Government Health Reform Four components of Health Reform: Coverage - - PDF document

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Strategic Planning and Cultivating Nursing Roles Strategic Planning and Cultivating Nursing Roles – Developing a Five SEVEN Year Plan The Norton Healthcare Experience

Tracy E Williams, DNP RN

Senior Vice President and System Chief Nursing Officer

Kim Tharp – Barrie, DNP RN, SANE

System Vice President , NHC Institute for Nursing

Making the Case

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Health Care Reform

Government Health Reform

Four components of Health Reform:

Coverage Reform puts everyone into the market for health care by mandating that everyone be covered by

insurance

Delivery System Reform. The proposed regulations issued by CMS on Accountable Care Organizations

and the Medicare Shared Savings program may prove unworkable – but all the buyers in this market (commercial health plans, state governments, employers and individuals) are demanding that providers address efficiency, cost and effectiveness deficits.

Payment Reform. In 2012, the Medicare Hospital Value Based Purchasing (VBP) program will cover all

acute care providers, and in future years the program will expand to cover outpatient care. CMS describes the VBP as the latest stage of the evolution of CMS from a “passive payer of claims based on volume to an active purchaser of care based on the quality of care beneficiaries receive.”

Quality Improvement. A hospital admissions reduction program for preventable Medicare inpatient

hospital admissions starting in FY 2013 which can reduce payments by one percent for targeted cases and up to 3% in 2015 and subsequent years.

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A Prescription for Patient Value The Value Proposition

• Achieving universal coverage and access to care are essential, but not

enough

• The core issue in health care is the value of health care delivered
• Value: Patient health outcomes per dollar spent
• Value is the only goal that can unite the interests of all system participants

– Patient / Physician / Provider / Payor

• How to construct a dynamic system that keeps rapidly improving
• The central goal in health care must be value for patients, not access,

volume convenience or cost containment volume, convenience, or cost containment Value = Health Costs / Cost of Delivering the Outcomes

Hospital ‐ ER services, OP services, IP stays

Value in the Future is… the Patient Care Continuum

Specialty Physician Diagnostic Center Skilled Nursing; LTAC; Rehab Patient Home Home ICC Care Team Center Wellness Center

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The Norton Healthcare Accountable Care Ecosystem

 Population Management  Humana – Brookings Dartmouth

Partnership

 Medicare Advantage  Health Department Partnerships Coordinate Manage to

Components of Accountable Care

Effective Health Management

 Employers  Patients  Hospitals  Physicians  Acute, sub‐acute and long‐term

care providers The Players p p

 Healthy Start  Flu Vaccination  Needs Assessment  N‐Good Health Employee

Program

Cost and Efficiencies Effective Health Management Coordinate Items and Services Manage to Quality Standards

Manage Costs and Efficiencies Manage to Quality Standards Coordinate Items and Services

 Clinical Effectiveness with

Integration of:

 Ambulatory care centers  Pharmaceutical companies  Medical device manufacturers  Care Givers (physicians, nurses,

home health, clinical social worker, clinical psychologist, and other ancillary providers)

 Payors  Federal government  Care Management  Service Excellence  Quality  Quality Transparency Reporting  Data Management and Analytics  Epic  Amalga  Norton Nursing Institute  Risk Management  Finance and Accounting Integrated in

Quality Prioritization

 Disease management with Cost Data from

External Partners (i.e. Humana, Anthem, United)

 Measurement of Clinical, Operational and

Financial Key Performance Indicators in Combined Dashboard

 Norton Healthcare Center for

Wellness and Prevention

 Practice Health Navigators  Telemedicine (Rural)  UK Partnership for Outreach

for a Healthier Commonwealth

 Supply Chain Maximization  Women and Children’s Agenda

Community Health Needs Assessment

• Patient Protection and Affordability Care Act
• Applies to all 501 3C Organizations
• Every three years
• Documented action plans

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Clinical Re‐Engineering…the Nursing Perspective

• Improved care coordination and communication
• Improved access – physician extenders – email – phone call etc.
• Prevention and early diagnosis
• ED and Immediate Care Center visits
• Increase generic medication utilization
• Hospital re-admissions and multiple ED visits
• Improved management of complex patients

– Care Coordination and High Resource Utilizers

Institute of Medicine Report

Six Aims for Improvement

• Safe

Safe

• Effective
• Patient Centered
• Timely
• Efficient
• Equitable

Crossing the Quality Chasm: A New Health System for the 21st Century; National Academy Press, 1999

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IOM Report

Ten Rules for Redesign:

1. Care is based in continuous healing relationships. 2 C i i d 2. Care is customized according to patient needs and values. 3. The patient is the source of control. 4. Knowledge is shared and information flows freely. 5. Decision making is evidence‐ based. 6. Safety is a system property. 7. Transparency is necessary. 8. Needs are anticipated. 9. Waste is continuously decreased.

• 10. Cooperation among

clinicians is a priority.

Crossing the Quality Chasm: A New Health System for the 21st Century; National Academy Press, 1999

IOM report, Future of Nursing Key Messages

– Nurses should practice to the full extent of their education and training. – Nurses should achieve higher levels of education and training through an improved education system that promotes seamless academic progression. – Nurses should be full partners, with physicians and other health professionals, in redesigning health care in the US. – Effective workforce planning and policy making require Effective workforce planning and policy making require better data collection and an improved information infrastructure.

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IOM report, Future of Nursing Recommendations

 Remove scope of practice barriers.  Expand opportunities for nurses to lead and diffuse collaborative improvement efforts.  Implement nurse residency programs.  Increase the proportion of nurses with a baccalaureate degree to 80% by 2020.  Double the nurses with a doctorate by 2020.  Ensure that nurses engage in lifelong learning.  Prepare and enable nurses to lead change to advance health.  Build an infrastructure for the collection and analysis of interpersonal health care workforce data.

• What are the framing questions we

need to ask...and answer?

So How Do We Begin….

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• What is Nursing’s

role? Framing Questions

• If Nursing doesn’t

manage Nursing, someone else will…

• What are we willing to

change?

Framing Questions

• How can nursing drive

care across continuum?

• How can nursing create

patient centered focus?

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• Are we willing to

“diminish” inpatient hospital care? Framing Questions hospital care?

• If Nursing stays defined

within the four walls of acute care, what is its acute care, what is its future?

• How will we

evaluate and VALUE Nursing’s Framing Questions Nursing’s contribution?

• What are the

metrics to metrics to determine success and establish ROI?

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• Is this strictly a “MD”

thing? A Hospital thing? Framing Questions

• What is Nursing’s role

to be in this new reform culture?

• How do we shift the

roles within the kf ? Framing Questions workforce?

• What are the

implications and models for care delivery? for care delivery?

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• And finally…
• What are the

Framing Questions implications for Nursing professionals?

• What are the

implications for Nurse Executives? Executives?

Call to Action

IOM

Nursing Strategic Plan

Pt Protection & Affordability Act Health care Reform

ACO

Transparency

Value Proposition

Workforce Needs

Meaningful Use

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Change Process vs. Grief Process Evolution vs. Revolution

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Integrated Delivery Network of Five Not‐for‐Profit Hospitals 15 Out‐patient Centers

Norton Healthcare

Norton Healthcare

1.6 Million yearly patient encounters $1.6 Billion yearly revenue 11,000 Employees 4800 Registered Nurses 600 Employed Providers 2,000 Physician Medical Staff 1,857 Licensed Beds 60 000 Admissions/year 60,000 Admissions/year 46% market share

Validated Key Findings

• Functioning within silos; not working as a system
• Everything is a priority

N d d f

• No standard of care across system.
• Limited resources were not effectively used
• Lack of education, understanding
• Non‐hospital divisions view of value and reform as a

“clinical” issue

• Scattergun and “flavor of the month”
• System resources view of “ownership”
• System resources view of ownership
• No accountability structure
• No incentives to “succeed”
• Results not achieved and sustained

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Risk Analysis

RISK MITIGATION STRATEGY Erosion of the bottom line financials and/or a reduced market share that may realign the organization’s priorities No margin = no mission Align to mission, vision, values. Align to strategic plan in multiple areas. “Mission critical” to achieve

• priorities. No margin = no mission.

Mission critical to achieve

• bjectives.

Non achievement of significant results in a short time frame. Set the right stretch achievable goals. Support owners with system resources. Visibility of success to BOT, Execs, etc. Celebrate! Lack of alignment of incentives for key leadership Connect to variable compensation (short term). Connect to perform appraisals (LT).

• Sr. leaders presentations to BOT, etc.

The program costs are too high for long term sustainability. Use and retool existing resources.

Strategic Principles

• System Level Initiative
• Within all components of strategic plan
• Within all components of strategic plan
• Drive Focused Measurable Approach

– Quality

– Safety – Service – Process Outcomes Process Outcomes – Financial

• Engagement of the Entire System

– Key Distinction

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Internal Stakeholder Assessment

• BOT, Executive, Operations & System

Leadership, Service Line, MD leaders

• Patient/ Family/Community focus groups
• Identification of Need & Validate

– Issues, concerns, frustrations, suggestions – 1:1 interviews (informal conversation supplemented with interview guide) – Document review – Feedback of findings & validation of accuracy

Integration and Alignment

• Prioritize efforts by facility/division
• Integrate Quality, Safety, Process, Service and

Fi i l Financial

• Align work across Norton Healthcare

– Balancing system vs. “local” needs – Sharing information – Replicating process and practice – Aligned Incentives

• Executive compensation
• Managers’ evaluations
• Staff evaluations
• Reward & Recognition
• Physician goals

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• Engagement of the broad stakeholder base in all phases of

the project. S d b “ h i ” j d hi ( d

Internal marketing plan

• Structured to be “their” project and ownership (and

accountability) resides with the operations leaders.

• Opportunities for the “owners” to visibly share their

experiences, successes and difficulties are built into the process.

• All reinforce:

 the programs  the programs,  reinforce behavior,  support cultural change,  influences compensation (both variable and performance reviews) and  breed success.

Nursing 2020

Creating Care that is Accountable to Patients & Families

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• Model of Care – Acute Care

– Patient and Caring Focused

Nursing 2020

– Differentiated Practice Model – Credentialing and Privileging – Family Care Partners – LPN Acute Care – Multidisciplinary Team Performance Multidisciplinary Team Performance – Individual Accountability

• Model of Care – Acute Care

– RN placement and transitions of patient based on care needs – Patient Cohort alignment based upon Nursing care needs

Nursing 2020

Patient Cohort alignment based upon Nursing care needs (clean/potentially contaminated; high flow/low flow; high RN intensity/low RN intensity) – Nursing centralization of expertise

• “EICU” (and use with regional “affiliates”)
• Remote Central Monitoring
• Central Order Management
• Placement and Transition
• Pt/Family education and support
• Continuum Management
• Nursing Hospitalist
• CNS/NP/Educator Model
• Acute Care and Critical Care NP model

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• Model of Care – Acute Care

– Program Development (chronic, elderly, specialty surgical high recidivism)

Nursing 2020

surgical, high recidivism) – Enhanced communication tools for patient/family – Enhanced Technology/Automation (equipment interface and auto population, remote monitoring, documentation – Nursing Sensitive Indicators

• Unit based dashboards
• Individual measurement of performance
• Model of Care – Continuum Management

– Multi specialty Nursing Practice at key locations matched with key physician partners and practices to leverage

Nursing 2020

with key physician partners and practices to leverage relationships – Neighborhood “watch” – Health ministries expansion and redefinition – Alignment with Schools for provision of care and education – Alignment with Community agencies for provision of care and education – RN in physician practices to manage D/C, transitions, pt education and pt follow up – Practice Navigator

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• Nursing Systems

– Credentialing and Privileging

Nursing 2020

– Clinical Advancement Programs (RN, LPN, PCA) – Certification – Nursing Sensitive Indicators – NDNQI – CERP and Prioritization – Patient/Family Advisory Councils – Clinical Design and Transformation – Nursing Finance and Modeling

• Nursing Systems

– Grants

• RWJ Kellogg IHI etc

Nursing 2020

RWJ, Kellogg, IHI, etc.

– Practice Governance

• System Governance Launch
• Non hospital governance launch
• Expansion of acute care governance (care providers)

– Nurse Leader Development

• Nurse Executive Initiative
• Nurse Executive Fellows
• Nurse Leadership Initiative

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• NHC Institute for Nursing

– Workforce Preparation

• Preparation of “continuum care practitioners”
• Specialty orientation extension programs (ED, OB, Children)

Nursing 2020

p y p g ( )

• PCA development/upgrade/transition
• Defined education/orientation units
• “Personal/cultural “nursing orientation

– School of Nursing Affiliations

• Joint Appointments
• LPN Acute Care Models
• CNS certification program
• “Faculty practice” model
• “Faculty practice” model
• “Shared class” faculty

– Simulation

• Mobile/Fixed
• Development of Affiliation Relationships (SON, Rural Network)
• Development of Learning Laboratory

Workforce

• RN credentialing and Privileging
• BSN
• Role requirements
• Differentiated Practice
• Advanced Practice
• Doctoral preparation
• Roles beyond hospitals (i.e. Navigators,

“Neighbors”, etc.)

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Executive Nurse Leadership Intensive GED N‐CAP Credentialing/ Leadership Development Norton A d

NHC Workforce Development

Career Development School at Work Credentialing/ Privileging

Harnessing Our Learning Culture

Workforce Development Norton University

Continuing Education Academy Shadow Program p Program at Work College at Work Partnerships PCA Development Program Norton Scholars & Educational Assistance

Institute for Nursing

Extern Program

Lessons Learned

• Integration vs. Silo
• Pilot, adapt, adopt, system
• Local Constituencies vs. Standardization of

System

• Hardwiring
• Accountability structure

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Lessons Learned

• Be Revolutionary in thought and Evolutionary

i ti in action.

• No is not a “forever” answer.
• Negotiation is not a one time thing.
• Be a good mother and let the child grow up

and move on beyond you and move on beyond you. NHC 30 day select chronic readmission pattern 5/1/08 – 10/31/09

47106 40031 40068 47106 47172 40026 40031 40068

Hospital ICC Physician Office 4 7 1 0 6 4 0 0 3 1 4 0 0 6 8 4 4 7 1 2 4 4 7 1 0 6 4 7 1 7 2 4 0 0 2 6 4 0 0 1 0 4 0 0 3 1 4 0 0 6 8

Hos pital IC C P hys ic ian O ffic e

40217 40203 4 2 9 40211 40202 40241 40207 40219 40213 40291 40299 40023 40059 40223 40245 40014 40023 40067 40022 40068 4006 4 47124 47117 47122 47136 47119 47150 47129 47172 47130 40258 40216 40212 40210 40215 40214 40208 40204 40206 40205 40218 40228 40220 40222 40242 40243 40056 40245 40010 40014 40068

Physician Office 4 0 2 1 7 4 0 2 0 3 40209 4 0 2 1 1 4 0 2 0 2 4 0 2 4 1 4 0 2 0 7 4 0 2 1 9 4 0 2 1 3 4 0 2 9 9 4 0 0 2 3 4 0 0 5 9 4 0 2 2 3 4 0 2 4 5 4 0 0 1 4 4 0 0 2 3 4 0 0 6 7 4 0 0 2 2 4 0 0 6 4 7 1 2 2 4 7 1 3 6 4 7 1 1 9 4 7 1 5 0 4 7 1 2 9 4 7 1 3 0 4 0 2 5 8 4 0 2 1 6 4 0 2 1 2 4 0 2 1 0 4 0 2 1 5 4 0 2 1 4 4 0 2 0 8 4 0 2 0 4 4 0 2 0 6 4 0 2 0 5 4 0 2 1 8 4 0 2 2 8 4 0 2 2 0 4 0 2 2 2 4 0 2 4 2 4 0 2 4 3 4 0 0 5 6 4 0 2 4 5 4 0 0 1 4

40291 40177 40177 40071 40272 40118 40109 40165 40229 40047 40071

= 1 RN = 1 Patient 4 0 2 1 9 4 0 2 9 1 4 0 1 7 7 4 0 1 7 7 4 0 0 7 1 4 7 1 1 7 4 0 2 7 2 4 0 1 1 8 4 0 1 0 9 4 0 1 6 5 4 0 2 2 9 4 0 2 2 8 4 0 0 4 7 4 0 0 7 1

= 1 R N = 1 P atient

44

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Defying Gravity

Questions