1. Hader, Richard PhD, NE-BC, RN, CHE, CPHQ, FAAN

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Competition among healthcare providers will grow increasingly more intense as the payment structure for care transforms from a fee-for-service methodology to a bundled or comprehensive reimbursement. It's anticipated that payment structures will soon change to encompass a patient's illness across the entire continuum of care rather than episodic interventions. Medicare, managed care, and commercial payers will be offering physicians and healthcare systems incentivized reimbursement if they effectively manage their patients' chronic illnesses by minimizing acute care hospitalization and reducing overall costs.

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Hospitals have long been in the mode of building business by increasing the number of patients admitted to their facilities. This paradigm is expected to shift with the development of accountable care organizations (ACOs), in which financial incentives will be determined by the quality of care provided at the lowest possible cost. Hospitals and healthcare organizations that depend on "repeat business" for economic survival will need to strategize innovative methods to grow business. This new type of reimbursement will severely impact organizations in which the majority of inpatient business is from medical admissions (such as congestive heart failure and chronic obstructive pulmonary disease) rather than surgical, diagnostic, or procedural care.


If healthcare reform proceeds as anticipated, patients with chronic diseases will be cared for primarily in an outpatient or home setting. Reimbursement will be enhanced if the quality of care meets or exceeds expected outcomes based on the delivery of evidence-based care and protocols. At the point that the patient develops complications from the illness, it puts the ACO at financial risk. Wellness or quality of care will become more lucrative than caring for sick patients.


A greater emphasis on quality is anticipated, which will place significant accountability for the care provided on nurse leaders. Protocol driven, effective nursing care can reduce or eradicate complications of care, such as pressure ulcers, ventilator-associated pneumonia, and central line infections. Nurse leaders will be responsible for ensuring that their team delivers care with the greatest of clinical expertise and competence to avoid unnecessary complications. More than ever, reliable and effective nursing care will be drawn to the center of scrutiny because failure will directly affect the financial stability of the organization.


Each team member must be a champion for quality. Leaders can facilitate this process by encouraging staff nurses to participate in quality improvement and peer review processes. The opportunity to address these issues with bedside practitioners will increase the likelihood of sustained success. Staff members need to be educated that their individual work performance will have a direct impact on the overall financial health of the organization. The development of staff-driven councils that focus on quality initiatives will spark interest among the team to develop and employ new methods of caring for patients that will yield positive clinical and fiscal outcomes.


In this new era of healthcare, winning is about quality not volume. Ensuring that each individual patient receives the highest quality of care will ensure the success of your organization and will build business on positive outcomes.


Richard Hader

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