VH Insights

August 03, 2018

Pivoting with Nurses from Fee-for-Service to Value-Based Care

Love it or hate it, value-based care is here to stay and is federal law. However, the largest component of human capital in our healthcare system (specifically for most managed care organizations - the nurse), has been detached from many of the discussions regarding the transition to value-based care, and the difficulties that lay ahead for patients, providers, and payers alike.

In the 2011 report by the Institute of Medicine, the committee emphasized that “nurses have key roles to play as team members and leaders for a reformed and better-integrated, patient-centered health care system”. Yet in many of the discussions regarding our transition to a value-based care system (Do financial incentives work? Who will be the winners and losers in a value-based system?), have not adequately addressed how we can apply, or further develop our nursing staff knowledge, skills, and abilities to ease this transition from fee-for-service to value-based care.

The attractiveness of emphasizing nursing staff in this transition is they are already involved within all domains impacted by value-based care in most organizations, and engaged with documenting performance related measures impacted by value-based care (e.g., patient experience, efficiency and cost reductions, clinical outcomes, and clinical processes of care). For example, the majority of outcome measures for value-based care designated by the Center for Medicaid Services are either identical or directly related with nursing-sensitive measures (measured by NDNQI – national database of nursing quality indicators). This overlap in nursing outcomes should be leveraged and emphasized by organizational leadership to the nursing staff, as it presents an opportunity to minimize disruption by leveraging existing resources (e.g., nursing staff) to ease the transition to value-based care.

Here are three simple ways to ignite or continue the process of involving your nursing staff in the transition to value-based care:

  1. Make all nursing staff familiar with the HCAHPS – The section on nurse communication in the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) has the greatest impact on overall patient satisfaction, and influence on whether the patient will recommend the hospital to family and friends. Have your nursing staff look at the actual HCAHPS questionnaire items, and have them become familiar with the topics patients will be asked to address. Highlight to nursing staff that it’s the patients’ perception of care that will matter – and that they can influence patient perception in positive ways through their working relationships with patients and their families. Emphasize the importance of nursing staff on this outcome: they make up the largest group of health care workers and are the “face” of the daily care patients receive in your organization.
  2. Determine Nursing Staff Adherence to HAC Prevention Protocols – The ability of nursing staff to reduce hospital acquired conditions (HACs; ‘never events’) should not be overlooked, as more than half of these ‘never events’ are linked to nursing-sensitive outcomes, like pressure ulcers, patient falls, ventilator-associated pneumonia, and catheter-associated urinary tract infections. The impact of nursing staff on these HACs is not trivial. Studies on protocols in which nursing is a key component of the quality improvement team have shown that HACs can be reduced by 70% (catheter-associated urinary tract infection), and even approach zero events(ventilator-associated pneumonia) after nursing staff intervention. Despite proven effectiveness of HAC prevention strategies led by nursing staff, adoption and adherence of these strategies remains low, with exception to the ICU setting. A recent survey found that adherence by nursing staff to central line-associated bloodstream infection protocols ranged from 37-71%, 45-55% for ventilator-associated pneumonia, and 6-27% for catheter-associated urinary tract infections. So even if HAC prevention protocols are in-place at your organization, it is likely they are being underutilized by your nursing staff. It is recommended, based on a large evidence base, that an audit should be conducted to understanding existing nursing staff adherence levels to your HAC prevention protocols, followed by engaging with your nursing staff on the prevention process, providing them with additional education, and the development of a feedback mechanism that allows for continual monitoring of protocol adherence moving forward.
  3. Use Clinical Nurse Leaders (CNLs) to further educate nursing staff on the value-based care system, new payment formula, and the importance of collecting data – Lastly, clinical nurse leaders (CNLs) can become your internal ‘nurse champions’ to educate nursing staff about changes related to healthcare reform, value-based care, and outcome-based reimbursement. The role of a CNL is especially well-matched for this specific task as their preparation includes understanding the “economies of care, business principles, and how to work within and affect change in systems”. In addition to nursing staff education, CNLs are prepared to assume leadership roles related to risk assessment, care coordination, healthcare management of patient outcomes, and other high value areas related to value-based care. Achieving and sustaining CNL performance on value-based care will fall under the scope and accountability of the CNO. It is imperative to ensure the importance of the CNLs role is emphasized by the CNO to hospital leadership, physicians, and nursing staff alike.

Moving forward with value-based care will be daunting and uneasy, and without the support of your nursing staff the transition will be an uphill battle. So leverage the power of your nursing staff, state your expectations to them, and clearly communicate their importance in this new care system, so they can be your greatest champion during this transition period. Your nursing staff has the tools necessary to succeed and flourish in a value-based care environment, they just need to know. Tell them.


  1. Institute of Medicine (US) Committee on the Robert Wood Johnson Foundation Initiative on the Future of Nursing, at the Institute of Medicine. The Future of Nursing: Leading Change, Advancing Health. Washington (DC): National Academies Press (US); 2011. Available from: https://www.ncbi.nlm.nih.gov/books/NBK209880/doi:10.17226/12956
  2. Kavanagh, K. T., Cimiotti, J. P., Abusalem, S., & Coty, M.-B. (2012). Moving Healthcare Quality Forward With Nursing-Sensitive Value-Based Purchasing.Journal of Nursing Scholarship,44(4), 385–395. http://doi.org/10.1111/j.1547-5069.2012.01469.x
  3. Kutney-Lee, A., McHugh, M. D., Sloane, D. M., Cimiotti, J. P., Flynn, L., Neff, D. F., & Aiken, L. H. (2009). Nursing: A Key To Patient Satisfaction.Health Affairs (Project Hope),28(4), w669–w677. http://doi.org/10.1377/hlthaff.28.4.w669
  4. Berenholtz, S.M., et al. (2011). Collaborative cohort study of an intervention to reduce ventilator-associated pneumonia in the intensive care unit. Infect Control Hosp Epidemiol, 32(4), 305-14.
  5. Stone, P.W., et al. (2014). State of infection prevention in US hospitals enrolled in the National Health and Safety Network. American Journal Infection Control, 42(2), 94-9.