Journal of Healthcare Management - September/October 2016 - 370

J o u r n al of H ealt H care M anageMent 61:5 S epte Mber /o ctober 2016 that helped to improve quality of care. One CEO noted that "physicians increase the medical knowledge available," but "NPs are more inclined to listen to patients and think about their social context than are physicians." Many stated that NPs gave patients a greater choice of providers and helped make the CHC's services more patient centered. External Constraints and Opportunities Across all types of CHCs, CEOs noted that their institutional history was vital to understanding current staff configuration and hiring decisions. Nearly all CHCs in our study sample began-or included sites that began-as other organizations, such as a medical residency clinic, a birthing center, a dental clinic, and an "urban Indian" free clinic. Staffing needs and preferences were linked to those histories. For example, a CHC that had served as a medical residency site employed only physician providers until the CEO added NPs to diversify the staff. A CHC that had absorbed a birthing center had many midwives on staff until the CEO began hiring physicians. CEOs described these changes as challenging, especially when incumbent providers were unconvinced of the need for different types of providers. In addition to the historical constraints, hiring choices were constrained by the local supply of physicians, NPs, and PAs. While some CEOs had turned to more proactive approaches, such as the use of headhunters to recruit providers, CEOs in rural and underserved areas often "took what they could get" from among providers already in the local area. A CEO in Alaska reported, "Most of [the hiring] has been serendipity. People say, 'I have some medical background-can I help?' " CEOs in remote areas suggested that even if a physician were available, the limited medical infrastructure diminished any added value from having a physician on staff. One CEO reported, "I've been told by our medical director that there's nothing an MD can do that an NP or a PA can't do, because they don't have the local labs, the local referrals, the local hospitals, the local anything." At the other end of the spectrum, a CEO in Washington, D.C., complained that an oversupply of semiretired and researcher physicians looking to volunteer part time strained the CHC's training capacity and made standardization of services a challenge. Respondents also cited local salary differences among the three provider groups as an important factor in hiring decisions. In some rural locations, physicians' salaries were twice those of NPs and PAs, while in urban areas, the differential could be small. A CEO in rural Tennessee explained that she could "hire an NP and a bilingual patient navigator for the price of a physician." On the other hand, a CEO in Washington, D.C., cited NPs' lower productivity as offsetting the salary differential with physicians, making her more inclined to hire the latter. About half of the CHCs in our sample were in states that allowed NPs to practice independently of physicians (American Association of Nurse Practitioners, 2015). Across all sites, however, study participants agreed that SOP laws 370

Table of Contents for the Digital Edition of Journal of Healthcare Management - September/October 2016