Nsg Pay 4 Performance:Ethical Challenges and Opportunities

Nursing Pay for Performance: Ethical Challenges and Opportunities

Kate ONeill, DNP (c), RN CNO and VP of Quality and Safety

iCareQuality, Inc. 10.25.15

www.iCareQuality.org

Objectives for this Presentation

1 Understand P4P Models and

How it Applies to Healthcare & Nursing

2 Analyze Legal and Ethical Issues Related to P4P &

Nursing

3

5 Call to Action/ Summary

Review Current Challenges & Opportunities in P4

4 Explore Solutions for

Resolutions, including

Peer Review Option

1


• 63 yo Certified Nurse Educator works on

Oncology Unit for 35 years, received

numerous practice awards.

• Her hospital is Magnet and unit reported

NDNQI data for 2014: Hospital Acquired

Pressure Ulcers = 9.2, and CLABSI =

2.54.

• In APN meeting, Ann stated to openly:

Description of True Clinical Dilemma

2

DO YOU THINK:

Ann is a leader on her unit?

Ann is a patient advocate?

Ann is a safe practitioner?

Nurse Ann’s Story

“ Kate, I haven’t looked at a

nursing policy or procedure

in 25 years, I’m too busy,

and I don’t have time”


Overview of Pay-for-Performance (P4P)

• Payment incentives to improve care

quality, efficiency, and VALUE

• Hospitals and MD’s are paid when

they achieve QI targets.(James, J 2012)

• Payments linked to individual, group

or hospital’s performance (Donaldson, 2006)

• P4P needs to identify 2 key things:

1. “WHAT” of quality nursing care

2. “HOW” of paying for quality (Unruh, 2007)

3

ANSWER: Nsg P4P

ANSWER : NDQI


1. Over 400k deaths from Adverse

Events per year (James, JT 2013).

2. US spends 2x more on healthcare,

than other nations, ranks last for

population health (Squire 2015)

3. ACA 2010 tied quality to payment

reform with VBP. Report outcomes

data for more effective and efficient

care. (CMS, 2015)

4. MD’s & hospitals participate in CMS

incentive pay P4P for reaching target

measures.

4

Background: Why Should Nurses Care about P4P?

DEATH

DOLLARS

DATA

DOCTORS


Health and Well Being

Prevention and

Treatment

Person Centered

Care

Care Coordination

Patient Safety

Affordable Care

Better Care

Affordable Care

Health

People/Communities

National Quality Infrastructure (AHRQ, 2015)

Infrastructure Supports

Payment

(VBP)

Patient

Safety

Organizations

Quality

Improvement

Organizations

Certification

Regulation Consumer

Incentives

Measurement of

Process and

Outcomes

(NDNQI, etc.)

Health

Information

Technology

Public

Reporting,

Workforce

Development

Rapid Cycle

Learning &

Innovation

Significance to Nsg & P4P is National Quality Strategy

5


Ann breached ANA professional

standards of Code of Ethics in care

delivery due to lack of:

- Provision 3.3: Ann had a

commitment to practice with

competence using EBP.

- Provision 3.4: Ann had the

responsibility to promote health

and patient safety, and reduce

preventable harm.

- Provision 4.2: Ann had duty to

be accountable for her practice

and responsible for care

delivery in an ethical manner.

(ANA, 2015)

Ann’s lacks current knowledge EBP

and hospital P&P. Ethical issues are:

1. Non-Maleficence - Ann had the

duty to avoid causation of harm,

and by not keeping current with

EBP she contributed to high rates

of infection on her unit as seen in

her NDNQI scores.

2. Fidelity – Ann had “promise

keeping” to her patients when she

assumed care. She breached her

promise to uphold her patient

commitment for providing care in

the patient’s best interest.

(Guido, 2014)

6

Back to Ann’s Story in Clinical Practice: Potential Nursing Ethical and Legal Ramifications

ETHICAL ISSUES LEGAL ISSUES

www.iCareQuality.org 7

STEP 1: REALM (R)

STEP 2 : Individual, Organization and/or Societal

• Individual/ Ann – did not focus on good of the patient care, and rights, duties and for RN-Patient relationship.

• Organization – should be concerned with systems that will facilitate enterprise goals, improved patient outcomes & NDNQI, instead of supporting culture of “old boys club”, hidden agendas and little practice accountability

•Societal - concerned with population health, reducing harm, policy, P4P and quality measures, HAC scores , for ALL providers, RN & MD’s.

INDIVIDUAL PROCESS (I,P)

Moral Judgement, Motivation and Courage

•Moral Judgement – Ann lacked ability to decide right versus wrong actions, and not reviewing hospital policy for EBP, or modeling this behavior for new hires.

•Moral Motivation - Ann did not place a priority on ethical values over her own self-interest, & status. Ann lacked “Professionalism” which should be primary “motivator” for ethical behavior.

•Moral Courage – Ann lacked Moral Courage to do “Right” thing and didn’t demonstrate that EBP is the safest practice with best patient outcomes.

SITUATION (S)

Issue/Problem and Silence

• Issue/ Problem: Ann’s lack of

professional practice and EBP

would have been evident with

P4P practice models .

• Issue / Problem: P4P is NOT

linked to nursing practice.

Federal legislation is behind in

bringing nursing practice into full

partnership with other

healthcare providers.

•Silence of Staff –

characterized by no one

speaking out and explaining that

Ann’s behavior was wrong for not using EBP in practice.

STEP 3: Further Analysis STEP 3: Further Analysis

RIPS Ethical Decision Framework & P4P

STEP 3: Further Analysis


Ethics: P4P and Conflicts of Interest

Provision #2

• Pay incentive could alter traditional nursing values

• Pay incentives could alter clinical judgement

• Could drive economic self gain & self interest

• P4P could be negative practice driver

Ethics: P4P and Competency

Provisions # 4 & 5

• Performance is part of ACA

• Can be measured by Real-time Nsg Peer Review/Surveillance

• Align staff pay with quality, NDNQI data, EBP, and CDS use.

• Supports Life Long Learning

• Adds value in nursing via accountability & transparency

VERSES


9

Options for Resolution for P4P

OPTIONS Nurse Ann

Individual or Unit Level

Resolution

Hospital

Organization Level Resolution

OPTION 1

Root Cause

Analysis

Ann thinks she is just too busy and

Leadership just doesn’t “get it”

Complete RCA to evaluate gaps in

Ann practice and patient outcomes.

OPTION 2

Do Nothing

Culture. Biz

as usual.

Ann assumes she is right we have

always practiced this way.

Hospital has a negative culture

leads to hidden culture non-

disclosing clinical issues, and

possible adverse events.

OPTION 3

Call Ann into

office

Nurse Manager calls Ann into the

office and has Courageous

Conversation and Ann gets a

Written Warning

Hospital Leaders review incident

reports and file them away in nursing

yearly evaluation and not part of a

learning culture.

OPTION 4

Peer to Peer

Real-time

Ann is accountable to her practice

using real-time Peer to Peer (P2P)

Surveillance to measure her

performance to EBP guidelines.

Hospital leaders have daily unit

dashboards on competency and

offer nursing financial rewards for

improved patient outcomes.


Peer Review Option Selected for Resolution & Why

P4P Resolution for Ann Weekly Peer to Peer (P2P) Reviews of

Ann’s clinical practice, with real time clinical

observations of performance on her unit

Ann values shared non-punitive life long

learning

Ann understands EBP, Ethics, Practice,

Quality, are tied together like a

“performance care bundle”.

Ann values her improved competency

scores and outcomes. She is rewarded

with pay incentives if she can hit target of

95% on performance scores

P4P Resolution for Nsg Profession Build real-time Peer model that would

support frontline nursing performance

Build a Learning Organization Culture

AND Nursing Profession

Financially reward best practice. Build

accountability and transparency in

nursing practice.

Improve patient outcomes data, NDNQI

and staff could obtain financial

incentives at the individual, unit and

organization level.

10


Professional Standards &

Ethic Decision Making

Peer to Peer Clinical Competence Performance

Evidence Based

Practice

Quality and Value to

Healthcare

Nursing Pay for Performance

Resolution Implementation and Evaluation

DA

TA


Building Value in Nursing via P4P

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Safety Practice Performance Ethics

Nursing Pay for Performance 4 Pillars to Transform Care

Pay for Performance & Future Considerations

12


Getting Ethics Right in P4P in Healthcare

Beneficence and Providers in P4P –for Providers all over US to do “GOOD” for patients and want to provide the best care.

Beneficence and Hospitals in P4P – for hospitals to do “GOOD” for population health and have better healthier communities, and support Healthy People 2020 Goal.


Summary and Future Nursing

P4P Considerations

For P4P to become reality, Unruh

2007 recommends:

1. Maximize nursing knowledge, skills

& scope of practice

2. Healthcare policies should support

safe staffing ratios

3. Federal policies should support

advanced nursing education

4. Have right provider incentives to

make lasting quality improvements

5. Engage nursing leaders to

advocate for this change.


AHRQ. (2015). Report to Congress: National Strategy for Quality Improvement in Health

Care. Retrieved from http://www.ahrq.gov/workingforquality/

American Nurses Association (ANA). (2015). Code of ethics for nurses: With interpretive

statements. Retrieved from

http://nursingworld.org/DocumentVault/Ethics_1/Code-of- Ethics-for-

Nurses.html

Centers for Medicare and Medicaid. (2015). Better Care, Smarter Spending, Healthier

People: Improving Our Health Care Delivery System. Department of Health and

Human Services.

Donaldson, B. (2006). Pay-For-Performance American Nurses Association Policy

Legislation introduced to House of Delegates.

Guido, G. W. (2014). Legal and ethical issues in nursing. (6th ed). Upper Saddle River, NJ:

Prentice Hall

Health and Human Services. (2015). Healthy People 2020. Retrieved from

http://www.healthypeople.gov/sites/default/files/HP2020Framework.pdf

James, J. (2012). Health Policy Brief: Pay-for-Performance. Health Affairs, October 11, 2

2012..

References


James, JT. (2013). A new, evidence-based estimate of patient harms associated with

hospital care. Journal of Patient Safety, 9(3):122-8. doi:

10.1097/PTS.0b013e3182948a69.

Kennedy, R., Murphy, J. Roberts, D., (September 30, 2013) "An Overview of the National

Quality Strategy: Where Do Nurses Fit?" OJIN: The Online Journal of Issues in

Nursing. Vol. 18, No. 3, Manuscript 5.

Pierce, A. & Smith, J. (2013). Ethical and Legal Issues for Doctoral Nursing Students.

Lancaster, PA: DEStetch Publishing.

Squires, D. & Anderson. C. (2015) U.S. Health Care from a Global Perspective: Spending,

Use of Services, Prices, and Health in 13 Countries. Issues in International

Health Policy. The Common Wealth Fund

Swisher, L., Arslanian,L., & Davis, C. (2005). The Realm-Individual Process-Situation

(RIPS) Model of Ethical Decision Making. Health Policy & Administration,

Vol. 5 No. 3, October.

Unruh, L., & Hassmiller, S.( 2007). Legislative: Economics of Nursing Addressing Quality

and Payment in Nursing Care. Online Journal of Issues in Nursing.

References


Join the iCare Journey® #ZeroPatientHarm Patient Safety Learning Lab www.iCareQuality.org

Kate ONeill, DNP (c), RN CNO and VP of Quality Patient Safety

iCareQuality, Inc. [email protected]

c.610.505.0996 www.icarequality.org

http://www.icarequality.org/

mailto:[email protected]

Nsg Pay 4 Performance:Ethical Challenges and Opportunities

Healthcare

Transcript of Nsg Pay 4 Performance:Ethical Challenges and Opportunities