Pay to Play
Quality is the name of the game in healthcare, and nurses are consistently seen as playing a major role in improving hospital quality. As the demand and requirement from payers (both governmental and private) for high quality healthcare delivery grows, so will the pushback on nurses to find more and creative ways to up their game while cutting costs.
Will all this effort improve work conditions for nurses? Apparently not, according to a new study by Ellen Kurtzman, MPH, RN, FAAN, assistant research professor in the George Washington University School of Nursing in Washington DC. Kurtzman's study indicates these linkages could actually hurt the fabric of nursing, both weakening the nursing workforce and harming the practice environment. Kurtzman's research showed nurses were more likely to be burdened by such policies. Nurses also are more likely to be blamed when financial goals were not met when nursing-sensitive "never events" occurred, all without looking at staffing levels, the practice environment or salaries.
"This research has given us an unprecedented opportunity to be in the field and interview hospital leaders and unit nurses about the impact of performance-based incentives. While nurses are not typically considered in the design of such incentive programs, our study indicates that they influence the implementation of such policies and are impacted-in some cases negatively-by these programs. Overall, interviewees reported favorable effects of financial incentives on patients but viewed these emerging policies as burdensome to nurses and having little positive effect on improving nurse staffing or turnover," Kurtzman said in announcing her findings.
The study was part of a larger, 2-year Robert Wood Johnson Foundation project looking at how nurses were impacted by performance measures, public reporting and performance-based financial payment policies. Kurtzman interviewed both staff nurses and nurse managers in acute care facilities across the country in 2008. She asked the nurses she spoke with about performance-based reimbursement incentives, including CMS hospital-acquired conditions. Everyone agreed nurses were very important drivers for patient care and that reimbursement incentives could help increase patient safety and outcomes, and noted putting such a system in place would be difficult when per diem and float nurses were involved. In addition, nurses might shy away from taking on challenging patients (such as those who could develop pressure ulcers) because they don't want to be in the position of "being the nurse who lost the hospital reimbursement money."
When the discussion turned to the impact the policies could have on nursing, staff nurses and nurse leaders saw things differently.
Staff nurses cited additional paperwork, technology, training and staff as potential burdens taking them away from the bedside. Managers shared a concern that pay-for-performance measures could actually lead to a loss in reimbursement which would negatively impact nursing through budget and staff cuts
What's the answer?
Kurtzman suggests nurses get more involved politically, educating the people enacting policies about the "real world" of hospital nursing. They should let legislators know what front-line caregivers do and help them understand the constraints of their work. Incentives only work if they truly are shared, she said - if nurses are held responsible for metrics, they also should be rewarded when the hospital performs well.
What do you think? Is pay-for-performance a good idea? Are governmental regulations making your job more difficult? Is your facility changing its policies and procedures to comply with patient safety and outcomes measures? Are you responsible for them? Let us know what you think.