Health Administration

Quiz Instructions

Top of Form
Flag question: Question 1
Question 14 pts
Healthcare financial management for providers requires they balance what items?
Group of answer choices
A. The generation of financial reports and timely delivery of medical care
B. Accurate pricing and provision of decision-making aids
C. Costs and the provision of quality care
D. Meeting accounting standards and legal requirements
E. None of the above.
Flag question: Question 2
Question 20.5 pts
Match the following activities and items to their relevant type of accounting:
Informs on the returns expected on investments in personnel.
Group of answer choices
None of the above
Flag question: Question 3
Question 30.5 pts
Match the following activities and items to their relevant type of accounting:
Communicates information to outside parties like creditors and investors
Group of answer choices
None of the above
Flag question: Question 4
Question 40.5 pts
Match the following activities and items to their relevant type of accounting:
Statements must meet accrediting standards
Group of answer choices
none of the above
Flag question: Question 5
Question 50.5 pts
Match the following activities and items to their relevant type of accounting:
Allows for the type of analysis to determine the optimal sales mix for the firm’s products
Group of answer choices
None of the above
Flag question: Question 6
Question 60.5 pts
Match the following activities and items to their relevant type of accounting:
Provides the ability to determine future service demand levels
Group of answer choices
None of the Above
Flag question: Question 7
Question 70.5 pts
Match the following activities and items to their relevant type of accounting:
Is useful for making decisions
Group of answer choices
None of the above
Flag question: Question 8
Question 80.5 pts
Match the following activities and items to their relevant type of accounting:
Helps identify production bottlenecks and inefficiencies
Group of answer choices
None of the above
Flag question: Question 9
Question 90.5 pts
Match the following activities and items to their relevant type of accounting:
Draws insights into the needs of patients and payers
Group of answer choices
None of the above
Flag question: Question 10
Question 100.5 pts
Match the following activities and items to their relevant type of accounting:
Useful for inventory valuation
Group of answer choices
None of the above
Flag question: Question 11
Question 110.5 pts
Match the following activities and items to their relevant type of accounting:
Determines cash flow from operations and investments
Group of answer choices
None of the above
Flag question: Question 12
Question 124 pts
Identify the correct answers concerning the financial governance and responsibility structure of an HCO.
Which of the following are recognized as the leaders of a healthcare organization? (Choose all that apply)
Group of answer choices
A. The administration
B. The chief executive officer
C. The medical staff
D. Senior managers
E. The governing body
F. All of the above
Flag question: Question 13
Question 134 pts
Identify the correct answers concerning the financial governance and responsibility structure of an HCO.
What are the implications for an HCO in having licensed independent contractors working within a healthcare organization in its ability to reach its goals?  (Choose all that apply)
Group of answer choices
A. These contractors’ decisions drive much of the organization’s use of resources
B. Their leadership must be chosen from within their own ranks
C. Participation in organizational quality programs are voluntary
D. These professionals cannot be clinically supervised by an unlicensed practitioner
E. They may not be hired as employees within the organization
F. None of the above
Flag question: Question 14
Question 144 pts
Identify the correct answers concerning the financial governance and responsibility structure of an HCO.
What are the differences between an organization’s Controller and Treasurer positions?  (Choose all that apply)
Group of answer choices
A. Controllers produces internal documents and statements whereas the Treasurer deals with external communications dealing with financial matters.
B. Both positions are concerned with similar activities but for different purposes.
C. Both report to the Chief Executive Officer
D. The Treasurer is the Chief Financial Officer with the Controller as the subordinate
E. Neither are responsible for the financial accounting function
F. None of the above
Flag question: Question 15
Question 155 pts
Where can the leaders of an HCO’s medical staff be drawn from? (choose all that apply)
Group of answer choices
A. Internally from the medical staff, as from the nursing pool
B. From the licensed independent contractors used by the organization
C. After doing a national search
D. Anyone already serving on the governing board
E. A non-practicing physician or nurse
F. All of the above
Flag question: Question 16
Question 165 pts
An insurance company that pays a portion of a patient’s hospital bill is referred to as a what?
Group of answer choices
A. A health care provider.
B. A payer of last resort.
C. An indemnity plan.
D. A third-party payer.
E. None of the above
Flag question: Question 17
Question 175 pts
Which category accounts for the largest share of National Health Expenditures?
Group of answer choices
B. Medicaid
C. A fee-for-service payer.
D. Hospital Expenditures
E. Physician and Clinician Services
F. Prescription Drugs
Flag question: Question 18
Question 184 pts
Retrospective reimbursement can refer to what?
Group of answer choices
A. Paying for services based on an organization’s cost of care.
B. Paying for services where the providers have incentives to be inefficient.
C. Paying for services based on the charges of care.
D. Paying for services already rendered.
E. All of the above.
F. None of the above.
Flag question: Question 19
Question 194 pts
Who normally is billed charges from a health care provider? (Choose all that apply)
Group of answer choices
A. Those called private-pay patients.
B. Insurance plans that deem the provider out-of-network.
C. Self-pay patients.
D. Fee-for-service plans.
E. All of the above.
Flag question: Question 20
Question 201 pts
Match the following descriptions of types reimbursement to their relevant term.
Payments made based on the provider’s chargemaster
Group of answer choices
A. Prospective FFS – Per Procedure
B. Charge-based
C. Cost-based
D. Bundled
E. Prospective FFS – Per Diagnosis
F. Capitation
Flag question: Question 21
Question 211 pts
Match the following descriptions of types reimbursement to their relevant term.
Payments are based on a previously negotiated rate for an episode of care rather than individual services.
Group of answer choices
A. Prospective FFS – Per Procedure
B. Charge-based
C. Cost-based
D. Bundled
E. Prospective FFS – Per Diagnosis
F. Capitation
Flag question: Question 22
Question 221 pts
Match the following descriptions of types reimbursement to their relevant term
Payments are typically made for outpatient services for each type of medical activity performed.
Group of answer choices
A. Prospective FFS – Per Procedure
B. Charge-based
C. Cost-based
D. Bundled
E. Prospective FFS – Per Diagnosis
F. Capitation
Flag question: Question 23
Question 231 pts
Match the following descriptions of types reimbursement to their relevant term.
Providers are paid a fixed amount per covered life per period, regardless of the amount of services.
Group of answer choices
A. Prospective FFS – Per Procedurevvv
B. Charge-based
C. Cost-based
D. Bundled
E. Prospective FFS – Per Diagnosis
F. Capitation
Flag question: Question 24
Question 244 pts
Under the Per Diagnosis reimbursement methodology, what is the appropriate method for Inpatient Hospital providers?
Group of answer choices
E. None of the above
Flag question: Question 25
Question 254 pts
Under the Per Diagnosis reimbursement methodology, what is the appropriate method for Skilled Nursing providers?
Group of answer choices
E. None of the above
Flag question: Question 26
Question 264 pts
What does a Contractual Allowance refer to?
Group of answer choices
A. Payments for Medicare Part A and Part B medical claims or Durable Medical Equipment (DME) claims for Medicare Fee-For-Service (FFS) beneficiaries.
B. Taking into account the mix of patients being treated in a facility.
C. Allowing those Medicare-eligible to chose between traditional Medicare or Medicare Advantage
D. The difference between what a provider bills for the service rendered versus what it will be paid based on prior negotiations with a payer, typically Medicare
E. None of the above
Flag question: Question 27
Question 2710 pts
Compare and contrast the concepts of financial accounting and managerial accounting.
Reading Material
Managing Health Care Professionals
Sharon B. Buchbinder and Dale Buchbinder
By the end of this chapter, the student will be able to:
image  Distinguish among the education, training, and credentialing of physicians, nurses, nurse aides, midlevel practitioners, and allied health professionals;
image  Deconstruct factors affecting the supply of and demand for health care professionals;
image  Analyze reasons for health care professional turnover and costs of turnover;
image  Propose strategies for increasing retention and preventing turnover of health care professionals;
image  Create a plan to prevent conflict of interest in a health care setting;
image  Examine issues associated with the management of the work life of physicians, nurses, nurses’ aides, midlevel practitioners, and allied health professionals; and
image  Investigate sources of data for health workforce issues.
Health care organizations employ a wide array of clinical, administrative, and support professionals to deliver services to their patients. The Bureau of Labor Statistics (BLS) indicated that there were close to 16 million jobs in hospitals, offices of health practitioners, nursing and residential care facilities, home health care services, and outpatient settings (Torpey, 2014).
The largest employment setting in health care is hospitals and the largest category of health care workers is registered nurses, with 2.7 million jobs, 61% of which are in hospitals (BLS, 2014h). According to the BLS, there were 691,400 physicians and surgeons who held jobs in 2012 (BLS, 2014e). Increasingly, physicians are choosing to practice in large groups or to be employed by hospitals, rather than in solo or small practices. In 2013, Jackson Healthcare re-conducted a survey of physicians and found 26% were employed by hospitals, an increase of 6% over the previous year. Ownership stakes in practices, solo practices, and independent contractor statuses all declined in the same period (Vaidya, 2013). Employment offers physicians a safe haven in a volatile health care environment. Under the umbrella of a hospital or other large health care organization, they have better work hours, benefits, and time off, which they could not always afford in small or solo practice. It is expected the proportion of employed physicians will continue to grow in the coming decade. In 2012, physician assistants held 86,700 jobs, over 55% of which were in ambulatory health care services, including physician practices, about 20% were in hospitals, and the rest in nursing care facilities and government settings (BLS, 2014f). Allied health professionals constitute a broad array of 28 health science professions, including, but not limited to, anesthesiologist assistants, medical assistants, respiratory therapists, and surgical technologists (Commission on Accreditation of Allied Health Education Programs, 2015).
These statistics mean that, as a health care manager, in many instances you will be working with a mix of people with either more or less education than you have. It also means you will not have the clinical competencies that these health care providers have—an intimidating scenario, to say the least. Instead of clinical expertise, however, you will bring a background that enables you to enhance the environment in which these highly specialized personnel deliver health care services. You will be the person responsible for making sure nurses, doctors, and other health care professionals have the resources to provide safe and effective patient care. Your role will be to provide and monitor the infrastructure and processes to make the health care organization responsive to the needs of the patients and the employees. The more you understand clinical health care professionals, the better prepared you will be to do your job as a health care manager. The purpose of this chapter is to provide you with an overview of who your future colleagues are, how they were trained, and ways to manage the quality of their work environment.
Physicians begin their preparation for medical school as undergraduates in premedical programs. Premedical students can obtain a degree in any subject; however, the Association of American Medical Colleges (AAMC) (2015) indicates that the expectation is that they will graduate with a strong foundation in mathematics, biology, chemistry, and physics. Entry into medical school is competitive; applicants must have high grade point averages and high scores on the Medical College Admission Test (MCAT).
There are some shorter, combined Bachelor of Science/Medical Doctor (BS/MD) programs; however, the majority of medical school graduates will have 8 years of post–high school education before they go through the National Residency Matching Program (NRMP), a matching process whereby medical students interview and rank their choices for graduate medical education (GME), also known as residencies, and the residency training programs do the same (NRMP, 2015). Once matched with a residency training program, physicians are prepared in specialty areas of medicine. Depending on the specialty, the length of the residency training program can be as short as 3 years (for family practice) or as long as 10 years (for cardio-thoracic surgery or neurosurgery). According to the Accreditation Council for Graduate Medical Education (ACGME), “When physicians graduate from a residency program, they are eligible to take their board certification examinations and begin practicing independently. Residency training programs are sponsored by teaching hospitals, academic medical centers, health care systems and other institutions” (ACGME, 2015, para. 4–5). Due to recent GME legislation working on the physician shortage, there will be a gradual increase of residency training positions over the coming years with a priority on primary care physician residency spots (AMA Wire, 2015a). Some authors have begun to question the need for lengthy training programs, given the presence of shorter pre-medical programs, competency based education, the looming shortage of physicians, and levels of debt incurred by medical students (Duvivier, Stull, & Brockman, 2012Emanuel & Fuchs, 2012). Regardless of the specialty, length of physician training programs, or number of trainees, depending on the type of health care organization where you are employed, you may be working with residents-in-training and medical students, as well as physicians who have been in independent practice for decades.
In addition to having a long time before they can practice independently, residents work extensive hours as part of their training programs. At one time, it was not uncommon for residents to be on call continuously for 48 hours, because ceilings on hours of work for residents varied by residency training program. However, that all changed due to the death of Libby Zion, an 18-year-old college student, who was seen at the Cornell Medical Center in 1984 and allegedly died due to resident overwork (AMA, Medical Student Section, n.d.). Although the hospital and resident were exonerated in court, the battle over resident work hours had begun. New York was the first state to institute limits on resident work hours in 1987. Over the past two decades, various specialty societies, medical associations, and legislators fought over the definition of “reasonable” work hours for physicians in training. The battle has continued, and new rules have been updated from those published in 2003. Per these new rules, hospitals and residency training program directors will be required to limit resident work hours to no more than “80 hours per week, averaged over a four-week period, inclusive of in-house call activities and all moonlighting” (i.e., side jobs in addition to the 80 hours per week) (ACGME, 2014, p. 4). First-year residents (PGY-1) are not permitted to moonlight (ACGME, 2011).
“Sponsoring institutions and programs must ensure and monitor effective, structured hand-over processes to facilitate both continuity of care and patient safety” (ACGME, 2014, p. 13). This mandate means when the resident goes home, the next person taking care of the patient must be briefed to ensure that the patient care team has all relevant information. Despite the restrictions on work hours, residents are not permitted to walk out the door without communicating this important patient care information. At times, this means a delicate balancing act to ensure compliance with all standards, which also emphasize the need for interpersonal and communication skills, professionalism, systems-based practice as components in a culture of safety and patient-centric care.
When the work-hour rules first went into effect, physicians who trained under the “work until you drop” mentality protested that professionalism would decline and residents would miss out on learning opportunities associated with continuity of the care from patient admission to discharge. Surgeons, in particular, protested, fearing walk-outs in the middle of long cases, a reflection of a time-clock-punching and a shift-work mentality. Ethnographic research conducted among medical and surgical residents in two hospitals did not find evidence for those fears. Over the course of three months, Szymczak, Brooks, Volpp, and Bosk (2010) followed residents, observed behaviors, and conducted in-depth face to face interviews. These researchers found that rather than leave at a critical juncture, the residents were, on occasion, more inclined to stay—off the clock. Interviews elucidated thoughtful, analytical rationales for the non-compliant behaviors, as well as a respect for the work-hour rules. Residents were mindful of the implications of their behaviors and the implications of non-compliance and were conflicted about under-reporting their hours, i.e., lying about their time on duty. These work-hour rules and patient handoff protocols underscore the fact that residents are in the hospital for education, not to provide service to the hospital, a major departure from the way graduate medical education was conducted a few decades ago. More time is needed to see if the pendulum will swing back to longer duty-hours in light of actual behaviors.
The implications of limits on resident work hours are multifold. While residency training program directors are responsible for monitoring resident work hours, they must be in compliance with the health care institution’s policies as well. You may be responsible for ensuring compliance by collecting work-hour data for your managers. Health care managers are obligated to ensure adequate coverage of the hospital with physicians. Resident work-hour restrictions may mean that you need to employ more physicians or midlevel practitioners—physician assistants and nurse practitioners. And your organization may need to hire ancillary staff and allied health professionals, such as intravenous therapists and surgical assistants, to do tasks previously covered by resident physicians.
Most physicians are eligible to obtain a license to practice medicine after one year of postgraduate training. Licensure, granted by the state, is required for physicians, nurses, and others to practice and demonstrates competency to perform a scope of practice (National Council of State Boards of Nursing [NCSBN], 2015a). Limited licensure is granted for PGY-1s in hospital practice under supervision. State Boards of Physician Quality Assurance (BPQA) establish the requirements for medical licenses. These requirements are lengthy and strenuous. For example, the state of Maryland requires the following (Annotated Code of Maryland, 2015):
image  Good moral character;
image  Minimum age of 18 years;
image  A fee;
image  Documentation of education and training; and
image  Passing scores on one of the following examinations:
• All parts of the National Board of Medical Examiners’ examinations, and/or a score of 75 or better on a FLEX exam, or a passing score on the National Board of Osteopathic Examiners, or a combination of scores and exams; or
• State Board examination;
• All steps of the U.S. Medical Licensing Examination (USMLE).
Candidates must demonstrate oral and written English-language competency and supply the following:
image  A chronological list of activities beginning with the date of completion of medical school, accounting for all periods of time;
image  Any disciplinary actions taken by licensing boards, denying application or renewal;
image  Any investigations, charges, arrests, pleas of guilty or nolo contendere, convictions, or receipts of probation before judgment;
image  Information pertaining to any physical, mental, or emotional condition that impairs the physician’s ability to practice medicine;
image  Copies of any malpractice suits or settlements, or records of any arrests, disciplinary actions, judgments, final orders, or cases of driving while intoxicated or under the influence of a chemical substance or medication; and
image  Results of all medical licensure, certification, and recertification examinations and the dates when taken.
In addition to the above requirements, many states also mandate Continuing Medical Education (CME) in such topics as domestic violence, child abuse, drug abuse, and quality assurance, to name but a few. A new commission is working to help streamline the process for those physicians seeking licensure in multiple states. The eligible physician designates her “principle state of licensure and selects other states in which she desires licensing” (AMA Wire, 2015b, para 3). At the time of this writing, seven states were participating in this compact. It is anticipated that with the rise of telemedicine, more states will join the Federation of State Medical Boards, Inc. (FSMB)–initiated agreement.
Physicians must also undergo criminal background checks (CBCs) in all but a few states. As of 2014:
image  “45 state medical boards conduct criminal background checks as a condition of initial licensure;
image  39 state medical boards require fingerprints as a condition of initial licensure;
image  43 state medical boards have access to the Federal Bureau of Investigation database; and
image  The Minnesota Board of Medical Practice will conduct criminal background checks and require fingerprinting (including access to the FBI National Crime Information Center [NCIC]) by January 1, 2018” (FSMB, 2014, p. 1).
The reasons for increasing numbers of medical boards requiring CBCs are numerous and include, but are not limited to, increasing societal concerns about alcohol and drug abusers, sexual predators, and child and elder abusers. If a CBC contains information about convictions, the state licensure board will examine the application on a case-by-case basis. The reviewers will be looking for level and frequency of the criminal behavior, basing their decision on that, along with other materials submitted by the applicant, such as proof of alcohol and drug rehabilitation.
In addition to obtaining a license, physicians may voluntarily submit documentation of their education, training, and practice to an American Board of Medical Specialists (ABMS) member board for review (ABMS, 2015). Upon approval of the medical specialty board (i.e., successful completion of an approved residency training program), the physician is then allowed to sit for examination. Successful completion of the examination(s) allows the physician to be granted certification, and she is designated as board certified in that specialty (e.g., a board-certified pediatrician or a board-certified general internist). Certificates are time-limited; physicians must demonstrate continued competency and retake the exam every 6 to 10 years, depending on the specialty. The purpose of American Board of Medical Specialties Maintenance of Certification (ABMS MOC) is to ensure that physicians remain up-to-date in their specialties (ABMS, 2015). Board certification is a form of credentialing a physician’s competency in a specific area. For staff privileges and hiring purposes, most hospitals, HMOs, and other health care organizations require a physician to be board certified or board eligible (i.e., preparing to sit for the exams) because board certification is used as a proxy for determining the quality of health professionals’ services. This assumption of quality is based on research that more education and training leads to a higher quality of service (Donabedian, 2005Tamblyn et al., 1998). Lipner, Hess, and Phillips (2013) conducted a meta-analysis of the perceptions of the value of ABMS MOC on stakeholders. The authors found patients and health care organizations valued MOC and participation across the boards was high, perhaps due in large part to hospitals requiring it for privileging. However, not all physicians were not convinced re-certification was useful. The same literature review found the association between physician board certification and quality of care to be positive, but “modest in effect sizes and are not unequivocal” (Lipner et al., 2013, p. S20). Since the ABMS MOC is still a relatively new requirement, it remains to be seen if the impact on quality of care will grow over time.
Most states require that physicians complete a certain number of continuing medical education (CME) credits to maintain state licensure and to demonstrate continued competency. Additionally, hospitals may require CME credits for their physicians to remain credentialed to see patients (National Institutes of Health [NIH], 2015). Seven organizations, the ABMS, the American Hospital Association (AHA), the AMA, the Association of American Medical Colleges (AAMC), the Association for Hospital Medical Education (AHME), the Council of Medical Specialty Societies (CMSS), and the FSMB, are members of the Accreditation Council for Continuing Medical Education (ACCME) (ACCME, 2015b). The ACCME establishes criteria for determining which educational providers are quality CME providers and gives its seal of approval only to those organizations meeting their standards. The ACCME also works to ensure “uniformity in accreditation” of educational offerings to maintain the quality of continuing physician education and now requires educational providers to reapply for maintenance of recognition (ACCME, 2015a).
Physician credentialing is the process of verifying information a physician supplies on an application for staff privileges at a hospital, HMO, or other health care organization. Most health care organizations have established protocols, and as a health care manager, you will be required to follow that protocol. Physicians are tracked by the AMA from the day they graduate from medical school until the day they die. Information about every physician in the U.S. is in the AMA Physician Masterfile, which has been in existence for more than 100 years. Originally created on paper index cards to establish biographic records on physicians, “the Masterfile…serves as a primary resource for professional medical organizations, universities and medical schools, research institutions, governmental agencies, and other health-related groups” (AMA, 2015b, para. 5). Physician credentialing is a time-consuming, labor-intensive, costly process that must be repeated every two years. When physicians apply for privileges at a hospital, they must specify what they want by specialty and, within the surgical specialties, by procedure. For example, a general surgeon who wants to do laparoscopic cholecystectomies (i.e., removal of the gall bladder through a very small incision, using an instrument like a tiny telescope) would apply for both general surgery privileges and for that specific procedure. Using extensive documentation, the surgeon must demonstrate competency for those privileges.
Normally, physician credentialing criteria are established by the department where the physician would be affiliated. Core privileges cover a multitude of activities that a physician is allowed to do in a health care services organization. Using family practice (FP) as an example, the Department of Family Practice in a hospital would establish the criteria for privileges. Core privileges for a FP might include: admission, evaluation, diagnosis, treatment and management of infants and children, adolescents, and adults for most illnesses, disorders, and injuries (American Academy of Family Practice [AAFP], 2015b). Specific privileges would be those activities outside the core privileges and would require documentation of required additional training and expertise in a procedure. In this example, if the FP also wanted to be allowed to deliver babies at a hospital, that FP would be required to provide documentation of that training and might be subject to observation or proctorship to ensure he or she had the requisite competencies (AAFP, 2015a). If there are two departments with physicians who do the same thing (e.g., Obstetrics and Gynecology and Family Practice), each department is responsible for its own criteria. The Medical Staff Office would enforce, but not establish, the criteria. A hospital must conduct diligent research on physicians before granting privileges, or it can be held liable in a court of law for allowing an incompetent physician on its staff, should there be a bad outcome. The same is true for HMOs, ambulatory care centers, and other health care delivery organizations. In Taylor v. Intuitive, lawyers for the estate of Fred Taylor alleged Intuitive, the company that created the daVinci robotic surgery system, failed to provide adequate training for the surgeon, which led to major complications and the death of the patient. Intuitive argued it had no responsibility for assessing the surgeon’s competency in using the technology. The jury agreed with the defense, underscoring the importance the hospital’s legal liabilities associated with negligent credentialing and privileging (Pradarelli, Campbell, & Dimick, 2015).
It is preferable to obtain primary, meaning firsthand, verification and documentation by contacting each place of education, training, and employment individually by phone and obtain original documents, such as transcripts with raised seals. Verification can include, but is not limited to, the following elements (Government Accountability Office [GAO], 2010):
image  Name, address(es), and telephone numbers;
image  Birthdate and place of birth;
image  Medical school;
image  Residency training program and other graduate education, including fellowships;
image  State licensure details, including date of issue and expiration;
image  Specialty and subspecialty, including board certification and eligibility;
image  Continuing medical education;
image  Educational and employment references;
image  Drug Enforcement Agency (DEA) registration status; and
image  Licensure, Medicare/Medicaid, and other state or federal sanctions.
The importance of primary verification of these elements has been underscored by an audit of the credentials of physicians employed by six Veterans’ Affairs Medical Centers (VAMCs) (GAO, 2010). The auditors “looked for evidence of omissions by physician applicants related to medical licenses, malpractice, and at five of six VAMCs visited, gaps in background greater than 30 days” (GAO, 2010, p. 42). They found that of 180 physician files they reviewed, 29 lacked proper verification of state licensure and 21 physicians failed to disclose malpractice information (GAO, 2010).
An entire industry of companies who conduct physician credentialing for a wide array of requirements now exists for physicians and health care organizations. Regardless of who completes the work, it still must be reviewed and approved by the organization where the physician will be practicing. As a health care manager, you may find yourself working in the physician relations and credentialing department of a hospital, HMO, or other health care delivery organization, and you may be responsible for determining whether the credentials offered by a physician are legitimate. Physician credentialing requires excellent interpersonal skills, organizational skills, persistence, an eye for details, and the ability to identify inconsistencies in data.
Since physicians are tracked from the moment they graduate from medical school, the first thing to verify is that there are no gaps in their resumes. Physicians rarely take time off “to find themselves.” If there is a significant gap between educational or employment placements (e.g., nothing on the resume for four years between a residency training program and an evening-shift job working at a clinic with a poor reputation), you need to question what has transpired in this individual’s life. Physicians are human, and they can have events in their lives such as mental illness, addiction, or imprisonment. Since you will be responsible for safe, effective patient care, you must be mindful about who is providing that care. The first clue will be in the credentials, especially in the chronology of life events.
Occasionally, you will come across an individual who claims to be a physician but is not. In this Internet and computer age, physician imposters can obtain fraudulent credentials from medical schools in other countries, or even in the U.S. Physician imposters are rare, but potentially dangerous, individuals. There is no substitute for personal interaction with the institution where someone claims to have been educated or employed. This is where an eye for details and inconsistencies and interpersonal skills come into play. You will be required to handle telephone inquiries with the utmost tact to ensure that you obtain verification. If no one at an institution knows the individual, or if the medical school has “burned down, leaving no records,” alarm bells should be ringing in your head, and you should notify your manager immediately there may be a problem with the application.
A comprehensive review of a physician’s credentials involves making electronic queries to the National Practitioner Data Bank (NPDB), aka “the Data Bank.” At one time, physicians who were disciplined or lost their license in one state could simply move to another state and get a license there. Other than person-to-person contacts, there were few ways to track “bad docs” who moved across state borders. The NPDB was created to have a system whereby state licensing boards, hospitals, professional societies, and other health care entities could identify, discipline, and report those who engage in unprofessional behavior. “The National Practitioner Data Bank (NPDB) is an electronic information repository created by Congress. It contains information on medical malpractice payments and certain adverse actions related to health care practitioners, entities, providers, and suppliers. Federal law specifies the types of actions reported to the NPDB, who submits the reports, and who queries to obtain copies of the reports” (National Practitioner Data Bank, 2015, para. 1). One of the main criticisms of the NPDB is that a physician can be reported for having been sued, but the outcome of the lawsuit, even when dismissed, is not reported, and the lawsuit remains on the physician’s record. In an era of increasingly litigious consumers of health care, this is not a minor complaint. Physicians may dispute the report, but it can take much time and effort, much like trying to get a correction on a credit report. Hence, the information in the Data Bank should be used along with other data to look for patterns of deviation from professional behaviors.
When credentialing physicians, it is critical to have other physicians review the application to ensure that experts who understand the nuances of the data contained in an application render the final judgment as to whether to approve or disapprove privileges. Using the example of a surgeon applying for general surgical privileges at a hospital, after the physician credentialing department receives a physician’s application for privileges and conducts due diligence in verifying each and every claim on the application, the materials are submitted to a surgical credentialing committee. Unless the hospital is very small, each department will have its own credentialing committee. In this case, if the department of surgery’s credentialing committee approves the application, it then recommends that the documents be forwarded to a medical executive committee, which is a subcommittee of the hospital board of directors. The subcommittee then makes a recommendation to the board, which then approves or disapproves the application. Under certain circumstances, temporary credentials can be granted. Usually, however, the time from submission of the application to final approval can take three to six months. If there are problems with the application or missing documents, the process can take even longer.
Some hospital systems are now instituting system-wide credentialing processes to ensure standardization across multiple settings. Regardless of protocol or process, physician credentialing is one of the most important jobs in any health care delivery setting. By approving a physician’s privileges, the health care organization indicates that it believes that this physician will provide safe, effective patient care. It is not a responsibility to be taken lightly. The lives of patients and the financial survival of the health care organization depend on how well this process has been done.
International Medical Graduates
International Medical Graduates (IMGs), formerly referred to as Foreign Medical Graduates (FMGs), can be U.S. citizens who attend school abroad or foreign-born nationals who come to the U.S. seeking educational and professional opportunities and filling voids in health care services delivery for the U.S. population. IMGs represent 25% of the total physician population in the U.S. physician workforce, or approximately 245,005 physicians (Traverso & McMahon, 2012). In 2009, the top country sending foreign-born physicians to the U.S. was India (AMA, 2015a).
Researchers have repeatedly demonstrated that IMGs are more likely to go where U.S. medical graduates (USMGs) prefer not to go (i.e., inner-city and rural areas) and to serve populations increasingly at risk of medical abandonment (Hagopian, Thompson, Kaltenbach, & Hart, 2003Hallock, Seeling, & Norcini, 2003Mick & Lee, 1999a1999bMick, Lee, & Wodchis, 2000Polsky, Kletke, Wozniak, & Escarce, 2002Thompson, Hagopian, Fordyce, & Hart, 2009). In 2008, nearly 60% of the IMGs in the U.S. were in primary care (internal medicine, pediatrics, family medicine) or specialized in psychiatry, anesthesiology, obstetrics/gynecology, general surgery, or cardiovascular disease (Smart, 2010). More than three-quarters of the IMGs in practice were in direct patient care. At one time, the quality of care provided by non-USMGs was a major concern. Over the past decades, however, a formidable system of checks and balances has been implemented, and foreign-trained and foreign-born medical graduates (FBMGs) are now required to pass rigorous English-language and written and clinical skills assessment examinations prior to being allowed to apply for GME, that is, residency training positions (Whelan, Gary, Kostis, Boutlet, & Hallock, 2000). This arrangement has improved the quality of the IMG applicant pool that continues to fill graduate medical education positions still left unfilled by USMGs (Cooper & Aiken, 2001McMahon, 2004). Additionally, a study examining quality of care provided by IMGs in Pennsylvania found the quality of care provided to be as good as or better than that given by graduates from U.S. medical schools (Norcini et al., 2010).
We are now facing a shortage of physicians across all specialties. This shortage of physicians is a result, in part, from the aging of the Baby Boomer population, physician retirements, changing ethnic and racial demographics, increased access to care with the implementation of the Affordable Care Act (ACA), increased utilization of services, advances in health care technology, a hostile malpractice environment, and medical school graduates (both female and male) who desire reasonable work hours (Bureau of Health Professions, 2003Cooper, 20022003). While some experts argue over the exact numbers of physicians in the workforce and whether to use the American Medical Association Masterfile or the U.S. Census Bureau Current Population Survey for workforce projections, they agree that the physician workforce will be younger and work fewer hours per week regardless of gender (Steiger, Auerbach, & Buerhaus, 20092010).
In response to the predicted workforce shortage, U.S. medical schools have increased enrollments and new medical schools have opened their doors. This upsurge in production of U.S. trained physicians is predicted to bump international medical graduates, both foreign and U.S. born, out of graduate medical education programs. An increase in supply in U.S. medical graduates creates new questions about of the diversity of residents in training and their ability to provide culturally responsive care as well as the education and training of international medical graduates whose home countries have relied on them to return home to provide high quality care (Traverso & McMahon, 2012). As residency training programs begin to reduce acceptances of IMGs, the question still remains: who will provide medical care to an aging U.S. population?
Even with attempts to ramp up the physician workforce, there is a pipeline effect. Students admitted to medical school in 2010 will not be prepared to provide primary care until 2017, at the earliest. Despite increases in residency training positions, longer specialty training means longer wait times for the population needing to be served and greater mortality rates. The American College of Physicians (2008) estimated “the addition of one primary care physician per 10,000 population in the U.S. resulted in 3.5 fewer people dying each year” (p. 7). In the meantime, with the increase of chronic disease, longer lifespans, and re-merging epidemics, health care managers will struggle with recruitment, retention, and optimal utilization of physicians, whether USMG or IMG. According to the BLS (2014e), employment of physicians will increase by 18% over the next decade due to expansion of the health care industry. Some of the issues you will be most likely to encounter with IMGs will surround the physician credentialing process and the J-Visa, which provides legal entry to the U.S. for training purposes. Physicians who graduate from foreign medical schools will have to provide, in some instances, additional documentation and verification that the information they have provided is true and correct. The Educational Commission for Foreign Medical Graduates (ECFMG) offers online credential verification services that can ease some of the burden but not all of the responsibility or liability in the granting of privileges (ECFMG, 2011).
In summary, physicians are critical to the provision of safe, effective patient care. Ensuring the quality of the physicians practicing in an organization is one of the roles of the health care manager. To fulfill this responsibility, you will need to know all the steps in the education, training, and credentialing of physicians. It will take attention to detail, organizational skills, and excellent interpersonal skills to do it well.
Employed Physicians and Turnover
At one time, the majority of physicians in the U.S. were self-employed, solo practitioners, or in partnership with one or two other physicians. Recent data suggest that the old images of the independent physician practitioner need to be updated to reflect the growing numbers of physicians who are now employed by organizations such as hospitals and large single- or multispecialty group practices (Isaacs, Jellinek, & Ray, 2009). One recruiter reported that in some communities, as many as 90% of the physicians may be employees (Butcher, 2008). In 2008, about one-third of all physicians, male and female, between the ages of 45 and 54 were full-time hospital employees (Smart, 2010). A 2013 survey of 3,456 physicians found the number of employed physicians was up by 6% from the previous year and the number of solo practitioners was down by the same proportion (Vaidya, 2013). Continued robust growth in physician hospital employment reflects the desire of these organizations to improve their bottom lines by becoming accountable care organizations (ACOs), i.e., health care providers that focus on continuity and quality of care of a given population. Medicare rewards ACOs with shares of savings from reduced health care utilization. This increased demand for hospitalists and other employed physicians arrives at the same time newer generations of medical school graduates are expecting a balanced work–family life.
Combined with the consolidation of physicians’ practices and enrollment growth in managed care organizations, these trends will continue to accelerate. However, employment goes hand in hand with turnover (i.e., the proportion of job exits or quits from a facility in a year). Buchbinder, Wilson, Melick, and Powe (2001), using data from a nationally representative sample, studied a cohort of 533 post-resident, non-federal, employed PCPs who were younger than 45 years of age, had been in practice between two and nine years, and had participated in national surveys in 1987 and 1991. They combined data from this sample with a national study of physician compensation and productivity and physician recruiters to estimate recruitment and replacement costs associated with turnover. The authors found that by the 1991 survey, slightly more than half (n = 279, or 55%) of all PCPs in this cohort had left the practice in which they had been employed in 1987; 20% (n = 100) had left two employers in that same five-year period. Estimates of recruitment and replacement costs for individual PCPs for the three specialties were $236,383 for family practice (FP), $245,128 for internal medicine (IM), and $264,645 for pediatrics (Peds). Turnover costs for all PCPs in the cohort by specialty were $24.5 million for FP, $22.3 million for IM, and $22.2 million for Peds. They concluded turnover was an important phenomenon among the PCPs in this cohort and that PCP turnover has major fiscal implications for PCP employers. Loss of PCPs causes health care organizations to lose resources that could otherwise be devoted to patient care, as well as potentially sidelining their goal to becoming an ACO.
A physician retention study conducted by Cejka Search and American Medical Group Association (AMGA) reported physician turnover remained at about the same level from the previous year, however, primary care physician turnover increased by 9% and specialist physician turnover increased by 6% in 2013 (Cejka Search & AMGA, 2013). Retirements escalated, with 18% of physicians in the survey indicating that reason for leaving employment. Women and new physicians appeared to be more vulnerable to turnover, in general. Women were more likely to leave practices with 3 to 50 physicians. Both genders were equally likely to turnover in practices with over 500 physicians. The vast majority of the groups surveyed indicated they “offered flexible schedules, less than a full-time schedule, and extended time off” (Cejka Search & AMGA, 2013, p. 18). Most medical groups indicated they plan to hire more physicians, as well as advanced practice clinicians, or APCs, such as physician assistants and nurse practitioners. The majority of the groups plan to focus on ensuring their physicians “are working at their maximum efficiency with our APCs” (Cejka Search & AMGA, 2013, p. 11). These are clearly management issues related to physician recruitment, retention, turnover, and utilization.
Employee turnover has been clearly linked to job dissatisfaction and job burnout. Job satisfaction is the “pleasurable or positive emotional state resulting from the appraisal of one’s job or job experiences” (Locke, 1983, p. 1300). Job burnout is “a prolonged response to chronic emotional and interpersonal stressors on the job” (Maslach, 2003, p. 189). In the past, most solutions to job burnout involved removing the affected individual from the job. However, it is the organization that is the primary cause of job burnout (due to heavy workload, poor relations with coworkers, etc.) and job dissatisfaction. Therefore, it is the health care manager’s role to address these issues. Health care managers employed in these kinds of settings must be alert to signs of physician job dissatisfaction and burn-out, the harbingers of turnover (Dunn, Arnetz, Christensen, & Homer, 2007). “Achieving a patient-centered and professionally satisfying culture and closing the quality chasm in cost-effective ways depend on accountable organizational arrangements, strong primary care, and effective team performance” (Mechanic, 2010, p. 556). As a health care manager in a hospital or physician owned medical group practice, you will be expected to work with the physicians to help create a positive practice environment and to provide recommendations for interventions to improve retention.
Employed Physicians and Conflict of Interest
There has long been a requirement for researchers to disclose funding sources for biomedical research because of concerns that the outcomes of the research could be biased in favor of the company that has, in essence, paid for the research. The NIH and the majority of biomedical journals require investigators to disclose any financial relationships that might exist between the researcher and the funding entity (Drazen et al., 2010NIH, 2014). Related to these concerns have been growing fears about the influence of gifts and other financial incentives on physicians’ prescribing practices and purchasing behaviors. Some states, such as Massachusetts, Minnesota, and Vermont, enacted laws earlier than others to prohibit pharmaceutical or medical device companies from giving more than $100 in gifts to a physician (Ross et al., 2007). These laws and Open Payments, aka, the Sunshine Act, have led to a more transparency in health care as well as greater urgency for organizations to create their own conflict of interest policies for physicians employed by health care organizations.
Open Payments, aka, the Sunshine Act, which was created as part of the Affordable Care Act, requires medical device manufacturers and group purchasing organizations (GPOs) (entities that work with multiple health care organization to buy in large volumes to decrease costs) to report any payments and “transfers of value” to physicians’ or teaching hospitals, as well as any ownership of investment interest physicians or immediate family members have in a company. This information must be reported annually. These “transfers of value” can be as small as $7.77 for coffee and donuts. Records of these gifts are maintained on the Centers for Medicare and Medicaid Services (CMS) website and are open to anyone with access to the Internet, hence, the name “Open Payments” (CMS, 2015Dreger, 2013). It is imperative that physicians periodically check this website to ensure the accuracy of these reports. If there is a discrepancy, physicians and hospitals have the right to appeal. Physicians who do not want to give even the appearance of impropriety are now telling sales representatives to desist in bringing food. Office staff who looked forward to free lunches from sales representatives are sometimes resentful of this loss in “benefits.” As managers in physician offices and teaching hospitals, it will be up to you to be vigilant about ensuring your employer’s integrity by deterring these gifting behaviors.
Conflict of interest is a term used to describe when an individual can be influenced by money or other considerations to act in a way that is contrary to the good of the organization for whom he or she works or the patient for whom he or she should be advocating in their best interests. In most health care organizations, conflict of interest disclosures are required for all employees who make purchasing decisions—including physicians and administrators—and include a series of questions to which the individual must respond no or, if yes, must explain. These questions include but are not limited to the topics of:
image  Personal gifts;
image  Meals, invitations, and entertainment;
image  Attendance at industry-sponsored (and third-party industry sponsored) conferences, education sales, or promotional events;
image  Industry-sponsored scholarships and other education support for trainees;
image  Speaking, consulting arrangements, and advisory services with industry;
image  Fiduciary, management, or other financial interests with industry;
image  Detailing, tying, switching, or ordering;
image  Conflicts of commitment;
image  Site or facility access by industry representatives;
image  Publications/ghost-writing/ghost-authoring; and
image  Free drug/product samples.
There must be full disclosure if a conflict exists, and the individual must remove himself or herself from the decision-making role. The individual must certify his or her responses to all of the above questions are complete and accurate to the best of their knowledge and, if anything changes, they must update their disclosure document. Conflict of interest documents must be updated annually (Medstar Health, 2015).
Your job as a health care manager will be to ensure that first and foremost you complete the same type of document you expect physicians to complete. Even the appearance of any potential conflict of interest should be avoided. Your reputation and the reputation of the health care organization where you are employed depend on ethical behaviors of all employees.
At one time, all nurses were trained in hospital-based programs and received diplomas upon graduation. Before 1917, nursing was essentially an apprenticeship, without a set curriculum, which then morphed into hospital-based diploma schools that produced their own nursing workforce. The hospital-based diploma nursing school is part of a passing era; in 2011, they represented only 10% of the nursing programs in the U.S. (American Association of Colleges of Nursing [AACN], 2011). Currently, the majority of nursing education is provided in degree-based settings. Over half the nursing workforce holds baccalaureate, four-year degrees; many of these RNs began with associate degrees and returned to school to earn a bachelor’s of science in nursing (BSN) to improve their opportunities for career advancement (Health Resources and Services Administration [HRSA], 2013). “Between 2007 and 2011, nursing master’s and doctoral graduates increased by 67 percent” (HRSA, 2013, p. ix). This increase in advanced degree nurses means increased production capabilities of undergraduate nurses. Indeed, the overall numbers of RNs has increased; however, due to aging, nurses continue to retire faster than they can be replaced in the workforce.
Nurses with BSNs can continue their education and enter a wide array of graduate educational programs including, but not limited to, post-baccalaureate certificates; masters of science in nursing (MSN) degrees for community health nursing and nurse education; advanced practice degrees (nurse practitioner, clinical nurse specialist, nurse midwife, nurse anesthetist); and doctoral degrees, such as the nursing doctorate (ND), doctorate in nursing science (DNS), or a doctor of philosophy (PhD).
The undergraduate nursing school curriculum (BSN) is rigorous and demands a good understanding of the biological sciences. At Stevenson University, for example, students are eligible to continue to the third year of the program only after completing a specific sequence of courses and maintaining a 3.0 or B average overall GPA and in all science courses (Stevenson University, 2015).
The current shortage of nursing faculty means fewer slots for nursing students—there are fewer faculty to teach (AACN, 2014b). “In the 2014–2015 academic year, 265,954 completed applications were received for entry-level baccalaureate nursing programs (a 1.9% decrease from 2013) with 170,109 meeting admission criteria and 119,428 applications accepted. This translates into an acceptance rate of 44.9%” (AACN, 2014a, para. 12). Due to a crisis-level national nursing shortage and demands for workers, state legislators are pressuring universities and colleges to increase the number of graduates from nursing programs. However, unlike other undergraduate degrees, nursing students must learn clinical skills and be carefully supervised in health care organizations by master’s or doctorally prepared nursing faculty. The nursing faculty clinical supervisor is only allowed to have a specific number of student nurses. Exceeding that number could endanger the lives of patients and the faculty member’s nursing license.
As nursing students progress through their program of study, meeting state requirements for licensure and passing the National Council Licensure Examination (NCLEX) is uppermost in everyone’s mind. A student must pass the NCLEX to become a licensed registered nurse (RN) in the U.S., and nursing programs’ pass rates on the NCLEX are used as a proxy for the quality of their educational curriculum. With the current nursing shortage, many graduating nurses have a job offer in hand before graduating—contingent upon obtaining state licensure and passing the NCLEX (NCSBN, 2015b).
As of 2012, 40 boards of nursing out of 55 required CBCs for nurse applicants for licen-sure (Council of State Governments [CSG], 2012). The CSG has called for fingerprinting to be added to the CBC requirements for nurses based on evidence that RNs with criminal backgrounds do not always self-disclose and go undetected without fingerprinting (CSG, 2013). Again, the reasons are multifold and include but are not limited to increasing societal concerns about alcohol and drug abusers, sexual predators, and child and elder abusers. If a criminal background check contains information about convictions, the licensure board will examine the application on a case-by-case basis. As noted previously, the reviewers will be looking for level and frequency of the criminal behavior, basing their decision on that, along with other materials submitted by the applicant, such as proof of alcohol and drug rehabilitation and a monitoring program utilizing random drug testing reported to the state board of nursing.
After graduation, RNs, unlike physicians, do not have postgraduate programs that last from 3 to 10 years. In the past, new RNs have been hired to work in hospitals or other health care organizations, given a brief orientation, then placed on a nursing unit and left to sink or swim. This Darwinian approach to nurse staffing led, in part, to massive turnover. Although the vast majority of nurses are female (only 9% are male), women now have career choices other than nursing, teaching, or homemaking; older nurses continue to retire faster than new ones come into the field (HRSA, 2013Steiger, Auerbach, & Buerhaus, 2000). Nursing turnover costs have been estimated to be 1.3 times the salary of a departing nurse, or an average of $65,000 per lost nurse (Department for Professional Employees AFL-CIO, 2010Jones & Gates, 2007). Multiply that by the number of nurses who quit their jobs, and the costs can be in the millions of dollars for health care organizations. Health care managers cannot afford to ignore the loss of nurses from the workforce.
Any strategy that improves the retention of nursing staff saves the organization the costs of using agency or traveler nurses, replacing lost nurses and training new ones, as well as the loss of productivity from burdening the remaining staff. A survey conducted among 67 new nurses from 13 hospital departments indicated that new graduates were concerned about communicating with physicians and were afraid of “causing accidental harm to patients.” Additionally, this group identified a desire for “comprehensive orientation, continuing education and mentoring” (Boswell, Lowry, & Wilhoit, 2004, p. 76). Nurse residency programs (NRPs) were created in response to low satisfaction levels and high turnover rates among new graduates. The University HealthSystem Consortium (UHC)/AACN Residency Program has 92 practice sites in 30 states that offer the year-long post-baccalaureate residency. As of this writing, more than 26,000 nurses have completed the program. Satisfaction, as reflected by a 95.6% retention rate versus previous turnover rates of 30%, serves as a strong indicator of the success of this program (AACN, 2015). While much work has been done to develop a model with a strong curriculum and excellent outcomes, thus far the participants are only in academic health centers and large health systems. NRPs need to be replicated beyond these elite and well-endowed settings to community hospitals where much of the health care is provided in the U.S.
A difficult transition into practice isn’t the only reason that nurses leave health care organizations. Nurses quit jobs where they feel overworked, underpaid, and disrespected by their coworkers and managers. Using national focus groups, on behalf of the Robert Wood Johnson Foundation, Kimball and O’Neil (2002) found RNs are concerned about being unable to physically continue to do the work, increases in their daily workloads, and the lack of ancillary staff to support them. These groups also indicated they were confused about health care financial issues, felt powerless to change things in their work environments, and thought their nurse managers were overextended and unable to help them. The respondents gave a list of suggestions to improve the retention of nurses, including:
image  Decreasing workloads;
image  Providing support staff;
image  Empowering nurse managers;
image  Increasing salaries;
image  Encouraging physicians to treat nurses as colleagues;
image  Improving the orientation process; and
image  Providing paid continuing education (Kimball & O’Neil, 2002, p. 46).
Overwork of nurses and high patient-to-nurse ratios lead to patient mortality, nurse burnout, and job dissatisfaction (Aiken, Clarke, Sloane, Sochalski, & Silber, 2002). Aiken et al.’s (2002) benchmark article reported “that the difference from 4 to 6 and from 4 to 8 patients per nurse would be accompanied by 14% and 31% increases in mortality, respectively” (p. 1991). The Joint Commission (2002) report called a high patient-to-nurse ratio “a prescription for danger” and indicated that “staffing levels have been a factor in 24% of 1,608 sentinel events (unanticipated events that result in death, injury, or permanent loss or function)” (p. 6). In addition, Aiken and her colleagues reported that more nurse education and training led to higher quality of service and lower patient mortality (Aiken, Clarke, Cheung, Sloane, & Silber, 2003). A recent longitudinal survey of predictors of turnover among newly licensed RNs found Magnet Hospital Status was not related to turnover, but on the job injuries were directly predictive. This means implementing policies to prevent strains and sprains can reduce nursing turnover (Brewer, Kovner, Greene, Tukov-Shuser, & Djukic, 2012). In light of these data, it makes financial sense to employ more RNs per patient, to protect them from on the job injury and to hire RNs with a baccalaureate level or higher. Given the nursing shortage, the health care manager’s next best choice would be to hire RNs with an associate degree, provide tuition assistance, and create incentives for them to return to school for their BSN.
Conflict and Communication: Creating a Culture of Safety
Encouraging physicians to treat nurses as colleagues has always been a challenge. Recommendations for collaborative practice between physicians and nurses have been in place for decades, going back to nursing shortages in the 1980s and the National Commission on Nursing’s 1983 Summary Report and Recommendations, calling for nurse-physician joint practice (National Commission on Nursing, 1983). One of the problems in this dyad has been the gap between physician and nursing education. In previous years, when diploma schools dominated nursing education, physicians had at least 20 more years of formal education than the RNs they worked with. In that era, when a physician walked into a room, a nurse would stand as a sign of respect—and give him her chair. Nurses now have formal educational programs in degree-granting settings, and the educational gap between the two health care professional groups is diminishing. Women have also “come of age” since the women’s rights movement in the 1970s, and nurses are no longer the doctor’s handmaidens. They, too, are health care professionals.
Teamwork is essential to a culture of safety. Physician resistance to acknowledging nurses as professionals and colleagues leads to poor teamwork and interpersonal conflict and can result in poor patient outcomes. One study found that physicians and nurses differed widely in their opinions about teamwork in an ICU setting. Almost three-quarters of the physicians reported high levels of teamwork with nurses, but less than half of the nurses felt the same way (Sexton, Thomas, & Helmreich, 2000). Despite demonstrated need and effectiveness of interdisciplinary teamwork, formal educational training in this important skill for physicians and nurses is rare (Baker, Salas, King, Battles, & Barach, 2005Buchbinder et al., 2005). A poll conducted in 2004 by the American College of Physician Executives (ACPE) revealed that about one-quarter of the physician executive respondents were seeing problem physician behaviors almost weekly (Weber, 2004). Approximately 36% of the respondents reported conflicts between physicians and staff members (including nurses), and 25% reported that physicians refused to embrace teamwork.
It is no longer an option for physicians or nurses to refuse to play well with other health care professionals. The operating room and the ICU are two units that must rely on team-work to accomplish life-saving procedures. An orthopedic surgery symposium emphasized the need to address problem physicians’ behavior immediately and warned that avoidance of confrontations enables toxic personalities to continue to create hostile workplaces (Porucznik, 2012). Teamwork in the ICU is critical, yet despite studies that document associations between positive caregiver interactions and positive patient outcomes, an extensive review of the literature failed to determine a one best approach to improving teamwork (Dietz et al., 2014). No doubt this inability to have a one-size-fits-all approach is due, in part, to the wide variety of tasks and teams, not to mention organizational settings. Other authors have reported that combining the Agency for Healthcare Research and Quality (AHRQ) training program, TeamSTEPPS, with specialty team protocols improves role delineation and communication among team members, leading to better patient outcomes (Gupta, Sexton, Milne, & Frush, 2015Tibbs & Moss 2014). Regardless of how the team arrives at improved performance, it must include respectful communication and behaviors from all team members.
Intimidating and disruptive behaviors include “overt actions such as verbal outbursts and physical threats as well as passive activities such as refusing to perform assigned tasks or quietly exhibiting uncooperative attitudes during routine activities” (The Joint Commission, 2008, p. 1). Disruptive behaviors, whether from physicians or nurses, are unacceptable and counterproductive to a patient-centric culture of safety. Disruptive behavior is considered a sentinel event, i.e., “a Patient Safety Event that reaches a patient and results in any of the following: death; permanent harm; severe temporary harm and intervention required to sustain life” (The Joint Commission, 2014, para. 2).
People who behave like schoolyard bullies in health care organizations must be dealt with through counseling sessions, disciplinary actions, or terminations. Trust and good communication are central to excellence in health care delivery.
Communication between physicians, nurses, and other health care professionals is critical to a culture of safety. The Joint Commission established new standards to address communication and published a book for clinicians and health care managers with strategies to improve communication between staff members, patients, and teams (The Joint Commission, 2009). In this book, as well as in peer-reviewed articles, physicians and nurses are tasked to focus on patient-centered care and patient safety (Levinson, Lesser, & Epstein, 2010Nadzman, 2009). However, nurses and physicians rarely receive education on effective communication in their professional programs. While it is hoped that medical and nursing school curricula will respond to the need for this important skill, those courses are not in place at this time. For this reason, it may become your duty as a health care manager to ensure that resources such as educational seminars and teamwork training are in place to support a culture of safety at your health care organization.
Organizational climate is critical to promoting job satisfaction and retention of nursing staff. Laschinger and Finegan (2005) found that nurses who perceived that they had access to opportunity, experienced honest relationships and open communication with peers and managers, and trusted their managers were more likely to be retained and to have higher job satisfaction. The American Association of Colleges of Nursing (AACN, 2002) published a white paper titled Hallmarks of the Professional Nursing Practice Environment. The attributes of hospitals with work environments that support professional nursing practice were reviewed and the questions a new graduate should ask were listed. They are: Does your potential employer:
image  Manifest a philosophy of clinical care, emphasizing quality, safety, interdisciplinary collaboration, continuity of care, and professional accountability?
image  Recognize the contributions of nurses’ knowledge and expertise to clinical care quality and patient outcomes?
image  Promote executive-level nursing leadership?
image  Empower nurses’ participation in clinical decision making and organization of clinical care systems?
image  Maintain clinical advancement programs based on education, certification, and advanced preparation?
image  Demonstrate professional development support for nurses?
image  Create collaborative relationships among members of the health care provider team?
image  Utilize technological advances in clinical care and information systems?
The AACN also recommends that applicants inquire about RN staff education, vacancy, tenure, and turnover rates; patient and employee satisfaction scores; and the percentage of registry/traveler nurses used. The questions posed by the AACN challenge health care organizations to rise to higher standards and to reach for American Nurses Credentialing Center Magnet Recognition Program status (ANCC, 2014a). Unless these questions are answered in the affirmative, nursing turnover will continue to be one of the largest human and financial costs that the health care manager will be forced to control.
Like physicians who sit for board certification examinations, RNs can take ANCC’s or other nursing specialty organizations’ (e.g., the Wound, Ostomy, and Continence Nurses’ Society; the American Association of Critical Care Nurses, etc.) examinations to demonstrate additional competence in a specialty, after they have earned a baccalaureate or higher degree and practiced for a specific number of hours in a specialty area. Thus, nurses can be certified in a large number and variety of specialty areas. Nurses who are credentialed in specialty areas must demonstrate continuing competency by fulfilling requirements for certification renewal via one or several of the following mechanisms: continuing education hours, academic courses, presentations and lectures, publications and research, or preceptorships.
In many states, nurses are required to obtain nursing continuing education units (CEUs) to renew and maintain their nursing licenses. The ANCC Commission on Accreditation, the credentialing unit of the American Nurses Association (ANA), reviews and approves providers of nursing CEUs (ANCC, 2015).
There are literally hundreds of providers of nursing CEUs and multiple ways to obtain nursing CEUs, including but not limited to online courses; magazine or journal articles; workshops and conferences; audiotapes, CDs, and DVDs; and the previously noted academic courses, presentations and lectures, publications and research, or preceptorships. Nurses can even attend other health care providers’ workshops that have been approved for awarding nursing CEUs. There is no dearth of opportunities for nurses to obtain continuing education. It is the responsibility of the RN to maintain his or her license. Your role as health care manager will be to ensure that resources (i.e., money and time) are available for nurses to participate in these educational opportunities.
Foreign Educated Nurses
The nursing shortage, caused by a confluence of the aging of the U.S. nursing workforce, declining enrollments in nursing schools, higher average age of new graduates from nursing school, and organizational retention and turnover difficulties, would have been difficult enough for health care managers on its own. However, we have what some people call “the perfect storm” in health care because the nursing shortage is now combined with demographic forces and market forces, such as aging Baby Boomers, increasing racial and ethnic diversity, increased demand for health care services, increasing longevity of U.S. citizens, new treatments for chronic diseases that used to kill people (like asthma, diabetes, hypertension), and educated and demanding health care consumers (AACN, 2014bHRSA, 2013).
Since U.S. health care organizations are experiencing a crisis in the nursing workforce and cannot survive without nurses to deliver care, it is not surprising that foreign-educated nurses are coming to the U.S. to fill gaps in nursing services. However, the annual number of internationally educated NCLEX passers has declined from nearly 23,000 in 2007 to only 6,100 in 2011 (HRSA, 2013). In 2010, the majority of internationally trained nurses who took the NCLEX came from the Philippines, trailed by South Korea, India, Canada, and Nigeria (NCSBN, 2010). According to the Commission on Graduates of Foreign Nursing Schools (CGFNS) (2015) for nurses educated outside the U.S., all U.S. State Boards of Nursing require credentials evaluation, certification, or verification as a first-step in the application process. The CGFNS International Certification Program provides a credentials review, a qualifying exam of nursing knowledge, and an English-language proficiency examination. The CGFNS International Certification Program is required for licensure by a number of State Boards of nursing licensure and can be utilized for federal Visa screening requirements for immigration. The CGFNS Certification Program removes a major burden from an employer. However, as a health care manager, your job may require you to ensure that foreign-educated nurses are who they say they are, have fulfilled all the requirements of the State Board of Nursing, and are legally allowed to work in the U.S. (McFarlane, 2013).
Due to the stringent requirements the U.S. has for RN licensure, concerns about the U.S. depleting other nations of their nursing workforce are not based on hard data (Aiken, Buchan, Sochalski, Nichols, & Powell, 2004). However, these types of misperceptions can influence coworker relationships and may contribute to conflicts between U.S.-educated and foreign-educated nurses and between physicians and foreign-educated nurses. Different cultures bring varying expectations to the work setting. These expectations may well be at odds with those of their coworkers. Excellent interpersonal skills, conflict management, cultural proficiency, and sensitivity to diversity issues are critical for you to be able to be an effective health care manager for these employees.
In 2012, there were about 738,400 Licensed Practical Nurses (LPNs) or Licensed Vocational Nurses (LVNs) working under the supervision of physicians and nurses in the U.S. According to the BLS (2014c), they were employed in nursing homes and extended care facilities, hospitals, physicians’ offices, and private homes. Most work full time. After graduation from high school, LPNs are trained in one-year, state-approved programs. Most are trained in technical or vocational schools, although some high schools offer it as part of their curriculum. In order to be employed as an LPN, students must graduate from a state-approved program, then pass the LPN licensing exam, the NCLEX-PN (BLS, 2014c). LPNs are trained to do basic nursing functions such as checking vital signs, observing patients, and assisting patients with activities of daily living (ADLs), such as bathing, dressing, feeding, and toileting. With additional training, where state laws allow, they can also administer medications. LPNs are the backbone of the long-term care (LTC) sector of the health care industry, providing around-the-clock care and supervision of certified nurse’s assistants (CNAs) in nursing homes and convalescent centers. Many LPNs go on to earn their RN, and in some states, LPNs can take challenge examinations to earn their RN licensure. LPNs are an important part of the health care team and should be included in the health care manager’s tuition assistance plan to encourage key personnel to return to school for additional education.
In 2012, there were over 1.5 million nursing assistants and orderlies employed in nursing and residential care facilities and in hospitals (BLS, 2014d). Nursing aides, nursing assistants, certified nursing assistants (CNAs), orderlies, and other unlicensed patient attendants work under the supervision of physicians and nurses. They answer call bells, assist patients with toileting, change beds, serve meals, and assist patients with ADLs. Regardless of employment setting, aides are frontline personnel. Since nursing aides held the most jobs, at 1.5 million, and were employed most often by nursing care facilities, that will be the focus of the remainder of this section.
Nurse’s aides have made the news in negative ways in recent years. In the past, CNAs were not required to have CBCs, and elder abusers, sexual predators, and thieves saw the elderly population as easy prey. Now the majority of states and employers require CBCs. However, a clean CBC doesn’t guarantee that the person hasn’t abused or won’t abuse a patient. Therefore, it is incumbent upon the health care organization to have policies about neglect and abuse prevention in place, and the health care manager must enforce them. Some nursing homes have installed “granny-cams,” video surveillance systems to keep an eye on caregiver behavior and to document misbehavior. When working with vulnerable populations, the health care manager must be in a state of constant vigilance for neglect and abuse.
CNAs are often trained on the job in 75 hours of mandatory training and are required to pass a competency examination. CNAs provide direct care to patients over long periods of time and are often the most overlooked group of workers in terms of pay, benefits, and opportunities for advancement. Seavey (2004) conducted a literature review and found that estimates of turnover from LTC facilities ranged from 40% to 166%, with indirect and direct costs per lost worker ranging from $951 to $6,368. She estimated a minimum direct cost of $2,500 per lost worker. Ribas, Dill, and Cohen (2012) utilized longitudinal data collected between 1996 and 2003 and found 73% of the sample working in occupations other than nurse’s aide over time. Over half those who left nurse aide work moved into higher paying occupations; however, when they excluded those who became RNs from the sample the number dropped to 35% (p. 2189). The researchers pointed to lack of clear career paths and lack of career ladders for these workers, resulting in lower wages.
It’s a vicious cycle: poor quality of work life begets turnover, which begets poor quality of work life, which begets more turnover. And it’s not just the CNAs and other aides who are affected. Once the CNAs are gone, the LPNs will go, then the RNs will be stressed, become emotionally burned out, and leave (Kennedy, 2005). Then who will provide the care? The job of the health care manager is to improve retention to slow down or stop turnover by addressing the quality of work life. The place to start is with a comparable market wage analysis. Are the workers being paid the same as or better than workers with comparable jobs at other comparable facilities? Nursing home administrators have confided that CNAs will leave one facility to go to another one for a pay raise of 25 cents per hour. Is the pay fair? Does the facility pay tuition assistance for CNAs? What kind of benefits package is being offered? Are there career paths and ladders presented to the CNAs to encourage them to move up?
After looking at these basic items, the health care manager then needs to assess the work environment, including employee job burnout and satisfaction, preferably using an outside organization so workers can respond freely without fear of retribution. While not an exhaustive list, some of the items to be included in a work life analysis include worker perceptions of:
image  Job autonomy, variety, and significance;
image  Fairness of pay and benefits;
image  Opportunities for promotion and advancement;
image  Relationships with supervisors;
image  Relationships with coworkers;
image  Level of job burnout; and
image  Overall job satisfaction.
All health care workers, not just nurses, want to be treated as colleagues and with respect. If you conduct a survey of the organizational climate—as seen by the workers—you must be prepared to respond and intervene. If you do nothing, you will lose employees’ trust, and the revolving door of turnover will continue.
In 2012, there were 875,100 home health aides employed in the U.S. (BLS, 2014b). Hospitals continue to discharge patients quicker and sicker, which means more and more health care that used to be provided strictly in hospital settings is now given at home (Landers, 2010). In addition, due to the demographic tsunami of aging Baby Boomers who wish to age in place (i.e., at home) and due to the increasing longevity of individuals with chronic diseases and disability, this area of employment is expected to grow dramatically over the next decade. Many of the same issues associated with nursing aides will come along with this dramatic employment surge in home health aides. Since these individuals go to people’s homes to provide their services, all of the concerns noted above related to the need for CBCs, prevention of abuse of vulnerable populations, and turnover apply here as well. In addition,
home health aides who work for agencies that receive reimbursement from Medicare or Medicaid must get a minimum level of training and pass a competency evaluation or receive state certification. Training includes learning about personal hygiene, reading and recording vital signs, infection control, and basic nutrition. Aides may take a competency exam to become certified without taking any training. These are the minimum requirements by law; additional requirements for certification vary by state. (BLS, 2014b, para 3)
Many hospitals and health care organizations have branched out into home health care services. While you may think you will be employed by a hospital and work only on inpatient services, the reality is you may very well become a manager for these outpatient, in-home services. It will be your responsibility to ensure that the people who are hired for these jobs are trustworthy and competent.
Midlevel practitioners include advanced practice nurses (APNs), such as nurse practitioners (NPs), clinical nurse specialists (CNS), nurse anesthetists, and nurse midwives, as well as physician assistants (PAs). “Between 2001–2011, the number of NP graduates grew from 7,261 to 12,273, a growth of approximately 69 percent” (HRSA, 2013, p. 50). According to Bureau of Labor Statistics, PAs held about 86,700 jobs in 2012 (BLS, 2014f). These health care professionals are called midlevel practitioners because they work midway between the level of an RN and that of an MD. Midlevel practitioners serve in a variety of settings, including hospital emergency rooms or departments, community health clinics, physician offices, and health maintenance organizations. They may also cover hospital floors for physicians. Midlevel practitioners are usually less expensive than physicians, often replacing MDs at a 2:1 ratio. Although APNs were resisted by many state medical societies early in the 1970s, over time physicians realized that APNs could increase their productivity and ease their workload. Midlevel practitioners are much sought after by health care organizations because they can provide many of the same services as physicians at a lower cost.
Advanced Practice Nurses
There are many organizations and accrediting bodies that certify advanced practice nurses (APNs). The following discussion is not intended to be an exhaustive listing of the specialty certifications that are available. Rather, it is meant to be illustrative of the variety of roles that APNs can assume. In addition to the educational preparation noted below, all APNs must demonstrate continuing competency by obtaining CEUs. APN certification must be renewed every five years, either by documenting evidence of practice or by retaking the examination. Below are some examples of APNs.
Nurse practitioners (NPs) are prepared, according to the American Association of Nurse Practitioners (AANP), in either an NP MSN, a post-master’s certificate, or a doctoral program (AANP, 2010). To become certified in Adult, Family, and Adult-Gerontology Primary Care by the AANP’s Certification Program (AANPCP), candidates must provide documentation that they are graduates of an accredited college or university’s master’s or post-master’s level adult, gerontologic, and family nurse practitioner program (AANPCP, 2015, p. 9) They must also take a competency-based exam. “The certification program is recognized by all State Boards of Nursing, the Centers for Medicare and Medicaid Services (CMS), the Veterans Administration, private managed care organizations, institutions, and health care agencies for credentialing purposes” (AANPCP, 2015, p. 6). This means they can bill for services rendered, as can the organization that employs them. NPs can also become certified in areas of care that include but are not limited to acute, adult psychiatric/mental health, advanced diabetes management, family psychiatric/mental health, medical-surgical, school, and pediatric. They must pass a certification exam and maintain their competency through continuing nursing education and recertification exams (AANPCP, 2015). To respond to changes in the field, some examinations are retired (the Gerontologic NP) or being retired (the Adult NP). Qualified NPs can elect to apply for conversion to the Adult-Gerontology Primary Care Nurse Practitioner (AANPCP, 2015, p. 9). On May 12, 2015, Maryland became the 21st state to enact the full practice law, which enables nurse practitioners to evaluate patients, diagnose, order and interpret diagnostic tests, initiate and manage treatments, including prescribing medications, under the exclusive licensure authority of the state board of nursing (AANP, 2015). In light of the physician shortage, it is anticipated more states will follow suit and enact full practice laws for NPs.
Clinical nurse specialists (CNSs) have in-depth education in the clinical specialty area at a master’s or doctoral degree level. To be certified as a CNS, the RN must have all of the same educational qualifications as an NP, but in their area of focus, plus a minimum number of hours of supervised clinical practice as specified by each specialty area. Areas of certification include:
image  ACNS-BC (Adult CNS – Board Certified);
image  GCNS-BC (Gerontological CNS – Board Certified);
image  HHCNS-BC (Home Health CNS – Board Certified);
image  PCNS-BC (Pediatric CNS – Board Certified); and
image  PMHCNS-BC (Psychiatric Mental Health CNS – Board Certified)—used for both Child/Adolescent and Adult (ANCC, 2015, para 3).
They, too, must pass a certification exam and maintain their competency through continuing nursing education and recertification exams (ANCC, 2015).
Certified registered nurse anesthetists (CRNAs) are APNs who specialize in providing anesthesia. Between 2001 and 2011, their numbers grew from 1,159 graduates to 2,447 graduates (HRSA, 2013). According to the American Association of Nurse Anesthetists (AANA), nurses have been providing anesthesia care since the U.S. Civil War (AANA, 2015). They work in cooperation with anesthesiologists, surgeons, dentists, and other health care professionals. Education and experience required to become a Certified Registered Nurse Anesthetist (CRNA) include:
image  A Bachelor’s of Science in Nursing (BSN) or other appropriate baccalaureate degree.
image  A current license as a registered nurse.
image  At least one year’s experience in an acute care nursing setting.
image  Graduation from an accredited graduate school of nurse anesthesia. These educational programs range from 24–36 months, depending upon university requirements, and offer a master’s degree.
image  All programs include clinical training in university-based or large community hospitals.
image  Pass a national certification examination following graduation.
It takes a minimum of seven calendar years of education and experience to prepare a CRNA. The average student nurse anesthetist completes almost 2,500 clinical hours and administers about 850 anesthetics (AANA, 2015, para 1–3). “As of Nov. 1, 2014, there were 114 accredited nurse anesthesia programs in the U.S. utilizing more than 2,500 active clinical sites; 32 nurse anesthesia programs are approved to award doctoral degrees for entry into practice” (AANA, 2015, para 6).
A review of six years of data from the Centers for Medicare & Medicaid Services (CMS) found no adverse outcomes in states where nurse anesthetists were allowed to practice solo, that is, without the supervision of a physician (Dulisse & Cromwell, 2010). Other researchers made a strong case for the cost-effectiveness of nurse anesthetists as well as the quality of care provided (Hogan, Seifert, Moore, & Simonson, 2010Mackey, Hogan, Seifert, Moore, & Simonson, 2010). Nurse anesthetists and anesthesiologists have similar postgraduate training; these data provide evidence that the positive health outcomes for patients of solo nurse anesthetists are similar to those of physicians and cost-effective.
Certified nurse midwives (CNMs) are licensed as independent practitioners in all 50 states, the District of Columbia, American Samoa, Guam, and Puerto Rico. CNMs provide prenatal care and deliver babies. They are defined as primary care providers under federal law (American College of Nurse-Midwives [ACNM], 2014). More than 80% of all nurse midwives have master’s degrees; another 4.8% have doctoral degrees. Nurse midwives were introduced to the U.S. in 1925 with the Frontier Nursing Service (FNS), founded by Mary Breckenridge (FNS, 2015). As of 2010, all CNM applicants were required to have graduate degrees and to graduate from a nurse-midwifery education program accredited by the ACNM and pass a national certification examination (ACNM, 2014).
Physician Assistants
According to the BLS (2014f), in 2012 there were 86,700 employed PAs in the U.S. PAs were created in the 1960s in response to a primary care physician shortage in the U.S. Vietnam veteran medical corpsmen were selected for a “fast-track” training program and trained to assist physicians wherever they practiced (American Academy of Physician Assistants [AAPA], 2015b). Once a male-dominated profession, now over two-thirds (67%) are female. In 2015, there were 196 accredited PA educational programs that must confer graduate degrees (Accreditation Review Commission on Education for the Physician Assistant, Inc., 2015). Only graduates of accredited PA programs are eligible to take the Physician Assistant National Certifying Examination (PANCE). PAs must demonstrate competency and be recertified every 10 years and must earn 100 CME hours every two years (National Commission on Certification of Physician Assistants, 2015). PAs are certified to practice with a team of physicians and can prescribe medication in every state in the U.S., the District of Columbia, and most U.S. territories. A physician assistant’s responsibilities depend on state laws, practice setting, their experience, and the physician’s scope of practice (AAPA, 2015a2015c). PAs practice in every conceivable setting, although the major employers of PAs are hospitals, followed by single- and multi-specialty physician group practices (AAPA, 2013). PAs are versatile and valuable members of the health care team and are highly sought after by hospitals, physician practices, and other employers.
The term allied health professionals refers to more than 2,000 programs in 28 health science occupations (Commission on Accreditation of Allied Health Education Programs [CAAHEP], 2015). A full list of allied health occupations is provided at the CAAHEP website, Each has its own body of knowledge, program requirements, and competency expectations. Allied health professionals assist physicians and nurses in providing comprehensive care to patients in a variety of settings. Many of the occupations, such as anesthesiologist assistant and surgical assistant, have grown from the unmet demand for help in the highly specialized operating room environment. Other occupations, such as perfusionist and electroneurodiagnostic technician, have grown out of the technological boom and the need for people to operate highly specific equipment. Radiologic technologists and technicians (often shortened to “rad techs”) assist radiographers in imaging technologies, which are changing with dizzying speed. The rate of accreditation of licensed rad techs is not keeping up with the speed of change in technology, and shortages are predicted for this high-demand field (BLS, 2014g).
Laboratories that analyze clinical specimens with increasingly sophisticated technologies need to be staffed with qualified personnel. The National Accrediting Agency for Clinical Laboratory Sciences (NAACLS) is responsible for maintaining the quality of programs in the clinical laboratory sciences. “Accredited programs include Clinical Laboratory Scientist/Medical Technologist, Clinical Laboratory Technician/Medical Laboratory Technician, Cytogenetic Technologist, Diagnostic Molecular Scientist, Histologic Technician, Histotechnologist, and Pathologists’ Assistant” (NAACLS, 2015). The BLS (2014a) indicates that job growth will be brisk in the coming years for clinical laboratory technologists and technicians and that the majority of this growth will occur in hospitals; however, other settings will need these workers as well.
Respiratory Therapists (RTs)
This section will address one allied health occupation in greater detail: respiratory therapists (RTs). In 2012, RTs held about 119,300 jobs, with most employed by hospitals (BLS, 2014i). RTs evaluate, treat, and care for patients with respiratory disorders, such as asthma, emphysema, pneumonia, and heart disease. An associate’s degree is required for entry into the field to become a certified respiratory therapist (CRT). Additional education is required for advanced practice and eligibility for the registered respiratory therapist (RRT) designation. RTs are certified by the National Board for Respiratory Care (NBRC), and registration is available only to graduates of accredited programs in respiratory care of the Commission on Accreditation for Respiratory Care (CoARC; NBRC, 2015). All states except Alaska, as well as the District of Columbia and Puerto Rico, require RTs to obtain a license (AARC, 2010BLS, 2014i). In addition, most employers require cardiopulmonary resuscitation (CPR) certification because RTs are usually members of hospital rapid response teams.
Shortages exist in almost all the allied health occupations, but respiratory therapy continues to be particularly affected. With a vacancy rate of 9% that translates to a national shortage of 12,000 respiratory therapists, recruitment and retention are critical matters (Brady & Keene, 2008). The authors, who are respiratory therapists, paint a disturbing picture of work life for these health care professionals. Understaffed and overwhelmed, the demands of a high patient load can be tipped into disaster when a code is called and all the other less critical patients have to wait—with anxious and angry family members who don’t understand why their loved one’s treatment is delayed. Brady and Keene (2008) recommend strategies to retain RTs, beginning with appreciating the important work they are doing. They also recommended approaches to assess and assign workload more evenly and expressed concerns that overwork and short staffing compromises patient care. Since recruitment and retention are under the domain of the health care manager, you will be expected to come up with creative approaches to address this ongoing dilemma.
Staffing shortages across all health care professions will continue to be an issue, along with recruitment, retention, job satisfaction, burnout, and turnover. Maintenance of currency and the relevance of an up-to-date health care workforce will always be an evergreen topic for researchers and health care managers alike. Many of the resources used in writing this chapter also include extensive research holdings and data sets that are available to students and academic researchers. Herewith is a partial listing of these resources.
image  Agency for Healthcare Research and Quality TeamSTEPPS®: Strategies and Tools to Enhance Performance and Patient Safety;
image  Bureau of Labor Statistics (BLS) Occupational Outlook Handbook Healthcare;
image  Centers for Disease Control and Prevention (CDC) Collaboration Primer;
image  Foundation for the Advancement of International Medical Education and Research;
image  Hospital Consumer Assessment of Healthcare Providers and Systems;
image  Hospital Research and Educational Trust (HRET);
image  Inter-university Consortium for Political and Social Research (ICPSR);
image  Open Payments;
image  The Robert Wood Johnson Foundation; and
image  U.S. Department of Health and Human Services Health Resources and Services Administration (HRSA) Coordinating Center for Interprofessional Education and Collaborative Practice (CC-IPECP).
You will have an abundance of information at your fingertips at any one of these websites.
This chapter has described the education, training, and credentialing of physicians, nurses, nurses’ aides, midlevel practitioners, and allied health professionals and has given an overview of the supply of and demand for health care professionals. In addition, some of the reasons for health care professional turnover and costs of turnover have been discussed, along with some strategies for increasing retention and preventing turnover. Conflict of interest as it relates to employed physicians has been addressed, and issues related to the management of the work life of physicians, nurses, nurses’ aides, midlevel practitioners, and allied health professionals have been interwoven through all of these topics. These are issues that can and should be addressed by you, the health care manager, with respect for each and every health care professional. The challenges await you; there will be no shortage of problems for you to solve.
1. Delineate the steps in attaining state licensure for physicians.
2. Describe the steps in attaining state licensure for nurses.
3. Compare and contrast licensure and credentialing.
4. Distinguish between core privileges and specific privileges in physician credentialing.
5. Why is physician credentialing one of the most important jobs in a hospital?
6. What is the National Practitioner Data Bank, and why was it created?
7. What is an international medical graduate, and what populations have they traditionally been most likely to serve?
8. Why might we begin to see fewer foreign-educated nurses in the U.S.?
9. Why might we begin to see fewer foreign-educated physicians in the U.S.?
10. Define the following terms: “job burnout,” “job satisfaction,” “retention,” and “turnover.” Why are they of importance in managing health care professionals? What can health care managers do to minimize physician burnout?
11. What is the “Sunshine Law,” how does it relate to conflict of interest, and why is it important among employed physicians?
12. What is the relationship among nursing education, nursing burnout, job dissatisfaction, and patient mortality? What can health care managers do to minimize nursing burnout?
13. What are the attributes of hospitals that support professional nursing practice?
14. Distinguish among the following: advanced practice registered nurse, certified registered nurse, and physician assistant.
15. Distinguish among licensed practical nurses, certified nurses’ assistants, and home health aides. What are some of the health care manager’s challenges with these groups?
16. Who are allied health professionals? What are some health care management issues in working with them?
Cases in Chapter 18 that are related to this chapter include:
image  United Physician Group
image  Death by Measles
image  Full Moon or Bad Planning
image  The Brawler
image  I Love you. . .Forever
image  Managing Health Care Professionals—Mini-Case Studies
image  Such a Nice Young Man
image  The New Toy at City Medical Center
Case study guides are available in the online Instructor’s Materials.
Accreditation Council for Continuing Medical Education (ACCME). (2015a). Maintenance of recognition. Retrieved from
Accreditation Council for Continuing Medical Education (ACCME). (2015b). Member organizations. Retrieved from
Accreditation Council for Graduate Medical Education (ACGME). (2011, July 1). Common program requirements. Retrieved from
Accreditation Council for Graduate Medical Education (ACGME). (2014). Frequently asked questions: ACGME Common duty hour requirements: July 1, 2011, updated June 182014. Retrieved from
Accreditation Council for Graduate Medical Education (ACGME). (2015). ACGME fact sheet. Retrieved from, para 4–5.
Accreditation Review Commission on Education for the Physician Assistant, Inc. (ARC-PA). (2015). Accredited PA programs. Retrieved from
Aiken, L. H., Buchan, J., Sochalski, J., Nichols, B., & Powell, M. (2004, May/June). Trends in international nurse migration. Health Affairs23(3), 69–77.
Aiken, L. H., Clarke, S. P., Cheung, R. B., Sloane, D. M., & Silber, J. H. (2003). Educational levels of hospital nurses and surgical patient mortality. Journal of the American Medical Association290(12), 1617–1623.
Aiken, L. H., Clarke, S. P., Sloane, D. M., Sochalski, J., & Silber, J. H. (2002). Hospital nurse staffing and patient mortality, nurse burnout, and job dissatisfaction. Journal of the American Medical Association288(16), 1987–1993.
AMA Wire. (2015a, May 20). 4 things students should know about the new GME bill. Retrieved from
AMA Wire. (2015b, May 19). New commission to help streamline medical licensure. Retrieved from
American Academy of Family Practice (AAFP). (2015a). AAFP-ACOG joint statement on cooperative practice and hospital privileges. Retrieved from
American Academy of Family Practice (AAFP). (2015b). Family medicine specialty. Retrieved from
American Academy of Physician Assistants (AAPA). (2013). AAPA national survey report. Retrieved from
American Academy of Physician Assistants (AAPA). (2015a). Become a PA. Retrieved from
American Academy of Physician Assistants (AAPA). (2015b). History. Retrieved from
American Academy of Physician Assistants (AAPA). (2015c). I’m a PA. AAPA Brochure. Retrieved from
American Association for Respiratory Care (AARC). (2010). State licensure. Retrieved from
American Association of Colleges of Nursing (AACN). (2002, January). Hallmarks of the professional nursing practice environment. AACN white paper. Retrieved from
American Association of Colleges of Nursing (AACN). (2011). Fact sheet. Retrieved from
American Association of Colleges of Nursing (AACN). (2014a). New AACN data confirm enrollment surge in schools of nursing. Retrieved from
American Association of Colleges of Nursing (AACN). (2014b, August 18). Nursing faculty shortage. Retrieved from
American Association of Colleges of Nursing (AACN). (2015). Nurse residency program. Retrieved from
American Association of Nurse Anesthetists (AANA). (2015). Certified registered nurse anesthetists fact sheet. Retrieved from
American Association of Nurse Practitioners (AANP). (2010). What is a nurse practitioner? Retrieved from
American Association of Nurse Practitioners (AANP). (2015). State regulatory map. Retrieved from
American Association of Nurse Practitioners Certification Program (AANPCP). (2015, February). Candidate handbook and renewal of certification handbook. Retrieved from
American Board of Medical Specialists (ABMS). (2015). Board certification and maintenance of certification. Retrieved from
American College of Nurse-Midwives (ACNM). (2014). Essential facts about midwives. Retrieved from
American College of Physicians. (2008). White paper: How is a shortage of primary care physicians affecting the quality and cost of medical care? A comprehensive evidence review. Retrieved from
American Medical Association (AMA) International Medical Graduates’ Section. (2015a). IMGs in the United States. Retrieved from
American Medical Association (AMA). (2015b) AMA physician masterfile. Retrieved from
American Medical Association (AMA) Medical Student Section, Committee on Legislation and Advocacy (COLA), Subcommittee on Medical Education. (n.d.). Resident work hours.
American Nursing Credentialing Center (ANCC). (2014a). ANCC certification center. Retrieved from
American Nurses Credentialing Center (ANCC). (2014b). Magnet recognition program overview. Retrieved from
American Nursing Credentialing Center (ANCC). (2015). ANCC announces new credentials for clinical nurse specialists. Retrieved from
Annotated Code of Maryland (COMAR). (2015). Licensure: Qualifications for initial licensure. Retrieved from
Association of American Medical Colleges (AAMC). (2015). Aspiring docs: The basics. Retrieved from
Baker, D. P., Salas, E., King, H., Battles, J., & Barach, P. (2005, April). The role of teamwork in the professional education of physicians: Current status and assessment recommendations. Journal on Quality and Patient Safety31(4), 185–202.
Boswell, S., Lowry, L. W., & Wilhoit, K. (2004). New nurses’ perceptions of nursing practice and quality patient care. Journal of Nursing Care Quality19(1), 76–81.
Brady, S., & Keene, S. (2008). Respiratory therapists can facilitate positive change with institutional support. The Internet Journal of Healthcare Administration 6(1), 1–5.
Brewer, C. S., Kovner, C. T., Greene, W., Tukov-Shuser, M., & Djukic, M. (2012). Predictors of actual turnover in a national sample of newly licensed registered nurses employed in hospitals. Journal of Advanced Nursing68(3), 521–538.
Buchbinder, S. B., Alt, P. M., Eskow, K., Forbes, W., Hester, E., Struck, M., & Taylor, D. (2005). Creating learning prisms with an interdisciplinary case study workshop. Innovative Higher Education29(4), 257–274.
Buchbinder, S. B., Wilson, M. H., Melick, C. F., & Powe, N. R. (2001). Primary care physician job satisfaction and turnover. American Journal of Managed Care7(7), 701–713.
Bureau of Health Professions (BHPr). (2003, Spring). Changing demographics: Implications for physicians, nurses and other health workers. Washington, DC: U.S. Department of Health and Human Services, Health Resources and Services Administration, Bureau of Health Professions, National Center for Health Workforce Analysis. Retrieved from
Bureau of Labor Statistics (BLS). (2014a). Clinical laboratory technologists and technicians. Occupational outlook handbook, 2014–15 edition. Retrieved from
Bureau of Labor Statistics (BLS). (2014b). Home health aides. Occupational outlook handbook, 2014–15 edition. Retrieved from
Bureau of Labor Statistics (BLS). (2014c). Licensed practical and licensed vocational nurses. Occupational outlook handbook, 2014–15 edition. Retrieved from
Bureau of Labor Statistics (BLS). (2014d). Nursing assistants and orderlies. Occupational outlook handbook, 2014–15 edition. Retrieved from
Bureau of Labor Statistics (BLS). (2014e). Physicians and surgeons. Occupational outlook handbook, 2014–15 edition. Retrieved from
Bureau of Labor Statistics (BLS). (2014f). Physician assistants. Occupational outlook handbook, 2014–15 edition. Retrieved from
Bureau of Labor Statistics (BLS). (2014g). Radiologic and MRI technologists. Occupational outlook handbook, 2014–15 edition. Retrieved from
Bureau of Labor Statistics (BLS). (2014h). Registered Nurses. Occupational outlook handbook, 2014-15 edition. Retrieved from
Bureau of Labor Statistics (BLS). (2014i). Respiratory therapists. Occupational outlook handbook, 2014–15 edition. Retrieved from
Butcher, L. (2008, July). Many changes in store as physicians become employees. Managed Care. Retrieved from
Cejka Search & American Medical Group Association (AMGA). (2013). 2013 Benchmarks for retention, recruitment and growth.
Centers for Medicare & Medicare Services (CMS). (2015). Open payments. Retrieved from
Commission on Accreditation of Allied Health Education Programs (CAAHEP). (2015). About CAAHEP. Retrieved from
Commission on Graduates of Foreign Nursing Schools (CGFNS). (2015). The certification program. Retrieved from
Cooper, R. A. (2002). There’s a shortage of specialists. Is anyone listening? Academic Medicine77, 761–766.
Cooper, R. A. (2003). Medical schools and their applicants: An analysis. Health Affairs22(4), 71–84.
Cooper, R. A., & Aiken, L. H. (2001). Human inputs: The health care workforce and medical markets. Journal of Health Politics, Policy and Law26, 925–938.
Council of State Governments (CSG). (2012). Proposed policy resolutions. Retrieved from
Council of State Governments (CSG). (2013, July). Capitol facts & figures: Nurse licensure criminal background checks. Retrieved from
Department for Professional Employees AFL-CIO (DPEAFLCIO). (2010). Fact Sheet: The costs and benefits of safe staffing ratios. Retrieved from
Dietz, A. S., Pronovost, P. J., Mendez-Tellez, P. A., Wyskiel, R., Marsteller, J. A., Thompson, D. A., & Rosen, M. A. (2014). Administration/Teamwork: A systematic review of teamwork in the intensive care unit: What do we know about teamwork, team tasks, and improvement strategies? Journal of Critical Care299, 908–914. doi:10.1016/j.jcrc.2014.05.025
Donabedian, A. (2005). Evaluating the quality of medical care. The Milbank Quarterly83(4), 691–729.
Drazen, J. M., de Leeuw, P. W., Laine, C., Mulrow, C., DeAngelis, C., Frizelle, F. A., …Zhaori, G. (2010). Toward more uniform conflict disclosures—the updated ICMJE conflict of interest reporting form. New England Journal of Medicine363, 188–189.
Dreger, A. (2013, February 6). What the Sunshine Act means for health care transparency. The Atlantic. Retrieved from
Dulisse, B., & Cromwell, J. (2010, August). No harm found when nurse anesthetists work without supervision by physicians. Health Affairs29(8), 1469–1475.
Dunn, P. M., Arnetz, B. B., Christensen, J. F., & Homer, L. (2007). Meeting the imperative to improve physician well-being: assessment of an innovative program. Journal of General Internal Medicine22(11), 1544–1552.
Duvivier, R. J., Stull M. J., & Brockman, J. A. (2012). Shortening medical education. Journal of the American Medical Association308(2), 133–136. doi:10.1001/jama.2012.7022
Educational Commission for Foreign Medical Graduates (ECFMG). (2011). International credentials services. Retrieved from
Emanuel, E. J., & Fuchs, V. R. (2012). Shortening medical training by 30%. Journal of the American Medical Association307(11), 1143–1144. doi:10.1001/jama.2012.292
Federation of State Medical Boards (FSMB). (2014). Criminal background checks: Board by board overview. Retrieved from
Frontier Nursing Service (FNS). (2015). Frontier nursing service. Retrieved from
Government Accountability Office (GAO). (2010, January). VA health care: Improved oversight and compliance needed for physician credentialing and privileging processes. Report number GAO-10-26. Washington, DC: Author. Retrieved from
Gupta, R. T., Sexton, J. B., Milne, J., & Frush, D. P. (2015, January). Practice and quality improvement: Successful implementation of TeamSTEPPS tools into an academic interventional ultrasound practice. American Journal of Roentgenology204(1), 105–110.
Hagopian, A., Thompson, M. J., Kaltenbach, E., & Hart, L. G. (2003). Health departments’ use of international medical graduates in physician shortage areas. Health Affairs22(5), 241–249.
Hallock, J. A., Seeling, S. S., & Norcini, J. J. (2003). The international medical graduate pipeline. Health Affairs22(4), 64–96.
Health Resources and Services Administration (HRSA). Bureau of Health Professions National Center for Health Workforce Analysis (2013, April). The U.S. nursing workforce: Trends in supply and education. Retrieved from
Hogan, P. F., Seifert, R. F., Moore, C. S., & Simonson, B. E. (2010). Cost effectiveness analysis of anesthesia providers. Nursing Economic$28(3), 159–169.
Isaacs, S. L., Jellinek, P. S., & Ray, W. L. (2009). The independent physician—going, going… New England Journal of Medicine360, 655–657.
Jones, C., & Gates, M. (September 30, 2007). The costs and benefits of nurse turnover: A business case for nurse retention. The Online Journal of Issues in Nursing12(3), Manuscript 4. Retrieved from
Kennedy, B. R. (2005, December). Stress and burnout of nursing staff working with geriatric clients in long-term care. Journal of Nursing Scholarship, 37(4), 381–382.
Kimball, B., & O’Neil, E. (2002, April). Health care’s human crisis: The American nursing shortage. Robert Wood Johnson Foundation. Retrieved from
Landers, S. H. (2010). Why health care is going home. New England Journal of Medicine363(18), 1690–1691.
Laschinger, H. K. S., & Finegan, J. (2005). Using empowerment to build trust and respect in the workplace: A strategy for addressing the nursing shortage. Nursing Economic$23(1), 6–13.
Levinson, W., Lesser, C. S., & Epstein, R. M. (2010). Developing physician communication skills for patient-centered care. Health Affairs29(7), 1310–1316.
Lipner, R. S., Hess, B. J., & Phillips, R. L. (2013). Specialty board certification in the United States: Issues and evidence. Journal of Continuing Education In The Health Professions33, S20–S35. doi:10.1002/chp.21203
Locke, E. A. (1983). The nature and causes of job satisfaction. In M. Dunnette (Ed.), Handbook of industrial and organizational psychology (pp. 1297–1349). New York, NY: John Wiley & Sons.
Mackey, B., Hogan, P. F., Seifert, R. F., Moore, C. S., & Simonson, B. E. (2010). Cost effectiveness analysis of anesthesia providers. Nursing Economic$28(4), 287.
Maslach, C. (2003, October). Job burnout: New directions in research and intervention. Current Directions in Psychological Science12(5), 189–190.
McFarlane, J. (2013). Freeze on foreign nurses as NHS chiefs admit they have no idea how many lied about qualifications and experience using fake IDs. Daily Mail. Retrieved from
McMahon, G. T. (2004). Coming to America: International medical graduates in the United States. New England Journal of Medicine350, 2435–2437.
Mechanic, D. (2010). Replicating high-quality medical care organizations. Journal of the American Medical Association303(6), 555–556.
Medstar Health. (2015). Guidance on interaction with industry. Retrieved from{}1.Medstar-COI-and-Interactions-with-Industry.pdf
Mick, S. S., & Lee, S. D. (1999a, Winter). Are there need-based geographical differences between International Medical Graduates and US Medical Graduates in rural US counties? The Journal of Rural Health15(1), 26–43.
Mick, S. S., & Lee, S. D. (1999b). International and US medical graduates in US cities. Journal of Urban Health: Bulletin of the New York Academy of Medicine76(4), 481–496.
Mick, S. S., Lee, S. D., & Wodchis, W. P. (2000). Variations in geographical distribution of foreign and domestically trained physicians in the United States: “Safety nets” or “surplus exacerbation.” Social Science & Medicine50, 185–202.
Nadzman, D. M. (2009). Nurses’ role in communication and patient safety. Journal of Nursing Care Quality24(3), 184–188.
National Accrediting Agency for Clinical Laboratory Sciences (NAACLS). (2015). Programs. Retrieved from
National Board for Respiratory Care (NBRC). (2015). Examinations. Retrieved from
National Commission on Certification of Physician Assistants. (2015). Maintaining certification. Retrieved from
National Commission on Nursing (NCN). (1983). Summary report and recommendations. Chicago, IL: Hospital Research and Educational Trust.
National Council of State Boards of Nursing (NCSBN). (2010). Quarterly examination statistics. Volume, pass rates & first-time internationally educated candidates’ countries. Retrieved from
National Council of State Boards of Nursing (NCSBN). (2015a). History. Retrieved from
National Council of State Boards of Nursing (NCSBN). (2015b). Number of candidates taking NCLEX examination and percent passing, by type of candidate. Retrieved from
National Institutes of Health (NIH). (2014). Financial conflict of interest. Retrieved from
National Institutes of Health (NIH). (2015). Frequently asked questions. Retrieved from
National Practitioner Data Bank (NPDB). (2015). National practitioner data bank: About us. Retrieved from
National Residency Matching Program (NRMP). (2015). Match process. Retrieved from
Norcini, J. J., Boulet, J. R., Dauphinee, W. D., Opalek, A., Krantz, I. D., & Anderson, S. T. (2010). Evaluating the quality of care provided by graduates of international medical schools. Health Affairs28(8), 1461–1468.
Polsky, D., Kletke, P. R., Wozniak, G. D., & Escarce, J. (2002). Initial practice locations of international medical graduates. HSR: Health Services Research37, 907–928.
Porucznik, M. A. (2012). How to deal with the “problem physician”: Fall meeting symposium focuses on crucial conversation tips. AAOS Now. Retrieved from
Pradarelli, J. C., Campbell, D. A., Jr., & Dimick, J. B. (2015). Hospital credentialing and privileging of surgeons: A potential safety blind spot. Journal of the American Medical Association313(13), 1313–1314. doi:10.1001/jama.2015.1943
Ribas, V., Dill, J. S., & Cohen, P. N. (2012, Dec.) Mobility for care workers: job changes and wages for nurse aides. Social Science & Medicine75(12), 2183–2190. doi: 10.1016/j.socscimed.2012.08.015
Ross, J. S., Lackner, J. E., Lurie, P., Gross, C. P., Wolfe, S., & Krumholz, H. M. (2007). Pharmaceutical company payments to physicians: early experiences with disclosure laws in Vermont and Minnesota. Journal of the American Medical Association297(11), 1216–1223.
Seavey, D. (2004, October). The cost of frontline turnover in long-term care. Retrieved from
Sexton, J. B., Thomas, E. J., & Helmreich, R. L. (2000). Error, stress, and teamwork in medicine and aviation: Cross sectional surveys. British Medical Journal320, 745–749.
Smart, D. R. (2010). Physician characteristics and distribution in the US. Chicago, IL: AMA Press.
Steiger, D. O., Auerbach, D. I., & Buerhaus, P. I. (2000). Expanding career opportunities for women and the declining interest in nursing as a career. Nursing Economic$18(5), 230–236.
Steiger, D. O., Auerbach, D. I., & Buerhaus, P. I. (2009). Comparison of physician workforce estimates and supply projections. Journal of the American Medical Association302(15), 1674–1680.
Steiger, D. O., Auerbach, D. I., & Buerhaus, P. I. (2010). Trends in the work hours of physicians in the United States. Journal of the American Medical Association303(8), 747–753.
Stevenson University. (2015). Nursing program. Retrieved from
Szymczak, J. E., Brooks, J. V., Volpp, K. G., & Bosk, C. L. (2010). To leave or to lie? Are concerns about a shift-work mentality and eroding professionalism as a result of duty-hour rules justified? Milbank Quarterly88(3), 350–381. doi:10.1111/j.1468-0009.2010.00603.x
Tamblyn, R., Abrahamowicz, M., Brailovsky, C., Grand’Maison, P., Lescop, J., Norcini, J.,… & Haggerty, J. (1998). Association between licensing examination scores and resource use and quality of care in primary care practice. Journal of the American Medical Association280(11), 989–996.
The Joint Commission (TJC). (2002). Health care at the crossroads: Strategies for addressing the evolving nursing crisis. Retrieved from
The Joint Commission (TJC). (2008, July 9). Behaviors that undermine a culture of safety. Sentinel Event Alert, Issue 40. Retrieved from
The Joint Commission (TJC). (2009). The Joint Commission guide to improving staff communication (2nd ed.). Oak Brook, IL: Joint Commission Resources.
The Joint Commission (TJC). (2014, November). Sentinel event policy and procedure. Retrieved from
Thompson, M. J., Hagopian, A., Fordyce, M., & Hart, L. G. (2009). Do international medical graduates (IMGs) “fill the gap” in rural primary care in the United States? A national study. The Journal of Rural Health25(2), 124–134. doi:10.1111/j.1748-0361.2009.00208.x
Tibbs, S., & Moss, J. (2014, Nov.). Promoting teamwork and surgical optimization: Combining TeamSTEPPS with a specialty team protocol. AORN Journal100(5), 477–488. doi: 10.1016/j.aorn.2014.01.028. Epub 2014 Oct 25.
Torpey, E. (2014, Spring). Healthcare: Millions of jobs now and in the future. Occupational Outlook Quarterly. Retrieved from
Traverso, G., & McMahon, G. T. (2012). Residency training and international medical graduates: Coming to America no more. Journal of the American Medical Association308(21), 2193–2194. doi:10.1001/jama.2012.14681
Vaidya, A. (2013, June 18). Survey: Number of hospital-employed physicians up 6%. Becker’s Hospital Review. Retrieved from
Weber, D. O. (2004, September–October). Poll results: Doctors’ disruptive behavior disturbs physician leaders. The Physician Executive30(5), 6–14.
Whelan, G. P., Gary, N. E., Kostis, J., Boutlet, J. R., & Hallock, J. A. (2000). The changing pool of international medical graduates seeking certification training in US graduate medical education programs. Journal of the American Medical Association288, 1079–1084.

"Place Your Assignment Here And It Will Handled By professional writers And Delivered Within The shortest Time Possible

Order Now