I recently found myself chatting with a physician who heads the infectious disease department at a New York City medical center that had been denied Magnet accreditation (a sign of "nursing excellence") several years ago. I told him that his hospital needed to focus on improving its nursing care and staffing.
"It costs too much," he said, "and it doesn't make a difference."
If a physician whose specialty is infectious disease doesn't find value in nursing, how might hospital administrators respond to the new regulations taking effect in October, which will deny hospitals Medicare payment for the treatment of preventable, hospital-acquired conditions, such as catheter-associated urinary tract infections (UTIs), that result largely from inadequate nursing care?
Aetna, WellPoint, and other private payers are taking similar stances, refusing to pay for the treatment of a variety of hospital-acquired conditions. And why shouldn't they? Hospital-acquired UTIs cost an average of $44,000 to treat. Perhaps financial disincentives will finally prod hospitals to improve staffing and increase the time nurses spend providing direct care (by reducing the time they spend hunting for supplies, for example).
On page 30 Ellen Kurtzman, MPH, RN, and Peter Buerhaus, PhD, RN, FAAN, discuss the new Medicare regulations, arguing that they give nurses an opportunity to "redefine their economic relationship to hospitals." By preventing hospital-acquired conditions that Medicare will no longer cover, nurses may finally be seen as contributors to profits instead of just a cost.
"This will focus a laser beam on nursing," Lillee Gelinas, MSN, RN, FAAN, told me. She is vice president and chief nurse officer of VHA, Inc., a national network of nonprofit hospitals and physician practices. "Staff nurses should be considered rainmakers who contribute to the bottom line." She said that one health care system encompassing several hospitals has estimated that these changes from Medicare could cost it $10 million per year.
But the regulations might undermine the quality of hospital nursing. Already, inadequate nurse staffing leads to increases in preventable conditions; if nurses are laid off in an effort to offset reduced revenues, more preventable conditions will occur because of staffing reductions, and so on. Gelinas has already seen reductions in full-time nurses at some hospitals. But she noted that the best CEOs are asking their chief nursing officers, "What can we do to reduce the number of preventable events?"
Politics and ignorance are always at play, but nurses need not be at their mercy. Nothing should stop nurses from analyzing the factors associated with preventable conditions that occur on their unit. (Gelinas said that data on nurse staffing are best framed as hours per patient day; staffing ratios don't mean much when nurses spend only 35% of their time with patients, rather than the 60% seen at the best hospitals.) You might see this work as the purview of nurse managers. But in the best hospitals, frontline staff are involved in developing quality-improvement initiatives of this nature.
You might also ask, as I do, why we have to work so hard to prove our worth. In the December 20, 2007, New England Journal of Medicine, Lindenauer and colleagues reported on the first multisite study of the financial and clinical outcomes associated with hospitalists. The study found modest gains-savings of $125 per patient and a 0.4-day reduction in length of stay-but no impact on readmission and mortality rates. Even so, Laurence F. McMahon, Jr., MD, MPH, noted in an accompanying editorial: "The hospitalist movement has arrived, and it has transformed the care of hospitalized patients. Investigations [horizontal ellipsis] focused on cost and comparing outcomes with those of other providers should begin to wane[horizontal ellipsis]. It is time to move on."
Why can't we conclude the same for nursing? Why must we repeatedly prove our worth to hospitals? Let's take the opportunity Medicare has provided and close this case.