Documentation program saves the day
Patients, nurses, Medicare surveyors all like it
A Michigan home care agency had received a passing score by a Medicare surveyor in 1995, but the agency was warned that it would have to improve its documentation in 1996.
So the clinical supervisor and the performance improvement coordinator for Alpena General Hospital Home Care Services in Alpena, MI, saved the day.
Sandra Purol, RN, clinical supervisor, with assistance from Mary Jo Skiba, BSN, RN, performance improvement/marketing coordinator, put together a new documentation program that taught nurses how to become focused on specific patient problems while treating the patient holistically. Before, they focused only on the specific nursing procedures.
The change landed the agency a high rating during its 1996 Medicare survey, which was conducted by a surveyor from the Joint Commission on Accreditation of Healthcare Organizations of Oakbrook Terrace, IL. The agency has deemed status, so every year a Joint Commission surveyor conducts its Medicare survey, and every third year the agency receives a full Joint Commission survey.
Alpena is a hospital-based agency that has 23,000 visits a year in four counties of northern Michigan.
The surveyor had told the agency in 1995 that their documentation was a concern: "She told us that if we changed the documentation format, we’d improve our compliance 100-fold," Purol says.
Nurses, who at first were reluctant to change, now are pleased with the change. (See program for improving documentation, p. 12.)
Purol and Skiba held a five-part series of inservices on a fresh way for nurses to document patient care, admissions, and discharges. They spent three months working on the inservice, concentrating on improving the trouble spots noted in the agency’s 1995 Medicare survey.
"The nurses weren’t focused on the documentation portion of what they should be doing," Purol explains, adding that the way nurses used to fill out documentation forms was to note a lot of extra details.
"They might write down how a patient was sitting in a chair, dressed in a nightgown because they thought they had to fill in all this unnecessary information," she recounts. "So a lot of times they would fill in this excess information and never document what they taught and what the problem was."
Previous problems led to education for nurses
Purol gives another example of how the previous documentation process was too vague: "One part-time LPN always felt that when she went to a home, she had to do something physical, something hands-on with the patient."
Once the agency switched to problem-oriented documentation, the nurse started to focus on specific problems. She had difficulty making the patient’s dietary needs or caregiver teaching a priority before, but after the change she did. Purol says she began to look at the whole picture.
Education was the key: Purol and Skiba held five mandatory meetings for nurses that lasted 11¼2 hours to two hours each. "We met with the nurses and reviewed all their cases, giving them clues on how to impact the care plan process," Skiba says.
They started with a plan for implementing the series. Their goals were to improve documentation, improve quality of care, receive better reimbursement, and improve compliance with survey findings.
Their plan outline went like this:
• Present each series in two-hour classroom lecture format.
• Videotape each series.
• Prepare handouts to correspond to each lecture.
• Incorporate the series into all new RN’s initial orientation.
• Follow-up with a documentation update every six months.
• Hold case management meetings, which focus on following the plan of care and revising it, with each RN case manager individually. (These were set to last one half hour with the performance improvement coordinator, starting every two weeks and then decreasing to once a month.)
• Have performance improvement coordinator do in-depth admission paperwork reviews on every admission.
• Provide constructive employee feedback until learning is ingrained and the employee is able to process the information independently; also, perform recertification brief review to ensure care planning process is ongoing.
At first, the nurses resisted the changes, Purol recalls. "Some of the nurses have been here a long time. They felt offended that we were telling them that their documentation no longer is good enough."
Nurses have to think more
Initially, the agency used check-off work sheets. The change gave nurses more documentation, Skiba says. "Now the system is much better, but they have to think more."
Skiba and Purol eased the growing pains their staff felt by offering plenty of positive reinforcement.
"We nurtured them, gave them a lot of TLC," Skiba says. "Eventually they saw how much better it worked."
After the successful Joint Commission accreditation in 1996, management met with staff to provide positive feedback.
Purol acknowledges that not everyone adjusted to the change. Several nurses left the agency because they could not adapt to the changes. "But the remaining nurses are doing well."
Since the change, the nurses have become more focused. When they admit a patient, they identify exactly which problems the patient has. An example might be if the patient has had changes in his or her diet.
Purol emphasizes, "Maybe the patient had a 15-pound weight loss, and so that’s why we’re going in there to teach the patient proper diet and nutrition."
Skiba has noticed that the agency’s nurses also are taking better care of patients’ wounds and documenting medication more effectively.
"Before they were filling out forms without understanding why," she says. "They were just writing down exactly what they did without writing down why they were doing it. Now they have a whole better understanding of it."
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