A patient is worried. She has an incision that is going to need a bandage for the next week or so, and she is not going to be able to get to the store to buy supplies. To tide her over, the nurse puts three boxes of 4-inch-by-4-inch gauze and rolls of tape in a bag for her. Just think of it as a get well present, she says.
This scene played out for years in hundreds of hospitals. But during the past few years, hospitals have begun to teach staff that every Band-Aid affects the bottom line. As hospitals close their doors because of financial failure, those that remain have focused on educating nursing staff about the business of healthcare.
Kimberly Glassman, RN, PhD, NEA-BC, senior vice president of patient care services and CNO at NYU Langone Medical Center in Manhattan, says the shift began more than 20 years ago. In the mid-80s when Diagnosis Related Groups were established, hospitals moved from a per-diem payment system to a payment based on a limited number of days. This meant hospital reimbursement was based on the national average cost of caring for a patient admitted with a particular diagnosis, adjusted for regional differences, instead of a daily rate.
About the same time, Glassman says, care pathways began to be developed to reflect best practices. She says that nurses always have looked toward navigating the best path through hospital services for patients. Conservation of resources is a natural byproduct of this type of planning.
Too Much of a Good Thing
Too much care is not always good quality care. Its important to have the right care at the right time in the right amount, Glassman says. The highest quality patient care continues to be the primary goal, but reaching that goal within the financial constraints of todays economy is one of the challenges for nurses.
For many staff nurses, this approach is familiar. Glassman says baccalaureate programs often include classes on healthcare business management, and more than 92% of the nursing staff at NYU Langone has BSNs. The hospital culture reinforces what the new graduate has been taught: high quality care doesnt have to break the bank.
Glassman says the nursing staff at the medical center are involved in selecting products and supplies. They look at the best value, and one of the parameters considered is the cost. By selectively looking at processes, waste can be removed from the system, making care more efficient and effective.
Karen Beltran, RN, MSN, CCTN, a staff nurse on the surgical unit at NYU Langone Medical Center, sees this philosophy in action every day. She says cost-savings and conservation starts from the ground up. Procedure manuals include prices so everyone knows the cost of the supplies used. Nurses are not likely to take more than they need for any particular procedure because they are mindful of the cost of waste, Beltran says.
The Prevention Bonus
Beltran points out one of the biggest cost savings also is a bonus for patients. Preventing problems such as infections makes the patient safer and saves dollars. She works on a surgical unit, where patient education and discharge teaching, including hand hygiene and basic infection prevention, begins on admission. This teaching is built into the clinical pathway that guides the patients care.
Readmission to the hospital is a huge cost to the patient and to the hospital, Beltran says. We educate the patient and family about possible complications. Knowing what to look for and what to report to their doctor can help prevent re-hospitalization.
Patients receive a follow-up phone call 24 hours after discharge to reinforce the teaching and to see how the patient is managing. Community services are arranged as needed to provide care and further teaching.
Challenges at HomeMJHS Home Care staff members Mary Wagner, RN, vice president of clinical practice, sitting, and Jocelyne Francois, RN, a wound ostomy continence nurse, focus on cost-savings to improve patient care.
Home care agencies have similar challenges. Medicare calculates home care reimbursement using a complicated algorithm based on the patients diagnoses, his or her level of independence and various co-morbidities. Agencies able to offer the most effective care in the fewest number of visits are financially rewarded. Mary Wagner, RN, BS, MEd, vice president of clinical practice at MJHS Home Care in New York City, regularly discusses the business end of healthcare with staff. The agency is required to give the patient supplies during the episode of care; the astute field nurse will provide the patient with what he or she needs in a cost-effective way.
I think in home care we have always been attuned to reimbursement issues, Wagner says. When the agency revamped their formulary with their supplies provider, they chose products found to be most effective within cost parameters. The focus is on consistency of practice, and best practices geared toward optimum outcomes.
Jocelyne Francois, RN, BS, a wound ostomy continence nurse at MJHS Home Care, says sometimes the cost is worth it. She says some dressings containing silver compounds are expensive, but when appropriately used the wound heals faster a much better outcome. Teaching the caregiver the proper technique and adjusting the teaching plan as needed decreases the time to reach autonomy.
Wagner says using standards of practice and guidelines that focus the nurses assessment on helping the patient reach the desired outcome-independence is, ultimately, the best cost-saving measure. A gentle push or pull, and ultimately walking hand-in-hand with the patient toward self-management is the desired destination.