This slide share is a brief overview of Nursing Pay for Performance, Ethical Issues and Opportunities to consider in the current landscape of healthcare in US

1. Nursing Pay for Performance:
Ethical Challenges and Opportunities
Kate ONeill, DNP (c), RN
CNO and VP of Quality and Safety
iCareQuality, Inc.
10.25.15

2. www.iCareQuality.org
Objectives for this Presentation
1
Understand P4P Models and
How it Applies to Healthcare &
Nursing
2
Analyze Legal and Ethical
Issues Related to P4P &
Nursing
3
5 Call to Action/ Summary
Review Current Challenges &
Opportunities in P4
4
Explore Solutions for
Resolutions, including
Peer Review Option
1

3. www.iCareQuality.org
• 63 yo Certified Nurse Educator works on
Oncology Unit for 35 years, received
numerous practice awards.
• Her hospital is Magnet and unit reported
NDNQI data for 2014: Hospital Acquired
Pressure Ulcers = 9.2, and CLABSI =
2.54.
• In APN meeting, Ann stated to openly:
Description of True Clinical Dilemma
2
DO YOU THINK:
 Ann is a leader on her unit?
 Ann is a patient advocate?
 Ann is a safe practitioner?
Nurse Ann’s Story
“ Kate, I haven’t looked at a
nursing policy or procedure
in 25 years, I’m too busy,
and I don’t have time”

4. www.iCareQuality.org
Overview of Pay-for-Performance (P4P)
• Payment incentives to improve care
quality, efficiency, and VALUE
• Hospitals and MD’s are paid when
they achieve QI targets.(James, J 2012)
• Payments linked to individual, group
or hospital’s performance (Donaldson, 2006)
• P4P needs to identify 2 key things:
1. “WHAT” of quality nursing care
2. “HOW” of paying for quality
(Unruh, 2007)
3
ANSWER: Nsg P4P
ANSWER : NDQI

5. www.iCareQuality.org
1. Over 400k deaths from Adverse
Events per year (James, JT 2013).
2. US spends 2x more on healthcare,
than other nations, ranks last for
population health (Squire 2015)
3. ACA 2010 tied quality to payment
reform with VBP. Report outcomes
data for more effective and efficient
care. (CMS, 2015)
4. MD’s & hospitals participate in CMS
incentive pay P4P for reaching target
measures.
4
Background: Why Should Nurses Care about P4P?
DEATH
DOLLARS
DATA
DOCTORS

6. www.iCareQuality.org
Health and
Well Being
Prevention
and
Treatment
Person
Centered
Care
Care
Coordination
Patient
Safety
Affordable
Care
Better Care
Affordable Care
Health
People/Communities
National Quality Infrastructure (AHRQ, 2015)
Infrastructure Supports
Payment
(VBP)
Patient
Safety
Organizations
Quality
Improvement
Organizations
Certification
Regulation
Consumer
Incentives
Measurement of
Process and
Outcomes
(NDNQI, etc.)
Health
Information
Technology
Public
Reporting,
Workforce
Development
Rapid Cycle
Learning &
Innovation
Significance to Nsg & P4P is National Quality Strategy
5

7. www.iCareQuality.org
Ann breached ANA professional
standards of Code of Ethics in care
delivery due to lack of:
- Provision 3.3: Ann had a
commitment to practice with
competence using EBP.
- Provision 3.4: Ann had the
responsibility to promote health
and patient safety, and reduce
preventable harm.
- Provision 4.2: Ann had duty to
be accountable for her practice
and responsible for care
delivery in an ethical manner.
(ANA, 2015)
Ann’s lacks current knowledge EBP
and hospital P&P. Ethical issues are:
1. Non-Maleficence - Ann had the
duty to avoid causation of harm,
and by not keeping current with
EBP she contributed to high rates
of infection on her unit as seen in
her NDNQI scores.
2. Fidelity – Ann had “promise
keeping” to her patients when she
assumed care. She breached her
promise to uphold her patient
commitment for providing care in
the patient’s best interest.
(Guido, 2014)
6
Back to Ann’s Story in Clinical Practice:
Potential Nursing Ethical and Legal Ramifications
ETHICAL ISSUES LEGAL ISSUES

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STEP 1: REALM (R)
STEP 2 : Individual,
Organization and/or Societal
•Individual/ Ann – did not
focus on good of the patient
care, and rights, duties and
for RN-Patient relationship.
•Organization – should be
concerned with systems
that will facilitate enterprise
goals, improved patient
outcomes & NDNQI, instead
of supporting culture of “old
boys club”, hidden agendas
and little practice
accountability
•Societal - concerned with
population health, reducing
harm, policy, P4P and
quality measures, HAC
scores , for ALL providers,
RN & MD’s.
INDIVIDUAL PROCESS (I,P)
Moral Judgement,
Motivation and Courage
•Moral Judgement – Ann
lacked ability to decide right
versus wrong actions, and not
reviewing hospital policy for
EBP, or modeling this
behavior for new hires.
•Moral Motivation - Ann did
not place a priority on ethical
values over her own self-
interest, & status. Ann lacked
“Professionalism” which
should be primary “motivator”
for ethical behavior.
•Moral Courage – Ann lacked
Moral Courage to do “Right”
thing and didn’t demonstrate
that EBP is the safest practice
with best patient outcomes.
SITUATION (S)
Issue/Problem and Silence
•Issue/ Problem: Ann’s lack of
professional practice and EBP
would have been evident with
P4P practice models .
•Issue / Problem: P4P is NOT
linked to nursing practice.
Federal legislation is behind in
bringing nursing practice into full
partnership with other
healthcare providers.
•Silence of Staff –
characterized by no one
speaking out and explaining that
Ann’s behavior was wrong for
not using EBP in practice.
STEP 3: Further AnalysisSTEP 3: Further Analysis
RIPS Ethical Decision Framework & P4P
STEP 3: Further Analysis

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Ethics: P4P and
Conflicts of Interest
Provision #2
• Pay incentive could alter
traditional nursing values
• Pay incentives could alter
clinical judgement
• Could drive economic self
gain & self interest
• P4P could be negative practice
driver
Ethics: P4P and
Competency
Provisions # 4 & 5
• Performance is part of ACA
• Can be measured by Real-time
Nsg Peer Review/Surveillance
• Align staff pay with quality,
NDNQI data, EBP, and CDS use.
• Supports Life Long Learning
• Adds value in nursing via
accountability & transparency
VERSES

10. www.iCareQuality.org 9
Options for Resolution for P4P
OPTIONS Nurse Ann
Individual or Unit Level
Resolution
Hospital
Organization Level Resolution
OPTION 1
Root Cause
Analysis
Ann thinks she is just too busy and
Leadership just doesn’t “get it”
Complete RCA to evaluate gaps in
Ann practice and patient outcomes.
OPTION 2
Do Nothing
Culture. Biz
as usual.
Ann assumes she is right we have
always practiced this way.
Hospital has a negative culture
leads to hidden culture non-
disclosing clinical issues, and
possible adverse events.
OPTION 3
Call Ann into
office
Nurse Manager calls Ann into the
office and has Courageous
Conversation and Ann gets a
Written Warning
Hospital Leaders review incident
reports and file them away in nursing
yearly evaluation and not part of a
learning culture.
OPTION 4
Peer to Peer
Real-time
Ann is accountable to her practice
using real-time Peer to Peer (P2P)
Surveillance to measure her
performance to EBP guidelines.
Hospital leaders have daily unit
dashboards on competency and
offer nursing financial rewards for
improved patient outcomes.

11. www.iCareQuality.org
Peer Review
Option Selected for
Resolution & Why
P4P Resolution for Ann
Weekly Peer to Peer (P2P) Reviews of
Ann’s clinical practice, with real time clinical
observations of performance on her unit
Ann values shared non-punitive life long
learning
Ann understands EBP, Ethics, Practice,
Quality, are tied together like a
“performance care bundle”.
Ann values her improved competency
scores and outcomes. She is rewarded
with pay incentives if she can hit target of
95% on performance scores
P4P Resolution for Nsg Profession
Build real-time Peer model that would
support frontline nursing performance
Build a Learning Organization Culture
AND Nursing Profession
Financially reward best practice. Build
accountability and transparency in
nursing practice.
Improve patient outcomes data, NDNQI
and staff could obtain financial
incentives at the individual, unit and
organization level.
10

12. www.iCareQuality.org 11
Professional
Standards &
Ethic Decision
Making
Peer to Peer Clinical
Competence
Performance
Evidence
Based
Practice
Quality and
Value to
Healthcare
Nursing Pay for
Performance
Resolution Implementation and Evaluation
DATA

13. www.iCareQuality.org
Building Value in
Nursing via P4P
CultureofQuality
CultureofAccountability
andTransparency
CultureofPatient
Safety
CultureofNursing
Competency
SafetyPracticePerformance Ethics
Nursing Pay for Performance 4 Pillars to Transform Care
Pay for Performance & Future Considerations
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14. www.iCareQuality.org 13
Getting Ethics Right in P4P in Healthcare
Beneficence and Providers in P4P –
for Providers all over US to do “GOOD”
for patients and want to provide the
best care.
Beneficence and Hospitals in P4P –
for hospitals to do “GOOD” for
population health and have better
healthier communities, and support
Healthy People 2020 Goal.

15. www.iCareQuality.org 14
Summary and
Future Nursing
P4P Considerations
For P4P to become reality, Unruh
2007 recommends:
1. Maximize nursing knowledge, skills
& scope of practice
2. Healthcare policies should support
safe staffing ratios
3. Federal policies should support
advanced nursing education
4. Have right provider incentives to
make lasting quality improvements
5. Engage nursing leaders to
advocate for this change.

16. www.iCareQuality.org
AHRQ. (2015). Report to Congress: National Strategy for Quality Improvement in Health
Care. Retrieved from http://www.ahrq.gov/workingforquality/
American Nurses Association (ANA). (2015). Code of ethics for nurses: With interpretive
statements. Retrieved from
http://nursingworld.org/DocumentVault/Ethics_1/Code-of- Ethics-for-
Nurses.html
Centers for Medicare and Medicaid. (2015). Better Care, Smarter Spending, Healthier
People: Improving Our Health Care Delivery System. Department of Health and
Human Services.
Donaldson, B. (2006). Pay-For-Performance American Nurses Association Policy
Legislation introduced to House of Delegates.
Guido, G. W. (2014). Legal and ethical issues in nursing. (6th ed). Upper Saddle River, NJ:
Prentice Hall
Health and Human Services. (2015). Healthy People 2020. Retrieved from
http://www.healthypeople.gov/sites/default/files/HP2020Framework.pdf
James, J. (2012). Health Policy Brief: Pay-for-Performance. Health Affairs, October 11, 2
2012..
References

17. www.iCareQuality.org
James, JT. (2013). A new, evidence-based estimate of patient harms associated with
hospital care. Journal of Patient Safety, 9(3):122-8. doi:
10.1097/PTS.0b013e3182948a69.
Kennedy, R., Murphy, J. Roberts, D., (September 30, 2013) "An Overview of the National
Quality Strategy: Where Do Nurses Fit?" OJIN: The Online Journal of Issues in
Nursing. Vol. 18, No. 3, Manuscript 5.
Pierce, A. & Smith, J. (2013). Ethical and Legal Issues for Doctoral Nursing Students.
Lancaster, PA: DEStetch Publishing.
Squires, D. & Anderson. C. (2015) U.S. Health Care from a Global Perspective: Spending,
Use of Services, Prices, and Health in 13 Countries. Issues in International
Health Policy. The Common Wealth Fund
Swisher, L., Arslanian,L., & Davis, C. (2005). The Realm-Individual Process-Situation
(RIPS) Model of Ethical Decision Making. Health Policy & Administration,
Vol. 5 No. 3, October.
Unruh, L., & Hassmiller, S.( 2007). Legislative: Economics of Nursing Addressing Quality
and Payment in Nursing Care. Online Journal of Issues in Nursing.
References

18. www.iCareQuality.org
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Kate ONeill, DNP (c), RN
CNO and VP of Quality Patient Safety
iCareQuality, Inc.
Kate.oneill@icarequality.org
c.610.505.0996
www.icarequality.org