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Rightsizing and Reengineering Ourselves

05/09/2014 | 5 Comments

Rightsizing and Reengineering Ourselves

As it stands right now, we, as an overall healthcare industry, have reached a milestone, wherein the cost of care is too great for any one person to bear, which is a very bad situation for our industry. Since their inceptions in 1966, our biggest payers (Medicare, Medicaid, and other government programs), have re-engineered themselves many times. The latest payment reform was initiated in 2005, as a result of the Deficit Reduction Act (DRA), and essentially introduced a pay-for- performance (P4P) approach. That was later refined, in what we know today as “value-based purchasing” (VPB). Providing the service itself is simply no longer sufficient, and now payers are looking for the “value-added” that is expected with the service. In the last iteration of this program, hospitals’ performances will be based on clinical process measures; patient experience; outcomes mortality measures; patient safety indicators; health care-associated infections; and efficiency measures, such as “Medicare spending per beneficiary”, or  “MSPB” (CMS, 2013). We have now fully entered a new paradigm: no outcome, no income.

So here we are, in an environment that holds all of us accountable for outcomes, and yet for the most part, we have the same infrastructure in our acute care hospitals that we’ve had for decades. I still see us deploying resources, somewhat in the fashion as a few decades ago, such as nurses working 12-hour shifts . I also see us deploying resources, primarily Monday through Friday, and yet we say we are a 24/7 operation. Every day counts (actually I say that every hour counts). More than ever, deploying resources in way that will benefit our patients serves us better as an industry. Just think about length-of-stay, for example. If we do not offer certain radiology procedures or services on weekends, and our patients need those services before they can be transitioned to another level of care, we create barriers that will be detrimental to both our patients and ourselves.

I realize that rightsizing and re-engineering ourselves is a very complex issue. Make no mistake— the status quo is not a viable option, either. It will never be like it was before. Embrace, and look forward to, the future. We, as leaders, must be innovative and find ways to engage everyone in this journey. I have been taking the lead on educating many about what’s happening in health care. I often challenge myself, and others, on what the future will be, so that we can implement processes that will survive tomorrow. I challenge all of us to think about our health care industry, and to refocus our efforts on the service itself: caring for others and staging the best possible experience for them.

Department of Health and Human Services. Center for Medicare & Medicaid Services (2013).  Hospital Inpatient Prospective Payment Systems for Acute Care Hospitals and the Long Term Care; Hospital Prospective Payment System and Fiscal Year 2014 Rates; Quality Reporting Requirements for Specific Providers; Hospital Conditions of Participation; Payment Policies Related to Patient Status; Final Rule. Accessed on May 8, 2014, via:

Source: Sylvain "Syl" Trepanier, DNP, RN, CENP, past vice president & system chief nursing officer
Content Updated: 5/9/2014 10:06:25 AM
5 comments about this post
Pam 5/9/2014 1:42:02 PM

What an exciting journey we are challenged with. Having to live on the other side of the bed rails gives one an appreciation for the need to add value into the care equation, and not just inpatient care.

Pidge Gooch 5/10/2014 8:21:26 AM

One of the most frustrating aspects is that hospitals are the responsible parties for what is essentially an independent practitioner's treatment plan. I agree a shift is in order - but I also look to the payers to look at physician billing practices. How many of those radiology or GI exams could be done as outpatient post discharge? Is it physician convenience? Ability to bill for an additional hospital round or encounter? Hospitals (and therefore - by default - nurses) should not be held as the responsible party for over utilization patient management by physicians - especially in jurisdictions unable to employ physicians. Hospitalist programs help this - but true reform won't happen until physicians are reimbursed by P4P or VBP standards.

Dr. Syl 5/10/2014 10:29:46 AM

Pidge, Thank you for your comment. I appreciate your perspective. You are correct that we need a complete alignment with our physician colleagues. At the current time, many do not see the importance of aligning themselves with hospitals efforts and this could be partially related to their own reimbursement model. Furthermore, unless everyone and I mean everyone, embraces a “patient centered care” as opposed to a “provider centered care” we will not be successful in a P4P, VBP environment. I recently had the pleasure to listen to a great speaker from The Advisory Board who reminded that audience that the most important competitive advantage any healthcare system can have is to be organized around the needs of our customers. As I look at how we plan our day in the acute care environment, how we schedule surgery / procedures for example, it is NOT organized around the needs of our customers (for many of us). Great point on your part and thank you challenging us.

Terry Fry 5/12/2014 3:18:23 PM

This is such a complex system that we are dealing with. I agree with Pidge about aligning the physicians within the infrastucture healthcare is in. I think nursing still has a way to go to understand the difference in healthcare today and healthcare 10 years ago. Challenges lead to opportunities to make things better for our patients. We need to keep thinking outside the box!!

Eve 8/17/2014 6:05:58 AM

I was struck by the honetsy of your posting

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