DiversityNursing Blog

Work/life balance has been on people’s minds for decades. As individuals and companies strive to improve work/life balance, we want to focus on work/life balance for Nurses. Are you familiar with Dr. Brooks Quality of Nursing Worklife Survey? If not, this article will help you and your place of employment.

Any discussion of quality of life would not be complete without addressing the concept of worklife and specifically nursing worklife, a critical element in healthcare delivery. Developing and retaining the nursing workforce is one of the biggest challenges facing health care employers today. Importantly, the quality of healthcare is frequently judged by the quality of nursing care. The overall quality of care and excellence in nursing is intimately tied to the quality of nurses’ worklife. Quality of nursing worklife is clearly essential to quality care and is an essential component in recruitment and retention of the nursing workforce. Here I make the case for measuring quality of nursing worklife, instead of job satisfaction. 

Historically nursing has focused on measuring job satisfaction and linking job satisfaction to patient outcomes. In practice settings one often hears “satisfied nurses make for satisfied patients.” The relationship between job satisfaction and organizational outcomes has been discussed for so long in the literature that a causal relationship is often inferred, when in fact studies have actually denounced the relationship (Bradfield & Crockett, 1955; Hom & Kinicki, 2001; Iaffaldano & Muchinsky, 1985; Judge, Thoresen, Bono, & Patton, 2001; Organ, 1988). The validity of the concept of job satisfaction and its relationship with organizational and performance outcomes has been questioned for decades (Brayfield & Crockett, 1955; Hom & Kinicki, 2001; Iaffaldano & Muchinsky, 1985; Judge et al., 2001; Organ, 1988). 

In fact, much nursing job satisfaction research linked to patient outcomes found only a correlational relationship not a causal one (Ma, Samuels, & Alexander, 2003). The questionable nature of this relationship might be in part due to questionnaire items (empirical referents) that do not have a strong theory base or unclear and ambiguous conceptual definitions of job satisfaction (Brown, 1999). This leads to inconsistent operational definitions that directly influence how job satisfaction is measured. On the other hand, quality of worklife, and in particular quality of nursing worklife, as the variable of interest does not suffer from the weaknesses in job satisfaction research in job satisfaction research.

Quality of worklife (QWL) has strong theoretical underpinnings that can be traced back to socio-technical systems theory. Socio-technical systems theory maintains one must co-optimize both social (people) and technical (equipment, the environment) subsystems to not only improve worklife, but to also improve the organization's productivity. In fact, going back as far as the 1950s Trist and Bamforth (1951) found a causal link between improved QWL and productivity. In addition, psychologists have found that as much as 30% of the variance in measures of job satisfaction measure personality something an employer has little influence over (Agho, 1993; Judge, 1993; Remus & Judge, 2003). Yet, employers continue to attempt to improve satisfaction in order to improve productivity.

There is increasing conceptual clarity around the construct of QNWL. My dissertation research synthesized years of empirical and conceptual research that studied QWL. A conceptual framework devised by nurse researchers at the University of Toronto was based on many of the principles underlying sociotechnical systems theory. Moreover, measures of QWL take into consideration the balancing act employees do between their worklife and home life. This too made sense for QNWL since nurses, like any employee, balance work and family. The strong theoretical underpinning from socio-technical systems theory (STS), the conceptual framework, and qualitative research exploring the worklife of nurses from the research unit became the basis of Brooks' Quality of Nursing Worklife Survey(C). Requests to use Brooks’ Quality of Nursing Worklife Survey have been received from graduate students and researchers in 30 countries from Greece to Estonia, Canada (Ontario, Quebec), India, Iran, Australia, Malaysia, Turkey, and Taiwan. And, my survey has been translated into 5 languages. 

It's important for organizations to look beyond job satisfaction when attempting to improve the work life of their employees, as well as the productivity of the organization.

Related Article: Nurses Practicing Self Care

Congresswoman Lois Capps of CA is committed to helping people improve their daily lives through better schools, quality health care, and a cleaner environment. During her 20-year tenure as a Nurse and public health advocate, she felt her education and background was needed in Congress to help improve health care in the US and strengthen our Nursing workforce across the country.

We know that the important work of strengthening our health care system is not yet done — it’s far from it. But legislation like this will help get us there.

A Nurse Is a Nurse

Are you being asked to float in an area outside your specialty? How about stepping in to help out on the Rapid Response team when necessary? How do you feel about it? Do you see it as an opportunity to learn something new and fill in when needed? Or, do you feel it puts the patients at risk because of lack or training? Please read this article and let us know your thoughts.

A recent Medscape article addressed a reader's question about whether a hospital could require critical care registered nurses (RNs) to cover shifts on their hospital's rapid response (RR) team.

RR teams rely on hospital staff with critical care expertise to provide bedside assessment of non–critical care patients who appear to be deteriorating. RR teams can differ in their makeup and typically consist of a "physician and nurse, intensivist and respiratory therapist, physician assistant alone, critical care nurse and respiratory therapist, or clinical specialist alone."^[1]

As many as 84% of patients who have a cardiac arrest demonstrate clinically identifiable signs of deterioration in the 6-8 hours before the event,^[2] and identifying changes in a patient's condition early can often be the difference between life and death. Failure to recognize a patient's deteriorating status and intervene is known as failure to rescue, and although it does not necessarily mean that a patient's caregivers have been negligent, it does represent missed opportunities to prevent potentially catastrophic outcomes.

The original question (above) noted that the nurse's manager said nurses needed only a brief orientation to function on the RR team. The reader asked whether the hospital could force nurses to serve on the RR team.

Carolyn Buppert, MSN, JD, author of the article, responded that critical care nurses are a good choice to be RR providers, and hospitals can require them to participate on RR teams. But, she wrote, "Each nurse needs relevant education and supervised experience to feel adequately prepared to provide the care the hospital assigns."

Nurses with RR experience wrote in with their thoughts, and even more commented on "floating" to unfamiliar clinical areas in general. Many said they had inadequate preparation for these situations and voiced concern about their patients' welfare. Time and again, nurses wrote that they were frustrated with the one-size-fits-all idea that "a nurse is a nurse." Read on for more of their thoughts. (Note: Comments may have been edited for clarity or length.)

The RR Role

Several readers commented that they had been thrown into the role of RR with little preparation. One nurse had many years of intensive care unit experience, but when her hospital instituted an RR team she received no formal training. She wrote:

My first experience as an RR nurse was having a bag, a cell phone, and this role thrust upon me. I had a caseload but another nurse would "watch over my patients." Even as an experienced nurse, I was uncomfortable doing the job and felt that I just had to rely on prudent nursing principles. There was no specific job description or protocol except basic ACLS. There were no specific personnel or roles on the team other than a respiratory therapist. There was no primary physician to manage orders. I had to contact the patient's physician during each event, which meant I was working with a different physician each time (when they responded). This process ate up time. My mind always raced to when could I get back to my patients, were there any new orders or changes in condition, were their medications given? I survived the transition to electronic charting, and I believe this was the straw that finally broke the camel's back for me. I changed jobs and I am happier for it!

Another nurse, who worked as an Army civilian nurse in an administrative position "embedded in an outpatient clinic" wrote:

I was suddenly assigned as RN on the rapid response team, 1 hour a week during the lunch hour. I objected but did not refuse, though I was not trained and in fact had pursued an alternate career path in nursing, starting with inpatient psychiatric nursing immediately upon graduation. I never worked on a medical/surgical unit and had no clinical patient care experience. I was told that my BSN degree and current RN license satisfied the training requirement for clinical nursing.

"It is reasonable to ask some nurses to fill in on RR teams, just as it is reasonable to ask an emergency room physician to assist in an in-house emergency," one nurse explained. "However, it is not reasonable to ask all nurses to do the same task. Would you want a pathologist assisting with the birth of your child? Both are physicians."

One nurse said that experienced critical care nurses "should be able to work as RR nurses when needed" and offered this advice: "You will have to obtain the history on the patient, admission reason, and hospital course, if any. My next step would be to treat the patient as if he or she were my patient in the intensive care unit and make the same basic recommendations within my scope as RR nurse, such as administering oxygen, intravenous access, obtaining an electrocardiogram, and notifying the attending, or start cardiopulmonary resuscitation or code blue if needed," she wrote. "However," she added, "never work outside your scope of nursing practice."

In her article, Buppert wrote that in addition to receiving adequate training, RR nurses must use their skills often enough to stay current. "To be assigned to RR once a month or less is not optimal and may not be safe," she wrote.

"An acceptable alternative would be to be put on the RR rotation once a schedule to maintain your comfort level when responding to these situations," one nurse commented.

Another reader had this to say about RR assignments:

Assignment to an RR role does require specific training. At the least, the nurse needs to know what the protocols are and what can be done independently. Nurses need to remember that if they don't know the role and don't have the training specific for that role, they can refuse that role. Yes, there are consequences to refusing, but there are also consequences to taking on something you're not trained or educated to do.

Floating to Unfamiliar Units

The Medscape article was about whether critical care nurses should be required to staff RR teams, but nurses who have been "floated" to unfamiliar units or settings (and who has not?) related to the article as well.

Nurses widely agreed that floating nurses should be given assignments that reflect their skills and experience, and in some circumstances they should not be given a patient assignment at all but instead perform such tasks as taking vital signs and administering familiar medications.

"I'm in a very similar situation where decisions are made with the assumption that, as long as I am a nurse, I can cover any area," one nurse wrote. "The decisions are being made by managers with non-nursing backgrounds who are looking to get the most out of nurses without providing adequate orientation. Nursing is the only profession that I know of that would allow its nurses to be placed in such a predicament."

"I have been transferred from an acute setting to a long-term care unit where floating for RNs, licensed vocational nurses, and certified nurse assistants happens routinely," commented another reader. "I'm an experienced nurse of 30 years, hold a masters as a clinical nurse specialist, and still find this practice intolerable and dangerous for all. Although nursing care is not the issue, the assignments are. Nurse-to-patient ratios are 30:1."

Floating to other units is a reality that often cannot be avoided, particularly in the hospital setting. Staffing needs rise and fall, and unexpected events occur, including sick calls and census changes.

Refusing Assignments

In the Medscape article, Buppert said that a nurse can refuse to accept an assignment under certain circumstances, including lack of sufficient orientation, inadequate staffing for patient acuity, inappropriate skill mix, and when the assignment poses a serious threat to the health and safety of the patient. Nurses in this situation should file their institution's patient assignment objection form. Buppert acknowledged that doing so may result in disciplinary action or dismissal but said that repercussions, if any, may differ for those working under a collective bargaining agreement. Buppert cautioned against first accepting an assignment and then refusing it, because this could be considered patient abandonment.

One reader related:

On one occasion, the charge nurse gave me an assignment consisting of four patients clustered near each other down at one end of the hall, and my fifth patient was in the very last room on the other end of the hall. Her rationale was, "I want the nurses to keep the same patients they had yesterday." I refused to accept the fifth patient, stating that her decision was not in the patient's best interest, and I felt that she was compromising his care, my license, and the hospital. Was she mad? Absolutely. But after talking to the house supervisor about my refusal and my reason for it, she changed the assignment.

One nurse wrote about her experience of being expected to perform peritoneal dialysis without proper training:

 

One nurse wrote about her experience being expected to perform peritoneal dialysis without proper training. 

The job was thrust upon nurses with absolutely no training. Then they sent someone to train us who had no training skills at all. Peritoneal dialysis is a specialty. I feel that nurses are getting hammered with all sorts of additional duties and being told that it's alright when it isn't. Managers and administrations are causing nurses to treat patients like herds of cattle.

"In this age of specialization," asked another nurse reader, "why is it expected that a nurse can float to any unit at any time? We become specialized in our area of expertise and are more proficient in the performance of our duties because of familiarity. It devalues me as a professional by insinuating that I have no special talents or abilities that I have acquired through years of working on a specific unit in a specific field."

Floating as a Growth Experience

Floating can have positive effects as well, and nurses should try to approach these experiences as opportunities for learning and developing relationships with other hospital staff.

One nurse was advised to be open to floating so that she would become a more well-rounded nurse. "I always spoke up and asked questions, and was received with kindness and patience from the more experienced nurses," she explained. "I was there to help them and they respected me for that. Job descriptions and duties were easily accessible on the units for every shift, so I would know what was expected of me. I find it difficult nowadays to actually find a duties list on any of the facilities that I have been to."

Although many of us have had to float to other units, most of us have also been grateful for extra help when we have needed it. One reader offered, "I worked on a unit where we frequently pulled staff from other units, but I always tried to be careful with the assignment of the substitute staff member, and as charge nurse, I frequently checked on them to make sure they felt supported in every way! Also, I was sure to let them know how grateful we were that they were there with us helping us take care of our patients."

One nurse said, "This article is great because it has provided the resources needed to protect yourself from supervisors who look upon staff as 'anyone who can plug a hole.' It may not prevent poorly made decisions to plug that hole, but as the nurse who is floating, you can be on record as attempting to protect yourself. Document, document, document!"

Floating to Specialty Areas

Nurses working in obstetrics and pediatrics were particularly vocal. If nurses are subjected to the "a nurse is a nurse" concept, obstetric and pediatric nurses may be especially vulnerable. There is a huge difference between caring for an adolescent patient and caring for a newborn, and many nurses accustomed to caring for adults and adolescents are way out of their comfort zone when caring for babies in whom even the smallest mistake can have disastrous consequences.

Although many nurses who work in obstetrics are expected to be proficient in all areas of obstetrics—labor and delivery, newborn nursery, postpartum, and even high-risk antepartum—some nurses have specialty areas within the obstetrics unit in which they are most proficient. Many of these nurses strongly objected to being floated to other areas of the hospital, such as adult medical/surgical and orthopedics, and some were uncomfortable floating to the neonatal intensive care unit (NICU), labor and delivery, and pediatrics.

Would you want an adult nurse to care for your preemie baby in the NICU? 

One nurse wrote, "I work postpartum, and we don't take laboring patients—only stable women in preterm labor. Or we act as a second pair of hands, helping with patients or assisting with deliveries and cesarean deliveries. In pediatrics, we take the easier patients, usually those who are almost ready to go home."

Another nurse added, "I work on a mother-baby floor where we also take care of high-risk antepartum patients. Not every mother-baby nurse works in the baby admission area on labor and deliver—only those who want to. Why," this reader asked, "is it okay to float to a NICU where all the babies are on cardiac monitors? I feel like a fraud going to NICU. I've been a nurse since 1983, and I don't feel safe going to NICU or pediatrics. Why do hospitals think it's okay to do this? Would you want a pediatrician to see your adult mother? Would you want an adult nurse to care for your preemie baby in the NICU?"

Gratitude and Solutions

Nurses on all sides of the situation may be able to make things easier by being proactive. Critical care nurses, particularly newly hired ones, can ask about RR responsibilities and training. It might also be helpful for RR nurses to request a 1-day or half-day orientation on units to which they might be expected to respond.

All nurses can ask their employers for additional training, and although it should be provided, when it isn't, nurses can obtain it for themselves. Having additional critical care training, including the care of pediatric and neonatal patients, is a feather in a nurse's cap if and when he or she is looking for employment elsewhere.

One nurse wrote:

Good action points at the end of the article! Let's push our organizations for the training. Say how inappropriate it is and what the barriers are when you assume a position that you don't have any training for. Be specific. Propose a training plan; say what protocols/equipment nurses need to be familiar with. Talk with people who are long-time RR nurses. Identify issues (eg, no one skilled in drawing arterial blood gases when you evaluate a patient on the medical-surgical floor) and make solutions (develop a go-bag with an arterial blood gas puncture kit and analyzer, and all the other gear you would need).

Another nurse added, "We solved this issue by asking for volunteers who would be in a critical care float pool, and float nurses were oriented to a unit similar to their own. We had an RR team. We set up a competency review for the float pool and the RR team that had to be completed yearly. We had a good turnout of nurses who were willing to be oriented and float."

It is helpful to develop collaborations between units with similar types of patients, and nurses who feel comfortable floating to certain units should speak up. For example, a nurse on an obstetrics unit may also have pediatric experience and volunteer to float when nurses are needed there. Postpartum nurses with experience in adult medical-surgical or orthopedics units might volunteer to float there when needed.

Nurses whose units receive help from a floating nurse can also help to make things run smoothly.

A nurse who works in maternal-child health wrote:

Once in a while, we will be bursting at the seams, and so will our other maternal-child health units. When that happens, we are usually able to get a certified nursing assistant or licensed vocational nurse to float to us. Sometimes we will get a registered nurse, and they seem really nervous at first. When we tell them that we would never give them a patient assignment and just ask them to help out with vital signs, basic patient care tasks, and whatever they might feel comfortable with, they relax a bit. At the end of the shifts, they always tell us that they would be happy to come back and help us anytime!

One nurse suggested, "When a nurse from another unit floats to our department, we only give them very stable, easy patients, with our charge nurse being a resource person and the rest of us helping out. We only take 'growers and feeders' when we float to the NICU."

Another nurse stressed, "Nurses want what is best for the patient—no one is shirking their duty. Safety of the patient is the first order of business. But how safe for a patient is it when the unit does not have adequate staffing, and the floating staff member is not familiar with the unit's protocols for patient care?"

Another reader summed it up with, "I love safety, I love competence, but I love stretching my abilities and being the best nurse, too—one that could handle anything. We got this, nurses! Good luck!"

Have questions about floating and rapid response duty or maybe just a general question? Ask one of our Nurse Leaders! 

 

We’ve all experienced or heard about long wait time to receive medical attention in the Emergency Room. It’s tough on everyone involved – the patients, their families and medical staff. Many people put off going to the emergency room for this very reason. If they can avoid it, they do. Here’s an interesting article about a Canadian study where Nurses are helping to alleviate this situation. Seems to make sense. What are your thoughts about it?

Emergency room crowding is a common and complex problem for hospitals all over the world, and anything that can be done to improve patient flow without compromising care is a great help. Now, a new study shows how carefully written nurse-initiated protocols can dramatically reduce time in the emergency room for certain targeted patients.

Implementing procedures where nurses start the diagnosis or treatment before patients are treated by a physician or nurse practitioner have been suggested as a possible way to improve the flow of patients in the emergency room (ER).

The new Canadian study, published in the Annals of Emergency Medicine, describes how nurse-driven protocols cut ER lengths of stay for patients with fever, chest pain, hip fractures, and vaginal bleeding during pregnancy.

Lead author Matthew Douma, clinical nurse educator at Royal Alexandra Hospital in Edmonton, Alberta, says: 

"Nurse-driven protocols are not an ideal solution, but a stop-gap measure to deal with the enormous problem of long wait times in emergency departments especially for patients with complex problems."

Protocols cut ER time in busy, inner-city hospital

For their study, Douma and colleagues carried out a  controlled evaluation of six nurse-initiated protocols in a busy, crowded, inner-city emergency room.

They measured a number of outcomes, including length of stay in the ER, time to diagnostic test, time to treatment, and time to consultation.

The results showed that nurse-driven protocols:

• Reduced the median time taken to administer acetaminophen to emergency patients with pain or fever by over 3 hours (186 minutes)
• Decreased average time to troponin testing for emergency patients with chest pain suspected to be heart attack by 79 minutes
• Cut average length of stay for patients with suspected hip fractures and patients with vaginal bleeding during pregnancy by nearly 4 hours (224 and 232 minutes, respectively).

"Given the long waits many emergency patients endure prior to treatment of pain," says Douma, "the acetaminophen protocol was a quick win."

Need for 'broad and creative strategies' to cut ER time

The researchers conclude that implementing carefully written nurse-driven protocols targeted at specific patient groups can result in improved time to test or medication, and in some cases, cut length of stay in the ER.

They also note that, "A cooperative and collaborative interdisciplinary group is essential to success."

According to the Centers for Disease Control and Prevention (CDC), around one in five American adults visited the ER one or more times in 2014, the most recent year for which full data is available.

In 2011, there were nearly 136.3 million visits to the ER in the United States, and 27 percent of patients were seen in under 15 minutes.

A number of approaches are being tried and used to improve patient flow through the ER. These include: extending the chain, decreasing and smoothing variation, matching capacity to demand, scheduling the discharge, and pull systems.

An example of a pull system is the "Be a Bed Ahead" scheme of pulling patients from the ER to the inpatient unit.

"Emergency department crowding will continue to require broad and creative strategies to ensure timely care to our patients."

Matthew Douma

Related Article: Emergency department nurses aren't like the rest of us

If you are a Nursing student wondering what Specialty is right for you, please read on. Perhaps you’re an Experienced Nurse thinking about changing your area of focus. If so, this article is for you too. We hope you find it helpful!

The nursing profession has evolved considerably over the last century, including the introduction of specializations for nurses, with specific knowledge and experience to practice in certain fields. There are now many possible areas that a nurse may choose to specialize in, and these continue to grow.

Some of these are covered in more detail below, although there are more beyond this list.

Advanced Practice Registered Nursing

Advanced practice registered nurses have acquired more advanced skills and knowledge through a master’s degree program, in addition to the undergraduate degree to become a registered nurse.

This extended training distinguishes them from other nurses and they often go on to work as a clinical nurse specialist (CNS), nurse practitioner (NP), nurse anesthetist (CNA), or certified nurse-midwife.

Ambulatory Care Nursing

Ambulatory care nurses provide health services to patients directly in an environment outside of a hospital, wherever it is required. They are responsible for following treatment plans for acute conditions, monitoring signs, communicating with the patient and their family, and promoting overall patient health.

Cardiac Nursing

Cardiac nurses care for patients with cardiovascular disease or health problems related to the heart and have specialized knowledge in this area. They are responsible for monitoring signs, treating symptoms, addressing clinical needs, and providing relevant support and education to the patient and their family.

Case Management Nurse

Case management nurse care for patients who require ongoing support and work to develop and implement a treatment plan that aims to stabilize health and minimize hospitalization.

Critical Care Nursing

Critical care nurses work with patients who are critically ill or injured and require close monitoring and care. They are responsible for looking after patients with potentially fatal conditions and following the treatment care plan for the best outcomes.

Dialysis Nursing

Dialysis nurses care for patients who require dialysis as part of their treatment plan, such as those with kidney disease. They are responsible for monitoring signs and progress, administering medications, and providing support and advice to patients throughout the process. They may work in a hospital, clinic, or provide in-home care.

Genetics Nursing

Genetic nurses care for patients with a genetic disease and have in-depth knowledge about the role of genetic in the pathology of these conditions. They are responsible for conducting family risk assessments, analyzing genetic data, researching genetic diseases, and providing support to affected individuals and families.

Geriatric Nursing

Geriatric nurses care for elderly patients and have a thorough understanding of the health and treatment of conditions that commonly affect the elderly. Geriatric nurses often specialize further, to care for elderly patients with a specific health condition.

Mental Health Nursing

Mental health nurses, also known as psychiatric nurses, care for patients with mental health, psychiatric, or behavioral disorders. They help to provide support to these patients and their families while they recover.

Neonatal Nursing

Neonatal nurses care for young infants in the first few weeks of their life and have specialized knowledge about how to take care of infants and the conditions that may affect them.

Oncology Nursing

Oncology nurses care for patients who have cancer. They help in the treatment and monitoring of the disease, in addition to providing support and education to patients and their families.

Pediatric Nursing

Pediatric nurses care for young children and their families. They have specialized knowledge about the function of young bodies and the health conditions that may affect them and assist in the diagnosis, treatment, and monitoring of these patients.

Other Specializations

There are many possible fields that a nurse may choose to specialize in, including:

• Gastroenterology nursing
• Holistic nursing
• Medical-surgical nursing
• Midwifery nursing
• Neuroscience nursing
• Obstetrical nursing
• Occupational health nursing
• Orthopedic nursing
• Ostomy nursing

Have questions about changing your area of focus or maybe you have a general question, just ask one of our Nurse Leaders. 

We here at DiversityNursing.com are looking for a variety of topics that we hope you’ll find interesting. Is this article about new bundled payments models something that is helpful and informative for you? Please let us know your thoughts.

On July 25, the Centers for Medicare and Medicaid Services (CMS) proposed a new bundled payment model for heart attacks and bypass surgeries; it will be launched in 98 markets that have yet to be determined. The proposed model is scheduled to go into effect over a five year period, beginning in July of 2017.

“The extension of mandatory bundled payments to cardiac care provides further confirmation that CMS means to reshape healthcare delivery away from fee-for-service and towards value-based care,” says Michel Abrams, co-founder and managing partner of Numerof & Associates. “Practically speaking, it means that the profitability of two high utilization treatments in cardiology has likely peaked, and for many hospitals, these important revenue centers have leaner days ahead.”

The CMS proposal also extends the current Comprehensive Care for Joint Replacement (CJR) model to include other surgical treatments for hip and femur fractures beyond hip replacement. It also includes:

• A new model to increase cardiac rehabilitation utilization; and
• A proposed pathway for physicians with significant participation in bundled payment models to qualify for payment incentives under the proposed Quality Payment Program.

How the proposal will affect continuity of care

Abrams says the fee-for-service model has, over time, encouraged healthcare delivery organizations to allocate fewer resources to activities that weren’t explicitly paid for, such as care coordination. “This has been one of the drivers of the high costs and mediocre results that characterize our current system of care,” Abrams says. “Making acute care providers accountable for the costs and outcomes of the total care experience is a logical path to reversing the current situation.”

“Bundles encourage care redesign by incentivizing gainsharing and risk taking among previously disparate provider groups,” says Christopher Donovan, partner at Foley & Lardner LLP. “This will produce better outcomes over the long term through IT investments and clinical practices that focus on care management and continuity/prevention.”

Do bundled payments keep costs down?

To make its case for mandatory bundled payments, CMS points to a number of pilot programs it claims have shown they can help providers work more closely together to provide better care at lower costs. These programs include:

• The Medicare Acute Care Episode (ACE) demonstration project tested bundled payments for cardiovascular and orthopedic care;
• The Medicare Participating Heart Bypass Center Demonstration project tested bundled payments for bypass surgery; and
• The Bundled Payments for Care Improvement Initiative included cardiac and orthopedic bundles.

“Data from these pilots and other state and private research initiatives all suggest that bundled payments encourage better care coordination and lower delivery costs,” says Abrams.

But according to Denise Burke, a partner in the Memphis office of Waller Lansden Dortch & Davis, LLP, official CMS studies show that bundled payments have had only limited success so far. For example, Burke says the CMS ACE pilot project, which included 28 cardiac and nine orthopedic procedures, reported a savings of only $319 per patient. “Preliminary results from the voluntary programs, however, show promise,” she says. 

Why make bundled payments mandatory?

CMS has set a goal of having 50% of traditional Medicare payments flowing through alternative payment models by 2018. According to Abrams, results of a recent company survey, which assessed U.S. hospital progress toward adopting value-based care models, “confirmed that hospitals, given the option of staying with the historical fee-for service model, won’t meaningfully change their approach to care delivery on their own.”

“CMS is in a unique position to reshape the industry, and it must do so if it is to connect payments with improved outcomes and avoid the sea of red ink that waits at the end of the current trend in healthcare cost inflation,” Abrams says.

What could be bundled next?

Jerrod Ullah, RN, BSN VP Product Management at ViiMed, says based on conversations with practitioners and experts, he believes the industry can expect to see similar models on the horizon for oncology and maternity care. “Each of these areas involves a significant amount of care coordination throughout the treatment process, and patients could see big benefits through a bundled payment approach,” he says.

According to Abrams, the industry can expect to see the subsequent expansion of bundled payments for chronic conditions within already established service lines. “For example, congestive heart failure is a likely candidate for expansion once the cardiology project is underway,” he says.

The proposed rule was published in the Federal Register on August 2. Comments will be accepted for 60 days after publication.

If you have more questions about bundle payments please click below to ask one of our Nurse Leaders!