The following speech was delivered at INS 2015 in Louisville, Kentucky, on May 21, 2015.
As a profession, we should be grateful for change. Imagine if change did not exist. Suppose the profession of nursing had been frozen in the 19th century. Nurses would be wearing long, cumbersome dresses to work. Much of our work would be cleaning and washing linens. Most of our colleagues would not have had any education or training. The first so-called training for nurses was introduced post Civil War, in 1873.1 Nurses would certainly not be inserting peripheral intravenous catheters, let alone peripherally inserted central catheters (PICCs) and other central vascular access devices (CVADs).
The post-Civil War years in the United States brought tremendous change to hospitals as they emerged slowly from almshouses and chronic care facilities to the present-day acute care facilities. The trend in health care was moving acute care from the home into hospitals.2 It's very interesting that we're reversing that trend today. We cannot depend on things to remain as they are. The one thing we can always depend on, for better or worse, is that change will happen.
As humans, we find change difficult; however, change is truly inevitable and necessary. Indeed, embracing and managing change well is our best hope. To adapt to and manage change, it must first be put in perspective. Step back, and look at the big picture. We must begin to understand and view change as a means to a better state. We must ask ourselves what is the driving force behind this change. Is it necessary? Change comes about for many reasons.
The stimulus for change can affect how we view and accept the change and whether we are likely to work through change to a positive end. Natural disasters, such as the tsunami that hit Japan's Fukushima Daiichi power plant in 2011 and the F5 tornado that devastated Moore, Oklahoma, in 2013, caused tremendous change in the lives of those affected. In the best-case scenario, the change inspired by these catastrophic events will result in improved safety initiatives. Change stimulated by Mother Nature is hard to accept but usually elicits a collective humanitarian response in which we see the best in people.
War also heralds many changes for people and communities. Change brought about by greed and corrupt government officials has been demonstrated to be a senseless, never-ending cycle in the history of humans. It is hard to understand and accept this type of change. It is even harder to lead change for positive solutions in these horrific situations, though it has been done.
Necessity is said to be the mother of invention, and as such, war tends to accelerate the development of science and technology benefiting society in peacetime as well. Indeed, tools of our trade-antibiotics, fluid resuscitation, and the techniques for infusion therapy via CVADs-were initiated and developed in response to war injuries.3,4 The stimulus behind change is often not good, but humans have shown a remarkable ability to meet the challenges and produce positive outcomes.
The extended time it takes to make major changes in culture can cause participants to lose hope, give up, and lose their way. It is only when we step back and look at the progress from a distance that we can truly appreciate the effects of change. Consider that President Abraham Lincoln's Emancipation Proclamation was issued in 1863; yet, 100 years later, race riots were occurring in major cities across the United States, and Martin Luther King, Jr., delivered his famous "I Have a Dream" speech in our nation's capital. This year we recognize the 50th anniversary of "Bloody Sunday" in Selma, Alabama. The movement through change for racial equality has been long and painful. But imagine if those steps had not been taken. Imagine if there were no brave people willing and courageous enough to embrace the needed change and lead the country forward.
There are models available to help us with change-for example, the "Un-freezing, Change, Refreeze" by Kurt Lewin1 and the Change Acceleration Process model, initially used by General Electric.5 Using these models successfully assumes planned change in which you have some control and can move the group engaged in the change at the same time. The components of these models are very helpful to nurses who are planning change in the process of care delivery. The more proactive we are, purposefully embracing change and using a planned approach, the more successful we will be.
Though we may not be faced with a natural disaster or war, the changes in health care reimbursement are creating restructuring in health care that affect all health care team members. These changes present real threats to job security for many. Basically, the economic model for health care payment and delivery is changing.
A review of health care economics over the past 50 years sheds light on the pressures we are currently experiencing. In 1965, President Lyndon Johnson signed Medicare and Medicaid-Centers for Medicare & Medicaid Services (CMS) into law.4 For the first time, hospitals and primary care providers (PCPs) received payment for patients who previously would have been considered charity care. In addition, the reimbursement model was "fee-for-service," meaning reimbursement was provided for the service rendered regardless of the patient's outcome. The longer the patient stayed in the hospital, and the more CVADs that were placed, the more money the hospital/PCP made. As time progressed, it was recognized that this was not economically sustainable.
In 1983, a new payment structure for CMS, called diagnosis-related group (DRG), was implemented.5 Under this system, hospitals and PCPs were paid a set amount for a particular diagnosis, and if the cost of care was more, the hospital/PCP lost money; if the cost was less, the hospital/PCP gained. The DRG ruling caused some tightening of belts but was still an expensive reimbursement model. Health care costs in the United States have risen faster than any other country, but our life expectancy has not kept pace with these costs.6
In the 2000s, new models have been rolled out in which hospitals/PCPs are no longer reimbursed based on services alone but also on outcomes. Further changes in reimbursement include the development of accountable care organizations and a reimbursement model for "bundled care," meaning payment goes to a health care system including physicians, hospitals, and other members of the health care team as one payment instead of individually. The bundled reimbursement model is negotiated to encompass the total cost of a care episode. These models are being introduced as gradual change, over a few years. Goals of the US Department of Health and Human Services include that by 2016, 50% of Medicare payments will be tied to quality through alternative payment models, and by 2018, 90% of remaining fee-for-service reimbursement will be tied to quality.6 Approximately 50% of hospitalized patients in the United States are covered through CMS, and this will increase as our population ages.7
This is planned change. It is being rolled out slowly, with incremental changes in reimbursement and more emphasis on quality outcomes each year. On the one hand, this is good for patients as it means more emphasis is placed on quality in hospital board rooms and at the bedside; on the other hand, it is a financial challenge for health care systems. To maintain a viable health care system we need to look closely at how we deliver care. Care delivery needs to be as efficient as possible and deliver the best-quality outcomes.
This is an opportunity for infusion nurses. The emphasis on reducing costs in health care and increasing quality provides a unique opportunity for infusion nurses to demonstrate their value to the health care system. The majority of patients in both acute and chronic care rely on infusion therapies. There is no provision for extra reimbursement when complications such as central line-associated bloodstream infection or extravasation injuries occur. If a patient's PICC or implanted port becomes occluded with a thrombus and must be replaced, an extra burden is added to both the patient and the health care system. If a patient goes for days with the wrong type of intravenous access, we've increased the length of stay and missed an opportunity for high-quality care.
The patient experience is affected by the skill and caring of the infusion nurse, and hospital reimbursement is highly influenced by patient experience. Currently one-third of CMS reimbursement is tied to patient experience-your patient satisfaction scores. Only infusion nurses have the specialized skill and knowledge to ensure high-quality vascular access and infusion care. As infusion nurses you are leaders. You touch all areas of health care and, as such, can be highly influential in both patient and staff satisfaction, as well as clinical outcomes.
As we take a collective deep breath, think about the nurses at the turn of the century. Change was no easier for them than it is for us.
Finally, to manage the changes we're facing, nurses must first understand the change and accept that it will happen. Then be flexible and resilient, retool, and learn new skills to meet the change proactively. Work in teams and collaborate with others. Learn to use the Internet for literature searches and evaluate evidence to determine best practice. Use performance improvement methods to apply best practice. Learn to create spreadsheets for your own data. Collect data, and use them to demonstrate your worth and value to the health care system. Measure and report your own outcomes. Data are powerful.
We may need to reinvent ourselves, our skills, our processes, and our work flow. Your career is not about a particular job-it's about your legacy, how you spend your life, and your unique contribution to the health care of patients, families, and communities. If we are willing and courageous enough to embrace and manage change, we will find success.
Remember the phoenix-the mythical bird who, when it perceives its own death, ignites itself into a flame, and then rises from the ashes reinvigorated and fully alive. Embrace the changes-reinvent yourself to meet the needs. Find the phoenix within yourself.
REFERENCES