Smooth out your remaining problems with OASIS
January 1, 2000 6 minutes read
Smooth out your remaining problems with OASIS
Even after years of anticipation and months or years of preparation, the Outcome and Assessment Information Set (OASIS) continues to pose some inconvenient quality improvement problems for many home care agencies.
"OASIS is a big issue," says Cheryl Lamade, MSN, RN, director of nursing for Cambridge Home Health Care Inc. in Medina, OH. "Making sure you have all of the multiple time points on OASIS forms completed is a big issue for everybody."
While the OASIS form makes documentation more consistent and gives quality managers consistent data for in-house benchmarking, it can be difficult to train staff to complete the forms accurately and consistently.
"Making sure every box is filled out accurately can be a real issue," Lamade says.
Mind the gaps
Lamade provided OASIS feedback forms to nurses, and did an analysis of the staff’s most frequently missed questions. Once she learned which areas needed the most work, she developed a few strategies to improve OASIS documentation. Here are some of those strategies:
• Reassess the form. Sometimes the OASIS form has questions or answers that are not easily understood. It could be something very simple. For example, Cambridge Home Health managers discovered that some questions on the agency’s 14-page OASIS tool were repeatedly missed by nurses because the questions and answer boxes were hard to discern from the question above them. "Everyone misses the question about psychiatric nursing," Lamade says. "But when you look at the question, it blends in with the question above it."
Those types of issues result from tool-design problems. So it’s a good idea for home care quality managers to reassess their OASIS tool, looking for design flaws that consistently pose problems for nurses. If they find such problems, then they can discuss them with the vendor and perhaps assist in redesigning the tool. Or they may choose to select a different tool to use.
• Teach with self-learning packet. When the Ohio agency started using the OASIS tool early in 1999, the agency had a short startup and orientation time. So Lamade developed a self-learning packet that continues to be used by new employees.
Lamade included in the packet some exercises she found in the Health Care Financing Administration (HCFA) Medicare manual. She put some examples and learning criteria about OASIS and Medicare in the learning packet. In all, the self-learning packet may take staff about two hours to read and complete.
"Whenever we have a new hire, I have them read the packet before I go over the OASIS form with them, and it does save [inservice] time," Lamade notes. "What was originally a three-hour inservice, I can teach in 45 minutes to one hour."
• Teach staff how to avoid common mistakes. After conducting an analysis of completed OASIS forms, Lamade learned which mistakes were most commonly made. She taught the staff how to avoid those problems.
For example, employees sometimes didn’t understand that they were must answer a particular question and never to leave it blank.
"Sometimes they left it blank because they thought this was an answer they didn’t have to respond to," Lamade says. "Sometimes it was a lack of understanding in interpretation."
However, the OASIS form the agency uses has choices available to cover all contingencies, so there should be no blank answer boxes. If an answer is left blank, then it means the data entry clerk must contact that nurse to find out what the correct answer should be. It complicates and delays the documentation process.
"We don’t have the luxury to chase down the nurse and ask, Did you really mean there was nothing there, and that’s why you left it blank?’" Lamade explains.
For example, one question asked for the resumption-of-care date. Among the answers was an "N/A" box, located in an odd position near the question. So the staff often missed the "N/A" box and would leave the answer box a blank when there was no resumption of care, Lamade explains. "We had to go through and do a lot of item-analysis inservicing for some of the questions."
It adds up to zero
Another example relates to the wound care section, where there are a series of questions that branch off in a decision-tree manner. If there is a wound, then the nurse can go into depth in answering questions about the wound. If there is no wound, then the nurse will skip the pattern. "The nurses had a lot of trouble with that skip pattern of answering what they needed to answer and then leaving the rest alone," Lamade says.
Then if there was a wound, such as a decubitus ulcer, the nurse would need to answer a series of questions about the wound, answering each question completely. However, nurses often assumed they could answer only the relevant questions and leave the others blank. Instead, they were supposed to put zeros next to the questions that didn’t apply.
"So we had to spend a lot of time talking about that, because we couldn’t assume that if it was left blank it mean a zero," Lamade says.
• Give monthly updates: Initially, Lamade gave nurses updates on OASIS items and changes through a two- to four-page newsletter. It had graphics and was eye-catching and effective.
Now she incorporates the updates into staff meetings. Lamade keeps a running tally of mistakes in her OASIS folder and shares those problems with the staff.
• Audit OASIS forms regularly. Lamade audits the staff’s OASIS forms each week, looking for omissions and mistakes. She uses one audit form that works for every OASIS tool, whether it’s for admission, discharge, recertification, inpatient admission, or resumption of care.
She has a column that shows if the form has been turned in. That’s the first level of the audit. Next, she logs in the date the form was received and the date it was given to the data entry clerk and the date the data entry clerk returns the form to Lamade.
"This way I can look at the time flow, which is a critical thing with HCFA because they want these forms in seven days," Lamade says. "I can look at this audit form to see where the breakdown is if there’s a problem."
The next audit level is spot auditing of selected questions. "I can’t audit every tool or the whole tool, but I can pick an indicator of the week and go through it to see what the nurses are responding to and if it’s outside what their 485 says or the documentation shows," she says.
Then once a month, Lamade checks OASIS forms for five patients to see whether the OASIS data is correctly entered into the computer. She compares the answers the clerk has entered to the actual sheet the nurse turned in. Occasionally, she finds a few mistakes. "I can scan through it real fast and find out what the error rate is and whether I need to go further in depth," she explains.
• Give frequent pep talks. Managers had to emphasize how important it was for nurses to get their OASIS forms in on time, and this required frequent pep talks.
"We tell them to go ahead and get their OASIS forms in before all other paperwork is done, including the 485," Lamade says.
Managers also tried to alleviate the staff’s anxiety about OASIS and convince them that completing the form doesn’t have to be as confusing as some of them were making it. For example, some nurses were doing their patient assessments while using the OASIS forms and asking patients questions as they appeared on the form.
Lamade taught them not to ask questions directly off the form. Instead, they should do their regular patient assessment and later fill out the OASIS form from that information. "We told them not to ask the questions strictly off the tool because it will cause them more time and confusion. The language on the form is not what the patients and families will understand," she says.
• Cheryl Lamade, MSN, RN, Director of Nursing, Cambridge Home Health Care Inc., 3567 Reserve Commons Drive, Suite 100, Medina, OH 44256. Telephone: (800) 315-9124.
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