News Flash: "Trickle-Down" Does Not Save Lives

This week the New England Journal of Medicine published an evaluation of Premier HQID, a Medicare pay-for-performance program that provides monetary incentives to hospitals to improve quality of care. Hospitals that perform well on certain measures get 1-2% bonuses and hospitals that underperform are penalized by the same amount. 

In the study, a huge number of hospitals, 252 in the Premier program and 3363 not, submitted data to Medicare on 33 quality indicators for common conditions such as heart failure, pneumonia and joint replacement.  Data from over 6 million patients  went into the analysis. 

The headline-making conclusion went like this:

"Tying financial incentives to performance, often referred to as pay for performance, has gained broad acceptance as an approach to improving the quality of health care....We found no evidence that the largest hospital-based pay-for-performance program led to a decrease in 30-day mortality. Expectations of improved outcomes for programs modeled after Premier HQID should therefore remain modest."

To me, and I imagine others who were not consulted when this program was planned, this finding comes as little surprise.  Let me explain why:

•  Financial incentives in the program did not necessarily go to the people who prevent hospital deaths. They went to hospital administrators who had the freedom to use the dollars as they wished.  So our tax dollars - make no mistake -  might have paid for nurse education or better staffing, and they might have bought a fancy new office suite for the CEO, the benefits of which would presumably trickle down to the little people.

• Almost all of the Medicare quality indicators concern processes of care, not patient outcomes.  Processes (like which drugs are given and when) are only thinly linked to patient outcomes because of the complexity of human beings (whether patient or health care provider) and big organizations like hospitals.  If the right antibiotic is given at the right interval before surgery, is there certainty that the patient will not have an infection post-operatively? Of course not. It helps, but the maddening and wonderful complexity of humans and organizations means the process can only boost the odds in the patient's favor, not ensure the desired outcome. In short, there are no guarantees.

All the hospitals in the study report their data on Medicare's Hospital Compare website; this characteristic was equalized because public reporting is widely understood as a way to improve hospital quality. However, this understanding is based upon assumption, not fact, and some emerging data suggest otherwise.

This new study's findings about pay-for-performance are not unique.  I did find some evidence of success of the Premier program on (surprise!) Premier's website, where one also finds the list of Premier and other health care executives as well as the cadre of physicians who comprise the Premier board of directors.  Again excluding the largest group of health care providersin the country.

Lest this post appear as a rant from a burned-out nurse, I will add that nearly 1 in 5 older adults discharged from a hospital is re-admitted within 30 days. About half of these patients saw a physician in the interim, so it appears doctor visits did not prevent readmission.  Moreover, errors in health care are deadly - to nearly 200,000 people a year. And studies from across the globe show that nursing care saves lives. We understand the scope o the problem, and we know at least part of the solution. When will we stop making up voodoo quality strategies and start implementing what works?

Joint Commission, are you listening?

I mourn for the demise of nursing care. I miss giving back massages, changing linens merely for comfort, sitting down to talk with people. I especially miss the value formerly placed on nursing measures as critical to quality health care.

Quality has been redefined to suit the criterion of measurability over any other. Now the ability to track standardized processes of care (not the outcomes necessarily) is the primary purpose of the medical record, and fluff like which position the person prefers for sleeping because of rib fractures and chronic back pain is devalued, and even discouraged. There is little room these days for individualization of care, which is where nursing has always excelled.

Because of the poor quality of its documentation of standardized processes, the hospital where I work is threatened with revocation of its Joint Commission approval - which means if our quality does not improve, we can't get Medicare reimbursement, and Medicare constitutes the major source of payment for any hospital. This could shut our doors.

Our Joint Commission status is "provisional," meaning if they show up and look around and find us wanting, we are history. To say our administrators are concerned would be like saying the KKK is concerned about the qualities of persons with enhanced dermal melanin content. Just doesn't quite capture the true spirit of the thing.

Pain management is one criterion on which our hospital was cited by Joint Commission. Certainly a worthy goal. The Joint Commission take on quality pain management requires that pain be quantified, treated, and re-assessed after treatment, and it follows that these elements must be documented such that they can be easily audited. Management has repeatedly stressed that nurses document these elements (not that nurses do these things.) Documentation is the only proof of adequate pain management that "The Joint" requires or desires. Indeed, our chief nurse executive informed us that one of the benefits of having computerized charting is that now she can tell who is documenting correctly and who is not - and disciplinary action can thus be taken. (Way to improve quality - threats!)

There is no evidence, unfortunately, that good documentation = good nursing care. There is nowhere to chart that, despite my giving the 71-year-old Cantonese-speaking lady more narcotic than was ordered, her pain was still a 7 out of 10. Nowhere to chart that her snoring respirations caused me enough concern that I was reluctant to increase her dose of narcotic further in spite of the pain she complained of whenever she was asked. Nowhere to chart that the non-verbal pain indicator scale did not concur with what she said when her son was there to translate. Nor is there anywhere to document that I spoke with the physician, who concurred with my plan. This is what quality nursing care looks like: letting her family remain at her bedside for comfort, judging cautiously how much narcotic to give and when, covering her with warm blankets when she was cold, believing what she said over the mandatory pain scale, wiping her forehead with a cool cloth when she vomited, speaking softly to her. But none of these actions is documented. None of them count.

The Joint doesn't know that these are quality nursing measures because they didn't even begin to ask nurses until 2003, when their first nurse advisory group was convened. The American Hospital Association and the American Medical Association have long been integral to the Joint Commission, but historically the American Nurses Association had been shut out.

There is hope: in 2008, one of the 13 Joint Commission officers is a nurse. In 2002, they released a white paper on the nursing shortage with recommendations for improving the supply of nurses. Some of the white paper covers what we already know: the shortage is unprecedented, people are aging, and nurses are crucial health care providers. Other parts of the report are insightful and action-oriented. The need for fiscal incentives to enhance nurse retention, ongoing education and federal funds for nursing enhancements in educational and health-care settings are plainly pointed out.

I am happy to conclude that "The Joint" is starting to get it, and I hope that one day they will stop to read all of what I put in my patient's chart and see how the individuality of each person informs my caring much more profoundly than a Joint Commission mandate ever could.

I will continue wiping foreheads and applying warm blankets. Perhaps there will be a time when such caring measures are also considered meaningful indicators of quality nursing care.