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Focus on Health Care Delivery, Quality, and Nursing

Posted on: Sunday, 30 October 2005, 03:01 CST

By Sparkman, Catherine A G

The 109th US Congress has passed or is considering several health care acts that may affect the delivery, financing, and quality of medical care. This article explains these acts and their implications for perioperative nurses. For a copy of these acts, visit http://www .thomas.loc.gov and enter the name or number of the act.

MEDICAL MALPRACTICE

Medical malpractice reform failed to pass during the 107th and 108th Congresses; however, in July 2005, the House of Representatives successfully passed the Help Efficient, Accessible, Low-cost, Timely Healthcare (HEALTH) Act of 2005 (HR 5) by a recorded vote of 230 to 194.' The HEALTH Act caps noneconomic damages at $250,000 for compensating patient injury, limits attorneys' contingent fees, and requires a finding of malicious intent to support an award of punitive damages. This act exempts manufacturers or distributors of medical products from punitive damage awards when the product was previously approved by the US Food and Drug Administration (FDA) or recognized by qualified experts to be safe and effective pursuant to conditions established by the FDA. The measure was sent to the Senate and has been referred to the Senate Judiciary Committee.

The Medical Malpractice Relief Act of 2005 (HR 2291) proposes to amend the Internal Revenue Code to allow a business tax credit for qualified expenditures for medical malpractice insurance, alleviating the financial burden on physicians caused by rising malpractice insurance premiums.2 The act has been referred to the House Subcommittee on Health.

PATIENT SAFETY AND QUALITY IMPROVEMENT

The Senate passed the Patient Safety and Quality Improvement Act of 2005 on July 21, 2005.3 The purpose of this act is to encourage a culture of safety and quality in US health care systems by providing legal protection of information reported voluntarily for the purposes of improving quality and patient safety. This act also ensures accountability by raising standards and expectations for continuous quality improvements in patient safety.

The act is based on the findings of the 1999 Institute of Medicine report, To Err is Human: Building a Safer Health System, that medical errors constitute the eighth leading cause of death in the United States and may be responsible for as many as 98,000 deaths annually.4 The findings further conclude that to address deaths and injuries caused by medical errors, health care systems must identify and learn from errors so that systems of care can be improved. Voluntary data-gathering systems are more supportive than mandatory systems in creating the learning environment necessary to improve patient safety.3

The act establishes a mechanism for collecting patient safety data and reporting to patient safety organizations that could result in improved patient safety, health care quality, and health care outcomes. The act authorizes patient safety organizations to conduct efforts determined by the organization to

* improve patient safety and quality of health care delivery;

* collect and analyze patient safety data; and

* disseminate information to providers with respect to

* improving patient safety through recommendations, protocols, and best practices;

* using patient safety data for the purposes of encouraging a culture of safety;

* providing direct feedback; and

* assisting providers to effectively minimize patient risk.

The act further provides for the confidentiality of all patient safety data and protects those who report information to a patient safety organization or to a provider. The act provides that the secretary of Health and Human Services (HHS) shall maintain a patient safety network of interactive, evidence-based management resource databases for providers, patient safety organizations, and other health care personnel. All information collected or disseminated pursuant to the act is required to be nonidentifying to prevent identification of providers and patients.

INFORMATION TECHNOLOGY

Health information technology is receiving Congressional attention. Sen Michael Enzi (R-Wyo) and cosponsors introduced the Wired for Health Care Quality Act (S 1418) to increase the awareness of a nationwide health information technology system and improve quality and reduce costs associated with health care in the United States.5 The act creates the Office of National Health Information Technology headed by a national coordinator appointed by the US President. The national coordinator will be responsible for facilitating the adoption of a nationwide system for electronic exchange of health information.

The act also provides for the establishment of a public and private US health information collaborative created to recommend specific actions to achieve a nationwide health information technology infrastructure and create a forum for stakeholder participation and input in the development of the technology. Based on the recommendations of the collaborative, the HHS secretary will develop criteria to ensure uniform and consistent implementation of standards for the electronic exchange of health information. The secretary also will carry out a study that examines variations among states relating to licensure, regulation, and certification of medical professionals and how variations affect the secure electronic exchange of health information.

The act creates competitive grants and loans to facilitate widespread adoption of health information technology. The grants will be awarded to states to help them develop, purchase, or enhance the use of qualified health information technology. The act directs relevant federal agencies to develop systems to measure the quality of care patients receive.

Finally, the act creates a center for best practices to provide technical assistance and develop best practices to support and accelerate efforts to adopt, implement, and use health information technology. The center will provide a forum for exchanging knowledge and experience and accelerating transfer of lessons learned from existing public and private sector initiatives.

MEDICARE ACT AND PROJECTS

Congress is examining the efficient and cost-effective delivery of quality medical care under the Medicare program. An act titled the Medicare Value Purchasing Act of 2005 (S 1356) is a comprehensive amendment to the Social security Act to provide quality measurement systems for Medicare value-based purchasing programs.6 It also authorizes a Medicare Payment Advisory Commission (MedPAC) study to report on the impact of Medicare value-based purchasing programs.7 The act addresses programs that provide incentives to facilities, providers, and other entities that submit data appropriate for measuring health care quality. The act creates a national health information network pilot project that will facilitate exchanging clinical claims and outcomes data with respect to beneficiaries under Medicare and Medicaid programs.6 The act also establishes a health care value project to document, track, and quantify the value of patient outcomes and reduced expenditures of delivering highquality health care.6 Other demonstration projects provided by the act include a study of data aggregation related to quality of care, and reports on the accuracy and completeness of quality data.

NURSE FACULTY EDUCATION

The 109th Congress is focusing attention on nursing issues and initiatives. The Nurse Faculty Education Act of 2005 (S 1575) authorizes a demonstration program to increase the number of doctorally-prepared nurse faculty members.8 Although the Nurse Reinvestment Act of 2002 has supported students preparing to be nurse educators, nursing schools still are forced to deny admission to individuals due to a lack of qualified nurse faculty.9 The act states that health care systems are facing unprecedented workforce and health access challenges with current and future shortages of deans, nurse educators, and nurses. The act directs the HHS secretary, through the Health Resources and Services Administration, to establish a nurse faculty education program to ensure an adequate supply of nurse faculty members by awarding grants to eligible entities. Eligible entities are defined as schools that offer doctoral degrees in nursing. The grants are designed to support hiring new faculty members, retain existing faculty members, and purchase educational resources. The nursing school must develop and implement a plan to use grant funding. The act enumerates 10 opportunities for fund expenditures, including partnering with practice and academic institutions to facilitate doctoral education and research, creating cooperative education programs, establishing nurse faculty mentoring programs, and developing an RN baccalaureate- todoctorate program to expedite completion of a doctoral degree and entry into a nurse faculty role.

A similar act, titled the Nurse Education, Expansion, and Development Act of 2005 (HR 3569) calls for grants to be awarded to eligible schools of nursing to promote increasing nursing faculty.10 The act provides a fixed amount of money (ie, $1,800) for each full- time or part-time student who is enrolled at the school in a nursing graduate program that leads to a master's or doctoral degree and $1,405 for each student who pursues a bach\elor's or associate's degree in nursing. The funds are to be used to hire new faculty members, retain current faculty members, purchase educational equipment, enhance clinical laboratories, repair and expand infrastructure, or recruit students. Grant awards are contingent on the eligible institution formulating plans to expand educational and programming opportunities, increase diversity in student populations, develop programs to encourage practice in specialty areas where nursing shortages are most severe, partner with economically disadvantaged communities, and support enrollment of financially disadvantaged students. The act also requires eligible institutions to achieve graduation and examination passage rates and meet increasing enrollment targets.

SAFE NURSING AND PATIENT CARE

Acts involving nurse staffing and mandatory overtime are part of the legislative landscape in the 109th Congress. Two acts, one in the House of Representatives (HR 791)11 and one in the Senate (S 351)12 address safe staffing of health care providers who receive payments under Medicare. The acts, both titled Safe Nursing and Patient Care Act of 2005, cite studies that show that higher nurse staffing levels result in better patient outcomes but that job dissatisfaction and overtime are contributing to the departure of nurses from their profession.

The act cites studies that show that mandatory overtime requirements for nurses pose dangers to patients. Nurses who work shifts of 12.5 hours or more are three times more likely to commit an error than nurses who work standard shifts of 8.5 hours or less.11,12 Consequently, the acts adopt a prohibition on mandatory overtime that limits a nurse's work shift to no more than 12 hours in a 24-hour period and no more than 80 hours in a consecutive 14- day period. The acts provide limited exceptions, such as a declared state of emergency in which providers are expected to make reasonable efforts to fill immediate staffing needs through alternative means. The acts provide civil penalties for violation of the provisions. Nurses who report violations of the mandatory overtime limitations are protected from retaliatory actions if they act in good faith. The acts do not prohibit nurses from voluntarily working more than the periods of time described. Providers subject to provisions of the acts include hospitals; outpatient departments; ambulatory surgery centers; clinics (eg, rural health clinics); and federallyqualified health centers.

QUALITY NURSING CARE

Nurse staffing ratio acts also are pending in both the House and Senate. The House version (HR 1372)13 is titled the Quality Nursing Care Act of 2005 and the Senate bill (S 71) is the Registered Nurse Safe Staffing Act of 2005.14 Both acts cite findings that there is a critical shortage of RNs in the United States and that patient safety is adversely affected by unsafe staffing levels, thus creating a public health crisis. The acts require Medicare- participating hospitals to adopt and implement a staffing system that guarantees a number of RNs on each shift and in each unit of the hospital to ensure appropriate staffing levels for patient care.

The staffing system requirements should take into account the number of patients, level and variability of intensity of care, level of preparation and experience of those providing care, and patient acuity and existing conditions. The acts also require hospitals to post the staffing system and the current number of RNs and unlicensed nursing staff members directly responsible for patient care in each unit.

Hospitals are required to keep records of staffing systems, nurse- sensitive patient outcomes, operational outcomes, and patient complaints in order to evaluate the effectiveness of the staffing system. The acts provide for whistle blower protection for employees who report violations of the mandated staffing systems.

Medical errors constitute the eighth leading cause of death in the United States and may be responsible for as many as 98,000 deaths annually.

The Wired for Health Care Quality Act creates a center for best practices to provide technical assistance to support and accelerate health information technology.

The Nurse Faculty Education Act authorizes a program to increase the number of doctorally-prepared nurse faculty members.

The nurse staffing ratio acts require hospitals that receive payments from Medicare to implement a staffing system that guarantees a number of RNs on each shift and in each unit to ensure appropriate staffing levels.for patient care.

NOTES

1. "HR 5," Thomas Legislative Information on the Internet, http:/ /thomas.loc.gov/cgi-bin/query /D?c109:1:./temp/~c109BwxmzD:: (accessed 30 Aug 2005).

2. "HR 2291," Thomas Legislative Information on the Internet, http://thomas.loc.gov/cgi-bin/cjuery /D?c109:1:./temp/~c109N72Zhq:: (accessed 31 Aug 2005).

3. "S 544," Thomas Legislative Information on the Internet, http:/ /thomas.loc.gov/cgi-bin/cjueri/ /D? c109:1:./temp/~c109Ccy6wl:: (accessed 31 Aug 2005).

4. L T Kohn, J M Corrigan, M S Donaldson, To Err is Human: Building a Safer Health System (Washington, DC: National Academy Press, 2000).

5. "S 1418," Thomas Legislative Information on the Internet, http://thomas.loc.gov/cgi-bin/cjuery /D?c109:1:./temp/~c109AxSGAG:: (accessed 31 Aug 2005).

6. "S 1356," Thomas Legislative Information on the Internet, http://thomas.loc.gov/cgi-bin/query /D?c109:1:./temp/~c1092cjb8oc:: (accessed 31 Aug 2005).

7. "What's new," Medicare Payment Advisory Commission (MedPAC), http://www.medpac .gov/ (accessed 31 Aug 2005).

8. "S 1575," Thomas Legislative Information on the Internet, http://thomas.loc.gov/cgi-bin/query /D?c109:1:./temp/~c109XDVe2A:: (accessed 31 Aug 2005).

9. "Nurse Reinvestment Act of 2002," US Department of Health and Human Services, Bureau of Health Professions, http://bhpr.hrsa.gov/ nursing/reinvesttext.htm (accessed 23 Aug 2005).

10. "HR 3569," Thomas Legisla tive Information on the Internet, http://thomas.loc.gov/cgi-bin/query D?c109:1:./temp/~c109NA7Nt6:: (accessed 31 Aug 2005).

11. "HR 791," Thomas Legislative Information on the Internet, http://thomas.loc.gov/cgi-bin/query /D?c109:1:./temp/~c109RnEpMa:: (accessed 31 Aug 2005).

12. "S 351," Thomas Legislative Information on the Internet, http://thomas.loc.gov/cgi-bin/query /D ?c109:1:./temp/~c109AWmcNa:: (accessed 31 Aug 2005).

13. "HR 1372," Thomas Legisla tive Information on the Internet, http://thomas.loc.gov/cgi-bin/query /D?c109:1:./temp/~c109gC4ZBb:: (accessed 31 Aug 2005).

14. "S 71," Thomas Legislative Information on the Internet, http:/ /thomas.loc.gov/cgi-bin/auery /D? c109:1:./temp/~c109abvzdf:: (accessed 31 Aug 2005).

CATHERINE A. G. SPARKMAN

JD

AORN SENIOR LEGISLATIVE ANALYST

Copyright Association of Operating Room Nurses, Inc. Oct 2005

Source: Association of Operating Room Nurses. AORN Journal

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