Printer Friendly Version / PDF Version
(These documents are 33 pages long)

INTRODUCTION

I. BACKGROUND
In 2001, a "Las Vegas Region Comprehensive Labor Report" was completed and published by the Nevada Development Authority (NDA). The report was funded by a consortium of public entities and 14 private sector companies.

The report documented the growth industries in the region and the labor force needed to staff their respective companies. One of the fastest and most important growth industries in our region is the medical and healthcare industry cluster.

Consistent with Southern Nevada's rapid population growth, area hospitals continue to expand their facilities and services to meet the needs of our new residents and visitors. Total hospital patient beds in Southern Nevada total nearly 3,100 and the area's 11 major hospitals employ over 14,000 medical and support staff. In total, 40,000 people are employed in the medical and healthcare industries in Southern Nevada.

Five new hospitals are planned in the area in the next two to five years. By the year 2008, it is projected that we will have openings for an additional 4,740 nurses, which is a 62% increase for Registered Nurses and a 59% increase for Licensed Practical Nurses.

Nevada currently ranks last in the country in the number of nurses per 100,000 people. The U.S. Department of Health and Human Services reported Nevada's nurse-to-population ratio is 520 nurses per 100,000 people, compared to the national average of 786 nurses per 100,000.

The rise of professional liability insurance premiums is a very serious issue for all Nevadans. Currently, physicians are being forced to leave the state and establish their practices in more business friendly environments. President Bush and Congress are promoting new regulations at the federal level. Nevada Legislature is also struggling with this issue in its current session. It may be more difficult to attract the level of physicians that we need to make this region a "center of excellence" if there is a perceived, or real issue, with professional liability insurance coverage.

II. MEDICAL INDUSTRY COALITION
One of the significant recommendations of the Comprehensive Labor Report was to form a Medical Industry Coalition to develop strategies and new partnerships to help our medical and healthcare industries grow. To devise such a plan, medical and healthcare professionals were recruited by the economic development entities within Clark County. In 2002, the Medical Industry Coalition met quarterly to hold focus groups and suggest priorities and recommendations for improving their current and future workforce, techniques for collaboration, legislative issues and marketing/public relations opportunities.

Today, the Medical Industry Coalition totals approximately 150 professionals, and includes hospital CEOs, university administrators, nursing school educators, private practitioners, local businesses, economic development professionals and state and local politicians. This report is their attempt to build a collaboration of medical, academic, Chambers of Commerce, and government officials and focus on strategies to complement local and federal initiatives to assist in the growth of our healthcare industry.

III. INDUSTRY COALITION CONCEPT
The Medical Industry Cluster Group was created by using successful models for industry clusters designed by the U.S. Economic Development Administration and National Governors Association.

The Economic Development Administration last year sponsored a study to identify America's industry clusters. The study identified 19 separate types of clusters within four major groups in the country. Health services was one of the primary industry clusters.

These industry clusters are the engines of the U.S. economy. In total, they employ 57% of the U.S. workforce. They generate over 61% of the nation's output and produce 78% of the nation's exports.

The Southern Nevada Medical Industry Coalition reviewed cluster and collaboration models from Connecticut, Minnesota, Arizona and San Diego. Four general themes were consistent within the cluster strategies from each of these regions:

1. Organizing/prioritizing the delivery of government services to its most important growth industries;
2. Strengthening formal networks of business, government and education around cluster industries (enhanced communications/ strategic alliances);
3. Targeting public investments (legislation, R&D, etc) around their state's top clusters;
4. Developing outstanding human resources (workforce) for the cluster
   • education resources
   • training assistance
   • retention efforts
   • recruitment strategies

• American College of Healthcare Executives (report entitled Futurescan 2002)
• Nursing's Agenda for the Future (a report by 21 national nursing organizations, April 2002)

The Futurescan report, which highlights eight major trends or themes in the nation's healthcare systems, will be discussed in Chapter 1 of the report.

The Nursing's Agenda for the Future, discusses ten distinct domains, or areas of focus, for their work to bring about positive changes for nursing and the healthcare system. The nursing agenda is discussed in Chapter 2 of this report. Workforce issues were the number one topic for our local Medical Industry Coalition and nurses were the highest priority within these discussions.

IV. PLAN OF ACTION
The final chapter of this report will focus on recommendations for action and collaboration The plan of action contains strategies from the Nursing's Agenda for the Future and separate recommendations developed by the Medical Industry Coalition's focus meetings.

The goal of the plan is to have each of our collaborative partners assist in the implementation of the report. Substantial work has already been started by our local hospitals and academic leaders. The medical industry recognizes that their efforts can not occur in isolation. To this end, the medical community is engaging additional external stakeholders to help with this effort. Our region's economic development future is directly tied to our success in helping our region's medical industry grow.

CHAPTER 1:  A NATIONAL FORECAST OF HEALTHCARE TRENDS
2002 – 2006

The Medical Industry Coalition reviewed a very important document entitled Futurescan 2002, published by the American College of Healthcare Executives. This report helped build a foundation for understanding the dynamics of the healthcare industry on a national level and how we should look at these trends from a local perspective.

Futurescan 2002 is based in part on a national survey of 374 healthcare CEOs, executives, strategists, marketers and communicators. The report was also co-sponsored by the Society of Healthcare Strategy and Market Development of the American Hospital Association.

The overview of the report suggests that American healthcare is poised for growth in both volume and revenues. This growth is powered by population expansions, the aging of the baby boom generation and new technology. However, with these rising healthcare expenditures, there will be a return of medical inflation, with double-digit increases for employers, most cost ? shifting to consumers, and the threat of more government regulations.

Eight major themes were developed in the report:

• The consumer choice market
• Growth
• The post-managed care era
• Medical cost inflation
• Workforce shortages
• The quality imperative
• Physician relations
• Terrorism

A. Consumer – Choice: Summary
In a complete reversal of the assumptions of the 1990s, consumers now have a virtually unlimited choice of hospitals, physicians, and medical technology. Gatekeepers and prior authorization have given way to call centers and internet-based health information. Direct-to-consumer marketing is firing up consumer demand for the latest drugs and treatments. Consumers are paying more for drugs and health coverage, but the tradeoff is that services are affordable for most consumers. The market is every consumer's dream, and every provider's favorite scenario.

Consumer – Choice: Trends

1. As managed care's power wanes, insured private patients can gain access to the hospitals, doctors, and treatments of their choice.
2. Consumer access to health information on the internet will direct patients to providers that offer the most interactive websites and online communications.
3. Customer relationship management (CRM) uses databases to profile consumers who are most likely to need a health service or provider.
4. Consumers will pay more out-of-pocket, as employers and health plans shift costs to patients.
5. Innovative design and exemplary facilities can provide a competitive advantage while lowering costs and improving outcomes.
6. In a consumer-choice market, providers must have "brand names" that are widely recognized for quality and satisfaction.
7. A hospital's patient satisfaction ratings may be the best predictor of future success and profits.

B. Growth: Summary
The surprising challenge of 21st century healthcare is coping with rising demand and capacity constraints. Volume indicators are trending upwards for both inpatient and ambulatory services. Downsizing and taking beds out of service in the 1990s have produced a capacity shortage in many facilities, especially in hospitals in high-growth locations, in "must-have" hospitals popular with consumers, and in safety-net hospitals serving the poor.

Growth: Trends

1. The 15-year decline in volume indicators is reversing, leading to bed shortages and the need to expand.
2. Many hospitals are launching long-overdue construction of new inpatient, surgical, and critical care capacity.
3. Emergency departments (EDs) are collapsing under a flood of demand, with many EDs on "diversion" until ED capacity is expanded.
4. Hospitals are experiencing a rising tide of seriously ill patients who need more resources (costs) and time (length of stay).
5. Facing an unexpected surge of demand, many hospitals are making new master-site facility plans for capacity expansion.
6. Meeting the "capacity crunch" and upgrading information systems requires capital, operational profits, and higher bond ratings.
7. Hospitals are focusing their capital investments and marketing budgets on market-leading centers of excellence, including heart, cancer, women's, neuroscience, and emergency care.
8. The first products of the genomic revolution will arrive in the next five years, altering the structuring of healthcare in profound ways.

C. Post-managed care: Summary
Health costs are rising across America and employers are fuming. Managed care is not working, the workforce is aging, and employers could lose ERISA protection for company health plans. Most employers are facing 8% to 12% increases in health plan premiums. HMOs may not be a solution to rising Medicare costs, and dozens of plans exited the managed Medicare market in 2001, while seniors still in HMOs were asked to pay higher premiums and copayments. Can health plans and providers cooperate in the future, or will they battle over reimbursement and control?

Post-managed care: Trends

1. The rapid rise in health benefits costs is alarming many employers.
2. Health plans are experiencing higher costs – "medical loss ratios" – pushing up premiums and consumer co-pays.
3. Plans and employers are using short-term "fixes" like increased consumer cost-sharing and fewer choices of plans.
4. Major employers are moving aggressively to reduce their health benefit costs by cost-shifting and negotiating for lower rates with health plans.
5. Some dissatisfied employers may drop their HMOs and insurers to contract directly with provider organizations.
6. Businesses have another solution to rising health plan premiums – "direct contribution" – eliminating employer sponsorship of health benefits.

D. Cost Inflation: Summary
The restraints of managed care are wearing off and medical costs are rising above the CPI. An economic recession could dampen health spending, or increase it in the short-term if laid off workers use COBRA health benefits to address postponed health problems. Hospital revenues will rise, but increases in the top-line may not increase profits in all hospitals. Rural facilities dependent on Medicare and Medicaid payments fear that government will not pay for the increasing costs of care in rural areas, including labor costs and HIPAA compliance.

Cost Inflation: Trends

1. Health costs could grow at rates of 6% to 8% percent in the next two to five years, driven by consumer demand, technology, and the waning power of managed care.
2. Increased healthcare expenditures on a national basis will translate into strong growth of top-line revenues for hospitals, physicians, and suppliers.
3. Wall Street's falling stock prices are affecting non-operating income, reducing the "cushion" of investments that assist hospital viability.
4. Rural hospitals in "exurbia" near metro areas are enjoying a boom, but financial vulnerability continues in small, remote facilities.
5. End of the federal budget surplus may doom prospects for a Medicare drug benefit, and could even revive the Medicare Balanced Budget Act.
6. As economic growth stalls, corporate layoffs will increase the number of uninsured, possibly to 45 to 50 million people.
7. Inflation and recession could combine to force millions into uninsured status and revive the health reform debate.
8. The cost of HIPAA compliance may exceed $22 billion, even under an extended deadline.

E. Workforce Shortages: Summary
Labor shortages threaten to derail the expansion of the nation's $1.3 trillion health industry in the decade ahead. A chronic shortage of staff is impairing the ability of U.S. hospitals to respond to rising demand for inpatient beds, and emergency and critical care. Short-term strategies such as sign-on bonuses are only quick-fixes. For the long-term, "magnet hospitals" recognize that staff loyalty and retention are culture issues, not compensation issues. Today's physician surplus may rapidly turn to a physician shortage.

Workforce Shortages: Trends

1. A crisis of capacity is emerging, with hospitals " on diversion" because emergency rooms, medical-surgical units, and critical care units are full.
2. "Magnet hospitals" are model employers with low nursing turnover and high morale.
3. The recession of 2001-2002 could help ease the nursing shortage, and bring back some 500,000 nurses not working in healthcare today.
4. Hospitals are investing in technology solutions such as handheld electronic medical records that could free up nursing staff time for patient care.
5. Staffing, wages, quality, and job security are key issues as trade unions seek to expand representation of health workers.
6. Concern is growing that staffing shortages could have a negative impact on quality, leading to regulation of staff-patient ratios.
7. Providers, educators, and legislators must act soon to increase the training "pipeline" with scholarships, training grants, and loan forgiveness programs at federal and state levels.

F. Quality Imperative: Summary
Recent reports by the Institute of Medicine, To Err is Human (1999) and Crossing the Quality Chasm (2001), have focused national attention on the issues of patient safety and medical errors. Major employers, provider organizations, and government agencies are taking leadership in promoting quality outcomes and ensuring patient safety. National standards, mandatory reporting of errors, and bonuses for quality performance are all being considered.

Quality Imperative: Trends

1. Employer coalitions like the Leapfrog Group are becoming a strong market force for quality.
2. Employers are joining with health plans to reward hospitals that promote quality, but providers are skeptical this trend will be significant.
3. Hospitals are stepping up their investments in technology like computerized order entry systems to promote quality outcomes and improve patient safety.
4. The Leapfrog Group is strongly encouraging hospitals to employer full-time "intensivist" physicians to manage critical care patients.
5. Creation of a national medical error database has been recommended by the Institute of Medicine; federal or state legislation is considered likely.
6. The Dartmouth Atlas of Healthcare is becoming a national model for statistical analysis of variation in cost and quality.
7. Hospitals are developing quality improvement plans that help ensure patient safety while promoting best-of-breed clinical outcomes and top-quartile patient satisfaction.

G. Physician Relations: Summary
The decline of managed care is rendering many hospital-sponsored physician organizations – PHOs, MSOs, IPAs – obsolete. Many hospital-owned physician groups have been spun off or restructured to minimize subsidies. "Retro" strategies that focus on joint ventures and the traditional medical staff are lower-cost and lower-risk than the employment model. Hospitals and their doctors are returning to arms-length relationships, collaborating in some areas and competing in others.

Physician Relations: Trends

1. A medical staff revival is occurring, as large medical groups and IPAs flounder or go bankrupt.
2. America may be facing a physician shortage, with not enough doctors to staff new programs and facilities.
3. Market-savvy hospitals are developing strategic plans to grow the medical staff, identify key shortage areas, and target clinical services for physician recruitment.
4. A revival of hospital-physician competition is occurring in the wake of the breakup of many hospital-employed physician groups.
5. Medical demographics are shifting dramatically as the training pipeline produces growing numbers of women physicians.
6. Physician acceptance of the internet is rising rapidly, paving the way for telemedicine, electronic medical records, and virtual medical staffs.

H. Terrorism: Summary
America's worst public health nightmare has arrived. Bioterrorism and aerial attacks have occurred on U.S. soil. No longer can the United States be complacent that terrorism will not occur within its boundaries. The dangers of biochemical and even nuclear attacks are boosting visibility and funding for public health organizations at the federal, state, and local levels.

Terrorism: Trends

1. Hospitals across the nation are ill-prepared to handle large numbers of mass casualties, but since September 11, over 90% of hospitals plan to spend more on disaster preparedness.
2. Health authorities are scrambling to build stockpiles of drugs and supplies, and will need billions in aid to ready America's hospitals to respond to terrorism.
3. A national network of strategically located emergency departments, trauma, and public health units is being mobilized, but every hospital is preparing to respond to terror.
4. Public education is needed to reduce fears, recognize symptoms, and seek timely medical care.
5. Cybersecurity is a growing issue for consumers and health officials, but hospitals are improving the security of electronic records and information systems.
6. Bioterrorism has raised the visibility of public health, leading to an increased federal funding to improve command-and-control systems.

CHAPTER 2:  NURSING'S AGENDA FOR THE FUTURE
The second building block in our regional Medical Industry Coalition's research was the national report entitled Nursing's Agenda for the Future. Local workforce issues were some of the major topics of discussion at the Coalition's recent focus group meetings and the need to tackle the local nursing shortage was high on our local agenda similar to the nation's problems.

The Nursing's Agenda for the Future was an excellent starting point to understand the viewpoints of 21 national nursing organizations and their recommendations for improvement. Their report outlines a future vision for nursing and identifies 10 distinct domains, or areas of focus, for their work to bring about positive changes for nursing and the healthcare system.

The 10 domains were refined and narrowed during National Summit discussions, based on work done by other coalitions and from priorities identified in research literature, in particular, the recent Institute of Medicine study, Crossing the Quality Chasm: A New Health System for the 21st Century.

The 10 domains are:

1. Leadership and Planning · Economic value
2. Delivery systems · Work environment
3. Legislation/regulation/policy · Public relations/communication
4. Professional/nursing culture · Education
5. Recruitment/retention · Diversity

Overview
As healthcare's frontline professionals, nurses practice in virtually all healthcare settings and communities across our country. They number 2.7 million and rank as the nation's largest healthcare profession, and their professional commitment runs deep. Nursing is a rewarding profession that offers diverse career paths for men and women. Experienced nurses are in demand for a wide range of job opportunities and enjoy both national and international job mobility.

However, there is a growing disparity between the supply and demand of nurses that is leading to a potentially overwhelming nursing shortage and healthcare crisis. This shortage reflects a confluence of powerful forces including changing demographics, ever-decreasing resources and increased demands on the healthcare system and professionals, a declining social value on nursing as career, and changes in career opportunities. This nursing shortage crisis, when compared to previous workforce shortages, has been characterized as more severe and complex and, therefore, poses a significant threat to the nation's health.

While the healthcare system is very dependent on nurses, their contributions receive little recognition in many arenas. Nurses are also frontline providers in long-term care, home care, primary and preventive care, health promotion and public health. Yet, nursing's role in driving decision-making around healthcare remains limited. The changing economics of healthcare reimbursement, along with other pressures, such as mounting documentation requirements and stressful working conditions, have contributed to nurses' diminishing sense of career satisfaction. This has resulted in a growing and ever-worsening nursing shortage, with a clear need to improve the recognition of nurses' value and the image of the profession.

Intent on tackling the systemic issues that have resulted in this serious nursing shortage, the nursing community came together to address the problem. In mid-2001, the American Nurses Association (ANA) convened a steering committee of national nursing organization representatives to work swiftly to develop a comprehensive strategic and tactical plan, through a nursing summit.

The American Nurses Foundation awarded a grant of $100,000 to help fund a Call to the Nursing Profession summit. Nursing leaders began to identify the scope of the work required to attain nursing's desired future state. Then, they narrowed that work to the vital few strategies and objectives that would advance nursing's vision for the future by quantum leaps, rather than by small, incremental steps.

As participants in the national summit developed their plans in each of the 10 domains, common themes emerged: collaboration at all levels within nursing, developing nurses' leadership and public communication skills, stepping up collaborations with policy-makers and business leaders to assure that nursing's voice is heard and will help shape the future, and communicating successes to the public.

Focus areas for the plan follow, with strategies outlined. Each domain's work is guided by co-champions, organizations that will monitor the implementation and results of work plans.

It is also anticipated that groups external to nursing will seek to participate in actualizing the Nursing's Agenda for the Future plan, as well as enhance it with the resources that they could provide to acknowledge nursing's value and secure the role of the registered nurse in healthcare. Our regional Medical Industry Coalition is one of those external groups and plans to participate in its implementation.

A. Leadership and Planning
Leadership and planning are critical to the successful development and implementation of a strategic plan to achieve nursing's desired future state. Both are required to coordinate and monitor progress on the agenda, engage external stakeholders and secure additional resources.

Four strategies were identified to achieve the vision and one of these was identified as the primary or driving strategy. They are:

1. Collaboration and accountability guide nursing in the development and implementation of its own plan: Nursing's Agenda for the Future.
2. Unified commitment within nursing leads to success and a sense of shared accountability in accomplishing Nursing's Agenda for the Future.
3. Decision-making and positive change are driven by reliable data.
4. Well-prepared nurse leaders assume positions of power and influence on key decision-making bodies throughout the profession and healthcare.

Co-champions:

• The American Nurses Association
• The Nursing Organization Liaison Forum

B. Economic Value
How society values nursing must change to make major strides in recruiting and retaining nurses. Educating the public about nursing's pivotal role in healthcare will be basic to involving nurses in healthcare policy formulation and in key business decisions that affect nursing's future.

Five strategies were identified:

• Leadership is provided to leverage economic influence.
• A united profession achieves its key economic goals.
• The economic value of nursing is better understood through the use of quantified nursing data.
• Innovative compensation strategies are widely implemented.
• New and existing economic resources are applied to support nursing education.

Co-champions:

• American Association of Nurse Anesthetists
• American Psychiatric Nurses Association

C. Delivery Systems/Nursing Models
Nurses will aim to influence how healthcare is delivered through work with nurse educators, policy-makers and business leaders, armed with sound research on practice models.

Five strategies were identified:

• Design integrated practice models. "Integrated" practice models are: interdisciplinary, nurse-led (or co-led), applied across the areas of nursing education, practice, research and policy, and blended across practice settings.
• Nursing practice management is redefined and reshaped for positive change.
• Strategic partnerships are created both within the profession and among influential outside groups.
• Nurse leaders contribute to shaping both public and health policy.
• Efforts are successful to advance the value and image of nursing.

Co-champions:

• American Academy of Nursing
• Association of Women's Health, Obstetric and Neonatal Nurses

D. Work Environment
In this area so basic to nursing's future, members of the profession will work to improve nurses' work environments so that quality patient care is optimized and professional nursing staff is retained.

Six strategies were identified:

• Nurses have an effective voice in decision-making.
• Professional development is fostered for nurses in all roles.
• Sound methods are identified and utilized to assure appropriate staffing.
• Collaborative work relationships are actively enhanced and promoted.
• Support is demonstrated for quality of work life and safety at work.
• Practices are defined and implemented that produce quality patient care.

Co-champions:

• American Nurses Association
• American Organization of Nurse Executives

E. Legislation/Regulation Policy
New collaborations will increase nursing's role in shaping public policy.

Five strategies were identified:

• Nurses are policy-makers at the local, state, national, and international levels.
• Nursing collaborates with all stakeholders for the development of public policy.
• Reliable data support all health policy formulation.
• Universal access is ensured through the delivery of outcome-driven quality healthcare services.
• Health policy is congruent with standards for nursing education and practice.

Co-champions:

• National Council of State Boards of Nursing
• Oncology Nursing Society

F. Public Relations/Communication
Nursing's pivotal role in healthcare will be demonstrated on a regular basis to various public entities outside of the profession.

Four strategies were identified:

• Effectively communicate nurses' impact on the quality of care and health outcomes.
• Advance a valued, respected image of nursing.
• Convey nursing's influence in healthcare delivery and public policy-making.
• Portray nursing as a top career choice.

Co-champions:

• Emergency Nurses Association
• Sigma Theta Tau International, Honor Society of Nursing

G. Nursing/Professional Culture
Asserting nursing's high standards of professional practice, education, leadership and collaboration will enhance professionalism, image and career satisfaction.

Five strategies were identified:

• Professionalism is supported by infrastructures for education and leadership development.
• Nurses promote a healthy environment of respect and caring for one another.
• Nurses believe in, articulate and demonstrate the value of nursing.
• Collaboration is a professional imperative.
• Nurses achieve substantial external influence and recognition for their value to society.

Co-champions:

• American Association of Critical-Care Nurses
• Infusion Nurses Society

H. Education
Stakeholders in this area will focus on reexamining and reshaping nursing education to improve nursing practice, enhance nursing's image and better meet patient care needs.

Five strategies were identified:

• Establish congruence between the educational enterprise and societal needs.
• Enrich the high caliber of nursing faculty.
• Attain clarity in education about nursing roles and scopes of practice.
• Work for universal excellence in nursing education.
• Promote the value of nursing education to the profession and the public.

Co-champions:

• American Association of Colleges of Nursing
• National League for Nursing

I. Recruitment/Retention
Building on work in other domains, professional opportunities will be enhanced to attract and sustain excellent nurses for long, rewarding careers.

Five strategies were identified:

• Professional/career development opportunities are evident across the career span.
• Funding is secured for creative educational initiatives that support nurses across the career span.
• Nursing is seen as a highly desirable and appealing career choice.
• Nurses develop professional practice models and work environments that ensure career satisfaction.
• Comprehensive recruitment and retention strategies demonstrate nursing's strong public image and appeal to a diverse population.

Co-champions:

• Association of periOperative Registered Nurses
• American Nurses Credentialing Center

J. Diversity
The profession aims for diversity that reflects the patient population, in order to better meet population needs.

Five strategies were identified:

• Increase health system leadership that reflects and values diversity.
• Create diversity and cultural competence through educational programs and standards in the workplace.
• Increase diversity of faculty, students and curricula in all academic and continuing education.
• Focus recruitment and retention programs to greatly increase diversity.
• Target legislation and funding for diversity initiatives.

Co-champions:

• National Black Nurses Association
• National Student Nurses' Association, Inc.

Summary NEXT STEPS AND THE CALL TO THE NATION
Nursing recognizes that it must look beyond its ranks to help resolve critical problems that devalue the profession and leave us all vulnerable to a public health crisis. American healthcare is essential to each of us, and nursing is one of the most important aspects of our healthcare system. Achieving nursing's desired future state will require input and collaboration from a variety of communities, or stakeholders, in our society.

With compelling evidence signaling a crisis of historic proportions, the time to tackle this problem is now, before the "baby boomers" increase their need for healthcare services. The size of the population older than 65 is projected to double over the next 30 years, growing to 70 million by 2030. In addition, those over age 85, who tend to require more healthcare services than the young, are the fastest growing segment of this population. Such a burgeoning population of elderly promises to place unprecedented demands on a faltering system that threatens to crumble under the burden of increased need.

Even before growing numbers of elderly are factored into the mix, patients express concern about the impact of a nursing shortage. Results of a Harris Poll showed that more than half of Americans believe the quality of healthcare that people receive is affected "a great deal" by a shortage of nurses. In the same poll, only 4% of people said that the quality of healthcare that people receive is not affected by a nursing shortage. (Harris Poll, July 7, 1999). More recently, a national public opinion poll found that 93 percent of Americans believe that the nursing shortage jeopardizes the quality of healthcare. (Penn, Shoen, & Berland, December 2001).

Successfully resolving this crisis in healthcare, ensuring both healthy patient outcomes and a healthy, viable healthcare system, is only possible by setting aside elusive, short-term gains, and investing in long-term results. Therefore, an immediate, significant investment must be made in cultivating a stable, skilled workforce.

CHAPTER 3 - MEDICAL INDUSTRY COALITION
As noted in the Introduction of this report, the Southern Nevada Medical Industry Coalition began its collaborative efforts in 2002. The genesis of the concept came from the Economic Development Directors of the cities of Henderson, Las Vegas and North Las Vegas, along with the Nevada Development Authority.

From an economic development perspective, the medical and healthcare industry has been noted as one of the top growth industries for our region. This growth is both in employment and facilities. In addition, it is one of the highest priorities from a "quality of life" perspective for new companies relocating to our region and the retention of existing businesses.

The current Medical Industry Coalition contains over 150 outstanding individuals and is growing in size. Membership is open to all stakeholders and new members are being recruited each month.

At our second meeting on August 15, 2002, the Medical Industry Cluster Group discussed the challenges and opportunities to grow our local medical and healthcare industry. Listed below are the outcomes of this meeting:

1. Challenges
• Nurses are expected to work harder, smarter with fewer opportunities for higher salary increases.
• Issues with retention, recruitment and supply of medical professionals.
• Clark County's population growth is compounding our challenge of finding adequate professionals.
• Medical businesses are losing money and profits due to a lack of nurses (which also creates ethical issues on adequate care).
• A lack of nurses was discussed in detail, but physicians and clinical pharmacy staff were mentioned, too.
• Government (legislative mandates) is hurting medical businesses by adding extra costs.
• In Clark County's cost-of-living index, medical costs are higher here than the national average.
• 500,000 nurse shortage nationwide (Wall Street Journal).
• Most healthcare institutions are paying big dollars for recruiting new staff.
• Retention is also a major issue beyond just supply and recruitment.
• Respect for nurses by the community and doctor community is lacking.
• State certification issues are tough to get around in creating new alternatives for nursing programs.
• Articulation issues with college credits in Nevada for nursing students.
• Need additional tort reform; we've gone through Phase I recently, need more phases.
• The rising and unreasonable costs of professional liability insurance premiums which are forcing our physicians to leave Nevada.
2. Opportunities
• Change the "image" of nursing to a more positive one.
• Seek the assistance of government, chambers, economic development, who have marketing expertise to help with this strategy.
• Need to be more aggressive in our marketing of Southern Nevada to recruit medical professionals (doctors, nurses).
• Recruit more males into nursing.
• Johnson & Johnson is spending large dollars in marketing now (potential to partner/leverage).
• We could seek more grants/funding from state & federal government (partner more on applications).
• A creative program of UNLV working with Ukraine nationals for U.S. nursing positions is to be investigated. (i.e. an import business). Issues of immigration and competency will be part of this new effort.
• Create new programs/initiatives for medical assistants as an alternative to traditional nursing programs.
• Increase the respect for nurses through joint marketing efforts (government and education partnerships that currently do not exist and building on current efforts, too).
• Create a "team approval" to healthcare including nurses to be more involved with doctors, decisions, care, and communication.
• Create a new two-year degree for nursing, with added on-site experience with local hospitals to add to their education experience requirements.
• Create a nursing assistant program/track similar to the physician assistant program.
• Create a new pathway for developing nurses.
• A two-year program
• A three-year program
• A four-year program
• Rename nurses to a new medical status.
• Work more collaboratively in Clark County on medical legislative priorities.
• Find/identify gaps in our medical cluster (business services that are not here) and see those as opportunities for business attraction/recruitment by the cities' economic development and NDA.
• Make Nevada State College (NSC) a quality institution that is recognized on a national level. Do something there that is truly unique from a nursing education perspective.

In October 2002, the regional Medical Industry Coalition met again in a facilitated focus group meeting. Their #1 issue discussed was the workforce and specifically, nurses.

Their ideas focused on three major themes:

• Training/Creative Strategies
• Communications/Collaborations
• Administrative Issues

Following are recommendations for each of these areas:

1. Training/Creative Strategies
1. Create evening classes/weekends for nursing and allied health studies (longer process, but a new venue) to help fill the pipeline for new nurses.
2. Need to raise more money from the private sector and public grants for the use of scholarships (encourage new students and upgrade existing nurses).
3. Need to get more people interested in the CNA program.
4. Look to increasing the number of nursing programs locally by recruiting new academic (private sector) programs to the region, i.e. Western University.
5. Need for a private and public sector coalition to go to the legislature/governor for increasing the capacity of nursing students at UNLV/CCSN. We need to double the capacity and provide funding specifically for more staff and students.
6. Examine the current curricula to insure we are not over-educating our nursing students. We should educate to a degree of applicable needs for the patient and physicians. Collaborate more between doctors and nurses to find this balance (a team approach).
• Perhaps some of the liberal arts classes are not needed
• Maybe we should lessen the courses for trained nurses versus more education for physician assistants.
• Are we creating a nurse who is constantly performing jobs they feel are beneath them due to the education requirements?
• Re-evaluate our nursing programs (academics, physicians, and nurses) to reconstruct the qualifications needed for the job, which could increase the output (supply) of nurses and increase their job satisfaction, too.
7. Create specialized certifications for licensed MAs or CNAs which would give them the training needed to give additional services; such as injection certification, pharmacy certificate.
• Develop public and private sector support for new certifications
8. We need to create additional training programs/facilities for other healthcare professionals, including; pharmacists, medical support and lab technicians.
9. Career development and exposure needs to occur early (elementary/middle schools) and school counselors need to be more advocates for the profession.
2. Communications/Collaborations
1. Program for connecting "health community" with academia (taking for example, medical assistants and helping them become family practice nurses; utilizing incentives from the doctors and guaranteeing employment upon completion).
2. Need more communications between existing physicians and nurses.
3. Sponsor a forum/discussions between the nursing departments and medical facilities (sponsored by cluster association)
4. Doctors would like more input into the curriculum of the nursing colleges (more practical application knowledge).
5. We need to understand what the competition is doing in regards to workforce shortages (what creative ideas can we research and apply here).
6. From a marketing perspective, we need to promote a "be-a-nurse" program.
7. We need to change the "image" of Southern Nevada to become a center for excellent medicine. Utilize a cooperative effort of the cities, chambers, business and academia that have marketing and public relations talents and budgets for advertising.
8. Market all healthcare, not just the hospitals. Educate patients/public on services available throughout the valley, such as urgent care available outside of the ER setting.
9. Start a public relations campaign to write about the need for a quality academic medical center.
10. We need to change the "image" of nursing to a more positive one. Not enough nursing students. To compound the issue, we are suffering from a shortage of nursing teachers, too.
3. Administrative Issues
1. Help nurses be licensed here who have their credentials from other states. Make the process less cumbersome and exclusive. Expedite the process and utilize a Nevada website to do so.
2. Need to increase our residency programs so graduates will stay in the Southern Nevada region.
3. We need to have a quality academic medical school/center in Las Vegas. It must be part of the community's overall synergy to work. The state and the community need to make a commitment to the fullest to have a center of national importance. The legislature should bring doctors, citizens, educators and politicians together to make the necessary changes and investigate the reorganization of the current system.
4. Investigate/research magnet hospitals. How have magnet hospitals worked in other states?
5. We are facing a growing shortage of certain medical specialties, including pediatric cardiac surgeons, general surgeons, Ob/Gyns.
6. The working environment needs to be improved for healthcare professionals, including work hours, pay and benefit schedules and increased training opportunities.
7. Research the issue of nurses "capping out" too early on their salaries – the negative impact this has on the career growth and retention efforts.

The Medical Industry Cluster Group met again January, 2003 and had an excellent presentation by Dr. Rudy Manthei, who requested the assistance by the Group for his "Keep Our Doctors in Nevada" campaign.

The following outline describes the presentation by Dr. Manthei and the issues for their campaign.

I. The Problem – The Crisis Continues

1. The Medical Industry Coalition agrees that the workforce is its #1 issue.
2. And the current #1 medical workforce threat in Nevada? The state's ongoing medical liability insurance crisis.
1. In the past year alone, according to the Nevada State Medical Association, over 200 doctors have left Nevada, retired early or are strongly considering closing their practices due to skyrocketing medical liability insurance rates, putting Nevada families at risk of losing their access to quality healthcare.
2. The front pages of Nevada's newspapers highlighted the many lows, including pregnant women forced to go out-of-state to find doctors to deliver their babies and Las Vegas area physicians who moved to other states to practice medicine with lower insurance premiums.
3. In some cases, insurance rates for Nevada physicians have jumped from $40,000 to $200,000 per year. In the end, as quality healthcare diminishes, the quality of life for Nevadans is threatened.

II. The Root of the Problem – Why Have Medical Liability Insurance Rates Skyrocketed?

1. The root of Nevada's "med-mal" crisis can be explained in two words – lawsuit abuse.
2. Like most doctors' insurance rates, lawsuits and jury awards have shot through the roof.
1. In Clark County alone, medical liability lawsuits have more than doubled in the past year.
2. Between 1996 and 2001, the total jury award amounts for related claims in Clark County exploded from roughly $525,000 to over $21,000,000.
3. It's effect on patients? Nevada's doctors are either closing their practices or leaving the state, leaving Nevada communities without access to affordable, quality care.
4. It's time for a common sense solution.

III. The Solution – Keep Our Doctors in Nevada

1. Keep Our Doctors in Nevada is a coalition of mothers, taxpayer advocates, businesses and doctors formed to strengthen the provisions of Assembly Bill 1, which was signed into law in August 2002.
2. The coalition supports measures to end lawsuit abuse and ensure that quality, affordable medical services are available for all Nevadans.
3. To end the mass departure of qualified physicians and keep critical medical services available for Nevada families, Keep Our Doctors in Nevada qualified an initiative with the Nevada Secretary of State through the petition process, with more than 95,000 signatures from Nevada voters in 14 counties.
4. The key components of the initiative include:
1. Limit Runaway Lawyer Fees
   Those injured deserve their award – not trial lawyers. "Keep Our Doctors in Nevada" limits lawyers' fees to 40% of the first $50,000, 33.3% of the next $50,000, 25% of the next $500,000 and 15% of everything over $600,000.
2. Stop "Double Dipping"
   "Keep Our Doctors in Nevada" ensures juries are told BEFORE a verdict when damages or medical expenses are already covered by insurance carriers or other parties -- to stop "double dipping" and restore fairness to our system.
3. Extend Payments
   "Keep Our Doctors in Nevada" says that rewards over $50,000 will be paid through regular installments, instead of a lump sum.
4. Stop Exceptions
   "Keep Our Doctors in Nevada" strengthens the $350,000 limits on non-economic damage awards – the real key to lowering medical liability rates and restoring fairness to our system.
5. Create "Fair Share" Liability
   "Keep Our Doctors in Nevada" makes sure defendants found liable pay damages in proportion to their fault – no more, no less.
5. The measures mirror those of California's MICRA – Medical Injury Compensation Reform Act, which for nearly three decades has kept a lid on California's medical liability insurance rates, some of the lowest in the country.
6. For example, an obstetrician/gynecologist in Los Angeles pays an average insurance premium of roughly $52,000 per year. In Clark County, the same physician pays over $140,000 – a difference of over $88,000 per year.

IV. The Road Ahead

1. Under Nevada law, the State Legislative had a 45-day period to enact, reject or ignore the Keep Our Doctors in Nevada initiative, beginning February 4, 2003, the first day of the legislative session.
2. Unfortunately, State Legislators decided to ignore this initiative – and the nearly 100,000 Nevadans who signed the initiative petition. So what now?
3. Because the initiative was not enacted, it now goes to a public vote. Nevadans will have the opportunity to vote for these reforms – in the November 2004 general election—in a chance to make it law.

V. The Bottom Line – A Common Sense Solution

1. The Keep Our Doctors in Nevada initiative is solution that's proven to work in other states.
2. It will seal legal loopholes – bringing predictability and fairness to the state's insurance market – and keep healthcare costs down for both consumers and businesses.
3. It's a common sense solution to protect the quality of life for all Nevadans.

CHAPTER 4 - PLAN OF ACTION

I. BACKGROUND
The Medical Industry Cluster Group has built important and new partnerships during the past year. However, action and movement towards collective goals must begin now.

The implementation of new initiatives and providing additional support for several existing programs must be a collaborative effort. The primary partners for this Group effort include:

1. Academia – UNLV, UNR, Nevada State College and CCSN
2. Chambers of Commerce (Henderson, Las Vegas, North Las Vegas)
3. Private sector companies
4. Economic Development entities
5. Local government
6. Medical healthcare institutions and practitioners

II. STRATEGIES and RECOMMENDATIONS
As a starter, the Medical Industry Cluster Group has eight major strategies to implement in 2003. Recommendations for programs and projects are listed within each strategy. From our collaborative partners, a champion or co-champions will be responsible for guiding each of these strategies and recommendations. Independent task forces or committees will be developed to assist in the implementation of each strategy. The Group will act as a Board of Directors overseeing the progress of the Plan of Action and adopting new strategies as the group matures and grows in the number of new partners and volunteers.

Strategy 1: Leadership
It is very important to maintain the momentum and interest in the Medical Industry Cluster Group. The Group needs to maintain its non-partisan, independent and collaborative orientations and serve as the public-private leadership model for growing our medical/healthcare industry.

Recommendations include:

• Maintain the Group and develop sub-committees and champions for each of the strategies.
• Create a process/action that provides for ongoing communication, collaboration, support and monitoring of the overall plan activities.
• Maintain accountability for promoting and establishing a common focus within the medical community and promoting synergy of effort and resources.
• Develop a website for internal and external communications.

Strategy 2: Regional Center of Excellence
Southern Nevada has an outstanding opportunity to succeed as a regional medical "center of excellence." The Las Vegas region continues to lead the nation in population growth, which creates both opportunities for medical professionals and institutions and a serious demand by residents for quality healthcare.

The concerns of the nursing profession have been very well articulated in this plan of action, but equal attention and concerns need to be expressed for growing other segments of our healthcare system, including physicians, pharmacists, mid-level providers and the creation of high level academic centers.

Excellence breeds excellence and acts as a magnet for a higher level of medical care. The potential of a high level academic residency program combined with incentives for physicians to stay in Nevada would raise medical care to higher levels.

Recommendations include:

• A plan should be put into place to attract name recognized medical specialists or groups/clinics that could not only attract/keep Nevadans from leaving the region, but also attract a higher level of physician provider; foster a more academic climate which attracts better residents/fellows, research dollars/ facilities and business spin-offs like device and pharmaceutical companies.
• Support the City of Las Vegas and their recruitment of the Cleveland Clinic.
• Support the City of Henderson in their recruitment of Touro University's academic medical center.
• Support the Nevada College of Pharmacy in their growth and development in the region (the state's first academic school of pharmacy)

Strategy 3: Improving the workplace/economic value for nurses
Despite efforts such as the legislature-mandated program at the university and community college levels, there remains a nursing shortage in Southern Nevada, partly due to poor work conditions and salaries in the medical industry.

Recommendations include:

• Improving nurses' work hours.
• Research a new salary schedule for nurses to help them avoid "capping out" too early in their careers.
• Providing more incentives for students to work in clinics and hospitals while earning their certification.
• Increasing the numbers of grants and scholarships available.
• Improving communication among medical staff to improve quality of care.
• Scheduling regular staff trainings to improve quality of care.
• Devise and/or evaluate varying models of innovative compensation packages designed to recruit and retain registered nurses.
• Advocate for passage of state tax incentives for registered nurses.
• Develop new educational reimbursement programs for individuals pursuing careers in nursing, working in collaboration with policy-makers.
• Develop an LPN/RN refresher course for "retired" nurses for those who would like to return to work. Given the poor national economy, there may be interest in this concept.
• Research the development of night or partial day classes for MA to LPN, or LPN to RN, allowing the student to continue on with their regular job perhaps with modified hours. This type of program could be done in conjunction with an employer who would grant flexible time in return for a certain number of years of guaranteed employment.

Strategy 4: Legislation/regulation policy
The Group needs to have a common legislative agenda and have that supported by the Chambers of Commerce, local units of government, academia and the medical community.

Recommendations include:

• Establish a web-based network among partners that would scan current legislative and regulatory issues and issue alerts when support or opposition is required.
• Cultivate a cadre of medical experts to serve in key, state and local positions, including internships.
• Identify existing databases and begin developing workforce and patient outcome databases that are shared and utilized for policy-making.
• Hold a health policy planning summit with key partners, media and elected officials to plan collaborative efforts.
• Collaborate with the Las Vegas Workforce 2010 organization and their sub-committee on healthcare for a common legislative agenda.
• The legislature allows that only nurses with a Master in Nursing are allowed to teach nursing classes. Any other master degree holders in the health profession cannot teach nursing classes. This limits the number of qualified faculty in ADN, BSN, and PN.
• Work together to institute changes in the state's professional liability/tort reform arena. The "Keep our Doctors in Nevada" campaign needs to be supported in this year's legislative session.
• Opportunities to address the professional liability insurance issue could include encouraging medical groups/facilities to offset portions of the insurance premiums with salary differentials or ideas such as "loan" forgiveness packages for doctors.

Strategy 5: Education
The difficult process of becoming a nurse has deterred some from entering the profession.

Recommendations include:

• Continually increasing the number of students entering nursing programs
• Simplifying the process for credentialed nurses to transfer credentials from other states to Nevada (mutual recognition program)
• Simplifying the process of transferring within the medical field.
• Starting a program to hire nurses from other states and overseas.
• Reevaluating program curriculum as often as needed to ensure all coursework are essential to the nurse's job description. Unnecessary courses should be dropped from the curriculum.
• Providing schools with practical application knowledge (i.e. from doctors and nurses already in the field). Guest lecturers should be encouraged.
• Redefine scopes of nursing practice and the educational preparation for each scope of practice to meet the general and specialized healthcare needs of society.
• Pursue adequate funding for individuals who are seeking a nursing education to prepare for RN licensure, and for individuals seeking advanced education degrees for roles as nurse educators.

Strategy 6: Public Relations/communications
Negative publicity has plagued the nursing profession due in part to strenuous work conditions and low wages. Proponents need to do whatever possible to promote the nursing profession.

Recommendations include:

• Promoting the nursing program by:
• Educating children beginning in the elementary schools
• Starting a mentoring program for those interested in possibly becoming nurses (i.e. a shadowing program)
• Beginning a campaign utilizing public relations and advertising people to promote image of nursing profession.
• Improving programs which encourage nurses to speak to nursing students about the positive aspects of the nursing profession.
• Developing a position statements by nursing organizations that demonstrate the positive impact of nursing on quality care. Distribute statements to nurses, general public, students and media.
• Developing and distributing a single-sentence key message for internal and external constituents of nursing organizations about the positive impact that each nursing focus/specialty has on quality care.
• Supporting the UNLV Nursing Connections Program which is a one-week hands-on summer enrichment program for students interested in the profession and aggressively market this program to all physician practices.

Strategy 7: Recruitment/retention
In 1999, in response to the nursing shortage, the nursing department at UNLV received permission to hire additional faculty members, which allowed it to increase new student enrollment to 48, up from 32. Last fall, enrollment increased to 56. At CCSN, new student enrolments increased from 40 in 1999, to 64 in 2003. Although this is a start, eliminating Nevada's nursing shortage involves more than simply increasing the number of seats into a classroom of nursing students.

According to Carolyn Sabo, Dean of UNLV's College of Health Sciences, and Rosemary Witt, Chair of UNLV's Department of Nursing, other issues include promoting nursing as a desirable career, and making sure that nursing students succeed in their studies. That step, according to Witt, quickly reduced the waiting list so that students could be admitted into the program and begin classes immediately. This helped in terms of reducing the number of students changing their major from nursing due to long wait-time to begin classes, but the shortage continues to worsen. A major factor is that the rapid growth in Southern Nevada has led to an increase in senior citizen residents who typically require more medical care than the general population.

Another difficulty is finding a sufficient number of practicum placements. A statewide effort includes a legislature-mandated plan for increasing the capacity of nursing programs at each institution. Other problems include students dropping out of the program due to stringent science and math requirements. UNLV is combating this problem by providing free tutoring for students as needed. Networking among students, including monthly discussion sessions is also taking place at the university. Student Financial Services has offered support and is trying to increase available funding as well.

Other programs include students working at area hospitals in exchange for financial aid, and clinical facilities offering financial reimbursement to employees. Also, scholarships and grants are being awarded in some cases.

Efforts to promote nursing have been in effect, such as nursing faculty members and students speaking in classrooms and at career days. In addition, Sabo has written a grant proposal seeking funding from the U.S. Department of Health and Services to expand on its recruitment and retention efforts.

While aggressive recruitment strategies are essential to increasing the number of nurses in the Valley, the outcome of such efforts will take time. In addition to launching a strong campaign to attract nurses from outside of Nevada and beyond, we need to immediately focus on retaining the talent we have. A number of nurses are so frustrated with their careers that they are leaving the state, or leaving the industry altogether. We need to improve retention in order to save the current workforce as well as ensuring a long-term return on our recruiting investment.

A commitment needs to be made to enhance careers and to provide challenging and rewarding opportunities. Facilities should ensure nurses are treated as valuable members of their family and encourage a high number of candidate referrals from satisfied employees. As a result, facilities will enjoy the benefits of a motivated and focused workforce. Programs should be designed to increase nurse loyalty and retention, reducing the risk of losing valued employees.

Nurse management and care programs could include:

• Counseling on internal career paths, industry opportunities, career management strategies, and networking opportunities,
• Training opportunities,
• Mentor programs – either to use a mentor or become a mentor,
• Employee recognition programs,
• Facility education programs - complete employment orientation, concise expectation definitions, escalation paths, etc.,
• Following up on the first day of employment, and thereafter on average once a week, by Human Resources and / or Management Departments,
• Competitive benefits package, including 401(k), tuition reimbursement, flexible spending, medical, dental and disability, and more (exact plan depends on tenure and status),
• Performance-related bonuses and awards,
• Loyalty programs that reward length of service,
• Prompt follow-up on any problems, safety concerns or other issues reported by nurses – all inquiries are logged and tracked until completion, assuring expedient resolution of all requests.

Recommendations include:

• Research national, professional development models for mentoring, leadership and diversity for nurses across their career trajectory.
• Address diversity issues by obtaining funding to support an increase in minority enrollment, identifying a specific mobility track for nurses of diverse cultures throughout their careers, and creating a specific curriculum to address diversity.
• Develop and distribute promotional and recruitment materials that attract individuals of diverse backgrounds into the variety of nursing career opportunities.
• Recruit retired nurses to form the foundation of a professional mentoring corps.
• Develop a recruitment campaign, with the assistance of the Chambers of Commerce and economic development entities, to target nurses from the western U.S. to come to Southern Nevada.
• Advocate for standardized internships and residencies through partnerships between schools of nursing, professional organizations and practice sites. Graduates will participate in an individualized mentoring program to socialize them into the profession and enhance their knowledge of clinical practice.
• Negotiate professional development opportunities with employers that are supported through a variety of resources such as: paid time-off, education days, cost reimbursement, or as part of the scheduled workday.
• Support the global recruitment efforts of institutions such as Mountainview Hospital and Sunrise Hospital & Medical Center in their pursuit of nurses in such areas as South Africa, Philippines and Europe.
• Reduce wait time for students to enrol in local nursing programs
• Collectively define "critical specialties" and design comprehensive recruitment plans.
• Support the Nursing Institute of Nevada's Subcommittees on Attraction and Retention.

Strategy 8: Business Development
From an economic development perspective, the healthcare and medical industries have an excellent opportunity to grow in Southern Nevada. Through an open communication process, the medical industry can help identify new business opportunities and needs in our local region. The economic development professionals can then implement a recruitment process to market and attract these new medical businesses to our region.

Recommendations include:

• A survey of medical businesses in Southern Nevada by the Group asking for information on what kinds of businesses, both medical and sub-suppliers, that we are missing or in need of in our area.
• Develop marketing materials to introduce the benefits of expanding certain medical businesses to Southern Nevada.