420 ■ III: ROLE FUNCTIONS OF DOCTORAL ADVANCED NURSING PRACTICE
of health care expenditures (Berwick & Hackbarth, 2012). These authors delineate
six categories of wasteful behavior: overtreatment, lack of care coordination, failure
in care delivery processes, administrative complexity, pricing failures, and fraud and
abuse. Another common theme in post- ACA’s discussions is the cost of medication
errors in acute care settings. While most patients have not read the IOM’s trilogy on
patient safety, they know that medication errors are more than costly; they can cause
death (IOM, 1999). Nationally, there are many efforts within the health care, medical,
nursing, pharmacological, technological, and accreditation communities to improve
medication practices and make hospitals safer places. At the governmental level,
beginning in 2009, Medicare changed its hospital payment system and withheld addi-
tional payments to hospitals when patients were found to have acquired infections,
pressure ulcers, or injuries from falls during their hospital stays (Watcher, Foster &
Dudley, 2008).
Insurance plans compete on product design and price. Health care is a lucrative
business; capitalism rewards the most successful health entrepreneurs. Market forces
are influenced by supply and demand, not vulnerability, poor health status, need, or
poverty. Cost plays an important role in the American health care establishment because
health care affects all sectors of the economy. Berwick and Hackbarth (2012) are not
alone in thinking that competition among health care providers will bring down costs.
Yet, this assumption about the health care marketplace has yet to produce a health care
delivery system that improves health status, enhances the quality of care, and lowers
health care costs in America.
POPULATION HEALTH AND BUILDING A CULTURE OF HEALTH CARE
Although population health has been a mantra in public health circles for years, it
is now identified as an Essential VI in the AACN’s Essentials of Doctoral Education
for Advanced Nursing Practice (AACN, 2004; Marmot, 2005). Interest in population
health speaks about a global awareness that treatment of disease provides only a par-
tial answer to improving health status of individuals and populations (Starfield &
Shi, 2002). The social, environmental, and living situations that determine health are
increasingly linked to improved health status, reduced health disparities, and cost
control (Centers for Disease Control [CDC], 2015). The IOM (2016) recently published
a high-level framework to educate future health providers about the importance of the
Social Determinants of Health. In 2013, the RWJF working with the RAND Corporation
embarked on an ambitious project, a Culture of Health Initiative (Acousta et al., 2016).
Their vision was expressed as six priorities: bridging health and health care; build-
ing demand for healthy places and practices; eliminating health disparities; engaging
business for health; strengthening vulnerable children and families; and leadership
(RWJF, 2015). Plough (2015) describes this initiative as a challenge for the public
health workforce. Essential VI , Clinical Prevention and Population Health for Improving
the Nation’s Health , identifies DNP- prepared APNs as leaders in population health
(AACN, 2004). Although the DNPs’ role in promoting and transforming health care
into a culture of health is yet to be articulated in the nursing literature, the AACN’s
(2004) essentials document and the newly released AACN (2016a) report on Escalating
Academic Nursing’s Impact on Transforming Health and Health Care are compatible with
this vision. Plough’s related call to learn how to use big data sets is also very relevant
to any nurse leader or researcher who aspires to analyze patterns of population health
in real time.