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Medicare plans to spend about $7 million a year on bonuses, $21 million over the course of the project, and hospitals with high numbers of Medicare patients could earn significant extra cash. An interim report will be unveiled in mid-2004 with early 2005 set for the first-year results.

If both of the Methodist hospitals rank in the top tier, they can gain an additional $250,000 a year in bonuses, Davis said, but money was never the motivation to join the demonstration project.

Many of the 34 tracking measures are also part of other quality care benchmarking programs such as that of the Joint Commission on Accreditation of Healthcare Organizations. The two Dallas hospitals had been able to compare their performance to other medical centers in Texas and had done well. But Davis is eager to see how her hospitals stack up against a nationwide sample. That’s one of the main motivators in taking part in the demonstration, she said.

Already she’s seeing changes. Once the project started, nurses were given greater responsibility to carry out some of the measures, such as smoking cessation.

“We’ve always given that to respiratory therapy,” Davis said. “Now, that’s something nursing owns.”

Whether someone might be more willing to absorb the smoking education from a nurse isn’t clear, Davis said, but a nurse has the medical knowledge and usually already has established a connection with the patient.

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In the past, the hospitals’ process was for nurses to ask patients who were identified as smokers if they wanted information about the dangers of smoking and options for quitting. If they said they did, the nurse referred the patient to a respiratory therapist. With smoking cessation counseling now one of the quality measures being tracked for both heart failure and pneumonia, the hospitals streamlined the process to reach more patients, Davis said.

Now, during patient admission assessment, nurses give tobacco education information to all patients with a history of smoking in the last 12 months. If the patient desires more intensive counseling, the RN refers them to cessation classes or other hospital resources.

“This revised process is more direct, has fewer hand-offs and, as a result, more patients are receiving information that will help them consider their options and reasons for stopping smoking,” Davis said.

The hospitals developed their own database to give doctor- and nurse-specific feedback on quality measures while the patient is still in the facility. The nurses are excited about the opportunity to get “real-time” performance information, Davis said, so they can see how to improve their care.

Nurses also are playing a significant role in extracting the data, reviewing 750 to 1,000 charts a month. Not all the information can be captured electronically. Davis said she plans to hire a master’s-prepared nurse as a “super-duper case manager” or outcomes coordinator to help with the project.

At Peninsula Regional Medical Center in Salisbury, Md., nurses already are seeing early positive results from tracking quality measures. The hospital has joined other Maryland medical centers in a statewide quality initiative to reduce surgical infection rates, which may prove advantageous when they start participating in the Medicare project.

The hospital’s surgical infection rate dropped 39% in 2003 compared to 2002, said Donna Thompson, RN, BSN, director of performance improvement. In the statewide project, the hospital used its open-heart surgery patients as the test group and tracked the quality measures for administering antibiotics.

“I guess we’re kind of ahead of the game with the [Medicare project],” Thompson said, as a result of the participation in the Maryland initiative.

The 320-bed hospital has three nurses, all with intensive care backgrounds coordinating the data collection. Thompson hired Denise Conklin, RN, BSN, and Gayle Kittile, RN, BSN, as analyst consultants to work with the multidisciplinary teams involved in the initiative.

The hospital is in a popular retirement area, and its Medicare population is growing. Last year, Thompson said, about 50% of the hospital’s patients received Medicare benefits.

“I like the goals of the project,” Kittile said. “I think it’s the right thing to do for our community.”

When the nurses see outcomes, they know they are making a difference, Thompson said, and the hospital posts the data for nurses to monitor.

“It’s really important for them to see the big picture,” she said. “They get so caught up in the day-to-day minutiae. It’s good to see the fruits of their labor.”