Performance improvement: Make the most of Joint Commission requirements
Effective plan can provide competitive advantage
Performance improvement (PI) gets a lot of press today. It is a mainstay of the revised Joint Commission on Accreditation of Healthcare Organizations (JCAHO) home care standards and a re-engineering buzzword.
But sources say some providers are struggling with its implementation, bogging down in details, or glossing over plans that could significantly affect patient outcomes rather than just meeting JCAHO intent.
"There is a lot of variability in what providers think is important, and differing amounts of effort put into performance improvement," says Deborah Kranz, RN, MPH, a consultant with Kranz and Lamb Associates, an Oak Park, IL-based home care consulting firm.
But an effective PI plan can be a real competitive advantage, enabling providers to improve their patient outcomes and differentiate and quantify their care.
JCAHO standard PI.1 makes this requirement: "The organization has a planned, systematic, organization-wide approach to designing processes, and measuring, assessing, and improving its performance." This broad directive gives little guidance, but sources say you can design and implement an effective PI plan with the following key actions:
· Determine organizational priorities.
The first PI implementation step is determining what is important to your business. Organizational priorities often fall out of the strategic planning and budgeting process, says Kranz. For example, new services or programs for payers are typically accounted for in annual budgets, although they may be implemented over the course of a company's fiscal year. A provider should establish two to three broad objectives that can be accomplished within a year, suggests Kranz.
· Identify routine measures.
Routine measures are the day-in, day-out patient care and customer satisfaction gauges most companies use, such as chart audits, patient satisfaction surveys, incident reports, and other methods. In developing its performance improvement plan, an organization should review its established measurements.
· Establish a steering committee.
The steering committee oversees the entire PI process. It establishes the overall plan, identifying targets, determining process methodology, assessing individual team progress, and determining board and executive management reporting frequency. Senior management and multidisciplinary staff representation on the committee is essential, says Kranz. As a resource gatekeeper, the senior manager should keep the committee pointed in the right direction, preventing it, for example, from pursuing projects too costly for the organization to undertake.
Don't forget to include office staff
Most organizations have clinicians on the steering committee but may omit office-based staff. Because "clinical staff lose focus on the impact of changes in the office," as Kranz puts it, she recommends including the office manager or someone familiar with the company's clerical procedures. Human resource and finance functions also should be represented.
· Designate improvement targets.
Improvement targets may be predetermined based upon organizational priorities, or they may arise from routine measurement trends. For example, a provider may expand its technology-dependent continuous care program. As many of the patients receiving such services require respiratory support, the company may decide in advance that it should target improved ventilator management. Alternatively, the organization's chart audits may reveal infections in several existing ventilator patients, thus prompting a focus on improved ventilator management.
For Oak Park, IL-based Community Nursing Service West (CNSW), improvement targets now arise from its participation in the Health Care Financing Administration-sponsored Outcome and Assessment Information Set (OASIS) prospective payment system demonstration project. CNSW scores patients on 79 assessment measures at two different stages, usually admission and discharge, or 120 care episodes, reports Nancy Santucci, RN, MSN, quality management and education coordinator.
Measures with higher scores for all patients generally suggest improvement targets. Although the demonstration project involves only Medicare patients, CNSW uses OASIS assessments on all its patients, most of whom are on Medicare. One such indicator, which subsequently became an improvement target, is improved oral medication management.
Before its OASIS participation, CNSW identified targets through a company process review. With a consultant's help, CNSW completed flowcharts for many organizational processes, such as documentation, intake, admissions, and billing.
"It was a helpful way of thinking and looking at the organization. It helped us look at overlapping efforts," says Pamela Steinbach, RN, MS, executive director. Other targets came from its routine measures such as rehospitalizations.
· Determine process methodology.
Most organizations use one of two common performance improvement techniques:
- PDCA (plan, do, check, act);
- FADE (focus, analyze, design, execute).
Either approach works well as long as staff are properly trained "to understand organizational expectations and be educated about ways they wouldn't have looked at the data," says Kranz. JCAHO offers a number of PI-related education vehicles, including seminars, videos, and books.
· Establish performance improvement teams.
Individual performance improvement teams should include staff involved in the process being investigated. The CNSW team reviewing improvement in its oral medication management target included a home health aide, physical therapist, registered nurse, case manager, Santucci, and Steinbach, who facilitated.
· Outline and implement target improvement plans.
In several brainstorming sessions, the team outlined factors affecting oral medication management. Team members also audited 20 patients' charts - 13 patients who had improved their oral medication management and seven who had not - according to OASIS scoring.
Common thread: Patient assessment
These reviews produced 14 variables. From the chart audits and subsequent nursing staff interviews, the team determined a thorough patient assessment was the common thread among eight of the 14 variables. It then outlined possible interventions for these variables and designed and documented revised assessment procedures to improve patients' oral medication management.
CNSW designed its plan over about five weeks. Santucci estimates it required 12 to 15 hours of each team member's time.
Plan implementation involved educating staff about the team's findings and interventions, using the revised patient assessment procedures, and conducting chart audits to test their impact. The initial chart audits indicated that though educated to do so, staff were not adequately documenting assessment of their patients' oral medication management capabilities, says Santucci. As a result, CNSW recently developed a separate oral medications management form, which will be completed along with other assessment documentation. (See sample assessment form, p. 147.)
Avoid miscues to enhance effectiveness
While most providers perfect the structure of performance improvement, many fail to maximize its potential impact on their organization, says Kranz. The following implementation mistakes can make the difference between an effective plan and one that meets JCAHO intent but doesn't pack a punch:
· Attacking nonessential issues.
Providers sometimes select insignificant improvement targets. The dividing line between a substantive issue and a superficial one is the degree to which it affects patient outcomes and use of organizational resources.
The more an improvement target can increase healing, decrease morbidity, or improve patient satisfaction while saving organizational time or resources, the more substantive it is. Smaller processes may make sense initially; early wins help gain buy-in needed to attack larger problems. But providers should move on rapidly, says Kranz.
CNSW's oral medications management target "seems so basic, but it can prevent rehospitalization if it stops a patient from incorrectly taking their meds, and it reinforces patient independence," says Santucci. "A lot of our patients have 24-hour caregivers, either paid or family members, and we found we were relying too much on the caregivers. The patients weren't becoming independent because we weren't asking them to. And in terms of organizational resources, it has helped us utilize our visits more purposefully."
· Applying quality assurance-like thinking.
Performance improvement requires critical thinking and problem solving, but this is where many providers miss the mark, says Kranz. "People have a tendency to come up with broad strokes and move right into action steps. They don't think about [variables impacting their improvement target]."
For example, some organizations would readily conclude that to improve oral medication management, "they should send a nurse three times a week to check compliance or give all patients medication boxes," rather than outlining causative factors and developing interventions. Not just settling with the obvious conclusion is the heart of effective performance improvement, she adds.
· Including the wrong people.
Involving the right staff in your performance improvement process is critical, says Kranz. Without the appropriate leadership, the process can stagnate and lose focus. "Team leaders should be process owners and critical thinkers able to look at variable issues. Otherwise, the team won't go where it needs to go," says Steinbach.
· Doing too much too soon.
"You can select a process that is so big it takes forever and is overwhelming. Try to break it down into something more manageable," Steinbach says.
Santucci concurs. "You really have to focus on the problem and the key variables [impacting its solution]. It is easy to go too broad, so you have to keep pulling back to exactly what you're looking at."
· Inadequately training staff.
Employees sometimes initially react negatively to the PI process. "People have a tendency to look at excuses like, 'our patients are sicker or older,' but you have to overcome that and say, 'what can we do to improve patient outcomes?'" says Santucci. The key to doing so is education about your organization's goals and process, she adds.
Administrative commitment required
Regardless of the targets selected, PI is challenging. "It requires time," says Steinbach. "It is so easy to get bogged down in day-to-day issues, and nonproductive time has costs. You have to focus it as a priority. There must be an administrative commitment."
But the effort is worth it, says Santucci. "The old-state quality assurance focused on whether the right form was in the right place. It didn't improve anything. Now we spend the same amount of time but are affecting patient care."
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