Chapter 22 New Healthcare Delivery System; Nurses and Work with Patients and Families; the Future of Nursing
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Description
Dr. Summers offers her views on how changes in the healthcare delivery system are affecting the institution and influencing changes in the practice of nursing.
She first sketches the financial pressures and “mindboggling” challenges of the current healthcare environment.
Dr. Summers goes on to describe the ways that nurses are uniquely positioned to attend to patients and families because of their education and roles in care.
[the recorder is paused briefly]
She then describes the institution-level Patient and Family Experience Executive Committee and notes ways she had already been addressing family issues.
Dr. Summers explains how she is addressing value-based care by focusing on clinical teams.
Dr. Summers next talks about the next steps for the field of nursing.
Dr. Summers concludes with words about how she would like to be remembered.
Identifier
SummersB_03_20140429_C22
Publication Date
4-29-2014
Publisher
The Making Cancer History® Voices Oral History Collection, The University of Texas MD Anderson Cancer Center
City
Houston, Texas
Interview Session
Barbara Summers, PhD, Oral History Interview, April 29, 2014
Topics Covered
The University of Texas MD Anderson Cancer Center - Building the InstitutionThe Administrator The Leader Building/Transforming the Institution MD Anderson Snapshot Multi-disciplinary Approaches The Business of MD Anderson MD Anderson Culture MD Anderson in the Future Fiscal Realities in Healthcare Professional Practice The History of Health Care, Patient Care Understanding the Institution The Institution and Finances Career and Accomplishments
Creative Commons License
This work is licensed under a Creative Commons Attribution-Noncommercial-No Derivative Works 3.0 License.
Disciplines
History of Science, Technology, and Medicine | Oncology | Oral History
Transcript
Tacey Ann Rosolowski, PhD:
Interesting. Very interesting. Yeah. I’m wondering how some of these issues dovetail with some of the challenges that are arising from changes in the healthcare delivery system. When I was doing background research, that came up over and over again as something that you have to address. Could you talk about what some of those changes are and then how these movements in nursing practice are addressing them?
Barbara Summers, PhD:
Well, there are almost, you know, a mindboggling number of challenges in healthcare today. Some of the challenges that come to top of mind for people most frequently include the financial pressures, and in combination with the financial pressures we have the expected shortage of workforce members to deliver care. Physicians, nurses, every type of healthcare worker are going to be in short supply. Then we have the need to significantly improve the attitude towards and structures and systems that allow us to meaningfully engage patients and families as partners in their care. Those are just three things that are happening right now, and you can just add on to that the requirement that every organization demonstrate the value that they’re contributing to the health of the individuals that they care for. So when I think about those challenges, the good news is that they’re related and that you can tie one to the other. The better news is that we have very good initiatives already under way that are designed to address these challenges, that we have a very strong Workforce Development Program for nurses, that we are refining our patient care delivery system for nursing practice that will allow us to elevate the practice of nurses so that nurses will be practicing at top of license, which will mean that as we have a shortage of professional nurses, we will be prepared to address that through our pipeline, but also by having refined the practice of the nurse so that we will not need as many professional nurses as we have right now, because we will have nurses practicing at the highest level and not serving in the role of the medical assistant. And then the hiring of educationally baccalaureate-prepared nurses and providing them with professional development so that they become skillful in the art of engaging patients and families as members of the team that makes decisions about their treatment. And to be able to do that, nurses have to, number one, themselves become activated and engaged and believe in the importance of patients and families as partners, not just passive recipients, but active partners. And then the nurses have to become skillful in activating the patients and the families and using our nurse-caring factors to bring the patients and families to the point where they believe they have the capacity to be members of the team. And then promoting health literacy with our patients, so that the patients make informed decisions and have the capacity to ask the right question so that as decisions are made in partnership with the patient and family, it’s truly informed, and they understand the entire array of options and the consequences of each of the options.
Tacey Ann Rosolowski, PhD:
Now, working with families is, of course, something that I’ve heard a number of clinical MDs, clinical faculty, talk about, but it also seems that the nurse is uniquely placed to work with that because the relationship is so—perhaps there’s more contact with a nurse, and the relationship is established there. Can you tell me more about that, sort of the nurse in the family dynamic, the nurse in the dynamic of the patient psychology?
Barbara Summers, PhD:
Well, you know, one of the areas of focus in nursing education is, number one, the paramount belief that the patient is the family; the patient is not the person. The patient is the family. And nurses are exposed to Family Systems Theory in their education because we understand that no individual comes to us as an independent human being without contacts with other human beings in their lives. They come to us with a constellation of relationships. They have relationships within their nuclear family. They have relationships within their work family. They have relationships within their community family, their church family. So understanding that the individual who presents with the identification of patient has multiple attachments, and in the context of cancer care, these attachments physically come with them everywhere they go. So you almost never see a patient by themselves in the organization. They always have family with them—one, two, three, four, five family with them. And I would say that the culture of the organization is one that is accepting of the fact that the patients and the families are always together. I think that our physician colleagues have an understanding of that dynamic of patient comes with family. I don’t believe that they have the same formal educational exposure to the importance of family and the family unit, and the fact that then contributes to the very pressing need for us to be thinking about treatment in the context of family, not only how is the family going to help the patient, which I think is kind of where most of the physicians focus, but what is this experience of cancer going to mean in terms of the roles of the individuals in the family. If the individual with the cancer diagnosis is the husband, and he has been the primary wage earner and he has a wife who has been working a part-time job, and some adolescent children, and the husband becomes profoundly debilitated because of the cancer treatment, well, then the roles change at home. The wife’s role changes, the adolescent children’s roles change, and that change can have a dynamic that can be very detrimental to the family unit, can be an impediment to healing for the patient, so you have to be—
Tacey Ann Rosolowski, PhD:
Now, just thinking about the level of depression and—
Barbara Summers, PhD:
Oh, my gosh, you have to be attentive to all of that.
Tacey Ann Rosolowski, PhD:
—masculine identity, all of these issues.
Barbara Summers, PhD:
All of that. So I think nurses are, just by virtue of our education, more attuned to the fact that the patient and the family really are the unit together, and understanding that there is family that extends beyond the biologic relatives, that people can, and do, benefit from having the support of their co-workers and the support of people, if they are part of a faith community, the support of people in their church community. So, again, MD Anderson, I think, accepts patients and families coming together. We understand that they travel as a pack. But we haven’t really gotten our arms around true patient and family engagement as partners in decision-making. How do we meaningfully engage them in decision-making? And we’re more in the stages of informing the patients who have the family sitting next to them of the, you know, let’s say, two or three treatment option and then kind of recommending one. So that’s kind of using a consulting model. That’s not really engaging the patients and families fully. It’s not bad, but we could do better, because if they are truly engaged, then they take ownership for the way that they can contribute to the outcomes instead of just being recipients of care.
Tacey Ann Rosolowski, PhD:
Now, is this developing beyond this consulting model? Do you have initiatives in progress?
Barbara Summers, PhD:
Oh, yes, we do, and lots of other healthcare institutions do too. I mean, there was a report in 2012 by the Institute of Medicine on the need to radically change healthcare that highlights the importance of patient and family engagement. And then in 2013, the Institute of Medicine put out another publication focused specifically on cancer care, and that singled out the necessity for patient and family engagement as partners in care delivery and care decisions.
Tacey Ann Rosolowski, PhD:
What are some of the initiatives that the Division of Nursing is taking to develop this? Let me just pause this for a second. (end of first audio file) [The recorder is paused.]
Tacey Ann Rosolowski, PhD:
Okay.
Barbara Summers, PhD:
So this is not an initiative that can be run by nursing. Nursing has to be an integral part of it. So we have an institution-level Patient and Family Experience Steering Committee Executive Committee, and we are working with physicians and social workers and all the members of the team in designing our strategic plan, forming our Patient and Family Advisory Council, etc. I am one of the executive cosponsors for this effort. I have a physician who is also my partner and executive cosponsor.
Tacey Ann Rosolowski, PhD:
And that is?
Barbara Summers, PhD:
Dr. Marshall Hicks in Radiology. He’s the division head in Radiology. What I would say is that we are just launching this as an organization. The Inpatient Nursing Operations has been focusing very extensively on our patient experience and patient engagement strategies for probably five years, and two years ago, I created a position for director of Patient and Family Engagement, and that person now actually leads the Patient Experience Steering Committee. She has a physician partner, but she really is the driving force behind that. So I think that we have brought this to an acute level of awareness. We’ve been able to demonstrate the enormous progress that has been made in our patient experience. Scores for the inpatient areas, we now have to find equivalent success in Ambulatory Care, which we don’t have yet.
Tacey Ann Rosolowski, PhD:
Mm-hmm. Interesting. Wow. This has been such an interesting conversation, because, I mean, as I said in the very first session, I really realize that I didn’t know what nurses do. (laughs) And so here’s a whole other area that’s just opened up, quite amazing, and also obviously opening up the future of the field as well.
Barbara Summers, PhD:
Yes.
Tacey Ann Rosolowski, PhD:
It’s an enormous transformation, adding a whole new facet. Are there other ways that you’re addressing changes in the healthcare delivery system? We’ve listed these various areas and we kind of exhausted those at that point: the financial pressures, the shortage of workers, the need to improve the attitudes, which we just talked about, and the demonstration of value of [unclear].
Barbara Summers, PhD:
Yeah, I think the demonstration of value and financial pressures go hand-in-hand. We have to be able to demonstrate, to prove that we are continually improving the quality of outcomes while we are simultaneously reducing costs, not to a point of zero, but to a point where we are getting the best value, which is the highest possible outcome at the lowest possible cost.
Tacey Ann Rosolowski, PhD:
And how are you going about assessing that?
Barbara Summers, PhD:
Well, we’re actually, as an organization, engaged in a very formal activity called time-driven activity-based costing, and we’re doing that in partnership with some folks up at Harvard Business School, Dr. Michael Porter [phonetic] and Dr. Bob Kaplan [phonetic].
Tacey Ann Rosolowski, PhD:
I’m sorry, the name of that was time-driven—
Barbara Summers, PhD:
Activity-based costing, TDABC, where we work with clinical teams to understand the contributions of each member of the clinical team to the delivery of care to patients, and then using a costing model, we assign the dollars that are required to perform that activity, and then we determine how many times that activity is performed by which level of provider, and from that we can demonstrate the cost.
Tacey Ann Rosolowski, PhD:
Wow.
Barbara Summers, PhD:
And then we are measuring the outcomes of care, both the patient-reported outcomes as well as well as the clinical outcomes. And our goal then is to use the TDABC information to review each of the individual clinical team member contributions and identify do we have the right people performing the right work. And that’s where we start to look at redefining roles and responsibilities and optimizing the skills and the training of every member of the team and focusing them on those things that they uniquely can contribute.
Tacey Ann Rosolowski, PhD:
Do you anticipate that this result in a lot of changes?
Barbara Summers, PhD:
I think that the need to improve value is going to result in tremendous change across healthcare. I think that we’re challenged, number one, to figure out how do you measure it.
Tacey Ann Rosolowski, PhD:
Right.
Barbara Summers, PhD:
I mean, that’s just a huge challenge in healthcare in general. We tend to measure value in terms of what bad things didn’t happen. We have much more difficulty in quantifying what are the good things that are supposed to happen. So that in itself is a change. When we look at nursing quality data, really it’s defined in terms of bad things that don’t happen. We look at our rate of fall. We look at the rate of pressure ulcers. We look at the rate of infections of central venous catheters. Those are all bad things, and so we want to reduce the numbers of those bad things, but we have a difficult time—same thing in medicine—very difficult time defining what are the good things that we’re supposed to see. So when you look at medicine, you tend to measure, for example, in cancer, are we delivering cancer care treatment which is in alignment with the accepted treatment algorithm for this particular diagnosis. So in healthcare, we’re just generally challenged to define a positive outcome. With cardiac care, we look at, okay, how many readmissions have you had to the hospital for heart failure? Well, that’s measuring a negative event, because we have a hard time defining what are the positive things. So, yeah, we have a lot of change ahead of us, a lot of change ahead of us, and we have to incorporate patient-reported measures. We can’t just be looking at our processes. We need to include the perspective of the patient and what are the patient-reported measures, and beyond that, what are the patient-reported measures that are of importance to the patients, because there’s an entire universe of patient-reported outcome measures, called PROMs, but there has been very little work done in identifying which of these PROMs are actually important to patients. We’ve had patients help us design the instruments to measure these things. What we haven’t spent a lot of time figuring out, okay, we’ve got all of these measures, but which ones do you really care about? So they’ve been designed based on what clinicians think patients care about. So it’s an exciting time.
Tacey Ann Rosolowski, PhD:
Very exciting time.
Tacey Ann Rosolowski, PhD:
Well, we have a little less than ten minutes left, and I wanted to ask you, first of all, if there’s anything else you want to add on subjects that we’ve already touched on.
Barbara Summers, PhD:
I can’t think of anything right now.
Tacey Ann Rosolowski, PhD:
Okay. Well, then my next question would be what are the next projects that you want to see implemented in your role as VP of Nursing and for the division. I mean, is there anything not yet on the table but something that you really want to see put in place?
Barbara Summers, PhD:
You know, I think just building on the things that we have initiated. I want to see us build on our nursing care delivery model, primary team nursing. I want to see us really redesign the role of the professional nurse in oncology care. I want to see us build our body of nursing science. I want to see us continue to advance the level of educational preparation of our nurses. I want to see us as an organization become highly skilled in the area of patient and family engagement. So I want to see us take these things that we’ve been talking about and optimize them and get us to the point where we are the best of the best in each of those arenas, with the goal that we are focusing on the patients and families that we serve and that we are also focusing on getting the best possible experience for the people who take care of the patients and families.
Tacey Ann Rosolowski, PhD:
And how would you like to be remembered? I know retirement’s not on the deck yet, but looking now at kind of what you’ve done here at MD Anderson, how would you like to be remembered?
Barbara Summers, PhD:
I think I’d like to be remembered as, first, a nurse who was an effective leader in advocating for the advancement of professional nursing and the improvement of outcomes of care for our patients. I think on a personal level, I’d like to be remembered as being inspirational and aspirational and someone who challenged and encouraged others to be their very best.
Tacey Ann Rosolowski, PhD:
Is there anything else that you’d like to add?
Barbara Summers, PhD:
I can’t think of anything. It’s been a delight, though.
Tacey Ann Rosolowski, PhD:
Yeah, I’ve really enjoyed talking to you. It’s opened a whole new window on the institution for me, certainly.
Barbara Summers, PhD:
Well, I appreciate the opportunity.
Tacey Ann Rosolowski, PhD:
Well, thank you very much for your time, Dr. Summers.
Barbara Summers, PhD:
My pleasure. Thank you.
Tacey Ann Rosolowski, PhD:
And I’m turning off the recorder at 11:55. (end of session three)
Recommended Citation
Summers, Barbara PhD and Rosolowski, Tacey A. PhD, "Chapter 22 New Healthcare Delivery System; Nurses and Work with Patients and Families; the Future of Nursing" (2014). Interview Chapters. 1259.
https://openworks.mdanderson.org/mchv_interviewchapters/1259
Conditions Governing Access
Open
