Fundamentals of Nursing The Health Care Delivery System CHAPTER 2 Challenges to Healthcare ● ● ● ● ● ● ● ● Uninsured patients ○ More likely to avoid treatment for acute & chronic illnesses ○ Likely to die prematurely Reducing health care costs while maintaining high-quality care for patients New technologies & medications ○ Shortens length of stay at hospitals ○ Causes health care costs to increase Improving access and coverage for more people Encouraging healthy behaviors Earlier hospital discharges result in more patients needing nursing homes or home care New millennium healthcare system is less service oriented and more business oriented due to cost-saving initiatives, causing tension between business & care The values of nursing are rooted in helping people to regain, maintain, or improve their health, illness prevention, and find comfort and dignity Challenges to Healthcare The National Priorities Partnership ● A group of 52 organizations from different healthcare disciplines that have merged together to work toward achieving better & affordable care, healthy communities, and healthy people ● Set the following national priorities: ○ Promote best practices ○ Promote prevention, treatment, and intervention practices for the leading causes of mortality ○ Ensure person- and family-centered care ○ Make care safer ○ Promote communication and coordinated care ○ Make quality care affordable Challenges to Healthcare The Institute of Medicine (IOM) ● ● ● ● The IOM calls for a healthcare delivery system that is safe, efficient, patient-centered, timely, effective, and equitable ○ Put forth a vision for a transformed health care delivery system The nursing profession continues to lead the way in change & retain values for patient care while meeting challenges of new roles and duties New changes challenge nurses to provide evidence based practice, compassionate care, and the patient advocate role According to the IOM (IOM, 2011), nurses need to be transformed by: ○ Practicing the full extent of their education and training. ○ Achieving higher levels of education and training through an improved education system that provides progression. ○ Full partnership with physicians and other health care workers in redesigning the healthcare system. ○ Improving data collection and information infrastructure for effective workforce planning and policy making. Health Care Regulation & Reform ● ● ● Improve the quality of health care, provide healthcare to more citizens, and decrease the cost of health care Professional standards review organizations (PAROs) ○ Created by federal government to review the quality, quantity, and cost of hospital care provided through Medicare and Medicaid Utilization review (UR) committees ○ Review admissions, diagnostic testing, and treatments ordered by physicians who cared for patients receiving Medicare ○ In medicare-qualified hospitals ○ Supervised by physicians Health Care Regulation & Reform ● ● ● Prospective payment system (PPS) ○ Payment mechanism for reimbursing hospitals for inpatient health care services in which a predetermined rate is set for treatment of a specific illness ○ One of the most significant factors that influenced healthcare payment ○ Established by Congress in 1983 Diagnosis-related groups (DRGs) ○ Group of patients classified to establish a mechanism for healthcare reimbursement based on LOS ○ Classification is based on: primary and secondary diagnoses, comorbidities, primary and secondary procedures, and age ○ Grouped by the PPS Capitation ○ Means that providers receive a fixed amount per patient or enrollee of a health care plan ○ Aims to build a payment plan for select diagnoses or surgical procedures that consists of the best standards of care at the lowest cost ○ Influences the way healthcare providers deliver care Health Care Regulation & Reform ● ● ● Resource Utilization Groups (RUGs) ○ Method of classification for health care reimbursement for long term care facilities ○ Used in many rehabilitation settings Profitability ○ Health care settings try to manage costs so the organizations remain profitable Managed care ○ Health care system or provider receives a predetermined capitated payment for each patient enrolled in program ○ The managed care organization assumes financial risk plus providing patient care ○ The organization’s focus of care: individual illness care, illness prevention, early intervention, outpatient care ○ Systems of managed care focus on lowering costs, increasing patient satisfaction, and improving the health or functional status of individuals Health Care Regulation & Reform ● “Never Events” ○ A list of 29 devastating events that should never occur ○ Revised and defined by the National Quality Forum (NQF) ○ Organized into 7 categories: surgical, product or device, patient protection, care management, environmental, radiological, critical ○ Requires analysis after event occurs ○ Reporting of these events when they occur are mandatory in many states ○ Medicare ruled in 2007 that they would no longer pay for costs associated with these errors ○ Health care organizations are fighting to eliminate “Never Events” ❏ ❏ ❏ ❏ ❏ ❏ ❏ Wrong site surgery Wrong implant Foreign object retained after procedure Wrong medication administration route Scalding of patient Falls from poorly restricted windows Misplaced oro- or nasogastric tubes Health Care Regulation & Reform ● Patient Protection and Affordable Care Act (PPACA) Law ○ Access to healthcare for everyone ○ Reducing costs ○ Improving quality ○ Provisions include: ✶ Insurance industry reforms ✶ Increased funding for public programs ✶ Improved coverage for children Emphasis on Population Wellness ● ● Health Services Pyramid ○ Managing health instead of illness ○ Emphasis on wellness & health enhances quality of life Life expectancy for americans have increased due to: ○ Sanitation advancements & prevention of infectious diseases (ex: immunization) ○ Patient education (ex: BP control) ○ Injury-prevention programs (ex: child seat laws) Health Care Settings & Services ● ● ● 5 levels of healthcare in the U.S. Integrated delivery networks (IDNs) ○ An organized network of facilities, providers, and services to deliver continuing care to a population of patients at a capitated cost at a particular setting ○ Found in larger healthcare systems Accreditation & certification ○ The Joint Commission (TJC) ○ Sought by health care agencies to display quality & safety in the delivery of care; evaluate the performance of the organization based on quality standards ○ Accreditation and certification survey processes help organizations to identify problems and create solutions for safety and quality improvement of delivered care and services Health Care Settings & Services Preventive & Primary Health Care ● ● ● Primary care ○ Focuses on improved health outcomes ○ Requires collaboration that focuses on improving health care equity, person centered health care systems, and health promotion & protection Preventive Care ○ Disease oriented ○ Reduces and controls risk factors for disease (ex: immunization, BP and cancer screenings) Health promotion programs lower overall costs ○ Reduces occurrence of disease ○ Minimizes complications ○ Reduces need for more expensive resources (ex: nutrition counseling) Health Care Settings & Services Secondary & Tertiary Care ● In secondary & tertiary (aka acute) care, the main focus is to diagnose and treat ● Disease management is the most common and expensive service of the health care delivery system ● Postponement of care by uninsured contributes to high costs ○ Hospitals ○ Intensive care ○ Psychiatric facilities ○ Rural hospitals Health Care Settings & Services Secondary & Tertiary Care Hospitals ● Hospital emergency departments, urgent care centers, critical care units, impatient medical surgical units provide secondary and tertiary levels of care ● Large hospitals also offer a variety of services such as social services, respiratory therapy, physical and occupational therapy, and speech therapy ● Quality, safe-care, patient satisfaction are important in hospitals ○ Work redesign ○ Discharge Planning Health Care Settings & Services Secondary & Tertiary Care Hospitals: Work Redesign ● A lot hospitals have redesigned nursing units ○ More services are now available on nursing units ○ Reduces need to transfer & transport patients across different treatment areas ○ Restrains healthcare costs Health Care Settings & Services Secondary & Tertiary Care Hospitals: Discharge Planning ● Discharge planning is centralized, coordinated, and interdisciplinary ● Discharge planning begins the moment a patient is admitted into healthcare facility ● The focus of hospitals is to provide the highest quality of care possible so patients are discharged early, but safely ● Some patients are more in need of discharge planning due to the risks they present (example: patients with limited financial resources, limited family support, chronic illnesses, long-term disabilities, or chronic illness) Health Care Settings & Services Secondary & Tertiary Care Hospitals: Effective Discharge Planning ● ● ● Effective discharge planning depends on patient & family education Patients and family members need to know what to do when they get home, how, & what to observe when problems arise Patients require the following instructions before they leave health care facilities: ○ Access to available and appropriate community resources ○ Safe and effective administration of medication ○ Safe and proper use of medical equipment ○ Rehabilitation techniques to support adaptation and/or functional independence ○ Instruction in potential food-drug interactions and counseling on nutrition and modified diets ○ The patient’s and family’s responsibilities in the patient’s ongoing health care needs; knowledge & skills needed to carry out those responsibilities ○ When and how to obtain further treatment ○ When to notify health care provider for changes in functions or new symptoms Health Care Settings & Services Secondary & Tertiary Care Hospitals: Effective Discharge Planning The Referral Process ● ● ● ● Make a referral as soon as possible, especially when planning therapies. Provide health care provider receiving referral with as much information about patient as possible. Involve patient and family caregiver in referral process; including selection of referral. Determine what the health care provider receiving referral recommends for the patient’s care; include this in patient’s treatment plan as soon as possible. Health Care Settings & Services Secondary & Tertiary Care Intensive care (ICU) or Critical care unit ● Hospital unit in which patients receive close monitoring and intensive care ● Advanced technology ● Patients usually monitored on multiple devices ● Most expensive health care delivery site Health Care Settings & Services Secondary & Tertiary Care Psychiatric facilities ● ● ● ● Patients who suffer from emotional and behavioral problems require special counseling and treatment from psychiatric facilities. Located in hospitals, independent outpatient clinics, or private mental health hospitals. Nurses, doctors, social workers, and activity therapists work together to create a plan of care that allows patients to return to functional states. Upon discharging from inpatient facilities, patients usually receive a referral for follow-up care at clinics or with counselors. Health Care Settings & Services Secondary & Tertiary Care Rural hospitals ● ● ● ● ● ● Access to healthcare in rural areas have been a serious problem Most hospitals experienced a severe shortage of primary care providers In 1989 the Omnibus Budget Reconciliation Act (OBRA) directed the U.S. Department of Health and Human Services to create a new health care organization called the rural primary care hospital (RPCH) The Balanced Budget Act 1997 established Critical Access Hospitals (CAH) for rural areas ○ Provides 24-hour emergency care ○ No more than 25 inpatient beds ○ Temporary care for 96 hours or less to acutely ill or injured patients Nurses who work in rural hospitals or clinics require skill in physical assessment, clinical decision making, and ER care Having a culture of evidence-based practice (EBP) is important in rural hospitals so nurses practice using the best evidence to achieve optimal patient outcomes and an environment of quality and safety Health Care Settings & Services Restorative Care ● ● ● ● For patients recovering from an acute or chronic illness/disability Helps individuals “restore” maximal function and enhance quality of life Interdisciplinary; Nurses must be aware that success depends on effective and early collaboration with patients & family members Patients are more likely to follow treatment plans when they are involved in plan of care ○ Patients/family members must have a clear understanding about recovery goals, reasons for any physical limitations, purpose, and potential risk for therapies Health Care Settings & Services Restorative Care: Home Health Care ● ● ● ● Supply of medically related services and equipment to patients/families in their homes for health promotion & maintenance, education, illness prevention, diagnosis and treatment of disease, palliation, and rehabilitation purposes Focuses on independence of patients and families Nurses address recovery and stabilization of illness in the home and identify problems related to lifestyle, safety, environment, family dynamics, and health practices Nurses in home health give personalized care to help patients adjust to long-term or short-term physical routines ○ Vital sign monitoring, assessment, administration of parenteral or enteral nutrition, medication administration, and intravenous (IV) therapy, blood therapy, wound care, and respiratory care are provided to home health patients Health Care Settings & Services Restorative Care: Rehabilitation ● ● ● ● ● ● ● Restores a person to their fullest potential physically, mentally, socially, vocationally, and economically Includes physical therapy, occupational therapy, speech therapy, and social services Specialized rehabilitation services: cardiovascular, neurological, musculoskeletal, pulmonary, mental health programs, drug rehabilitation centers Begins on admission Focuses on preventing complications Nurses and other health care team members visit homes and help patients and families learn how to adapt to an illness or injury Maximizes patient function and independence Health Care Settings & Services Restorative Care: Extended Care ● ● Extended care facility ○ Provides intermediate medical, nursing, or custodial care for patients recovering from a/an acute illness, chronic illness, or disabilities (ex: skilled nursing centers, assisted livings) ○ Provides around the clock nursing coverage Intermediate care/skilled nursing facility ○ Provides care to patients until they can return to their community or residential care location ○ Offers skilled care from a licensed nursing staff ○ Includes IV administration, wound care, long-term ventilator management, and physical rehabilitation Health Care Settings & Services Continuing Care ● ● For people who are disabled, functionally dependent, or suffering from a terminal disease Available within institutional settings or in the home: ○ Nursing centers ○ Assisted living ○ Respite care ○ Adult day care ○ Hospice Health Care Settings & Services Continuing Care: Nursing Centers or Facilities ● ● ● Provide 24/7 intermediate and custodial care ○ Nursing, rehabilitation, diet, social, recreational, and religious services ○ Residents of any age with chronic or debilitating illness Regulated by standards: Omnibus Budget Reconciliation Act of 1987 ○ Government regulations require staff to comprehensively assess each resident and make care planning decisions ○ A residents functional abilities, long-term physical, and psychosocial status are main focus Interdisciplinary functional assessment of residents is the focus of clinical practice ○ Staff must complete the Resident Assessment Instrument (RAI) ○ The Minimum Data Set (MDs) is required by Department of Health; serves as framework for state-specified assessment instruments to develop a care plan for new admitted residents Health Care Settings & Services Continuing Care: Assisted Living ● ● ● ● ● ● ● ● Long-term care setting Home environment Residents require some assistance with daily living but are relatively independent Shared dining and social areas Provides independence, security, and privacy Delegating nurse Medication administration No fee caps Health Care Settings & Services Continuing Care: Respite Care ● ● ● Respite care provides short-term relief or “time off” for people providing home care to a(n) ill, frail (weak), or disabled individual Settings include home, day care, or health care institution with overnight care Trained individuals enable family caregivers to leave the home for errands or social time Health Care Settings & Services Continuing Care: Adult Day Care ● ● ● Provides many health and social services to specific patient populations who live alone or with family members Allows family members to sustain their employment & lifestyles and still care for their relatives Nurses that work in day care centers provide continuity between care delivered in the home and the center (ex: medication administration) Health Care Settings & Services Continuing Care: Hospice ● ● ● ● Family centered care that allows patients to live with comfort, independence, and dignity while easing the pains of terminal illness Focuses on palliative (not curative) care May take place in patients home, hospice home, or inpatient hospice unit Many hospice programs provide respite care to help maintain the health of primary caregiver and family Care Coordination ● ● Accountable care organizations (ACOs) ○ Created to coordinate medical care by primary care and specialty physicians, hospitals, and other healthcare providers with the goal of providing coordinated & high quality care ○ An ACO’s aim is to ensure that patients receive the right care at the right time, without duplicating services or making medical errors ○ Nurses have a major role in ACO, acting as leaders and care coordinators Patient-centered medical home (PCMH) ○ Coordinates care, gathers clinical data, monitors patient outcomes ○ Goal is to provide efficient, effective, continuous, comprehensive, patient centered, and coordinated care for patients ○ Reports show: Patients in a PCMH have higher access to care & PCMH helps to lower discrepancies for lower-income patients ○ Primary care providers function as the center of the PCMH Issues in Health Care Delivery ● ● ● Nursing shortage Competency Quality and safety in health care ○ ○ ○ ○ ○ Health care providers define the quality of their services by measuring health care outcomes that show a patient’s progress The institute of medicine defines quality care as “the degree to which health care services for people and populations increase the likelihood of desired health outcomes while still being consistent with current professional knowledge” (IOM, 2001) NQF Pay for performance Patient satisfaction IOM COMPETENCIES FOR 21st CENTURY Provide Patient Centered Care ★ Alleviate pain and suffering ★ Coordinate continuous care ★ Effectively communicate with and educate patients ★ Share decision making and management ★ Notice & respect differences in patient’s values, preferences, and needs ★ Advocate for disease prevention & promotion of health Work in Interdisciplinary Teams ★ Cooperate, collaborate, communicate ★ Integrated care to ensure that it is constant and reliable Use Evidence Based Practice ★ Merge best research with clinical practice & patient values ★ Engage in research activities as possible Apply Quality Improvement ★ Identify errors and risks in care ★ Practice using basic safety design principles ★ Measure quality in relation to structure, process, and outcomes ★ Develop & test interventions to change processes Use Informatics ★ Use information technology to communicate, manage knowledge, reduce errors, and support decision making (IOM,2001) Issues in Health Care Delivery Quality and Safety in Health Care: NQF ● NQF endorsed performance measures to better health care; guarantee safer care & ensure accountability ● NQF practices include: hand hygiene, teamwork, training, influenza prevention, catheter associated UTI prevention, central line associated bloodstream infection prevention, medication reconciliation, pressure ulcer prevention, fall prevention Issues in Health Care Delivery Quality and Safety in Health Care: Pay for performance ● ● ● Pay for performance programs and public reporting of hospital quality data are intended to promote quality, effective, and safe patient care by physicians and health care organizations ○ Quality improvement strategy that financially rewards excellence motivate change and improvement Health plans throughout the United States use the Healthcare Effectiveness Data and Information Set (HEDIS) as a quality measure ○ Created by The National Committee for Quality Assurance (NCQA) to gather different data to measure the quality of care provided via different health plans ○ Database of choice for centers for Medicare and Medicaid Services ○ Compares how well health plans perform on measures across eight domains of care The TJC requires health care organizations to determine how well an organization meets patient needs & expectations (for accreditation purposes) Issues in Health Care Delivery Quality and Safety in Health Care: Patient satisfaction ● ● ● ● ● The Hospital Consumer of Assessment of Healthcare Providers and Systems (HCAHPS) is a survey created to measure a patient’s judgement of their hospital experience ○ Created by the CMS and the AHRQ as a tactic for hospitals to gather and report data publicly for comparison purposes Patient and family centered health care leads to improved outcomes and more patient/family satisfaction ○ Patient centered care concepts include respect and dignity, sharing of information, participation in care and care decisions, and collaboration Learn a patient's expectations of comfort, information, and availability of family and friends early ○ Ask the patient what his/her expectations are when they first enter the health care setting, while care continues, and when patient is being discharged Enhancing relationships through nursing actions improves patient family satisfaction A Patient and Family Advisory Council is an effective tactic to obtain patient and family feedback to develop patient and family centered care Issues in Health Care Delivery ● Magnet Recognition Program ○ Established by the American Nurses Credentialing Center to acknowledge healthcare organizations that achieve excellence in nursing practice ○ Health care organizations that apply for magnet status must demonstrate quality patient care, nursing excellence, and innovations in professional practice ○ The Magnet model has 5 components: 1. transformational leadership 2. structural empowerment 3. exemplary professional practice 4. current knowledge, innovation, and improvements 5. empirical quality outcomes ○ If a nurse works in a healthcare facility with magnet status, they must gather data on specific nursing sensitive quality indicators/outcomes and compare to them other areas of the country Issues in Health Care Delivery Magnet Recognition Program: Nursing-Sensitive Outcomes ● Nursing-sensitive outcomes/indicators, are elements of patient care that are directly affected by the practice of nursing (“3 Types Nursing Sensitive Indicators”, 2011), such as: ■ ■ ■ ■ ■ ■ ■ ● ● changes in patient symptom experiences functional status psychological stress safety RN job satisfaction total nursing hours/patient day costs ○ Should reflect the structure, process, and outcomes of nursing care (ANA, 2004) ANA developed the National Database of Nursing Quality Indicators (NDNQI) to measure and evaluate nursing-sensitive outcomes ○ The NDNQI reports quarterly results on nursing outcomes at the nursing unit level ○ Created to measure/monitor nursing-sensitive outcomes to improve work-loads, enhance patient safety, and develop sound policies related to nursing practice and healthcare Nurses seize accountability and responsibility for achieving and accepting the consequences of outcomes Issues in Health Care Delivery Nursing Informatics & Technological Advancements ● ● ● ● ● Nursing informatics is a field of nursing that merges nursing sciences, technology, and information sciences to sustain and develop medical data and systems to support nursing practice, and improve patient care outcomes (“What is Nursing Informatics”, 2019) ○ Gives the ability to access quality electronic sources of healthcare information to plan and coordinate care ○ Does not replace critical eye and clinical judgement Data are separately distinct pieces of reality ○ Collected to deliver safe patient care & improve patient outcomes Telemedicine or telehealth uses technology to improve patient outcomes ○ Effective tool in promoting self care in patients with heart failure; led to improved survival rate in patients in ICUs Managing communication, information, and data is challenging in health care Nurses have a major roles in evaluating and implementing new technological advances; you will use technology and informatics to improve the effectiveness of nursing care, enhance safety, and improve patient outcomes Issues in Health Care Delivery ● ● ● Globalization of healthcare ○ Globalization is the growing connectedness of the world’s, economy culture, and technology ○ Reshaping the healthcare delivery system ○ Internet and social media has allowed nurses, patients, and other health care providers to connect and communicate with others worldwide about health care issues Vulnerable populations ○ Collection of individuals who are more likely to acquire health problems due to excess risks, limited access to health care services, or being dependent on others for care The special focus of nursing on caring allows nurses to address issues from globalization Issues in Health Care Delivery Globalization of healthcare: International Council of Nurses (ICN) ● Based in Switzerland, but represents nursing around the world (ICN, 2015) ● Mission: Represent nursing worldwide, advance professions, and influence health policies (ICN, 2015) ● Goal: Bring nursing together, advance nursing practice, and influence global health policies (ICN, 2015) Quality & Performance Improvement ● ● ● Quality improvement (QI) is the framework used to systematically improve the processes of providing healthcare services to meet the needs of patients ○ Processes can be measured, analyzed, improved, and controlled Performance improvement (PI) is when an organization analyzes and evaluates current performance; uses the results to develop focused improvement actions ○ PI activities are usually clinical projects made in response to specific clinical problems; designed to use research findings to improve clinical practice Quality data are the outcomes of both quality improvement and performance improvement strategies ○ Things such as fall rates, the occurrence of medication errors, incidence of pressure ulcers, and infection rates in patients, are all examples of quality data Quality & Performance Improvement Quality Improvement Programs ● ● ● A thoroughly organized QI program focuses on processes or systems that contribute to patient, staff, or system outcomes All health care staff should understand their responsibility toward improving health care quality As a nurse, you will identify problems, and initiate opportunities to improve the quality of care Quality & Performance Improvement Quality Improvement Programs: Models for QI & PI ● ● ● Patient Self-Determination Act/PDSA Cycle ★ Plan ➜ Review available data to understand existing practice conditions or problems to identify the need for change ★ Do ➜ Select an intervention on the bases of the data reviewed and implement change ★ Study ➜ Study/evaluate results of change ★ Act ➜ If the process change has positive outcomes, act on the practices by integrating them into daily unit performances Six Sigma or Lean is a model used by organizations to carefully evaluate processes to reduce costs, enhance quality, and improve teamwork while using the talents of existing employees Rapid-cycle improvement or rapid-improvement event (RIE) model is used when a serious problem exists that greatly affects patient safety and needs a rapid resolution ○ Week long event ○ Committee rapidly evaluates problem and initiates change ○ Effects of change are measured quickly, results are evaluated, further changes are made if needed The Future of Healthcare ● Change opens up opportunities for improvement. ● The greatest issue in delivering health care is ensuring the health and well-being of the population. ● Health care delivery systems have to address the needs of the uninsured and the underserved. ● Health care organizations are aiming to become more prepared to deal with challenges in healthcare. ● The nursing profession has an important role in the future of healthcare delivery. ● The solutions needed to improve the quality of health care rely mainly on the active participation of nurses.
