价值导向的护理实践：它是什么以及如何使其成为真实

High value care produces an improvement in patient outcomes while using the least amount of resources. Preventative care (e.g., vaccinations) is one example of high-value care. The vignette above, on the other hand, illustrates low-value care: multiple EKGs given to Mrs. X to calm her and her family's fears, tied up hospital resources with little to no improvement of Mrs. X's outcome. In the end, that element of Mrs. X's care was wasteful.

While low-value care care may seem innocuous—after all, no harm was done and Mrs. X and her family were reassured she was ok—provision of unnesessary, redundant services wastes valuable (and costly) health care resourses that could instead be used for other worthy causes. In our example, the repeat unnesessary testing made the equipment and technician time less ailable for other patients, potentially leading to delays in their diagnosis and treatment; while Mrs. X was occupying the room, an emergency room (ER) patient may he been waiting for an inpatient bed, and yet other patients may he been waiting for an ER bed. Aggregated across the U.S. health care system, such instances of wasteful use of health care resources add up to as much as $935 billion annually, with up to $286 billion being preventable through judicious use of resources. (

Shrank et al., 2019

) Instead of being wasted, this amount of money could provide full Medicaid coverage to all currently uninsured people in the U.S., or allow all U.S. hospitals to nearly double their nursing staff.

Because nurses make decisions about the use of costly resources in countless care delivery settings 24 hours a day, nurses are inseparably connected to not only the quality and safety of care, but to the cost-of-care as well. Additionally, nurses are the largest health profession—estimated 3.6 million in 2021—and among the highest-paid health professions. Consequently, we need a more comprehensive vision of nursing practice, one that holistically recognizes that nursing practice affects patients in two ways—directly, through care provided by a nurse to their patients, and indirectly, by tying up costly health care resources which could otherwise benefit the care of other patients. This article describes value-informed nursing practice—nursing practice that focuses not only on outcomes, but also on the cost of care (

Buerhaus Simon Yakusheva, 2022

Yakusheva et al., 2020

Yakusheva et al., 2021

)—as a new way to envision nursing practice.

The Economic Imperative

Given the low performance of the U.S. health care system and its exorbitant costs, the ongoing transition to value-based payment models was inevitable. For decades, a fee-for-service payment system incentivized overuse of human and other health care resources. Reimbursement based on the volume of services provided, with little regard for the patient outcome, created a clunky and unprecendlty costly health care system that eventually led to stagnating, even diminishing, health outcomes and unacceptable health disparities. Rising health care spending (currently 17.9% of the gross domestic spending or nearly 20 cents of every dollar spent in the U.S.) is a major problem facing U.S. individuals and families. The nation can no longer afford to ignore the true value of health care services, including costs, who pays for it, and how. Governmental and private payors are transitioning away from fee-for-service reimbursement and toward value-based payment, meaning that payments increasingly reflect quality and cost indicators; 40% of traditional Medicare, 30% of commercial payments, and 25% of Medicaid payments are made through some sort of value-based arrangements. The inclusion of cost considerations makes hospitals, nursing homes, and physician practices increasingly more accountable for both the quality and the cost of the services provided. Over the decade, nurses, too, can expect an increasing need to measure and improve the value of care in all practice settings, as cost, price, and provision of care will become increasingly transparent. Consequently, it is essential that nurses direct efforts toward controlling costs and improving the value of care. This shift means that nurses must learn to provide value-informed care that aligns with evolving payment systems, reduce waste and unnecessary costs, and better meet the needs of patients, families, communities, and the society-at-large.

What Does Value-Informed Nursing Practice Mean?

Value-informed nursing practice is practice that consistently incorporates the considerations of, both, the outcomes and the cost of resources required to achieve the outcomes, in clinical decision making.

Buerhaus Simon Yakusheva, 2022

Yakusheva et al., 2020

Yakusheva et al., 2021

In our opening paragraph, value-informed nursing practice would be to directly address the root-cause of the situation, Mrs. X's anxiety. Practicing value-informed nursing care would, therefore, help to oid a chain reaction of repeat unnecessary testing, while doing no harm to Mrs. X; in fact, Mrs X may he learned some calming techniques and used them at home, possibly preventing unnessesary future readmissions.

Practicing value-informed nursing care means that the nurse carefully assesses the situation with an eye toward using resources effectively and judiciously. In Mrs. X's case, even though following routine protocols may he been a time-sing choice for the nurse at that moment, a careful consideration of the full chain of potential downstream consequences, and costs, may he led to a different clinical decision—one that would reduce overall resource use and cost, and improve patient outcomes.

A key part of value-informed nursing practice is being thoughtful about how a clinical decision in regards to one patient's care may impact the care of other patients. While nurses are not new to hing to allocate their time among the many needs of their patients, it is important to remember that the downstream effects can impact patients beyond those directly assigned to your care. These other patients may experience their care delayed or lessened when the resources they need are tied up in the care to the patients immediately at hand. Though these other patients are ‘invisible’ to you at that moment, they are your colleagues’ patients and they may become your patients tomorrow, and so their needs and outcomes matter just as much as the patients’ directly in front of you right now.

Eddy, 1996

) Value-informed nursing practice means being a judicious resource-user and using the smallest amount of resources required to achieve a desired outcome for your patients, as part of the ‘nursing lens.’

Buerhaus Simon Yakusheva, 2022

Yakusheva et al., 2020

Yakusheva et al., 2021

While discussing what value-informed nursing practice ‘is,’ it is equally important to stress what value-informed nursing practice ‘is not.’ Value-informed nursing practice does not, and should not, require that the nurse trades off the quality of care provided to a patient, in order to cut down the cost. In our vignette, addressing Mrs. X's anxiety without unnecessary testing likely would he provided the same or even better outcomes, given that the core problem of anxiety would he been more directly recognized and addressed. The primary objective value-informed nursing practice remains to deliver high-quality patient care, just doing so in a way that reduces or eliminates wasteful use of health care resources.

Currently, unnessessary testing and other overtreatment and/or low-value services constitue about 10% of the nearly one trillion dollar annual health care waste. (

Shrank et al., 2019

). The other two major sources of health care waste are administrative complexity (up to 35%) and care delivery and coordination failures (about 25%). (

Shrank et al., 2019

). Nursing already incorporates care coordination as part of nursing practice, with many research and quality-improvement efforts led by nurses to reduce coordination failures and streamline care processes (e.g., hospital-to-home tranisions, medication administration). However, addressing overtreatment, low-value care, and administrative complexity is not entirely in the nurses’ domain of influence and will require buy-in from administration and medicine. Nevetherless, nurses must begin to incorporate into their practice the responsibility to call-out low-value care and inefficient, cumbersome administrative processes that inhibit nurses' ability to provide coordinated, high-value patient care.

What Can Nurses Do To Make Value-Informed Nursing Practice a Reality?

Adopting a value-informed lens as part of nursing practice will need significant support from nursing leadership, educators, and researchers. Moving toward value-informed nursing practice will require transformational, courageous and resilient nursing leadership at the highest level. As evidenced by the continued barriers to full practice authority for advance practice nurses, nursing leaders will he to be ready to confront the political power of both medicine and administration. Nursing leaders must speak about the importance of value-informed care; they must encourage and elevate nurses who identify ways to promote efficient use of resources and cost-containment; and they also must be ready to support and safeguard nurses against potential retaliation. Nursing units must be staffed appropriately to allow nurses the bandwidth needed for critical evaluation of resource use and the delivery of value-informed care. Lastly, nurse leaders must ally with hospital administration and medicine to ensure a transparent and fair distribution of financial gains from nurse-initiated or nurse-led cost-sing reousrce-use innovations, and reinvestments of these gains back to the unit.

For nursing educators, it is crucial that nurses more deeply understand the factors that contribute to the value of health care, as well as reimbursement and expenditures connected to nursing care. Cost and value competencies must be incorporated as foundational to professional nursing practice. The 2021 Entry-level Essentials now include cost and efficiency as key elements of nursing practice—this is a significant development and a first step toward value-informed nursing education (

Yakusheva et al., 2021

We will discuss the role of educators in more detail in Part 6 of this Series

Buerhaus Simon Yakusheva, 2022

Nursing researchers need to study how nurses can contribute to waste- and cost-reduction through their everyday practice. Although a robust body of evidence demonstrates the contribution of nursing to quality and safety outcomes, the extent to which nurses can reduce unnecessary use of resources and costs is largely unknown. Among other glaring evidence gaps are nurse-led approaches to social determinants of health and nurse actions to reduce exorbitant environmental hospital waste. Nursing science should address these important, feasible research questions to help control health care spending, reduce costs and increase the value of nurses

Cohen et al., 2021

Conclusion

Value-informed nursing care is nursing practice that focuses not only on the outcomes but also on the costs of the care. Practicing value-informed nursing care means identifying and eliminating unnecessary, redundant, low-value care, and it requires practicing nurses, nursing leaders, nursing educators, and nursing researchers to work together to identify, scale-up, and disseminate innovative nursing practices to reduce waste, lower cost, and improve patient outcomes. In Part 2 of this series on value-informed nursing practice, we discuss the economic and policy drivers that necessitate the adoption of value-informed nursing practice.

正文翻译（仅供参考）

摘要

医生每天 24 两星期就在无数医疗透过生态之中采用廉价的财力做出暂时。因此，医生不仅与医疗极低质量和人身安全密切相关，而且与医益密切相关。本文是关于零售业价值告知医疗工具论的 6 之外三部文章的第 1 之外。它详细描述了“以零售业价值为出发点的医疗工具论”的概念——这种工具论不仅关心结果，还关心医益——作为不切实际医疗工具论的一种新手段。

正文

在轮班开始时上传患病病人名单，您注意到 X 妻子已被重新接纳。89岁的她，很有个性。你想起她兴较极低采烈地称呼自己为“Noo Youk Goull”，执意要她化妆并随时一目了然头发！然而，今日，X 妻子是一个蓬头垢面、充满焦虑的定格。您还想起 X 妻子之前的住院计划侧重于政府机构她狡猾的焦虑的策略性。当你转到她的病院时，她正试图可能可能会呼吸。她颤抖着。她想起你：“我这次心脏病发病了，我确定！” 她恳求。看着她的心脏监护仪显示正常的窦性心律，你真的那不是真的。但是，12 导联测量仪器是这两项的，它则可能会让她平静下来……另外，你还有其他病人要担心，其之中一些病人病得很重。在她 11 两星期的患病长期，X 妻子循环进出可能可能会呼吸，并开展了 3 次测量仪器检查，均正常。住院后，她和丈夫都隆了一口气。“一切为她完毕了，”他们说。他们对飞行测试的数量觉得用心。但是你想真的他们所用心的“一切”否太多了。

1 此情景基于其之中一位写作者所见所闻的真实故事。

在极低年收入之中，零售业价值被定义为透过的病变医疗结果相乘用于意味着结果的财力效益。较极低零售业价值医疗可以在采用最少财力的同时优化病变的病人优点。传染病性医疗（例如疫苗接种）是较极低零售业价值医疗的一个例子。另一方面，上面的小原唱说明了极低零售业价值的医疗：为 X 妻子和她的丈夫开展了多次测量仪器检查以平息她和她丈夫的恐惧，占用了病院财力，而 X 妻子的结果几乎无法优化。到头来，X妻子的那份关怀是无用的。

虽然极低零售业价值的医疗看起来无伤大雅——毕竟，无法造成任何后果，而且 X 妻子和她的丈夫确信她没事——但透过但可能会的、多余的服务于可能会无用宝贵的（且廉价的）医疗财力，而这些财力无论如何可以被采用其他有零售业价值的原因。在我们的示例之中，重复使用但可能会的飞行测试使其他病变的设备和技术工作人员的等待时间减小，可能随之而来他们的诊断和病人延误；当 X 妻子占用房间内时，于在 (ER) 病变可能长期以来在等待患病病床，而其他病变可能长期以来在等待急诊病床。在整个澳大利亚极低年收入子系统之中，此类无用极低年收入财力的事件每年总计较极低逾 9350 亿美元，通过高明地采用财力可以传染病较极低逾 2860 亿美元。(Shrank 等人，2019) 这笔钱就可能会被无用，而是可以为澳大利亚所有以外无法保险的人透过进一步的 Medicaid 保险，或者让澳大利亚所有病院的医疗工作人员增加近百一倍。

由于医生每天 24 两星期在无数医疗透过生态之中暂时采用廉价的财力，因此医生不仅与医疗极低质量和人身安全密不作分，而且与医益密切相关。此外，医生是最大的环境卫生业余球队——2021 年据估计为 360 万人——并且是年收入最较极低的环境卫生业余球队之一。因此，我们能够对医疗工具论有一个更为进一步的引介，从整体上引介到医疗工具论以两种手段实际上影响病变——实际上通过医生为病变透过的医疗，以及间接通过占用廉价的极低年收入财力，否则有利于其他病变的医疗。本文详细描述了以零售业价值为出发点的医疗工具论——不仅关心结果，而且关心医益的医疗工具论（琼斯沃德和雅库舍瓦，2022;Yakusheva 等人，2020,Yakusheva 等人，2021 年)——作为不切实际医疗工具论的一种新手段。

经济势在必行

鉴于澳大利亚极低年收入子系统的极低绩效和较极低昂的效益，向基于零售业价值的缴交Mode的持续交替是某种程度的。几十年来，按服务于收费的缴交子系统努力可能可能会采用财力和其他极低年收入财力。基于透过的服务于量的报销，几乎不回避病变的结果，成立了一个笨重且前所未见的廉价的极低年收入子系统，最终随之而来肥胖症结果停滞不前，甚至减小，以及不作遵从的肥胖症落差。大幅度下降的极低年收入支出（以外占国内总支出的 17.9% 或在澳大利亚花费的每一美元之中的近百 20 美分）是澳大利亚个人和之中产阶级面临的主要问题。国家就让忽视极低年收入服务于的真正零售业价值，包括效益、谁缴交以及如何缴交。和效益衡量；40% 的有别于医疗保险、30% 的零售业缴交和 25% 的医疗补助缴交是通过某种基于零售业价值的安排开展的。效益回避主因使病院、疗养院和护士工具论越发多地对所透过服务于的极低质量和效益主要职责。在过去的十年之中，医生也可以考虑到在所有工具论生态之中衡量和提较极低医疗零售业价值的供给越发大，因为效益、价格和医疗透过将趋于越发透明。因此，医生需要努力管控效益和提较极低医疗零售业价值。这种转变假定医生需要学可能会透过与大幅度工业发展的缴交子系统相一致的零售业价值出发点型医疗，减小无用和但可能会的效益，并能够地受限制病变、丈夫。

零售业价值告知的医疗工具论假定什么？

零售业价值告知的医疗工具论是在外科决策之中无论如何回避结果和意味着结果所需的财力效益的工具论。(琼斯沃德和雅库舍瓦，2022;Yakusheva 等人，2020,Yakusheva 等人，2021 年) 在我们的开篇段落之中，以零售业价值为出发点的医疗工具论将实际上化解这种情形的根本原因，即 X 妻子的焦虑。因此，实行以零售业价值为出发点的医疗将有助于避免重复使用但可能会的飞行测试的连锁反应，同时就可能会对 X 妻子造成后果；事实上，X 妻子可能已经学可能会了一些让自己平静下来的技巧，并在家里采用它们，则可能会防止未来可能会但可能会的再次入院。

工具论零售业价值告知医疗假定医生妥当评估情形，着眼于有效性和高明地采用财力。在 X 妻子的范例之中，尽管当时遵循这两项方案对医生来说可能是一种费时的必需，但妥当回避潜在的下游后果和效益的整个螺栓则可能会随之而来不同的外科暂时——一种可以减小总体财力采用和效益并优化病变预后的工具。

以零售业价值为出发点的医疗工具论的一个关键之外是回避关于一个病变医疗的外科决策如何实际上影响其他病变的医疗。虽然医生对于需要将等待时间分配给病变的众多供给极为陌生，但最重要的是要记住，下游实际上影响则可能会实际上影响到实际上分配给您医疗的病变之外的病变。当这些其他病变能够的财力被立即用于对病变的医疗时，他们的医疗则可能会延时或减小。尽管此时这些其他病变对您来说是“好比的”，但他们是您助手的病变，他们今晚则可能会视为您的病变，因此他们的供给和结果与您现在实际上在您一旁的病变一样最重要。

涡旋，1996 以零售业价值为出发点的医疗工具论假定作为“医疗场景”的一之外，视为高明的财力采用者，并采用最少的财力为您的病变意味着考虑到结果。(琼斯沃德和雅库舍瓦，2022;Yakusheva 等人，2020,Yakusheva 等人，2021 年)在发表意见零售业价值出发点的医疗工具论“是”时，同样最重要的是要务实零售业价值出发点的医疗工具论“不是”。零售业价值告知的医疗工具论就可能会也不一定可能会要求医生慎重考虑为病变透过的医疗极低质量，以降极低效益。在我们的小原唱之中，在无法但可能会的飞行测试的情形下化解 X 妻子的焦虑则可能会透过大致相同甚至能够的结果，因为焦虑的核心问题可能会得到更为实际上的引介和化解。以零售业价值为出发点的主要要能医疗工具论仍然是透过较极低极低质量的病变医疗，只是以减小或避免极低年收入财力无用的手段这样做。以外，但可能会的检测和其他可能可能会病人和/或极低零售业价值服务于有约占每年近百 1 万亿美元的极低年收入无用的 10%。(Shrank 等人，2019）

。极低年收入无用的另外两个主要缺少是行政机关重复性（较极低逾 35%）以及医疗服务于透过和相互合作收场（有约 25%）。(Shrank 等人，2019）。医疗已经将医疗相互合作作为医疗工具论的一之外，许多分析和极低质量改进工作由医生积极支持，以减小相互合作收场和简化医疗步骤（例如，病院到之中产阶级的交替、政府机构）。然而，化解可能可能会病人、极低零售业价值医疗和行政机关重复性问题极为实质上属于医生的实际上影响范围，能够行政机关和医学部门的支持。尽管如此，医生需要开始在他们的工具论之中不属于责任，即呼吁极低零售业价值医疗和极低效、繁琐的政府机构步骤，这些步骤可能会可抑制医生透过相互合作的、较极低零售业价值的病变医疗的能力。

医生可以做些什么来使零售业价值告知的医疗工具论视为本质？

在医疗工具论之中采用零售业价值出发点的视角能够医疗积极支持、教育工写作者和分析工作人员的大力支持。引领以零售业价值为出发点的医疗工具论将能够最较极低级别的变革性、勇于和有弹性的医疗积极支持。正如较极低级社可能会工写作者医生进一步社可能会工写作者越权的持续阻碍所断定的那样，医疗积极支持者需要准备好面对医学和行政机关部门的政治权力。医疗积极支持者需要谈谈零售业价值告知医疗的最重要性；他们需要努力和提拔那些发现工具来推动财力有效性利用和效益管控的医生；他们还需要准备好支持和保护医生免受潜在的报复。医疗单位需要配备必需的工作人员，以使医生能够得到对财力采用开展关键评估和透过零售业价值告知医疗所需的带宽。最后，医生积极支持需要与病院政府机构部门和医学部门对抗，以确保透明和平等地分配由医生发起或由医生主导的最大限度效益的财力采用技术创新所带来的帐目收益，并将这些收益再入股回单位。

对于医疗教育者来说，医生更为侧重地了解实际上影响极低年收入零售业价值的主因以及与医疗相关的报销和支出至关最重要。效益和零售业价值能力需要作为从业者医疗工具论的根基。2021 年入门级要点现在将效益和效率作为医疗工具论的关键要素——这是一项重大工业发展，也是引领零售业价值告知医疗教育的第一步

（Yakusheva 等人，2021 年）。我们将在本三部的第 6 之外（琼斯沃德和雅库舍瓦，2022）。

医疗分析工作人员能够分析医生如何通过日常工具论为减小无用和效益做出贡献。尽管有大量证据表明医疗对极低质量和人身安全结果的贡献，但医生可以在多大程度上减小但可能会的财力和效益采用在很大程度上是未知的。其他明显的证据落差包括以医生为主导的肥胖症社可能会暂时主因工具和医生为减小过较极低的生态病院无用而采取的秘密行动。医疗生物科学一定可能会化解这些最重要的、难以意味着的分析问题，以协助管控极低年收入支出、降极低效益并提较极低医生的零售业价值。

（怀特等人，2021）。

结论

零售业价值告知医疗是一种医疗工具论，不仅关心结果，还关心医益。工具论零售业价值告知的医疗假定辨别和避免但可能会的、多余的、极低零售业价值的医疗，它能够社可能会工写作者医生、医疗积极支持者、医疗教育者和医疗分析工作人员共同努力，辨别、扩大和传布技术创新的医疗工具论，以减小无用、降极低效益并优化病变病人优点。在本三部关于零售业价值告知医疗工具论的第 2 之外之中，我们发表意见了能够采用零售业价值告知医疗工具论的经济和政策液压主因。

本文转载自其他网站，不代表肥胖症界观念和主张。如有细节和图片的著作权断然，再三及时联系我们（邮箱：guikequan@hmkx.cn）

。

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