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AJN, American Journal of Nursing:
doi: 10.1097/01.NAJ.0000425740.53236.4a
In the News

Regulatory Issues, Incentives, and Nurses

Wallis, Laura

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Abstract

Do payment-based incentive programs change the way nurses do their jobs?

As health care reform is gradually implemented, the incentive programs popularized over the past decade are becoming the new reality for hospitals across the country. The stated goal of these programs is to improve the quality of patient care by creating financial incentives to do so and, ultimately, to lower health care costs. Although providing excellent patient care is always a high priority for nurses, questions remain about whether these programs will do what they're supposed to do and whether they will place additional burdens on already overtaxed nurses.

In October 2012, the Centers for Medicare and Medicaid Services (CMS) instituted its Hospital Value-Based Purchasing Program in all acute care hospitals. Included in the calculation that determines incentive payments is the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) survey—a national standardized survey of hospital patients after discharge. Other CMS payment-based programs include the Medicare and Medicaid Electronic Health Records Incentive Programs and CMS's hospital-acquired condition provision, which denies payments for certain preventable conditions, such as pressure ulcers and urinary tract infections, that develop during hospital stays.

Ellen T. Kurtzman, assistant research professor at the George Washington University School of Nursing and lead author of a February 2011 report in Health Affairs on the effect on nurses of performance-based payment incentives, says that many nurses she has spoken with are concerned about the burden of more intense documentation and the lack of recognition built into the system of the role nurses play in keeping patients safe. A nurse might be tasked with doing a full skin assessment on admission to avoid accountability for preventable pressure ulcers later, for instance. “Of course this assessment would be done anyway,” says Kurtzman, but the new regulations result in “an intense need to ‘get it right,’ and there are financial consequences for the hospital, so there's more pressure. And at the same time, it's physicians who are ultimately responsible for the accuracy of these assessments and the documentation that's required under the policy.” Kurtzman believes that such attitudes are received by many nurses as messages that they have second-class status.

Furthering this sentiment, perhaps, is the fact that the incentives themselves have been largely invisible to nurses. “I was interested in seeing how the incentives would affect nurses, whether bonuses might be shared or penalties directly passed along. For the most part they were not,” says Kurtzman. She explains that although nurses could be disadvantaged if the payments aren't received—by cutbacks on training or even staffing cuts—the upside has been less obvious to them.

Another instance in which the burden falls to nurses is when hospitals script nurses’ conversations with patients in an attempt to elicit better survey results. These surveys, such as the HCAHPS survey, contain many items for which nurses are responsible—day-to-day patient comfort, pain relief, privacy, and so on. In some hospitals, nurses have been instructed to work key words into the conversation to remind patients that they're being well cared for. Although scripting could conceivably result in getting health care providers to focus on the things that matter to patients, many nurses have said that the practice distracts from patient-centered care.

Kurtzman thinks the key to the success of incentive programs may be in nurses taking ownership of them. “These conditions [and policies] were not chosen at random. Many of the problems are preventable with a standard of care that is agreed upon. This is a huge opportunity for nursing. With strong leadership, nursing can take some responsibility for what these policies are trying to do—and take some of the credit for improving patient care.”

Whether that's possible without improvements in staffing and support isn't clear.

Nurses may not see direct financial rewards from incentive programs, but such programs could lead to improvements in workplaces that allow them to provide better patient care. “These big systems do care about quality,” says Kurtzman. “There will be new vendors, better products, equipment closer to patients’ rooms to improve access—the little changes that make hospitalization a better experience overall.”—Laura Wallis

© 2013 Lippincott Williams & Wilkins, Inc.

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