The Evidence Behind ANCC’s Pathway to Excellence^® Credential’s Return on Investment

Abstract

In today’s resource-constrained healthcare environment, a business case is often used to provide formal justification for a project or initiative. Aspects covered in a business case include benefits, costs, risks, and strategic alignment between a project and an organization. The Pathway to Excellence^® (Pathway) designation is supported by evidence in each of these areas. The author reviews current evidence in developing the business case for allocation of resources to support Pathway designation.

Numerous challenges are facing healthcare leaders on a global basis, as well as specifically in the nursing workforce, the largest segment of healthcare professionals¹. Nurses are in a unique position to assist in tackling global health concerns and helping patients achieve optimal levels of health^1–3. To achieve desired health outcomes, leaders must focus on developing an engaged, competent nursing workforce including addressing nursing shortages^1–3. In addition, educational systems must be developed that prepare the next generation of nurses in sufficient numbers and educators must consider nurse well-being as an essential curriculum component^1–3. Research supports that nurses want to work in positive practice environments (PPEs) where evidence is used in practice and nursing has a voice in professional governance^1,3.

An evidence-based framework supporting a healthy PPE can lead to improved patient, nurse, and organizational outcomes^4–11. American Nurses Credentialing Center’s (ANCC^®) Pathway to Excellence^® (Pathway) designation is recognized as a framework to support high-performing PPEs¹².

Development of a Business Case

Return on investment (ROI) has typically been utilized in the business sector as a method to measure financial gains or losses based on an investment¹³. ROI is also utilized as a tool in developing a business case to evaluate potential investments’ returns for strategic decisions¹³. The use of ROI in the healthcare setting is becoming increasingly useful in determining what investments will garner benefits to the organization¹⁴. The ROI concept in healthcare is that numerous types of benefits can be realized with investment beyond profit, such as patient care quality benefits, quality improvement benefits, human resource benefits, cost benefits, containment, avoidance, and savings¹⁴. In a systematic review of the concept of ROI in healthcare quality improvement, the authors developed a QI-ROI framework to include all facets of both fiscal and nonmonetary benefits when evaluating ROI that can be used when developing a business case¹⁴.

In today’s cost-constrained healthcare environment, it is imperative that organizations understand the value of their investments and estimated returns¹⁵. The development of a business case, or formal justification, to support the journey and attainment of the Pathway to Excellence designation is one way to support enhanced practice environments for nurses. Components of a business case include identifying the investment and multiplying by 100 to convert benefits, costs, risks, and strategic alignment with organizational goals¹⁴. Nurse executives and nurse leaders must be able to articulate the benefits of the Pathway journey to stakeholders, decision-makers, and the nursing workforce if support is to be truly realized. A business case is a clear way to communicate these benefits.

The Evolution of the Pathway to Excellence Program

Pathway originated in Texas in 2003 as the Texas Nurse Friendly (TNF) program, whose primary objective was to attract and retain a competent nursing workforce in the state of Texas¹⁶. TNF was created by the Texas Nurses Association to improve the work environment and recruitment of nurses¹⁶. In 2007, ANCC acquired the TNF program and created a national nursing excellence credential for PPEs, Pathway to Excellence¹⁶. The original program was designed for acute care hospitals in the United States and has since expanded internationally to include care settings beyond hospitals. Pathway began with 12 evidence-based standards that were streamlined to combine overlapping concepts and consolidated into 6 standards: shared decision-making, leadership, safety, quality, well-being, and professional development^12,16.

Benefits of Pathway Designation in Developing a Business Case

Reducing the Cost of Turnover and Recruitment

With 10% of the global gross national product spent on healthcare and nurses being the biggest sector of providers¹, nurses are an essential resource to the success of an organization. Increasing employee engagement and attracting and retaining nurses can reduce the cost of turnover for healthcare organizations^4,17. The cost to replace a bedside registered nurse (RN) is $61,110, which is estimated to cost the average hospital 3.9 to 5.7 million dollars annually¹⁸. Hospitals are at risk of losing or potentially saving an estimated $289,000/y with each percentage change in RN turnover¹⁸. Although RN hospital vacancy rates decreased by 0.3% in 2024, the reported overall hospital vacancy rate remains high at 9.6%. The use of contract personnel has increased in recent years for both vacancies and skill deficits¹⁸. The cost of a travel nurse is reported to be an average of $79,090/y more than an employed nurse¹⁸. Studies showed that PPE was associated with lower nurse burnout^4,9,17, higher nurses’ intent to stay^4,9,17, and a better perception of the units’ nursing care^4,17. Thus, initiatives that increase nurse engagement and involvement in hospital affairs, nurse retention, and decrease burnout can have a positive financial return for healthcare organizations^4,9,17,18.

Nursing Care Quality

Nursing care quality is paramount to patient outcomes and organizational costs. Improvements in care quality are typically aligned with the strategic goals of healthcare organizations¹⁵. The National Database of Nursing Quality Indicators™ (NDNQI^®) measures nursing quality by examining the performance of nursing-sensitive indicators (NSIs)¹⁹. The Agency for Healthcare Research and Quality (AHRQ) conducted a meta-analysis review of additional costs incurred by hospital-acquired conditions that included NSIs and estimated the average increased costs per patient. Of the 10 conditions evaluated, the top 2 most costly conditions were NSIs. Central line–associated bloodstream infections (CLABSIs) were the highest cost, with an estimated per patient cost of $48,108 and ventilator-associated pneumonia (VAP) at $47,238; catheter-associated urinary tract infection (CAUTIs), falls, and pressure ulcers also showed increased costs per patient⁵. PPEs have shown numerous benefits to an organization’s finances: nurse retention⁴, improved care quality⁵, patient satisfaction⁶, better nurse engagement⁷, and organizational loyalty⁶. Research has shown that missed nursing care is less of an issue in PPEs, and lower levels of missed nursing care have been associated with higher quality of care²⁰.

Patient Experience Costs

Patient experience can impact an organization’s bottom line. Negative patient experiences can result in reputational costs, including a reduction in patient retention and loyalty, reduced patient referrals to others, and higher costs associated with patient complaints²¹. In the United States, Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) results are reported on the Hospital Compare website, giving consumers the ability to review hospital ratings and consider options for care²². In the Hospital Value-Based Program (VBP), lower HCAHPS scores in patient experience can result in lower Medicare reimbursements or financial penalties. In contrast, VBP offers financial incentives for high-performing organizations in quality and patient experience²³.

In a recent study, the impact of Pathway designation on patient satisfaction outcomes of hospital rating and willingness to recommend an organization was examined using the HCAHPS and the American Hospital Association’s (AHA) 2023 data sets⁶. The results indicated that patients in Pathway organizations, compared to non-Magnet^®/non-Pathway organizations, reported significantly higher hospital ratings and a greater likelihood of recommending the organization to others. There was no difference between Pathway and Magnet designated organizations in terms of their impact on patient satisfaction⁶. In another study in Swiss hospitals, patient experience was found to be associated with increased revenue, a higher number of elective patients, and lower costs²⁴.

Additional Research Supporting the Pathway Standards

In addition to the areas described above, the following categories of Pathway standards are supported by evidence that can be used in the development of a business case.

Shared Decision-making

Research shows that PPEs and nurses’ engagement in shared decision-making results in lower nurse job dissatisfaction, less likelihood for nurses to leave the job, and lower reporting of poor care quality by nurses^8,9,11. RN participation in hospital affairs is associated with lower readmission rates²⁵ and a higher reported quality of working life by RNs¹⁷. Nurse empowerment to influence patient care quality was realized in a retrospective observational quality improvement project; RNs empowered to practice at their full scope in managing Foley catheter discontinuation decreased CAUTIs from 7.6/1000 catheter days to 0/1000²⁶. Interprofessional collaboration, a key component of Pathway, is essential to achieving desired outcomes. Research showed patients managed by wound ostomy certified nurses (WOCNs), in partnership with orthopedic surgeons, had a reduced length of stay compared to those who were not²⁷.

Leadership

Nurses who reported higher levels of leadership support and effective leadership communication reported improved outcomes to include fewer adverse events, increased nurse-reported errors, higher patient satisfaction, better patient care quality reporting²⁸, greater RN innovation, and prioritizing teamwork over individual gain and psychological safety²⁹. Supportive practice environments and higher ratings for nurse managers showed nurses were more likely to complete incident reports, promoted a culture of safety, and influenced nurses’ intent to stay^10,30. Competent nursing leadership has been shown to have an impact on staff well-being, safety culture, care quality, and patient satisfaction^31–35. The American Organization for Nurse Leadership (AONL) created nurse leader core competencies that focus on essential knowledge, skills, and abilities to provide transformational nursing leadership to include fiscal and business acumen³⁶. Experienced and competent nurse managers were associated with better practice environments, which in turn had fewer missed nursing care and higher quality care³¹.

Safety

Studies indicate that a climate of safety in PPEs shows lower rates of medical errors³⁷ and a higher likelihood of disclosing medical errors with supportive leadership¹⁰. Another study found that units where RNs perceived a better safety culture reported higher job satisfaction, and with good staffing levels had lower rates of hospital-acquired infections³⁸.

Quality

Studies that examined the impact of interprofessional and RN-led quality improvement projects have demonstrated improved patient outcomes^27,39–42. In addition to the aforementioned quality improvement initiatives that improved care quality, an evidence-based central venous catheter pediatric protocol also resulted in a decrease in CLABSI rates⁴⁰.

Well-being

The National Academy of Medicine (NAM) recognized the significance of healthcare workers’ well-being and published a National Plan for Health Workforce Well-Being in 2022, noting critical linkages between clinician well-being and the delivery of safe, quality care⁴³. There is mounting evidence that organizations that invest in strategies for healthcare providers’ well-being realize numerous benefits. Studies have shown that well-being programs have resulted in lower intent to leave the organization, better nurse satisfaction, lower burnout symptoms, and increased resilience^44,45. In a review of meaningful recognition and the DAISY Award^®, meaningful recognition is a low-cost strategy that can impact nurses’ wellness, reduce burnout, support resiliency, and nurse retention, potentially resulting in improved patient satisfaction and organizational savings⁴⁶. Nurses’ health and well-being can impact safety; nurses who reported better health were less likely to commit medical errors⁴⁷. In addition, it has been shown that organizations that support wellness in the workplace have nurses who report better health and higher professional quality of life⁴⁷.

Professional Development

Professional development and lifelong learning begin with the onboarding of new graduates or new hires. Transition-to-practice programs have shown increased confidence, competency, and retention⁴⁸. In an integrated review, nurses reported that professional development enhanced their clinical care, communication skills, potential career advancement, and knowledge, reducing work-related anxiety⁴⁹. The ability for bedside clinicians to professionally grow in professional advancement programs has been shown to favorably impact RN turnover rates⁵⁰. Organizational support for leadership development showed lower intent to leave and higher job satisfaction among nurse managers³².

Assessing the Value of Pathway

Pathway has several methods to assess designated organizations’ satisfaction with the value of the designation related to areas previously noted in a business case, including cost, quality, and organizational alignment. Stories are often used as powerful examples in relating value to stakeholders. Table 1 displays the drivers for organizations seeking designation and outcomes reported by Pathway-designated organizations^51–57. Designated organizations are invited to share case studies on the ANCC’s website regarding their journey to designation and the organizational impact. Table 2 lists the reported outcomes of designated Pathway organizations’ case studies from the literature⁵⁸. Pathway has an annual customer satisfaction survey completed by chief nursing officers (CNOs) and Pathway program directors (PPDs) to evaluate the value of the Pathway journey and achievement of the credential. Table 3 shows the Pathway’s customer satisfaction results, which show the value, likelihood to recommend, quality and likelihood to renew Pathway, and the top 5 reasons Pathway designation added value⁵⁹. In a recent study comparing Pathway and Magnet organizations to non-ANCC designated organizations, both designations outperformed non-designated organizations⁶⁰. Pathway had significantly higher scores in all practice environment domains, better RN retention, and RN’s reporting higher perceived quality care, less missed nursing care and greater professional development opportunities and access than non-designated organizations⁶⁰. This study supports what organizations have reported in both their case studies and value of the Pathway credential.

Table 1.

Pathway-designated reported drivers/outcomes

Drivers to Pursue Pathway Designation	Pathway Designation Reported Outcomes
Improve nurse retention51	Improved care quality outcomes51–53
Create a positive practice environment52,54,55	Increased RN engagement/empowerment51–53,55
Cost savings/reductions51,55	Improved nurse satisfaction53
Improve patient outcomes/evidence-based practice51,53,55,56	Lowered RN turnover/vacancy rates52,53,55,56
Increase professional development56	Improved well-being programs/ nurse well-being55–57
Develop strong shared governance/shared decision-making processes53,54,56	Increased professional development among nurses53,55
Focus on well-being programs57	Increased patient satisfaction and better outcomes at lower cost52

Table 2.

Pathway-designated case studies reported outcomes^a

Improved quality and safety outcomes

Better interprofessional collaboration

Better communication between nursing leadership and staff

Active shared governance

Increased RN engagement and empowerment

Greater nurse recognition

Improved nurses’ well-being and increased well-being programs

Greater professional development among nurses, such as certification and academic progression

Improved recruitment and retention metrics

Improved nurse and patient satisfaction

^a Of the 17 organizations that have shared their case studies, all of the standards were highlighted by one or more of the participants, with shared decision-making highlighted the most⁵⁸.

Table 3.

Customer satisfaction 2024 results

Customer Satisfaction Metric	Rating	CNOs (%)	PPDs (%)
Likelihood to recommend Pathway credential	Likely to recommend the Pathway credential	100	99
Quality of Pathway credential	Rated the quality of the Pathway credential as good or excellent	100	98
Pathway Credential value	Rated as good or excellent	97	99
Likelihood to renew the Pathway credential	Likely to renew the Pathway credential	100	96
Top 5 reasons Pathway designation added value
(1) Validated excellence and best practices
(2) Increased nurses’ satisfaction
(3) Positive impact on patient outcomes
(4) Increased recognition and prestige
(5) Enhanced recruitment and retention

CNO indicates chief nursing officer; PPD, Pathway Program Director.

Note: The likelihood of recommending Pathway over the last 4 years (2021-2024) has remained high, between 94% and 100%⁵⁹.

Response rate: CNO: 64/258 (25%); PPD: 106/258 (41%).

Pathway’s Return on Investment

The evidence behind PPEs and the influence on an organization’s finances is apparent. Pathway has created a ROI calculator noted in Table 4 for organizations to evaluate the potential benefits of getting credentialed and estimate ROI. CNOs can use the calculator to assess estimated organizational financial returns such as potential savings and cost avoidance and advocate for the necessary resources as part of a business case to move forward with Pathway. When an organization is considering the Pathway journey, all required costs and resources necessary should be considered, as well as cost savings/avoidance as described above. Pathway’s ROI calculator can be populated with application costs and potential targeted outcomes that can impact cost savings/avoidance. CNOs and nurse leaders can include metrics that need attention in their organization to identify the value of engaging the workforce to meet desired goals for costly quality/retention metrics. Table 4 shows a hypothetical example using the ROI calculator with a 400- to 599-bed organization fee structure and relevant evidence-based returns based on the impact on retention and NSIs.

Table 4.

Pathway to Excellence ROI hypothetical example for 400-599 licensed beds

Pathway to Excellence Application/Designation Costsa
Applicant Registration/Appraisal Fees-Licensed Beds (400-599)	Due Date	Fee
Applicant registration (all applicants)	Submission of Pathway Application	$3750
Appraisal fees	Document Submission	$33.125
Year 1 Annual Paymentb Designation Anniversary	Year 1	$11,042
Year 2 Annual Paymentb Designation Anniversary	Year 2	$11,042
Year 3 Annual Paymentb Designation Anniversary	Year 3	$11,042
TOTAL APPRAISAL REVIEW FEES OVER 4-YEAR DESIGNATION (Fees vary based on licensed bedsa; N/A if not designatedb)	Year 4	$66,250
Nursing Workforce Metrics
Nursing Workforce Metric	Data Input b	Potential Cost Savings/Avoidance
Employed nurses (Headcount)	500
Nurse turnover rate (%)	5% (500×5%=25); 25×$61,110	$1,527,750
Nurse vacancy rate (%)	4% (500×4%=20); 20×$61,110	$1,222,200
Contract RNs use rate (%) (over 12 mo)	2% (500×2%=10); 10×$79,090	$790,900
TOTAL Nursing Workforce Metrics		$3,540,850
Nursing-Sensitive Indicators
Nursing-Sensitive Indicator	Data Input c	Potential Cost Savings/Avoidance
CLABSI (enter the number for the last 12 mo)	2 × $48,108	$96,216
VAPs (enter the number for the last 12 mo)	1 × $47,238	$47,238
Pressure ulcers (enter the number for the last 12 mo)	1 × $14,506	$14,506
CAUTI rate (enter the number for the last 12 mo)	2 × $13,793	$27,586
Patient falls	3 × $6694	$20,082
TOTAL Nursing-Sensitive Indicators		$205,628
TOTAL Potential Cost Savings/Avoidance	$3,540,850+$205,628	$3,746,478
ROI TOTAL	$3,746,478−$66,250	$3,680,228

CLABSI indicates central line–associated bloodstream infection; RN, registered nurse; ROI, return on investment; VAP, ventilator-associated pneumonia.

^a 2024 Pathway to Excellence Application Fees: ANCC Pathway to Excellence Current Fee Structure is on the ANCC website: https://www.nursingworld.org/organizational-programs/pathway/apply/fees/ ⁶¹

^b 2025 NSI National Health Care Retention & RN Staffing Report; NSI Nursing Solutions, Inc.: Average cost to replace an RN $61,110, lose or potentially save an estimated $289,000/y with each percentage change in RN turnover, travel nurse costs an average of $79,090/y¹⁸.

^c AHRQ (2017): Average estimated additional cost for each NSI: CLABSI—$48,108, VAP—$47,238, pressure ulcers—$14,506, CAUTI—$13,793, falls—$6694⁵.

This is a hypothetical example—CNOs can input data on those quality and nursing workforce metrics to focus on when considering seeking the Pathway to Excellence® designation and the potential value of the Pathway designation. Also, other costs associated with seeking the Pathway credential (such as program manager, staff protected paid time, and costs of potential initiatives to meet Pathway standards) should be included when estimating ROI.

Implications for Nursing Leadership

Through a review of the literature, it is evident that PPEs make a difference in care quality, safety, nurse retention, and well-being. An engaged nursing workforce that participates in shared decision-making and is supported by leadership to develop professionally translates to a work environment that is evidence-based and influences quality and financial outcomes^{4,5,7,13,14,17,18,25,28,29,51–57,60}. Evaluating not only the clinical and human resource advantages of Pathway designation, but the impact on quality of care should be a consideration in starting the journey. Pathway can serve as a roadmap to achieve nursing excellence through PPEs¹². Developing strategies that are aligned with the organization’s goals are a key competency of a CNO. A beginning might be to crosswalk Pathway standards to strategic plans to evaluate congruency with organizational goals. The ROI calculator can serve as a resource to demonstrate the potential benefits for the Pathway journey and designation when developing a business case to advocate for Pathway designation and ultimately nursing excellence.

Conflicts of Interest

E.S. received compensation from ANCC as an independent contractor, she also provides consultation as an independent contractor for another organization that advises on nursing credentialing documents, including Pathway to Excellence documentation.