Urgent: ANA Position Paper

[SheaTab]

Hi allnurses community,

The ANA has called for nurse comment on a position paper draft regarding pay-for-performance. They are due in by 1700 EST today. You might consider, if you so desire, sending them your thoughts. Mine are below. Thanks so much for the work you all do to care for our patients, Tabitha

Dear American Nurses Association:

Thank you for the opportunity to comment on the draft of your position statement available at http://www.nursingworld.org/HomepageCategory/NursingInsider/Archive_1/2009-NI/Oct09NI/Public-Comment-Pay-for-Quality-Principles.aspx. As a licensed Registered Nurse in the state of Georgia, I believe that any improvement in healthcare should be evaluated based upon the degree to which its mandates elicit the intended goal. One would hope it that intended yield from Pay-for-Performance (P4P) measures would be improvements in the quality of care delivered to our patients across throughout the United States. As a bedside nurse, I am concerned that P4P, though noble in theory, has and will continue to confound a system that has become increasingly complex to navigate for all providers of health-related services. As CMS and other private insurance companies push out lofty goals to those who rely on their reimbursements to continue to support the myriad of costs associated with healthcare delivery, there exists a possibility that our Nurses will pay the ultimate cost. Because healthcare is a profit-driven industry and also by virtue of the reality that many quality-related outcomes are nurse-driven and sensitive, these unfunded mandates are pushed out to the nursing staff without the necessary resources with which to meet the demands of P4P. For example, failure to copy a patient's medication list accurately may result in increased risk to the safety of our patients and also the wrath of employers because most hospitals are zeroed in on the Medication Reconciliation process (a Joint Commission requirement). Medication reconciliation must start when the patient hits the front door and as such, the first form is often completed in the Emergency Department. In theory, Medication Reconciliation is of critical importance because so many harmful errors have occurred as a result of mistakes in the reconciliation process. However, giving Nurses yet another paper to complete and not allowing us additional time to fulfill yet another mandate is the way of healthcare and represents yet another lofty goal without requisite resources. As it becomes more difficult to turn a buck and sustain a profit, look for mass-casualties among nursing staff and our patients. Does the medication reconciliation process result in improved outcomes for our patients? It sounds good; however, it works only to the degree to which it is utilized and embraced by the nurse that completes the form and the physician who should be reviewing the appropriateness of the regimen. In my experience, the form has been a source of great contention among Nursing staff because there is simply not enough time in a typical ED triage to fill out the form in its entirety especially since many systems have turned to manufacturing models of care and as such, there is a substantial push to remove inefficiencies and to deliver care in the fastest manner possible. I was once told that a good triage nurse could collect all necessary data from the patient within ten minutes. This is not the case since there are times when accurately transcribing a medication list can take this long and that doesn't even account for the time spent collecting a medical, social, and surgical history on our complex patient populations. We must now verify that there is no evidence of any pressure-related skin breakdown present before admission and also note if the patient has had a flu, tetorifice, or pneumonia vaccine. We have to assess if there are any spiritual, cultural, or religious needs and also if the patient is at risk for domestic violence. Again, all of these things represent the holistic nature upon which nursing care was founded; however, if the paperwork and other mandates act as a barrier to safe and effective Nursing care, then Nurses must advocate for the necessary resources to meet the well-intentioned goals. As the hoops to jump through become more plentiful, and you can be assured that they will, you will witness the desensitization of Nursing staff to the intended effects of these quality measures. To a disengaged, overworked, and overstretched team of professionals, these measures represent one thing, more work. Across the country, nurses are nearly exhausted with our current system of healthcare delivery which has never had "doable work" as its underlying principle. Even technologically savvy nurses, including myself, have found themselves nursing the computer or papers more than the patient. If we'd really like to improve the quality of healthcare in the United States, we would achieve infinitely more by innovating solutions which would allow nurses to spend more time with their patients. This "more with less" has been an effective catalyst in the unfortunate result of mass burnout among healthcare professionals. In addition to the concerns of mounting documentation requirements to prove compliance with certain measures, more administrative staff are required throughout each facility to monitor, prepare, and submit the documentation to the powers that be. It would seem that these precious fiduciary resources would be better utilized if allocated toward Registered Nurse FTEs. Again, if the intended effect is improvement in healthcare quality, the question remains, will requiring nurses to complete even more documentation result in better outcomes? My mother was admitted to an inpatient oncology unit for 11 days recently and on only one occasion did a nurse use her stethoscope during his or her shift assessment; however, you can be assured that on at least 22 occasions that heart, lung, and bowel sounds were documented somewhere in the medical record. This translates into falsifying shift assessment documentation on at least 21 occasions. Nurses have neither the time nor the resources to thoroughly assess their patients if they are to carry out other orders in a timely manner and also document the care that they have given, and in the above case, not given. It is difficult to support the position that my mother just happened to have a few lazy Nurses assigned to care for her or that the hospital where she was admitted was an exception to the care that is given at other hospitals. When the point at issue is universal, we must stop looking at the individual and start looking at the system to find the source of the problem. Many of us have run of time and also of the energy required to do the right thing every time for our patients. Frankly, the manpower resources are lacking to the extent that it is virtually impossible. We are so busy making sure that all of our paperwork is filled out to fulfill our hospital's documentation requirements that we have lost sight of the most important thing that Nurses do, and that is assessment. How can we justify any intervention when we have not adequately performed the one thing that our interventions are supposed to be based upon? How can we possibly recognize and respond to our patients' signs of deterioration without assessing them systematically and regularly? Neglectful assessment could easily explain the untold numbers of failure to rescue that healthcare systems across the country are struggling to eliminate. While it is true that an experienced nurse can often look at a patient from across the room and know whether or not they are stable; we now know that patients often show subtle signs of decompensation long before they become unstable. This is why it is imperative that all Nurses of all levels of experience use their stethoscope to listen, their hands to palpate, their eyes to look at the whole patient, and their hearts to give the highest quality of care to each and every patient. With this in mind, healthcare administrators and United States lawmakers, we are desperate for the resources to get our head above water. We will all have to make a choice in our current state of healthcare delivery, paperwork and profit or quality patient-care.

American Nurses Association, history has taught us time and again that healthcare systems across the country will respond and make drastic changes only to the extent to which it is profitable, or at the very least, that the changes will not result in a considerable loss in revenue. United States healthcare systems were remiss to jump on the quality bandwagon until insurance companies began to incentivize doing so and also impose strict penalties for poor health-related outcomes. For example, in the 19th century, both Florence Nightingale and Joseph Lister suggested that infection might be prevented by hand hygiene practices. Many of you know that there is a landmark campaign in 21st century healthcare designed to encourage patients to remind providers to wash their hands. Sadly, left to our own devices, nearly 200 years have passed and we still cannot get that one simple task right all the time. That is, not until insurance companies incentivize low infection rates. In the present profit-driven healthcare system, if health insurance companies promise higher reimbursements, hospitals will give their utmost to do whatever insurance companies ask including enlisting the help of our patients. The industry has known about these deplorable conditions since around 1991 when "The Harvard Medical Practice Study" estimated a total of 120,000 yearly preventable deaths resulting from the care we deliver in our country. In fact, this figure was such a shock that many healthcare professionals turned the other cheek and continued to operate under the misguided and false premise that U.S. citizens were receiving the highest quality healthcare in world. The Institute of Medicine did their best to educate the public and medical community about the relative dangers of the U.S. healthcare system in 1999 with the "To Err is Human" report and then followed up in 2001 with the "Chasm" report. While the profit-driven medical insurance companies may have questionable motives with regard to P4P, it is worth serious consideration that many healthcare professionals had no knowledge of the quality improvement efforts throughout the system until the P4P concept went public in 2007. In 2008, the Centers for Medicare & Medicaid Services have begun to deny reimbursement to hospitals for the treatment of what they have termed "never events" since they can be reasonably prevented. Examples of these include pressure-related skin breakdown, air embolism, and patient falls to name a few. According to the Institute for Healthcare Improvement, an estimated 15 million acts of harm occur each year in our healthcare system which equates to 40,000 injuries daily. Today, most all educated healthcare professionals know about healthcare improvement measures, however, we are still falling short in the quality game and many of us know why. This is clearly a case of, "great answers, wrong question." We have an overwhelming amount of exciting quality improvement measures, data, and best practices being pushed out faster than we can keep up with and most are all great answers. However, there is nothing more frustrating than lofty goals being pushed out to a group of haggard health professionals. To add insult to injury, many times these goals are not accompanied by the resources with which to achieve them. Healthcare administrators are demanding better outcomes for the patients in their facilities but are refusing and/or are unable to devote the necessary human resources toward achieving those goals. What these new measures become is yet another thing to "manage" in a system that is entirely unmanageable. I ask that you please consider supporting P4P only to the extent to which hospital systems will be required to dedicate additional Nursing staff needed to do the work. Another innovative approach might be to incentivize safe nurse-to-patient ratios. Give nurses a doable workload, and prepare to be amazed at all we are able to accomplish in terms of facilitating quality outcomes. Maintain the status quo and nurses will continue to make disheartened attempts at quality patient care in effort to prevent the inevitable and well-studied end result of burnout, exhaustion. I would like to thank you again for allowing the larger community of Nurses the opportunity to comment on your position statement regarding P4P in healthcare.

Warmest Regards,

Tabitha, RN, MSN

[ellakate]

Why does 'improvement' always involve more nursing documentation?

[PostOpPrincess, BSN, RN]

It's always non-bedside people who make the decisions too. I'm sure there will be exclusions when we have pay for performance.

I mean seriously, how does one get blamed for a non-compliant 400 pound diabetic who comes in with all of his/her issues?

Even now there are exceptions with CSM. Just have to document, that's all.

[SheaTab]

It's always non-bedside people who make the decisions too. I'm sure there will be exclusions when we have pay for performance.

I mean seriously, how does one get blamed for a non-compliant 400 pound diabetic who comes in with all of his/her issues?

Even now there are exceptions with CSM. Just have to document, that's all.

Hi Jo:

P4P is already alive and strong. We will just continue to see more of it in the future. I can definitely see the merit in the underlying principles. If you look at the data, you will note that an appalling number of patients throughout the U.S. are not receiving the appropriate therapies for their conditions. I have a vague recollection of some data in a particular state that showed that only 20% of diabetics that seek treatment were having their HgbA1c tested per the recommendations. In this way, rewarding providers for following best practice guidelines makes sense. History has shown us time and again that we will not make significant changes until it hits us where it hurts. That is a sad state.

Of particular interest to me is the effect that P4P has on the daily workload of nurses. Our documentation will need to support meeting the guidelines and as you well know, more documentation means more time away from doing what matters most -- patient care. In the case of the non-compliant diabetic patient, I feel your pain. More research must be conducted to address these issues of non-compliance. Lifestyle changes are some of the most difficult to assist patients with. I feel the pain of the DM patient. Most patients don't eat their way into a 400 lb. body because they love food. Most of those folks, in my experience, wear their weight as evidence of a much deeper psychic pain. I'm concerned that there is not enough being done to address the emotional aspects of disease and often wonder if this accounts for many of our poor outcomes. Many disease processes would be more effectively treated with a comprehensive approach including treatment of the mind, body, & spirit. How many times have you seen a prescription written for Insulin? MANY! How about exercise, counseling, sunlight, etc. I wish there were 40 hours in a given day!

What do you think?

Thanks for your thoughts,

Tabitha

[Onekidneynurse]

Hi Jo:

P4P is already alive and strong. We will just continue to see more of it in the future. I can definitely see the merit in the underlying principles. If you look at the data, you will note that an appalling number of patients throughout the U.S. are not receiving the appropriate therapies for their conditions. I have a vague recollection of some data in a particular state that showed that only 20% of diabetics that seek treatment were having their HgbA1c tested per the recommendations. In this way, rewarding providers for following best practice guidelines makes sense. History has shown us time and again that we will not make significant changes until it hits us where it hurts. That is a sad state.

Of particular interest to me is the effect that P4P has on the daily workload of nurses. Our documentation will need to support meeting the guidelines and as you well know, more documentation means more time away from doing what matters most -- patient care. In the case of the non-compliant diabetic patient, I feel your pain. More research must be conducted to address these issues of non-compliance. Lifestyle changes are some of the most difficult to assist patients with. I feel the pain of the DM patient. Most patients don't eat their way into a 400 lb. body because they love food. Most of those folks, in my experience, wear their weight as evidence of a much deeper psychic pain. I'm concerned that there is not enough being done to address the emotional aspects of disease and often wonder if this accounts for many of our poor outcomes. Many disease processes would be more effectively treated with a comprehensive approach including treatment of the mind, body, & spirit. How many times have you seen a prescription written for Insulin? MANY! How about exercise, counseling, sunlight, etc. I wish there were 40 hours in a given day!

What do you think?

Thanks for your thoughts,

Tabitha

Your posts are interesting just very difficult to read. Could you separate some of the sentences to make it easier to read for this old nurse. Thanks so much.

[NRSKarenRN, BSN, RN]

I see this is a golden time for Nursing and predict that over the next 10 -20 years a shifting paradigm in hospitals where our documentation of Nursing Quality Indicators/Care, initially used for pay for performance will become the norm for payment of services AND justification while pateints need to be hospitalized. Nursing Care will be recognized for its own value just not a room charge.

Advanced Practice RN's have lead the way for payment for their practice. Homecare now being reimbursed under MC PPS with payment for episode of care based on OASIS documentation of patient care needs and starting P4P in next 2 years.

Savy hospitals will realize that INCREASING amount of hours spent at bedside will improve their bottom line and staff accourdingly OR could swing to RN as gatekeeper of the chart directing others providing the care. It is pivotal that nurses SPEAK UP to have input in which direction their facility takes and support given by national organizations.

[SheaTab]

Your posts are interesting just very difficult to read. Could you separate some of the sentences to make it easier to read for this old nurse. Thanks so much.

Kidney,

I'm sorry! I guess I just can't seem to make good use of the paragraph, huh? Thanks for the feedback! Tabitha

[SheaTab]

Hi NRSKaren,

I like the way you think. I long for the day that the value of nursing is realized. Nurses save lives! Tabitha

I see this is a golden time for Nursing and predict that over the next 10 -20 years a shifting paradigm in hospitals where our documentation of Nursing Quality Indicators/Care, initially used for pay for performance will become the norm for payment of services AND justification while pateints need to be hospitalized. Nursing Care will be recognized for its own value just not a room charge.

Advanced Practice RN's have lead the way for payment for their practice. Homecare now being reimbursed under MC PPS with payment for episode of care based on OASIS documentation of patient care needs and starting P4P in next 2 years.

Savy hospitals will realize that INCREASING amount of hours spent at bedside will improve their bottom line and staff accourdingly OR could swing to RN as gatekeeper of the chart directing others providing the care. It is pivotal that nurses SPEAK UP to have input in which direction their facility takes and support given by national organizations.

[tewdles, RN]

hi nrskaren,

i like the way you think. i long for the day that the value of nursing is realized. nurses save lives! tabitha

it is interesting to me that i know this, you know this, many nurses know this...but by and large many, many other disciplines and professionals do not know this. of course, we get kudos when we are heroic in the icu or er, etc. however, it is the daily, bread and butter care that is delivered with skill, critical thought, and caring at the bedside of the average hospital patient that saves lives in ways that is not well appreciated by the masses or the management. as long as administrators continue to view nursing as a set of required tasks to be performed there will be no substative change. as long as administrators consider nurses an expensive necessity we will work with minimal staffing. we will continue on the circular path of ever changing rn/lpn/cna ratios with more and more nursing duties given to non-nurses and more and more paperwork given to the nurse. i agree that we must be better organized in order to effect meaningful change for nursing and patients. i am so glad that there are young ambitious nurses willing to take up the battle.

[herring_RN, ASN, BSN]

Hi NRSKaren,

I like the way you think. I long for the day that the value of nursing is realized. Nurses save lives! Tabitha

Nurses notice the subtle changes in a patients behavior or symptoms. Then plan and intervene to prevent the dramatic rescue.

And of course when needed we are with the patients 24/7 to rescue when needed.

IF we have enough staff so we can be there.

The attached study documented this.