A simple benchmarking project for hospice
Improve outcomes and meet QAPI requirements
Keep it simple. Start with one study. Pick an event or symptom that is easy to monitor. As hospice managers began looking for ways to meet the Quality Assessment Performance Improvement (QAPI) requirements of the new hospice Conditions of Participation, experts recommended that hospices new to performance improvement studies choose a study that is easy to monitor, analyze, and implement improvement strategies.
Because patient falls greatly affect outcomes, falls reduction has been a topic chosen by many hospices, because it is easily measured and there are a number of interventions that can be used to improve fall rates.
Although the performance improvement project is only a few months old, the staff at Hernando Pasco Hospice in Hudson, FL, are happy with the almost 50% reduction in falls seen in two of the three hospice care centers during the first months.
"Our goal was to reduce falls by 10% over the previous month, and we reached that goal during the second test of our data collection tool," says Jana Donovan, RN, administrator of the Hernando Hospice Care Center in Brooksville, FL, one of five hospice care centers operated by Hernando Pasco Hospice. As the project continued testing different tools and policies related to falls prevention, the staff's level of awareness of the importance of this issue increased, she says.
"People often assume that hospice patients will fall because of the progression of their illness or the medications they are taking, so there is often a 'so-what' attitude," says Charlene Ross, RN, MSN, MBA, partner and consultant with RBC Consulting for hospices in Phoenix. "The reality is that hospice patients often fall into the category of high risk for falls, because they are over the age of 65, in a weakened physical condition, and on many medications that contribute to falls," she says.
Hospice staff members should be concerned about falls because the patient has chosen hospice as the type of health care they want at the end of their life. Falls must be avoided to allow the patient to stay in their home, says Ross. "We have to respect the patient's wishes and do what we can to ensure a safe environment, so the patient does not have to go to a nursing home or hospital."
When Norwell (MA) VNA and Hospice started the hospice program for the agency one year ago, there was no question about whether the home health agency's falls reduction program would be implemented, says Jackie Crossen-Sills, PhD, PT, director of program development for the agency.
The home health agency has a falls reduction program titled "Watch Your Step" that has been in place for years, she says. They have modified the program for hospice patients, but it is just as comprehensive as the home health program, Crossen-Sills adds.
Patient and family educational fliers; environmental assessments for items such as scatter rugs, low lighting, or lack of grab bars; and a medical assessment to determine if the patient's physical condition, mental status, or medications might increase the risk of falls, is provided for all hospice patients, says Crossen-Sills. "The falls risk assessment form for home health is built into our electronic OASIS [Outcome and Assessment Information Set] forms used by the nurses, but because hospice doesn't use OASIS, we have printed paper copies of the forms for the hospice nurses to use," she explains.
Almost all hospice patients are at high risk of falling at some point during their care, admits Crossen-Sills. "This doesn't mean that we can't reduce the risk of falls to prevent hospitalization or injury to the patient," she adds.
Staff training is a key part of any falls reduction program, says Ross. Because collection of falls data is an integral part of identifying reasons for falls, trends, and numbers of falls, staff members need to understand the importance of collecting the information, she says. Although educational meetings at the beginning of a falls reduction performance improvement project are important, hospice managers also should plan on offering several types of programs related to falls reduction throughout the year to maintain awareness, Ross suggests. Staff members also should be involved in the creation of tools or the analysis of the data to improve understanding of the project, she says.
Although assessing risk factors at the start of care is important, the most critical data collection tool is your incident report form, says Ross. It is important to collect information about location, time, and activity during the fall, she says. "All hospice employees need to understand the importance of reporting falls, even if they were not witnessed," Ross adds.
Of course, the first step to being able to report a fall is understanding what a fall is, says Donovan. "We had employees who didn't complete an incident report form because they did not think the patient had fallen," she says. The employee would report that the patient went to her knees or that the patient was found sitting on the floor, but there would be no report of a fall, Donovan says. "Now, we have a clear definition of a fall that is not open to interpretation, so we have more consistency in our reports," she says. The agency describes a fall as "a sudden, uncontrolled, unintentional downward displacement of the body to the ground or other object, excluding falls resulting from violent blows or other purposeful actions."
Once the reports are collected and the data analyzed, the performance improvement person or team should identify the most likely cause of the falls and implement an intervention strategy, suggests Ross. "It can be as simple as reminding aides to have the patient sit at the edge of the bed for a few minutes before getting out of the bed or placing a bell next to the bed if the patient fell while reaching for something out of his or her reach on the bedside table," she says. Test the intervention in a small group of patients to see if it has a positive effect, then implement it hospicewide, she says.
Review of data, analysis of causes, and implementation of interventions are a continuous process that demonstrates to the Centers for Medicare & Medicaid Services (CMS) that the agency is meeting QAPI requirements, says Ross.
Although a hospice's data over time can be used to show trends and improvement, benchmarking against other hospices also is important, says Ross. "The challenge with benchmarking data for hospices is that there is not a lot of published data on fall rates in hospices," she admits. "However, a hospice should establish a fall rate and benchmark with itself quarter over quarter or with peer hospices if the data is available. Multisite programs have the advantage to benchmark with other programs within the organization."
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