Healthcare Reform and Bariatric Nursing: Exploring Differences in Patient Experience between Bariatric and Non-Bariatric Patients

Introduction

The nursing profession, in particular within the hospital environment, has long sought a mechanism by which to demonstrate its financial value to an organization. Over the last decade, there has been substantial investment in holding healthcare providers accountable for the quality of care provided in hospitals, ¹ which in turn has increased the desire by leaders to place a value on nursing care and services. In March 2008, the U.S Department of Health and Human Services posted on its Hospital Compare website the results of the first large-scale, national, standardized survey of patients' perceptions of patient care. ² HCAHPS, the Hospital Consumer Assessment of Healthcare Providers and Systems survey, offered a level of healthcare transparency not known before to the public. This transparency was heralded by consumers as an opportunity to search for optimal outcomes, and in essence, “shop” for their healthcare. This survey would begin to change the healthcare landscape, and eventually would become a major component within healthcare reform. In April 2011, almost 3 years later, the Affordable Care Act was announced, which implemented a Value-Based Purchasing (VBP) program that would allocate approximately $850 million to hospitals based upon their overall performance of specific quality measures, including HCAHPS. ³ For nursing services, the addition of HCAHPS to a reimbursement structure could not be of greater importance. The impact of nursing care on patient satisfaction has been long established, but never before linked to financial rewards. ⁴ The ability to quantify nursing's contributions to healthcare organizations cannot be overstated. Patient perception has been measured by healthcare organizations and vendor companies for many years, offering a glimpse into the patient experience. Within patient perception, a question naturally arises: is there a difference in patient perception between bariatric and non-bariatric patients? With the prevalence of adult obesity in the United States, approximately 32.2% among men and 35.5% among women, ⁵ it is important to understand the potential differences in patient perception and care needs. Before this question is answered, it is important to understand better the nursing components of the HCAHPS survey, and how the HCAHPS survey impacts the new VBP program.

VBP, Core Measures, and HCAHPS

Beginning in fiscal year 2013, 1% of Medicare reimbursement will be withheld to create an incentive fund ⁶ that will yield approximately $850 million for incentive payments. VBP will reimburse specified Medicare dollars based upon specific criteria. Currently within the VBP program, there are two segments that will be considered: core measures and HCAHPS. Core measures, including those of myocardial infarction (MI), heart failure (HF), pneumonia, healthcare associated infections, and surgical care improvement (SCIP), yield 70% of the VBP program. Although not discussed here, it is important to note that many of the core measures included in this program are directly impacted by nursing, specifically at the point of care. The other 30% of the reimbursement structure includes HCAHPS. For the first time, patient care provided by nurses at the bedside will have the potential to impact reimbursement directly. The ability for nursing to generate revenue will now be a reality.

HCAHPS and Nursing Care Satisfaction

The HCAHPS survey, developed by the Agency for Healthcare Research and Quality, asks patients 27 questions about their experiences in the hospital; responses to 14 of the questions are summarized by Centers for Medicare and Medicaid Services (CMS) and reported as composites. ⁷ There are five VBP composite nursing measures that are found within the HCAHPS survey: nursing communication, responsiveness of staff, pain management, communication of medications, and discharge information. Within these five composites, there are specific questions related to perception of care; these items are listed in Table 1. There are three other composites—doctor communication, cleanliness/quietness of hospital environment, and overall rating—that are not included within the scope of this paper.

As opposed to many patient perception surveys that ask a patient to rate their care based upon an excellent or very good scale, the HCAHPS survey asks a very different type of question, which is solely based upon frequency, of which the possible answers are: always, usually, sometimes, or never. For example, “How often did your nurses treat you courtesy or respect?” is very different from “Please rate your nurses' courtesy and respect as excellent, very good, good, fair, or poor.” The ability for patients to quantify care as always courteous and respectful can be much more difficult, which may require a different provision of care.

Patient Experience Differences in Bariatric and Non-Bariatric Patients: A Case Study

In September 2009, our organization developed a bariatric surgery service line and rebranded our bariatric surgery program, and, by May 2010, we were designated a Center ofmonths that followed the initial Excellence through the Surgical Review Corporation (SRC). This program would be housed in an existing general surgery unit that also provided care to a small pediatric inpatient population. In essence, there would be several patient types housed on one unit, which would ultimately provide a wealth of information related to patient experience, meaning the same nursing team would be providing care to various types of patients and diagnoses, so there would be some control over providers. This unit historically has maintained excellent patient perception scores through their patient satisfaction survey vendor, typically reaching at or above the 85th percentile within their respective database nationally. Much like other healthcare organizations, our focus has been traditionally on patient perception or satisfaction, and HCAHPS has only recently begun to take center stage. Therefore, the data discussed are within the realm of patient satisfaction rather than HCAHPS, but correlations will be made. The differences between bariatric and non-bariatric patient perception will be discussed within the following areas: nurse's communication, responsiveness of staff, pain management, communication of medications, and discharge information.

Recommendations from our Experience

Implementation of any new program provides for challenges and opportunities for learning and growth.

(1) Maintain focus of all patient populations during change. During any change to a process that directly impacts patients and patient care, it can be difficult to maintain focus. Enlist nursing team members early to identify issues and problems. Ideally, having front-line nursing staff input during the planning stages will allow for a greater sense of empowerment and autonomy once the care process change is underway.

(2) Bariatric service-line development. One of the first initiatives developed was the implementation of the bariatric service line. This multidisciplinary team comprises eight surgeons, a nursing director, and a manager, and representatives from pharmacy, nutrition, wellness centers, marketing, finance, and radiology. In addition, we requested that nurse representation from the inpatient unit be included, as (s)he understands the unique needs of our inpatient population. This nurse could bring back patient perceptions and concerns to the team to be addressed with solutions developed quickly.

(3) Beware of making multiple changes at one time. When multiple changes are made within a patient care area, it is difficult to ascertain what change is impacting patient satisfaction and perception. If possible, make changes one at a time to measure impact on patient care. In addition to patients, it is imperative to measure changes upon the nursing team. When multiple changes to processes made at one time and patient satisfaction suffers, it is difficult to know which of those changes impacted care.

(4) Rounding with patients. There is perhaps no more important opportunity than that of rounding with patients during their inpatient stay. Nursing manager rounding has been found to positively impact HCAHPS scores throughout the country. ⁸ Whether it be a nursing manager or charge nurse, it is imperative to connect with patients and understand their care experience. In addition, rounding with patients allows for an opportunity to explore individual needs and to connect themes between patient types. It is much easier to recover service before a patient is discharged than afterwards.

(5) Development of in-house bariatric surgery support group. There is a preponderance of literature that defines the success of support groups after bariatric surgery. Within our organization, we have begun to utilize our bariatric surgery staff nurses to assist with these groups. This has tremendous benefits for multiple reasons. Our nurses are offered the opportunity to experience a patient's weight loss success. Many times, nurses discharge patients and never have the opportunity to see firsthand the weight loss journey. Patients coming back for support group offer invaluable insight into strategies for improving patient care—what we need to continue to provide for patients, and what innovative changes can be provided for future patients.

Conclusion

Gladwell ⁹ describes a “tipping point,” which defines the contagiousness and dramatic changes associated with an epidemic. Within nursing, have we reached our “tipping point” within healthcare reform? The coming changes to healthcare reform will continue to challenge nursing in many ways. However, as a profession, we must also realize and appreciate the greater accountability that will exist with our care. Reimbursement based upon nursing care is of monumental value, but we must be ready to accept the responsibility. We have been seeking this challenge and recognition for decades; it is time to take advantage of this new day in nursing.