they need care?
Germany and the Netherlands 
Australia and New Zealand 
Canada and the U.S.
Correct! Yes, only 48 percent of people under 65 in the U.S. and 41 percent of people in Canada are able to get a same- or next-day appointment. However, U.S. residents do, on average, have relatively fast access to specialists.
About how much does the U.S. spend annually on health care per person?
Less than $4,000
$4,000 to $6,000
$6,000 to $8,000
More than $8,000
Correct! You got it! The U.S. spends $8,745 per person on health care annually, which is more than any other nation and $5,000 more than Japan, a low-spending country. Despite this high rate of spending, U.S. health outcomes are not superior.
In which countries do people have the longest life expectancy?
Germany and the U.S.
Japan and Switzerland
The Netherlands and Sweden
Correct! Japan and Switzerland have the longest life expectancy, at 83 years. In the U.S., it is 79.
What country other than the U.S. has a large uninsured population?
Germany
England
Neither
Correct! But it isn't just Germany and England who [sic] have smaller uninsured populations than the U.S. No other industrialized country has a large uninsured population.
In which countries are most hospitals publicly owned?
Denmark and New Zealand
The U.S. and Japan
New Zealand and the Netherlands
That’s partly correct!
Partly right. The majority of hospitals are publicly owned in New Zealand, but in the Netherlands the majority of hospitals are privately held. Australia, England, France, Italy, Norway, and Sweden are other countries where the majority of hospitals are publicly owned.
Health spending growth has slowed in the U.S. in recent years. How has health spending been growing in other industrialized countries?
Faster than in the U.S.
Slower than in the U.S.
About the same as in the U.S.
Sorry. That’s incorrect!
Wrong. Health spending is growing at about the same rate in other industrialized countries as it is in the U.S. However, the U.S. still spends much more on health care – 16.9 percent of the GDP compared to the median rate of 9.3 percent of GDP for all industrialized countries.
About how much more, on average, does an orthopedic surgeon earn in the U.S. than in France?
$114,000 more
$288,000 more
$362,000 more
Sorry! That’s incorrect!
No, think higher. Think $288,00 more. In the U.S., orthopedic surgeons on average earn $442,450, while in France they earn $154,380.
Where do adults age 65 and older have out-of-pocket health care costs on par with those paid by older adults in the U.S.?
Switzerland
Germany
The U.K.
Sorry, that’s incorrect!
Nope. In Germany, only 7 percent spent $2,000 or more on health care. Twenty-two percent of older adults in Switzerland and 21 percent of older adults in the U.S. spend that much.
In which areas of care does the U.S. perform well relative to other countries?
Patients talk with health care professionals about diet and exercise
Patients with chronic conditions have treatment plans that can be carried out in daily life
Patients have enough time with their regular doctors
All of the above
Correct! The U.S. does well in all of these areas. Fifty-eight percent of chronically ill older adults in the U.S. reported they had discussed their treatment goals with their doctor and had clear instructions about when to seek further care. With the exception of the U.K., fewer than half of chronically ill people in the other surveyed countries reported the same. Eighty-three percent of U.S. respondents reported they had a treatment plan they could carry out in their everyday lives—one of the highest rates of the nations surveyed. And the vast majority (86 percent) of older adults said they had enough time with their doctors.
Do Americans go to the doctor more or less frequently than people in most other industrialized countries?
More often
Less often
At about the same frequency
Sorry, that’s incorrect!
No. Americans tend to go to the doctor less frequently than people in other high-income countries. There are about four visits per person in the U.S. annually, compared to almost eight in Canada.
Despite the several incorrect answers, the quiz ranked the total of these responses as reflecting a “Seasoned Traveler” who “may not be able to lead the tour group yet [but] you know your way around a health system.” The overarching issues that emerged from this quiz were the perplexing fact that while the U.S. spends nearly twice as much as other industrialized countries on health care, the nation still lags behind many other countries in terms of accessibility and the outcomes achieved. While it is clear that more money is needed to provide better health care coverage for U.S. citizens, other factors, including preventive care services that reduce the need for long-term acute care.
3. Review one of the tutorials on quality measures from the AHRQ: National Quality Measures Clearinghouse website. Provide an overview of what you reviewed and its application in your practice.
A review of the AHRQ’s “Sample design tutorial” describes the methods for accessing and interpreting the data provided through the Healthcare Cost and Utilization Project (HCUP) online database. The tutorial stresses the need to develop a clear understanding concerning how the various available database should be used in order to avoid introducing errors in design and data interpretation as well as some of the common errors that are encountered in this process. In addition, the tutorial provides links to other online resources that can provide additional tips for data analysis as well as other related health care-related databases.
4. The assigned article "Large-System Transformation in Health Care: A Realist Review" identifies several outcomes for effective transformation. Discuss one of those measures and the implications for change in your practice.
In this article, Best, Greenhaigh, Lewis et al. (2012) emphasize that need for large-system transformation (LST) initiatives that are needed to improve the Canadian health care system. Citing a paucity of timely and relevant research concerning evidence-based strategies, Best and his associates (2012) stress the importance of measures such as the “Knowledge to Action for System Transformation” sponsored by the Canadian Institutes of Health Research to facilitate the “rapid systematic review and synthesis of knowledge about LST for the provincial Saskatchewan Ministry of Health in Canada” (p. 422). This measure was designed to evaluate four ongoing policy initiatives for the Canadian health care system as follows: (a) patient- and family-centered care, (b) primary health care improvement, (c) “lean” management for health care, and (d) shorter surgical wait times. This strategy provides the benchmark data needed to gauge the effectiveness of interventions that are designed to improve each of these four categories of health care, an approach that is highly applicable to virtually any DNP practice setting.
5. The DNP degree empowers nurses to create programs for improving quality outcomes. What barriers need to be alleviated to increase the APN role in health care change?
Doctors of nursing practice are well situated to assume a leadership role in their health care organizations, but physician resistance to their expanded authority remains a major barrier to their increased role in effecting meaningful changes in the American health care system (Feldman & Greenberg, 2009). While physician attitudes towards advanced practice nurses are slowly changing, this barrier needs to be alleviated in order to increase their role in implementing and sustaining evidence-based changes in the U.S. health care system.
6. Patient-centered care has been shown to increase positive patient outcomes. Provide an example of how collaboration within the health care team has enhanced patient outcomes in your practice.
Noting an increase in the number of medication errors being made on a specific surgical ward, the director of quality assurance collaborated with the assistant director of pharmacy services to identify the source and primary cause of these errors. Based on this collaborative effort, it was determined that the majority of the medication errors were attributable to deviations from mandated protocols including using the wrong path and giving patients drug at the wrong time. The results of this collaborative effort were used to raise awareness of these problems among the nursing staff of the responsible ward, and their medication error rate dropped by more than 80% over the next 6 months as a result.

7. Utilize the National Committee for Quality Assurance (NCQA) website to examine the criteria that a Patient Centered Medical Home (PCMH) must meet to be credentialed. What is the value of the PCMH to patient outcomes
One of the frequently overlooked responsibilities of many quality assurance services is the need for the verification of practitioner credentials. The NCQA’s criteria for credentialing patient centered medical homes is a determination of whether it has “clearly defined and documented procedures for assessing its practitioners’ qualifications and practice history” (Summary of credentialing requirements, 2018, para. 2). Therefore, by ensuring that medical practitioners are qualified for their assigned positions, this criterion represents the first step in achieving improved patient outcomes in PCMHs.
8. One key issue related to poor adherence to prescribed treatment is patient lack of understanding. What tools are available to determine a level of health literacy and how can they be utilized to improve patient outcomes
There are several tools available to the DNP for improving patient adherence to prescribed treatment regimens, including (a) simplifying the regimen characteristics, (b) imparting knowledge to patients concerning the importance of adherence, (c) modifying patient beliefs when necessary, and (d) evaluating adherence levels to identify opportunities for improvement (Afreja & Bellam, 2009).
9. Discuss the role of research collaboration and the dissemination of this research. What are the opportunities for dissemination, and what is the role of DNP in pursuing those opportunities?
One of the fundamental responsibilities of some DNPs is multidisciplinary collaboration and the codification and dissemination of the findings of this research to relevant stakeholders. While a number of avenues are available dissemination, it is the role of the DNP to identify which communication strategies are most effective in achieving the desired outcomes and taking the initiative to pursue them. This latter requirement represents one of the most challenging aspects of the process, but its importance cannot be overstated. As Vincent and Johnson (2014) emphasize, “Any transformation of the health care system will require clinicians who clearly understand the context of health care delivery and can translate newly discovered/reported scientific knowledge into the provision of health care to the diverse subpopulations of the United States” (p. 1).
10. Discuss recent health care innovations in your practice and your role in implementation
Perhaps the most significant recent health care innovation in this author’s practice has been the introduction of electronic health care records (EHRs). Although the use of EHRs has proven efficacy in reducing medication errors and improving other patient health care outcomes, their use involves significant privacy issues that must also be taken into account (Allen-Graham & Mitchell, 2018). Therefore, in their capacity as health care leaders, APNs can facilitate the implementation and administration of these resources by educating practitioners concerning the privacy issues that are involved with their usage.
Conclusion
The research was consistent in underscoring the increasing importance of the advanced practice nursing role in health care settings of all types and sizes. In addition, the research also showed that simply throwing money at health care disparities is not always the optimal solutions as evidenced by the profound differences in outcomes that are being achieved in the U.S. compared to other industrialized countries which offer universal health care services. Finally, it is reasonable to conclude that current barriers to the expanded role of advanced practice nurses will continue to erode in the face of growing demand and dwindling budgets.
References
Afreja, A. & Bellam, N. (2009, March 15). Strategies to enhance patient adherence: Make it simple. Medscape General Medicine, 7(1), 4.
Allen-Graham, J. & Mitchell, L. (2018, February). Electronic health records and online medical records: An asset or a liability under current conditions. Australian Health Review, 42(1), 59.
Best, A., Greenhalgh, T., Lewis, S. et al. (2012, September). Large-system transformation in health care: A realist review. Milbank Quarterly, 90(3), 421–456.
Canadian people. (2018). CIA world factbook. Retrieved from https://www.cia.gov/ library/publications/the-world-factbook/geos/ca.html.
Feldman, H. R. & Greenberg, M. J. (2009). Educating nurses for leadership. New York: Springer Publishing Company.
The birth of Canadian Medicare. (2018). Canadian Dimensions. Retrieved from https://canadiandimension.com/articles/view/the-birth-of-medicare.
Martin, D. & Miller, A. P. (2018, February 22). Canada's universal health-care system: achieving its potential. Canada’s Global Leadership on Health, 391(10131), 1718-1735.
Roy, A. (2015, January 27). Conservative think tank: 10 countries with universal health care have freer economies than the U.S. Forbes. Retrieved from https://www.forbes. com/sites/theapothecary/2015/01/27/conservative-think-tank-10-countries-with-universal-health-care-are-economically-freer-than-the-u-s/#ee7cbb0137e6.
Summary of credentialing requirements. (2018). NCQA. Retrieved from http://www.ncqa. org/programs/certification/utilization-management-and-credentialing-um-cr/oc-program-evaluation-options/cr-standards-and-guidelines.
Vincent, D. & Johnson, C. (2014). DNP-Prepared nurses as practitioner-researchers: Closing the
gap between research and practice. Web NP Online Retrieved from http://www.doctorsofnursing practice.org/wp-content/uploads/2014/08/Vincet_et_al.pdf.