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Value-Based Purchasing Transfer in Healthcare Research Paper

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Updated: Aug 8th, 2020

VBP Degree of Implementation

Value based purchasing (VBP) is a healthcare system that ties Medicare payment incentives to specific quality measures categorized into domains (CMS, 2016). Unlike the FFS system that focuses on quantity, the Medicare VBP plan rewards providers meeting the predefined set of measures on quality care and best clinical practices. Hospital performance is evaluated based on measures that fall into four domains: clinical process, patient experience, outcome, and efficiency. Providers are awarded achievement and improvement points for every VBP indicator using the 50th percentile as the threshold.

My organization runs various VBP projects, mainly in the finance and clinical support departments, to align its clinical processes with the quality and patient safety goals. The initiatives entail active participation of the medical staff and partnerships with state/national institutions on quality programs. The hospital participates in the ‘Every Patient Counts’, an alliance that promotes quality care delivery and safety to all patients. The hospital has adapted the ‘improvement map’ of the Institute for Health Improvement (IHI) to align healthcare costs with quality through lean practices (Tompkins, Higgins, & Ritter, 2009). The institution has also deployed EHRs for clinical documentation to provide actionable real-time data. The rationale is to satisfy the indicators related to the clinical process and efficiency domains.

The facility has established linkages between finance department and quality care staff. Departmental restructuring saw the quality director reporting to the hospital’s chief finance officer. Other VBP initiatives involve stroke prophylaxis projects, free dental/medical clinics to reduce readmissions, and the adoption of telemedicine. These VBP initiatives support quality-finance alignment and measurable progress in the four domains.

Departments Impacting VBP

The three departments with the most impact on VBP in the hospital are clinical support (ER), nursing, and physician services departments.

Explanation of Roles and Functions

Emergency room (ER)

The ER department promotes the clinical process of care domain (preventive care) and related hospital VBP measures. My rationale for selecting the ER is that the department provides medical and surgical care to patients with a broad spectrum of complications and trauma. Thus, implementing a preventive measure to promote safety and quality in this department, minimize hospitalizations, and lower costs for CMS and the provider would lead to better clinical process outcomes (Cox & Link-Gelles, 2011).

Nursing

The nursing department promotes patient experience of care domain and related measures. My rationale for selecting the nursing department is that the patient-clinician contact hours is high for the nursing staff (RNs and nurse aides). They provide bedside care and communicate with the patient throughout the hospitalization period; thus, they influence patient satisfaction or care experience.

Physician services

The physician services department supports the outcomes domain of a VBP initiative. My rationale for choosing this department is that physician services influence key quality indicators, including hospitalizations, readmission rates, and post-discharge morbidity and mortality. For the hospital, readmission rates and mortality rates could be reduced significantly through post-discharge follow-ups, especially for patients with chronic illnesses.

Goals

ER department

  • The department will formulate assessment protocol guidelines for the vaccination of influenza patients by the end of year 1.
  • The ER will immunize 80% of adults and children admitted with influenza meeting the protocol guidelines by the end of year 2.

According to Cox and Link-Gelles (2011), Influenza accounts for 200,000 hospitalizations and 36,000 deaths annually in the US. Chronic episodes of the nosocomial influenza increase healthcare spending due to high length of stay. Pneumococcal vaccines, such as PPV, can reduce hospitalization rates due to related comorbidities. Therefore, a timely assessment of vaccine needs implemented through an ER policy and protocol can reduce hospitalizations and healthcare costs to meet the SMART goals indicated.

Nursing department

  • The nursing department will initiate hourly bedside rounding for each shift in each unit by year 1.
  • The department will require nurses to leave the shift report at the patient side by shift end by year 3.

Research indicates that systematic rounding improves patient satisfaction (Blakley, Kroth, & Gregson, 2011). Thus, in VBP, incentive payments are connected to patient satisfaction scores. Nursing responsiveness and communication with patient/family determines the rating on the patient experience of care domain.

Physician services

The department will initiate transition care guidelines to reduce 30-day mortality rate due to heart failure by 50% by end of year 1.

In the US, heart failure has a prevalence of 5.8 million and accounts for one in eight deaths nationally (Bui, Horwich, & Fonarow, 2011). The High HF morbidity is ascribed to inadequate transition to community-based care after discharge. In addition, the 30-day risk of death is related to gaps in care continuity. Thus, outcome measures for HF are a good indicator of an organization’s performance or quality of care.

Attaining Quality

ER department

Goal 1: The department will formulate assessment protocol guidelines for the vaccination of influenza patients by the end of year 1.

Quality Outcomes Maximize Reimbursements
  • A decline in length of stay compared to baseline data
  • Low hospitalization rate
  • No ICU admission
  • Decreased readmissions due to vaccination needs assessment
  • Short LOS related to improved influenza management

Goal 2: The ER will immunize 80% of adults and children admitted with influenza meeting the protocol guidelines by the end of year 2.

Quality Outcomes Maximize Reimbursements
  • Low 30-day mortality rate
  • Low mortality rate due to heart failure (HF)
  • Better achievement scores related to preventive services
  • Reduced healthcare costs due to shorter LOS

Nursing. Goal 1: The nursing department will initiate hourly bedside rounding for each shift in each unit by year 1.

Quality Outcomes Maximize Reimbursements
  • Enhanced nurse-patient communication
  • Patient empowerment
  • Collaborative care
  • Improved patient education, contributing to quality care
  • Decreased readmissions resulting in better outcomes
  • Better HCAHPS due to higher patient satisfaction
  • Increased census related to improved community reputation

Goal 2: The department will require nurses to leave the shift report at the patient side by shift end by year 3.

Quality Outcomes Maximize Reimbursements
  • Better outcomes due to improved clinical communication
  • Better pain management by hospital staff
  • Low readmissions resulting in better outcomes
  • Higher HCAHPS score due to improved patient satisfaction

Physician services. Goal: The department will initiate transition care guidelines to reduce 30-day mortality rate due to heart failure by 50% by end of year 1.

Quality Outcomes Maximize Reimbursements
  • Reduced risk-adjusted 30-day death rates, indicating better quality of care
  • Decreased prevalence of HF morbidity
  • Reduced 30-day mortality rate related to better outcomes
  • Reduced annual hospitalization costs related to high HF hospital discharges to outpatient care

Critical Key Points

The nurse leader should promote good patient communication practices among the nursing staff for better patient experience of care scores. According to Sullivan (2013), the nurse leader is a coach, teacher, facilitator, and motivator. The critical components to understand that are derived from this goal include:

  • The significance of bedside reporting/documentation at the end of each shift
  • Effective clinical communication process and implementation plan
  • Clinical collaboration
  • Patient/family involvement in care planning
  • Impacts of patient satisfaction scores on organizational growth
  • Patient health information confidentiality/privacy

Marketing the Key Points

The marketing of the critical components of the communication goal to the nursing staff will involve various tactics. Quarterly training programs for the nursing staff will be established to communicate clinical communication guidelines and promote buy-in. Further, an incentive program will be initiated to reward nurses who create bedside reports at the end of each shift. Another tactic will involve monthly staff meetings to sell ideas on clinical collaboration and patient confidentiality. The nurses will also share their views on the practices challenges faced.

The messages will be placed in framed posters displayed in strategic places within the facility. The posters will be placed near the reception desk. Postcards containing the messages will also be sent to all staff members via email. The information will also be shared on blogs and hospital sites that nurses can access and learn about patient/family communication. Another marketing tactic will involve sharing the components through short videos uploaded on the blogosphere. Short brochures with the information will also be distributed to the nurses.

Ethical Clinical and Ethical Business Practices

The ethical principles guiding clinical practice include beneficence, nonmaleficence, autonomy, justice, and fidelity (Goold & Lipkin, 2009). Justice in clinical practice demands that the hospital offers “minimum level of care” to all patients regardless of their socioeconomic status (Goold & Lipkin, 2009, p. 29). A just distribution of care should be integrated into the hospital’s health care plans. Further, the hospital should emphasize on autonomous choices and involvement of patients in healthcare planning. The support for the patient’s right to self-determination should be demonstrated by a full disclosure of healthcare options, sentinel events, and patient satisfaction scores.

Business practices relate to the fiduciary responsibility of hospitals. Business ethics in clinical settings should balance between returns on investment and the ethical conduct. The hospital should promote an ethical corporate culture through the establishment of a code of business conduct. In addition, the hospital should built accountability systems to instill ethical practice in line with regulatory and community expectations. Evidence-based practice is a pillar of managed care. Clinicians need to acquire skills to understand the impact of patient beliefs and values on patient experience of care (Peil, 2013). Therefore, the hospital should integrate evidence-based medicine into care management and treatment to observe the bioethical principles in managed care plans.

Coordinating Events

The events will be coordinated for the ER, nursing, and physician services departments based on the identified goals as follows:

ER

The department aims to formulate assessment protocol guidelines for the vaccination of influenza patients by the end of year 1. I would take two actions to coordinate information and educational events for year 1, namely, conducting a skills audit on influenza vaccination and involve staff in protocol development and organizing educational meetings aimed at policy development. Staff education/training will involve multiple channels, e.g., video demos and pamphlets, to build capacity.

By the end of year 2, the vaccine will be administered to 80% of patients diagnosed with influenza based on the guidelines. In this respect, I would release quarterly reports with immunization statistics. In addition, I would engage experienced staff to train others on this protocol.

By the end of year 3, the ER will assess, screen, and vaccinate all admitted patients in line with the protocol guidelines. My actions in this period will involve sharing monthly statistics and ratings based on hospital compare data to promote compliance.

Nursing

The goal of nursing is to initiate hourly bedside rounding for each shift in each unit by end of year 1. First, I would involve the nursing staff in creating the hourly rounding guide for RNs/LPNs through workshops. Other activities will involve educating the nurses on how to complete the rounding log through video demos and brochures.

By the end of year 2, the shift report for 80% of patients in Medical Surgical areas will be placed at the bedside. I will continue with staff training on round log completion and introduce incentives, e.g., recognition awards, for complying staff.

By the end of year 3, the shift report for all patients will be placed at the bedside. My action during this period is to survey patient/nursing satisfaction to reinforce or change the guide.

Physician services

The goal is to reduce 30-day mortality rate due to heart failure by 50% by end of year 1 through effective transition care. My actions in year will involve developing and implementing a physician-community transition/follow-up policy. Roussel (2015) states that improvement in healthcare quality and safety requires a framework for predicting and managing healthcare risk. Physician training on this policy will involve formal training on risk identification and management.

By end of year 2, the 30-day mortality rate will be reduced by 70% through a physician follow-up framework. I will document community visits by physicians and coordinate transition to outpatient care based on availability.

By end of year 3, the 30-day mortality rate will be reduced by 90%. Again, my activities will involve coordinating post-discharge follow-ups and home visits by physicians to promote patient outcomes.

Timeline

Time Increments Nursing ER Physician
Year One Establish patient safety systems and communication initiatives Develop an immunization policy Identify community clinics for post-discharge care
Year Two Evaluate nursing practice based on national/state benchmarks Identify quality indicators Create a consultant program for HF patients
Year Three Redesign clinical workflows to reflect best practices Evaluate policy implementation Continuous monitoring of transition care outcomes

Executive Summary

The hospital actively participates in CMS reimbursement through the adoption of VBP in its clinical processes. The components of VBP that are most pertinent to the hospital include nursing staff communication to improve HCAHP scores, reduction of 30-day HF mortality rates, and quality-driven care (Rodak, 2013).

The ER department serves as the first point of contact with the patient. Therefore, patient experience of the hospital’s care begins at the ER department. ER is an important department preventive medicine through outreach programs that enhance community health outcomes. The department should lead vaccination campaigns because it admits patients with varied medical illnesses that require emergent care.

Preventive initiatives at the ER can significantly reduce morbidity and mortality rates. The hospital launched an interdisciplinary program that brings together physicians and nursing staff to manage patients presenting with HF symptoms. Thus, clinical initiative would reduce mortality and improve the quality of life of HF patients. All levels of hospital administration will participate in the preparation of the nursing department for the implementation. The leadership involvement will be based on the concepts of participatory leadership style. The staff will be involved in developing effective nurse-driven communication strategies and tactics. The department will also strive to promote nurse-patient communication through greater bedside care and rounding to impact on satisfaction and quality of care offered. As a result, the overall outcomes and the patient experience will improve, leading to better HCAHP scores.

In order to be successful, education, training, and reinforcement of best practices is foundational. The staff will engage in online web activities (training packets), monthly meetings providing information, support and data evaluation. The nursing units will engage in mock communication sessions that will help them engage even with the most difficult of patients, as well as HIPAA training. Using multiple learning methodologies will have a greater impact on staff to use the training and education most effective.

With regard to the physician services department, the hospital’s physician champion will spearhead the physician services initiatives. A multidisciplinary approach will be adopted to manage the change and promote implementation. The initiatives will bring together nursing educators, clinical nurse specialists, case managers, and other professionals. Using specialists as consultants, this team will create efficient order sets for the HF clinical pathway in an effort to improve patient outcomes thus reducing mortality and the sequalae related to chronic morbidities. Educational updates will continually be provided to staff at the Hospital as well as physicians receiving privileges to treat their patients here. Marketing to the community regarding the importance of this will also be included in the training for all staff.

References

Blakley, D., Kroth, M. & Gregson, J. (2011). The impact of nurse rounding on patient satisfaction in a medical-surgical hospital unit. Medical surgical Nursing, 20(6), 327–332.

Bui, A., Horwich, T., & Fonarow, G. (2011). Epidemiology and risk profile of heart failure. National Review of Cardiology, 8(1), 30-41.

Centers for Medicare & Medicaid Services [CMS]. (2016). Hospital Value-Based Purchasing. Web.

Cox, C., & Link-Gelles, R. (2011). Web.

Goold, S., & Lipkin, M. (2009). The doctor–patient relationship: challenges, opportunities, and strategies. Journal of General Internal Medicine, 14(1), 26–33.

Peil, E. (2013). Evidence-based medicine and values-based medicine: partners in clinical education as well as in clinical practice. BMC Medicine, 7(1), 65-72.

Rodak, S. (2013). Web.

Roussel, L. (2015). Management and leadership for nurse administrators. Burlington Jones and Bartlett Learning.

Sullivan, E. (2013). Effective leadership and management in nursing. New York: Prentice Hall.

Tompkins, C., Higgins, A., & Ritter, A. (2009). Measuring outcomes and efficiency in Medicare value-based purchasing. Health Affairs, 28(22), 251–261.

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