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The Role of Nursing in P4P. Sean Clarke, PhD, RN, FAAN Associate Director, Center for Health Outcomes and Policy Research Class of 1965 25 th Reunion Term Assistant Professor of Nursing University of Pennsylvania Philadelphia, PA.

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the role of nursing in p4p

The Role of Nursing in P4P

Sean Clarke, PhD, RN, FAAN

Associate Director, Center for Health Outcomes and Policy Research

Class of 1965 25th Reunion Term Assistant Professor of Nursing

University of Pennsylvania

Philadelphia, PA

some major concerns of the nursing profession in the u s currently
Some Major Concerns of the Nursing Profession in the U.S. Currently

1. Supply of nursing personnel relative to need

2. Ability of agencies (and the health care system as a whole) to pay for nursing services

3. Safety/quality of services nurses provide as a discipline and in collaboration with other disciplines

As well as the impact of #1 on #3.

larger issues in the health care system executives payors
Larger Issues in the Health Care System (Executives/Payors)
  • Costs of providing care
  • Quality of care
  • Strategies attempting to align incentives with reimbursement schemes (P4P)
state of the science in quality and safety related to nursing
State of the Science in Quality and Safety Related to Nursing
  • Adverse events more likely in hospitals/hospital units with lower levels of RN staffing—where 60% of RNs work
    • similar findings with respect to proportion of licensed personnel in long-term care
  • Leadership, resources beyond front-line staffing, interdisciplinary factors, etc. play important roles in quality of care—evidence growing
  • Clinical characteristics of patients critical to interpreting indicators properly
  • Much sparser data about
    • determinants of the quality of nursing care delivery
    • nursing in community settings, outpatient care etc.
bottom line
Bottom line
  • Many unanswered questions about optimizing outcomes of nursing care with finite resources–research rendered difficult by limited availability of high-quality data
slide7
The “NQF 15”--National Voluntary Consensus Standards for Nursing-Sensitive Care: An Initial Performance Measure Set

1. Death among surgical inpatients with treatable serious complications (failure to rescue)

2. Pressure ulcer prevalence

3. Falls prevalence

4. Falls with injury

5. Restraint prevalence (vest and limb only)

6. Urinary catheter-associated urinary tract infection for intensive care unit (ICU) patients

7. Central line catheter-associated blood stream infection rate for ICU and high-risk nursery (HRN) patients

8. Ventilator-associated pneumonia for ICU and HRN patients

National Quality Forum (2004)

slide8
The “NQF 15”--National Voluntary Consensus Standards for Nursing-Sensitive Care: An Initial Performance Measure Set (2)

9. Smoking cessation counseling for acute myocardial infarction

10. Smoking cessation counseling for heart failure

11. Smoking cessation counseling for pneumonia

12. Skill mix (Registered Nurse [RN], Licensed Vocational/Practical Nurse [LVN/LPN], unlicensed assistive personnel [UAP], and contract)

13. Nursing care hours per patient day (RN, LPN, and UAP)

14. Practice Environment Scale—Nursing Work Index (composite and five subscales)

15. Voluntary turnover

National Quality Forum (2004)

pay for reporting with an eye to p4p in the mma

Pay for Reporting (with an eye to P4P) in the MMA

- One of the first major contact hospital nurses will have with quality measure reporting and its impacts on operations

cms jcaho acute myocardial infarction starter set measures
CMS/JCAHO Acute Myocardial Infarction Starter Set Measures
  • ACE Inhibitors/ARB for Left Ventricular Systolic Dysfunction
  • Aspirin at arrival
  • Aspirin at discharge
  • Beta blocker at arrival
  • Beta blocker at discharge
  • Percutaneous Coronary Intervention within 120 minutes of arrival
  • Smoking cessation advice/counseling
  • Thrombolysis within 30 minutes of arrival
cms jcaho heart failure starter set measures
CMS/JCAHO Heart Failure Starter Set Measures
  • ACE Inhibitor or ARB for Left Ventricular Systolic Dysfunction
  • Assessment of Left Ventricular Function
  • Discharge instructions
  • Smoking cessation advice/counseling
cms jcaho pneumonia starter set measures
CMS/JCAHO Pneumonia Starter Set Measures
  • Pneumococcal vaccination
  • Initial antibiotic(s) within 4 hours of arrival
  • Oxygenation assessment
  • Smoking cessation advice/counseling
  • Appropriate initial antibiotic(s)
  • Blood culture prior to first dose of antibiotic
cms jcaho surgical infection prevention starter set measures
CMS/JCAHO Surgical Infection Prevention Starter Set Measures
  • Preventive antibiotics 1 hour before incision
  • Preventive antibiotics stopped within 24 hours postoperatively
slide14

Odds Ratios for Cases Meeting CMS/JCAHO AMI-Specific Composite Indicator Criteria by Hospital RN HPPD, 2004 (N=3378, Mean 272 cases/hospital)

OR

Hours Per Patient Day

Landon et al., Arch Intern Med 2006; 166: 2511

slide15

Odds Ratios for Cases Meeting CMS/JCAHO CHF-Specific Composite Indicator Criteria by Hospital RN HPPD, 2004 (N=3575, Mean 283 cases/hospital)

OR

Hours Per Patient Day

Landon et al., Arch Intern Med 2006; 166: 2511

slide16

Odds Ratios for Cases Meeting CMS/JCAHO Diagnosis/Treatment Composite Indicator Criteria (AMI, CHF, Pneumonia) by Hospital RN HPPD, 2004 (N=3590, Mean 404 cases/hospital)

OR

Hours Per Patient Day

Landon et al., Arch Intern Med 2006; 166: 2511

slide17

Odds Ratios for Cases Meeting CMS/JCAHO AMI-Specific Composite Indicator Criteria by Hospital LPN HPPD, 2004 (N=3378, Mean 272 cases/hospital)

OR

Hours Per Patient Day

Landon et al., Arch Intern Med 2006; 166: 2511

slide18

Clarke, S.P. (Principal Investigator). Validating NQF Nurse-Sensitive Performance Measures. Grant under Interdisciplinary Nursing Quality Research Initiative (INQRI), Robert Wood Johnson Foundation, 2006-2008.

penn study using cms starter set measures
Penn Study UsingCMS Starter Set Measures
  • Approximately 600 non-federal, acute care general hospitals in PA, CA, and NJ
  • Linkages between HospitalCompare (CMS), nurse survey and patient outcomes (discharge abstract) datasets
  • Analyses of 2005 and 2006 data
practice environments staffing and hospital outcomes
Practice Environments, Staffing, and Hospital Outcomes
  • Practice Environments
  • Resource adequacy
  • Unit-level environment
  • Hospital-wide environment
  • Professional practice foundations (education, QA, etc.)
  • Nurse-physician relations
  • Safety culture
  • Patient outcomes
  • Failure to rescue (FTR)
  • Falls, pressure ulcers, nosocomial infections
  • Condition-specific mortality and FTR
  • Process of care
  • Implementation of protocols and evidence-based practices

Leadership

decisions

  • Staffing
  • Ratios
  • Skill mix
  • Educational composition of
  • staff

STRUCTURE/CONTEXT

PROCESS

OUTCOMES

research questions
Research Questions
  • Question 1: Do nursing factors (staffing and organization) account for performance on process measures?
  • Question 2: Do process measures account for impacts of nurse staffing and organization on clinical outcomes?
  • Results due out next year
nurses as a resource in meeting performance targets
Nurses as a Resource in Meeting Performance Targets
  • The more complex the system, the greater the odds of breakdowns and the more complex the solutions (very true in hospital care)
  • Maintain an eye on:
    • Staffing levels
    • Staff development/education issues
    • Leadership
    • Interdisciplinary processes related to nursing services
systems redesign
Systems Redesign
  • Diagnosing problems with processes and redesigning them (logistical issues in getting things done)
    • Involving nurses responsible for care for specific clienteles
    • Nurses with systems training and leadership roles as resources in redesign
slide25

Intended Mechanism for P4P to

Improve Quality of Care

Actual/potential reimbursement

Provider behaviors

and investments

in agency

resources

Better

performance

measures

slide26

Potential Mechanism for a Downward Spiral

in Quality for Agencies on the Edge

Limited resources

Poor quality of care

or

Limited ability to improve

processes/documentation

Lower reimbursements

Poor indicators

nursing perspectives on p4p
Nursing Perspectives on P4P
  • Philosophical issues
    • Documentation for narrow performance issues vs. “real” quality of care
    • Diversion of attention from broader issues in safety and quality of care
  • Burden of documentation adding to nursing workload (hospital nurses spend ~30%+ of their time in documentation and other paperwork)
  • Encouraging accountability (nurses enthusiastic) vs. unintended consequences
  • Discussion in the nursing literature and in the professional community just beginning