Value-based Purchasing Solutions are Often Hidden Beneath the Surface

In my spare time I teach nursing leadership and management at Missouri State University. During a recent course I was helping the students review and prepare for an exam when I realized there was so much content that they really were unsure of where to start. We took a time out to review, and I’m happy to report that the students did very well on their exam.

It occurred to me that this is very much like what hospital executives are facing today. There is so much coming at them from regulatory agencies, patients, physicians, their colleagues and the local market that it may feel overwhelming to determine where the highest and best priorities lie. Quality and safety of the care provided in the hospital have been on the front burner for many years, as has patient experience. Pay for reporting, core measures and patient safety goals have been priorities for at least a decade. Now, the challenges are exploding, the result of value-based payment (VBP), new quality metrics, the need to partner with other providers and much more.

As a staff nurse in the 1980s I was expected to respond to patient satisfaction surveys. However, reaction and accountability for patient satisfaction (and quality too) was very department specific based on the survey data. Today, there is no room for silos. Under value-based purchasing, those responsible for patient satisfaction, core measures and clinical outcomes will have to work together to ensure full reimbursement and maintain market share. It isn’t just about meeting reporting rules; it is about improving care quality across the board. In addition, our reimbursement is as much tied to how others are performing as it is to how the individual hospital is performing. When you begin comparing anything to anyone else, everyone begins to get better. That makes it even harder to continue that improvement. With VBP, we also know that when a measure is “topped out” – meaning the majority of organizations are scoring at the highest level – that measure is removed and another takes its place.

How does a hospital executive determine how best to meet these challenges? As I realized with my nursing students, sometimes the solution to the challenge that the executive thinks will work best, may not be the right solution for sustainable improvement and success within VBP. HCAHPS is a great example. The hospital might be scoring low on the nurse communication domain, and the executive may appropriately say that this means the nurses are not communicating as well with the patients as they need to be. The suggested solutions may be more training, goal setting and accountability for nurse communications. But what if it’s not the nurses’ communication skills that are the problem? You’ve trained them well, you’ve established goals and accountability but still it only gets better for a short time. What’s missing is the root cause for why those nurses may not be communicating well (and the physicians too!).

It is important to remember that you cannot separate the patient experience from what we do to the patient. Do nurses have time to establish relationships with patients? Do we have mechanisms in place that look at staffing not only for the midnight census but also recognizing what happens throughout the day on the busy inpatient units, where beds may actually be “turned over” twice to reduce length of stay and assure observation patients are discharged appropriately? Or are we also incorporating acuity into our staffing algorithms? Have we assured that we aren’t creating a situation where the post-anesthesia care unit or the emergency department bolus patients to the inpatient units because either the elective schedule for the operating room has too many peaks and valleys or the ED must wait for admission orders from the hospitalist? That hospitalist may be the only one on duty; he or she may want all patients held in the ED so that he/she can come see all the patients and write the orders for admission in one visit. These issues must be factored into the solution to improve the HCAHPS domain of nurse communication.

This is just one example of making sure that the solution we think is best to address an issue is really the right solution and the issue is really what we think it is. This kind of root-cause analysis that has worked so well to reduce risk and improve quality should be employed with our core measures and patient experience metrics. A Band-Aid for the immediate situation may help in the short term, but what solution will offer the best sustainable improvement and success? Sometimes it’s not necessarily the ripple we see on the surface but the iceberg under the waterline that is the real concern.



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