The Role of Nursing in P4P

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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 25th Reunion Term Assistant
  Professor of Nursing
• University of Pennsylvania
• Philadelphia, PA

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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.

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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)

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State of the Science in Quality and Safety
Related to Nursing

• Adverse events more likely in hospitals/hospital
  units with lower levels of RN staffingwhere 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 careevidence 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.

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Bottom line

• Many unanswered questions about optimizing
  outcomes of nursing care with finite
  resourcesresearch rendered difficult by limited
  availability of high-quality data

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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)
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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 ScaleNursing Work Index
  (composite and five subscales)
• 15. Voluntary turnover

National Quality Forum (2004)
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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

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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

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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

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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

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CMS/JCAHO Surgical Infection Prevention Starter
Set Measures

• Preventive antibiotics 1 hour before incision
• Preventive antibiotics stopped within 24 hours
  postoperatively

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Odds Ratios for Cases Meeting CMS/JCAHO
AMI-Specific Composite Indicator Criteria by
Hospital RN HPPD, 2004 (N3378, Mean 272
cases/hospital)
OR
Hours Per Patient Day
Landon et al., Arch Intern Med 2006 166 2511
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Odds Ratios for Cases Meeting CMS/JCAHO
CHF-Specific Composite Indicator Criteria by
Hospital RN HPPD, 2004 (N3575, Mean 283
cases/hospital)
OR
Hours Per Patient Day
Landon et al., Arch Intern Med 2006 166 2511
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Odds Ratios for Cases Meeting CMS/JCAHO
Diagnosis/Treatment Composite Indicator Criteria
(AMI, CHF, Pneumonia) by Hospital RN HPPD, 2004
(N3590, Mean 404 cases/hospital)
OR
Hours Per Patient Day
Landon et al., Arch Intern Med 2006 166 2511
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Odds Ratios for Cases Meeting CMS/JCAHO
AMI-Specific Composite Indicator Criteria by
Hospital LPN HPPD, 2004 (N3378, Mean 272
cases/hospital)
OR
Hours Per Patient Day
Landon et al., Arch Intern Med 2006 166 2511
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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.
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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

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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
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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

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Some Thoughts About Implications
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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

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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

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Intended Mechanism for P4P to Improve Quality of
Care
Actual/potential reimbursement
Provider behaviors and investments in
agency resources
Better performance measures
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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
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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

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Questions?