Monthly Archives: January 2016

Reimbursement for Nursing Services: A Pipe Dream or Potential Reality

I have the privilege of studying for my MSN in Informatics in an entirely online format with Capella University. An interesting line of analysis arose, during a discussion of universal nursing terminology. There are a number of universal terminologies, perhaps the best known being NANDA, NIC and NOC. The Omaha System is integrated within SNOMED, perhaps making it the most likely candidate for eventual universal utilization.

Be that as it may, the question arose: would the use of standardized nursing terminology ultimately lead to billing separately for nursing services. Why or why not? Would nursing be perceived differently if their departments were revenue-earning? My reply is below:

I think the key lies in re-framing both the public and the industry’s perception of nursing as ‘revenue draining’, and instead creating a ‘value added’ perception.

Increasingly numerous studies are indicating that better nursing environments lead to nurses’ ability to perform their job better and subsequently better patient outcomes. Because of my passionate belief in advocacy and the use of social media to change perception, I would like to refer you to my blog post in in this regard which can be found here:

This post refers to a study authored by Jeffrey H. Silber, MD, PhD, from the Perelman School of Medicine at the University of Pennsylvania. Dr. Silber found that the higher the acuity of the patient, the more difference the nursing environment made. Perhaps most germane to this discussion was Dr. Silber’s conclusion:

Hospitals with better nursing environments and above-average staffing levels were associated with better value (lower mortality with similar costs) compared with hospitals without nursing environment recognition and with below-average staffing, especially for higher-risk patients.

Simply put, more nurses working in a better environment result in better patient care and lower mortality with similar costs. On a systemic level, more nurses and better working conditions for nurses actually results in decreased cost relative to outcomes, and increased value. The abstract is accessible from the reference citation below. I was made aware of it through the ANA’s news outlet for members, ANA SmartBrief. Members can subscribe at the ANA member website to read the most current news about nursing.

Whether or not the government – driver of reimbursement reform and change – will pick up on this and ultimately require nursing services to be unbundled and tracked for outcomes will probably be the determining factor as to whether floor nursing services will be separately reimbursable. Hospitals, however, could conceivably offer a ‘tiered’ service. OK, that sounds terrible but it is the way this county works. We are definitely a health care industry, not a socialistic system where everyone gets the same. As such, market forces prevail. Hospitals could offer patients Cadillac services at a higher price, which the patient/family would pay out of pocket. Sort of like staying at the Hilton as opposed to the Red Roof Inn…

It is a fascinating discussion (here comes the soap box), but unless we as individuals and as a profession advocate for such a change, it is highly unlikely. Unless, perhaps, President Sanders is elected. (Where is my unicorn?).


Silber J., Rosenbaum P., McHugh MD, et al. (2016). Comparison of the value of nursing work environments in hospitals across different levels of patient risk. JAMASurg.  Advance online publication. doi:10.1001/jamasurg.2015.4908.

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Taking Care of our Veterans: Supporting HR 1247

The Veterans Administration would like to update their policies to allow APRNs to practice to the full extent of their license and training within the VA system. On January 8th, the draft regulation to implement this policy was transmitted to the Office of Management and Budget. It is reflected in the language of HR 1247. After the OMB clears the regulation as drafted, it will be published in the Federal Register for comment.

I am somewhat stymied to report that the House Representative from Michigan’s 1st Congressional District (where I live…) has written a letter opposing this policy. Dr. Dan Benishek stated that the concern he had was that this may imperil the health of fragile Veterans by allowing CRNAs to practice without direction physician supervision.

This is a false claim. The definitive source for meta-analysis of medical issues with absolute global credibility is the Cochrane Review. On July 11, 2014, a review entitled, “Physician anaesthetists versus non-physician providers of anaesthesia for surgical patients” was published, authored by Lewis, Nicholson, Smith and Alderson. They found that there is no evidence sufficient to show any difference between the two types of providers. It is difficult to argue with the Cochrane Review.

Disclosure: my husband is a veteran and gets almost all of his medical care from a Veteran’s Facility. He has no complaints about the CRNA who performed his anesthesia. He agrees that better access to care, decreased cost to taxpayers, and less waiting time to see a provider are benefits that he and all his fellow Vets value. He understands that APRNs practice to the extent of their training and licensure, and don’t infringe upon the practice of physicians. He understands that there are many things that physicians do that APRNs are not licensed or trained to do, and that there is no risk whatsoever to the patient. Why can we not get this message across to the general public?

What can you do? Learn more about this issue here:

Write to your Representatives and Senators and ask them to support the VA’s decision to allow APRNs to manifest the Institute of Medicine’s recommendation that they be allowed to practice to the full extent of their training. Why not take a moment to get involved? The men and women who have served our country deserve our support.


Lewis SR, Nicholson A, Smith AF, Alderson P. Physician anaesthetists versus non-physician providers of anaesthesia for surgical patients. Cochrane Database of Systematic Reviews 2014, Issue 7. Art. No.: CD010357. DOI: 10.1002/14651858.CD010357.pub2.

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Water Crisis in Flint, Michigan:What Would Flo Do?

Children in Michigan are screaming while being tested for lead poisoning, and already exhibiting signs and symptoms. All of this because the state and local legislators wanted to save a little bit of money and alter the source of their drinking water. Now it is polluted, poisonous, and there is no relief in sight.

For the latest on this subject, follow Eclectablog here:

The question we must pose ourselves as nurses is, what would Florence Nightingale do? I submit that she would speak out strongly in an effort to obtain clean water for Flint’s population and to ensure adequate resources were dedicated to that effort. Children will be permanently affected by this example of uncaring and appalling action on the part of Michigan’s politicians. Please lend your voice in support of the children of Flint. You can contact your local office of your state representatives, post your own commentary on Facebook, and contribute to the Twitter conversation at #FlintWaterCrisis.

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Happy CRNA Week – January 24-30, 2016

It’s CRNA week, and I am glad to report good news for the #Michigan68.

First to the celebration:

They are celebrating in Michigan, as a legitimate and fair contract has finally been negotiated, allowing the #MI68 to go back to the jobs and patients they love. Find the whole story here:

Perhaps the most powerful statement made in the news from the #MI68 is this one-

We have proven our conviction to stand up for what is right. We have shown the extent of our moral fortitude by remaining committed to the CRNA profession and our campaign despite the personal cost. And, most importantly, have shown the selfless ability to forgive – exemplifying the compassion and professionalism inherent throughout the entire nurse and advanced nurse practice field.

Nurses, exhibiting compassion, professionalism and CARING, while remaining true to their values. It is truly worth celebrating that your efforts, their efforts, and the combined pressure of public opinion, nursing professionals, and just plain ethics resulted in the ability for all parties to come to a reasonable and appropriate agreement.

I hope you will join me in now turning your attention to the #Asheville96 and support them in any way you can as they work through these same issues. Together we can keep CARING in nursing without sacrificing our core values. It takes a village…



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High-Quality Nursing Environment = Better Outcomes. Is that not what we want?

This photo of a Civil War era nurse reminds us of where we have come from. We have made such significant progress in all areas of nursing and medical care, except perhaps in the area of nursing’s status as an independent profession deserving of respect and equality. In this era of outcomes-driven healthcare regulation, it only seems logical to ensure the availability of well-educated nurses in a supportive environment. This week’s ANA Smart Brief highlighted a Journal of the American Medical Association – Surgery article which stated clearly that high-quality nursing environments cost no more but result in better survival of surgical patients. Here is the cite:

Hospital study links high-quality nursing environment to better outcomes
A study that included hospitals in Illinois, New York and Texas found higher-quality nursing environments had similar costs but better survival rates for surgical patients, compared with hospitals that had poorer nursing environments. “While better outcomes and value may be owing to other features of hospitals with good nursing, excellent nursing environments appear to provide a strong signal to patients and referring physicians for better quality, lower cost, and higher value,” researchers reported in JAMA Surgery.

…better quality…lower cost…higher value. What then is the impetus for higher nurse-to-patient ratios, reducing compensation for CRNAs and diminishing or decreasing the quality of the nursing environment? It is outright counter-productive!

As study results mount demonstrating the added value of an educated and supported nursing staff, perhaps we will finally be able to address these issues with legislation. Some active issues include:

  • legislating nurse-to-patient staffing ratios that cannot be exceeded as in California
  • lifting restrictions on APRN practice
  • Safe Patient Handling and Mobility (SPHM)
  • workplace violence.

Becoming politically active is not a huge commitment. It could be a single phone call or email to one of your representatives to educate them about an issue that is important to you as a nurse. Just imagine if we all did this. Now, imagine if we all did it as an entire profession! If nursing took up just one issue, focused on it with the power of the entire profession, and reached out to politicians and policymakers, I am sure we could advance our agenda a great deal. Let’s all commit to taking the first step. Remember Meryl Williamson’s inspirational video. We are the only things in our way!








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Dedicated Medical Professionals when Disaster Strikes: Kudos to the #Asheville96

Facing termination by an uncaring administration, the doctors and nurses comprising the #Asheville96 respond by going the extra mile to ensure their community has the excellent medical care they need in the fact of disaster.

In pursuit of the “Iron Triangle” of access, outcomes (quality) and cost, all too often we overlook the big C which is supposed to be at the heart of our system – CARING. These nurses and physicians are demonstrating their caring despite being put into a disrespectful, compromised position by the hospital.

We all must continue to keep the big C at heart of medical “care”. We can talk about medical services, and medical service administration but the act of a medical professional interacting with a patient on their behalf is still called medicare CARE.

Please support the #Asheville96 as they seek to continue to provide excellent medical CARE to their community, and let your own voice be heard! Together we can move forward without losing sight of the big C.

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Why is nursing informatics important in healthcare?

As a MSN student specializing in Informatics, this post really resonated with me. So much so that I have reblogged it to my blog. Thank you for the great post.

Do you want just anyone doing this? What’s happening in Anesthesia?

I was all set to blog about the water tragedy in Flint and #whatwouldflodo when I came upon a situation which roughly parallels the #Michigan68. Now there are the #Asheville 96. In their case, however, not only the CRNAs are facing termination, but the physicians are as well. Here is the post from their Facebook group Asheville Crna:

As we posted yesterday, anesthesia services in Western North Carolina face an uncertain future. We, the certified registered nurse anesthetists (CRNAs), are the people who provide your direct, hands-on anesthesia care in our home community. We safely get you off to sleep, watch over every single breath and every heartbeat while you’re having surgery, and wake you up safely and comfortably. We provide your anesthesia care for the birth of your children. We serve you in times of your greatest joys and highest vulnerabilities. We are your lifeline, and we take enormous pride in that.

Due to circumstances in which we had no part, we are facing a huge change in our employment this Spring. More importantly, the stability that our group has provided for 45 years may vanish. In short, come Spring you may have a new group of anesthesia providers who know nothing of hospital protocols, surgeon preferences, quality measures we’ve perfected over decades, heck – even how to find their way around the hospital.

All we want is to continue providing the highest level of care to surgical patients of WNC—our home community—just as we always have. We want the stability of 45 years of quality care to continue for another 45 years and beyond. We want to come into work before the sun, give our very best to you, and not be concerned about our employment. After all, we have more important things to focus on.

How can you help? Pass this on to everyone you know, especially in medical circles. Tell them that we are facing the uprooting of a stable, highly skilled anesthesia care community. Talk with your family, your doctor, your dentist, your cousin who is a nurse, your minister, your coworkers. Ask them whom they would prefer to have put them to sleep, watch over them and wake them up—the group that’s done it for 45 years and lives here with you or someone who hasn’t had time to unpack boxes.

Please share your support for ‪#‎Asheville96‬

It is once again time to join together to voice our support for our colleagues, to advocate for nurses, nursing, and patient care and safety. If we come together, we will be stronger in number and power. Please support the #Asheville96.

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Communication: the key to success.

Good news from the #Michigan68! The hospital has agreed to meet with them again, in a good-faith attempt to resolve outstanding disputes. Read more about it here:

Would this have happened without the power of social media. Doubtful.

Nursing and nurses need to understand the power they hold in numbers and the influence they can bring to bear by tapping into current mainstream communications outlets such as Facebook, Twitter, etc.  Nursing leaders like Barbara Glickstein, Twitter handle @BGlickstein have made their voices known in a powerful way utilizing technology and social media.

As we seek to have our perspectives count in the continued melee of health care reform, we need to advocate for ourselves personally and professionally. There is strength in numbers. If we come together as a profession, we will represent the largest segment or sector of the health care industry’s work force. Let’s start now. The bravery and success of the #MI68 should inspire us all to do what we can. Let’s communicate!





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The Answer to areas of Medical Desert: APRNs.

One of the things that the #Michigan68 have shown us is the ongoing belief that nurses are disposable. This one doesn’t work the way you think it should? Just throw it out and get a new one…And yet astute thinkers in all segments of health care understand that Advanced Practice Registered Nurses (APRNs) are the key to providing affordable and accessible primary care.

This was eloquently stated by Juan Quintana, President of the American Association of Nurse Anesthetists in the following  article in the online journal Modern Healthcare:

As we move forward with the IOM’s vision for 21st century health care, we recall that their recommendations for the Future of Nursing include removing restrictions on APRNs. It is in all of our best interest to add our voices to this movement.


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