Rebecca Hendren, for HealthLeaders Media, February 8th, 2011
Bob Donaldson is clinical director of emergency medicine and president of the medical staff at Ellenville Regional Hospital in New York. His current projects sound much like any medical staff president's goals.
What might surprise you is that Donaldson is not a physician but a nurse practitioner. He was elected to this influential position by his physician colleagues and enjoys great support from the hospital's medical staff.
I interviewed Donaldson to find out how a nurse practitioner broke down physician hierarchy and found an innovative hospital that could be a model for provider collegiality and meeting a community's healthcare needs.
Donaldson has a long background in emergency nursing and came to Ellenville Regional in 2004 when he was approached by the owners of an emergency medicine group that staffed providers for the ER, which at the time was staffed by all physicians, and asked to be the first non-physician provider for the ER.
He interviewed with the new CEO, with whom he immediately hit it off. The CEO convinced him that despite the hospital's financial difficulties those things would change, so Donaldson came on board.
"I passed muster, if you will, as the first non-physician, full-time, sole provider here as an NP working in the ER alongside the docs," he says. "It was so successful that we ultimately eliminated all the docs here and replaced them all with nurse practitioners or physician assistants."
In 2004, the ER saw 8,000 visits per year. Now, it sees 12,500 per year, a number it has maintained for the last two years. Donaldson notes that the non-physicians provider arrangement is unusual but explains that his CEO conducted extensive research on nurse practitioners and their practice as part of his graduate work.
"We have been saying in nurse practitioner circles for years that nurse practitioners can do most of the things that docs have been doing," says Donaldson. "[The CEO] felt we could do a comparable job. So we've been doing it—and people like it."
As an admitting provider in the ER, the hospital's medical staff got to know Donaldson well and in 2008 he was invited to be on the team to review and revise the medical staff bylaws.
"The medical staff, all physicians, voted to give equal rights to nurse practitioners on the medical staff," says Donaldson. "Which means if you have a practice here and you are involved in admissions to this hospital, that you are equal to a doctor as far as privileges at the facility and within the medical staff."
In another unusual move, Donaldson's work in the ER means he admits patients to the hospital and its various providers every day, so the hospital decided to give him attending status.
Donaldson says that in 2009 the hospital needed to fill the position of medical staff president and was having difficulty attracting volunteers. So he put his name in the hat.
"I look at that as like anything else nurse practitioners have done," he says. "There's a void and we step in and we do the job. So that's what I did."
Donaldson notes with a laugh that once a nurse practitioner's name was in the running, other physicians stepped up to add their names. After three rounds of voting, he was elected with more than 50% of the all-physician vote. Since his election, he has enjoyed success and support from his colleagues
Donaldson now holds the quarterly medical staff meetings away from the hospital in a local restaurant and enjoys excellent attendance. Unlike most medical staff meetings, the event includes any member of the medical staff, whether physicians, nurse practitioner, or physician assistant.
"For a long time, we looked a lot at other hospitals to see what happened," says Donaldson. "When I look at other hospitals, I find that very few places have it that non-physicians can be members of the medical staff hierarchy."
Donaldson recommends other hospitals follow Ellenville Regional's lead. Anyone who has the capability or qualifications to run should be allowed to run if they are a member of the medical staff and meet the appropriate criteria. "Folks are doing such a large part of the job," he says. "Why wouldn't you want to get their input into what's going on?"
Donaldson doesn't spend much time worrying about hierarchy or turf wars. He's too busy getting on with patient care and helping the hospital experience a financial turnaround that's seen the ER expanded by 50% in the last five years.
Donaldson quotes his first physician collaborator, who once noted turf wars are for politicians.
"The people who are actually in the field doing the work are happy to have a colleague alongside them doing the same work in the same manner," he says. "It's not the people in the field who are making these comments and fighting over turf. They're trying to get their patients taken care of. It's the people in the medical societies who makes those battles."
Look at what happened at Ellenville, he says. Turf wars don't have to be a distraction. Clearly, this hospital has collaborative practice figured out.