As 2011 comes to a close, the realities of accountable care and accountable care organizations (ACOs) have become truly meaningful. Although the term accountable care isn't new to healthcare, it has taken on new nuances of meaning as U.S. healthcare reform moves forward. The focus has shifted to collaborative management of patient care by hospitals and other providers. Key areas of accountable care include financial performance, clinical excellence, patient-centered care, stakeholder engagement, and effective leadership. In addition, pay-for-performance (P4P) incentives and value-based purchasing (VBP) are being integrated to deliver quality healthcare at the lowest cost. As nurses, we sit squarely in the midst of the multidisciplinary teams being held accountable.
Nurses provide care that is evaluated for a variety of quality-measurement indicators, including those that examine structures (resources used in care delivery), processes (specific tasks or treatments), and outcomes (direct measures of the results of care, including the patient's experience). Today, most VBP programs are based on a mix of structure and process measures that rarely include nursing-specific indicators, and although the Centers for Medicaid and Medicare (CMS) understand the importance of nursing care in quality outcomes, a rule to formally include a set of 12 nursing measures used by the National Quality Forum (NQF) was tabled earlier this year.
How, then, do we highlight our critical role in quality patient care within ACOs? We can participate fully in the American Nursing Association's (ANA's) National Database of Nursing Quality Indicators (NDNQI). NDNQI collects data on 11 of the 12 NQF-endorsed measures; hospitals participating in the database receive state, regional, and national comparative data that allow them to gauge their own results and progress toward improved quality of care. Hospitals who report data to NDNQI also have access to educational resources and research data that can help them plan and implement quality initiatives.
We can also use the ANA's Principles of Pay for Quality to guide discussion and planning for VBP. Developed in 2010 by their Congress of Nursing Practice and Economics, this tool outlines 10 principles for VBP that underscore our need for professional accountability, for ongoing development of knowledge related to healthcare quality, for continued data collection and analysis, and perhaps most importantly, for recognition of a nursing workforce that has the sheer numbers and skills to support quality outcomes across all roles in all settings.
We can again look carefully at the possibility of "unbundling" nursing care from hospital room and board charges and instead reimbursing nurses (or nursing departments) directly for the care provided. The current bundled approach doesn't recognize nurses' economic value. If we are to charge for the care we provide, we will need to speak a common language that ties interventions to outcomes. The Nursing Interventions and Outcomes Classification (NIC/NOC) system provides one such language.
We also can strengthen the evidence on the relationships between nursing workforce characteristics and patient outcomes. Nursing-sensitive quality indicators-falls, pressure ulcers, ventilator-acquired pneumonia, and other healthcare-acquired infections-provide one model for linking the economic value of nursing care to reduced costs and negative outcomes.
Obstacles exist. Change is difficult. However, we have support and expertise to influence and implement changes in quality and payment. The Institute of Medicine's (IOM's) The Future of Nursing: Leading Change, Advancing Health underscored the belief that nursing has the potential to bring enormous changes to the healthcare landscape: "Nurses are poised [horizontal ellipsis] to enable the full economic value of their contributions across practice settings [horizontal ellipsis] In addition, a promising field of evidence links nursing care to high quality of care for patients, including protecting their safety" (IOM, p. 3).
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