Variance tracking, analysis easier with guidelines
Care managers at Grady Health System in Atlanta don't use critical paths for tracking variances. Because the hospital doesn't use paths at all, program developers have set specific goals for variance tracking and implemented a reporting form for variances, explains Laura W. Hurt, MHA, RN, CNNA, director of medical/surgical nursing and developer of the Grady Care Management Model.
The system's 10 care managers follow these eight guidelines when collecting and documenting variances:
1. Purpose:
* to serve as a systematic method for data collection;
* to document accurately and completely each discipline's contribution to care and the client's response to that care;
* to serve as a tool analyzing the need for enhancing service delivery.
2. Nature of form:
The Care Management Variance Reporting Tool is a one-sided form that is completed in blue or black ink and is not a permanent part of the medical record. It is a confidential record and is used by the care manager for case reviews, evaluations, recommendations, computations, and analysis for the improvement of service delivery.
3. Operational definition:
The Variance Reporting Tool is a unit-based clinical outcome report used to record the differences between what is affected within the episode of illness and that which was achieved.
A variance is anything out of the normal course described in the patient plan of care.
4. Types of variances:
* Patient condition or severity of illness. The patient has an exacerbation of the primary diagnoses or experiences a medical complication, such as an infection or drug reaction.
* Caregiver-related or practice pattern/practitioner. Individual practice patterns or behaviors that altered the expected outcome, such as incorrect diet/preps, failure to obtain a permit, procrastinated appropriate care, and lack of timely orders for procedure.
* Hospital systems. Internal or external department practices, actions, and policies that delay expected course of care, such as operational inefficiencies, which are under hospital control, frequent machine breakdowns, unacceptable log times in receiving X-ray and lab data results, or unavailability of certain services or personnel on weekends.
* Relative severity. Rate on a scale of one to three the severity of the variance as it affected the patient:
1 = A. no prolongation in hospital stay;
B. no immediate danger to the patient;
C. no medical/nursing treatment required.
2 = A. there is delay in discharge;
B. medical/nursing treatment interventions required.
3 = The occurrence is life-threatening, such as unexpected death, unscheduled return to surgery, nosocomial bacteremia confirmed by positive blood culture, serious complications of anesthesia, or fall with serious injury.
5. Patient population:
This form applies to all patients in the medical-surgical area.
6. Persons responsible:
It is the responsibility of the Care Manager to initiate and complete the tool for each patient on the unit.
7. Tool placement:
The Care Manager will place the reporting tool in a three-ring notebook. The report, when not in use, will be kept in a locked drawer.
8. Detailed instruction:
Type of Variance: State the type of variance as caregiver RN, MD, LPN, NA, SW, PT, RT, internal system, external system, and/or severity of illness. State the nature of the variance, identify names of individuals with caregiver variances.
Cause: Investigate the cause of the variance. If known, explain; if unknown, state unknown.
Intervention Action: State what was done by health team. State what was ordered. State what was done by patient.
Relative Severity: Categorize according to the scale.
Outcome: The outcome is the end result of the occurrence of a variance. Examples of negative outcomes are increased LOS, deterioration of patient condition, injury to patient, and delay of treatment or diagnosis. Be very specific when describing negative outcomes. If outcome was positive, just state no negative results.
Follow-ups: Note if patient was readmitted or returned to emergency department since discharge. Note if patient kept or missed clinic appointment. *
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