Track Records
Medicare quality initiative allows hospitals and nurses to measure the results of their efforts to improve patient care

By Donna Hemmila
May 3, 2004

When two Texas hospitals joined the Medicare pay-for-performance project, Virginia Davis, RN, MSN, vice president of quality for the facilities, saw a chance to improve patient care.

Now, nurses are telling her the quality initiative also is improving their role as patient advocates.

The Methodist Health System’s Dallas and Charlton medical centers are among 278 hospitals participating in a three-year demonstration project sponsored by the Centers for Medicare & Medicaid Services. Launched last year, the project aims to standardize hospital quality measurements and inspire patient care improvements. It also is testing whether financial incentives have an effect on patient care.

Hospitals that perform well in the demonstration project will earn Medicare reimbursement bonuses. Those that don’t improve will face reduced Medicare payments. Also, each hospital’s performance data will be posted on the CMS website for public scrutiny.

The hospitals want to deliver the best care, Davis said, and having measurable standards helps nurses achieve that goal.

“They can be stronger patient advocates,” Davis said. “It really empowers them to make it happen with the team.”

On the right track

The Premier Hospital Quality Incentive Demonstration Project, as it is called, is part of the care improvement initiative that the U.S. Department of Health and Human Services launched in 2001. The overall goal is to hold hospitals responsible for improving inpatient care for Medicare beneficiaries.

Voluntary participation in the pay-for-performance project was open to hospitals that use the Premier Inc. online database to track quality performance. About 1,500 nonprofit hospitals nationwide belong to the Premier purchasing group and 500 hospitals use the database.

The Medicare demonstration project tracks five clinical conditions prevalent among its recipients: acute myocardial infarction, coronary artery bypass grafts, heart failure, community-acquired pneumonia, and hip and knee replacements.

For each condition, hospitals are collecting data on standardized specific measures — a total of 34 for all five conditions.

For example, for pneumonia patients the hospitals track:

> The percentage of patients who received an oxygenation assessment within 24 hours before or after hospital arrival.
> Initial antibiotic consistent with current recommendations.
> Blood culture collected before first antibiotic administration.
> Influenza screening/vaccination.
> Pneumococcal screening/vaccination.
> Percentage of pneumonia patients who received first dose of antibiotics within four hours after hospital arrival.
> Smoking cessation advice/counseling.

Hospitals that score in the top 10% will receive an additional 2% of their Medicare reimbursement for the measured condition. Those in the second 10% will receive a 1% bonus. Conversely, in the third year, hospitals in the lowest 10% will have a 2% reduction, and those who score in the second-lowest 10% will see a 1% cut in reimbursement. Hospitals have the option of quitting the project at the end of the second year. All hospitals that rank in the top 50% will receive public recognition for their efforts, even if they don’t qualify for the financial rewards.

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.

Close to you

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.”

Going my way

Another side effect of the project has been to build teamwork between physicians and nurses. When nursing staff and medical staff are all tracking the same measures, project coordinators said, it’s easier to convince physicians to do things a certain way.

“On the West Coast, we leave so much to the physician practices,” said Chief Nurse Executive Gwen Matthews, RN, MSN, of the Glendale (Calif.) Adventist Medical Center. “It’s good to have protocol-driven measures. We will have some standardization in medical practice.”

One of the treatment measures for hip and knee replacement patients is to discontinue antibiotics within 24 hours after surgery. When you have an orthopedist who’s been practicing for 25 years, Matthews said, that physician may have a different approach to treatment. Now, nurses can point to the quality measures to reinforce the standards.

The Glendale hospital is one of 10 Adventist Health System hospitals participating in the pay-for-performance project. About 41% to 47% of its patients are Medicare recipients. Hospitals have been used to monitoring quality internally, Matthews said.

Now, there’s a wildfire of support for outside agencies looking at patient care and quality improvement.

“They’re holding hospitals accountable and, as a consumer, I think that it’s time,” she said.

Sheila Strand, RN, is director of quality resources at the 302-bed Adventist Medical Center in Portland, Ore., where 35% to 40% of the admissions receive Medicare benefits. Although the hospital doesn’t perform bypasses, it has a large number of patients seeking treatment for the other four quality measurement conditions.

Strand also sees nurses and medical staff working more closely together these days. “This is the first time in a formal way that we’ve aligned the medical and nursing staff,” Strand said. Her hospital has regular meetings of a quality council that RNs, physicians and other clinicians attend.

At those meetings, nursing leaders forge team relationships with the physicians. When a change needs to be made, Strand said, the decision has some “oomph to it” since the entire team endorses it.

Nurses are playing a key role in extracting the information to log into the database. The hospital collects half its data on paper and half electronically. RNs also audit the data to correct errors, a reason the hospital has such clean data, Strand said.

She believes the measures being tracked eventually will become mandatory for all hospitals with Medicare admissions. Once the project results for each hospital become public, she thinks consumers will use the information to make care decisions.

Strand receives calls from people with inquiries such as how many times a physician who has scheduled them for a surgery has performed that procedure. Such calls are becoming more frequent, she said, as consumers take a more involved role in their care. Yet the biggest consumers of quality data will be employers who purchase health care benefits, she said.

“This project covers Medicare, but most people will tell you that how you treat your Medicare patients is an indicator of how you treat all your patients.”

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