Who Can Say No: A Stakeholder Analysis for Launching a Hospital-at-Home Program
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Doctor of Nursing Practice Program, Aspen University
DNP855: Organizational Leadership and Systems-Based Practice
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Month Day, Year
Who Can Say No: A Stakeholder Analysis for Launching a Hospital-at-Home Program
A well-designed program can fail because a group with the power to stop it was not engaged. Stakeholder analysis is the systematic identification of the individuals and groups with an interest in a decision, their positions, their influence, and how to work with them. This paper conducts a stakeholder analysis for a proposed hospital-at-home program at a composite community hospital, places each stakeholder by power and interest, names those who can block the plan, and proposes an engagement strategy for each.
The Proposal
Riverside Community Hospital, a composite 300-bed hospital that runs above 95 percent occupancy most winters, proposes a ten-bed hospital-at-home program. Selected patients with conditions such as heart failure exacerbation, pneumonia, cellulitis, and chronic obstructive pulmonary disease would receive acute care at home, with daily visits by registered nurses and paramedics, remote monitoring, a physician or nurse practitioner visit each day, and access to intravenous therapy, oxygen, and laboratory testing. The evidence is encouraging. In a randomized trial of acutely ill adults, home hospitalization reduced the adjusted mean cost of the acute episode by 38 percent, with fewer laboratory orders, imaging studies, and consultations, less time spent sedentary or lying down, and fewer 30-day readmissions, 7 percent compared with 23 percent, although the trial was small and patients were highly selected (Levine et al., 2020).
Method
Brugha and Varvasovszky (2000) describe stakeholder analysis as an approach for understanding a system by identifying the key actors and assessing their interests in a policy or change, and they emphasize assessing each stakeholder's position, influence, and interest. This analysis identified stakeholders through interviews with 18 leaders and clinicians, then rated each by power, the ability to influence or block the program, and by interest, the degree to which the program affects them, and recorded each group's likely position.
The Stakeholders
High power, high interest: the hospitalist group, whose physicians would admit and oversee patients; the chief financial officer, who controls start-up funding; the chief nursing officer, responsible for nursing staff and standards; and the emergency department medical director, whose physicians would identify eligible patients. High power, lower interest: the board of trustees, the risk management department, and commercial insurers, who decide whether to pay for home hospitalization. Lower power, high interest: registered nurses and paramedics who would staff visits, the home infusion pharmacy, patients and families, and the community paramedic program. Lower power, lower interest: laboratory and imaging departments, whose workload would shift slightly.
Who Can Block the Plan
Five stakeholders could stop the program. The hospitalist group could decline to admit patients to the program, citing workload or liability. The chief financial officer could refuse start-up funding if the payment model is uncertain. Commercial insurers could decline to reimburse, leaving the program dependent on Medicare patients alone. Risk management could advise against the program if safety protocols are weak. And the nurses' union could object to home visits without clear staffing, travel, and safety provisions. A stakeholder does not need to oppose the program to block it; the hospitalists need only be too busy to refer.
Positions and Interests
The hospitalists' interest is manageable workload and protection from liability; their current position is cautiously skeptical. The chief financial officer's interest is financial sustainability; the program could free inpatient beds for surgical patients, who generate higher margins, but depends on payment. Insurers' interest is lower total cost; published evidence of lower episode costs and fewer readmissions speaks directly to it. Risk management's interest is patient safety and liability; its position depends on escalation protocols. The union's interest is the safety and fair treatment of its members. Patients and families want comfort and safety; many would prefer home if they feel supported, although some caregivers worry about the burden.
Engagement Strategies
For the hospitalists: involve two hospitalists in designing eligibility criteria and escalation protocols, provide a dedicated nurse practitioner to handle daily visits so hospitalist workload does not rise, and clarify coverage and liability. For the chief financial officer: present a financial model with conservative volume assumptions, the value of freed inpatient beds, and a break-even point. For insurers: share the trial and observational evidence and propose a pilot contract with one commercial payer. In an observational study of a bundled hospital-at-home and transitional care program, participants had shorter lengths of stay and lower rates of readmission, emergency department revisits, and skilled nursing facility admission than comparable inpatients (Federman et al., 2018). For risk management: co-develop protocols for deterioration, response times, and transfer back to the hospital. For the union: negotiate staffing, travel reimbursement, and safety procedures for home visits before launch. For patients and families: develop clear information and a 24-hour contact line.
Sequencing the Engagement
Who hears about the program first shapes how everyone after them receives it. The hospitalists and risk management should be engaged first, because their design contributions shape the protocols every other group will judge. Once eligibility, escalation, and coverage are drafted with them, the chief financial officer can be shown a model based on protocols clinicians have already accepted, rather than on assumptions they might later reject. Insurer conversations follow, with a clinically endorsed design and a financial model in hand. The union should be engaged early and in parallel, not after the design is final, so that staffing and safety provisions are built in rather than negotiated as objections. Patients and families can be engaged through a small advisory group while materials are drafted. The board comes last, receiving a proposal that has already passed through each group with the power to stop it. Stakeholder analysis is not a one-time exercise: positions will shift as the design develops, and the grid should be revisited at each stage of planning.
Conclusion
The hospital-at-home program has strong evidence behind it, but its success depends on stakeholders who hold the power to stop it. This analysis names five: the hospitalists, the chief financial officer, commercial insurers, risk management, and the nurses' union. Understanding each group's interests, not just its position, points to specific strategies, from shared design to financial modeling to negotiated safety provisions, that can turn potential blockers into partners.
References
Brugha, R., & Varvasovszky, Z. (2000). Stakeholder analysis: A review. Health Policy and Planning, 15(3), 239-246. https://doi.org/10.1093/heapol/15.3.239
Federman, A. D., Soones, T., DeCherrie, L. V., Leff, B., & Siu, A. L. (2018). Association of a bundled hospital-at-home and 30-day postacute transitional care program with clinical outcomes and patient experiences. JAMA Internal Medicine, 178(8), 1033-1040. https://doi.org/10.1001/jamainternmed.2018.2562
Levine, D. M., Ouchi, K., Blanchfield, B., Saenz, A., Burke, K., Paz, M., Diamond, K., Pu, C. T., & Schnipper, J. L. (2020). Hospital-level care at home for acutely ill adults: A randomized controlled trial. Annals of Internal Medicine, 172(2), 77-85. https://doi.org/10.7326/M19-0600
How this DNP 855 Module 6 example is structured
DNP855 Module 6 samples usually build a stakeholder analysis naming who can block the plan. Aspen does not publish module deliverables, so check your classroom for the exact prompt. This example describes the proposal and its evidence, states a method, places stakeholders on a power-interest grid, names the potential blockers, distinguishes positions from interests and gives a strategy for each.
DNP855 Module 6 questions, answered
What does DNP855 Module 6 usually ask for?
The module usually asks for a stakeholder analysis of a proposed change, identifying stakeholders, their power and interest, who could block the plan and how to engage them. Aspen does not publish module deliverables, so your classroom's instructions govern.
What is a power-interest grid?
A tool that places stakeholders by how much power they have to influence a change and how much the change affects them, which helps decide whom to manage closely, keep satisfied, keep informed or monitor.
What does the evidence show about hospital at home?
A randomized trial found home hospitalization reduced the adjusted cost of the acute episode by 38 percent and 30-day readmissions from 23 to 7 percent, although the trial was small and patients were highly selected.
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