Improperly documented work could waste everyone’s time
August 1, 1999 4 minutes read
Improperly documented work could waste everyone’s time
Good’ documentation increases after QI program
Many hospitals and home care agencies have shown in recent years that home health services are essential to improving care and reducing the emergency room and hospital costs of congestive heart failure (CHF) patients.
But developing a thorough CHF home care program is only half the task. It is equally important to make sure your nurses document the care they provide meticulously and accurately.
Home Health and Hospice of the Whidden Memorial Hospital in Everett, MA, set up a special performance improvement project to address CHF documentation. As a result, the agency’s percentage of good CHF documentation rose from about 87% in May 1997 to nearly 94% in January 1999, says Marjorie Cook, RN, MBA, CNAA, director of performance improvement for Hallmark Health Home Care in Malden, MA. Whidden Home Health and Hospice is a part of Hallmark Health.
Cook describes how Whidden set up its CHF documentation project, outlining these steps:
1.Identify the problem.
The agency first identified the problem with CHF documentation in May 1997, after the performance improvement team took a close look at CHF patients and their outcomes. CHF was the agency’s most frequent diagnosis, with about 5% of patients being admitted solely for CHF and 20% of patients having CHF as one of their diagnoses, Cook says.
Although the agency’s hospital readmission rate for CHF was low, managers thought they could improve it through making sure nurses followed the standard of care and provided better documentation, Cook says. "We focused on improving documentation, and lowering the readmission rate was a positive side benefit."
As a result, the agency has a readmission rate below 5%, which is one-fourth the readmission rate of a peer agency with whom Whidden benchmarks some data.
The performance improvement team developed a cause-and-effect diagram to use as a visual aid when discussing what problems needed to be tackled in order to improve the documentation. The diagram listed problems under the categories of materials, people, equipment, and methods. For example, a people problem is lack of communication, and a materials problem is the lack of a CHF teaching tool. (See cause-and-effect diagram, inserted in this issue)
"We divided the problems into different categories so we could get a better picture of what we were faced with and why we had incomplete documentation," Cook explains.
Also, team members wrote down the driving forces and restraining forces affecting a goal of improved documentation. They looked at the positive elements of the project and also the road blocks they might encounter along the way.
For example, the team determined these were the driving forces:
• Increase patient education around the disease process to enable the patient to be independent in health care management.
• Prevent hospital readmissions for CHF.
• Decrease the number of visits required for CHF patients, while maintaining high-quality care.
• Ensure patient assessments are uniform, complete, and reflected in clinical documentation.
• Ensure communication occurs between clinician and physician regarding any status changes.
And these were the restraining forces:
• Lack of uniform teaching tool.
• High number of elderly patients with multiple health care issues.
• Elderly patients with cognitive issues preventing retention of taught information.
• Variation in staff’s ability to document in PtCT computer system.
• Lack of caregiver to instruct and entrust in patient care.
"The team had predicted the more important road blocks, but there are always some things you never think about until you actually do the project," Cook says.
2. Develop strategies to improve documentation.
The performance improvement team brainstormed and came up with a several strategies for fixing the problem, including:
• Developed a CHF teaching booklet that nurses would use when teaching patients and their families about the disease.
• Created a CHF flowchart, which is an overview of the operational process of what occurs when a referral comes in for a patient with CHF. The chart details how the referral is handled within the agency, step by step. At one point, the chart asks whether the CHF standard of care was adhered to. If the answer is no, then the chart directs managers to review the nurse’s documentation and intervene as necessary. (See CHF flowchart, inserted in this issue.)
• Designed a CHF standard of care chart that outlines the main actions needed in order to improve documentation. Each action also includes arrows suggesting dates and a timeline for improvements to be made and concluded. (See CHF standard of care chart, inserted in this issue.)
• Educated employees at staff meetings, at inservices, and on an individual basis about how to improve their documentation and care for CHF patients.
"We lived by the premise that if it wasn’t documented, you didn’t do it," Cook says.
Booth of answers
The agency reinforced the use of the CHF pathway and set up a booth on CHF teaching at a staff competency day. Nurses visiting the booth had to explain how they use the CHF teaching booklet and recite the CHF standard of care and how it is delivered. The booth manager provided additional CHF education to anyone who had problems answering those questions at the competency booth.
3. Measure staff’s documentation improvements.
The performance improvement team monitored nurses’ progress in improving CHF documentation by checking off a group of indicators on a CHF monitor form. (See CHF monitor chart, inserted in this issue.)
The agency monitors charts involving patients admitted with a diagnosis of CHF. Some of the areas that managers review are whether nurses assess with each visit a patient’s blood pressure, pulse, respiratory rate, edema, lung sounds, cough, and weight. Managers also check paperwork to make sure the nurse notified patients’ physicians within four hours of having an abnormal finding, and see if the nurse has documented patient teaching in a variety of areas.
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