Patient education like putty in the hands of outside regulators
Standards shape programs, teaching methods, materials
Following a mock survey in preparation for the real accreditation process conducted by the Joint Commission on Accreditation of Healthcare Organizations, administrators at York (PA) Health System hired a patient education coordinator one month prior to the process.
The goal of creating a new position was to improve compliance with the standards. When the mock surveyor asked who coordinated patient education or who was the central person responsible for it, there was no answer, explains Donette Lasher, MAT, who was hired as patient education coordinator at York in August 1998.
Other major changes at the health system included the formation of an interdisciplinary committee and the development of a record for documenting patient education.
"We relied on the mock surveyor to let us know what [the Joint Commission] was looking for, and the record was one of the recommendations she made because [the Joint Commission] is interested in how well we work together. The more we handed off to each other, the happier they were," says Lasher.
An interdisciplinary teaching record not only provides evidence of education; it provides evidence of interdisciplinary teaching, she says. (For information on where to find a mock surveyor, see editor’s note, p. 16.)
Although most health care facilities don’t undergo such a dramatic transformation before a Joint Commission survey, the standards of the Oakbrook Terrace, IL-based accreditation agency do shape and mold patient education throughout the health system.
While patient education was being done at Shands Hospital at the University of Florida in Gainesville, the Joint Commission survey prompted staff to create a team to go over the standards and look for areas for improvement, says Kathy Conner, ARNP, MN, coordinated care manager in the department of nursing and patient services at Shands.
The team saw the need to make patient education more interdisciplinary and collaborative. Therefore, they created an interdisciplinary tool for documentation so staff could easily see which disciplines had taught and built on the education.
Following the survey, the team focused on CQI efforts for education and came up with five recommendations that were approved. They include the creation of a multidisciplinary team to oversee patient and family education and developing a computerized index of patient education materials. (For information on preparing staff for a JCAHO survey, see article, p. 15.)
Program design shaped by standards
Standards for other regulatory agencies don’t have such a hospitalwide impact. Most affect how patients are educated within individual programs. For example, The Commission on Accreditation of Rehabilitation Facilities (CARF) in Tucson, AZ, creates standards for individual rehab programs.
"Whenever you get CARF-accredited, it is not an organization that gets accredited; it is specific programs within that organization, and there are different specialty accreditations," says Terrie Black, MBA, BSN, CRRN, RNC, a CARF surveyor and rehabilitation consultant at Hospital for Special Care in New Britain, CT.
There are standards for brain injury programs, spinal cord injury programs, outpatient rehab programs, and comprehensive integrated inpatient programs that include stroke patients, she explains.
CARF standards are more specific for some programs than for others. A spinal cord injury program must cover a wide range of education such as pulmonary care, sexual counseling, skin care, and substance abuse. However, the standards emphasize that the education must meet an individual’s needs, so it is not limited to the suggested topics.
"The program we have for spinal cord patients, Independent Living Skills, is driven by the CARF standards," says Susan Wise, BSN, RNC, DRRN, a rehabilitation educator at the University of Utah Hospitals and Clinics in Salt Lake City. However, many educational sessions are given in addition to the required curriculum. For example, patients are taken out to eat at a restaurant of their choice one day so they can get used to being in public.
To have a diabetes program recognized by the Alexandria, VA-based American Diabetes Association (ADA), stringent patient education standards must be met. There are 15 content areas that basic diabetes education must cover, and the teaching within these areas must be based on an assessment of patient needs, says Betty Nalli, ARNP, MSN, coordinated care manager in the department of nursing and patient services at Shands.
The ADA standards not only govern the topics taught, but the materials distributed as well. All patient education materials written in-house must be submitted for approval, says Amparo Gonzalez, RN, BSN, CDE, director of the Specialty Center for Diabetes Care at Saint Joseph’s Hospital of Atlanta. One of the most challenging aspects of the standards is the data collection required to prove the education is enhancing the patient’s ability to self-manage the disease.
Systems must adhere to standards
A fourth agency, the National Committee on Quality Assurance (NCQA) in Washington, DC, sets standards for managed care plans. Health systems that wish to contract with a managed care company to educate its members must adhere to the standards by which these companies are accredited.
"You have to use recognized guidelines. We go through a lengthy research process of educational designs. In that way we can take bits and pieces, but they have to be based strongly on a recognized entity and you have to quote that entity within your model," says Stacey Bateman, RN, BSN, director of program development at Flagship Healthcare in Miami Lakes, FL. For example, the ADA guidelines were used to design Flagship’s diabetes education program.
Also, outcomes are crucial. There must be some sort of proof that the education is effective, she says. (To learn how to tailor a patient education program to NCQA standards, see article on p. 17.)
Get a copy of HEDIS 3.0 (Health Plan Employer Data and Information Set), advises Nancy Walch, BSN, MPH, CDE, CHES, coordinator of the health education and wellness department at Queen’s Medical Center in Honolulu. HEDIS is a set of standardized performance measures set by NCQA to measure the performance of managed health care plans. Programs must help managed care meet these performance measures, she says.
Do all these standards fit together? "We see them complementing each other. The ADA standards reinforce where we see the Joint Commission going," says Sharon Valley, MS, CDE, education coordinator for the diabetes center at Shands Hospital. For example, the Joint Commission emphasizes an interdisciplinary approach for patient education, and ADA-recognized diabetes programs incorporate nurses, dietitians, physicians, and specialists in adult education.
The Joint Commission also looks for education over the continuum of care. Diabetes teaching is a perfect example because it often begins in the hospital and is completed in an outpatient setting, and follow-up continues to make sure that the outcomes were achieved.
Inpatient nurses and certified diabetes educators from the outpatient area at Shands worked together to create an education pathway that provides guidance on what to teach in an acute setting. "In the inpatient setting, we try to focus on the essential education, and then when the patient is referred to the diabetes center, the educators can do the follow-up with more in-depth education," says Valley.
The health system also created a documentation form to record inpatient education. A copy of the form is either sent or faxed to the diabetes center when the patient is discharged, says Valley.
Surveyors find common ground
Some accreditation agencies are beginning to work together. The Joint Commission and CARF now will arrange to do surveys of a health care facility at the same time. "There is a lot of collaboration going on between the two accrediting agencies that has not always existed in the past," says Black.
While it takes time to make sure educational programs are in compliance with standards from outside regulatory agencies, most educators agree that becoming accredited is well worth the effort. For diabetes programs, having your program recognized by the ADA helps ensure reimbursement for patient education.
"Any time I talk to a managed care company or case manager for a third-party payer, the first thing they ask is are you recognized. No one wants to talk to you if you are not," says Gonzalez.
The accreditation process, which ensures that standards are being met, is a catalyst for good patient education, says Lasher. "Surveys and standards are a benefit to us because every three years, on a regular cycle, they remind us of what good patient care is. They help keep us accountable and give us the priority to do it," she explains.
Following standards by a reputable agency ensures that you are implementing best-practice principles based on the latest research, says Valley. "If one wants to be associated with the cutting-edge clinical standards in a given specialty area, then one allies with that organizing body," Gonzalez says.
[Editor’s note: The mock surveyor used by York Health System came from Quality Systems Group Consultants, 25 South Arizona Place, Suite 570, Chandler, AZ 85225. Telephone: (602) 821-9116.]
Sources
For more information on meeting regulatory standards of outside agencies, contact:
• Stacey Bateman, RN, BSN, Director of Program Development, Flagship Healthcare, 8000 Governors Square Blvd., Suite 300, Miami Lakes, FL 33016. Telephone: (305) 822-3200. Fax: (305) 820-1063.
• Terrie Black, MBA, BSN, CRRN, RNC, CARF Surveyor and Rehabilitation Consultant, Hospital for Special Care, 2150 Corbin Ave., New Britain, CT 06053. Telephone: (860) 827-4769. Fax: (860) 827-4716.
• Kathy Conner, ARNP, MN, Coordinated Care Manager, Department of Nursing and Patient Services, Shands Hospital at the University of Florida, 1600 Southwest Archer Road, Box 100335, Gainesville, FL 32610. Telephone: (352) 395-0392. Fax: (352) 395-0253. E-mail: [email protected].
• Amparo Gonzalez, RN, BSN, CDE, Director of Specialty Center for Diabetes Care, Saint Joseph’s Hospital of Atlanta, 5667 Peachtree Dunwoody Road, Suite 100, Atlanta, GA 30342. Telephone: (404) 851-5906. Fax: (404) 851-5699. E-mail: [email protected].
• Donette Lasher, MAT, Patient Education Coordinator, York Health System, 1001 South George St., York, PA 17405. Telephone: (717) 851-3081. Fax: (717) 851-3049. E-mail: [email protected].
• Betty Nalli, ARNP, MSN, Coordinated Care Manager, Department of Nursing and Patient Services, Shands Hospital at the University of Florida, 1600 Southwest Archer Road, Box 100335, Gainesville, FL 32610. Telephone: (352) 395-0135. Fax: (352) 395-0253. E-mail: [email protected].
• Susan Wise, BSN, RNC, DRRN, Rehabilitation Educator, University of Utah Hospitals and Clinics, 550 North Medical Drive, Salt Lake City, UT 84132. Telephone: (801) 585-2177. Fax: (801) 585-3060. E-mail: [email protected].
• Kathy Ordelt, RN, CRRN, CPN, Patient & Family Education Coordinator, Egleston-Scottish Rite Children’s Health Care System, 1001 Johnson Ferry Road NE, Atlanta, GA 30342. Telephone: (404) 250-2757. Fax: (404) 250-2255. E-mail: [email protected].
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