Nursing Executive Center
Transforming Healthcare
Through Nursing
Implications for Practice and Education
2015
©2013 The Advisory Board Company • advisory.com
Nursing Executive Center
Practice Manager
Jennifer Stewart
Design Consultant
Pascale Chehade
Executive Director
Steven Berkow
LEGAL CAVEAT
IMPORTANT: Please read the following.
The Advisory Board Company has made efforts to verify the accuracy of the
information it provides to members. This report relies on data obtained from many
sources, however, and The Advisory Board Company cannot guarantee the
accuracy of the information provided or any analysis based thereon. In addition,
The Advisory Board Company is not in the business of giving legal, medical,
accounting, or other professional advice, and its reports should not be construed as
professional advice. In particular, members should not rely on any legal
commentary in this report as a basis for action, or assume that any tactics
described herein would be permitted by applicable law or appropriate for a given
member’s situation. Members are advised to consult with appropriate professionals
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trustees, employees and agents shall be liable for any claims, liabilities, or
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Board Company, or (c) failure of member and its employees and agents to abide by
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shall promptly return this Report and all copies thereof to The Advisory Board Company.
5
Transforming Healthcare
Through Nursing
Implications for Practice and Education
2015
6
©2013 The Advisory Board Company • 26427
Road Map
1
Our New Market Reality
2
Care Delivery Transformation
3
Implications for Nursing Practice and Education
7
What Business Are We In?
Businesses Displaced by Focusing on the Means Rather than the Ends
1990s
Digital cameras
enter mainstream
market
©2013 The Advisory Board Company • 26427
1976
90% market share
of commercial film
business
2012
Kodak files for
bankruptcy
”
Timeline for Eastman Kodak Business
Providing Health, Not Health Care
“…It's always better to define a business
by what consumers want than by what a
company can produce…whereas
doctors and hospitals focus on
producing health care, what people
really want is health. Health care is just
a means to that end—and an
increasingly expensive one.”
Study in Brief: What Business Are We in?
• Explores how Eastman Kodak Company’s camera and film business was
displaced by alternate mediums that fulfilled customers’ desires for images
• Draws parallels to the challenges that provider organizations face in shifting
activities from delivering health services to a broader spectrum of tactics for health
Source: Asch D., "What Business Are We In? The Emergence of Health as the Business of
Health Care,” NEJM, 367,2012: 888-889; Nursing Executive Center interviews and analysis.
8
Our Existing Business Model
Staying Afloat Through Cross-Subsidization
Traditional Hospital Cross-Subsidy
Commercial Insurance
• Above-cost pricing
• Steady price growth
• Robust fee-for-service
volume growth
• Only one component of
our total business
Above Cost
©2013 The Advisory Board Company • 26427
Public Payers
Below Cost
149%
86%
Hospital Payment-to-Cost
Ratio, Private Payer, 2012
Hospital Payment-to-Cost
Ratio, Medicare, 2012
Source: American Hospital Association, “Trendwatch Chartbook 2014,” available
at: www.aha.org; Health Care Advisory Board interviews and analysis.
9
Payer Cross-Subsidy Eroding
Projected Discharges by Payer, 2021
Commercial
Annualized Commercial Price Growth
Historical
Projected
6.5%
6-7%
3.5%
27%
52%
Medicare
Inpatient Contribution Income
©2013 The Advisory Board Company • 26427
20%
Medicaid
Weighted Per-Case Average
Medicine
Surgery
$2,927
$6,110
Source: American Hospital Association Chartbook, available at: http:
www.aha.org/aha/research-and-trends/chartbook/index.html, accessed
on April 29, 2011; Advisory Board Company interviews and analysis.
10
Public-Payer Reimbursement Still in the Crosshairs
Medicare Payment Cuts Becoming the Norm
ACA’s Medicare Fee-for-Service Payment Cuts
Reductions to Annual Payment Rate
2013
2014
2015
2016
2017
Not the End of the Story
Increases1
2018
2019
2020
2021
2022
($4B)
($14B)
($21B) ($25B)
($32B)
($42B)
($53B)
($64B)
($75B)
©2013 The Advisory Board Company • 26427
($86B)
$260B
Hospital payment
rate cuts,
2013-2022
1) Includes hospital, skilled nursing facility, hospice, and
home health services; excludes physician services.
2) Disproportionate Share Hospital.
$56B
$151B
Reduced Medicare
and Medicaid DSH2
payments, 2013-2022
Reduced Medicare
payments due to
sequestration and
2013 budget bill
“Notwithstanding
recent favorable
developments…
Medicare still
faces a substantial
financial shortfall
that will need to be
addressed with
further legislation.”
Office of the
Actuary, CMS
Source: CBO, “Letter to the Honorable John Boehner Providing an Estimate for H.R.6079, The Repeal of Obamacare Act,” July 24, 2012;
CBO, “Estimated Impact of Automatic Budget Enforcement Procedures Specified in the Budget Control Act,” September 12, 2011; CBO,
“Bipartisan Budget Act of 2013,” December 11, 2013, all www.cbo.gov; Health Care Advisory Board interviews and analysis.
11
Coverage Expansion and the Rise of Individualized Insurance
ACA (and Recovery) Making a Dent in Uninsurance
But Every Silver Lining Has Its Cloud
Percentage of U.S. Adults Without Health Insurance
2013 Q3
18.0%
Insurance
exchanges launch
Medicaid
expansion begins
Employer-sponsored
coverage grows
(highest on
record)
2014 Q3
13.4%
(lowest on
record)
©2013 The Advisory Board Company • 26427
A Bargain Still Unbalanced
$5.7B
Reduction in
uncompensated
care, 2014
vs.
$14B
ACA-related
reductions in Medicare
fee-for-service
payment, 2014
Source: Gallup, “In U.S., Uninsured Rate Holds at 13.4%,” http://www.gallup.com/poll/178100/uninsured-rate-holds.aspx; Department of Health and
Human Services, “Impact of Insurance Expansion on Hospital Uncompensated Care Costs in 2014,”
http://aspe.hhs.gov/health/reports/2014/UncompensatedCare/ib_UncompensatedCare.pdf; Health Care Advisory Board interviews and analysis.
12
Medicaid Expansion
Medicaid Expansion Contentious—and Consequential
28 States + DC Have Opted for Expansion
State Participation in Medicaid Expansion
Financial Impact
As of February 2015
“For-profit health
systems…report far better
financial returns through
the first half of the year than
expected, owed in large
part to expanded Medicaid”
©2013 The Advisory Board Company • 26427
PricewaterhouseCoopers
Participating
Expansion
by Waiver
Not Currently
Participating
9.6M
6.7%
2.4%
Increase in Medicaid,
CHIP1 enrollment,
July-Sept. 2013-Oct. 20142
Average Medicaid
enrollment increase across
non-expansion states
Advisory Board estimate of impact of
Medicaid expansion on typical hospital’s
10-year operating margin projection
1) Children’s Health Insurance Program.
2) Estimate does not include CT or ME.
Source: Kaiser Family Foundation, “Current Status of State Medicaid Expansion Decisions,” January 27, 2015, available at: http://kff.org/healthreform/slide/current-status-of-the-medicaid-expansion-decision/; CMS, “Medicaid and CHIP: October 2014 Monthly Applications, Eligibility Determinations and
Enrollment Report,” December 18, 2014; HHS, “Health Insurance Marketplace: Summary Enrollment Report for the Initial Annual Open Enrollment Period,”
May 1, 2014; PricewaterhouseCoopers, “Medicaid 2.0: Health System Haves and Have Nots,” Health Care Advisory Board interviews and analysis.
13
Another Year, Another Lawsuit
Challenge to Subsidies Making Its Way Through the Courts
The Question:
Potential Impact
Does the language of the ACA allow
subsidies in states that do not set
up their own exchanges?
Supreme Court Stepping In
Halbig v. Burwell
D.C. Circuit panel strikes down
subsidies on federal exchanges
Unsubsidized
Subsidized on
Federally-Run
Exchanges
2.7M
4.7M
0.7M
Subsidized on
State-Run
Exchanges
©2013 The Advisory Board Company • 26427
King v. Burwell
Fourth Circuit rules subsidies legal on
Virginia’s federally-run exchange
Supreme Court agreed to hear King
v. Burwell in November 2014; final
ruling expected by June 2015
Over half of all enrollees
collecting potentially
unallowable subsidies
14
Increasing Competition for Medicare Dollars
No More A’s for Effort
Medicare Value-Based Purchasing
Program Performance Criteria
Other Mandatory
Risk Programs
Hospital-Acquired
Condition
Penalties
Weight in Total Performance Score
20%
45%
70%
Clinical Process
25%
Patient Experience
Readmission
Penalties
30%
30%
©2013 The Advisory Board Company • 26427
10%
40%
Outcomes of Care
Efficiency
30%
30%
25%
20%
25%
FY 2013
FY 2014
FY 2015
FY 2016
1) Includes Value-Based Purchasing Program, Hospital Readmissions
Reduction Program, and Hospital-Acquired Conditions Program.
No Trivial Thing
6%
Medicare revenue at
risk from mandatory
pay-for-performance
programs1, FY 2017
Source: The Advisory Board Company, “Mortality Rates Are Only One of Many VBP Changes
to Come,” December 4, 2013, www.advisory.com; CMS, “Request for Information on
Specialty Practitioner Payment Model Opportunities,” February 2014, available at
www.innovation.coms.gov; Health Care Advisory Board interviews and analysis.
15
Many Facilities Receiving Multiple Penalties
Few Escaping Penalties Altogether, Almost Half Facing Two or More
Hospitals Receiving FY 2015 P4P Penalties1
Readmissions
Penalty
No
Penalties
1,071 (32%)
423 (13%)
48%
©2013 The Advisory Board Company • 26427
961 (29%)
Hospitals receiving
multiple P4P penalties
288 (9%)
318 (9%)
VBP
Penalty
152 (5%)
HAC
Penalty
43 (1%)
112 (3%)
1) Based on Readmissions and VBP proxy adjustment factors from FY 2015 IPPS Final Rule, proxy HAC adjustments from FY 2015 IPPS Proposed Rule.
Source: CMS, Advisory Board Analysis.
16
Overview of Risk-Based Payment Models
Key Attributes
©2013 The Advisory Board Company • 26427
Definition
Purpose
1) Center for Medicare and Medicaid Innovation.
Bundled
Payments
Shared Savings
Programs
(ACOs)
Capitation
Purchaser disburses single
payment to cover certain
combination of hospital,
physician, post-acute, or other
services performed during an
inpatient stay or across an
episode of care; providers
propose discounts, can gainshare
on any money saved
Network of providers
collectively
accountable for the
total cost and quality of
care for a population of
patients; ACOs are
reimbursed through total
cost payment structures,
such as the shared
savings model or
capitation
Provider receives a flat
per-member, per-month
payment for providing all
necessary care for a
defined population
Incent multiple types of providers
to coordinate care, reduce
expenses associated with care
episodes
Reward providers for
reducing total cost of care
for patients through
prevention, disease
management,
coordination
Reward providers for
reducing total cost of care
for patients through
prevention, disease
management,
coordination
Source: Health Care Advisory Board interviews and analysis.
17
The Market Force Course
12 Tools for Translating Market Forces into Frontline Terms
©2013 The Advisory Board Company • 26427
Sample Toolkit Resources
Nurse Manager
“Cheat sheets”
Plug-and-Play
Videos
Ready-to-Use
Posters
Customizable
Presentations
Interactive
Exercises
One-page
primers on
market forces
impacting
organizational
strategy
Short, easy-todigest videos
for frontline
staff on current
market forces
Visuals that
distill complex
concepts into
concrete actions
for frontline staff
PowerPoint slides
and scripting for
leaders to brief
staff on tough
messages
Games for
frontline staff and
managers aimed
at conveying
budget
constraints
To access The Market Force Course, visit advisory.com/nec/publications.
Source: Nursing Executive Center, The Market Force Course, 2014.
18
Operational Economics on the Brink of Failure
Margin Improvement Analysis Results
Five-Year Margin Projections
0-5% Decline
5-10% Decline
36%
Ten-Year Margin Projections
5-10% Decline
36%
13%
0-5% Decline 3%
15%
©2013 The Advisory Board Company • 26427
Improvement
13%
84%
Greater than
10% Decline
Improvement 0%
Greater than
10% Decline
HCAB Service in Brief: The Margin Improvement Intensive
• Combines customized scenarios for key financial and operational metrics with a
facilitated onsite session and an institution-specific action plan to help hospitals
and health systems improve margin performance
• Available to all Health Care Advisory Board members at no extra cost
• Visit www.advisory.com/MedicareBreakeven to participate
Source: Health Care Advisory Board interviews and analysis.
19
©2013 The Advisory Board Company • 26427
Road Map
1
Our New Market Reality
2
Care Delivery Transformation
3
Implications for Nursing Practice and Education
20
How Much Avoidable Cost Is There in Health Care?
©2013 The Advisory Board Company • 26427
$ 7 50 0 0 0 0 0 0 0 0 0
0
Source: Institute of Medicine, “Best Care at Lower Cost: The Path to Continuously
Learning Health Care in America”, 2012; Nursing Executive Center analysis.
21
A Clear Mandate for Meaningful Change?
Select Studies Analyzing Opportunities
for Reducing Health Care Costs
Estimated Magnitude of
Avoidable Cost Opportunities
©2013 The Advisory Board Company • 26427
Areas of Opportunity
Avoidable
Costs
Unnecessary Care
$210 B
Administrative Inefficiencies
$190 B
Inefficiently Delivered Services
$130 B
Missed Prevention Opportunities
$55 B
Fraud and Abuse
$75 B
High Prices
$105 B
30
Cents of every health care
dollar an unnecessary expense
Source: Best Care at Lower Cost: The Path to Continuously Learning Health Care in America. Washington, DC: The National Academies Press, 2012;
Kelley, Robert, “Where Can $700 Billion in Waste Be Cut Annually from the U.S. Healthcare System?” Thomson Reuters, 2009; Delaune J., Everett W.,
“Waste and Inefficiency in the U.S. Health Care System,” New England Healthcare Institute, 2008; Nursing Executive Center interviews and analysis.
22
Huge Opportunity for Improvement
Percentage of ED Visits that
are Avoidable in the US1
4.4M
Estimated number of
preventable trips to US
hospitals each year
71%
©2013 The Advisory Board Company • 26427
18%
1) Based on Truven Health Analytics analysis of 6,135,002 ED visits
in 2010; “Avoidable” includes all ED visits except those for which
medical care was required within 12 hours in the ED setting.
2) CMS, 2012.
30-day all-cause
readmission rate2
Source: Truven Health Analytics, “Avoidable Emergency Department Usage Analysis,” 2013, http://img.en25.com/
Web/TruvenHealthAnalytics/EMP_12260_0113_AvoidableERAdmissionsRB_WEB_2868.pdf; Robert Wood
Johnson Foundation, Reform in Action: Reducing Avoidable Hospital Readmissions,” 2013, http://www.rwjf.org/en/
about-rwjf/newsroom/features-and-articles/reform-in-action--reducing-avoidable-readmissions.html?cid=xtw_
qualequal; CMS's 2012 Inpatient Standard Analytical File (SAF); Nursing Executive Center interviews and analysis.
23
Unnecessarily Crowded
Many Medical Admissions Preventable
Ambulatory-Sensitive1
”
Inpatient Admissions
An Ounce of Prevention…
“It’s a lot easier to prevent people from
needing a service than it is to eliminate
the service once you offer it.”
Surgical 5.4%
94.6%
Medical
CFO
©2013 The Advisory Board Company • 26427
Medicare Revenue per Case
17%
Percent of Medicare
discharges considered
sensitive to better
ambulatory care
$8,510
$5,623
30 Most AmbulatorySensitive DRGs
1) Inpatient admissions associated with Agency for
Healthcare Research and Quality (AHRQ) Preventable
Quality Indicator conditions.
Overall
Source: MedPAR FY2009; Nursing Executive Center interviews and analysis.
24
Toward an Economics of Value
Adapting to New Rules of Competition
Description
Health System Strategy, c. 2003
Health System Strategy, 2013-2023
“Extractive Growth”
“Value-Based Growth”
Grow by being bigger: Leverage market
dominance to secure prime pricing, network status
Grow by being better: Leverage cost, quality,
service advantage to attract key decision makers
• Discharges
• Pricing growth
• Occupancy rate
• Process quality
• Share of lives
• Geographic reach
• Risk-based revenue
• Share of wallet
• Outcomes quality
• Total cost of care
• Clinical technology
• Ambulatory
surgery centers
• Primary care capacity
• Care management staff
and systems
• IT analytics
• Post-acute care
network
©2013 The Advisory Board Company • 26427
Performance • Service line share
Metrics • Fee-for-service revenue
Critical • Inpatient capacity
• Outpatient imaging
Infrastructure
centers
Source: Advisory Board interviews and analysis.
25
Disaggregating Health Care Reform
Financing
Coverage
Expansion
©2013 The Advisory Board Company • 26427
Delivery
System Reform
Source: Nursing Executive Center analysis.
26
Economics Aligning with Mission
Evolving Market Demand
©2013 The Advisory Board Company • 26427
Centering
Hospital Care
on the Patient
Managing
Chronic Care
for High-Risk
Patients
Building Long-Term
Patient Relationships
for Ongoing,
Coordinated Care
Improving
Overall Health
and Wellness of
the Population
Source: Nursing Executive Center interviews and analysis.
27
The New Reality
Establishing the Medical Perimeter
Extensive Ambulatory Care Network Addresses Medical Demand
Medical Management Investments
Patient
Activation
©2013 The Advisory Board Company • 26427
Medical Home
Infrastructure
Primary Care
Access
Electronic
Medical Records
Post-Acute
Alignment
Disease
Management
Programs
Population
Health
Analytics
Health Information
Exchanges
Source: Nursing Executive Center interviews and analysis.
28
If We Were Building from Scratch…
Governing Principles of the Transformed Care Enterprise
©2013 The Advisory Board Company • 26427
Personalized Management
Accessible Primary Care
• Care management appropriately
matched to individual patient,
population need
• Team available to patient
for access, education, decision
support
• Oriented toward patient-centered
goals that will drive clinical metric
improvement
• Accessible when, where patient
needs care
Aligned Across the Continuum
Outcomes-Driven System
• Multidisciplinary team works
together to maintain unified care
plan across patient needs
• Dashboard aligned to key cost,
quality goals for improving
population health
• Data transparency, sharing to
ensure streamlined patient care
• Information available across the
continuum to track utilization
Source: Nursing Executive Center interviews and analysis.
Key Factor Driving The Change Today:
The Rise of The Retail Triple-Threat
29
Unleashing the consumer… a force incumbent health systems are ill
prepared to cope with!
Retail consumer
behavior at the
point of…
Purchase
©2013 The Advisory Board Company • 26427
Spend
Lifestyle
Integration
Confronted with choices and
spending our own money, we make
very different purchasing decisions
High deductibles and narrow
networks make us price sensitive
with a high demand for value
Health and healthcare must fit into our
lives and be convenient; we will
reward those who can deliver and
retailers are lining up for the
opportunity
30
One Year In, Insurance Exchanges Generally on Track
Aggregate Numbers in Line With Expectations; Enrollee Mix Older
Initial Public Exchange Enrollment1
2013-2014
3.8M
8.0M
91%
Of enrollees still enrolled
as of September 2014
7.0M
(Original CBO
Projection)
2.1M
exchange
25M Projected
enrollment by 2018
©2013 The Advisory Board Company • 26427
2.2M
October to
December
January to
February
1) Numbers do not add precisely due to rounding.
March
Total
28%
Enrollees
aged 18-34
Source: HHS, “Health Insurance Marketplace: Summary Enrollment Report for the Initial Annual Open Enrollment Period,” May 1, 2014; Cheney K and
Haberkorn J, “Obama: 8 Million Enrolled Under ACA,” Politico, April 17, 2014, www.politico.com; Cheney K and Norman B, “Insurers See Brighter
Obamacare Skies,” Politico, April 15, 2014, www.politico.com; Health Care Advisory Board interviews and analysis.
31
Early Year Two Enrollment Outpacing First Round
Fewer Glitches, Greater Awareness Driving Increased Enrollment
A Solid Start for Both Federal, State Exchanges
©2013 The Advisory Board Company • 26427
First Round Enrollment
Second Round Enrollment
F EDERAL
E XCHANGE
106K
Enrollment during
first month
462K
Enrollment during
first week
M ARYL AND
E XCHANGE
16K
Enrollment during
first two months
16K
Enrollment during
first week
C OLORADO
E XCHANGE
204
Enrollment during
first week
6K
Enrollment during
first week
C ALIFORNI A
E XCHANGE
11K
Enrollment during
first fifteen days
11K
Enrollment during
first four days
Source: CNBC, ‘'Solid' Obamacare start: More than 1M apply in first week,” http://www.cnbc.com/id/102218144; Baltimore Sun, “Md. health exchange
enrolls 16,700 in first week,” http://www.baltimoresun.com/health/bs-hs-exchange-week-one-20141121-story.html; Colorado Public Radio, “Colorado health
exchange: Enrollment rate outpacing last year,” http://www.cpr.org/news/story/colorado-health-exchange-enrollment-rate-outpacing-last-year#.dpuf; Los
Angeles Times, “California enrolls 11,357 in first 4 days of Obamacare open enrollment,” http://www.latimes.com/business/healthcare/la-fi-obamacareenrollment-california-20141120-story.html; Health Care Advisory Board interviews and analysis.
32
Individuals Gravitating Toward Leaner Plans
People Choosing Cheaper Premiums and Higher Deductibles
Level 1: Choice of Metal Tier
Level 2: Plan Choice Within Metal Tier
Gold
Platinum
5%
9%
2% Catastrophic
All Metal Levels1
Any Other
Plan
65%
20%
36%
Bronze
LowestCost Plan
43%
21%
Silver
Second-Lowest-Cost Plan
©2013 The Advisory Board Company • 26427
Factors Influencing Metal Level
Premium Levers Beyond Benefit Design
Deductible
Non-Essential
Services Covered
Scope of Non-Essential Benefits
Copays
Network Composition
Negotiated Payment Rates to Providers
Out-of-Pocket
Maximum
Negotiated Rates
Utilization Patterns, Trends
1) Data from federally-facilitated exchanges only.
Source: HHS, “Health Insurance Marketplace: Summary Enrollment Report for the Initial Annual
Open Enrollment Period,” May 1, 2014; Health Care Advisory Board interviews and analysis.
33
High Deductibles Accelerating Consumerism
Aggressive Cost Sharing Troublesome for Provider Strategy
Individual Deductibles Offered On
Public Exchanges
2014
$2,500 $6,250
Median
Challenges for Providers
High out-of-pocket
costs discourage
appropriate utilization
Maximum
Individual Deductibles Chosen on
eHealth Individual Marketplace
<$1,000
Large patient obligations
lead to more bad debt,
charity care
©2013 The Advisory Board Company • 26427
16%
39%
$1,000$2,999 16%
$6,000+
Price-sensitive patients
more likely to seek lowercost options
30%
$3,000-$5,999
Source: Breakaway Policy Strategies, “Eight Million and Counting: A Deeper Look at Premiums, Cost Sharing and
Benefit Design in the New Health Insurance Marketplaces,” May 2014; eHealth, “Health Insurance Price Index
Report for Open Enrollment and Q1 2014,” May 2014; Health Care Advisory Board interviews and analysis.
34
Convenience Outranking Service and Cost
How Convenient Is Convenient?
Top Preferences for On-Demand Care
Consumers Want Virtual, 24/7 Access
#1 out of 56
#5 out of 56
“Walking in without appointment
and being seen within 30 minutes”
“The clinic is open 24 hours,
7 days a week”
6 OF TOP 10
FEATURES
RELATED TO
ACCESS,
CONVENIENCE
Access,
Convenience
Cost
Service
Increasing Consumer Preference
©2013 The Advisory Board Company • 26427
Convenience Consistently a Top Consumer Priority
Clinic located
near the home
Emailing provider
with symptoms
Clinic located
near errands
Clinic location
near work
Source: The Advisory Board Company, 2014 Primary Care Consumer Choice Survey, Marketing
and Planning Leadership Council; Health Care Advisory Board interviews and analysis.
35
Price Sensitivity at the Point of Care
Cost-Conscious Behavior Affecting Pillars of Profitability
Consumers Paying More Out-of-Pocket
MRI Price Variation Across
Washington, DC
Fall within HDHP deductible2
$2,183
$18K
Fall within PPO
deductible3
$730
$9K
$411
$6K
$900
$2K
©2013 The Advisory Board Company • 26427
$150 $275 $400
1) High-deductible health plan.
2) $2,086; based on KFF report of average HDHP
deductible.
3) $733; based on KFF report of average PPO deductible.
$900
$1K
$1,269
• Price-sensitive shoppers
will be acutely aware
of price variation
• MRI prices range from
$400 to $2,183
Source: KFF, “2012 Employer Health Benefits Survey,” available at: www.kff.org; New Choice Health, “New Choice Health
Medical Cost Comparison,” available at: www.newchoicehealth.com; Healthcare Blue Book, “Healthcare Pricing,” available at:
www.healthcarebluebook.com; Kliff S, “How much does an MRI cost? In D.C., anywhere from $400 to $1,861,” Washington
Post, March 13, 2013, available at: www.washingtonpost.com; Health Care Advisory Board interviews and analysis.
36
Retail Clinics
Meet Our New Competitors
Walgreens Aims to Become the Premier Health Destination
2013: Launches three ACOs;
begins diagnosing and
managing chronic disease
2009: Launches flu
vaccine campaign
Simple Acute
Services
Vaccinations and
Physicals
Chronic Disease
Monitoring
2007: Acquires Take
Care Health Systems
”
©2013 The Advisory Board Company • 26427
Chronic Disease Diagnosis
and Management
2012: Offers three new
chronic disease tests
Case in Brief: Walgreen Co.
Not Just a Drugstore
• Largest drug retail chain in the United
States, with 372 Take Care Clinics
“Our vision is to become ‘My Walgreens’ for
everyone in America by transforming the
traditional drugstore into a health and daily
living destination...”
• In April 2013, became first retail clinic
to offer diagnosis and treatment of
chronic diseases
Walgreen Co. Overview
Source: Japsen B, “How Flu Shorts Became Big Sales Booster for Walgreen, CVS,” Forbes, February 8, 2013, available at:
www.forbes.com; “Take Care Clinics at Select Walgreens Expand Service Offerings,” Reuters, May 31, 2012, available at: www.reuters.com;
Murphy T, “Drugstore Clinics Expand Care into Chronic Illness,” The Salt Lake Tribune, April 4, 2013, available at: www.sltrib.com,
Walgreens, “Company Overview,” available at: www.walgreens.com; Health Care Advisory Board interviews and analysis.
37
Walmart Enters Full Primary Care
Saving Money—For Its Associates and Customers
Walmart Care Clinic Model
Walmart associate or
customer visits Care Clinic
Care Clinic staffed by two NPs
from QuadMed, an employer
onsite clinic provider
NP provides primary care
services, refers to external
specialists and hospitals
©2013 The Advisory Board Company • 26427
The Largest “Activated Employer” Yet
“As the largest private employer in the U.S., we are
committed to finding ways to drive down health care
costs for our 1.3 million U.S. associates and the 140
million customers who shop our stores each week.”
Labeed Diab
President of Health and Wellness, Wal-Mart
$4
Visit fee for
Walmart
associates
$40
Visit fee for
Walmart
customers
Source: Canales MW, “Wal-Mart Opening Clinic in Cove,” Killeen Daily Herald, April
18, 2014, www.kdhnews.com; Health Care Advisory Board interviews and analysis.
38
Retail Clinics Expected to Continue Growing
Estimated Total Number of Retail Clinics in the
US
2000-20151
2868
Growth trajectory
depends on preferred
payer relations, PCP
capacity, and health
system partnerships
2243
1743
1135 1172 1220
1355 1418
868
202
©2013 The Advisory Board Company • 26427
2000 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015
Retailer
Operational
Retail Clinics1
1) As of Oct. 2014.
900+
400+
135
14
75+
Source: Accenture, "Retail medical clinics: From Foe to Friend?," 2013; Ritchie J, "After a stall, Kroger could
add clinics," Cincinnati Business Courier, July 5, 2013; Robeznieks A, "Retail clinics at tipping point," Modern
Healthcare, May 4, 2013; Health Care Advisory Board interviews and analysis.
39
Differentiating Effective Population Health
Managing Three Distinct Patient Populations
HighRisk
Patients
©2013 The Advisory Board Company • 26427
Rising-Risk
Patients
Low-Risk Patients
5% of patients;
usually with complex
disease(s), comorbidities
15-35% of patients;
may have conditions
not under control
60-80% of patients;
any minor conditions
are easily managed
Trade high-cost
services for lowcost management
Avoid unnecessary
higher-acuity, highercost spending
Keep patient
healthy, loyal
to the system
Source: Health Care Advisory Board interviews and analysis.
40
Chronic Disease Growth Outpacing Population
Population Growth
Projected Increase in Chronic Disease Cases
2003-2023
62%
53%
39%
©2013 The Advisory Board Company • 26427
29%
41%
54%
19%: Projected
population growth,
2003-2023
31%
Source: Milken Institute, available at: http://www.milkeninstitute.org/
pdf/chronic_disease_report.pdf, accessed April 27, 2011; Nursing
Executive Center interviews and analysis.
41
Plenty of Room for Improvement in Managing Care
Difference Between “Loosely-Managed” and “Well-Managed” PMPM1 Spending
2011
Medicaid
Commercial
©2013 The Advisory Board Company • 26427
$100.48
Loosely
Managed
Well
Managed
Medicare
$131.84
Loosely
Managed
Well
Managed
$449.79
Loosely
Managed
Well
Managed
Source: Milliman; Nursing Executive Center interviews and analysis.
42
Building a System that Never Discharges the Patient
Evolution of Patient Care Perspective
Perfecting Individual Transitions
Acute
Care
Achieving Care Continuity
SNF
ED
Home
PCP
©2013 The Advisory Board Company • 26427
Retail
Clinic
Rehab
Home
Health
Source: Nursing Executive Center interviews and analysis.
43
Finding the 80/20
Key Root Causes of Patients Receiving Fragmented, Episodic Care
Patients receive fragmented,
episodic care
©2013 The Advisory Board Company • 26427
Clinicians not
equipped to provide
continuous care
Clinicians only feel
accountable for their
immediate setting
Clinicians don’t
have necessary
patient information
Clinicians have a
siloed, settingspecific perspective
Clinicians don’t
know how
Clinicians’
incentives focus on
site-specific care
Clinicians don’t
have time
Patients and families
don’t manage their
care effectively
Patients lack
motivation
Patients don’t
know how
Patients face
economic
roadblocks
To access Achieving Top-of-License Nursing Practice, visit advisory.com/nec/publications.
Source: Nursing Executive Center interviews and analysis.
44
Investing in Nursing with Good Reason
Patient Complexity Increasing
Mounting Evidence Linking
Nursing to Patient Outcomes
Average Medicare Case Mix1
Representative Studies on the Impact of Nurse Staffing
1.60
Primary
Author
Needleman An increase in the number of RN hours per day from
et al., 2002 the 25th to the 75th percentile was associated with
better outcomes for medical and surgical patients
1.50
1.44
Aiken et
al., 2003
©2013 The Advisory Board Company • 26427
2001
2005
Top-Level Findings
2010
An increase in the proportion of RNs with a
Bachelor’s or Master’s degree across the entire
institution was associated with better outcomes in
mortality and failure to rescue
Kane et al., A review of the literature finds consistent
2007
associations between increased RN staffing and
lower odds of hospital-related mortality and adverse
patient events
McHugh
et al., 2013
1) Case Mix Index (CMI) in short-stay hospitals participating
in Medicare’s Inpatient Prospective Payment System;
excludes Medicare Advantage patients.
Hospitals with higher nurse staffing had 25% lower
odds of incurring Medicare readmissions penalties
than similar hospitals with lower nurse staffing
Source: MEDPAR 2001, 2005, 2010; Needleman J, et al., “Nurse-Staffing Levels and the Quality of Care in Hospitals,” New England
Journal of Medicine, 346 (2002): 1715-1722; Aiken L, et al., “Educational Levels of Hospital Nurses and Surgical Patient Mortality,” JAMA,
290 (2003): 1617-1623; Kane RL, et al., “The Association of Registered Nurse Staffing Levels and Patient Outcomes: Systematic Review
and Meta-Analysis,” Medical Care 45 (2007): 1195-1204; McHugh M, et al., “Hospitals with Higher Nurse Staffing Had Lower Odds of
Readmissions Penalties than Hospitals with Lower Staffing,” Health Affairs, 32(2013): 1740-1747; Nursing Executive Center analysis.
45
An Alarming Dichotomy
Health System Economics
Care Team Economics
Expenses per
Adjusted Admission
Percentage of Hospital Costs2
Comprising Wages and Benefits
2012
$10,533
$6,980
59%
2001
2011
Affordable Care Act’s Medicare
Fee-for-Service Payment Cuts1
©2013 The Advisory Board Company • 26427
2013
2014
2015
2016
Total RN Compensation
per Hour Worked
2017
$48.02
$36.21
($4B)
($14B)
($21B)
($25B)
($32B)
1) Reductions to annual payment rate increases; includes
hospital, skilled nursing facility, hospice, and home
health services; excludes physician services.
2) Does not include capital.
2004
2013
Source: American Hospital Association, “Trendwatch Chartbook 2013: Trends Affecting Hospitals and Health Systems,” available at:
http://www.aha.org/research/reports/tw/chartbook/index.shtml, accessed on December 2, 2013; CBO, “Letter to the Honorable John Boehner
Providing an Estimate for H.R.6079, The Repeal of Obamacare Act,” July 24, 2012, available at: www.cbo.gov, accessed on December 2,
2013; Bureau of Labor Statistics, “Employer Costs for Employee Compensation Historical Listing March 2004 – June 2013,” available at:
ftp://ftp.bls.gov/pub/special.requests/ocwc/ect/ececqrtn.pdf, accessed on November 12, 2013; Nursing Executive Center analysis.
46
Population Health Efforts Shaping Volume Outlook
Utilization Patterns Difficult to Predict
Inpatient Volume Under Different
Population Health Assumptions
42.6M
41.9M
40.8M
40.5M
40M
©2013 The Advisory Board Company • 26427
39.6M
2012
39.5M
2017
Quite a Difference
7.6%
Total inpatient volume
growth, 2012-2022, with no
additional population health
management effort
1.1%
2022
No Additional Population Health Management
Total inpatient volume
growth, 2012-2022, with
aggressive population health
management efforts
Typical Management
Aggressive Management
Source: Health Care Advisory Board interviews and analysis.
47
Designing the Care Team
for Accountable Care
Two Dimensions of Care Team Design
Efficient, Siloed
Care Team
Nurses practice to the full
extent of their training and
skills but within professional
silo
Efficient, Interprofessional
Care Team
Interprofessional care team
collaborates efficiently and
effectively, providing highquality, low-cost care
Nursing Team
Efficiency
©2013 The Advisory Board Company • 26427
Inefficient, Siloed
Care Team
Nurses do not practice to the
full extent of their training and
skills; caregivers work in
professional silos
Inefficient, Interprofessional
Care Team
Nurses and other caregivers
collaborate to provide care,
but nurses do not practice at
top of license
Interprofessional Team Integration
Source: Nursing Executive Center interviews and analysis.
48
A Unique Moment in Time to Build a
Different Kind of Care Team
Age Distribution of Practicing
Registered Nurses in the US
Opportunities to Redefine
the Care Team
2008
Fill vacant positions with
a different skill set
29.2%
25.8%
20.0%
12.7%
9.4%
2.9%
©2013 The Advisory Board Company • 26427
20-29
30-39
40-49
50-59
60-69
~1,000,000
Instill a new care team
philosophy in new hires
70+
Use attrition (rather than
cuts) to eliminate positions
Number of RNs reaching retirement
age in the next 10-15 years
Source: US Department of Health and Human Services, Health Resources and Services Administration, The Registered Nurse Population: Findings from the
2008 National Sample Survey of Registered Nurses, 2010, available at: http://bhpr.hrsa.gov/healthworkforce/rnsurveys/rnsurveyfinal.pdf, accessed on April 25, 2013;
US Department of Health and Human Services, Health Resources and Services Administration, The U.S. Nursing Workforce: Trends in Supply and Education, 2013,
available at: http://bhpr.hrsa.gov/healthworkforce/reports/nursingworkforce, accessed on May 7, 2013; Nursing Executive Center interviews and analysis.
49
A Nurse Isn’t a Nurse Isn’t a Nurse
Estimated Rate of Adverse Outcomes per 1,000 Patients
by Hospital-Wide Level of Nurse Education1
Failure to Rescue
Patient Mortality
90.4
83.1
76.2
©2013 The Advisory Board Company • 26427
21.1
20% BSN
19.2
17.5
40% BSN
60% BSN
20% BSN
40% BSN
60% BSN
1) Percentage of hospital staff nurses with BSN degree.
Source: Aiken L, et al., “Educational Levels of Hospital Nurses and Surgical Patient
Mortality,” JAMA, 290 (2003): 1617-1623; Nursing Executive Center analysis.
50
Three Paths for Building the High-Value Care Team
Overreliance on
Bedside RNs
Uncoordinated
Interprofessional Care
A “One-Size-Fits-All”
Care Team
1
2
3
Change the
Nursing Skill Mix
Align Interprofessional
Goals and Work
Deploy the Minimum
Core Team and Selectively
Scale Up Support
1.
Achieve Top-of-License
Nursing Practice
4.
2.
Right-Size the Proportion
of RNs in the Skill Mix
Root Cause
of Inefficiency
Path to
Higher Value
©2013 The Advisory Board Company • 26427
3.
Trade a Nursing Position
for an Expert RN Role to
Improve Unit Performance
Give All Care Team
Members the Same
Set of Goals
5. Transfer Work to
Specialized Team
Members
8.
Select Your Patient
Population of Focus
9. Identify Patients Needing
Additional Support
10. Define the Core and
Expanded Care Teams
6. Gather Physicians and
Staff at the Bedside at the
Same Time
11. Layer Additional Support
onto the Core Team
7. Keep Teams as
Consistent as Possible
12. Regularly Reassess
Patient Need for Support
Source: Nursing Executive Center interviews and analysis.
51
©2013 The Advisory Board Company • 26427
Road Map
1
Our New Market Reality
2
Care Delivery Transformation
3
Implications For Nursing Practice and Education
52
Nursing at the Heart of Transformative Change
”
Future of Nursing: Leading Change,
Advancing Health
©2013 The Advisory Board Company • 26427
Working on the front lines of patient
care, nurses can play a vital role in
helping realize the objectives set forth
in the 2010 Affordable Care Act,
legislation that represents the broadest
health care overhaul since the 1965
creation of the Medicare and Medicaid
programs.
Institute of Medicine
Source: Institute of Medicine, “The Future of Nursing: Leading Change, Advancing Health,”
available at: http://www.iom.edu/Reports/2010/The-Future-of-Nursing-Leading-ChangeAdvancing-Health, accessed November 11, 2011; Nursing Executive Center analysis.
53
Then and Now….
©2013 The Advisory Board Company • 26427
Single-needs patient an endangered species
Mr. Jones; 1975
Mr. Jones; 2015
AMI
AMI, HF, diabetes, obese
PCP
PCP, cardiologist,
endocrinologist,
hospitalist, geriatric NP
2 meds
15 meds
Lives at home
Lives in assisted living
Wife is caregiver
Multiple family members,
no one designated
LOS: 10 days
LOS: 2.5 days
One admission in 1973
Third admission in 2013
54
Imperatives for Nursing and Nursing Practice
Top of License Practice
• Non-valued added work
eliminated
• Care team as core in all
settings
• Core responsibilities clear
• Roles clearly defined,
supported, aligned with patient
needs
• Professional practice model
as foundation
Enhancing the Patient Experience
©2013 The Advisory Board Company • 26427
Inter-Professional Collaboration
Frontline Accountability
• Beyond satisfaction
• Value-based care
• Processes and systems
patient-’centered’
• Activity ‘completion’ not
enough
• Patient as partner
• Ownership of outcomes the
key
55
Imperative: Top of License Practice
Endorsing “Top-of-License” Nursing Practice
”
The Future of Nursing: Leading Change,
Advancing Health
“Nurses should practice to the full extent of their education
and training.”
Institute of Medicine
”
Broadening the Scope of Nursing Practice
©2013 The Advisory Board Company • 26427
“All health care professionals should support an
expanded, standardized scope of practice for nurses as
a way to improve health care in the United States.”
Julie A. Fairman, PhD, RN
John W. Rowe, MD
Susan Hasmiller, PhD, RN, FAAN
Donna Shahala, PhD
Source: Institute of Medicine, “The Future of Nursing: Leading Change, Advancing Health,” available at http://www.iom.edu/Reports/
2010/The-Future-of-Nursing-Leading-Change-Advancing-Health, accessed November 11, 2011; Fairman J, et al., “Broadening the
Scope of Nursing Practice,” New England Journal of Medicine, 364 (2011):193-196; Nursing Executive Center analysis.
56
Imperative: Top of License Practice
Defining “Top-of-License” Practice by Patient Needs
Establishing Consensus on Core Responsibilities
Core Nursing Responsibilities Across Settings
1
5
Assess Clinical and
Psychosocial Patient Needs
2
Manage Key Components
of the Clinical Record
6
Establish Patient Goals
and Track Progress
©2013 The Advisory Board Company • 26427
3
Coordinate Care with
Interprofessional Caregivers
7
Facilitate Safe
Patient Transitions
to the Next Care Setting
Provide Patient-Centered,
Outcomes-Focused Care
4
8
Educate and Engage
Patients and Their Families
Assess and Incorporate
New Technologies and
Evidence-Based Practice
Source: Nursing Executive Center interviews and analysis.
57
Imperative: Top of License Practice
An All-Too-Common Reality
©2013 The Advisory Board Company • 26427
Real Nurses’ Stories from the Front Line
Primary
Care Office
Emergency
Department
Inpatient
Skilled Nursing
Facility
Home
Health
• 10 minutes
looking for
patient’s suicide
risk in the EMR
• Hunted down
•
catheter because
no one else
available and care
time-sensitive
Wheeled patient
to radiology so
wouldn’t miss
scheduled
ultrasound
• Physician
kept referring
to the medical
assistants as
“nurses”
• Stuck waiting for • 20 minutes
• Transported
• Made four calls to
physician’s order
cleaning up large
resident to dining physician to have
to administer
spill to prevent an
room and stayed
patient’s medication
pain medication
avoidable fall
for the entire
adjusted
meal to assist
him with feeding
• Called hospital • Drove 20 miles to
charge nurse to
agency office to
decipher handdocument care in
written discharge the electronic
instructions
record
Source: Nursing Executive Center interviews and analysis.
58
Imperative: Top of License Practice
Opportunity Lies in Underleveraged Hours
Current Distribution of
Med/Surg Nursing Time1
$756,724
RN wages spent on non-valueadded time per med/surg unit
64%
36%
“Non-ValueAdded” Time3
”
“Value-Added”
Time2
©2013 The Advisory Board Company • 26427
“Most attention has been
focused on increasing nursing
staffing levels rather than on
increasing patient care time.”
Judith Lloyd Storfjell, PhD, RN
Osei Omoike, MS, MBA, RN
Susan Ohlson, MSA, RNC
1) Based on three-year study of nursing activities on 14 med/surg units in three hospitals.
2) Assessing, teaching, providing hands-on care, providing psychosocial support, coordinating care, and documenting care.
3) Waiting, disruptions, delays, work-arounds, and rework.
Source: Storfjell J, Omoike O, and Ohlson S, “The
Balancing Act: Patient Care Time Versus Cost,” JONA
38 (2008): 244-249; Nursing Executive Center analysis.
59
Imperative: Interprofessional Collaboration
Impeding Effective Patient Care
Staff Often Feeling Unsupported by Interprofessional Colleagues
Staff Strongly Agreeing with the Following Statements:
39%
35%
33%
31%
29%
28%
22%
23%
17%
©2013 The Advisory Board Company • 26427
RNs
24%
17%
APRNs
PCAs
Pharmacists
18%
Physical
Therapists
Social
Workers
“I receive the necessary support from employees in my
unit/department to help me succeed in my work.”
“I receive the necessary support from employees in other
units/departments to help me succeed in my work.”
Source: Advisory Board Survey Solutions Data Cohort, 2012.
60
Imperative: Interprofessional Collaboration
Poor Collaboration Leading to Poor Patient Outcomes
Association Between Nurse-Physician Collaboration
and Negative Patient Outcomes in the ICU
3.5
The lower the
nurse-physician
collaboration score,
the higher the risk
of a negative
patient outcome
2.5
0.77
1.0
0.86
©2013 The Advisory Board Company • 26427
0.47
Medical ICU
Surgical ICU
Med/Surg ICU
Med-Surg
Collaboration Score, 1 (Poor) to 7 (High)
Negative Outcome to Predicted Mortality Unit
Source: Baggs J, et al., “Association Between Nurse-Physician Collaboration and Patient Outcomes in Three
Intensive Care Units,” Critical Care Medicine, 27 (1999):1991-1998; Nursing Executive Center analysis.
61
Imperative: Interprofessional Collaboration
Estimating the Costs
InnInefficientollabortaionEstimating
the Cost of
Inefficient collaboration and communication….
Inefficient
CoCollabommunication
Annual
Economic Burden of Communication Inefficiencies
Average 500-Bed Hospital
$0.3 M
©2013 The Advisory Board Company • 26427
Cost of Wasted
Nurse Time
$4.6M
$1.8 M
Cost of Wasted
Physician Time
$2.5 M
Cost of
Increased LOS
Total annual costs attributed to inefficient
communication for average 500-bed hospital
Source: Agarwal R, et al., “Quantifying the Economic Impact of Communication Inefficiencies in U.S.
Hospitals,” Journal of Healthcare Management, 55 (2010): 265-281; Nursing Executive Center analysis.
62
Imperative: Interprofessional Collaboration
Renewed Emphasis on Interprofessional Education
1972 Institute of Medicine
Report
“Educating for the Health Team”
Educating for the Health Team
Institute of Medicine
1972
©2013 The Advisory Board Company • 26427
“We face, in the next decade, a national challenge
to redeploy the functions of health professions in
new ways, extending the roles of some, perhaps
eliminating others, but more closely meshing the
functions of each than ever before.”
Factors Reinforcing the Need for
Improved Interprofessional
Collaboration
Aging population with
multiple chronic conditions
New payment models rewarding
effective primary care and
population management
Impending health care
workforce shortages
Source: Institute of Medicine, “Educating for the Health Team,” National Academy of Sciences, October 1972,
available at http://www.ipe.umn.edu/prod/groups/ahc/@pub/@ahc/@cipe/documents/asset/ahc_asset_350123.pdf,
accessed November 12, 2012; Interprofessional Education Collaborative, “Core Competencies for Interprofessional
Collaborative Practice: Report of an Expert Panel,” 2011, available at http://www.aacn.nche.edu/educationresources/IPECReport.pdf, accessed November 12, 2012; Nursing Executive Center interviews and analysis.
63
Imperative: The Patient Experience
Is This All We Aspire to Do?
©2013 The Advisory Board Company • 26427
Summary of Eight HCAHPS Domains
1. Communication with nurses
5. Communication about medicines
2. Communication with doctors
6. Discharge information
3. Responsiveness of hospital staff
7. Hospital environment (quiet, noise)
4. Pain management
8. Overall hospital rating
Source: HCAHPS, available at: http://www.hcahpsonline.org/home.aspx,
accessed November 11, 2011; Nursing Executive Center interviews and analysis.
64
Imperative: The Patient Experience
Broadening Our Ambition
©2013 The Advisory Board Company • 26427
Patient Experience
• Ongoing Emotional Support
• Family Involvement and
Care Team Integration
• Avoidable Disruptions
Minimized
• Compassionate,
Empathetic
Caregivers
• Clear, Actionable
Patient Education
• Up-to-Date and
Thorough Information
• Physical and Emotional
Needs Anticipated
HCAHPS
• Communication
• Quiet at Night
• Information About
Medications
• Discharge Information
• Cleanliness
• Responsiveness
• Pain Management
Source: HCAHPS, available at: http://www.hcahpsonline.org/home.aspx, accessed November 11, 2011; Nursing Executive Center interviews and analysis.
65
Imperative: The Patient Experience
Still Ample Room for Growth
Percentage of Physicians and Patients
Agreeing With the Following Statements
About Compassionate Care
n=800 patients, 510 physicians
85%
78%
76%
©2013 The Advisory Board Company • 26427
54%
Compassionate care is very
important to successful
medical treatment
Physicians
Most health care professionals
exhibit compassionate care
Patients
Source: Health Affairs, “An Agenda For Improving Compassionate Care: A Survey Shows About Half Of Patients Say
Such Care Is Missing,” available at: http://content.healthaffairs.org/content/30/9/1772.full, accessed November 10, 2011.
66
Imperative: Patient Experience
Advancing Multiple Aims
©2013 The Advisory Board Company • 26427
Representative Studies About the Relationship
Between Patient Experience and Outcomes
American Journal of
Managed Care
Circulation: Cardiovascular
Quality and Outcomes
Relationship Between Patient
Satisfaction With Inpatient
Care and Hospital
Readmission Within 30 Days
Patient Satisfaction and Its
Relationship With Clinical
Quality and Inpatient Mortality
in Acute Myocardial Infarction
Journal of the American Board
of Family Medicine
Patient-Centered Care is
Associated With Decreased
Health Care Utilization
Source: Boulding W, et al., “Relationship Between Patient Satisfaction With Inpatient Care and Hospital
Readmission Within 30 Days,” American Journal of Managed Care, 2011, 17:41-48; Glickman S, et al.,
“Patient Satisfaction and Its Relationship With Clinical Quality and Inpatient Mortality in Acute Myocardial
Infarction,” Circulation: Cardiovascular Quality and Outcomes, 2010; 3:188-195; Bertakis K, et al., “PatientCentered Care is Associated with Decreased Health Care Utilization,” Journal of the American Board of
Family Medicine, 2011, 24:229-239; Nursing Executive Center interviews and analysis.
67
Imperative: Accountability
Growing Number of Metrics Linked to Reimbursement
©2013 The Advisory Board Company • 26427
HCAHPS Survey Measures
 During this hospital stay, how often did nurses treat you with
courtesy and respect?”
 During this hospital stay, how often did nurses
Core Process Measures
listen carefully to you? Acute Myocardial Infarction
 During this hospital stay, how
often did
nurses explain
things in a
 Aspirin
prescribed
at discharge
way you could understand?
Patient
Safety
and Quality Measures
 Fibrinolytic agent received within 30 minutes
of hospital
arrival
 During this hospital stay, after
you of
pressed
call button,
how
Mortality
Measures
 Time
receiptthe
of primary
percutaneous
coronary intervention
often did you get help as soon
as you
wanted it?
 Statin
prescribed
at discharge Acute Myocardial Infarction 30-day mortality rate
 During this hospital stay, how
often
were your room and bathroom
 Heart Failure 30-day mortality rate
Heart
Failure
kept clean?
 Pneumonia 30-day mortality rate
 Discharge instructions
 During this hospital stay, how often was the area around your
Readmission
 Evaluation of left ventricular systolic
function Measures
room quiet at night?
 Angiotensin converting enzyme
 inhibitor
Acute Myocardial Infarction 30-day risk standardized readmission
 During this hospital stay, did you need help from nurses or other
measure
Pneumonia
hospital staff in getting to the bathroom or in using a bedpan?
Heart
riskreceived
standardized readmission measure
 Blood culture performed in theED
priorFailure
to first 30-day
antibiotic
 How often did you get help in getting to the bathroom or in using a
 Pneumonia 30-day risk standardized readmission measure
 Appropriate initial antibiotic selection
bedpan as soon as you wanted?
Healthcare-Associated Infections
Surgical
Improvement
Project
 During this hospital stay, how
often Care
was your
pain well controlled?
 Central line associated bloodstream infection
 Prophylactic
 During this hospital stay, how
often did theantibiotic
hospital received
staff do within 1 hour prior to surgical
 Surgical site infection
everything they could to helpincision
you with your pain?
 for
Catheter-associated
Prophylactic
surgical patients urinary tract infection
 Before giving you any newmedicine,
howantibiotic
often did selection
hospital staff
Hospital-Acquired
Measures
Prophylactic
antibiotic discontinued
within 24 hoursCondition
after surgery
tell you what the medicinewas
for?
end time how often did hospital
 staff
Foreign object retained after surgery
 Before giving you any new medicine,
 Cardiac
surgery
patients
with 
controlled
6AM postoperative serum
Air embolism
describe possible side effects
in a way
you could
understand?
 Blood
 During this hospital stay, did glucose
doctors, nurses or other hospital
staff incompatibility
 you
Postoperative
catheter
poststages
operative
remoaval
Pressureonulcer
III &day
IV 1 or
talk with you about whether
would haveurinary
the help
you needed
 Falls and trauma
when you left the hospital? 2
 Surgery
patients on in
a Beta
Blocker
prior tocatheter-associated
arrival who receivedinfection
a

Vascular
 During this hospital stay, did
you get information
writing
about
Beta Blocker
perioperative
Catheter-associated
urinary tract infection
what symptoms or health problems
to lookduring
out forthe
after
youleft
theperiod
 Surgery patients with recommended
VTE prophylaxis
 Manifestation
of poor ordered
glycemic control
hospital?
 Surgery patients who receivedPrevention:
appropriate VTE
prophylaxis
within Measures
Global
Immunization
24 hours pre/post surgery
 Immunization for influenza
 Immunization for pneumonia
Source: Centers for Medicare & Medicaid Services; Nursing Executive Center interviews and analysis.
68
Imperative: Accountability
Frontline Accountability Foundational to Success
Practice Strategy Hierarchy
Peak
Performance
©2013 The Advisory Board Company • 26427
Critical thinking
essential to
addressing
needs
Innovation
Standardization
Frontline Accountability
for Organizational Goals
Protocol adherence
clearly important…
…Ownership of
protocol/standard of
practice outcomes
supported by critical
thinking essential
Source: Nursing Executive Center interviews and analysis.
69
What Lies Ahead?
Strategies for Nursing to Influence, Shape, Own,
and Lead…..
70
Holistic Care Transformation …
An Opportunity to Design the Future Together
Care Model
Care
Transitions
©2013 The Advisory Board Company • 26427
Population Health
Management
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