Smith, Leslie R. MSN, RN
Leslie R. Smith is the director of Hospice at Bon Secours Hampton Roads Health System in Portsmouth, Va.
Containing costs while promoting quality care can be complex. Rise to the challenge!
The author has disclosed that she has no financial relationships related to this article.
Nurse executives are tasked with ensuring a precise balance between promoting safe, quality care for patients and pursuing a positive bottom line. We must weather the nursing shortage and avoid costly expenditures, such as utilizing agency staff and approving overtime for regular staff. Interdisciplinary practice, safe work practices, and annual mandatory competencies are all areas in which we can promote patient safety. It's also the nurse executive's role to engage in team-building activities and taskforces to drive change that will improve performance and create a culture of safety.
A group of researchers in Quebec was tasked with promoting effective operations by reorganizing care and work to improve quality, retention, and reduction in costs.1 The researchers teamed up with key leadership to share the vision, mission, and values of the organization and identify the purpose and needs of the staff members. They found that it was vital to investigate the organizational structure, culture, leadership style, and environment before promoting change. They also noted that for organizational change to occur, leaders must encourage participation, mobilization, and innovation by team members.1 Nurse executives can utilize these strategies to promote change that will lead to a culture of safety.
The importance of a culture of safety
The Institute of Medicine (IOM) has authored several publications that focus on improving quality and safety in healthcare. The 1999 report, To Err is Human, estimated that close to 90,000 annual deaths in the United States are preventable and caused secondary to errors in the healthcare delivery process.2 This publication led healthcare leaders to make changes to improve the care given to patients. In a second report, Crossing the Quality Chasm, the IOM discussed the complex intricacies of the healthcare system and the need to improve care, focusing on six pillars: safety, patient-centered, effectiveness, timeliness, efficiency, and equity.3 Ensuring that care focuses on the six pillars promotes improved quality in a safe environment.
Growing the culture of safety has led healthcare leaders to put systems in place to reduce the chance of errors. Such systems are part of the integration of health information or, more specifically, chronic disease management systems (CDMSs) and the electronic medical record (EMR). One group of researchers presented a case study that reviewed health information technology (HIT) for its ability to potentially improve the overall efficiency and quality of care.4 They examined the implementation and use of an EMR and CDMS at one facility, seeking to understand how these systems are used to facilitate and enhance patient care and provider satisfaction. They found that HIT is slow to be implemented, but it's important to improve quality care and patient safety. Implementing CDMSs and EMRs will standardize and promote best practices, ultimately reducing errors and saving time.
Implications of pay for performance
Nurse executives provide the link between the executive team and the working staff. We're an integral part of achieving the organization's mission and promoting the organization's values, growth, and fiscal performance related to quality initiatives.5 The Premier Hospital Quality Incentive Demonstration (HQID) is a program in which the Centers for Medicare and Medicaid Services (CMS) “aims to see a significant improvement in the quality of inpatient care by awarding bonus payments to hospitals for high quality in several clinical areas, and by reporting extensive quality data on the CMS web site.”6 At the onset of this project, many healthcare leaders doubted the efficacy of the initiatives. One research study scrutinized the outcomes of hospitals participating in the HQID versus those that didn't participate.7 The study found that hospitals participating in the HQID had significantly higher composite scores in the three areas measured. The researchers also noted a more rapid pace of quality improvement in hospitals participating in the project. Both cohorts showed improvement, probably due to the pressures of public reporting; however, the added incentives helped boost the rate at which higher quality results were achieved in project participants.7
There are several organizations that provide guidance to nurse executives regarding improving quality and promoting patient safety. One such organization, the Institute for Healthcare Improvement, gives nurse executives the tools and guidelines to promote best care for their patients. This, in turn, assists hospitals in achieving the highest possible reimbursement, increasing the longevity of their organizations.
Nurse executives must balance the cost of safe, quality care delivery and the financial impact realized when care isn't as good as it should be. One mechanism for improving the degree of care in hospitals is with the clinical nurse leader (CNL) role. The American Association of Colleges of Nursing introduced this role, typically a Master's-prepared RN, as a means to improve care delivery. One study reported findings from three case studies aimed at identifying the impact of the CNL role on patient safety and quality measures.8 The case studies reviewed data collected on identified measures, including fall rates, hospital-acquired pressure ulcer (HAPU) rates, core measures, cost effectiveness, and patient satisfaction. The conclusion of each case study was that the CNL role had a positive impact on the outcomes measured. One of the facilities studied was able to show a 2-year period with no HAPUs and 100% compliance with pneumonia and flu vaccine administration. Another demonstrated improvement in physician and patient satisfaction, as well as core measure compliance. The researchers concluded that the cost of employing an advanced practice nurse to promote quality and patient safety in an organization will prove to be cost effective due to the healthcare dollars that are saved.
Promoting best practice to achieve quality outcomes is necessary in today's healthcare world. Nurse executives can utilize proven strategies, such as employment of a CNL, to lead quality initiatives or the creation of a robust performance improvement program to ensure that value-based initiatives are prioritized. It's vital for sustainability to strive for the best possible clinical outcomes.
The impact of regulatory requirements on staffing
The nursing shortage in the United States has led to nurses caring for more patients than is ideal. Nurse executives must be cognizant of the impact of the nursing shortage on the quality of care. As a response to nursing shortages, the CMS and The Joint Commission have imposed regulatory guidelines to ensure safe situations for patients. The American Nurses Association (ANA) Nursing Administration Scope and Standards of Practice and Standards of Clinical Nursing Practice, state boards of nursing, and state laws have also imposed regulations on nurse staffing ratios.9
Nurse executives are stuck in a difficult situation regarding nurse staffing ratios, quality care, and the nursing shortage. Many departments don't approve overtime, but have no choice in allowing the overage to provide care for their patients. Managed care restrictions add another layer to the mix. Patient acuity is increasing, making more work for the nurse. Today, caring for six patients is very different than it was 20 years ago. In addition to acuity, the education and experience level of the nurse must be considered when determining staffing patterns.9
As a result of the position taken by the IOM, The Joint Commission, and the CMS regarding the correlation between nurse staffing ratios and quality care, California instituted mandatory regulatory requirements that determine fixed nurse staffing ratios based on the type of nursing unit. A recent study examined the quality of care related to imposed nurse staffing ratios in California. The researchers specifically compared length of stay (LOS) and hospital-acquired urinary tract infections (UTIs) with the nursing hours per patient day (NHPPD). The results of the study suggest that “increases in both total NHPPD and RN proportion of skill mix lead to decreases in both UTIs and LOS” and “as RN proportion increased, the odds of acquiring UTI decreased by 4.25 times.”10 This has significant implications for nurse executives in the management of fiscal resources due to actual cost savings realized when adverse events are minimalized.
As more states consider adopting nurse staffing regulations, more research will be generated regarding preregulatory and postregulatory data.11 Regulatory oversight of nurse staffing ratios may cause a financial hardship to healthcare organizations but, in the long run, patient outcomes will improve and organizations with higher quality outcomes will attract more business.
Investing in the future
The nurse executive leads the team in imparting the best possible quality care for patients while ensuring cost containment for the organization. There are several strategies that we can utilize to achieve both a financially stable organization and quality outcomes. Flexing to volumes and negotiating with vendors for the lowest rates are two cost-saving measures. As patient acuity increases, the available healthcare dollars for reimbursement decrease. Organizations are now held accountable for the care given to patients and will suffer if they don't ensure that high-quality, evidence-based care is the norm. It's also essential for the nurse executive to ensure adequate numbers of competent staff; positive working relationships within the team; accountability and autonomy for nursing practice, with adequate compensation related to responsibility, education, and experience; continuing education and access to research; and access to appropriate technology with a focus on evidence-based practice.9 Investing in the team will prove to be valuable in the future of healthcare.
1. Viens C, Lavoie-Tremblay M, Leclerc MM, Brabant LH. New approaches of organizing care and work: giving way to participation, mobilization, and innovation. Health Care Manag (Frederick). 2005;24(2):150–158.
2. Institute of Medicine. To Err is Human: Building a Safer Health System. Washington, DC: National Academy Press; 2000.
3. Institute of Medicine. Crossing the Quality Chasm: A New Health System for the 21st Century. Washington, DC: National Academy Press; 2001.
4. Follen M, Castaneda R, Mikelson M, Johnson D, Wilson A, Higuchi K. Implementing health information technology to improve the process of health care delivery: a case study. Dis Manag. 2007;10(4):208–215.
5. Hader R. Board governance: what is your CNO's role? Nurs Manage. 2006;37(3):32–34.
7. Grossbart SR. What's the return? Assessing the effect of “pay-for-performance” initiatives on the quality of care delivery. Med Care Res Rev. 2006;63(suppl 1):29S-48S.
8. Stanley JM, Gannon J, Gabuat J, et al. The clinical nurse leader: a catalyst for improving quality and patient safety. J Nurs Manag. 2008;16(5):614–622.
9. Roussel L. Management and Leadership for Nurse Administrators. Sudbury, MA: Jones and Bartlett Publishers; 2012.
10. Esparza SJ, Zoller JS, White AW, Highfield ME. Nurse staffing and skill mix patterns: are there differences in outcomes? J Healthc Risk Manag. 2012;31(3):14–23.
11. Keepnews DM. Evaluating nurse staffing regulation. Policy Polit Nurs Pract. 2007;8(4):236–237.
© 2012 by Lippincott Williams & Wilkins, Inc.