Expert Panel Action Blog – Emerging and Infectious Diseases

Welcome to the Expert Panel Action Blog – Commentary and Information Posted by the American Academy of Nursing Expert Panels

Genetics, Violence, Informatics, Children Adolescents and Families, End of Life ………..

These are but a few of the Expert Panels of the American Academy of Nursing. The issues they follow and the activities they lead are important to the entire nursing community and warrant rapid dialogue among informed readers. Timely dissemination and responses are critical as traditional modes of publishing cannot keep up with the pace of information available. “Agility” is needed to deliver contemporary arguments electronically for persuasive commentary for building consensus that is timely, substantive and prepared for discourse. Blogging and blogs are increasingly providing a paperless platform for professionals to present and debate ideas in the socially connected evolving web. Nursing Outlook is now hosting an online environment for Expert Panel dissemination! Topics should engage nurses in discussions around focused topics that are important for the profession. “Op-Ed” pieces and other reports are posted for readers to learn from the distinguished leaders on the Expert Panels of the American Academy of Nursing who monitor and engage in health policy and practice today.

We invite commentary that is thoughtful and provocative! Join the online dialogue!

Veronica D. Feeg, PhD, RN, FAAN
Editor/Moderator (Contact

In Observance of National Women and Girls HIV/AIDS Awareness Day (March 10).

Believe it or not, there is an incontrovertible public health concern that needs addressed: the incidence of HIV/AIDS infections among girls and women. According to the Centers for Disease Control and Prevention, approximately 280,000 women are infected with HIV and face treatment hurdles that men do not with disproportionate distribution among African American and Latina women.  In observance of National Women and Girls HIV/AIDS Awareness Day, it’s an issue worth finding a constructive solution and silencing futile back-and-forth debate. To decrease the risk of HIV infection, establishing a system of routine testing in health settings is a good place to start. 

While there is an onus on individuals to utilize prevention methods, there’s a responsibility on health providers to make the testing process as seamless as possible. As a nation, we are falling well short of meeting acceptable standards of routine testing because of implementation and knowledge gaps. Without widespread testing, the disease burden at the individual, family, and community level of care will continue to increase. Consequently, rising rates of infection will reduce the known positive effects of prevention efforts. This is not an acceptable trend.

Statistics indicate nearly a quarter of infected individuals do not know their HIV/AIDS status, while more than half of new HIV/AIDS infections are passed on by unwitting individuals. For states and newly elected officials attempting to espouse a commonly held public health solution, implementing five-year old recommendations for routine HIV/AIDS testing can achieve widespread benefits. These recommendations were originated by the Centers for Disease Control and Prevention (CDC) in 2006, calling for routine HIV testing among people between ages 13-64 and eliminating unnecessary administrative barriers to receiving testing. Despite their societal promise, the recommendations have not been adopted across health care settings universally.

In December, an Expert Panel on Emerging and Infectious Diseases, endorsed by the American Academy of Nursing, drafted suggestions designed to see the manifestation of routine HIV testing and improve prevention initiatives leading to decreased transmission of HIV.  The expert panel calls for nurses to assume a greater leadership role in implementing the 2006 CDC recommendations.  The recommendations come in the wake of the Institute of Medicine Report, The Future of Nursing: Leading Change, Advancing Health, which identifies nurses as a catalyst for ensuring a high-quality, patient-centered health care system.

Among a host of suggestions delineated by the expert panel, nurses are key clinicians who can identify knowledge deficits among health care providers regarding the CDC recommendations, developing educational programs to address deficits among health care providers, and generating data to assess routine testing programs.

In addition the expert panel calls for the creation of interdisciplinary teams to develop specific implementation and evaluation plans to operationalize the CDC recommendations in hospitals and clinics.

Routine testing will save money and reduce rates of transmission. For clinicians, it’s imperative that they are equipped with the right information and resources. And for the sake of expanding a patient-centered health care arena, it’s a solution deserving of support, not discourse.

Corresponding Authors:

Rosanna F. DeMarco, PhD, PHCNS-BC, ACRN, FAAN
Co-Chair, American Academy of Nursing Expert Panel on Emerging and Infectious Diseases
Associate Professor, Public/Community Health, Connell School of Nursing
Affiliate Faculty of Dept. of African & African Diaspora Studies, College of Arts and Sciences
Boston College

Joe Burrage Jr., PhD, RN, FAAN
Associate Professor
Indiana University School of Nursing

AAN Leadership Interviews – “3 Questions” – Margaret McClure on Fellow Selection

Welcome to the Nursing Outlook Blog – “3 Questions” – Timely Interviews with Thought Leaders in Nursing

Health reform, quality and safety, medical liability, information technology, nursing education redesign………..

These are among the hot topics of the day. All the critical issues that are important to nursing warrant rapid dialogue among informed readers and traditional modes of publishing cannot keep up with the pace of information available. “Agility” is needed to deliver contemporary arguments electronically for persuasive commentary for building consensus that is timely, substantive and prepared for discourse. Blogging and blogs are increasingly providing a paperless platform for professionals to present and debate ideas in the socially connected evolving web. Nursing Outlook is now hosting an online environment – “3 Questions” – to engage nurses with nursing leaders in discussions around focused topics that are important for the profession. Interviews will be routinely edited and posted for readers to learn from thought leaders of the American Academy of Nursing and a variety of other nursing and health care megastars.

We invite commentary that is thoughtful and provocative! Join the online dialogue!

Veronica D. Feeg, PhD, RN, FAAN



Margaret McClure – Past President of the American Academy of Nursing and “Living Legend”

On Leadership, Change and Fellow Selection in the Academy

Question 1:As one of our most esteemed thought leaders in nursing and change agents in health care, can you describe how you see the horizon of health reform and its concomitant need for leadership?

To listen, click here.

Margaret McClure: I think for nursing, probably, this is probably a golden opportunity, and one that I hope we don’t miss. We’re about to cover 32 million new lives with our health care reform act. I have great faith that it will, in fact, be implemented much the way that we have it written. I realize that there are large numbers of people who are trying hard to prevent this from happening; however, I’m very much a proponent of the changes in health care that this portends. The problem, as I see it, is that we need nurses who are prepared to step up to the plate and assist in very important ways with the changes we are about to make. One of the things helping nursing to come to the forefront is the fact that it’s pretty clear, even to people who have never paid much attention to nurses that it can’t be done without nursing. That gives us a whole different grounding in the formation of public policy and how it’s carried out. Unfortunately, it had to come to a manpower issue, but we ARE at a manpower issue. We simply will not have enough primary health care providers in any of the more powerful roles that we’ve had all along. We don’t have enough of those folks and we’re going to have to have more and more nurses who are prepared to step forward. And to be honest with you, nurses know a great deal more than they have shared with others. The potential of nursing has never been tapped. This is an opportunity for us to participate in ways that we haven’t been able to in the past.

As we go forward, we have this golden opportunity if we play our cards right. What I’m most concerned about is that we’re rational about how we do the implementation of health care reform so that it does the best for the greatest number of people across the country.

Question 2: As the current co-chairperson of the Fellow Selection Committee, Past President of the American Academy of Nursing, and a “Living Legend,” as we prepare to solicit nominations of new Fellows, what do you see as the ingredients of leadership that when added to the mixtures of position and opportunity result in the records of achievement?
To listen, click here.

Margaret McClure: The thing that has troubled me a little bit in the past few years is the fact that I believe there are more able, wonderful candidates for admission into the Academy than we’re actually seeing join. While I recognize that we have very strong criteria for applying to the Academy on the one hand, and therefore not everyone can apply, it seems to me that at the moment the fellowship in the Academy is not representative enough of the fine leadership that exists across the country. Some of this is related to the fact that there are a lot of myths about what you have to do to be in the Academy. For example, some say “You can’t possibly get into the Academy without a PhD.” Well, obviously that’s not the case. If you look at our membership, in fact, we have a large numbers of Academy Fellows – great achievers – who do not have the PhD, EdD or DNSc and are making fabulous contributions and continue to make them. We need these people for leadership in health care reform. And we need them to be in the Academy to help us to influence policy in the most important ways we possibly can!

I am anxious to see greater diversity among the people who are Academy Fellows – and I’m talking about diversity in every possible way. Our field is so diverse. We have large numbers of people doing very important work that many don’t even know about.  We want to be sure that we capture those folks and they become a part of our Fellowship so that we can tap into them and involve them. My interest in this is very serious and it is the reason that I ran for the office of the Fellow Selection Committee.

One of the most interesting issues that we stumbled on recently that I want to make very explicit to members of the Academy is the fact that the bylaws were changed some time ago, changing the criteria for admission. We discovered that many Academy members are unaware of this. In the past, the bylaws said that one criterion for being admitted was that your important leadership contributions be above and beyond your employed position – in other words, beyond your job. We changed that several years ago because there were people who were making fabulous contributions – and every one of them, you could point to and say “Yes, but that was part of his or her job.” As an example, people who have very important positions in the military, such as the Chief of the Army Nurse Corps, have done incredible work which has had very important national impact both within and outside the military. But, if you sat on the Fellow Selection Committee and looked at the old criteria, you would say that all of their work was part of the job.

The truth of the matter is, we’re looking for people who are making a national impact, not people who are doing work above and beyond their jobs. And so, it became a stumbling block to admit some of our brightest and best. The consequence of our discovering this was a change in the bylaws – but obviously many of our fellows do not know about it and they are sponsoring people to the Academy saying to them “Be sure that you say in your application that what you’re doing is above and beyond your job.” And that’s not true at all. It is absolutely not necessary any longer. The most important thing for people to demonstrate is that they are making important leadership contributions to the profession in whatever area they work in – whether it’s in academia or elsewhere. We have people in practice, we have people in information technology, we have people in the insurance part of the world, we have people in policy, we have people in state government – many are doing wonderful work – and the “above and beyond” criteria would not fit! We don’t need it to fit.

What I really would like everyone in the Academy to understand is that the old definition is gone. Now we are looking for people who are leaders in their fields who are making important contributions with a national impact. Having said that, we are looking for people from all our diverse specialties, and more and more, we are beginning to see those folks applying to the Academy, although they often think they’re not eligible.

I think one of the things we haven’t done is to have Academy Fellows see themselves as recruiters – to go up to people they recognize as real leaders and say “Are you a Fellow of the Academy? If not, we have to do something to get you into the Academy.” We need to begin to bring these folks into the fold. They may say “I don’t think I’m eligible…” when in fact you know inside your heart that they are. This is the kind of thing we can help our own Fellows understand in terms of their own responsibilities. The Academy is going to have an important role to play in health care reform and we want to realize that in big ways.

Question 3:Can you discuss the leadership role of the Academy in preparing for this freight train of health policy change through its nomination and selection of Fellows who will drive it into the near and distant future?
To listen, click here.

Margaret McClure: The Academy has over the years increasingly positioned itself, thank goodness, to serve the people of the United States in policy reform and in helping to make health care better and better. I am encouraged about our own involvement in what has gone on to date – and I’m also encouraged at our potential to be tapped as one of the leadership organizations to turn to in health care as we begin these reform processes. A good example: President Catherine Gilliss is doing a terrific job and was recently interviewed by the New York Times. This is an acknowledgement that there is an Academy and that the Academy has something to offer. We have had fine leadership from our Executive Directors: Pat Ford Roegner did a great job to set us up in Washington and get us going. It’s the reason we need to be in Washington. Our new Executive Director, Cheryl Sullivan, has wonderful ties in the Washington area and will be in a position to help the Academy find opportunities to participate to move some of this. One of the most important things you do in an organization such as the Academy is to position yourself in such a way that when people are forming new commissions, new committees, new task forces at the federal level, they call the Academy and say “Do you have someone from nursing who can serve on this commission/committee/task force so that we’ll have that voice.” That they call the Academy – and that they know about the Academy! One of the problems we had being in Wisconsin, as fine as the folks were there, it did not place us where we needed to be in terms of health care policy. The move back to Washington was overdue, badly needed, and I’m so pleased we’re there with the kind of leadership we have at this moment.

The Academy represents our brightest and best in nursing. The Academy should be where we turn. We should work hand-in-glove with the ANA because often the ANA is the group that is called. With the great relationship we have with them, we can help them to place people as well. I remember when we were putting together Quality Commissions and nominating people to serve, we worked very closely with ANA so that we were speaking with one voice and we were putting forward the same people. It’s terribly important that we speak with one voice and that we do what we need to do.

I think the Academy is in a very strong position right now and I think we need to make sure that the officers of the Academy have a way to identify the right people for the right jobs. And then, of course, we have to have members who are willing to step up to the plate and say “Yes – I will sit on that commission – Yes – I will be a part of this work.” What I know of the Fellows of the Academy, it will not be hard work. We do not have difficulty convincing them to be heavily involved. We have a very important and bright future in helping to shape what will go on in health care reform in this country.

The Future of Nursing: Leading Change, Advancing Health (IOM/RWJ) Questions

On October 5, 2010 a landmark report on “The Future of Nursing“ was published by the Institute of Medicine, sponsored by the Robert Wood Johnson Foundation. This report is the most comprehensive and data based analysis of the various issues facing the profession and the discipline, written by a committee of experts from within and outside of nursing.

All nurses in leadership positions should read the 600 page report you can access via the web link provided here. The report provides a framework for the work to be done by all of us to maximize the contributions of the nursing profession to improving the health and well-being of citizens in this country and so many others.

I have asked several members of the IOM committee to share their thoughts about questions I posed. I highly recommend to you their valuable answers and insights —and WELCOME your thoughts in response!! Please do sign on and tell us what you are thinking…..
Marion E Broome, editor, Nursing Outlook: The Official Journal of The American Academy of Nursing

Question: What do you think is the single most important issue that nursing must address in the next 2 years?

Response from: Linda Burnes Bolton, DrPH, RN, FAAN
Vice President and Chief Nursing Officer,
Cedars-Sinai Health System and Research Institute, Los Angeles, CA

Nurses and nursing organizations must assume professional and leadership responsibility to adopt the committee’s recommendations on improving the professional nurses’ capacity to participate in the transformation of our health care system. As stated in the committee’s report we need nurses across all settings to be better educated and to work within and outside of their organizations for safer, patient centered, equitable, effective and efficient health care for the American public.

Question: Based on the work of the committee what advice would you give nurses newly entering the field who want to maximize their contributions to the field over the course of their career?

Response from: Linda Burnes Bolton, DrPH, RN, FAAN
Vice President and Chief Nursing Officer,
Cedars-Sinai Health System and Research Institute, Los Angeles, CA

New nurses entering the field should seek opportunities to participate in transitional programs that will facilitate their adoption of evidenced based, effective health care. Nurses must adopt a commitment to life-long learning that includes working with consumers, physicians and other health professionals as full partners in the promotion of health , prevention of adverse events and the fostering of health system renovation across the continuum of care. The greatest demand for nursing care remains outside of acute care settings. Individuals entering the field should seek to acquire knowledge, skills and experience to provide care across the life span and settings.

Response from: Liana Orsolini-Hain, PhD, RN
Nursing Instructor, City College of San Francisco, CA

Stay in school. I am hearing from chief nursing officers that they will become further financially strapped due to healthcare reform and probably won’t have the financial resources to train new graduates. They are being selective and are hiring BSN prepared nurses over AD prepared nurses in many parts of the country. Some hospitals in California are advertising that they prefer new graduates to have a master’s degree in nursing to make up for their lack of experience. Healthcare Reform will provide many new opportunities for nurses who get their NP and can practice primary care, especially collaboratively within medical homes and other chronic care management entities. A certification in geriatrics will go a long way as 78 million baby boomers continue to age. Also, consider a trajectory that will enable you to become a nursing educator. We have a serious nursing faculty shortage that will worsen as older faculty retire. We desperately need more doctorally prepared nurses to teach in universities and in community colleges offering the BSN degree. Lastly, join a few nursing, political, and leadership professional organizations. All of us should be active members of our specialty organization to help us stay up to date in our practice. We need more nurses to lead the implementation of health care reform, and we need to learn to lead at the national level.

Question: What strategies should leaders in nurse education employ most effectively to lead their faculty to respond to the mandates in the IOM report on the Future of Nursing?

Response from: Linda Burnes Bolton, DrPH, RN, FAAN
Vice President and Chief Nursing Officer,
Cedars-Sinai Health System and Research Institute, Los Angeles, CA

Presidents of universities and colleges must work with deans of nursing and other health professional schools to promote interdisciplinary education at the undergraduate and graduate level. It is essential that faculty actively lead efforts to prepare nurses to work within complex systems, engage consumers and patients at the community and point of care level, to identify opportunities to work environments so that they are beneficial to patients and less burdensome to health professionals through the use of technology and the creation of innovative systems of care.

Response from: Liana Orsolini-Hain, PhD, RN
Nursing Instructor, City College of San Francisco, CA

Every university that offers a BSN or higher degree in nursing should reach out to community college nursing programs and employers of RNs to form education consortiums which provide seamless co-enrollment of Associate Degree (AD) students, the automatic transfer of financial aid, joint-teaching appointments, shared staff RN clinical faculty in dedicated education units, elimination of curriculum redundancy and a streamlined process of earning a BSN degree in no more than 3 semesters. Universities should also streamline AD and diploma to MSN education for working RNs who wish to make a contribution to nursing that requires a minimum of a master’s in nursing degree. Community colleges that wish to offer the BSN degree should incentivize their faculty to return to school for a doctoral level degree and obtain and those colleges should maintain CCNE or NLNAC accreditation. We should also tap into our LVNs and incentivize them to return to school for higher degrees. Our LVN population has a level of diversity that is more reflective of the population of the US so recruiting them to return to school will probably increase the diversity of RNs.

Question: How do we best prepare and mentor dynamic leaders for the future of health care practice?

Response from: Linda Burnes Bolton, DrPH, RN, FAAN
Vice President and Chief Nursing Officer,
Cedars-Sinai Health System and Research Institute, Los Angeles, CA

Leaders of the future should be prepared by today’s leaders through the deployment of mentors from across health care settings and the implementation of programs where individuals have the opportunity to lead projects in diverse environs. Leadership is a practiced art and to create the leaders of the future we must provide individuals with the education and willingness to lead with opportunities to do so.

Response from: Michael R. Bleich, PhD, RN, FAAN
Dean and Dr. Carol A. Lindeman Distinguished Professor
Oregon Health & Science University School of Nursing

First, we need to embed clarity around the idea that every nurse is a leader, manager, and follower and improve conceptual clarity that leading requires innovation and risk, managing is both a set of personal attributes and an ability to persist in goal achievement, and that following is not a “less than” function, but is an act of acquiescence and energy given willingly to the “team.” If we can embrace a non-hierarchical perspective on this, then we look for traits in those entering the profession who are risk-takers, who believe that they can influence and engage with a range of stakeholders in the health system (beyond the expectation of roles with patients/families/communities), and who will bring forward their best game to work to outcomes. In basic nursing education, all students are given feedback on leadership skills in every course, strengthening the sense of self purpose and awareness in context with others.

Next, we need to create environments for leaders to flourish. This includes creating informational and transformational knowledge experiences of organizations, systems and work design, quality improvement, complexity science approaches to change to complement programmatic approaches to change management and the use of conflict engagement strategies.

Role models and mentoring should become part of a career and life experience, with individual and organizational strategies to “match” individuals both from within and outside of nursing and health care circles. Having a career plan that is developed for short and long term development is an imperative and employing and regulating/certifying organizations should encourage an articulation of this development plan.

Senior level nurses and stakeholders close to nursing must create opportunities and formal programs for leadership development, preferably staged to align with critical times in a professional trajectory. For example, the Veterans Administration as a system is a model for promoting continuous growth and aligning programs at sensitive times over the course of a career, engendering loyalty and an infusion of perspective to advance the health needs of veterans. Other programs that are examples of leadership development include programs sponsored by the Robert Wood Johnson Foundation, the Wharton School of Business at the University of Pennsylvania, Sigma Theta Tau, the American Organization of Nurse Executives, and the Cockcroft Fellows program at the University of South Carolina, and the University of California Center for the Health Professions. All of these programs – and others – have a history of producing effective leaders and can serve as a basis for expanded opportunities.

Question: What role should nurse scientists play in helping shape the future of nursing and how do they expand their capacity to do so? 

Response from: Linda Burnes Bolton, DrPH, RN, FAAN
Vice President and Chief Nursing Officer,
Cedars-Sinai Health System and Research Institute, Los Angeles, CA

Nurse scientists have made significant contributions to health care delivery, health policy and the design of effective programs that have facilitated the provision of safe, effective, efficient, equitable, patient centered care across the continuum of services. However, as stated in the report there are insufficient numbers of nurse scientists and nurses with earned doctorates to fulfill the needs for nursing faculty, nurse researchers, nurse executives and public health leaders. The committee’s recommendation on the increase in the number of nurses with BSNs from 50% to 80% of the workforce by 2020 is foundational to increasing the pool of applicants that will enter graduate and doctoral education. Our recommendation on the doubling of nurses with earned doctorates to teach nurses, to expand the number of nurse scientists actively engaged in comparative effectiveness research, translational research, health services research, community participatory research as well as basic and clinical research. The report also identifies the need for more data and nurse researchers are best positioned to lead and disseminated studies that will provide the profession with the requisite evidence to move forward in so many areas.

Response from: Michael R. Bleich, PhD, RN, FAAN
Dean and Dr. Carol A. Lindeman Distinguished Professor
Oregon Health & Science University, School of Nursing

First, nurse scientists must continue to play the critical role they already play in generating clinical knowledge through a nursing lens. From my vantage point, knowledge generation around symptom management, health promotion and maintenance, and discovery to expand knowledge around disease and disability can only strengthen our contributions to the public, inter-professional team performance, and our own discipline. The report reframes the importance of bending the cost curve of health care expenditures by placing added relevance to those areas which are within nursing’s purview of promotion and disease management and curtailment. We must prevail in these areas.

Second, it is my sense that this report challenges nurse scientists to expand our presence at other “systems” tables. As new models of care develop, the efficacy, efficiency, and scalability of these models will require nurses to gain and incorporate comparative effectiveness skills to test and advance new approaches to care. As the public grapples with the acceptance of nursing roles in expanded capacities, we will need nursing science to test and monitor how the nurses who contribute to care can assure safe and effective outcomes in contrast to or when combined with other disciplines, including physicians. The need for additional knowledge generation around nursing and inter-professional education is yet another critical area that nurse educators lament as lacking (and for which there is limited funding) and this report shines a light on the paucity of research to advance teaching, learning, and competency attainment. Finally, as a discipline, we cannot discount that nurse scientists will play expanded roles on inter-professional teams which may include research that is conducted outside of traditional academic settings.

Putting these needs together and in context, expanding our capacity to produce and engage scientists in research is no small task. The first fundamental question is “How do we enlist those nurses with current doctoral research preparation who have never substantively used their education for the purpose of research?” Are there non-research intensive environments where we could enlist these individuals in areas of workforce, educational, or organizational research that does not require an academic health science center setting, but may require linking them with each other and alternate settings, such as workforce centers? The second question is, “How do we enliven the experience of obtaining a research degree, such that it is more appealing and achievable than current perceptions?” Although ideal, not every nurse wants or even needs the same level of preparation for a purist science-based role. Are we able to address variability in learning styles and career trajectories within our doctoral education programs to address those who might want a blended role(s)? If so, how can we market the delivery of those programs and ensure that there is a research “return on investment” in all who graduate. Third, “How do we engage doctoral research educators – within and outside nursing – to augment our perspectives on research careers and expanded content consciousness?” Is there room in nursing education for organizational, econometric, environmental, and other scientists to expand our capacity similar to what was done in the pre-nursing PhD years?

If we can address these issues, then funding options for career development could expand beyond traditional federal funding. Organizations, including accountable care organizations, hospitals and health systems, professional societies, and philanthropy can step forward to play an added role in support.

Maelstrom of change: Back to the future

This past month, two very important reports were disseminated, both of which demand the attention of nurse leaders. The Carnegie Foundation’s Educating Nurses: A Call for Radical Transformation1 and the results of a Gallup Poll, Nursing Leadership from Bedside to Boardroom, funded by the Robert Wood Johnson Foundation,2 present provocative data about nurses and how and what we think we prepare them to do. The findings provide much food for thought.

Here are just some questions we must ask ourselves as we move forward:

  • Do all members of the professoriate in nursing have the commitment to change? To engage themselves in the work of changing undergraduate education?
  • What financial forecasting models are needed to determine the cost of preparing faculty for these new roles and pedagogies?
  • How do we predict and then accommodate changes in the numbers of students that can educated using new models?
  • How receptive will healthcare systems be to these new models, to embedding faculty into their leadership structures, and what can they offer in terms of support?

Read more…

1. Benner P, Sutphen M, Leonard V, Day L. Educating nurses: a call for radical transformation. San Francisco (CA): Jossey-Bass; 2010.

2. Gallup, Inc. Nursing leadership from bedside to boardroom: opinion leaders’ perceptions. [Submitted to] The Robert Wood Johnson Foundation, January 20, 2010.