The Role of Nursing in P4P

Sean Clarke, PhD, RN, FAANAssociate Director, Center for Health Outcomes and Policy Research

Class of 1965 25th Reunion Term Assistant Professor of NursingUniversity of Pennsylvania

Philadelphia, PA

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)

• 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

• 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

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

The “NQF 15”--National Voluntary Consensus Standards for Nursing-Sensitive Care: An Initial

Performance Measure Set1. Death among surgical inpatients with treatable serious

complications (failure to rescue)2. Pressure ulcer prevalence3. Falls prevalence4. Falls with injury5. Restraint prevalence (vest and limb only)6. Urinary catheter-associated urinary tract infection for

intensive care unit (ICU) patients7. Central line catheter-associated blood stream infection

rate for ICU and high-risk nursery (HRN) patients8. Ventilator-associated pneumonia for ICU and HRN

patients

National Quality Forum (2004)

The “NQF 15”--National Voluntary Consensus Standards for Nursing-Sensitive Care: An Initial

Performance Measure Set (2)9. Smoking cessation counseling for acute myocardial

infarction10. Smoking cessation counseling for heart failure11. Smoking cessation counseling for pneumonia12. 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 turnoverNational Quality Forum (2004)

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

• 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

• 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

• 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

• Preventive antibiotics 1 hour before incision

• Preventive antibiotics stopped within 24 hours postoperatively

Odds Ratios for Cases Meeting CMS/JCAHO AMI-Specific Composite Indicator Criteria by

Hospital RN HPPD, 2004 (N=3378, Mean 272 cases/hospital)

0.8

0.85

0.9

0.95

1

1.05

1.1

1.15

1.2

<3.0 3.0-4.8 4.8-6.4 >6.4

OR

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

Hours Per Patient Day

Odds Ratios for Cases Meeting CMS/JCAHO CHF-Specific Composite Indicator Criteria by

Hospital RN HPPD, 2004 (N=3575, Mean 283 cases/hospital)

0.8

0.85

0.9

0.95

1

1.05

1.1

1.15

1.2

<3.0 3.0-4.8 4.8-6.4 >6.4

OR

Hours Per Patient Day

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

0.80.850.9

0.951

1.051.1

1.151.2

1.251.3

<3.0 3.0-4.8 4.8-6.4 >6.4

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

0.8

0.85

0.9

0.95

1

1.05

1.1

1.15

1.2

<.3 .3-.8 .8-1.5 >1.5

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

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 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

Leadershipdecisions

Staffing•Ratios•Skill mixEducational composition of staff

Process of care•Implementation of protocols and evidence-based practices

Practice Environments•Resource adequacy•Unit-level environment•Hospital-wide environment•Professional practice foundations (education, QA, etc.)•Nurse-physician relationsSafety culture

Patient outcomes•Failure to rescue (FTR)•Falls, pressure ulcers, nosocomial infections•Condition-specific mortality and FTR

STRUCTURE/CONTEXT PROCESS OUTCOMES

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

Some Thoughts About Implications

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

• 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

Actual/potential reimbursement

Provider behaviorsand investments in agencyresources

Betterperformancemeasures

Intended Mechanism for P4P toImprove Quality of Care

Limited resources

Poor quality of careor

Limited ability to improveprocesses/documentation

Poor indicators

Lower reimbursements

Potential Mechanism for a Downward Spiralin Quality for Agencies on the Edge

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

Questions?