I am a new nurse and an informatician and am concerned about the presence -- or lack thereof -- of my profession at the highest levels of healthcare strategy and policy in this country and its healthcare institutions. Toward this end, I have had numerous discussions with my friend and mentor the brilliant nurse informatician Ann Farrell (L) whose coaching has taught me much.
Nursing has failed to establish itself as financially essential in healthcare organizations (HCOs) so this has limited its influence and participation at strategic levels. Partly to blame is a lack of data -- content, not quantity -- to support this contention. The other shortcoming is in our leadership. These three points -- finance, data, and leadership -- are the keys to nursing taking its rightful place at America's healthcare strategy table.
Background
We nurses comprise the largest segment of the healthcare workforce, numbering 2.7 million in the United States. Our work is essential to the new quality initiatives and metrics called for by the Affordable Care Act (ACA). Using reimbursements as an incentive, it seeks to raise the standards for healthcare outcomes. Yet, without good nursing, we would not get good outcomes. All this should strengthen the role and influence of nurses at the healthcare management boardroom and strategic decision-making tables. But that's not what we're seeing today.
Where nursing falls short
One disconnect is nursing pay: it is actually decreasing. Of this, Farrell writes, "Nurses are moving down the food chain and not powerful enough to sustain or increase their salaries". Why is this happening? What can be done to change it?
First, we don't have data to support nursing's case for its indispensability to quality and outcomes. It's not that data isn't being collected; on the contrary, vast volumes of "big data" in healthcare are gathered and growing. Rather, it's that none of the coding (the structures into which the data are collected and stored) are any of the nursing-designed ones.
The data structures in use today in electronic health records (EHRs) are built for charge capture, regulatory compliance, coordination of care, population health statistical analysis, and patient health data capture. None of these structures is suited for the purposes of nursing, in particular the correlation of outcomes with the nursing processes and actions that produce them. Farrell observes that "...we clearly should be able to show relationship between nursing care and outcomes. But we don't code nursing interventions." [personal communication] Collecting data is not enough. We do lots of that, especially in EHRs. What we don't (yet) do is to code it (enter it into appropriate data structures) that enable us to relate nursing care to outcomes and thus prove the value of what nurses do. When nursing is done well, outcomes are better and costs are lower. We know this but without the data how do we prove it? And without the proof, how do we justify the resources we need to consistently provide high quality nursing? Thus far, we have failed to do this.
Second, we have failed to create the financial structures that would have supported our bargaining power. Billing for individual nursing services -- termed fee for service (FFS) as practiced by physicians, ancillaries such as radiology and lab, and other healthcare providers -- would have kept our voice equal to theirs at the highest level of power, by being among those who bring in the money. Instead, our work has historically been bundled with the "room rate" like maid service in a hotel. It is too late to change this; it's a battle that was never fought and now the opportunity is gone. The financial structures of healthcare are entrenched and unlikely to change.
The third point I address in this essay is the anemia of nursing leadership. Our leaders lack the vision that would propel us toward our rightful place in healthcare hierarchies. But first, here is some discussion of root causes, the financial issues that drive this (and every) industry.
Follow the money
In healthcare, some financial structures are indeed changing. The private sector is getting on board with government to move toward new models: Major Health Care Players Unite to Accelerate Transformation of U.S. Health Care System.
Notably, FFS is going away. New mandates and metrics, especially the Value-Based Purchasing initiative (VBP, also known as pay for performance, P4P) undertaken by Medicare and MedicAid are taking its place. Reimbursements based on outcomes metrics make nurses more essential than ever. Yet one of the central features of the ACA, Meaningful Use (MU) that decrees the use of standardized nomenclatures, notably ICD-10 and CPT, do not include nursing terms. Our exclusion from the planning of the ACA has left our data needs unmet.
How can these failures be remedied? How can nursing be more present in healthcare strategic planning and compensation? How can it wield the influence that would enable it to ensure consistent high quality and the best possible outcomes? This, above all, is what the ACA is focused on delivering. Without nursing at the table, the likelihood of its success is diminished.
By not listening to strategists such as Farrell, our profession shoots itself in the foot. Nurse informaticians are -- or should be -- more than technicians. Our work has the potential to make health care better. It must be represented at strategic and policy levels.
Standards for nursing data
Collecting nursing data represents an opportunity for nursing at a strategic level. It would enable us to make a strong case for the importance of our work. When we do this, what form might this data take?
Data coded for nursing analysis would be based on the nursing process -- assess, diagnose, plan, implement, evaluate, and loop. Collecting data according to this model would enable us to quantify and demonstrate how nursing interventions impact outcomes.
Nursing data has a different focus than that of the traditional medical record which is the domain of doctors who diagnose and prescribe medications and order labs and procedures. Those actions are not in nursing’s scope of practice. Rather, nurses chart against a plan of care -- by diseases and problems. For example, Virginia Henderson's influential Basic Principles of Nursing Care (BPNC), first laid out in 1960, identified fourteen human needs (1. breathing, 2. eating and drinking, 3. elimination, 4. movement and posture, 5. sleep and rest, etc.) thus offering the basis for a nursing data system, a missed opportunity.
Nursing's failure to collect data in a structure that centers on its own activities is a result of internecine battles over which data standard to use. We have several standards. So far, none is a clear winner. Here are the most prominent:
- North American Nursing Diagnosis Association (NANDA) -- useful but not in the public domain
- International Classification for Nursing Practice (ICNP), derived from Henderson's BPNC
- Diagnosis Related Group (DRG) used by Medicare as the basis for payments to hospitals
- International Classification of Diseases, Tenth Revision (ICD-10), a comprehensive coding scheme for both diseases and treatments, but not suited for the recording of nurses’ observations and activities
- American Nursing Minimum Data Set System uses nursing diagnoses, a partial solution
- Donabedian care quality measurement framework gives metrics for nursing time and cost
- Virginia Saba's Clinical Care Classification System (CCC) is perhaps the best of the bunch because it both codes the elements of nursing practice and is designed for processing by computer. Alas, it never achieved widespread adoption.
In Nurses’ Own record keeping: The Nursing Minimum Data Set Revisited in Computers, Informatics, Nursing, Vol. 34, Winter 2016, regarding the nursing assessment process, Halloran et al observe, "What is now needed is a way to record [nurses'] clinical impressions within an authoritative format that is related to the depth and breadth of the clinical literature related to nursing and the needs of the patients and clients nurses serve. The International Council of Nurses’ Nurse-Patient Summary is proposed here to fill the gulf between narrative nurses’ notes, proprietary and widely varying electronic health record systems, and information from nurses about their patients and clients human needs. The International Council of Nurses’ Nurse-Patient Summary could replace nursing diagnosis items in the Nursing Minimum Data Set and serve as a substitute for the World Health Organization’s International Classification of Function, Disability and Health, a seldom used instrument derived from the International Council of Nurses’ Basic Principles of Nursing Care." Nursing data recording systems, Halloran et al observe, record either the work nurses do for patients or they record the need in patients. Either can be deduced from the other.
But why collect such data at all? Why aren't existing EHR data structures adequate? Unmet needs of nursing include:
- Prediction of staffing needs -- when your patients are numerous and/or very sick, you need more nurses; these predictions are impossible without census and acuity data.
- Analysis of nursing data relative to outcomes; Is progress being made according to a plan of care? What worked? What was cost-effective? Now we count and measure such things as the number of hospital-acquired infections (HAIs), of readmissions, and of patient satisfaction (Hospital Consumer Assessment of Healthcare Providers and Systems, HCAHPS).
- Financial aspects of nursing; what reimbursements are appropriate given nursing effort? As nursing effort is not measured, these calculations cannot be done.
Before such new tools can be fully effective, though, the traditional CFO mindset -- focused on bed charges -- must change. When a hospital's financial strategy centers on minimizing the cost of a patient day, the incentive is to lay off nurses whenever possible. Farrell:
With the new metrics, it becomes clear that investing in nurses is the better choice. Farrell observes, "A well-publicized article showed where a NICU had to add nurses to save money. Many people can’t get their arms around this (yet)... Even with staffing levels alone we can tie to mortality. Now need to go further and show what we do impacts outcomes, not just how many RNs are on duty." We need to code nursing interventions and then relate them to outcomes. This would prove that nursing can increase revenue and is not to be seen merely as an expense to be minimized. This brings us to my third point, that nursing leadership needs to promote this bigger picture.It was a travesty RNs never charged for services, or at a minimum that their hours of care were never reflected on the bill. But that boat has sailed, and I’m suggesting we need to move onto the emerging reimbursement models -- specifically what RNs know/do that care extenders can’t without compromising outcomes. We should give up things lesser qualified staff can do and achieve the same or better results so we can do more of what we have neglected –- patient education, care coordination, etc. While true in all PoS [points of service], suggested ANA start in hospitals -- where current attention and money is at risk and nurses losing their jobs daily or where [nurse staffing] ratios don’t exist, being given unsafe patient loads.
Some hospitals protect RNs and lay off support staff (housekeeping, dietary) and ask nurses do clean ups and pass trays. RNS prioritize clinically urgent task, so rooms get dirty, meals cold and HCAHCPS plunge -– only then, when execs feel it in their pocketbooks, do they pay attention. VBP COULD be the best thing to happen to nursing, but they are so busy self-congratulating and politicking amongst themselves that they don’t seem to get it.
Talking about room charges is a dead end, but if Nursing leaders did research to show value prop for RNs role in alternative models, you’d get a lot of attention, nurses would be served, and lives saved.
Yes, in the past, before VBP (HCAHPS) low staffing was a sound financial strategy -– if poor clinical one. But now, HCOs and providers are paid (albeit a small, but growing part) on patient satisfaction and clinica l outcomes (e.g. starting with HAIs, readmissions), they need to rethink this to adjust right staffing to achieve best outcomes that "pay off". Nursing care (at least in my day) was a leading contributor to positive patient satisfaction and patient outcomes.
What’s tragic is that unlike with FFS where RNs don’t bill for service and are labor expense, with ACA/VBP... RN care can be tied to top line (revenue), not just bottom line (expense). Failure to clearly articulate our value in patient outcomes and organization performance has resulted in loss of stature and respect. (RNs get lip service and platitudes, but remain largely invisible in board rooms, inner circles, many committees, Congressional lobbying/legislation) –- any surprise this is now reflected in lower salaries?
Where are our leaders?
Nursing's low participation in strategic decision-making, both in healthcare institutions and at a policy level, is a result of anemic leadership. Nursing's voice is muted or even absent. Our leaders have largely focused on tactical issues, notably staffing levels. This has been a major concern for our unions and it is undeniably important but it is not strategic.
At a national policy level, nursing's main advocate is the American Nurses Association (ANA). Its President, Pam Cipriano who delivered a keynote at a recent Healthcare Information and Management Systems Society(HIMSS) conference, had little to say about data structures and content -- especially in the EHR -- though she evangelized the role of informaticians. But what good are computers without useful data? The importance of nursing input into the design of these systems has yet to reach the highest levels.
Other nurse leaders include academics and CNOs. Writes Farrell, "[they] need to serve bedside RNs, their largest stakeholder group, by proving their value in a VBP world. Nursing as a profession would be influential if they thought, spoke and delivered on ROI." Nursing leaders must learn to speak with business leaders in business terms. She continues, "We are the largest HCP [health care provider] group who should have incredible power and influence... I blame the profession for being fragmented and unfocused -– we don’t speak with unified voice and presenting a compelling, data driven case that speaks to our positive contribution patient care and organization financial wellbeing. Until we do we will continue to be marginalized."
Conclusion
Nursing continues to be frustrated within health care organizations due to its inability to demonstrate its effect on bottom lines. When the charges for a patient who requires a lot of nursing care are the same as for one who doesn’t, yet has the same diagnosis, the perception of nursing as simply a cost center to be minimized is irresistible.
Yet, there is new hope given the ACA's mandate for improved metrics. Outcomes-driven payments can strengthen the position of nursing since our work can be shown to directly impact the ROI. Farrell writes, "We need to correlate/measure the role of RN-specific capabilities and skills (assessments, interventions, etc.) in the organization’s achievement of clinical and patient experience outcomes –- i.e. we need to show how we impact businesses (HCO) favorably financially." Good nursing yields better outcomes and thus higher reimbursements. "Nursing, in spite of all of our PhDs etc. doesn’t appear to have good studies on how RNs impact payments. We are losing to care extenders in some areas because we haven’t proven our worth." Until we nurses choose a data collection standard that captures nursing interventions -- and collect that data! -- we’ll remain voiceless. Until our leaders deliver this message and advocate effectively on these central issues, we'll remain sidelined. We have work to do. It's time to claim our seat at the table.