Sinai's incentive discharge program raises questions

Sinai Hospital of Baltimore launched an incentive program this week to encourage nurses to discharge more patients by noon, prompting questions about patient safety.

The program sets a goal for nursing units to discharge 20 percent of their patients by noon and offers the nurse on each unit with the most early discharges a $10 gift card.

An executive with LifeBridge Health, which owns Sinai, said the goals were taken out of context. The hospital was responding to patient concerns that they wanted to leave the hospital sooner after procedures, said Debbie Hollenstein, LifeBridge vice president of marketing.

Hollenstein said doctors decide if patients are medically ready for discharges, not nurses, but sometimes delays occur because prescriptions or medical equipment, such as walkers, haven't arrived. Other times, nurses get backed up and may prioritize sicker patients over those who may be ready to leave.

"Patients want to go home sooner," Hollenstein said. "What you see is nursing's attempt to provide some sort of an incentive for that to happen."

Hollenstein said patient care is not sacrificed because of the program.

A nurse who works at Sinai Hospital of Baltimore tweeted a photo of a page from a manager's manual explaining the program's goals and rewards with the message "I … kid you not," using an expletive to describe her feelings.

"I'm sorry very sick patient not ready to go home, but I want to win a $10 gift card," she later tweeted.

The nurse, who uses the Twitter name @Nurse_Rachel_, did not reply to requests for comment and subsequently deleted the tweets. She is still employed at the hospital, a hospital spokeswoman confirmed.

Safety patient advocate Karen Curtiss said the gift card rewards raise the potential for patient problems. Discharge is an important part of a patient's hospital stay, said Curtiss, author of the book "Safe & Sound in the Hospital: Must-Have Check Lists and Tools for Your Loved One's Care."

It is when nurses explain how to take a medication and what follow-up care is needed at home, so a patient doesn't end up back in the hospital, Curtiss said.

"The discharge process could be rushed with these goals," said Curtiss, also president of PartnerHealth, a Chicago patient safety consulting firm that also has a nurse training component.

Hospitals face increased pressure to meet patient safety standards. The Health Services Cost Review Commission, which sets Maryland hospital rates, looks at patient care metrics such as satisfaction when monitoring and incentivizing hospital performance.

"The patient satisfaction results have become a greater portion of the incentive program in recent years," Steve Ports, the commission's deputy director of policy and operations, said in an e-mail.

Asked about Sinai's effort to increase early discharges by rewarding nurses, Ports said: "Discharge decisions should be clinically based and be made in the best interest of the health and welfare of the patient. To the extent that these principles are met, the commission would not have a concern."

Curtiss said that patient surveys can be skewed because a patient takes them immediately after experiencing a long discharge.

Hospitals need to do a better job of explaining the discharge process to patients so they understand why it may take longer than it seems it should, said Neysa Ernst, a nurse who is president of the Maryland Nurses Association. They may not realize nurses are waiting on things such as results from blood tests.

Ernst said an incentive program like Sinai's raises concerns because the information patients get at discharge is crucial to a good recovery.

"If a patient has the right information when they are discharged they will be able to function safely at home," she said. "If we rush it. They end up confused."

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