The United States Healthcare System became an organized body through politics. The historical importance of The Flexner Report is that the report provided the framework for medical education reform in the US. Nonetheless, the current system of various payor sources, with Medicare and Medicaid being the largest, is going through yet another transformation and is looking to the future to provide better quality care at lower costs. The Essential Hospitals Institute (2013) explained the concept of the healthcare system development. There have been varieties of integrative health care development systems built to improve, correct, and lower cost, which are the main issues of the current health care system. There are two main integration systems: horizontal integration and vertical integration. Horizontal and vertical integrations are achieved by grouping multi hospitals, offer continuum of care, reduce cost and risk. Health care today is looking to provide better care and most importantly increase population wellness at a lower cost. The goal of The Patient Protection and Affordable Care Act (ACA) is to provide healthcare to those without health insurance or those underserved populations as explained by the Institute for Health Care Improvement. Faced with all these important changes in the health care system, nurse leaders are poised to play an important role in the present and future of the medical system. Therefore, the nurse leader must be experienced, knowledgeable and be dynamic and flexible enough to adapt to the changes. Roussel, Thomas and Harris clarified the importance of nurses within the context of the future of nursing and nurses as catalyst for change. By definition, nurses are the catalysts to bring about the change the ACA seeks to provide in the health care delivery system.

Keywords: essential hospitals institute, affordable care act, health care improvement, leadership, collaboration, professionalism

The 21^st Century nurse leader understands the need to embrace change; to be the agent for change. The 21^st Century Nurse Leader who clearly understands the aim of the ACA and places emphasis on education including business skills, collaboration, effective leadership and flexibility towards change, will truly succeed.

In October 2010, the Institute of Medicine (IOM) released the report, The Future of Nursing: Leading Change, Advancing Health, an assessment of the nursing profession, where we are and where we are going. The report is also an affirmation of the important role of nursing in the ever-changing healthcare system. Nursing was identified as the catalyst to bring about change.

According to the American Organization of Nurse Executives (AONE) (2015), the role of the nurse leader is expanding and evolving. As a result, nurse leaders need to build their knowledge base, “communication, knowledge, leadership, professionalism, business skills” (AONE, 2015). Each competency is represented by a circle. One circle that is at the center and touching the other four circles is leadership.

Importance of leadership management

Birk (2010) discussed leadership as innate. A leader’s ability to influence others, share a vision, have others understand, believe and implement the vision (Birk, 2010). AONE explained the criteria for such a leader, “foundational thinking skills, personal journey disciplines, systems thinking, succession planning, and change management”. For the nurse manager, AONE has different sets of competencies. The nurse manager is seen as the bridge between clinical and the administration (The executive). The nurse manager should understand the business aspect of management (The science), invest in personal and professional development (the leader within), and learn how to lead with leadership skills, knowledge of human resources (the art).

The nurse leader must be aware of the different organizational structures (functional, divisional or matrix) and be able to identify the right fit for his or her style of leadership. Friend¹ provided us with an understanding of the different structures. Matrix structure is a complicated intricate system used for large organizations. Functional structure is based on specific job definition. Divisional structure is applicable to business management. Knowledge of the strategic planning process is essential. The nurse leader must have clinical expertise. However, the nurse leader must also possess sound educational knowledge in the internal and external threats to the survival the health care system as well as know the potential opportunities; healthcare finance, managed care, system mergers, human resources, staffing, etc., etc. must all be in the 21^st Century leader’s executive practice repertoire.

The effective nurse leader must play the role well to embrace and implement strategic planning as part of the new leadership strategy. Rouse² defined strategic planning as the intent of the leader for the organization when viewing the organization’s future five years ahead. The leader defines the vision, mission and value of the organization. The result is the strategic plan, preferably developed by an Interprofessional strategic planning committee that serves as a road map to the future. The strategic plan becomes a document mapping the way forward for the organization to achieve its mission, vision and goals.² Leadership assures the actualization of the strategic plan.

Leadership has been the topic of discussion for centuries. Schools of Business delight in educating leaders. Mintzberg’s classic article entitled, “What Do Manager’s Do?” (HBR, 1973) seeks to define management roles verses leadership. From Aristotle to Bible leaders, there has always been the belief that to lead is to be a servant. Many would argue that being a servant, being humble, is in contemporary times, a sign of weakness in a leader. Yet, Greenleaf, who introduced the concept of Servant Leadership in his writing and Havard with his dissertation on Virtuous Leadership were both confident of the leader’s ability to achieve success. The observer could be assured of the successful outcomes of those leaders who apply one or better in concert, both, of these leadership styles, are favored with success in the delivery of Healthcare today and in the future.

The future of Healthcare in the United States is tied to the Patient Protection and Affordable Care Act of 2010 better known as the ACA or OBAMA Care. This major legislation of the OBAMA Administration, the ACA has become a political football being kicked between the major legislative branches of the United States Government. When looking at the ACA and the need for nurses to bring about change, it is clear that the staff nurses need to obtain, at the start, the BSN degree or be provided a 5-year period to achieve BSN status. To succeed, the nurse leader needs to ensure the staff is competent, knowledgeable, well versed on the health care system with emphasis on the financial aspect of health care. Staff nurses are making day to day operation decisions that are very important. As we move towards an increasingly changing health care system, the decision-making aspect of the staff nurse will increase. For example, a staff nurse might decide to send a patient with a peg tube home with some additional can feeding because the patient is being discharged before the insurance has authorized payment for the feeding. Some nurses may feel that the patient should pay for the cans of food, whereas, others feel the patient should not. We are experiencing these types of patient situations everyday where patients are being discharged prior to obtaining the necessary approvals from the insurance companies for certain services. The staff nurses’ decisions as are those of the Case Manager or Patient Navigator may have significant financial implications for the insurance company, possibly the hospital and for sure the patient.

As registered, professional nurses in the 21^st Century and beyond we must acquire the executive skills and the leadership style(s) to assure our patients receive care that is safe, compassionate, therapeutic and cost effective and that our followers are provided every opportunity for professional advancement. Servant Leadership seeks first to serve the interest of the followers encouraging the followers to assure the accomplishment of the organization’s goals and fulfill the organization’s mission. It is the concept of “Caring for the Caregivers,” who will in turn give their very best Nursing care to their patients. Advancement of a shared vision is achieved by addressing the highest priority needs, empowering and developing followers who themselves will become servant leaders as well.

Virtuous Leadership ignites a contagious effect to strive for personal/individual greatness, while simultaneously empowering followers to reach their fullest potential. The two styles are complementary and when utilized in concert, exponentially enhances the effectiveness of the leader, the performance and engagement of the followers and assures the delivery of care that is compassionate, therapeutic, safe, financially sound and culturally appropriate in an organization where the leaders at every level of the hierarchy are Magnanimous, Inclusive Servant Leaders. The 21^st Century Nurse Leader will lead the charge of the Healthcare Reform and the portions of the ACA that survives.

The United States spends $2.5trillion on health care, double what other developed countries spend per capita. Over the years, we have observed the shift from hospitalization to ambulatory care from illness to prevention. Reportedly ten percent of patients with chronic diseases utilize seventy percent of the healthcare costs. The implications for managed care companies, physician groups and hospitals remains most significant and usually quite quantifiable with Medicare and Medicaid the largest payers and subsequently, the most significant regulators.

To fully understand the Healthcare System in the US, from where we are and where we are heading, it is beneficial to look at the Canadian Health System. The Canadian is often referred when discussing health care and health care cost in the United States. All Canadians have access to the tax funded public system. The cost of health care is shared by federal, municipal, provincial, and territorial entities. A “primary care team” runs the hospitals. General Practitioners and specialists are on a fee for service basis, payment plan which provides high quality care and access to full everyone (universal). Canada has been able to balance access, quality, and cost for now.³

The plight of the poor and indigent has always percipated great political involvement and debate. The Patient Protection and Affordable Care Act affirmed that belief. “The implementation of the ACA continues to be a vexing process and a political flashpoint. [The ACA] can be categorized into four main cornerstones: create value, coordinate care, and expand access, payment reform.” Mason, Gardner, Outlaw and O’Grady (2016). Not to say the ACA reform is problem free, but this reform is focusing on correcting some wrongs and reducing costs by addressing the social determinants of health. Nurse leaders are in an important position to provide the charge to promote the needed change. It is not enough to keep repeating the teaching with the diabetic patient every time they are admitted to the hospital. What is being done outside of the walls of the hospital to continue the wellness that was established within the walls? The new challenge for the nurse leader is to forgo the status quo, embrace diversity, inclusion and innovation to become an effective leader.

The role of the nurse leader as explained by Roussel, Thomas & Harris is a, “champion of patient and staff”. To be the champion, the nurse leader must understand the basic principles of the ACA, such as: the role of the Accountable Care Organization and cost reduction, the movement of patients across the continuum of care, the role of information and technology (EMR), staff education, safety, quality, and cost (Roussel, Thomas & Harris, 2016). The nurse leader as a champion needs to question new technology as it relate to cost. According to Scott et al (2018), the cost for the implementation of an Electronic Medical Record (EMR) System continues to escalate. Implementing an EMR system involve: labor cost, change in the pattern of the work flow, increase in documentation time, “Interestingly, providers spent more time documenting patient encounters but less time interacting with patients post-EMR implementation”.⁴ Arndt⁵ found one of the cost saving factors associated with EMR is not working. The cost for a primary care visit went from $20.49 for 13minutes prior to EMR to $32.50 post EMR. Inpatient surgical procedure used to cost $215. The cost increased to $319.80. The increase in cost is attributed to variations in contracts between hospitals, health insurance, payers, and differences in price schedules.⁵ The nurse leader as a champion should take into consideration cost verses the added value, as in Value-Based Care and Patient-Centered Care and patient satisfaction.^6–16

The 21^st Century nurse leader understands the need to change, be the agent for change, and understands the aim of the ACA. The nurse leader, who places emphasis on education including business skills, collaboration, and flexibility towards change, will succeed.

Nurse leaders will need to strategize differently in different settings. Based upon our current, personal and professional observations, Rigidity appears to be a major trait in the current style of management for many nurse leaders. In contemporary and future practice, nurse leaders must let go of past practices and embrace innovation, inclusion and diversity. Nurse leaders must place more emphasis on building staff to be competent in providing care to the patient through patient-centered care coordinated models. The 21^st Century nurse leader embraces Servant leadership where the leader cares for the caregivers assuring they in turn take ownership, make appropriate decisions in care giving and support the leader’s vision and the organization’s goals and mission. Coupled with Virtuous Leadership, the 21^st Century Nurse Leader creates a win- win strategic initiative, one in which the Nurse leader and the Staff/ Followers are assured of mutual success.

None.

Author declares that there is none of the conflicts.

1. Friend L. What Is the Meaning of Organizational Structure? 2018.
2. Rouse M. Strategic Planning. 2016.
3. Wolper LF. Health Care Administration Managing Organized Delivery Systems. 5th ed. In: Sudbury MA, editor. Jones and Bartlett Publishers; 2011:1‒816.
4. Scott D, Labro E, Penrose C, et al. The Impact of Electronic Medical Record Implementation on Labor Cost and Productivity at an Outpatient Orthopaedic Clinic. The Journal of Bone and Joint Surgery. 2018;100(18):1549–1556.
5. Arndt RZ. EHRs do not lower administrative cost, study finds. 2018.
6. Blumenthal D. Fidel Castro's Health Care Legacy. 2016.
7. Essential Hospitals Institute. Integrated Health Care Literature Review. 2013:1‒34.
8. Lange D, Tapia AT. The Inclusive Leader. 2016.
9. Roussel L, Thomas PL, Harris JL. Management and Leadership for Nurse Administrators. 7th ed. In: Burlington MA editor. Jones & Barlett Learning; 2016. 470 p.
10. Reflections on Leadership: How Robert K. Greenleaf's Theory of Servant-Leadership Influenced Today's Top Management Thinkers.1st ed. In: Spears Larry editor. Wiley and Sons; 1995.
11. Robert K. Greenleaf. Servant Leadership: A Journey into the Nature of Legitimate Power and Greatness. 25th Anniversary. 2002.
12. Steven Brown, Phillip Bryant. Getting to Know the Elephant; A Call to Advance Servant Leadership through Construct Consensus, Empirical Evidence, and Multilevel Theoretical Development. 2015;2(1):10‒35.
13. Victor Trastek, Neil Hamilton, Emily Niles. Leadership Models in Health Care–A Case for Servant Leadership. Mayo Clin Proc. 2014;89(3):374‒381.
14. Alexandre Havard. Virtuous Leadership, an Agenda for Personal Excellence. New York: Scepter Publishers; 2007.
15. Alexandre Havard. Created for Greatness-The Power of Magnanimity. New York: Scepter Publishers; 2014.
16. Jamesetta Halley Boyce, Letrease Lachell Robinson, Elcedo Bradley. Actualizing the Vision: Utilizing a Literature Review Process to Develop and Implement an Organizational Strategic Plan and Theoretical Marketing Framework for Executive Leadership Success in a Professional Nursing Organization. JOCEPS: The Journal of Chi Eta Phi Sorority. 2013;57(1).