Competency math: Rating by the numbers
System removes subjectivity from evaluations
If someone challenged you to "prove" your staff was competent, what would you do? When put to the test, SNI Companies of Flourtown, PA, a health management company that provides hospital staffing and home health services out of three Pennsylvania offices, started an evaluation process using the numerator/denominator system. The system not only improves the quality of work among staff members and thus the care they give patients but could potentially be a selling point to managed care companies.
When challenged with the "prove it" statement by a consultant, SNI started by looking at all of its evaluation activities, says Beth Henn, MS, RN, director of quality management.
Henn says they used a flowchart process to find that "the tools we were using were subjective and contained scales like Superior, Above Average, Average,’ or Excellent, Good, Fair, Poor.’" Not only did the tools lack objective measurements, she continues, but they were lengthy and overlapped at points, and were conducive to reviewer interpretation.
Sample evaluations showed a wide range of interpretation and focus by managers. "What was important to one manager was not necessarily important to another manager," Henn explains. "A nurse with an Excellent’ rating did not necessarily prove she was a competent practitioner."
Expressing evaluations numerically
What was needed was more objective quality information that would do a better job at proving competency. There were already many items being collected that could help provide the kind of data Henn was looking for record reviews that would help evaluate documentation skills, for instance.
The goal was to express all evaluation points numerically and set a goal that compliance levels be at 95% or above. For example, if SNI wants 100% of inservice requirements to be met by each staff member, and nurse Jones has only nine of the 10 required hours, that indicator does not meet the 95% goal. It becomes a target for remediation.
A real example from the company occurred in 1996, says Debbie Mancini, BA, project coordinator. That year, there was an approximately 8% variance in medication occurrences by family either the wrong dose given, or given improperly. That put the level of compliance at just 91%. "We looked at each event and did individual remediation," says Mancini. "Because of this, we adjusted our pathways, which helped staff to focus on instruction to the family."
The result was improvement in the score for this area to 98% the following year. "Whatever isn’t 95%, we attack," Mancini says.
The benefit of the program, says Mancini, is that SNI can know at a glance how a particular nurse or team of caregivers is performing. "We are looking for anything that isn’t in line with our goals," she says. Anything not in line with the 95% goal sticks out and is attacked on an ongoing basis. "We don’t get blind-sided by an indicator once a year."
The program has been altered in the last year or so since its implementation, says Henn. For instance, those staff members who had productivity requirements as part of their annual goals have had this added to their evaluations as an indicator. And because the clinical competency program has started off so well, it is being adapted for management and other nonclinical teams, says Henn.
Program exposes causal relationships
The need for expansion to nonclinical areas is evident, she explains. "In one quarter, a nonclinical team that provides computer support scored a 15 in its indicator for the number of minutes of unscheduled server downtime a score of 85%. For the same quarter, the billing team showed a 0.5% decline in the number of bills processed. We could see the correlation between the server downtime and the decline in bills processed. It allowed us to see causal relationships between teams." The numerator/ denominator system lets SNI focus attention on server problems rather than on improving billing practices.
Henn says the system also lets the Joint Commission see that measuring the quality of staff is comprehensive at SNI. "We want to be sure that the commission can see our accountability throughout the organization," says Veronica McCabe, RNC, BS, quality management specialist.
There is another upside, too one that could have a positive financial impact on SNI. "When bidding for contracts in the managed care arena, it’s a great marketing tool," says Henn. "You can give meaningful data not only about clinical performances, but about other important concerns of managed care, like the ability to bill clean’ claims, the timeliness of billing and collections. It provides definitive numbers to support our position and the state of our corporate health to our customers."
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