Improving the quality of health care has been a hallmark of nursing since the pioneering work of Florence Nightingale in the mid-19th century. Nightingale's nightly nursing rounds tending to casualties of the Crimean War established her image as “the Lady with the Lamp,” but it is for her use of the scientific method and statistical analysis to improve the quality of nursing care that we remember her as the founder of modern nursing. In a recent interview, Beth Sharp, PhD, RN, senior advisor, women's health and gender research at the Agency for Healthcare Research and Quality (AHRQ), said, “If Florence Nightingale were alive today, AHRQ investigators would be clamoring to have her as a consultant on their grants for quality measurement, health care–associated infections, and training in patient-centered services.”1
Since 2005, acute care hospitals have been participating in the federal Inpatient Quality Reporting (IQR) program mandated by the Medicare Prescription Drug, Improvement and Modernization Act of 2003. In the first year of this pay-for-reporting program, hospitals submitted performance data on 10 specific measures of health care quality, often referred to as the “core measures.” The Centers for Medicare and Medicaid Services (CMS) paid hospitals that submitted these data the full Medicare payment, adjusted annually for inflation. This program has continued to develop, in both the number of quality measures required and the amounts of money tied to these measures. By October 2013, the program had grown to encompass 55 health care quality measures. If a hospital doesn't submit these data in a timely and accurate way each quarter, the hospital is penalized 2% of the total annual Medicare payment.
The Affordable Care Act (ACA) addresses three broad, health-related goals: improving the health care delivery system, expanding health insurance coverage, and controlling health care costs (see National Quality Strategy). To meet these goals, the ACA has developed a series of initiatives (see ACA Initiatives for Improving the Quality and Efficiency of Health Care). Quality improvement (QI) and patient safety initiatives are further described under Title III of the legislation: “Improving the Quality and Efficiency of Health Care” (see www.hhs.gov/healthcare/rights/law).
Three Key Programs
The CMS has implemented three key pay-for-performance programs to drive QI in hospitals, known as the Hospital Value-Based Purchasing (HVBP) program, the Hospital Readmissions Reduction Program (HRRP), and the Hospital-Acquired Conditions (HAC) reduction program. These programs apply to acute care hospitals and do not affect critical access hospitals. The quality measures included in these programs are a subset of the (currently 55) measures required by the IQR pay-for-reporting program.
The HVBP program is designed to reward hospitals that perform well on a set of quality measures, compared with all other reporting hospitals, and that improve over time, compared with their own baseline data. Hospitals that don't meet the CMS national benchmark (being equal to the mean of the top decile for each measure) or that don't improve over time are penalized. Because the program is “budget neutral,” no Medicare funds beyond those already budgeted are spent. Every year the CMS withholds a percentage of each hospital's Medicare payment until the performance data have been submitted and evaluated. The CMS determines the total amount of a hospital's Medicare payment according to the diagnosis-related group (DRG) classification system. Payments for treatments in each DRG—the base operating DRG payment—are standardized across U.S. hospitals, with some variation for geographic location and other factors. In fiscal year 2013, the first year of the program, 1% of base payments were withheld; in fiscal year 2014, 1.25% were withheld. The withheld amount increases by 0.25% each year until it reaches a maximum of 2% in 2017.
The HVBP program uses payment incentives to reward top-performing hospitals that provide high-quality care; poor quality of care results in financial penalties. The dollars withheld are redistributed to hospitals based on their total performance scores on all measures as compared with all other hospitals. Any withheld amount can be earned back, depending on a hospital's performance, and the best performers may earn back a greater percentage than was withheld for the year, while poor performers may be penalized up to the entire 1%. Each year, new measures may be added to the HVBP program and others deleted. More detailed information on the program will be included in upcoming columns.
The HRRP retroactively evaluates and compares hospitals using three years of data on 30-day all-cause readmissions in three disease processes: acute myocardial infarction, heart failure, and pneumonia. In fiscal year 2013, the penalty was 1% of base operating DRG payments (as in the HVBP program); the penalty will increase to 2% in fiscal year 2014 and to a maximum of 3% in 2015 and beyond. As part of the proposed regulations for 2014, additional disease processes or diagnoses will be added to this list in 2015, including chronic obstructive pulmonary disease, elective total hip arthroplasty, and elective total knee arthroplasty.2
The HAC reduction program will begin in 2015. Hospitals that score in the top quartile of hospital-acquired conditions will be penalized 1% of their base operating DRG payments. This penalty will be applied after adjustments are made for the HVBP program and the HRRP; in fiscal year 2015 (beginning Oct 1, 2014), a hospital that performs poorly according to the criteria of all three programs could be penalized as much as 5.5% of total Medicare payments. The proposed evaluation method includes two medical complication domains that will be combined for a total score. Domain 1 includes the AHRQ's Patient Safety Indicators 90, a composite of the rates of eight patient safety indicators: pressure ulcers, central venous catheter–related bloodstream infections, hip fractures, postoperative pulmonary embolism/deep vein thrombosis, sepsis, wound dehiscence, accidental puncture during surgery, and iatrogenic pneumothorax.2 Domain 2 includes the CDC's National Healthcare Safety Network measures for central line–associated bloodstream infection and catheter-associated urinary tract infection.2 These are reported as standardized infection ratios. It has also been proposed that more hospital-acquired conditions be added to Domain 2 in 2016 and 2017. This penalty has been capped at 1% for the following years.
The impact of these three programs on a hospital's total Medicare reimbursement may be significant, and the risk of decreased payments will increase each year. Table 1 shows the percentages of decreased reimbursements for each of the three pay-for-performance programs.
Where do Nurses Fit In?
Recent research has found that nurses may not be fully engaged while participating in QI initiatives at their facilities. Djukic and colleagues surveyed two cohorts of early-career RNs (defined as having been licensed within 10 years of taking the survey) from 15 states two years apart to compare reported participation in hospital QI activities.3 It was hypothesized that participation would be greater in the second cohort of RNs because of the growth of several national initiatives aimed at improving nurses’ engagement in QI (examples include the Institute for Healthcare Improvement's Transforming Care at the Bedside, the American Nurses Credentialing Center's Magnet Recognition Program, and the American Nurses Association's National Database of Nursing Quality Indicators). The survey focused on demographics, educational preparation in quality and safety as provided by nursing education programs and current employers, administrative support for RNs’ participation in QI initiatives, and 14 items related to nurses’ participation in such initiatives. Contrary to expectations, the results demonstrated no statistically significant differences between the two cohorts across the 14 measured activities except for their reported use of appropriate strategies to improve handwashing adherence. This study highlights the need to identify the most effective ways to improve nurses’ participation in QI initiatives early in their careers. The researchers recommended that RNs’ education and participation in QI include the Institute for Healthcare Improvement's Open School for Health Professions, the Quality and Safety Education for Nurses initative, and local and regional health care quality organizations. Every hospital has ongoing QI committees or groups, and every committee should have strong nursing participation. Nurses, regardless of their level of professional experience, are on the front line of health care delivery and, therefore, can provide unique perspectives as the voice of the patient and as the critical “touchpoint” for quality issues.
So where do nurses fit in this new world of health care quality and safety? In 2010, the American Nurses Association published “The Impact of Nursing Care on Quality,” a white paper emphasizing the undeniable impact of nursing care on health care quality and the critical role of the nurse in the provision of high-quality care.4 Although this article focuses on nursing-sensitive indicators of quality defined as processes or outcomes that are most affected by nursing (for example, falls, hospital-acquired pressure ulcers, and catheter-associated bloodstream infections), the current system-wide emphasis on improving quality of care and cost-effectiveness requires nurses to think beyond these specific quality indicators and to evaluate our important roles in all patient care quality and safety measures. There is a need to further document the link between nursing and the performance measures hospitals must achieve in both pay-for-reporting and pay-for-performance programs. For example, nurses are key in assessing, evaluating, and potentially preventing many hospital-acquired conditions (such as catheter-associated urinary tract infections, pressure ulcers, vascular catheter–associated bloodstream infections, and venous thromboembolic events) and are pivotal in the numerous process and outcome measures required of hospitals (such as administration of venous thromboembolism prophylaxis, timely administration of antibiotics, and patient experience and satisfaction measures). The time is now for nurses to lead the way in our challenging new world of health care quality.
2. Centers for Medicare and Medicaid Services. 42 CFR Parts 412, 418, 482, et al. Medicare program; hospital inpatient prospective payment systems for acute care hospitals and the long term care hospital prospective payment system and proposed fiscal year 2014 rates, etc. Washington, DC: Federal Register 2013;27486-823.
3. Djukic M, et al. Early-career registered nurses’ participation in hospital quality improvement activities J Nurs Care Qual. 2013;28(3):198–207
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