Do you need a PI program for your PI program?
Accreditation spurs action plan at one agency
When Judy Scarborough, RN, started her job as quality improvement and district nursing supervisor for the Cincinnati Health Department in 1996, she noticed that there was no method for regularly dealing with problems as they arose. She also noticed that performance improvement (PI) was a big part of the Joint Commission on Accreditation of Healthcare Organizations' (JCAHO) 1997/98 manual. Lastly, Scarborough noticed that proposed legislation that would change Medicare conditions of participation put greater emphasis on agencies having a PI program in place. It seemed obvious to her that the agency had to do something.
The result has been a yearlong process to put together a PI team and program so that when the department applies for JCAHO accreditation this summer, it is prepared.
Scarborough's first step was to gather a team of people who would be both helpful and interested in creating a valuable PI program. "We wanted to have a well-functioning PI committee that is proactive in identifying both problems and potential problems."
Initially, there were 10 members of the group, representing all of the programs offered by the department - maternal/child, adult care, disabled children, and medical social services. One staff nurse, four nursing supervisors, and five public health nurses sat on the team. The latter group are assistant supervisory level employees, and participated partially because their supervisors nominated them to participate in their stead, Scarborough explains.
Now there is a move to add to the team, bringing in the contract manager for the rehabilitation program and another staff nurse to replace the one who was recently promoted, she adds.
Help from her peers
In developing the PI program, Scarborough says she knew she needed assistance from others who had gone before her. She got in touch with two home care agencies in Cincinnati. "Sometimes, with so much competitiveness, it's hard to get information," she says. "In our area in particular we are inundated with Medicare agencies, so it can be really hard to pry information away."
Luckily, one of the nursing supervisors at the department sits on another agency's quality improvement committee. She introduced Scarborough to the manager of that quality program. She also used the Columbus, OH, health department as a resource. "They were already accredited, and they helped by providing me with sample documentation and some good books that could help." (For a list of helpful publications, see box, p. 110.)
Through her consultation and reading, Scarborough chose a problem-solving method that would suit the department: Plan Do Check Act (PDCA). Scarborough chose this method in part because it is used by the Columbus health department, which will allow for easier benchmarking between the agencies. "In looking at their documents, too, it seemed the easiest route to go," Scarborough says.
Simply choosing PDCA was just the beginning. "It may sound simple, but after we picked it, we had to understand the whole process of PDCA," she says. Scarborough went to her local library and searched for articles on the PDCA method, and she attended a Joint Commission workshop on PI that she found helpful.
Next, Scarborough and her team started to develop the forms the PI program would use. Because the Columbus health department was being so forthcoming, Scarborough opted to adapt those forms to the Cincinnati department's needs. Two forms resulted: one for employee suggestions for quality improvement projects, and another outlining project specifics. (See sample forms, at left and on p. 111.)
Scarborough says there were two issues she was concerned with in creating the forms. First, she knew that the Joint Commission liked to see a paper trail of problem identification, and the actions taken to correct those problems. Second, Scarborough wanted to create forms that would encourage staff members to identify a problem and submit it to the PI team.
Staff are often so busy, she says, that they can be put off by the idea of even identifying a problem for fear it will create more work and more bother. By creating a user-friendly form, Scarborough hopes to overcome that issue. "That is the proactive means of solving a problem," she says. "I wanted a form that would let me see the problem, put my thoughts down, and submit it to the PI group to see if it merited team action now, or if it should be put aside in favor of more urgent matters."
She is still at work on a third form that will track problem-solving, including spaces for records audits, materials needed for a particular project, and data requirements.
Next comes the training. Scarborough is fine-tuning her inservice program and putting together the teaching materials. She hopes to include a sample PDCA problem and a workbook for staff. "I want to have that training package finalized in late June or July so we can move on.
By the end of the summer, Scarborough hopes to be deep into the training. "Then the next step will be to identify one of our bigger problems as an agency and attack it using the new program," she says.
In the year she has been working on a PI program, Scarborough says she has learned a few lessons. "I read a lot," she says. "But you can get bogged down with too much information. If I had some management or statistical background, that might have helped me."
She has some fears about the future and her lack of expertise in graphing her data. "We have looked at results and put in the percentage of compliance and noncompliance. But we haven't ever graphed that data. It makes me nervous."
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