Nursing Grand Rounds | April 2018 | Population Health

Nursing Grand Rounds – April 2018

Exemplary Professional Practice & Innovation:  

Leading Improvement in a Health System Through Population Health

4/17/2018 – written by Katie Stephens, MSN, RN

Jimmy Dang, BSN, RN, Population Health RN

There is a growing gap between the population’s need for primary care services and the capacity of primary care to meet these needs. The number of retiring primary care physicians will soon surpass the number of physicians entering the primary care workforce (Bodenheimer & Bauer, 2016). The situation is exacerbated by the ever-expanding diverse, complex, and aging population that require advanced care coordination and transition management across the care continuum. These coordination and transition services will be vital for healthcare organizations seeking to achieve the Institute for Healthcare Improvement’s (IHI) Quadruple Aim: improving quality of care, improving the health of communities, reducing costs, and improving healthcare clinician work/life balance and job satisfaction (Institute for Healthcare Improvement, 2017).

In response to the changing primary care workforce, as well as payment reform, there is widespread awareness of the need for primary care to create new care delivery systems that can minimize physician burden while also increasing patient access to quality care. As the largest sector of the healthcare workforce, RNs provide a deep and unique set of clinical skills that can enhance the primary care team, increase access to care, and improve the overall patient experience (Bodenheimer & Bauer, 2016; Flinter, 2017; LEAP Program, 2014). When used to their fullest scope and potential, RNs are ideally suited to provide the bulk of care for the aging and increasingly complex primary care population with chronic illness (Bodenheimer & Bauer, 2016). Despite this evidence, RNs continue to be woefully underutilized in the primary care setting across the country.

Stanford Health Care’s Primary Care Department is being co-led by a team of Population Health Nurses.  Yesterday, we had the privilege of learning from our Primary Care – Population Health Interprofessional Team at our monthly Nursing Grand Rounds Forum.  Nursing Grand Rounds provides an educational forum for nurses to share expertise and experiences, nursing best practices and other topics of interest across the Stanford Health Care system.  Nurses can gain new knowledge and skills in a supportive environment of learning for both the art and science of clinical and leadership nursing practice.

The Stanford Health Care Primary Care – Population Health Interprofessional Team included Stanford’s Population Health Registered Nurses – Jimmy Dang, BSN, RN,  Mary Christensen, BSN, RN, CDE, Helene Jernick, MS, RN, and Michelle Coffman, BSN, RN –  as well as Dr. Anuradha Jayant Phadke, MD and Anna Simos, MPH, MS, CDE.  

The team discussed various topics, including: 

  • The Societal context and forces promoting Value-Based care
  • An introduction to Population Health
  • The Nursing Role and Scope in Population Health
  • The methodology of improvement used in RITE & CELT programs
  • The importance of multidisciplinary collaboration and thoughts from a provider on the value of having Nurses in the Population Health role
  • Successes & Opportunities
  • Establishment of Diabetes Education Program
  • The future state of Population Health at Stanford

We would like to thank our Population Health professionals for sharing their robust knowledge, expertise, and passion across the Stanford System.  These individuals are innovating in nursing & medical practice and positively impacting the patients in our community.  Excellent work and thank you greatly!

Read the Primary Care Population Health article in our 2017 Stanford Nursing Annual Report here


Bodenheimer, T., & Bauer, L. (2016). Rethinking the primary care workforce — An expanded role for nurses. New England Journal of Medicine, 375(11), 1015–1017.

Flinter, M. (2017). Primary care exemplars: Community health center, inc. in Connecticut. New York: Josiah Macy Jr. Foundation.

Institute for Healthcare Improvement. (2016, December 15). WIHI: Moving upstream to address the quadruple aim. Retrieved June 30, 2017, from Institute for Healthcare Improvement. (2017). The IHI triple aim. Retrieved April 14, 2017, from

LEAP Program. (2014, May 16). The RN role in collaborative care visits. Retrieved July 2, 2017, from

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