Agents for Change: Nonphysician Medical Providers and Health Care Quality

Nathan A Boucher, PA-C, MS, MPA, CPHQ; Marvin A McMillen, MD, FACS, MACP; James S Gould, PA-C, MS

Perm J 2015 Winter; 19(1):90-93 [Full Citation]


Quality medical care is a clinical and public health imperative, but defining quality and achieving improved, measureable outcomes are extremely complex challenges. Adherence to best practice invariably improves outcomes. Nonphysician medical providers (NPMPs), such as physician assistants and advanced practice nurses (eg, nurse practitioners, advanced practice registered nurses, certified registered nurse anesthetists, and certified nurse midwives), may be the first caregivers to encounter the patient and can act as agents for change for an organization's quality-improvement mandate. NPMPs are well positioned to both initiate and ensure optimal adherence to best practices and care processes from the moment of initial contact because they have robust clinical training and are integral to trainee/staff education and the timely delivery of care. The health care quality aspects that the practicing NPMP can affect are objective, appreciative, and perceptive. As bedside practitioners and participants in the administrative and team process, NPMPs can fine-tune care delivery, avoiding the problem areas defined by the Institute of Medicine: misuse, overuse, and underuse of care. This commentary explores how NPMPs can affect quality by 1) supporting best practices through the promotion of guidelines and protocols, and 2) playing active, if not leadership, roles in patient engagement and organizational quality-improvement efforts.


A prospective physician assistant (PA) student applicant explains to the admissions committee that s/he would like to become a PA rather than a physician because s/he "wouldn't have to worry so much about the administrative aspects of health care and could spend more time taking care of patients." Although this patient-centered sentiment may be noble, it is a misconception of modern nonphysician medical provider (NPMP) practice, including the roles of PAs, nurse practitioners, advanced practice registered nurses, certified nurse midwives, and certified registered nurse anesthetists. NPMPs, along with all other members of a patient's health care team, are increasingly asked to take on administrative and quality aspects of health care delivery that once were the sole concerns of supervising physicians or administrators. NPMPs can and should play a major role in shaping health care quality and outcomes.1 These medical providers can do so readily by educating staff, promoting adherence to clinical guidelines and protocols, playing active roles in quality-related decision-making processes for their organizations, and leading patient-engagement efforts aimed at quality improvement. NPMPs are especially appropriate members of the health care team to strengthen and uphold best practices owing to their advanced knowledge base2-4 and to their role in enhancing physician trainees' education.5,6 Furthermore, their training model and scope of practice are most often based on a collaborative approach to care, a paradigm of value in health care,7 and they often are able to expand the amount of care offered by a physician or medical service.8 The new paradigm may be that quality is everyone's business—all staff at all hours—and NPMPs can be an effective agent for change in many settings owing to their training and highly visible role in health care delivery.9

Health care quality improvement (QI) is a concern in many settings: outpatient and inpatient care; for individual patients and for public health; and in the context of specific illnesses, disciplines, product lines, and institutions. At the federal level, there has been a recent surge of support for improving health outcomes and patient satisfaction and allocating resources accordingly. As part of the 2009 economic stimulus package, the federal government dedicated $1.1 billion to study the effectiveness of medical modalities in curbing costs and improving quality for health consumers.10 Action steps aimed at improving quality in health care require shifts in an organization's culture and in health care workers' attitudes and a reworking of roles and processes.11-13 Mandates for QI now come from health reform legislation14 and professional certification bodies,15 and marketing influenced by consumer opinion has an impact as well.16 The PA maintenance of certification process, for example, now requires demonstration of participation in quality- and performance-improvement projects as well as continuing education credits during the ten-year recertification cycle.15 The emphasis on defining and improving health care quality delivered by the fractionated American system of care has increased the pressure on those very fractions to alter practices and communications to improve patient outcomes. This is congruent with many aspects of the unfolding health reform measures mandated by the Patient Protection and Affordable Care Act.17

Why are NPMPs of particular interest? As the population ages, there will be an increased need for medical practitioners. The Bureau of Labor Statistics projects 38% growth in the number of PAs and 31% growth in the number of nurse practitioners, certified nurse midwives, and certified registered nurse anesthetists for 2012-2022.18 These NPMPs diagnose conditions and counsel and treat many patients in many settings, including primary care and acute care settings, and the results are usually comparable to physicians and include high rates of patient satisfaction.19-21 Furthermore, the PA-physician practice model, for example, stipulates that a team approach be used when caring for patients. This model maintains clinical service stability and promotes optimal outcomes for patients.22 This practice architecture, coupled with growing support and utilization of collaborative care using interprofessional communication and practice models, can help to optimize the delivery of care.23-25

In Crossing the Quality Chasm, the Institute of Medicine emphasizes three problem clusters in the delivery of health care: misuse, overuse, and underuse of care.12 These problems can be avoided by gaining knowledge of and adhering to evidence-based clinical care guidelines (or consensus statements) published by authoritative, professional medical bodies26,27 and by using evidence-based clinical care protocols for select processes.28,29 Despite the national emphasis on the importance of clinical guidelines, adherence to guidelines in medical practice is often poor.30 Practicing physicians require extensive medical knowledge, but they may lack awareness of or be unfamiliar with the most recent guidelines or other evidence-based practices.31 This is an opportunity for NPMPs to add value to a medical practice or hospital service. They are well trained in the basic and clinical sciences and can play a key role in guiding health care staff in adherence to the most recent and relevant developments in evidence-based care. For example, they can thoroughly understand recent guidelines for target blood glucose levels in acute care settings, teach them to relevant staff, and oversee the monitoring. This adherence, driven by the NPMP, can be the cornerstone of a service's or practice's success in maintaining acceptable patient outcomes.22 Table 1 illustrates the triple C approach to optimal dissemination of clinical care guidelines and protocols using the NPMP as the change agent.

Nonphysician Medical Providers Can Affect Quality of Care

Health care quality can be assessed as objective, appreciative, and perceptive,32 and NPMPs can affect these quality aspects in positive ways. Figure 1 details three ways NPMPs can play active roles that affect the three aspects of quality. Objective quality has historically been the province of those working in the QI Department or administrators of a health care organization. External regulatory standards (eg, those set by the Joint Commission or the Centers for Medicare and Medicaid Services) or established internal criteria set by the health care organization itself steer objective quality goals. Examples of quality goals can be found in documentation by the Surgical Care Improvement Project33 and the Consumer Assessment of Healthcare Providers and Systems,34 and they are tied to reimbursement structures for health care services. NPMPs' active role in continually educating and updating other health care staff on developments in evidence-based practices can critically affect patient health outcomes (Table 1).

Appreciative quality is judged by colleagues and peers working in a similar setting. NPMPs can affect this aspect of quality by serving actively, even in leadership capacities, on organizational quality committees. Appreciative quality is less quantitative and more subjective (ie, opinion based on experience), but it may affect referral to providers and health care organizations.35 For example, a provider or organization that is known to provide exemplary care in concert with best practices is likely to have the opportunity to care for more patients, because more patients will be referred to them. In contrast, poor processes or outcomes, as judged by others in the same or a similar field, can be detrimental to reputation and revenue. Reputation and revenue are major considerations for any health care organization or provider delivering care under both for-profit and not-for-profit business models. Achieving good patient outcomes and discharging satisfied patients to the community is the best way to manage external appreciation of organizational quality. Internally, an organization can also enact a peer-satisfaction review process.36 By assuming membership and leadership on an organization's quality-related committees, NPMPs will be at the table to represent their respective services, disciplines, and practices. Their perspective is not always appreciated in health care operations, but their involvement has been shown to enhance care processes.37 Furthermore, such collaboration in organizational quality initiatives can also affect objective quality concerns.

The idiom "Vote with your feet" illustrates perceptive quality, an aspect of quality with a role for NPMPs
(Figure 1). Patients and family members, when not satisfied with their health care or provider, may have the option of switching providers. Patients often have strong opinions about the care they receive, and these opinions are not always based on objective data (eg, Was the treatment effective?). How patients feel the care was delivered may be just as important as the treatment's effectiveness from a customer service standpoint. In customer service industries—including health care—satisfied customers tell others, but dissatisfied customers tell many more. Dissatisfaction is communicated both informally, such as telling a friend or neighbor, and formally, via health consumer surveys by the Consumer Assessment of Healthcare Providers and Systems, for example.34 Therefore, leadership in patient engagement is an important potential role for NPMPs. The history of the NPMP as patient advocate, when coupled with the QI mandate, highlights the ideal role of the NPMP in patient engagement.38,39

Quality issues must be investigated, including patient or family interviews, with professionalism, attention to detail, advanced medical knowledge, and organizational awareness. A useful technique employed by one of the authors (NAB) is a brief quality conversation (Figure 1) with patients or families, where the focus is on assessing satisfaction with current care and determining what manageable solutions might be offered. If patients and families experience active engagement directed at ongoing QI, they feel attended to—even if some problems do not have an immediate solution. Sometimes answers to questions are less important than the patient's and family's perception that caregivers took the time to listen attentively.40


Quality in Care Delivery: A Good Habit

NPMPs can play an active leadership role in QI in their organization. NPMPs are critical decision makers at the bedside, but they may also be called upon to share the helm with administrators and quality professionals working on the big picture of a practice or organization's care delivery processes.41,42 NPMPs must make sure they seek a place at the table where decisions are being made, as they have the insight and training to effect meaningful changes in patient care. As lifelong learners, NPMPs have opportunities to develop skills to participate in QI and organizational change that enhance patients' clinical outcomes and improve that which is more subjective but equally important: patient satisfaction. NPMPs can place themselves and their organizations on the map by identifying suboptimal aspects of care with regard to the three quality aspects discussed above (Figure 1).

Aristotle is credited as the first to say, "Excellence is not an act, but a habit." Repeated acts create habit. In their repeated patient encounters, NPMPs have an enormous opportunity to think critically about actions they can take personally and changes that can be made within their health care organizations to optimize delivery of care to patients. NPMPs' appreciation of the bedside process of care may give them insights into analysis and corrective actions that less-clinically intimate administrators may lack. Health care administrators and physician leaders are encouraged to harness the skills and experience of NPMPs, who can act as agents of change for health care QI and patient safety.


Disclosure Statement

The author(s) have no conflicts of interest to disclose.


Leslie Parker, ELS, provided editorial assistance.


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