Federal bill would link Medicare hospital pay to quality

The "never event" legislation sparks a more comprehensive package that rewards quality vs. punish mistakes. Either way, the shortage of registered nurses, a fundamental element to quality care, will impede any such attempts to hold hospitals accountable for their care delivery. Best practices are almost impossible to achieve, on a sustained basis, since nurses are spread too thin: too many patients, too few support services, operational breakdowns due to inadequate processes based on antiquated models, and caring for too many people without financial resources to pay a hospital for the "quality" delivered. The outcome in many cases is to focus and shave labor dollars in nursing, further eroding the ability of nurses to practice safely. From my experience as a registered nurse and consultant, for 30 years, I know that legislation like this cannot achieve its goals until more nurses are available, and its leadership is trained in business processes that align nursing budgets to the actual work required. Because nursing services are not billable, it is easy to manipulate and shrink the number of nurses without measuring this impact on good clinical outcomes. The bottom line is that the best intentions from any legislation can only work if the supply of nurses matches the work demand. Nurses cannot take on the role of transport, housekeeping after hours, and unit secretary after hours (answering phones, pulling charts together and other administrative tasks which take time away from patient care). Already nurses spend only 30% of their time directly with patients. Until hospital CEOs focus on acquiring the expertise of nurses in adequate supply, legislation will only complicate the crisis of numbers of nurses. Forcing new quality measures in a landscape of shortage will not succeed. One example of securing more nursing labor dollars is to reorganize and delayer positions in the senior ranks, director levels, and management levels that drives productivity that is patient focused, not management focused. My dream is an organization with department managers organized into business units who work together everyday: radiology, nursing, finance, lab, housekeeping and an ER staff member to manage flow from the ER, under one business unit according to bundled specialties, with one business unit leader who reports to the COO. These business unit leaders would be manufacturing gurus skilled in Six Sigma and the like, working to build effective patient care processes with the unit managers. Gone are department directors. Gone are VPs over those directors. In fact there is no VP level at all. Approval for capital projects and budgeting is managed at the business unit level, with the expertise provided by the finance representative and unit manager. All quality measurement is managed by the manufacturing guru and unit manager. The work involved to create such a system is costly up front, but cost avoidance by eliminating unproductive top layers frees cash to use to create the new model. It will take 3-5 years to build, but it will be worth it in the long run. As it stands right now, the structure in hospitals is a significant barrier to innovative change, and quality legislation must take into account the failures of the current hospital system.

This sounds doable until the physicians enter the picture. Having the most power, and the greatest expertise (we hope - depends upon whether it is an urban teaching center with the best minds vs. community hospitals/rural hospitals who typically attract less trained or experienced physicians), the trickiest aspect is their buy in. A hospital who intends to reorg for the better has to figure out a way to include the doctors in the day to day operation of the new business units. Their ideas and expertise are crucial to success. They have to be allowed a voice in new ways. It starts with the right Medical Affairs leader; a strong person capable of listening and refraining from the usual resistance tactics to which they are known. When doctors can finally see there are enough qualified nurses (qualified = a decrease in the importation of less trained foreign nurses) to care for their patients, they will begin to see the benefits of a solid reorg plan.

Having said all this, we still have a crisis with insurance companies. Yet we must start from the inside out - proving to the feds, the states, and commerical carriers that they are paying for real performance. Bridging this gap may have to include the bad guys (insurors) in quality reviews that go beyond the nurse case management daily tasks, which fragment relations with physicians and ultimately do little to improve patient outcomes. Inviting insurance reps into the business unit activities to see firsthand the changes in quality may go a long way towards building the trust that is lost between insurors and hospitals. The contracts do not become the focus - the actual care is the focus with their input. Insurance companies are not going away, and they certainly have their share of financial challenges and unethical practices, so why not invite them into hospitals where ethics matter?

The Team of Rivals is making a comeback with the newly elected President. Why not build Teams of Rivals in healthcare? A room full of doctors, nurses, manufacturing gurus, and insurance folks fits the bill, wouldn't you say?