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...ongoing and cost-effective manner: delivering care high-acuity patients and progressively more medically complex, chronically ill populations; and providing ambulatory care nursing services using a variety of high-tech methods and in virtual environments, in addition to traditional face-to-face care. Both consumer and contextual factors are further escalating these challenges. Consumers are demanding safer, higher-quality, more convenient care and are shopping for quality care, similar to the way they pursue retail opportunities. External regulators continue to demand that all health care providers demonstrate that they are providing safe, high-quality care. Technology continues to explode and be accessible to more people and providers, permitting care to be delivered in settings once not thought possible.
Unfortunately, reimbursement for health care has only recently begun to incentivize and support investment of resources in quality, safety, convenience, and use of technology. Except for capitated care insurers, third-party payers reimburse by volume and types of services: the more visits and procedures, and the more complex the level of service, the better. Even in large group practices that are largely reimbursed in a capitated model, providers' productivity is also often measured in relative value units, rewarding volume and level of visits and procedures. The new pay-for-performance initiatives and the patient health care home, or "advanced medical home," initiatives are targeted at finding the right incentives to reward providing the appropriate and highest quality care to the greatest number of patients, not just lots of care to lots of patients.
Pay-for-performance initiatives are changing the quality landscape. Many quality indicators are now linked to payment for both inpatient and outpatient care. The financial incentives began with hospital quality and are now diffusing to ambulatory care. In March 2003, the Centers for Medicare and Medicaid Services (CMS) began the Premier Hospital Quality Incentive Demonstration, a Medicare pay-for-performance demonstration project. Since introducing the program, CMS reports indicate that quality of care has improved significantly in hospitals (CMS, 2007). With hospital premier, payment is linked to the overall quality of care delivered while a patient is in the hospital; care delivered to a patient or patient population is the focal point, not any one provider. The hospital places its reimbursement at risk for quality. With nurses providing the majority of direct patient care in the hospital, interventions by nurses are directly linked to quality indicators in support of the pay-for-performance program. Nursing-sensitive quality indicators in acute care have been established and widely accepted nationally (American Nurses Association [ANA], 2007; Kurtzman & Corrigan, 2007).
The ANA Quality Initiative includes the 1994 Patient Safety and Nursing Quality Initiative and the 1997 National Database of Nursing Quality
Indicators (NDNQI). Nurse-sensitive indicators relate to the structure (e.g., the number and mix of staff), the process (e.g., assessment), and the patient outcomes influenced or directly resulting from nursing care. More than 1,200 hospitals in 50 states and the District of Columbia participate in the NDNQI as of early 2008 (ANA, 2007). Through the NDNQI, nurses in acute care have been successful in identifying, measuring, and benchmarking patient outcomes and the value of the acute care RN's contribution.
These nursing-sensitive acute care quality indicators are inextricable linked to the CMS's recent plan. On October 1, 2008, Medicare will no longer pay extra for specific conditions that could generally be avoided if the hospital follows evidence-based preventive procedures or common precautions (Medical News Today, 2007). For example, Medicare will no longer reimburse hospitals for the additional days or resources needed to treat pressure ulcers developed while in the hospital, injuries caused by falls in the hospital, or infections secondary to prolonged use of catheters in the bladder or blood vessels. The CMS incentivized conditions, NDNQI nursing-sensitive acute care indicators, and the 15 nursing-sensitive quality indicators endorsed by the National Quality Forum (NQF) address many similar issues and their integration or intersection is depicted in Table 1.
As financial incentives are established for ambulatory care quality indicators, most of the national quality standardized performance measure sets are at the practice level or health plan level, not at...
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