What do you promote high-value care?

[guest940422]

I'm really interested to hear about how other people view/perceive/promote high value care.

I'm fairly new to my unit, everyone prides themselves on being "cost aware". People hold each other accountable for the tiniest of extra costs. I've been counseled by more than one colleague since I arrived for things like forgetting to credit a patient back an IV catheter or unused oxygen tubing.

But this is where the culture falls short. We do MRIs with anesthesia for patients who have never been in an MRI machine before in their lives. We don't even attempt po sedation or moderate sedation if they request anesthesia.

This week I sedated an 86 year old man for a biopsy who was a DNR, had refused chemo, and was being discharged to hospice care. There went at least $5K plus unnecessary risk and pain, along with an extra day in the hospital and no one could tell me why we were doing it.

We order pre-procedure tests and no one can explain why coags from last week aren't good enough before an angiogram when the patient isn't at risk for a bleed. All I get is "you have to have a PT/INR within 24 hours of an angio..." but no why.

Hourly portable Chest Xrays on post-lung biopsies... why hourly? Why not just once in x hours and prn if symptomatic? "Because that's how we always do it"

We order CMPs for patients who really just need a creatinine and GFR before a contrast study, send blood gases to lab when we have point of care tests that are faster and cheaper, order UAs on patients who only need an HCG, and the list really just keeps going.

I was always taught "because it's ordered" is never the answer to "why?". Now, when we are over-spending trillions of dollars a year in US healthcare, that is the answer everyone gives me.

So we all go out of our way to save the patient/hospital $10 for an IV catheter, but not $10k for an unnecessary procedure.

Any thoughts or advice on even incremental steps towards raising mindfulness or educating?

[RNperdiem, RN]

It sound like the source of the problems is not in nursing. Nursing seems to be doing its part in scanning supplies and not being wasteful. What you describe comes from doctors' orders.

Doctors have their protocols to follow, and also want to CYA in this culture of litigation.

The nurse might say: "Could we try some po sedation for Mr. X for the MRI?"

Only so much you can do.

[cleback]

Do you have rounds with physicians, care management? Maybe some of the things can be addressed by the team (like the biopsy on a hospice patient).

[JKL33]

Forgetting to credit something back is a different issue - you say that's what you were counseled for. Not being diligent about crediting something back could be looked at as fraudulent billing on your employer's part; they have every reason to not want to be accused of such.

[Davey Do]

I'm really interested to hear about how other people view/perceive/promote high value care.

I'm fairly new to my unit, everyone prides themselves on being "cost aware". People hold each other accountable for the tiniest of extra costs.

Any thoughts or advice on even incremental steps towards raising mindfulness or educating?

This thread seems to be more of a challenge of the necessity of procedures rather than an inquiry to how inquiry as to how we, as nurses, can promote a higher standard of care.

Like you, GaryRay, I disagree with the way many processes are handled at Wrongway Regional Medical Center. The processes and procedures are not illegal, immoral, or unethical- they're just, to my point of view, unnecessary or superfluous.

The way in which I promote a high value of care is to "accept the things I cannot change, courage to change the things I can, and wisdom to know the difference" and by being a model that I believe others should follow.

[canoehead, BSN, RN]

In a hospital I used to work in, a certain diagnosis came with insurance authorization for a particular group of tests. So we did all the tests whether they were needed or not, to maximize profit. That may be whats happening for the OP.

[Horseshoe, BSN, RN]

Your thread title is not well worded and is pretty vague. You would probably get more responses if you emailed a moderator and asked him to change the thread title to something that is clear and more relevant to the actual content.

I don't see that measures to ensure that patients are properly charged (or credited if appropriate) for the materials and services they actually receive should be viewed with annoyance. That's a whole other issue from unnecessary procedures and tests, which often happen because of an abundance of caution that is grounded in fear of litigation.

[kaylee.]

Are you at a for-profit hospital? I work at a so-called "non-profit" which is all about getting patients out to increase turn-around, since the money is made in the volume of patients.

No matter what the title of this thread was meant to be about, the economics of healthcare is an important topic.

I am not familiar with the notion of charging for specific supplies. The only thing we have to charge is the blood transfusion.

I definitely feel that high-value and high-quality are 2 different things...