The details:

Setting Ambulatory surgery hospital Problem Losing $200 per case per Medicare payer Payer mix One third each: Medicare, charity/self pay, managed care Strategic plan Grow business to valuable asset in the community hospital, enhancing its marketability in the larger hospital purchase/merger environment, for when it hangs out the “for sale” sign in 5 to 7 years.

Decision team Chief nursing officer (CNO; DNP)

Ambulatory surgery RN Human resources director Union representative Quality management director CFO (chief financial officer)

Marketing/community outreach director Rehabilitation director The team is internal. The team would eventually extend to or include external players, surgeons, and other contract services.

Solve for local and global success relative to the payer mix, the cost, and the culturally diverse Mexican American community.

Include understanding of fixed and variable costs, margin, length of stay, average daily census, average time for unit of service, quality care, professional growth, and introduction of Institute of Medicine (IOM) direction that pushes professional nursing practice to its highest level of training and education.

Sample $3,000 Medicare reimbursement Expenses Outpatient nurses 760 45/hour × 2 RN OR/PACU nurse 760 excludes benefit pkgs Supplies, IV, irrigation, equipment 500 Medications, intra op and OP 60 Allocation of fixed overhead 200 Contract anesthesia 400 $100/15 minute UOS Arthroscopy sterile package 600 Loss/UOS −200 Solving for current and future financial success should include the DNP using previous information related to understanding of fixed and variable costs, assets and liabilities, variance, and depreciation. For added complication—which would occur in the natural environment—

ethnic association, level of education, and length of time in the position may be added by individual readers and/or instructors. This exercise may be used as a simple discussion exercise or a detailed assignment. The exercise is meant to use 3D+ as the tool for arriving at the best local and global impact decision.

The disease of interest would be joint disease and/or trauma requiring arthroscopic surgery in an outpatient ambulatory surgery setting.

The disability of those who require surgery will be significant, with pain and loss of mobility taking them to this point of arthroscopic repair.

The discomfort, preop (in the community), and postop will need support, durable medical equipment, education, exercise regimens, and recovery from general anesthesia.

The internal environments to be assessed are the various physical states that come with need for the procedure.

The external environment includes community sports, farm worker soccer leagues, and other sports; church involvement by sportists; large ranches with or without insurance for the field workers; goodwill and donations by/from larger ranchers to a hospital foundation, and being the facility of choice for this local medical intervention with limited complications.

The ability of the patient population to participate in the plan of care, with professional guidance and education, will entail hours of care estimates for units of service (UOS).

The ability to resist other illness, anesthetic reactions, nausea and vomiting, pain not managed, and falls needs to be weighed into assessments.

The DNP needs to be skilled in the fixed costs of the unit, the variables, the allocation of hospital overhead as spread to the unit, the scope of practice and impact on cost of nursing service with a skill mix, bundled or unbundled charges, excluded costs, medications for perioperative events, anesthesia reimbursement, community wages of populations coming for uninsured service, dates and persons who negotiated managed care contacts, outreach to community sportists of all ages, the payer mix of the usual patient population, willingness of community large ranches to support injury to workers, relationships of the hospital to other social organizations, and many other contributing factors in order to maintain at least a costneutral operation. The DNP efforts do not rest with delivery of service, bottom line, and supply of “men, materials, and money.” The DNP needs to know all of the previously noted items plus additional creative components in order to ensure a sustainable ongoing arthroscopy service to a community with high rate of disease and/or traumatized joints, treatable by arthroscopic intervention. The narrative given is not intended to be inclusive, but rather to encourage 3D+ clinical and administrative reasoning.

AppendixLO1