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If the federal Patient Safety Act of 1997 becomes law, your day-to-day job may be in for some serious readjustment. If it doesn’t get through this time and it probably won’t rest assured it will be reintroduced until it passes in some form. To keep getting Medicare payments, hospitals are eventually going to have to comply with some new quality regulations, which adds yet another facet to your job.
The act aims to ensure better-quality patient care. It will require hospitals to increase and upgrade staffing and promote public disclosure of data. Those provisions will push up the cost of health care. (See related article on what the act requires, p. 74.)
Hospital Peer Review asked several quality improvement professionals how the bill might impact their jobs. The consensus is that it depends upon where you work. The act could have a favorable impact if your facility decides it needs to and can afford to upgrade staff. But your job is in jeopardy if you’re working at a hospital that could be forced to close because it can’t compete.
Judy Homa-Lowry, RN, MSBA, CPHQ, director of quality improvement with The Delta Group in Greenville, SC, takes a pragmatic view: "The legislation will enhance career opportunities simply because additional staff is going to be needed to analyze, submit, and publish the outcomes data."
The Patient Safety Act of 1997 (H.R. 1165) was introduced into Congress by Rep. Maurice Hinchey (D-NY) on March 20, and is now before the House Ways and Means Committee. The politically powerful American Nurses Association (ANA) in Washington, DC, lobbied for the bill. Because it would further regulate the hospital industry, and the current Congress is generally not favorable to increasing government regulation, the bill’s prognosis for this session is not favorable.
"It’s unlikely to move anywhere soon," says Alicia Mitchell, assistant director of media relations for the American Hospital Association. You cannot sit back and depend upon that, however, because if this bill isn’t passed, others will follow.
"What the bill is accomplishing, whether it becomes law or not, is making Congress aware of problems in our hospitals and that those problems put patient health in danger," says Sara R. Foer, MPH, MSJ, senior communications specialist with the ANA.
Provisions of the Patient Safety Act are drafted as conditions for participation in Medicare, and as such promise to result in considerable jockeying for contracts with Medicare. If outcomes data are made available to the public for comparison, changes in the marketplace will likely result. Managed care organizations and insurance companies are going to become more informed and armed with data. They’re going to be able to say, "These outcomes data come from this hospital, which is affiliated with us. Come sign up with us." Those facilities that don’t shape up are going to go out of business. That’s not a bad thing for the public and health care as a whole, but it becomes a bad thing if you have a job at one of those hospitals.
Patient safety, quality of care, and cost-control pressures go to the heart of the nursing profession today. Patients generally are not admitted to the hospital unless they require round-the-clock care. To meet that challenge, every member of the health care team must be as educated as is feasible, says John M. O’Donnell, MD, chair of the department of surgical intensive care at the Lahey Clinic in Burlington, MA.
This need for increased education flies in the face of today’s relentless focus on the bottom line, however. Cutting costs usually translates into cutting corners. In an article in The New York Times, O’ Donnell stated, "Nurses are the foundation of our health care system. Cutting labor costs by decreasing the nursing work force is irrational and naive. There are deserving targets for cuts physician spending, pharmaceuticals, middle management, and insurance. But don’t cut nursing care."1
An additional provision of the legislation is new whistle-blower protections. In talking about the Patient Safety Act, ANA president Beverly L. Malone, PhD, RN, claims health care decisions are increasingly driven more by a quest for short-term cost savings and profit than by a commitment to high-quality patient care.
"This legislation," says Malone, "lifts the veil of secrecy that keeps hospitals’ staffing and outcomes a mystery to patients. It gives consumers access to information they need to make informed decisions and protects nurses who speak out on behalf of safe patient care."
Judy Stokes, RN, director of quality resource management for Kaiser Permanente in Atlanta, says of the bill, "It’s high time that such federal whistle-blower protections are proposed. Hospitals who contract with Kaiser do on-site quality review and have in place their own protocols for untoward events. In general, the legislation’s provision to protect whistle-blowers and its requirement for facilities to divulge staffing levels will be a positive step toward quality." (See related article on de-skilling the work force, above.)
Homa-Lowry says, "I like the fact that the bill will require the reporting of data. Consumers have a right to know the facts so they can make better and wiser choices. My only problem with the bill has to do with consumer access to data. What kind of supporting information will they have so they can understand what they are reading? This is an ongoing issue in the information industry. Information has to be interpreted for the consumer.
"How managed care will respond to the bill remains to be seen," she continues. "If, for example, a hospital has one RN on duty on a night shift, and the mortality rate is 15% higher than that at a hospital that has two RNs on duty for a similar shift, the data are going to show a correlation in terms of patient safety or satisfaction. A mandate of a minimum of two RNs may come about. If reporting of outcomes is mandated, managed care companies will likely realize a correlation between staffing levels, resources, and outcomes, and managed care entities and even the federal government will probably require some minimum staffing levels." Indeed, there have already been attempts to determine whether there is a link between staffing and outcomes.
The ANA is lobbying for the Patient Safety Act in conjunction with its Nursing’s Safety and Quality Initiative. That bill focuses on educating the public, as well as policy-makers, about a growing trend toward de-skilling nurse staffing. Hospitals, in an attempt to enhance their bottom lines, are cutting budgets and replacing RNs with LPNs and minimally trained, unlicensed technicians, the ANA claims. While such de-skilling measures are seen as "boosting" profits by the ANA, your hospital may be employing such measures in a fight to survive or to return to profitability.
Part of the ANA’s Quality Initiative is the collection and measurement of data to highlight problems that arise from decreased RN staffing, especially linkages between nursing actions and patient outcomes. The ANA’s acute care report card project is one of a number of pilot studies that collect nursing’s quality indicator data to see the impact of skill mix on patient outcomes. (See article on nursing report cards, at right.) Once the project produces some viable data, the ANA will look at other groups that are developing report cards and try to unify data collection.
Two years ago, the ANA began to investigate the impact of health care restructuring on patient care and nursing. The 1996 version of the Patient Safety Act (H.R. 3355) was a component of the ANA’s "Every Patient Deserves a Nurse" public education campaign, which armed consumers with questions to ask prior to hospitalization and gave advice on reporting poor quality care. The new version of the Patient Safety Act is identical to the first one.
The public perception is that the quality of nursing has declined over the past 10 years, and that most of the changes have occurred because hospitals have had to tighten their belts and manage costs more aggressively. Nurses are seen as overworked, and their profession is perceived as being more task-oriented and as having lost its perspective of the patient being central. Quality concerns have become a luxury, according to many proponents of health care reform.