Try this QI refresher on advance directives
Improve documentation, patient education
Your nurses probably have often heard this refrain from patients: "Yes, I’ve got an advance directive, but I don’t know where it is."
That leaves your agency stuck in a documentation maze. You have to prove to state regulatory or accreditation officials that you have spoken with the patient about advance directives, and then you might have to obtain a copy for the patient’s chart. For example, the Oakbrook Terrace, IL-based Joint Commission on Accreditation of Healthcare Organizations requires all appropriate home care staff become aware of a patient’s preferences and the patient’s intent with regard to an advance directive.
But when you track down the doctor, the hospital, or the son whom the patient says might have the form, you discover that the patient was confusing the advance directive form with their estate will or even a "do not resuscitate" order.
At least that’s the problem that faced Citrus Memorial Home Health Agency in Inverness, FL.
"We had problems getting copies on the chart because usually the patient had no clue where the advance directives were, and they don’t have copiers at home and don’t want to let go of their personal documents," says Lisa Place, RN, BSN, quality improvement supervisor for the hospital-based agency.
Florida requires home care agencies to document that patients were told about advance directives, and mandates that copies of these be put in the patient’s charts. However, the home care agency found through a chart review that many case files were missing the advance directive forms, says Janice Powers, RN, BSN, director. The agency tackled the problem, finally achieving 100% compliance with the advance directive requirement, by initiating these quality improvements:
• The quality staff conducted a chart audit on all patients to see how many advance directives had documentation and were included in the chart, asking such questions as: "If a patient showed an interest in advance directives, was it clearly documented that the nurse answered the patient’s questions?"
• Then, the agency revised the advance directive documentation form to make it easier for nurses to use. Now it’s a one-page check-off form with two simple sections. One section lists the forms a patient has and the other section lists the forms the patient does not have and whether or not they want a particular form.
Also, managers put yellow sticky notes on any papers in the admission packet that need to be followed up on.
• Then, managers educated the staff about advance directives and how correctly documenting these are necessary. They found that employees were unsure what these forms meant, so they taught them the correct definition. For instance, an advance directive form may include a living wills, a durable power of attorney form, and/or a health care surrogate form. The education took place in staff meetings.
• Quality staff conducted two more chart reviews and found the changes had resulted in improved documentation. Within a year, the agency reached its goal of achieving a 100% compliance with advance directives regulations.
"We are very compliant now because of the process where we’re reviewing everyone," Powers says.
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