Collect these data to assess nursing quality
Impact on reimbursement will be 'huge'
The quality of nursing care will have a much bigger impact on reimbursement than ever before, as a result of the Centers for Medicare and Medicaid Services' (CMS) "no pay" conditions, according to a recent analysis.1
According to the researchers, CMS' final inpatient prospective payment system rule signals the need for "a serious commitment to nursing quality," says Ellen Kurtzman, MPH, RN, author of the analysis and assistant research professor in the department of nursing education at George Washington University in Washington, DC.
"So many of the events that CMS talks about go back to nursing care. The impact on nursing is going to be huge," says Susan B. Hassmiller, PhD, RN, FAAN, senior program officer and the leader of the human capital team at the Robert Wood Johnson Foundation in Princeton, NJ. "Any CEO who wants to stay the course with quality and not go further in the red financially really needs to pay a great deal of attention to how their nurses are going to be supported in doing their job."
Effective for patients discharged as of Oct. 1, 2008, the rule eliminates additional Medicare payments for eight conditions including: inpatient pressure ulcers, catheter-associated urinary tract infections, vascular catheter-associated infections, certain surgical site infections, objects left in the patient during surgery, air embolism, and blood incompatibility.
Since most of these conditions are linked by evidence to nursing care, hospitals are bolstering quality improvement programs geared toward nurses.
"Additional data will now be collected on these hospital-acquired conditions. The data will need to be analyzed, tracked, and translated into actionable QI strategies," says Kurtzman. "As CMS augments the list of inpatient hospital-acquired conditions, which it intends to do, an additional burden for measurement, reporting, and improvement will fall on quality."
At York Hospital (PA), part of the WellSpan Health network, the orientation program for new nurses has been changed to address the CMS changes. Nurses are asked to be vigilant in identifying patients admitted with community-acquired pressure ulcers and urinary tract infections, and documenting this, says Gregory M. Gurican, RN, MS, MBA, the hospital's nursing performance improvement coordinator.
Currently, the organization's rate of hospital-acquired infections and pressure ulcers is less than half that of national benchmarks, adds Gurican.
Data to assess the quality of nursing care are collected at the unit, service line, and house-wide levels, in addition to core measures and the organization's database of clinical indicators impacted by nursing and nursing care activities.
"Many hospitals will be paying closer attention to those areas where nursing might impact the CMS 'no pay' list," says Gurican. "At York Hospital, no special changes in quality improvement programs were necessary. However, something may be required in the future if we find the need to refine nursing protocols to reduce the financial impact of the CMS changes."
The worst thing an organization could do is "play the blame game," says Hassmiller. "We hope that does not happen. If nurses got blamed left and right for the money that a hospital has to pay out, that would send the morale of the nursing profession deeper than it already is," she says. "That would be disastrous for a hospital."
Closer collaboration
As a quality professional, you will need to collaborate with nurses and others to reduce or eliminate the eight "no-pay" conditions. The conditions warrant attention from multiple disciplines — nutrition services, infection control, case management, risk management, and patient safety, says Gurican.
There is a definite trend toward decentralization of the performance and quality improvement functions, leading to closer collaboration with nursing staff, says Gurican. Quality managers are training frontline staff in data collection and analysis. In some cases, external training is given, with qualified individuals placed directly on service lines to support nursing efforts.
"Here at Wellspan Health, there is a movement toward having many individuals trained in Lean Six Sigma outside the standard quality management and quality control departments," says Gurican. "So the talent is dispersed throughout the organization."
Plan-Do-Study-Act has been the methodology of choice at Wellspan for many years, to provide quick cycles of change at the unit level, service line level, and hospital-wide level. Newly established multidisciplinary clinical effectiveness teams are addressing disease- and care-specific issues.
York Hospital has several Six Sigma green belts already in place, and more will be added in the near future. The hospital plans to add about 10 new staff members to the ranks each year who are trained in lean methodologies, at every level within the organization.
"I strongly believe that this will improve quality initiatives and improve patient care," says Gurican.
At Cedars-Sinai Medical Center in Los Angeles, nurses are involved in all aspects of quality. This includes creation, implementation and evaluation of quality plans, collecting data, and preparing quality performance dashboards, says Linda Burnes Bolton, DrPH, RN, FAAN, vice president of nursing and chief nursing officer.
The chief nursing officer and all nursing directors co-lead quality teams. Currently, there are 20 teams, each with one staff nurse, a nurse manager, and other team members.
Five nurses conduct daily reviews of core measures, abstract medical records, and enter performance data at the patient, unit, and physician level. Quality performance is incorporated into the hospital's Unit Practice Council, and unit-based champions are used to coach staff performance. Nurses certified in quality improvement coach and remind physicians on what to include in their final discharge summary.
"We require physicians to write an order justifying why a patient should not receive an influenza or pneumococcal vaccine," says Burnes Bolton. She leads an interdisciplinary group that includes medical staff, residents, nurses, pharmacists, and patients on the process of mapping the evidence of conditions "present on admission."
"This is ongoing work and we have demonstrated some success with hospital-acquired pressure ulcers," says Burnes Bolton. "We are using forcing functions requiring physicians to address in their H&P or discharge summary items identified from the nursing assessment or assessment by others, such as dieticians who identify the patient was at risk due to poor nutritional status."
Here are three ways to work with nurses on QI initiatives:
• Don't "take over."
"If you want to improve quality on the front lines, the nurses have to be responsible for coming up with their own solutions," says Hassmiller. "We have found that when QI professionals take the lead and tell people what to do, it does not work as well. If a very strong QI person is telling nurses what to do, that's not very engaging for nurses. They want to be part of the solution."
• Make data collection a joint effort between nursing, QI, and IT staff.
"Nurses do need to step up to the plate and take responsibility for QI on their units," says Hassmiller. "QI professionals know the techniques to make change happen. They need to provide those tools to nurses, such as doing run charts or different ways of collecting data."
• Brainstorm with nurses for solutions.
"With the new CMS ruling, there are safeguards that need to be in place so hospitals can continue to get reimbursed," says Hassmiller. "Get with the nurses in a room and help them brainstorm solutions. Then say, 'Which three solutions do you think would have the best effect on this unit?' Don't wait to implement these — start improving immediately."
• Have competitions between units.
For instance, if an "interruption free" medication time is implemented on several units, medication errors can be tracked to see who comes up with the best results. "Then you can go back and determine what the best unit did to achieve the least number of errors," says Hassmiller. "Or if another unit didn't make much progress, ask them how we can improve that."
Reference
- Kurtzman ET. A summary of the impact of reforms to the hospital inpatient prospective payment system (IPPS) on nursing services. Washington, DC: George Washington University, Department of Nursing Education, School of Medicine and Health Sciences; 2007. http://www.rwjf.org.
[For more information, contact:
Linda Burnes Bolton, DrPH, RN, FAAN, Vice President, Nursing and Chief Nursing Officer, Cedars-Sinai Medical Center, 8700 Beverly Boulevard, Los Angeles, CA 90048. Phone: (310) 423-5191. Fax: (310) 423-6179. E-mail: [email protected]
Gregory M. Gurican, RN, MS, MBA, Nursing Performance Improvement Coordinator, York Hospital, 1001 South George Street, York, PA 17405-7198. Phone: (717) 851-2133. Fax: (717) 851-2089. E-mail: [email protected].
Susan B. Hassmiller, PhD, RN, FAAN, Senior Program Officer, Robert Wood Johnson Foundation, P.O. Box 2316, College Road East and Route 1, Princeton, NJ 08543-2316. E-mail: [email protected].
Ellen Kurtzman, MPH, RN, Assistant Research Professor, Health Sciences Program, University Hospital, 900 23rd Street NW 6th Floor, Washington, DC 20052. Phone: (202) 994-9439. E-mail: [email protected].
The Robert Wood Johnson Foundation has launched a virtual resource center for its hospital quality improvement program, Transforming Care at the Bedside. The resource provides a framework for developing and implementing quality improvement at the front lines, and can be accessed at www.rwjf.org.]
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