Remarks for the American Association of Colleges of Nursing’s Clinical Nurse Leaders Summit

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by HRSA Administrator Mary K. Wakefield

January 23, 2010
San Diego, Calif.

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Thank you, Susan (Dr. Susan Bakewell-Sachs, dean of the school of nursing at the College of New Jersey), for that kind introduction.

It's wonderful to be invited by AACN and to be here among so many nursing colleagues. To be with nurses and nurse faculty feels a bit like coming home – home to so many personal friends, home to shared professional experiences, to common values, and to the belief that while we've accomplished a great deal as a profession, there is, of course, a great deal to be done.

It's particularly interesting to talk about health care reform, which I'll be doing from my vantage point at HRSA. There's a lot of reform underway at unit levels, in academic institutions, and in state and federal policy.

I'm pleased to say that the federal government benefits from the talents of many nurse leaders.  At HRSA, we have nurses in several key leadership positions. For example:

• Dr. Deborah Parham-Hopson is in charge of our HIV/AIDS Bureau.  She administers a $2 billion budget and oversees the delivery of life-saving services to more than half a million people in the United States living with HIV/AIDS.
• Kerry Nesseler directs our Office of Global Health Affairs.  Kerry also is the chief nurse of the U.S. Public Health Service.
• Dr. Denise Geolot is director of our Office of Strategic Priorities, which examines and responds to emerging health issues.
• Dr. Regan Crump heads our Office of Regional Operations. In that job, he is responsible for activities at all 10 of HRSA's regional offices across the country.
• And Dr. Joan Weiss directs the Division of Diversity and Interdisciplinary Education in our Bureau of Health Professions.

Collectively, these nurse leaders – along with other nurses throughout the agency – are a big part of the great team I work with at HRSA. They are fine representatives of what nurses can, and should, do to shape national health policy and direct the activities of important federal health agencies, and, frankly, I'd like a lot more exceptional nurses on HRSA's team.

I'll come back to that theme later and I'll also discuss, in the context of my own work, the issues of care quality, leadership and public policy engagement that I know are so important to all of you. But first let me tell you about the range of work we do at HRSA, and then what we've been working on since I assumed leadership of the agency last March.

HRSA has a $7.2 billion annual budget, and we received an additional $2.5 billion under the American Reinvestment and Recovery Act, which President Obama signed soon after taking office. We're often called “the access agency,” because we expand access to high-quality health care for the populations served through our programs. Let me tell how HRSA touches the health care providers and the public they serve:

• HRSA's best-known asset is probably the health center network that we support.  Our 1,100 health center grantees provide quality primary care to more than 17 million medically underserved people at 7,500 sites in urban and rural areas across the nation.  Everyone who enters the door is served.  Payment is determined by sliding fee scales; the poorest pay nothing.
• We're also widely known for our administration of the Ryan White HIV/AIDS Program, under Deborah Parham Hopson's direction.  Our grantees provide some of the best care for people living with HIV/AIDS that can be found anywhere in the world. More than half a million people living with AIDS in the United States receive care every year thanks to the Ryan White program. We use metrics in both this program and the health center program to ascertain how well grantees are doing in terms of care.
• Our experts in the Maternal and Child Health Bureau lead the federal government's efforts to improve the health of mothers and their children. Every year, its block grant funds to states provide health services that reach six out of 10 women who give birth in the U.S.
• Our Bureau of Health Professions staff provide resources to help train the next generation of the health care workforce and, through the National Health Service Corps, we place them where they're needed most.  I'll talk more about the NHSC in a few minutes.
• We also run the 340B Drug Pricing Program, which gives safety-net providers access to discounted pharmaceuticals.  Some of you may work in health care facilities that benefit from the 340B program. And we have a range of other programs – from Poison Control Centers, to our Federal Organ Procurement and Donation efforts, to the National Vaccine Injury Compensation Program.

That's a quick summary of HRSA's core programs.  In 2009 we were very busy administering the $2.5 billion in Recovery funds; some of that spending will continue in 2010. Our Recovery funds were split three ways:

• First, we were given $2 billion to expand, improve and renovate the health center system.  With those additional billions our health centers served hundreds of thousands of new patients in 2009. With this appropriation, President Obama and Congress made a much-needed investment in primary health care for the underserved, and they signaled their trust in HRSA's ability to expand services to that population.
• Second, we received $200 million to counter health workforce shortages by expanding training and educational opportunities.  This investment reflects President Obama's commitment to attract and retain more nurses, physicians, and other health care professionals.  The new funds are expected to support the training of 8,000 additional students and credentialed health professionals by the end of fiscal year 2010.
• And third, we received $300 million to add thousands of new clinicians to the ranks of the National Health Service Corps.
  
  Let me pause here for a commercial: The NHSC is a great option for nurse practitioners, psychiatric nurse specialists and certified nurse midwives. Of the 4,300 NHSC clinicians currently in the field, about 650 are advanced practice nurses, and right now – thanks to the Recovery Act – we have vacancies for 1,700 advanced practice nurses at more than 1,400 sites.
  
  Here's the deal with the NHSC: health care professionals who sign up for two-year terms to work in underserved areas can get up to $50,000 in student loans paid for by the federal government. Nurses who choose a five-year commitment to the Corps can get up to $145,000 in loans paid off. We've worked hard to streamline the process of joining the Corps and we're accepting applications for Recovery Act funds through July 29 of this year, or until those funds are exhausted. If you know nurses who are dedicated to delivering primary care for the underserved – and who want the government to pay off their loans while making a palpable difference – please tell them about the NHSC and urge them to go to www.hrsa.gov to learn more.

That, in a nutshell, summarizes the uses to which we've put our Recovery funds. It goes without saying that this enormous influx of money, and the imposition of very tight deadlines to distribute the funds, created a great deal of work for our staff. I'm really proud to say that the women and men of HRSA pulled together like never before to award Recovery funds on schedule.

Of course, our Recovery work came on top of our regular portfolio of responsibilities, which last year also included reauthorizing the Ryan White HIV/AIDS Program and launching a new program to combat autism.

To my mind, 2009 was HRSA's best year ever.  At no other point in our history has an administration and a Congress viewed HRSA as being so central to rejuvenating primary care and restoring investments in health professions training.

But I'm also confident that 2010 will be HRSA's next best year ever. Both the Senate and House health reform bills envision sizable expansions for HRSA programs. For example, the Senate bill would add an additional $8.5 billion in appropriations over five years to the health center system and an extra $1.5 billion for the National Health Service Corps over the same period.

From this background, you can probably tell we've been working overtime to expand access to primary care, and expand and deploy the health care workforce, but we also are deeply engaged in work to improve the quality of the care our grantees deliver. For example, for years health centers have been involved in “health disparities collaboratives,” which bring together teams of health center staff – dentists, nurses, doctors and social workers – to improve their systems of care by learning about and then implementing better ways to care for their patients.

The collaboratives' emphasis of teamwork, on linking education to practice, and on bridging communication gaps mirror dimensions of the Clinical Nurse Leader model.

Data collection and analysis of patient outcomes are at the core of the collaboratives' work.  By tracking patient outcomes, health centers and HRSA staff are able to identify interventions that improve care for patients suffering from chronic diseases like asthma, cardiovascular disease and diabetes.  Our staff then work with grantees to share best practices in clinical care and strategies to implement them.

In 2008 the health center program added to its quality efforts by establishing a set of clinical performance measures for several key health conditions and age groups.  For the first time, all health centers in 2008 reported on:

• childhood immunization rates;
• entry into prenatal care;
• PAP testing;
• low birthweight;
• control of hypertension; and
• diabetes.

In addition to tracking these core health indicators, health centers also report data by race and ethnicity on low birth weight, diabetes and hypertension to track our progress in eliminating disparities in health outcomes. Reducing disparities is not good enough; I'm focused on eliminating them.

Here's what we've learned in preliminary findings from the 2008 data:

• Over the past year, the percent of low birthweight babies delivered by women who received prenatal care at health centers decreased from 7.8 percent to 7.6 percent, which is lower than the most recent national average of 8.3 percent.
• Among patients with hypertension, 62 percent have their blood pressure under control, and more than 30 percent of health centers exceed the Healthy People 2010 goal of 68 percent.  That's good, but obviously not nearly good enough.

These gains move us in the right direction, but I intend to push ahead forcefully with additional, continuing quality improvements at health centers during my term.

Improving quality is not just a concern of health centers, of course; it's central to the full range of HRSA programs.

In our Maternal and Child Health Bureau, which oversees the Title V block grant program to states, all of the 59 states and territories that receive funds from us report annually on their progress toward meeting health targets on 18 National Performance Measures. These data are published on our Web site. The reported measures include such things as:

• the percent of third-graders who have received protective sealants; and
• the percent of mothers who breastfeed their infants at 6 months of age.

When state officials apply for their MCH block grant funds each year, as they are required to do, Bureau staff meet on site with them and talk to them about their performance on these 18 measures, and, if needed, about ways to improve performance.

And since 2001, MCHB has funded a smaller quality effort called the Pediatric Emergency Care Applied Research Network – or “PECARN.” With an investment of just over $5 million annually, PECARN conducts research on the prevention and management of acute illnesses and injuries in children through a network of 21 participating hospitals.

We're delighted with PECARN's efforts because already their research has led to improvements in clinical care for sick and injured children in two situations. The first finding resulted in improved treatment for bronchiolitis -- a common infection of the respiratory tract in infants and a leading cause of their visits to hospital emergency rooms. The second led to improvements in treatment for head trauma in children, making new knowledge actionable, something that is for us, as it is for you, a high priority.

In our HIV/AIDS Bureau, quality activity is taking a new turn. In 2006, congressional reauthorization of the Ryan White HIV/AIDS Program made client-level data reporting a requirement for the first time. The challenges of moving from reporting in the aggregate in terms of software and training are substantial, and data security, of course, is a special concern for people living with HIV.

But the change is almost complete and already we're starting to see how the client-level data can be used to make real program improvements.

Staff tell me that grantees who completed the conversion to the new reporting system can now look at service utilization patterns and can, in minutes, see how resources are allocated. Now they can review data and improve service linkages by checking on how referrals are being made and how well clients are adhering to their treatment plan.

We plan to post the new client-level data in the aggregate once the data are “mature,” probably beginning with the 2010 data. That's, consistent with this administration's view about transparency – put it out for the public to know.

Other quality efforts at HRSA use the collaborative model that improved patient outcomes at health centers.

One of these efforts, called the Donation and Transplantation Community of Practice, brings together hospital executives, donation and transplantation professionals, and organ procurement organizations from across the country to identify and share best practices on integrating organ donation into hospitals' end-of-life care. Hospitals' commitment to meet donation rate goals and increase the number of organs donated per individual donor helped make possible the transplant of 3,088 more organs from deceased donors in 2008 than in 2003.

A second collaborative aims to improve patient safety by integrating clinical pharmacy services into the treatment of high-risk, high-cost patients.

Right now, this effort has 110 teams in 40 states. As in the other collaboratives, this one is marked by inquiry and learning, testing of best practices, and monitoring and adjustment of plans by organizations in the teams.

Already team members have reported averting hundreds of potential adverse drug events, and some cited instances in which life-threatening adverse drug events were identified and resolved, thanks to the skills they developed in the collaborative. Just as clinical nurse leaders are in the business of working collaboratively across teams and multiple stakeholders to improve patient care, so are we.

These issues of quality, safety, and accountability among health care providers also are part of the pending health care reform legislation.

A proposed Medicare Shared Savings Program, for example, would reward groups of health care providers that meet quality-of-care targets and reduce patient costs. If successful, the groups – which may include nurse practitioners – would be rewarded with a share of the savings they achieve for Medicare. Another initiative would make incentive payments to hospitals for reducing preventable readmissions of Medicare patients.

Other provisions would encourage our sister HHS agency, the Agency for Healthcare Research and Quality, to develop and disseminate “best practices” in health care quality, safety and value, and let the HHS Secretary enter into agreements with qualified institutions to develop quality measures for health care delivery. These could include measures to assess health outcomes, continuity and coordination of care, and care transitions for patients across providers and health care settings.

Let me conclude my remarks by summarizing President Obama's intentions in reforming health care during his first year in office.

Clearly, the President is focused on expanding access to primary care: both the Recovery Act investments and the reform bills reflect that goal.

Clearly, the President is determined to improve the quality and safety of U.S. health care. The Recovery Act also included billions to promote the expansion of health information technology to improve both care quality and safety. In fact, I believe that the link between HIT and quality is so strong that earlier this month I merged our old Center for Quality and our old Office of Health Information Technology into a single entity.

Clearly, President Obama is determined to expand health promotion and disease prevention strategies. He knows we can bring down the cost curve by improving the health of the American people and reducing the demand for more intense health care services. The President's emphasis on public and population health is not only overdue, it makes perfect sense. Every newly minted nurse knows that a shift “upstream” to focus on disease prevention and health and wellness promotion can save lives and dollars.

And clearly, this administration and this Congress know that we need to bolster the health professions through investment in the workforce. The President knows that nurses play a key role in keeping people healthy by spreading prevention messages, delivering primary care, and coordinating care that patients receive.

His administration “gets” that, and that's why tens of millions of dollars in Recovery money went to expand nurse training, and that's why his 2010 budget proposal sought even more money from Congress to train nurse educators. The President also asked Congress for an increase of $88 million for the Nurse Education Loan Repayment and Scholarship Program; those funds will support more than 1,600 additional contracts for nurses who serve in critical-shortage facilities.

These, then, are the issues that are important not just to nurses but to the health of the nation. And that leaves us with the question – how do we engage in health care policy? What should our response be? What are our roles and responsibilities as nurse leaders?

If I can leave you today with a clear message, it would be that you individually – and all of us collectively – recognize the absolutely essential role of nurses to engage in public policy.

I ask you to look for or create new opportunities to contribute to the health of the American people.

Open yourselves to new ideas – be thoughtful in evaluating them. This openness involves an inherent willingness to take risks. And it may take you out of a secure zone – as it did with me when I stepped away from a very comfortable and interesting tenured position as an associate professor at UND at age 33 to work in my Senator's office in Washington.

Health and health care is our work, but health care policy should be our work, too. And when nurse leaders are prepared to engage in policy as a nurse researcher, a clinician or a faculty member – or take on policy full time as I and other nurses have – we can use what we know about health care access, quality and financing to inform far-reaching policy development. It's challenging to get there, but it's critical that we do, because nurses and this profession have a great deal to offer. Some is being offered now, but much more can be.

I'll give you one example of the value of nurses in the political arena that, frankly, I don't think all nurses recognize. This past summer I was invited by senators and representatives in several states to take part in town hall meetings and televised town halls with voters to explain President Obama's plans for health care reform. In every meeting the senator or representative introduced me as a federal official who was a nurse. And just by saying that, no other credential needed to be highlighted. As a nurse, I brought a valued and respected perspective about the problems that afflict all Americans as a result of our broken health care system. It wasn't my name that mattered, it was that I am a nurse.

But let's be honest, it's not enough to say, “I'm a nurse and I know what we should do.” To be heard, we need nurses who understand politics and who know economics, informatics and system redesign. We need nurses who understand the issues involved in building a high-quality health care system and who can explain it to the public and to lawmakers. By virtue of your taking the time to attend this conference, with its focus on measuring health care quality, you get that part of the equation.

I'm not exhorting you to move to Washington and follow my path. There are many ways nurses can contribute. You can get involved on the state or local level. You can add your energy and expertise to a political campaign or to a nursing organization.

But nurses must be engaged in the dialogue. The scene may be local, statewide or national – in fact, the arena you choose to enter can be almost anywhere, but your voice should be heard. If I've learned anything in the last 30 years, it's that engagement in public policy is an important – and natural – option for a nurse. And when we're not there, it isn't just nurses that lose – the health of our people is diminished by losing the benefit of the expertise our profession has.

Let me give you another example. In 2008, I chaired a panel advising the Commonwealth Fund on a report titled “Organizing the U.S. Health Care Delivery System for High Performance.”

And I'm very glad I did, because a final draft made less mention of nurses – it wasn't intentional, it's just that others didn't bring that expertise to the table. A section dealing with care coordination barely mentioned nurses, yet all of you in this room know that it's often a nurse doing the coordination; indeed, it's a key role of Clinical Nurse Leaders. Nursing is at the core of care in America, but our potential contributions are often invisible to people.

That report, by a respected “think tank,” was better because a nurse was there. Because one nurse was involved, it acknowledged nursing's vital role in care coordination. It's all of our responsibility to ramp up nurses' engagement and influence in health policy issues.

Thank you for listening colleague to colleague. And thank you for all that you do – from myriad roles and places – to advancing the health of the nation.