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Mayo Clinic’s Current Status and Implementation of VBP
Value-Based Purchasing (VBP) is a practice of reimbursing hospitals for delivering a higher quality of care (CMS, 2012). It is a part of Medicare’s payment system that seeks to ensure improved quality outcomes for patients by rewarding healthcare facilities that show improved performance compared to the baseline period (CMS, 2012). The practice facilitates continuous improvement by incentivizing organizations to improve the quality and safety of care, reduce medical errors, decrease the numbers of patients that have contracted hospital-acquired infections, drop costs, improve existing processes, and facilitate evidence-based practices (CMS, 2012). The baseline is not static and relies on the hospital’s previous performances during the last period. Thus, it sets up a gradually higher standard of care as hospital improves. Some of the main outcome measures that count towards VBP scores include patient mortality, patient safety, readmission rates, patient experience, care effectiveness and timeliness, as well as efficient use of medical imaging.
The hospital selected for this paper is Mayo Clinic located in Florida, Jacksonville. Mayo is a nonprofit healthcare organization well-known for its high quality of care, having been rated top 1 hospital in the US (Mayo Clinic, 2020). Mayo Clinic embraces VBP practices in some areas of service that it provides. Namely, they focus on value of care for heart attack patients, heart failure patients, hip/knee replacement patients, and pneumonia patients (CMS, 2020). For pneumonia and heart patients, the primary VBP metric is patient mortality rate, whereas for hip/knee replacement patients it is complications rate and economic feasibility (CMS, 2020). The following sections will provide a strategic plan for further developing VBP in Mayo Clinic by focusing on departments that already practice some of VBP measurements, namely the cardiology, respiratory and pulmonary care, as well as the department of orthopedic surgery.
Strategic Plans for Individual Departments
Cardiology Department Strategic Plan
B1-B1a. Cardiology Department
This department treats individuals that have heart diseases or problems with blood circulation (Haghighathoseini, Bobarshad, Saghafi, Rezaei, & Bagherzadeh, 2018). A cardiologist is the primary specialist that investigates the issue with a patient’s heart, performs the necessary tests, and provides a treatment plan that usually involves medication treatment to reduce the symptoms of the disease (Haghighathoseini et al., 2018). In situations where surgical intervention is required, such as where there is a chance of heart failure or heart attack is imminent, the cardiac surgery subdivision of the cardiology department overtakes the patient into their care. It is that specific subdivision that currently implements VBP care practices in Mayo Clinic.
The role and function of this department is important for facilitating greater VBP in the chosen organization due to the fact that heart problems and heart disease are both very widespread in the US and are the direct cause of many mortalities across the nation. According to CDC (Centers for Disease Control and Prevention) (2020a), approximately 31 million Americans currently has heart disease. It is also considered the main cause of death in the US, with every 1 in 4 deaths being attributed to this specific group of illnesses (CDC, 2020a). Over 805,000 Americans experience a heart attack every year, out of which two thirds are first-time heart attacks (CDC, 2020a). Therefore, the cardiology department has to deal with diseases that kill the most people, and require significant material and financial resources to deal with. The quality of heart disease diagnosis and treatment is also important, as poor management of such can result in serious complications and even death. Thus, it is important to promote VBP in this department, in order to ensure that customers receive affordable and high-quality treatments that do not lead to complications and rehospitalizations further down the line.
B2. Goals
As it stands, Mayo Clinic’s death rate and payment rate for heart attack patients is no different than the country baseline (CMS, 2020). The national death rate currently stands at 12.7% for individuals under supervision within 30 days after their hospitalization. At the same time, the average payment per patient is at approximately 25,500 USD. These numbers, despite being at the country baseline, are very high, meaning that more than 1 in every 10 hospitalized cardiac patients dies within a month, whereas treatment costs for these patients, even with Medicare, remain significant. Therefore, SMART goals for Mayo Clinic within the scope of this business proposal are as follows:
- To reduce mortality rate in hospitalized patients diagnosed with heart failure or heart attack below 10% in the next 3 years;
- To reduce the average payment per patient for cardiac hospitalizations to 20,000 USD or below, in the next 3 years;
- Introduce customer satisfaction VBP rating within the department and achieve a rating above 76.5% (national average) in the next 3 years;
- Introduce a readmissions rate due to misdiagnosis and reduce it when compared to hospital’s own baseline statistics for the last 3 years.
B3. Attaining Quality Outcomes in patient care over the next 3 years
- Improved interprofessional collaboration when working with heart attack and heart failure patients.
Since heart failure is a dangerous and concealed disease, it is important to ensure that collaboration between different specialists happens in an accurate, quick, and efficient manner (Meaney et al., 2013). It is especially important in the cases with cardiac arrests, where time is of the essence. Interprofessional collaboration can be improved by placing only experienced nurses to work shifts in the department, having established teams of professionals rather than assembling them piece-meal, and have doctors and nurses alike practice their communication skills in real or mock scenarios.
- Improve doctor-patient communication during long-term stay.
In an event of a heart attack, the patient often is required to stay at the hospital for supervision in order to ensure their safety and to monitory their heart rate throughout the day, watching out for a repeat incident of a heart failure. Heart attack or heart failure is associated with significant stress on the patient, which can often exacerbate the issue (Meaney et al., 2013). Patient-doctor communication is notorious for establishing trust, ensuring collaboration, and reducing stress. Thus, it is an important quality outcome that has the potential to improve some of the critical VBP scores for Mayo clinic.
- Improve the quality of diagnoses during the primary visit to the cardiologist.
Misdiagnosis is a significant threat when it comes to heart disease (Meaney et al., 2013). If an individual with the potential of developing a disease that could lead to heart failure is misdiagnosed, their next visit to the hospital might result in an exacerbated issue, and potentially cause death. Misdiagnosis usually occurs due to a lack of time to properly examine the patient, a lack of skill in the nurse or a doctor making the diagnosis, or as a result of insufficient testing (Meaney et al., 2013). Increasing the amount of patient-nurse time spent on the procedure would help reduce misdiagnosis and improve patient death and expenditure ratings.
Attaining Quality Outcomes in reimbursement over the next 3 years.
- Reduced mortality rates leading to higher reimbursement.
As it stands, Mayo Clinic is at the baseline for heart disease mortality rate (CMS, 2020). The attainable quality outcomes, such as improved professional collaboration, doctor-patient communication, and quality of diagnoses would reduce readmissions and mortality rates, thus resulting in reduced work needing to be done as well as VBP reimbursements that Mayo currently does not receive in that position.
- Improved customer satisfaction scores in the Hospital Consumer Assessment of Healthcare Providers and Systems survey (HCAHPS) resulting in improved reimbursement.
Medicare reimbursements are, in part, dependent on patient satisfaction surveys (CMS, 2020). An establishment of a healthy and trusting relationships between patients and doctors always improves satisfaction scores, not to mention leading to better outcomes. Therefore, it is economically viable for Mayo to focus on increasing their patient satisfaction scores in the cardiac department and add it as a VBP value in their evaluation.
- Improved reputational scores leading to an increase in patient volume.
Should Mayo succeed in reducing patient mortality rates for cardiac patients, it would result in a higher number of individuals being brought into care. Using the economy of scale, the hospital could reduce prices for individual customers, thus working towards the other SMART goal.
B4. Key Points
- Spending more time per patient and increasing the quality of personnel would reduce misdiagnosis and readmission rates;
- Improved interprofessional collaboration would save critical time, lead to better outcomes, and increase reimbursement;
- Focusing on patient-doctor communication would increase popularity among patients, improve HCAHPS scores, increase reimbursement, and allow scaling up patient treatment.
B4a. Marketing Key points
- Planning and implementation of examination times increase for patients could be done in a staff meeting;
- Interprofessional collaboration objectives could be delivered to individual groups using ad-hoc meetings and e-mail notification;
- Patient-doctor communication could be discussed during staff meetings as well.
B5. Ethical concerns
Ethical-Clinical concerns: The proposed solutions are based on the principles of beneficence and nonmaleficence, and do not go against any of the other ideas within the ethical framework. However, the point about increasing nurse-patient times can potentially violate the principles of nonmaleficence and justice, especially when it is implemented in a situation where time resources are limited. This should be accounted for by hiring more staff or implementing the practice when there are less patients to take care of.
Ethical-Business concerns: Improved customer satisfaction should be the result of improved treatment and greater trust, not the end goal. The purpose of the hospital is to provide high-quality treatment, and being nice just for the purpose of attaining better scores is unethical. Achieving the economy of scale by increasing patient numbers should not be the end goal either. Rather, the purpose of such practice is to reduce costs for patients. If the hospital is at full capacity, taking on additional patients and reducing quality is not allowed.
B6 Coordinating Informational Events
- Published hospital scores;
- Newsletter emails.
- Patient communication training;
- Interprofessional collaboration training;
- Seminars on heart disease diagnosis.
Respiratory and Pulmonary Care Department Strategic Plan
B1-B1a. Respiratory and Pulmonary Care Department
This department focuses on helping patients that have some sort of a respiratory disease or disability, with the primary focus being the lungs and bronchial tubes. Their area of competence includes the diagnoses and treatment of respiratory diseases, sleep disorders, and the management of critical illnesses (Gibson & Waters, 2016). As it stands, Mayo Clinic only participates in VBP related to pneumonia and pneumonia-related illnesses.
In the US, over 250,000 people with pneumonia undergo hospital treatment a year (CDC, 2020b). Out of these people, nearly 50,000 die (CDC, 2020b). Due to the widespread disease of COVID-19, which provokes pneumonia, among many other complications, hospital workloads for respiratory and pulmonary care departments have increased dramatically. Therefore, it has a crucial role and function in ensuring patient safety, and is required to deliver the highest value of provided care.
B2. Goals
Current VBP statistics for Mayo Clinic do not exceed the baseline patient mortality rates and expenditures for treating pneumonia. They stand at 15.4% mortality rate and 18,300 USD average payments for treatment (CMS, 2020). SMART goals, within the scope of VBP, would be as follows:
- Reduce the mortality rate below 13% within the next three years;
- Reduce patient expenditures for treatment below 15,000 USD;
- Introduce customer satisfaction VBP rating within the department and achieve a rating above 76.5% (national average) in the next 3 years;
- Introduce a readmissions rate due to misdiagnosis and reduce it when compared to hospital’s own baseline statistics for the last 3 years.
B3. Attaining Quality Outcomes in patient care over the next 3 years
- Increase public awareness about pneumonia and its dangers if left untreated.
The majority of fatalities from pneumonia occur in old individuals, children, and adult patients who came to hospital too late (Gibson & Waters, 2016). Pneumonia is best treated when it is detected early on. Letting the community know of the dangers of procrastination should significantly improve outcomes.
- Reduce self-treatment practices in the general population.
Pneumonia is caused by viruses, bacteria, and fungi, which require specific drugs to treat (Gibson & Waters, 2016). Trying to overcome the disease on one’s own with off-the-counter antibiotics can result in the development of resistance to treatment. Going hand-in-hand with the previous quality outcomes, this one would help reduce the complexity of treatment.
- Improving patient-nurse communication and education.
A patient stationed in a hospital can be educated to prevent pneumonia from happening in the future (Gibson & Waters, 2016). Should a nurse build a relationship of trust and understanding with the patient, they would be more responsive to smoking cessation, vaccination, and other helpful practices.
Attaining Quality Outcomes in reimbursement over the next 3 years.
- Quicker appointments to hospitals would lead to better outcomes.
If patients report to Mayo Clinic with early symptoms of pneumonia instead of ignoring it as a simple flu or engaging in self-treatment, chances of survival would increase drastically, resulting in reimbursements.
- Treating pneumonia in early stages results in shorter hospital stays and cheaper treatments.
One of VBP’s metrics for evaluating hospitals is economic efficiency. If patients stay less and spend less, the hospital will be able to take in more patients while simultaneously receiving greater reimbursements for providing quality care.
- Increase in publicity as a result of information campaigns.
By educating the community of Jacksonville, Mayo would put itself at the forefront of public opinion, resulting in greater volume of patients, thus in better generation of income.
B4. Key Points
- Engaging the community about pneumonia can help prevent exacerbated cases that lead to greater expenditures, morbidities, and lower VBP scores;
- Educating stationary patients on reducing habits that may make them vulnerable to pneumonia can reduce readmission rates;
- Early admissions are cheaper and more beneficial to patients and the hospital alike.
B4a. Marketing Key points
- Public activities to increase awareness, meetings in schools and other public places;
- Newsletters and emails to inform staff members about changes and recent activities;
- Staff meetings for coordination;
B5. Ethical concerns
Ethical-clinical concerns: Greater numbers of early pneumonia cases may not leave enough room for the exacerbated cases, which will appear anyway. Mayo must always have a reserve of IVL machines and other equipment to accommodate them. At the same time, the hospital must ensure that all early cases are sufficiently cared for. Ignoring their needs and allowing the disease to progress would be an affront to beneficence and non-maleficence principles (Mandal, Ponnambath, & Parija, 2016). In line with the ethical principle of patient autonomy, some patients could be placed in home care.
Ethical-business concerns: An increase in popularity may result in more patients coming to Mayo than it can treat without decreasing the quality of provided care. Going after money instead of prioritizing patient health goes against ethical principles of benevolence and non-maleficence (Mandal et al., 2016). In an event of overcrowding, Mayo should refer extra patients to other healthcare facilities in the area.
B6 Coordinating Informational Events
- Public announcements;
- Newsletters and e-mails;
- Phone calls.
- Briefings about pneumonia and how it could be prevented;
- Briefings on discouraging self-treatment;
- Seminars on patient-nurse communications.
Department of Orthopedic Surgery Strategic Plan
B1-B1a. Department of Orthopedic Surgery
The department of orthopedic surgery at Mayo Clinic is a branch of the surgery division, and treats various negative conditions of the musculoskeletal system. They typically use invasive and non-invasive means of rectifying traumas, spine diseases, sport injuries, infections, congenial disorders, degenerative diseases, and cancer-related tumors (Cooper et al., 2016). Mayo Clinic is involved in the VBP program in relation to hip and knee replacement surgeries, with the specific metrics involved being patient complication rate and patient expenditures for treatment.
According to Maradit et al. (2015), the prevalence of total hip and knee replacement in the US population is between 0.83%-1.52%? corresponding to a total of 7.2 million individuals at the time of when the research was conducted. It was also predicted that the prevalence of the operation would increase in the next few decades due to the increases in the elderly populations and the increase in demand for the operation among the young. Therefore, the department’s role and function is already significant in the scope of patient care and VBP, and is only going to increase with time.
B2. Goals
As it stands, Mayo’s VBP scores for complication rates are not below the national average rate, which is at 2.4% (CMS, 2020). They have a favorable pricing range however, which is less than the national average, currently residing at approximately 21,000 USD (CMS, 2020). Nevertheless, the organization should strive to lower these two parameters even further and apply for other VBP metrics to receive additional reimbursement. SMART goals for this department should be as follows:
- Reduce the complication rates below the national average, to 2% or lower, within the next 3 years;
- Further reduce patient expenditures to approximately 18,000 -19,000 USD within the next 3 years;
- Introduce customer satisfaction VBP rating within the
B3. Attaining Quality Outcomes in patient care over the next 3 years
- Promote a healthy lifestyle among populations to reduce the necessity of hip/knee replacements.
Although it may seem counterproductive at first, reducing the number of patients that need the operation can be beneficial for Mayo and the community in general. Due to exponential increases in patient numbers expected between 2020-2040, the clinic may not have the capacity to treat all of them (Cooper et al., 2016). Allowing patients to maintain themselves longer without the need for an operation would benefit everyone.
- Acquire state-of-the-art equipment and adopt evidence-based practices to improve the quality of operations.
Complications often result from the inability of surgeons to avoid them due to limitations of knowledge and equipment. Utilizing advanced methods of surgery should reduce comorbidities and improve patient safety and satisfaction (Cooper et al., 2016).
- Create a post-surgery routine for patients to prevent potential issues after the operations.
A lack of patient education often results in too much stress on the joints before the body is recovered (Cooper et al., 2016). Creating a physical, diet, and psychological regimen for the patient and ensuring they adhere to it would improve success rates.
Attaining Quality Outcomes in reimbursement over the next 3 years.
- Improving the quality of operations would result in less comorbidities and more reimbursements.
Mayo should have a vested interest in ensuring that patients do not suffer complications. Once that is achieved, reimbursements would follow, in addition to money saved on having to handle rehospitalizations.
- Achieving better patient-nurse relationship leads to better HCAHPS scores.
Having a doctor practice the healthy routine with the patient would result in better satisfaction scores, higher trust ratings, and VBP reimbursement. In addition, loyal patients are likely to choose Mayo over others.
- Lower patient flow would allow doctors to focus more on those they have. Quality increase = reimbursement.
Due to the expected increase in patient numbers with hip/knee problems, there is a danger of overcrowding. Should Mayo influence the community to be healthy, their nurses and surgeons will not suffer from being overworked, and would deliver better care. VBP would support this.
B4. Key Points
- Engaging the community to promote a healthy lifestyle would prevent hip/knee issues in the young and some of the older patients, preventing overcrowding in the future;
- Best training and best technology for surgery is a worthwhile long-term investment;
- Patient recovery routine would reduce readmission rates and result in reimbursements.
B4a. Marketing Key points
- Meetings;
- Newsletters;
- Training seminars.
B5. Ethical concerns
Ethical-clinical concerns: The proposed solutions are beneficial both from the perspectives of beneficence and non-maleficence, but also from the perspective of ensuring patient autonomy, which is a valid ethical concern (Mandal et al., 2016). At the same time, Mayo should concern itself with individuals that cannot afford an operation or a healthy lifestyle, based on the ethical principles of social justice.
Ethical-business concerns: Ethics and business clash when it comes to preventive care, which potentially discourages future demand. However, since Mayo is a nonprofit organization, its concerns lie solely in sustaining itself and serving the community rather than generating profit margins (Mandal et al., 2016).
B6 Coordinating Informational Events
- Public announcements;
- Newsletters and e-mails;
- Phone calls;
- Personal interactions.
- Briefings about healthy lifestyle for patients at risk;
- Educational and practical seminars on utilizing new equipment and treatment methods;
- Seminars on patient-nurse communications.
Timeline for the Proposed Plans
Cardiology Department
Year 1 (Plan)
Developing and running test runs of customized interprofessional collaboration programs, patient-nurse communication practices, and testing out if it is possible to increase doctor-patient times without making people wait.
Year 2 (Do)
Communicate the reasons for change to all members. Start implementing programs. Collect feedback from patients, start collecting statistical data.
Year 3 (Study & Act)
Analyze the data collected during the second year. Make adjustments to the programs if necessary. Implement changes and continue. Evaluate successes or failures by changes in VBP scores.
Respiratory and Pulmonary Care Department
Year 1 (Plan)
Generate public awareness, anti-self-treatment, and nurse communication strategies customized to the community. Contact other public organizations (Schools, churches, etc.,) to have them facilitate communication. Find coaches and trainers for nurses.
Year 2 (Do)
Start working with the community inside and outside of the hospital. Nurses and doctors involved should be briefed and prepared by now. Implement the strategies developed during year 1
Year 3 (Study & Act)
Analyze the data collected during the second year. Make adjustments to the programs if necessary. Implement changes and continue. Evaluate successes or failures by changes in VBP scores.
Department of Orthopedic Surgery
Year 1 (Plan)
Create an evidence-based program for the community and patients. Study the newest practices in hip/knee surgery. Analyze and acquire the necessary equipment.
Year 2 (Do)
Start utilizing the new equipment and practices to improve the quality of care. Send nurses out into the communities to promote healthier lifestyle. Have patients undergo the regimen developed for them during year 1.
Year 3 (Study & Act)
Analyze the data collected during the second year. Make adjustments to the programs if necessary. Implement changes and continue. Evaluate successes or failures by changes in VBP scores.
Executive Summary
Section C1
Mayo Clinic is one of the best hospitals in the US, which implements a VBP system in departments, where the connection between quality of care, expenditures, and patient safety/life are most prominent. Mayo recognizes that providing high quality of care is not only beneficial to patients and communities, but also allows for a better return of investment through reimbursement, cutting costs, and reputational gains.
Three VBP parameters that are present and should be focused upon in the proposed strategic plan are nurse-patient communication, interaction between the hospital and the community, and improving the hospital’s internal standards of care.
Nurse-patient communication is important to VBP, as it improves trust and patient satisfaction. In addition, it makes the patient more likely to comply with the prescribed treatment, thus increasing the effectiveness of care provided to them.
Community-based awareness programs affect VBP indirectly by reducing the number of severe cases in the community and the hospital (thus improving success rates), increasing the hospital’s visibility and popularity (thus allowing the hospital to achieve economy of scale and reduce prices), and helping manage the potential workflow coming into the place.
Internal quality measures range from increase in practical knowledge to the application of new methods and equipment to directly affect VBP by improving the quality of care.
As Mayo is a non-profit organization, it follows its ethical responsibility to apply VBP factors, create value for customers, and see to it that the principles of beneficence, non-maleficence, autonomy, fidelity, and justice are upheld.
Section C2
The chosen departments to participate in deeper implementation of VBP in the next three years are the cardiology department, pulmonary and respiratory care department, as well as the department of orthopedic surgery. Its leaders and personnel are to be made ready to implement the solutions proposed in the strategic plan.
Before changes are implemented, all staff must be made aware of the goals, objectives, and rationale for the plan. The projects will rely on Lewin’s Freeze-Unfreeze model to overcome potential resistance to change (Nelson‐Brantley & Ford, 2017).
Workgroups of nurses and nurse leaders must be assembled in order to develop programs for internal change as well as customized practical guidelines for new practices and community-based activities.
Should hospital’s own expertise not be enough to facilitate training on their own, 3rd-party expert groups will be involved to provide the necessary expertise and assistance (Xu, 2016). An example of such would be the procurement and operation of the advanced surgery equipment for hip/knee operations for the department of orthopedic surgery.
Leaders of individual departments are to contact public community organizations and recruit them into the effort of spreading the information to the general populace.
Surgery Department objectives: Promote interprofessional collaboration, improve doctor-patient communication during long hospital stays, improve the quality of diagnosis.
Pulmonary and Respiratory Care Department objectives: Improve public awareness about pneumonia, reduce self-treatment practices among the general population, improve nurse-patient communication.
Department of Orthopedic Surgery objectives: Acquire new equipment and better evidence-based practices, engage the community to promote healthy lifestyles, provide comprehensive after-treatment plans for patients.
Section C3
Training and education plans will differ from one department to another based on the objectives outlined in the previous section.
Surgery department will not participate in any community-based interventions. Their objectives are to be completed by focusing on development of training programs for themselves and committing to them.
Interprofessional collaboration can be achieved by either on-site training or running mock drills for teams in order to increase understanding and communication fluency (Xu, 2016). The program can be developed within the hospital by senior nurses and experienced team members based on personal experiences as well as evidence-based materials.
Nurse-patient communication can be improved based on the application of social and cultural competence theories of nursing (Xu, 2016). Nurses will be briefed on the tenets of those, provided examples of them being used in a hospital setting, and will engage in mock sessions of interaction before being allowed to practice their knowledge on patients.
Quality diagnosis improvement is to be achieved by reducing the workload on nurses and doctors, allowing them more time per patient. This can be achieved by rescheduling and observing how well would that work out.
Pulmonary and respiratory care department will contact schools and other public organizations to use as vehicles to spread awareness about pneumonia and self-treatment practices. The materials will be prepared by the hospital and will be based on peer-reviewed and official sources. Nurse-patient communication training will follow the same pattern as in the section above.
Department of Orthopedic Surgery will contact a 3rd party company specializing in producing surgery equipment and training personnel in using it. In addition, surgeons and staff will attend seminars and training provided by other medical organizations to improve their own skills and knowledge of hip/knee replacement surgeries (Xu, 2016). Community and patient-related objectives will follow the outline as described for other groups.
References
Centers for Disease Control and Prevention (CDC). (2020a). Heart disease facts. Web.
Centers for Disease Control and Prevention (CDC). (2020b). Pneumonia.Web.
Centers for Medicare & Medicaid Services (CMS). (2012).Frequently asked questions: Hospital value-based purchasing program.Web.
Centers for Medicare and Medicaid Services (CMS). (2020). Hospital profile. Web.
Cooper, Z., Rogers Jr, S. O., Ngo, L., Guess, J., Schmitt, E., Jones, R. N.,… & Inouye, S. K. (2016). Comparison of frailty measures as predictors of outcomes after orthopedic surgery. Journal of the American Geriatrics Society, 64(12), 2464-2471. Web.
Gibson, V., & Waters, D. (Eds.). (2016). Respiratory care. New York, NY: CRC Press.
Haghighathoseini, A., Bobarshad, H., Saghafi, F., Rezaei, M. S., & Bagherzadeh, N. (2018). Hospital enterprise architecture framework.International Journal of Medical Informatics, 114, 88-100. Web.
Mandal, J., Ponnambath, D. K., & Parija, S. C. (2016). Utilitarian and deontological ethics in medicine. Tropical Parasitology, 6(1), 5-7. Web.
Maradit, K. H., Larson, D. R., Crowson, C. S., Kremers, W. K., Washington, R. E., Steiner, C. A., … Berry, D. J. (2015). Prevalence of total hip and knee replacement in the United States. The Journal of Bone and Joint Surgery-American Volume, 97(17), 1386–1397. Web.
Mayo Clinic. (2020). Mayo Clinic ranked No. 1 hospital nationwide by US news & world report. Web.
Meaney, P. A., Bobrow, B. J., Mancini, M. E., Christenson, J., de Caen, A. R., … Bhanji, F. (2013). Cardiopulmonary resuscitation quality: Improving cardiac resuscitation outcomes both inside and outside the hospital: A consensus statement from the American Heart Association. Circulation, 128(4), 417–435. Web.
Nelson‐Brantley, H. V., & Ford, D. J. (2017). Leading change: A concept analysis. Journal of Advanced Nursing, 73(4), 834-846. Web.
Xu, J. H. (2016). Toolbox of teaching strategies in nurse education. Chinese Nursing Research, 3(2), 54-57. Web.
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