It was Tuesday, 3:20 PM. The phone on my desk rang and I saw the extension was "1961"...
I knew. This was it!
Our Chief Nurse wanted to meet with me in Nursing Administration.
The ride down the elevator and the walk down the long hall were surreal. I found myself wondering, "Is this how people feel as they walk to the electric chair?"
I think so.
I walked in and there was the person from Human Resources along with the Chief Nurse. Neither one was smiling. I smiled...I think. I really don't remember.
The next several minutes were a blur of words:
"nothing done wrong"
"purely economic considerations"
"cuts made"
"today...last day"
"take time cleaning out office"
"severance pay"
"benefits...continuing and stopping"
"classes...resumes and job search and interview skills"
"apply for other openings in-house"
"everything...fine"
Then, I was carrying an envelope down the hall to the next room to sign up for one of those classes.
The irony of the situation did not escape me. My job had been created because of health care reform. And, now, it was being terminated because of the same health care reform.
Crazy world we live in, eh?
So what was my job and why was it created? And why did it go away?
What was My Job?
I was in charge of core measures. That, in and of itself, is kind of funny. When I arrived at this hospital about 5 years ago, I had never heard of core measures. I remember making an appointment with the Director of Quality Management and asking her, "what is a core measure and why should I care?"
Fortunately for me, she and I had worked together at a previous place of employment and she already understood my sense of humor. She proceeded to do exactly that.
Core measures are quality indicators that can be used by insurance companies, the Center for Medicare/Medicaid Services (CMS), The Joint Commission, and patients to compare the clinical care provided by hospitals. These measures are very specifically defined, measured a certain way, and based on evidence-based interventions for improved patient outcomes. The sampling methods are based on statistically based research methodology. The results are reported as a percentage of patients who received the appropriate care as defined by each measure. The goal is to be 100% on every measure every time, all the time.
Why Was My Job Created?
Last July, 2011, began a new era in health care reimbursement, "Value-Based Purchasing" (VBP). Over simplified, VBP is a formula that determines overall how well a hospital is meeting the core measures and customer service goals. If everything is 100%, the score comes out 100%. The nine months from July 2011 through March 2012 constituted what was known as the "qualifying period."
Each hospital's performance during the qualifying period will determine the amount of reimbursement for a designated time frame (the next fiscal year, I think).
My job was created to maximize our hospital's VBP score. I was serving as coordinator for concurrent auditing for all core measures for the hospital. Fortunately, there were teams in place prior to the creation of my position last October. There was a team for each category of core measures [Heart Failure (HF), Acute Myocardial Infarction (AMI), Pneumonia (PN), and Surgical Care Improvement Project (SCIP)]. The HF/AMI team and the PN team had been in existence and functioning very well for about five years when I took my new job last October. The SCIP team was the newest team...only a little over two years in existence. My primary role was with the SCIP core measures.
Every day, I would extract the potential SCIP patients from the Operating Room (OR) schedule and post the list on the SCIP website for the unit based concurrent auditors (staff nurses caring for the patient, Clinical Nurse Educators, Nurse Managers) to know which patients needed to be checked for compliance with SCIP core measures. As I made rounds every day, I would check and double check that all the i's had been dotted and all the t's had been crossed so that the documentation would accurately reflect the care the patient had received and would pass each core measure. Some of the patients that were on the list would turn out not to actually be SCIP patients after all. Some cases that did not initially look like they would fall into the SCIP measures would end up qualifying as SCIP after all. This normally occurred with exploratory laparotomies or diagnostic laparoscopic procedures because the procedure ended up being more...sometimes much more.
Over time, the staff was getting better and better at knowing which patients should receive which pre-op prophylactic antibiotics and giving it within the specified time frame. Patients who needed beta blockers were receiving a dose of beta blocker on the day of surgery or the day before and another dose on post-op day #1 or post-op day #2; pre-op hair removal and post-op temp was properly documented; post-op temp was in the right range to reduce post-op complications; sequential compression devices were used and documented on the cases who needed them; appropriate anticoagulant medications within 24 hours of surgery in appropriate situations; stopping prophylactic antibiotics on time; and removal of the indwelling urinary catheter by the end of post-op day #2. These had all improved immensely over the months. They were better, much better.
Better, but not always perfect on every measure every month. Each measure had reached 100% for one or more quarters. However, we had never had a quarter where all the measures were 100% at the same time.
My job was to catch the documentation that slipped through all the other pairs of eyes and dot those i's and cross those t's before the patient's medical record went to medical records...at the time of discharge.
The official review was done after the chart was fully coded and billed...if it was selected to be in the sample for that month. The official review was on a sample of the qualifying charts; the concurrent review was on about 200% of what turned out to be the actual SCIP population. Each month the number of patients concurrently audited varied slightly from 350 to over 500 potential SCIP patients.
Almost daily I would find one or two pieces of documentation that were missing and do the teaching with the appropriate staff member to make sure it was corrected. Some days, like last Friday, when the CCU was swamped, there were four that had to be corrected in that one unit in one day. This past Monday (the day before my job ceased to exist) I found five surgery cases from the weekend that all had the same documentation missing...due to handwritten Anesthesia Records. These were handwritten during the switchover from one computer documentation system to another. The CRNA forgot to document the route on the pre-op prophylactic antibiotic for five cases. I found and corrected them all...on Monday.
Then, came Tuesday.
Why Did My Job Go Away?
One of the changes wrought by healthcare reform is a 15% reduction in reimbursement to hospitals over a 10 year period...at 1.5% per year. For most hospitals that 1.5% translates into a few million dollars less in this year's budget compared to last year's every year for 10 years. For the last couple of years, our hospital has trimmed the budget by changes in supply choices, eliminating non-essential items from the budget (travel allowances, education reimbursement, continuing education reimbursement, conference travel funds, non-patient-related purchases, hospital week celebrations, gifts during nurses' week, etc.).
This year, there just wasn't any "fluff" left to cut from budgets. However, there needed to be a significant reduction from the bottom line costs. With a larger and larger percentage of uninsured patients (due to loss of patient's employment), our hospital - like others across the nation - is providing more and more charity care and writing off more and more patient charges each year. For the hospital to be able to keep the doors open, it is absolutely essential to maximize reimbursement while at the same time minimizing costs...thus came the reduction in force by approximately 30 positions this week and re-structuring of the organizational chart - yet again.
Summary
My job was created to meet the quality core measures that are required for Value-Based Purchasing, Blue Cross, and The Joint Commission...in order to keep the doors of the hospital open in this time of reduced reimbursement for care provided to Medicare and Medicaid patients.
My job was then cut to reduce costs because of reduced reimbursement for care provided to Medicare and Medicaid patients.
These reductions in reimbursement are part of the changes to health care (voted into existence since President Obama took office) in an effort to reduce the federal budget deficit.
Thus, my job was created because of Obamacare and then, in turn, eliminated by the same Obamacare.
The End...or rather, the Beginning of Looking for a New Job at the age of 58 years with more than 35 years' experience. Wow!
P.S. Wonder of if President Obama needs someone to work on the plan for healthcare reform from the grassroots level? ?
