Aleo, Giuseppe

Bagnasco, Annamaria

Catania, Gianluca

Dasso, Nicoletta

Sasso, Loredana

Watson, Roger

Zanini, Milko P

BMJ Quality & Safety

English

SASSO, LOREDANA

BAGNASCO, ANNAMARIA

ALEO, GIUSEPPE

CATANIA, GIANLUCA

DASSO, NICOLETTA

ZANINI MILKO

WATSON, ROGER

Archivio istituzionale della ricerca - Università di Genova

Incorporating nursing complexity in reimbursement coding systems: the potential impact on missed care

Repository@Hull - Worktribe

Sasso L, et al. BMJ Qual Saf 2017;26:929–932. doi:10.1136/bmjqs-2017-006622   929IntroductIon Globally, nurses constitute the largest segment of healthcare professionals; therefore, they are also the most expen-sive, and in a hospital these costs can reach 25% of the total expenditure.1 When costs are calculated, usually the monthly sum of nursing working hours and nursing labour costs is divided by the total number of patient days to produce mean general measures such as ‘nursing hours per patient’ or ‘nursing costs per patient day.’ This is only a general average cost calculation that takes into account large groups of nurses caring for large groups of patients, but through this system it is difficult to accurately control costs if the specific costs are unknown.2 In this regard, Needleman3 pointed to the ‘invis-ibility’ of a significant portion of nursing today, which explains why this discipline in many countries around the world is still not fully recognised by administra-tors, policymakers and the public. Invis-ible work includes monitoring patients, educating patients and families, preparing discharge plans, providing psychological support to patients who are seriously ill and their family members, and advocating for their patients.In the last few decades, the decreasing lengths of hospital stay of increasingly acute inpatients have been putting strong pressure in terms of time and intensity of care on nurses and this is inevitably leading to missed care.4 5 Missed care is an error of omission, defined as ‘any aspect of required care that is omitted either in part or in whole, or delayed.’6 In 2009, Kalisch and Williams also developed and validated a tool to measure missed care.6 Therefore, missed care is linked to the concept of ‘Complexity Compression,’7 which has been described as ‘what nurses experience when expected to assume additional, unplanned responsibilities while simultaneously conducting their multiple responsibilities in a condensed time frame.’8 This leads nurses to select which activities to leave undone and adopt workarounds9 leading to missed care. The theory of missed care is based on three antecedents: labour resources, material resources and communication, which have an impact on the way nursing care is provided.6 Due to financial restraints, workarounds are often accepted by local health administrators,10 and since missed care is an error of omission, it is easier to be ignored than an error of commis-sion.6 And yet, as reported by Kalisch and Williams, ‘acts of omission with poten-tially serious and widespread impact on patient outcomes’ definitely outnumber acts of commission.6Therefore, we consider missed care a call to incorporate intensity of nursing care into the Diagnosis Related Groups (DRG) systems, ensuring in this way that hospitals have fresh resources for nursing to address the antecedents of missed care and, consequently, improve patient outcomes. This paradigm shift also implies that nurse administrators make appropriate decisions to imple-ment nursing care models according to evidence-based staffing levels. Thus, also an evidence-based management approach is required to ensure that resources are effectively used.the complexIty of nursIngDrawing from the definition of ‘complex intervention’ originally provided by the UK Medical Research Council in 2008,11 a clear description of the complexity of nursing was provided by Richards and Borglin,5 “Nursing’s complexity is such Viewpoint1Department of Health Sciences, University of Genoa, Italy2University of Hull, Hull, Kingston upon Hull, UKCorrespondence toProf Loredana Sasso, Department of Health Sciences, University of Genoa, 16132 Genoa, Italy;  l. sasso@ unige. itReceived 21 February 2017Revised 12 July 2017Accepted 16 July 2017Published Online First 29 September 2017To cite: Sasso L, Bagnasco A, Aleo G, et al. BMJ Qual Saf 2017;26:929–932.Incorporating nursing complexity in reimbursement coding systems: the potential impact on missed careLoredana Sasso,1 Annamaria Bagnasco,1 Giuseppe Aleo,1 Gianluca Catania,1 nicoletta Dasso,1 Milko p Zanini,1 Roger watson2group.bmj.com on November 12, 2017 - Published by http://qualitysafety.bmj.com/Downloaded from 930 Sasso L, et al. BMJ Qual Saf 2017;26:929–932. doi:10.1136/bmjqs-2017-006622Viewpointthat it can be seen as the quintessential ‘complex inter-vention—defined as an activity that contains a number of component parts with the potential for interactions between them which, when applied to the intended target population, produces a range of possible and variable outcomes’”5 (p 351). Therefore, every time a nurse interacts with a patient to provide care or with another nurse to teach them, the nurse performs a complex intervention,4 inside a complex system, such as the healthcare system.Nevertheless, very often ‘…the work of nurses is not well understood. The most visible work of nurses is task oriented: delivering ordered care, taking vital signs, helping patients eat, ambulate, toilet and so forth’3 (p 3). In fact, healthcare administrators, funders and policymakers, unaware of the complexity of nurses’ work, frequently only see the nurses’ visible bedside tasks. They do not see all the ‘invisible’ work they do based on monitoring symptoms and assessing their patients to determine, for instance, if patients are at risk of developing complications, at risk of falls, and providing self-care education to patients before they are discharged.3ImplIcatIons of mIssed careThe lack of resources caused by global health cost crisis2 combined with complexity compression7 8 and lack of full understanding by hospital administrators of the complexity of nursing5 11 can lead to high levels of missed care,12 and also generate phenomena such as workarounds.9 10 Missed care, if left unaddressed by health policymakers, could have important impli-cations in terms of negative patient outcomes, reduced levels of patient safety and quality of care.Missed care also has financial implications in terms of higher healthcare costs due to longer lengths of stay and repeated readmissions to manage complications and adverse outcomes, which, instead could have been avoided if nurses had fully provided all their care.13 Moreover, this generates other costs in terms of higher nurse staff turnover rates14 and higher social costs related to mortality and human suffering.3In addition, this situation generates a vicious cycle where healthcare policymakers, especially with the current global crisis, do not recognise the invisible work of nurses. Therefore, they reduce the resources for nursing and trigger a mechanism that widens the scope of missed care. This also creates the illusion of false financial savings, which is why hospital adminis-trators, under pressure to cut costs as much as possible, are sometimes tempted to replace registered nurses with other lower skilled and less educated personnel.15IntensIty of nursIng careDue to the complexity of nursing care,5 11 which involves a holistic assessment of the patients’ needs, the clinical diagnosis on which most health organisa-tions base their reports is only the ‘tip of an iceberg’ compared with the actual intensity of nursing care provided. To illustrate this point, we propose two scenarios with two different patients included in the same DRG category, admitted to a trauma unit.Patient 1Hip fracture in a 75-year-old woman needing hip replacement surgery. She weighs 65 kg, is cooperative and with no cognitive impairment.Patient 2Hip fracture in a 82-year-old woman needing hip replacement surgery. She weighs 115 kg, is affected by dementia and diabetes, and non-cooperative.On the basis of current DRG systems that do not incorporate nursing intensity weights (NIW), hospitals obtain the same level of reimbursement for these two cases. Instead, from a nursing perspective these two cases require a completely different intensity of nursing care, and where the second case presents a higher level of nursing intensity (table 1). One practical way to measure nursing intensity is to use a set of NIWs for each DRG and apply them at discharge to adjust routine care and intensive care per diem charges.16 For our scenario, we based our NIW on the North Amer-ican Nursing Diagnosis Association (NANDA) Nursing Interventions Classification.17The patient in scenario 1 requires a much lower intensity of nursing care than the one in scenario 2, who will need a higher intensity of nursing care than the standard on which a healthcare organisation would plan its resources. However, according to current DRG systems the hospital will obtain the same level of reimbursement for the two patients.Ideally speaking, if intensity of nursing care was included in the DRG system, these two scenarios would require nurses to assess and document the level of patient complexity upon admission, and then plan and provide care accordingly. This would also entail the availability of appropriate levels of reimbursement and therefore the staffing and resources needed to cover the higher intensity of nursing care.However, this would require nurse administrators to use up-to-date knowledge and make decisions to implement nursing care models according to evidence-based staffing levels. If it is true that nurses in clinical setting must justify what they do, and how and why they are doing it, then nurse administrators/managers must justify what skill mix, and what nurse staffing level they are ensuring to determine good nursing practice without missed care, thus an evidence-based management approach.18nursIng-sensItIve outcomes: a possIble strategy to track mIssed careIt is important to consider the process that correlates nursing interventions with the outcomes to highlight the interdependent relationship between processes and group.bmj.com on November 12, 2017 - Published by http://qualitysafety.bmj.com/Downloaded from 931Sasso L, et al. BMJ Qual Saf 2017;26:929–932. doi:10.1136/bmjqs-2017-006622Viewpointoutcomes. Moreover, outcome measurements should not be limited to bedside tasks of nursing, but also include social, psychological, relational and physiolog-ical aspects that describe the disease experienced by patients. Therefore, it is necessary to identify specific tools for each specialty area, which measure and keep track of the nursing activities and processes that have been delivered and then compare the outcomes. In this way, the measurement of nursing-sensitive patient outcomes would also enable to highlight any nega-tive consequences of nursing activities left undone. Although challenging to implement due to the ‘invis-ible’ nature of a large portion of nurses’ work, nurs-ing-sensitive outcomes enable the documentation of patient outcomes directly linked to nursing care and could be useful to demonstrate the nurses’ vital role in delivering high-quality care and in ensuring an effec-tive and safe healthcare system,19 a practice that at its first stage should be promoted and implemented routinely by each nursing manager on each site.conclusIonsSince nurses provide complex nursing interventions ‘24/7,’ they remain the greatest element of cost for healthcare systems. Nevertheless, international litera-ture has shown that when patient-to-nurse ratios are higher than 6 this determines high levels of missed care that increase the number of adverse events for patients.4 7 15 20 This generates higher clinical, organ-isational, administrative and legal costs for health centres and also higher social costs.From the perspective of nursing administrators and leaders, one possible solution to missed care could be offered by the measurement of nursing-sensitive outcomes,19 which would contribute to make ‘visible’ all nursing activities. This would also imply a major focus on evidence-based management18 also on behalf of health and nursing administrators, who could for instance use evidence to redesign inpatient nursing care models based on low, medium and high levels of patients’ nursing needs, code nursing complexity and establish NIWs.To support this change also from a financial perspec-tive, to ensure inpatient care reimbursement for nursing intensity, maybe it is time to link NIWs to the various DRGs.21 Over time, NIWs could be optimised and adjusted using data collected through the Nursing Intensity Database.21 As originally envisaged in 1979, DRGs never included intensity of nursing care in the final models,21 but if it is true that we are now in the era of evidence-based practice, evidence-based management and big data, time is ripe to recognise nursing care intensity across DRGs.Competing interests None declared.Provenance and peer review Not commissioned; externally peer reviewed.Open Access This is an Open Access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: http:// creativecommons. org/ licenses/ by- nc/ 4. 0/© Article author(s) (or their employer(s) unless otherwise stated in the text of the article) 2017. All rights reserved. No commercial use is permitted unless otherwise expressly granted.references 1 Welton JM. Hospital nursing workforce costs, wages, occupational mix, and resource utilization. J Nurs Adm 2011;41:309–14.Table 1 An example of how nursing intensity can vary within the same DRG coding systemDRGNursing intensity(based on the international Nursing Interventions Classification)Scenario 1 Patient 1 ► Hip fracture ► 75-year-old woman ► Hip replacement surgery ► Weight: 65 kg ► Collaborative ► No cognitive impairment ► Day 3, out of bedHip replacement surgery Potential complications:a. Risk for infection (operative hip, urinary tract, blood infection, pneumonia)b. Risk of thromboembolismc. Pressure ulcerd. Risk of fallsScenario 2 Patient 2 ► Hip fracture ► 82-year-old woman ► Hip replacement surgery ► Weight: 115 kg ► Dementia ► Diabetes ► Non-collaborative ► Day 3, still in bedHip replacement surgery 1. Potential complications:a. Immobilisation syndromeb. Risk for peripheral neurovascular dysfunctionc. Risk for infection (operative hip, urinary tract, blood infection, pneumonia)d. Risk of thromboembolisme. Fat embolism syndromef. Risk of falls2. Impaired physical mobility3. Nutrition issues4. Multidrug management5. Pain: hipgroup.bmj.com on November 12, 2017 - Published by http://qualitysafety.bmj.com/Downloaded from 932 Sasso L, et al. BMJ Qual Saf 2017;26:929–932. doi:10.1136/bmjqs-2017-006622Viewpoint 2 Kaplan RS, Porter ME. How to solve the cost crisis in health care. Harv Bus Rev 2011;89:46–52. 3 Needleman J. Nursing skill mix and patient outcomes. BMJ Qual Saf 2017;26:525–8. 4 Ausserhofer D, Zander B, Busse R, et al. Prevalence, patterns and predictors of nursing care left undone in european hospitals: results from the multicountry cross-sectional RN4CAST study. BMJ Qual Saf 2014;23:126–35. 5 Richards DA, Borglin G. Complex interventions and nursing: looking through a new lens at nursing research. Int J Nurs Stud 2011;48:531–3. 6 Kalisch BJ, Williams RA. Development and psychometric testing of a tool to measure missed nursing care. J Nurs Adm 2009;39:211–9. 7 Wakefield BJ. Facing up to the reality of missed care. BMJ Qual Saf 2014;23:92–4. 8 Krichbaum K, Diemert C, Jacox L, et al. Complexity compression: nurses under fire. Nurs Forum 2007;42:86–94. 9 Alter S. Theory of workarounds. Commun Assoc Info Syst 2014;34:1041–66. 10 Cresswell KM, Mozaffar H, Lee L, et al. Workarounds to hospital electronic prescribing systems: a qualitative study in English hospitals. BMJ Qual Saf 2017;26:542–51. 11 Medical Research Council. Developing and evaluating complex interventions: new Guidance. London: MRC, 2008. 12 Sasso L, Bagnasco A, Zanini M, et al. The general results of the RN4CAST survey in Italy. J Adv Nurs 2016. 13 Dall TM, Chen YJ, Seifert RF, et al. The economic value of professional nursing. Med Care 2009;47:97–104. 14 Jones CB. The costs of nurse turnover: part 1: an economic perspective. J Nurs Adm 2004;34:562–70. 15 Aiken LH, Sloane D, Griffiths P, et al. Nursing skill mix in european hospitals: cross-sectional study of the association with mortality, patient ratings, and quality of care. BMJ Qual Saf 2017;26:559–68. 16 Welton JM, Zone-Smith L, Fischer MH. Adjustment of inpatient care reimbursement for nursing intensity. Policy Polit Nurs Pract 2006;7:270–80. 17 Butcher HK, Bulechek GM, Dochterman JMM, et al. Nursing Interventions classification (NIC)-E-Book. Missouri: Elsevier Health Sciences, 2013. 18 Walshe K, Rundall TG. Evidence-based management: from theory to practice in health care. Milbank Q 2001;79:429–57. 19 Doran D, Almost J. Nursing sensitive outcomes: the state of the science. Jones & Bartlett Learning 2003. 20 Ball JE, Murrells T, Rafferty AM, et al. ‘Care left undone’ during nursing shifts: associations with workload and perceived quality of care. BMJ Qual Saf 2014;23:116–25. 21 Thompson JD, Averill RF, Fetter RB, Planning FRB. Planning, budgeting, and controlling--one look at the future: case-mix cost accounting. Health Serv Res 1979;14:111.group.bmj.com on November 12, 2017 - Published by http://qualitysafety.bmj.com/Downloaded from impact on missed carepotentialreimbursement coding systems: the Incorporating nursing complexity inCatania, Nicoletta Dasso, Milko P Zanini and Roger WatsonLoredana Sasso, Annamaria Bagnasco, Giuseppe Aleo, Gianlucadoi: 10.1136/bmjqs-2017-00662229, 20172017 26: 929-932 originally published online SeptemberBMJ Qual Saf  http://qualitysafety.bmj.com/content/26/11/929Updated information and services can be found at: These include:References #BIBLhttp://qualitysafety.bmj.com/content/26/11/929This article cites 17 articles, 6 of which you can access for free at: Open Access http://creativecommons.org/licenses/by-nc/4.0/non-commercial. See: provided the original work is properly cited and the use isnon-commercially, and license their derivative works on different terms, permits others to distribute, remix, adapt, build upon this workCommons Attribution Non Commercial (CC BY-NC 4.0) license, which This is an Open Access article distributed in accordance with the CreativeserviceEmail alertingbox at the top right corner of the online article. Receive free email alerts when new articles cite this article. Sign up in theCollectionsTopic Articles on similar topics can be found in the following collections  (288)Open access (6)Health policyNoteshttp://group.bmj.com/group/rights-licensing/permissionsTo request permissions go to:http://journals.bmj.com/cgi/reprintformTo order reprints go to:http://group.bmj.com/subscribe/To subscribe to BMJ go to:group.bmj.com on November 12, 2017 - Published by http://qualitysafety.bmj.com/Downloaded from 

Loredana Sasso

Annamaria Bagnasco

Giuseppe Aleo

Gianluca Catania

Nicoletta Dasso

Milko P Zanini

Roger Watson

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University of Hull Institutional Repository

https://iris.unige.it/retrieve/handle/11567/880144/155806/VIEWPOINT%20-%20BMJ%20QUAL%20%26amp%3b%20SAF.full.pdf

Incorporating nursing complexity in reimbursement coding systems: the potential impact on missed care

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Archivio istituzionale della ricerca - Università di Genova

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University of Hull Institutional Repository