also developed a well-integrated information technology system to link its health professionals and its services.

The VA uses NPs as primary care providers to care for patients across all settings, including inpatient and outpatient settings. In addition to their role as primary care providers, NPs serve as health care researchers who apply their findings to the variety of settings in which they practice. They also serve as educators, some as university faculty, providing clinical experiences for 25 percent of all nursing students in the country. As health care leaders, VA NPs shape policy, facilitate access to VA health care, and impact resource management (VA, 2007).

The results of the VA’s initiatives using both front-line RNs and APRNs are impressive. Quality and outcome data consistently demonstrate superior results for the VA’s approach (Asch et al., 2004; Jha et al., 2003; Kerr et al., 2004). One study found that VA patients received significantly better health care—based on various quality-of-care indicators6—than patients enrolled in Medicare’s fee-for-service program. In some cases, the study showed, between 93 and 98 percent of VA patients received appropriate care in 2000; the highest score for comparable Medicare patients was 84 percent (Jha et al., 2003). In addition, the VA’s spending per enrollee rose much more slowly than Medicare’s, despite the 1996 expansion of the number of veterans who could access VA services. After adjusting for different mixes of population and demographics, the Congressional Budget Office determined that the VA’s spending per enrollee grew by 30 percent from 1999 to 2007, compared with 80 percent for Medicare over the same period.

Geisinger Health System7

The Geisinger Health System employs 800 physicians; 1,900 nurses; and more than 1,000 NPs, physician assistants, and pharmacists. Over the past 18 years, Geisinger has transformed itself from a high-cost medical facility to one that provides high value—all while improving quality. It has borrowed several restructuring concepts from the manufacturing world with an eye to redesigning care by focusing on what it sees as the most critical determinant of quality and cost—actual caregiving. “What we’re trying to do is to have [our staff] work up to the limit of their license and … see if redistributing caregiving work can increase quality and decrease cost,” Glenn Steele, Geisinger’s president and CEO, said in a June 2010 interview (Dentzer, 2010).

Numerous improvements in the quality of care, as well as effective innovations proposed by employees, have resulted. For example, the nurses who


Quality-of-care indicators included those in preventive care (mammography, influenza vaccination, pneumococcal vaccination, colorectal cancer screening, cervical cancer screening), outpatient care (care for diabetes [e.g., lipid screening], hypertension [e.g., blood pressure goal <140/90 mm Hg], depression [annual screening]), and inpatient care (acute myocardial infarction [e.g., aspirin within 24 hr of myocardial infarction], congestive heart failure [e.g., ejection fraction checked]).



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