Dempsey, Christina MSN, MBA, RN CNOR CENP; Reilly, Barbara PhD; Buhlman, Nell MBA
Central to the Affordable Care Act (ACA)1 is the shifting from paying for the volume of services provided to paying for the value of services provided (Figure 1). Multiple programs within the ACA support this aim by assessing quality and/or cost and encouraging desirable changes in performance through incentive payments or penalties. Hospital value-based purchasing (VBP)2 was the 1st such program to be implemented. In the initial year, VBP put at risk 1% of hospitals’ base operating diagnosis-related group (DRG) payments according to their performance on a set of process of care (POC) measures and on the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) survey.3 In 2013, the VBP program shifted both the amount of payment at risk, as well as in the aspects of performance being assessed. Furthermore, the Centers for Medicare & Medicaid Services (CMS) has implemented additional pay-for-performance (P4P) programs—specifically the Readmissions Reduction Program (RRP)4,5 and the Hospital-Acquired Condition (HAC) Reduction Program,6,7 both of which subject hospitals to payment penalties for poor performance.
By design, the VBP program changes from 1 year to the next: new domains and new measures are added, measures are retired, benchmarks and thresholds rise, and the amount of payment at risk increases. Yet even amid all the change, the HCAHPS domain remains its 1 constant—both in the aspects of performance being evaluated and in the incentive payments tied to HCAHPS performance.
The Role of HCAHPS and Patient Experience Within VBP
For Federal Fiscal Year (FFY) 2013 when 1% of hospitals’ base operating DRG payment was at risk, HCAHPS performance drove 30% of a hospital’s VBP score, while performance on POC measures accounted for 70% of a hospital’s score. For FFY 2014, which began October 1, 2013, the amount of payment at risk increased to 1.25%, the scoring methodology expanded to include outcome measures, and the weighting was adjusted so that outcomes drive 45% of the score, and POC measures drive 25% of the score. For FY 2015, the amount at risk rises to 1.5%, a 4th domain measuring efficiency is added, and the domain weighting is adjusted so that HCAHPS drives 25% of a hospital’s VBP Score (Figure 2). For the foreseeable future, patients’ perception of care will play a significant role in determining VBP scores and incentive payments. This creates an imperative for hospitals to focus on the POC, practices, and behaviors that drive HCAHPS scores. Adding to the imperative is a growing body of research that demonstrates an association between performance on HCAHPS and hospital performance on other CMS quality-based payment programs such as the RRP and certain HAC.8-11 In fact, ineffective communication is the most frequently cited cause for sentinel events in the United States.12 Another benefit of improved performance on HCAHPS is potential associated gains in profitability. In a study that analyzed public data on hospital profitability and the HCAHPS survey scores, researchers found that the top 25% of US hospitals with the highest scores on the HCAHPS question about performance were, on average, the most profitable and had the highest clinical scores.13
As providers consider the role of HCAHPS performance in their success under the P4P initiatives and consider the processes and practices that are associated with improving performance, they must consider the effect of rising thresholds and benchmarks in the program. Under VBP methodology, each program year has a new set of thresholds and benchmarks for each measure within all of the domains of performance. These benchmarks and thresholds, which are used to calculate VBP points earned, are derived from aggregate national performance in prior baseline years and therefore increase year over year as national performance improves (Figure 3). This creates a situation where, for all but the highest performers, sustaining performance equates to losing ground (and VBP points).
The HCAHPS survey comprises 32 questions, most of which ask patients to evaluate how often certain service behaviors occur during an inpatient stay. The questions are grouped in dimensions with each dimension scored individually. Scores reflect the average number of “top box” responses across the question in each dimension. Top box is defined by CMS as the most positive response on the survey.14 At present, 8 of the domains are taken into consideration for VBP scoring purposes.
* communications with nurses
* communication with doctors
* hospital environment
* responsiveness of hospital staff
* pain management
* communication about medicines
* discharge information
* transition of care (not included in VBP)
* likelihood to recommend (not included in VBP)
* overall rating
Nurse Communication: The Rising Tide That Lifts All Boats
Knowing the importance of HCAHPS in the VBP program, and the positive association between performance on HCAHPS and clinical metrics used in the various accountability programs, a hierarchical variable clustering analysis was performed by researchers at Press Ganey on all 8 HCAHPS dimensions15 to identify if there was a predictive relationship between the dimensions and the framework. This type of analysis differs from a traditional correlation analysis, which looks at the relationship between only 2 measures. The variable clustering technique identifies if there are multiple measures that “hang together” consistently, and the hierarchical analysis identifies which measure (or cluster of measures) leads the others.
The objective of the analysis can be likened to a statistician’s version of “follow the leader” that answers a stepwise series of research questions:
1. Which HCAHPS dimension is the leader?
2. Which dimensions follow the leader?
3. In what order do the other dimensions follow?
4. How closely do the other dimensions follow the leader and each other?
The analysis identified 5 HCAHPS dimensions that consistently cluster together in the following order:
* communication with nurses
* responsiveness of hospital staff
* pain management
* communication about medicine
* overall rating
As depicted in Figure 4, communication with nurses leads the other 4 measures. This means that when a hospital aims improvement efforts on the communication with nurses dimension, it likely will see associated gains in performance in the other 4 dimensions in the cluster.
The degree of associated gain a hospital will see in the other dimensions depends on how closely the other dimensions follow communication with nurses. To use the “follow the leader” analogy again, the rate of change and degree of change in performance will likely be greater for responsiveness of hospital staff—which follows communication with nurses very closely—than it would be for the overall rating, which is farthest behind the “leader” of the cluster.
Figure 4 also depicts how subclusters within the overall cluster are likely to influence each other, as illustrated by the brackets. Specifically, communication with nurses and responsiveness of hospital staff together are highly likely to influence performance on pain management. These 3 measures then will have a higher likelihood of influencing communication about medication. Finally, it is the full force of the 4—communication with nurses, responsiveness of hospital staff, pain management, and communication about medication—that influence the overall rating. As the industry moves toward a continuum of care model, the role of nurses and nurse communication will become even more important.15
Engaging Nurses to Improve Patient Experience
Clearly, nurse communication is integral to patients’ perception of their overall care. It stands to reason that engaged nurses are more likely to provide better patient care and quality and therefore a better patient experience. In fact, The Joint Commission in 2010 stated that “the future state of nursing is inextricably linked to the strides in patient care quality and safety that are critical to the success of America’s healthcare system today and tomorrow.”6(p1) While there may be considerable agreement with this concept, there are conditions in the present state of nursing that are obstacles to the industry’s future success. A survey cited in the 2011 Institute of Medicine’s The Future of Nursing16 reported that entry-level nurses who had left their 1st healthcare job cited poor management, stress, and a desire for experience in different clinical areas as reasons for their departure. Furthermore, some entry-level nurses who leave 1st time hospital jobs leave the profession entirely.16
Researchers have found that the highest degrees of engagement were found consistently among bedside nurses with less than 6 months’ tenure on the job (Figure 5). This finding is quite predictable within the nursing profession in general. While nurses overall are quite engaged, the most engaged are at the earliest part of their career, and engagement goes down substantially after a year on the job and does not trend upward in a substantial way for 10 years. In addition, nurses at the bedside have lower engagement than nurses involved in leadership and administration positions (Figure 6). There are 2 reported theories regarding this phenomenon. One is that the most engaged nurses are promoted away from patient care, and the 2nd is that nurse leaders are more engaged given the nature of the work and the broader view of the environment.17 In reality, it is most likely a combination of these 2 factors. The engagement dip in nurses of midrange tenure and the fact that the most highly engaged nurses are in leadership (not bedside) positions reveals an engagement gap that can have real consequences for patient care. In other words, those nurses who are providing the vast majority of direct patient care are the least engaged nurses. In addition, there is a distinct difference between bottom and top decile performers in terms of overall employee engagement (Figure 7). These data, coupled with the understanding of the relationship between HCAHPS and optimal care and outcomes, underscore the imperative of improving engagement of bedside nurses.
Using the Nursing Process to Engage Nurses
One of the 1st things student nurses learn is to use the nursing process when providing care. This process is also applicable when the aspect of care is the patient’s experience of care. By using this analogy, nurses are able to better link the quality of the experience to the quality of clinical care rather than focus on a score. Using a score to drive improvement rather than the quality of patient care may produce very different buy-in for direct care nurses. The metrics must be translated into the voice of the patient—what is the patient saying to the individual nurse about his/her perception of the quality of their care? The nursing process is depicted in Figure 8.
In interviews with nurses, nurse managers, and nurse executives, healthcare reform, changes in reimbursement, and the need to drive improved quality at a reduced cost are not well understood by bedside caregivers.18 One possible reason for this is that nurse leaders may be trying to buffer or shield bedside nurses from the reality of healthcare bureaucracy. However, shielding does not allow the nurses to see the bigger picture driving the need for improvement. As a result, strategies to improve communication: purposeful hourly rounding,19 bedside shift report,20 the use of white boards in patient rooms,21 earlier discharge planning,22 and so on, are perceived as “one more thing” for nurses to do during an already busy shift. Assessing nurses’ understanding of these issues is important to ensure that they have the rationale behind initiatives. Nurse leaders’ observation of interactions between nurses, between nurses and patients, and between nurses and their managers/leaders will establish the baseline for communication competence. Observing rounding behaviors, bedside shift report, and the consistent updating of whiteboard information will provide an accurate picture of how information is being shared with patients and between caregivers. Alongside the observation, nursing leadership needs to interview nurses, managers, physicians, ancillary staff, and patients to establish a foundation of perception of the present state of communication, quality, and collaboration. These interviews are a critical 1st step toward formulating the plan for improvement.
A review of the objective findings, when combined with the subjective information from the observation and interviews, will provide a comprehensive picture of key areas of the organization from which to begin diagnosing the issues and planning for improvement interventions. Data should include patient experience data; operational data including staffing productivity, skill mix, patient demand and acuity; cycle times for processes; and financial data. Just as financial and operational metrics typically include all patient data, patient satisfaction data should also include as much data as possible in order to drive targeted improvement. This census-based surveying approach provides greater depth and breadth of information in addition to the minimum numbers of mail or phone surveys used by CMS for HCAHPS analyses.
Using the overall patient experience-as-the-patient analogy once again, the nursing diagnoses that apply may include those found in Figure 9. Applying this nursing discipline confers distinct advantages because it is familiar to nurses and will help them more readily understand the connection between the patient’s experience and the patient care provided.
Following the completion of a thorough assessment and the identification of issues (stated as nursing diagnoses), intervention planning may begin. Nursing leaders ask basic questions to help narrow scope, determine responsibility and accountability, and specify how interventions will be delivered.
* What interventions will need to be done?
* When will the interventions be done?
* Who will perform the interventions?
* How will the interventions be performed?
* How will you know if they’ve been successful?
Interventions will be based on the planning outlined above and may include the following:
Formal and ongoing training related to the patient experience. Basic life support training is required annually in most hospitals so that when caregivers find a patient in a state of arrest, the caregiver has been trained so well that their actions become instinctual. Patient experience training should be perceived in the same manner and relative importance.
Purposeful Hourly Rounding
Patients who report that they were rounded upon frequently or hourly reported an overall better experience with their hospital stay.19 In a 6-week nationwide study on the effectiveness of hourly rounding,23 3 experimental groups participated in various rounding protocols from no rounding, hourly rounding, and 2-hour rounding. Regular rounding consisted of 12 specific actions such as offering toileting assistance and assessing the patient’s position and comfort. There was positive support for the benefits of 1-hour rounding, with the 1-hour-rounding group having the lowest incidence of call-light use, the highest levels of patient satisfaction, and significantly fewer falls than the 2-hour-rounding and control groups.23
Bedside Shift Report
The bedside shift report allows the patient to participate in her/her care and reduces the risk patients may feel being in the hospital.20 The bedside shift report provides an opportunity to “manage up” the oncoming nurse so that the patient hears that the nurse is competent and will take good care of them during the next shift. It also provides an opportunity for the patient to ask questions and for caregivers to provide information that may impact discharge transition. When these handovers are effectively executed, information is shared in a 2-way manner to provide accurate, up-to-date information about the patient’s care, treatment plans, use of services, current condition, and any anticipated changes to their condition. In a survey of 259 nurses who participated in a structured bedside handover improvement initiative, researchers identified improvement to continuity of care, which included involvement of patients, use of a structured handover tool, active patient checks, and checking documentation.20
Senior Leader Rounding
Senior leader rounding is a way that patients and staff are able to access the “C-suite.” It enables hospital executives to see 1st hand what is happening on the units and to interact with the people who care for the patients. It also provides patients with an opportunity to talk with the senior leadership and for the senior leaders to express their appreciation for the staff taking care of the patients and the patients who have chosen their hospital for care.24
Improving Patient Flow
Waiting times are a major source of frustration and dissatisfaction as evidenced by the results of inpatient scores for emergency department (ED) patients who have had long waiting times before admission.25 Improving the flow of patients requires a focus not only on the ED but also on every department in the hospital.26
Nurse Manager Training
It is imperative that nurse managers understand culture, behaviors, clinical outcomes, and operational issues. Often, these nurse managers were excellent clinicians who sought or were promoted based on this ability and not their management experience or expertise.27 As such, many lack the fiscal, operational, and cultural acumen to succeed in this highly stressful role. A formal training program for nurse managers that includes aspects from each of the components of patient experience: clinical, operational, cultural, and behavioral, will ensure that nurse managers are successful in their role and are able to coach and mentor their subordinates as well as to support and collaborate with those to whom they report.28
The final step in the nursing process is the evaluation.29 In this phase, the outcome of the interventions is determined through data, interviews, and observation in much the same way that the original assessment was conducted. The process is repeated in an iterative and ongoing fashion so that progress and improvement are continually made.
Barriers to Nurse Engagement
Barriers to nurse engagement may take the form of education, operational issues, or culture. Education regarding the rationale underlying patient experience strategies helps direct care nurses understand the necessity behind improving the patient experience in a tangible way. When considered in the context of VBP, there is a tangible cost to suboptimal HCAHPS performance. The cost of suboptimal performance increases when considering the positive association between performance on HCAHPS and readmissions and between HCAHPS and certain HACs. Ensuring the bedside nurses have a clear understanding of the far-reaching benefits of improving performance will help set the stage for success in implementing the strategies and encouraging nurses to embrace them.
Mentoring may prevent the early departure of nurses from the profession and may help to promote retention.30 A mentor who provides support and assistance well beyond the preceptorship and orientation period has been shown to improve nurse engagement and retention.30
Collaboration is key. Shared governance is a way in which to promote leadership and accountability within the direct care nurse population.28 Allowing nurses to determine ways in which to improve and methods by which to document accountability will help to promote buy-in and ownership. In this way, they own the work and the result rather than it being just 1 more thing they have to accomplish in an already busy shift.28
Reward and recognition do not always have to be monetary. In fact, some research has demonstrated that rewards do incentivize employees, to get more rewards rather than to change behavior.31 These authors suggest that rewards may not be necessary or desirable if a compelling case is made for the reason behind the desired outcome and corresponding necessary behavior change.31 Instead, publicly recognizing those outstanding participants along with their work provides longer-term satisfaction and a role model for others to emulate.
Leaders should link outcomes to quality rather than the score. The clinical nature of nursing care and the desire to help an ailing patient rather than provide a hotel-like atmosphere resonates to direct care nurses. Demonstrating the links between nurse communication and clinical metrics provides the link that will help many nurses understand how the patient experience fits with the clinical nature of the care provided.
Leaders should provide best practice solutions that will promote further ideas and best practice solutions. These include thank-you notes, pain menus that illustrate ways in which pain might be alleviated, and bulletin boards in public areas demonstrating quality- and value-based information (see Documents, Supplemental Digital Content 1, http://links.lww.com/JONA/A295, Supplemental Digital Content 2, http://links.lww.com/JONA/A296, Supplemental Digital Content 3, http://links.lww.com/JONA/A297, and Supplemental Digital Content 4, http://links.lww.com/JONA/A298, which depict a few such solutions).
Optimizing nurse communication has a direct and positive impact on other HCAHPS domains as well as key clinical outcomes such as readmission rates, HACs, and reduced mortality. This link has definite impact on the reimbursement to organizations under VBP and the ACA.2,4,6 Improving patient experience has proven to be difficult for organizations. With changing benchmarks, it requires a great deal more effort to achieve top decile performance and even more effort to stay there. In order to move the improvement needle, every member of the healthcare team must be focused. That focus requires engaged direct care nurses providing patient-centered care for every patient, every hour of every day. Key components in achieving highly reliable performance in patient experience are optimizing nurse engagement and improving nurse communication. Using the nursing process, taking a clinically focused and diagnostic approach to the patient experience, helps to motivate nurses by focusing on quality and ultimately to improve the patient’s perception of their care. In addition, positively reinforcing even small incremental changes helps to motivate further change and the ongoing improvement in patient experience. Nursing has a shared purpose with other healthcare providers to provide the optimal patient experience. Understanding what that experience impacts and how nurses impact it from the clinical, operational, cultural, and behavioral aspects of care will help to achieve a highly reliable and exceptional patient experience.
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