August 10, 2011

incentives-pay-for-performance1Strikingly, nurses saw the potential of such incentives (and disincentives, such as not paying for care needed for hospital-acquired conditions–bloodstream and urinary tract infections are two examples) in improving the quality of care patients receive, but their fear was that they could potentially lay the blame for poor performance on at the feet of nurses. Maybe nurses are not delivering the quality of care that patients need and should assume blame. But if one takes a systems perspective and recognizes that most nurses have too little say over staffing ratios and their work environment (inefficient and unsafe systems of care), then their fea may be well-founded. Think about the CEO of a hospital that has a higher-than-average rate of pressure ulcers, a condition that is often attributed to poor nursing care. As the hospital loses the revenue to cover the care of hospital-acquired pressure ulcers in Medicare patients, the CEO decides to cut nurse staffing to balance a budget with declining revenues and increasing expenses. The cut in nurse staffing leads to even poorer outcomes, as has been demonstrated in study after study. But the hospital leaders in this study were statistically less likely to view PFP as potentially leading to blaming nurses for poor peerformance.

Almost one quarter of the nurses in the study saw PFP as a burden, often in terms of increasing documentation, additional personnel needed to manage the data and reporting requirements, training of staff, etc. Only 10% of the hospital leaders spoke about PFP as being a burden.

The study has significant implications for policymakers and hospital administrators. For example, Kurtzman and colleagues note: “Nurses, who bear major responsibility in the adoption of these policies, may be vulnerable to expanded workloads and negative work-environment effects” and calls for Medicare to bear some portion of the costs of investing in the infrastructure that will be needed to manage and minimize any burdens that may be associated with PFP.

The authors also call for building non-punitive work environments and that the effects of PFP be evaluated. This latter recommendation needs to include looking for unintended consequences of the policy.

This study is also significant because most discussions of PFP seldom mention nurses. It’s time to heed the IOM’s recommendation that nurses be at all decisionmaking tables in health care, including in hospitals and other healthcare organizations. Kurtzman and colleagues concur. How do we get there?

Diana J. Mason, PhD, RN, FAAN, Rudin Professor of Nursing and Co-Director, CHMP