Most nurses focus on quality of care and not always on the cost of care. However, RNs have the ability to affect their facilitys bottom line. Nurses have tremendous power, says Rita Smith, RN, BSN, CNAA-BC, MPA, senior vice president of Patient Care Services at the Jersey City Medical Center, Jersey City. When you influence patient outcomes in the hospital, you automatically have financial input.
Jersey City Medical Center educates all of its 550 nurses about the relationship between care and cost and empowers nurses to act to keep expenses down and quality up. Jasmine Lopez, RN, BSN, a Performance Improvement nurse, says that RNs directly affect costs, but initially it can be a difficult concept for bedside nurses.
Once nurses understand it, they get caught up in it, and they are the ones to push the physicians and everyone else, Smith adds.
Every little thing we do affects cost, says Mabel LaForgia, RN,
MSN, clinical nurse leader in Critical Care. The hospital closely monitors costs, comparing one pay period to another.
An ounce of prevention
One of LaForgias jobs is to focus on prevention. She makes sure the heads of beds are elevated 30 degrees for all patients who are on ventilators. LaForgia checks to see that nurses interrupt sedation once a day and works with respiratory therapy to wean patients who are ventilator-dependent. She also monitors central lines and questions whether the patient still needs one.
Prevention is the key, LaForgia says. Interdisciplinary rounding is the core of what we do. Everybody gets together as a team, and we discuss components of care and make sure everything is in place.
Staff is seeing the benefits of their efforts at the University Hospital. During the past 1.5 years, the unit has had no catheter-associated bloodstream infections, which LaForgia estimates costs between $10,000 and $30,000 per case, and in the last 10 months, no ventilator-associated pneumonia, which she says can run between $7,000 and $15,000.
Hospitals currently receive an incremental increase in reimbursement from Medicare for these secondary conditions, but starting in October, Medicare will stop reimbursing for some hospital-acquired conditions like falls and pressure ulcers. If you are tying up the bed for 27 days when you should have had a patient out in three-and-a-half days, you have given up six, seven, eight admissions, at an average reimbursement of $8,000 or $9,000 for a medical patient. You have lost quite a bit of money, Smith says.
Lopez is working on a falls prevention project and on decreasing readmissions with patients who have congestive heart failure (CHF). The CHF program focuses on self-management education at the bedside upon discharge and in the outpatient resident clinic.
In 2006, Jersey City Medical Center established rapid response teams. Nurses call on the team whenever a patient does not look right, if vital signs are heading in a dangerous direction, if the patient has significant bleeding, or if the nurse has another concern. This effort has decreased the number of codes and transfers to the ICU, and as a result, dropped the length of stay and more expensive critical care.
Many times, patients receive the interventions they need and do not have to come to our unit, LaForgia says. There is a higher mortality rate with codes, and usually patients post-code have longer lengths of stay in the ICU.
Examine length of stay
Even basic length-of-stay issues affect finances. Its getting case management on board to the way we provide care at the bedside, so we are always thinking about the best outcome in the shortest length of time and with the fewest resources, Smith says.
Clinical nurse leaders help to manage flow and aid staff nurses in adopting evidence-based practices. One of my responsibilities is to reduce cost while still maintaining a high quality of patient care and improving patient safety, says Franca DeBrita, RN, MSN, CEN, clinical nurse leader in the ED.
DeBrita looks at every admission and assesses whether it is appropriate or if other resources could prevent an unnecessary stay. Those other resources might include Social Services working to find follow-up care or resolving insurance issues, or clinical staff ensuring that antibiotics are promptly initiated. A patient with a possible myocardial infarction may stay in an observation bed instead of being admitted, and she teaches nurses and physicians to consider whether all tests are necessary.
DeBrita says that her education gave her the knowledge and confidence to question diagnosis and treatment plans. She thinks she is making inroads but admits that the true measure of success will be whether nurses and physicians will do the right thing when she is not watching.
Retaining nurses also saves Jersey City Medical Center money. Smith estimates that turnover of just one RN costs the facility at least $80,000. Thats a huge hit on a hospital, Smith says. The hospitals turnover rate has remained at less than 3% during the past three years. Smith credits the shared governance model, mentorship and preceptorship programs, a strong clinical ladder, and tuition reimbursement
benefits as reasons that nurses are staying at Jersey City. Nurses have
a say over their individual practice, Smith says. All of those things affect retention, and that is the name of the game.
Smith encourages more nurses to develop an interest in finances and to take advantage of the clout that knowledge gives them. At Jersey City Medical Center, finance executives listen when Smith talks. She says, When I meet with the executive team and discuss finances with those who are involved in the process, I explain what I am talking about and I prove it with data, facts, and a calculator.