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is the largest national specialty organization dedicated to improving patient care and quality of life by defining, enhancing, and promoting the role of oncology nurse and patient navigators. This organization of over 8,200 members was founded in 2009 to provide a network for all professionals involved and interested in patient navigation and survivorship care services to better manage the complexities of the cancer care treatment continuum for their patients. It views itself as an organization consisting of “professional patient advocates” and, to that end, it supports and serves its members. This organization links to a separate credentialing arm and encourages nurse and patient navigator certifications as a means of enhancing and ensuring the quality of its members’ practice.

A Step Back: Affordable Care Act Emerged Where Efforts Converged

In March 2010, the US Congress passed and the President signed into law the ACA. Although the provisions were many and even over 10 years later remain amazingly controversial, from the perspective of driving improvements in quality several key provisions of the law, as they have been phased in, have provided significant opportunity to reshape delivery of care. Nurses played a critical role in designing and supporting passage of these provisions and have since had significant opportunity to influence, recommend, and in some cases design innovations in care delivery that are consistent with these provisions and with implementation of various aspects of the law focused on the improvement of quality. Nurses have also benefited from the emphasis on quality in clinical practice through inclusion in pay for quality reimbursement structures and alternative payment models that replace fee‐for‐service models. The following are some of the key provisions specific to quality and safety.

      Improving Health Care Quality and Efficiency

      The law established the Centers for Medicare and Medicaid Services (CMS), which conducts pilot demonstrations to test new ways of delivering care to patients. The Innovation Center develops new payment and service delivery models in accordance with the requirements of Section 1115A of the Social Security Act. Additionally, Congress has defined, through both the ACA and previous legislation, a number of specific demonstration projects to be conducted by CMS. This Center continues to search for existing and promising innovative programs that can be replicated or scaled up to improve the quality and safety of health care delivered, while also reducing the rate of growth in health care spending for Medicare, Medicaid, and the Children’s Health Insurance Program (https://innovation.cms.gov/innovation‐models/map#).

      New and promising innovations occur in numerous states and are continually seeking additional participants. A few of the latest entrants include a variety of initiatives focused on Accountable Care Organizations (ACOs). For instance, one innovation is studying the quality and cost of providing Program of All‐Inclusive Care for the Elderly (PACE) program services under Medicare and Medicaid models of care. Another is working to improve kidney care choices and end‐stage renal disease (ESRD) models of care for Medicare recipients. Yet another demonstration provided incentive payment awards to participating nursing homes that perform the best or improve the most in terms of quality. Nurses and nursing care figure prominently in each of these demonstrations. Included in this provision, the Department of Health and Human Services (HHS) was required to submit a National Strategy for Quality Improvement in Health Care that would include these programs in addition to those of third‐party payers.

      Linking Payment to Quality Outcomes

      Since 2010 the ACA has established a Hospital Value‐Based Purchasing (VBP) program for traditional Medicare participants. No longer do hospitals receive reimbursement for care based exclusively on the quantity of services delivered. This program offers financial incentives to hospitals to improve the quality of care provided to Medicare patients through CMS regulations implemented through the Hospital Inpatient Prospective Payment System (IPPS). This method of payment rewards institutions based on how closely they adhere to best clinical practice, as well as on their improvement of the patients’ experiences of care during hospitalization. The Hospital VBP program works for Medicare patients by creating disincentives and rewarding reductions during acute care inpatient stays based upon reviewing the following:

       Eliminating or reducing adverse events (health care errors resulting in patient harm).

       Adopting evidence‐based care standards and protocols in order to obtain the best outcomes for Medicare patients.

       Incentivizing hospitals to develop processes that improve patient experience.

       Increasing the transparency of care quality for consumers, clinicians, and others.

       Recognizing hospitals that provide high‐quality care at a lower cost to Medicare.

CMS withholds participating hospitals’ Medicare payments by a percentage specified by law (2%). It uses the estimated total amount of those reductions to fund value‐based incentive payments to hospitals based on their performance in the program. CMS applies the net result of the reduction and the incentive payment amount in the fiscal year associated with the performance period. In keeping with the intent of transparency and accountability, hospital performance is publicly reported using a quality star rating system in Hospital Compare (https://www.medicare.gov/hospitalcompare/About/Complications.html). The Hospital Inpatient Quality Reporting Program is based on measures relating to mortality and complications; health care–associated infections; patient safety, patient experience; process; and efficiency and cost reduction. Early in the development of this process stakeholders and quality alliances, including nursing, submitted public comments regarding the proposed rules that would implement the VBP provision. Fiscal year (FY) 2020 rules were based on eligible hospital discharges that occurred between July 1, 2015 and June 30, 2018. Rates of readmission include measures of unplanned hospital visits after an outpatient procedure and hospital return days, and the readmission measures are estimates of the rate of unplanned readmission to an acute care hospital in the 30 days after discharge from hospitalization. Patients may have had an unplanned readmission for any reason (https://www.medicare.gov/hospitalcompare/Data/Hospital‐returns.html).

      The work of developing and endorsing performance measures that meet the intent of this provision are the result of work in which various entities, alliances, and individual stakeholder organizations continue to engage. Measure development remains some of the more important and most challenging work in policy related to ACA. Measures, if appropriately defined, can quantify the quality of the care delivered for payment, and they also focus attention on issues that are major factors in whether patients survive medical or surgical interventions and hospitalizations. Measurement burden is a significant issue that has led to much greater reliance on only using measures that can be electronically collected. This burden and the realization that large number of measures being reported have resulted in significant measure‐reduction efforts and elimination of some measures that are most relevant to nursing care, but can be difficult to capture in electronic medical records. Equally challenging is the expensive pilot testing and subsequent endorsement and measure maintenance processes to demonstrate the adequacy and accuracy of such measures for reporting to the public, and for payment. Nurses have great opportunities for influence in the development and adoption of measures that reflect the outcomes and patient experiences of care, including care delivered by nurses.

      Encouraging Integrated Health Systems

      The ACA provided incentives for physicians and other providers to join together to form ACOs, which allow physicians and other providers to better coordinate patient care and improve health care quality, help prevent disease and illness, and reduce unnecessary hospital admissions. When an ACO provides high‐quality care while reducing costs to the health care system, rules allow the ACO to keep some of the money saved. Key stakeholder groups, including nursing, engaged in public comments in response to

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