The final measures and scoring methodologies for Medicare's value-based purchasing program still may be months away, but one thing already is certain: Health care executives fundamentally must rethink how patient care is approached, managed, supported and staffed.

Hospitals will be on the spot to improve how they perform clinical care processes, not just to "think about their hospital like a factory model and get patients through their factory as quickly as possible," says Trent Haywood, chief medical officer of health care alliance VHA Inc., Irving, Texas.

Additionally, the inclusion of several measures of patient experience makes that aspect of quality "more germane, so CEOs who really want to do well need to actually understand that. It fundamentally shifts the way that most people think about quality and value," Haywood says. "You will get to know your patient."

Physicians on staff will make or break the effort, says Marlon Priest, M.D., senior vice president and chief medical officer of Bon Secours Health System, Richmond, Va. Last December that system received the highest number of total awards for clinical performance in the fifth year of a value-based purchasing pilot conducted by Premier health alliance for the Centers for Medicare & Medicaid Services. The aggregate percentage of appropriate care systemwide was "in the high 90s," he says.

Those results, on some of the same measures proposed for the nationwide Medicare program, were achieved through "a risky partnership with private physicians" who, as in most community hospitals, admitted 80 to 90 percent of patients but were not employees, Priest says.

Hospital leadership first had to appeal to each doctor's sense of why they originally went to medical school—the best possible care of each patient—and combined that with continuously tracked progress on quality measures from a newly implemented electronic health record in all facilities from New York to South Carolina. The real-time record was pivotal in enabling nurses to alert doctors about certain conditions in newly admitted patients and what had to be done for a person with those conditions, says Priest.

Managers have to free up nurses to spend more time at the bedside instead of being pulled away for administrative chores or stocking supplies, says Haywood. By having to multitask, nurses aren't able to fully focus on patient needs, so some things go unaddressed, he says. That could end up dinging hospitals not just in clinical performance, but also on patient-experience measures such as pain management and responsiveness of hospital staff.

Priest says building excitement among the clinical workforce will go a long way toward creating an environment for success in meeting whatever specific measures CMS requires.

Bon Secours shook things up in the third year of the Premier pilot by taking on hospital-acquired sepsis, which was not a Premier/CMS measure, but constituted "an outcome measure that gets to your heart and soul … that every nurse and every doctor has seen, and heard of, and been impacted by."

The campaign resulted in a 40 percent drop in sepsis-related deaths and created a climate that drove improvement across the range of quality measures. "We were very transparent: Here are our scores, here are the people affected, here's someone who died of sepsis who shouldn't have, and how do we make it better," Priest says.


The Value Equation

The Centers for Medicare & Medicaid Services in January issued its proposal for value-based purchasing, as mandated by the Affordable Care Act. Once finalized, the rule will trim inpatient prospective payments by 1 percent starting in FY 2013, rising to 2 percent in 2017 and beyond. Hospitals that meet certain quality benchmarks will get a bonus payment. The American Hospital Association was generally supportive of the proposal, although opposes the inclusion of health care-acquired conditions. Hospitals already are subject to penalties for HACs under a different section of the law. A final value-based purchasing rule is expected sometime in the spring or summer. Here's a sample of the measures CMS proposed:

Heart attack
• Primary PCI received within 90 minutes of hospital arrival
• Aspirin prescribed at discharge

Heart failure
• Discharge instructions

Pneumonia
• Pneumococcal vaccination
• Blood culture performed prior to administering first antibiotic

HCAHPS
• Communication with nurses
• Responsiveness of hospital staff
• Pain management

Hospital-aquired conditions
• Foreign object retained after surgery
• Pressure ulcers stages III and IV
• Catheter-associated urinary tract infection

Source: Centers for Medicare & Medicaid Services, Notice of Proposed Rulemaking, January 2011