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How Value-Based Purchasing is Changing Nursing

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   June 14, 2011

The advent of value-based purchasing has thrown everyone into a mad scramble. You can't stand in a group of nurse executives without hearing someone ask about how others are improving their patient satisfaction or sharing notes about HCAHPS scores. 

"Value-based purchasing is a game changer," says Lillee Gelinas, MSN, RN, FAAN, vice president and chief nursing officer at VHA Inc.

On a long-term scale, it has everyone wondering how on earth they will achieve so much—from improved patient experience to sustainable quality outcomes—in such a short time. As hospitals plan how to best operate in this new world, it's worthwhile taking the time to reevaluate who should be working on what.

Gelinas recently presided over a meeting of 100 VHA CNOs and says it was one of the most successful CNO meetings VHA has ever held because rather than focusing on a specific topic, such as value-based purchasing, the group focused on innovation and how to develop strategies that will help organizations achieve transformation.

One of the meeting's "A-ha!" moments came when speaker Tim Porter-O'Grady shared a conversation he had with a CEO. The CEO was talking about his passion for patient care and how he was working on improving it. Porter-O'Grady responded that CEOs should not be concerned with things with which they have no competency.

The importance of organizations ensuring proper role delineation struck a chord with the CNOs. Gelinas says it's important that people who are competent to do so are responsible for the right things. The c-suite should be responsible for the context of care, whereas direct caregivers must be responsible for the content of care. Confusion over these two things only results in inertia and everyone trying to do everything.

"The context of the organization is owned by the c-suite. You are responsible for the context of care, meaning the environment, the culture, the behavioral standards, the organizational values," says Gelinas. "The content of care is owned by the caregivers. When it comes to transforming care at the bedside, taking waste out of work, that's what caregivers have to do and that's the content of care."

Gelinas equates c-suite involvement in provision of care decisions as akin to a radiologist trying to do heart surgery. What is far more important is that leaders devote their energies to leadership, cultural transformation, ensuring the organization enforces standards of behavior and codes of conduct, and that the values of the organization are in alignment with its mission.

"The hammer has fallen," says Gelinas. "First we had the tsunami of value-based purchasing and the realization we have to have whole-scale transformation to be successful. After that comes awareness. Now, what is the work that has to be done and where do we start?"

In the old days, if a nursing unit noted its rate of ventilator-associated pneumonia (VAP) was above average, it would start a quality improvement project. The traditional process would involve convening a team, figuring out a strategy, and implementing some tests of the changes. As rates improved, the hospital would celebrate, figure out how to maintain the improvements, and then move on to the next quality improvement project.

"It used to be that we could focus on quality improvement and if we got to a point where we had a 3% reduction in VAP we would be so happy," says Gelinas. "Now with value-based purchasing that's not good enough. Now it's about whole-scale transformation, not incremental improvement, and this difference is what has everyone's attention. Where do we start when we know the game's changed?"

As hospitals scramble to improve HCAHPS and quality outcomes all areas of the hospital are involved. Determining who should be responsible for what is a good first step.

See Also:
Berwick Announces CMS Final Value-Based Purchasing Rules

10 Ways CMS's Value-Based Purchasing Proposal is Flawed

Rebecca Hendren is a senior managing editor at HCPro, Inc. in Danvers, MA. She edits and manages The Leaders' Lounge blog for nurse managers. Email her at

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