Value Based Healthcare (HCAHPS)

[8mpg]

It seems that hospitals across the country are now going on a rampage to raise HCAHPS scores to secure their CMS (Medicare/Medicaid) reimbursements. Working for a large "for profit" hospital network, we are under the microscope as bedside nurses to increase patient satisfaction from admit to discharge. With the new scrutiny of the government with the value based healthcare initiative as part of the Affordable Care Act (aka Obamacare) the nurses are affected daily in their scope of practice and treatment of their patients.

With areas of HCAHPS such as pain management, these situations appear to be a "lose-lose" situation in which the patients often do not feel their pain is adequately treated and physicians are reluctant to prescribe more potent and higher dosages of narcotics. In the hospital in which I work, management has asked which doctors are the ones that are not prescribing to satisfy the patients pain goal. Their idea is to simply pressure the physicians group from the administrative side to increase HCAHPS scores. This is a clear violation in my mind against what medicine is all about. The separation of physician and hospital is there to increase patient outcomes by reducing unneeded expenses. The physicians are liable for their practice and have the discretion to treat patients in which they feel is proper.

HCAHPS is a flawed system in which the government has decided to base their hospital reimbursement on. This would be much like going in to a local grocery store and sating you will only pay 90% of your bill due to the dissatisfaction of the cashiers attitude.

Patient satisfaction should not have a bearing on reimbursement of their healthcare costs. This makes no sense. You can cure a patient of cancer and the family may have thought the hospital could have been cleaner, the discharge paperwork was not enough explanation, doctor didnt meet the pain goal of zero, etc. We have had emergent CABG surgeries and patients are upset due to having any pain after a cracked chest. Until we fixed this new flawed system, many of us nurses will be affected daily. We will lose staff, lose incentive, lose bonuses, etc.

Is anyone else upset about this? This alone has me reconsidering nursing all together. Maybe lobbying would be better career against this nonsense.

[MunoRN, RN]

First off, HCAHPS was not part of Obamacare, it was developed in 2002 and implemented in 2006. There are definitely some flaws to both HCAHPS and VBP, but there are also some much needed changes to how we spend our money.

The downside to HCAHPS is that it pulls attention away from all the care that they don't see, but improves their safety and gives them better outcomes. The upside is that it pays those who provide a less valuable product less money, rather than paying everyone the same whether they earn it or not. If CMS cut reimbursements for simply failing to achieve 100% satisfaction then I would agree that isn't fair, but that's not how it works. Providers are judged against the average, not a benchmark. So while it's true you'll never make every patient happy, neither will any other hospital which is who you're being judged against. Reimbursements aren't cut for just having unhappy patients, they're cut if your care is significantly worse that what others provide, which means your care is of less value to your patients and should be paid less accordingly. This casts a wider net than it should since patients grade hospitals on a much wider range of factors than just what HCAHPS addresses and more privileged hospitals will do better (just make them even more privileged).

Yet it's not just about making people happy, pain control for instance has a direct correlation to patient outcomes, noise at night contributes to delirium and sleep loss, both of which contribute to poor outcomes; facilities that do less to produce good outcomes shouldn't be paid the same as those who do their jobs better.

Same goes for Value Based Purchasing; if a hospital makes no attempt to prevent readmission then the service provided by the Hospital is of less value and shouldn't be paid the same as a Hospital that puts more effort into discharging patient better prepared to a readmission.

[zydecogirl]

HCAPS!!! Wow where to start? I am so disturbed by what is happening in the Hospital where I practice r/t HCAPS. I am all for anything that includes being kind, supportive and professional with your patients. That being said, I have to say that never in my career of 23 years have I considered leaving Nursing for good. Case Scenario: 6 patients, 2 of the six elderly with mild dementia including their spouses. Very demanding, cannot remember that you answered all their questions and concerns 10 mins ago, constantly on the light, constantly on your behind in the halls and at the nurses station. You as the RN are smiling, sweet, yes sir and yes ma'am can I get you anything else, etc etc etc. Now down the hall you have a new admit patient no. 3 in severe pain due to renal calculi - trying to get everything in computer, pain control, check orders to see if patient has anything for nausea - yes but its zofran and the patient is on levaquin etc etc etc. call the doctor etc. and still have elderly dementia spouse on your behind "what is happening where is the doctor I do not understand why nothing is happening and we are not being told what is wrong." Then down the hall patient no. 4 is quiet liver failure - not complaining at all. Critical platelet from prior shift of 5 on call doctor notified orders received to stop cleocin and hold asp. night nurse advised that MD would be in to see patient first thing. ON call Doctor noted on shift during shift change. Patient 5 confused gi bleed cannot keep in bed family will not sit with patient huge fall risk bed alarm constantly going off. Patient 6 Alcohol withddrawal - constant monitoring required, pulls IV out 3 times etc. etc. Now end of shift and Primary MD comes in regard patient with low platelets. Guess what on call doc never saw pt and nurse never followed up ( as in me) so stat cbc drawn, plt 3 now and orders received for transfusion. Not only are my 2 mild dementia pts staying on my behind - also the crew of management who go to every single room daily multiple times to ask "how things are with your care." to "help hcap" scores they are also coming to me to let me know what info the mild dementia spouses are ask for over and over and over again. So let me ask you this? Who is benefiting from high Hcap scores? Do they ask the question while surveying post discharge are you alive, are you better, are you at home now - instead of did you have a clean room, was it quiet enough for you to sleep, did the bed pan come quick enough, did you like the meals? It is a hospital not a resort we as Nurses should be able to give excellent care to sick patients and be supported in that. I believe they have openings at a local home improvement store. I have never felt so helpless in my career and ineffective as right now in the arHCAPS!!! Wow where to start? I am so disturbed by what is happening in the Hospital where I practice r/t HCAPS. I am all for anything that includes being kind, supportive and professional with your patients. That being said, I have to say that never in my career of 23 years have I considered leaving Nursing for good. Case Scenario: 6 patients, 2 of the six elderly with mild dementia including their spouses. Very demanding, cannot remember that you answered all their questions and concerns 10 mins ago, constantly on the light, constantly on your behind in the halls and at the nurses station. You as the RN are smiling, sweet, yes sir and yes ma'am can I get you anything else, etc etc etc. Now down the hall you have a new admit patient no. 3 in severe pain due to renal calculi - trying to get everything in computer, pain control, check orders to see if patient has anything for nausea - yes but its zofran and the patient is on levaquin etc etc etc. call the doctor etc. and still have elderly dementia spouse on your behind "what is happening where is the doctor I do not understand why nothing is happening and we are not being told what is wrong." Then down the hall patient no. 4 is quiet liver failure - not complaining at all. Critical platelet from prior shift of 5 on call doctor notified orders received to stop cleocin and hold asp. night nurse advised that MD would be in to see patient first thing. ON call Doctor noted on shift during shift change. Patient 5 confused gi bleed cannot keep in bed family will not sit with patient huge fall risk bed alarm constantly going off. Patient 6 Alcohol withddrawal - constant monitoring required, pulls IV out 3 times etc. etc. Now end of shift and Primary MD comes in regard patient with low platelets. Guess what on call doc never saw pt and nurse never followed up ( as in me) so stat cbc drawn, plt 3 now and orders received for transfusion. Not only are my 2 mild dementia pts staying on my behind - also the crew of management who go to every single room daily multiple times to ask "how things are with your care." to "help hcap" scores they are also coming to me to let me know what info the mild dementia spouses are ask for over and over and over again. So let me ask you this? Who is benefiting from high Hcap scores? Do they ask the question while surveying post discharge are you alive, are you better, are you at home now - instead of did you have a clean room, was it quiet enough for you to sleep, did the bed pan come quick enough, did you like the meals?

[monkeybug]

I'm all for improving care, but I seriously don't think this is the way to do it. Patients have unrealistic expectations. Judge hospitals on infection rates, judge them on outcomes, but for heaven's sake can we leave patient opinions out of it? Let's look at L&D. Even with a perfect epidural, there is going to be some discomfort involved. If you really focus on what is happening, logic is going to dictate that it's not going to be a pain-free event. Yet, some patients expect just that, and are really unhappy when they don't get it. I don't have a magic wand, nor am I a god, but that seems to be what management and patients expect.

[martymoose, BSN, RN]

Boy, I feel everyone's frustration on this one.

I too, am trying to figure a way to get out of nursing; This is only icing on the cake.

I've said it before, but sometimes I wonder if Medicare knows that the pts will never give good satisfaction scores, and therefore will not have to pay out for "services" , thereby putting more money in their pockets.

[lkulmann]

It would be interesting to place a list of MAGNET approved hospitals along side of this list and see the correlation...