Have you fine-tuned your QI process lately?
Revising forms, improving processes all part of QI
Sometimes the best QI project is applied to the QI process itself. At least, that’s what a Texas agency has discovered.
Comprehensive Home Health Services of Mesquite, TX, revamped its entire QI program more than a year ago with several goals in mind:
• to meet requirements of The Medical Center of Mesquite’s QI program so the two would be compatible;
• to follow all Medicare regulations;
• to follow all requirements of the Joint Commission on Accreditation of Healthcare Organizations in Oakbrook Terrace, IL.
"We didn’t feel the previous QI plan would meet all the standards; it was not consistent," says Jackie Cox, RN, administrator for the hospital-based agency, which provides about 5,500 visits a month in a service area that covers rural northeast Texas and a suburban area east of Dallas-Fort Worth.
The restructuring appeared to work. The agency sailed through its Joint Commission survey with a 98% soon after the changes were made, Cox says, adding that it was a big improvement over a previous survey.
The revamped QI program was named after the hospital’s program: Improving Medical Center of Mesquite Organizational Performance (IMOP). Along with an employee education program, the agency devoted energy to obtaining staff buy-in. Employees were given stickers of a mop symbol to wear on their badges. Posters of IMOP were hung in the offices, and inservices with free food were held.
Although resistant to the changes at first, staff have adapted to the new process, Cox says. "They look at the work they generated before and the work they generate now, and they know there are worlds of difference in quality."
Other agencies could take Comprehensive Home Health’s lead of restructuring their QI programs by following these guidelines:
1. Hold an open QI meeting.
The agency announced it would be holding a QI meeting that was open to any interested employees, says Patti O’Connell, RNC, QI director.
Administrators and managers were asked to attend. These included the director of professional services, clinical supervisor, and case managers.
"I asked them to suggest some field staff nurses, therapists, and aides to attend, so we had a pretty big first meeting," O’Connell says. About 20 people showed up, including most disciplines and some clerical workers.
O’Connell had prepared an agenda after reviewing charts and the agency’s existing practices and systems. The meeting reviewed Medicare’s Conditions of Participation and Joint Commission standards. Then the group offered some suggestions for which areas to focus on and which areas were a problem and needed to be improved.
The group’s suggestions filled nearly eight pages, O’Connell says.
"We weren’t just looking at what’s wrong, but we wanted to establish some processes so everybody is doing it the same way," she explains.
2. Develop quality control indicators for each problem.
They fixed the problems that were identified under a Joint Commission standard.
"Then we discussed whether we wanted to address each problem as a quality control indicator, or through process development and tracking, or through clinical record reviews," O’Connell says.
For example, an indicator might be: "Are home health aides receiving the required number of hours of inservices each year?"
Then the process is to have a manager check monthly to make sure all aides are up on their requirements for inservices.
Another indicator related to the agency’s compliance with the Medicare Conditions of Participation on advance directives.
"So we review a percentage of charts each month to look for documentation on advance directives," O’Connell says.
In all, 30% of the admissions charts are checked each month to track 11 different indicators, including the one on advance directives, she adds.
When they learned that advance directives documentation was a problem, an advance directives form was developed. (See Advance Direc tives Assessment form, inserted in this issue.)
Previously, when nurses discussed advance directives with a client, they wrote this down in the nursing assessment narrative. However, sometimes they forgot to write it down. The new form has cleared up the problem, O’Connell says.
3. Assess the agency’s incident reporting process.
This internal process is crucial, O’Connell states. An agency that fails to gather consistent data about accidents and other problems is unlikely to find the best solutions.
With this in mind, Comprehensive Home Health Services began to look at the way in which it collected information on complaints and patient occurrences, including falls.
"We decided to track how many patients fell in their homes, so we developed a process of reporting falls, whether they were witnessed by a staff member or not witnessed," O’Connell says. "Then we addressed safety issues and staff and patient safety education." (Editor’s note: Next month, watch for an article on this agency’s patient fall reporting process.)
However, the agency needed some very specific information to make the tracking useful, so they developed a new patient occurrence report. (See Comprehensive Home Health Services’ occurrence report, inserted in this issue.)
The report asked for such details as whether the employee filing the report had witnessed the fall or had received a complaint. It also requires detailed descriptions of what happened and the contributing factors.
"We wanted to generate some data from the report that we could use in our safety education program," O’Connell explains.
"The QI process part of it would be to educate staff on what to look for and what interventions to provide in the home," she adds. "Then we would like to track how many patients are referred to the physical therapist, and whether that affects the number of falls."
4. Revise clinical records.
The state of Texas requires home care agencies to conduct clinical record reviews each quarter. The reviews must include at least 10% of clients admitted to an agency and 10% of clients discharged during the three-month period, O’Connell says.
If the agency was going to succeed at restructuring its QI program, then revising this tool had to be a big part of it. So the QI committee broke into smaller groups to examine the tool and how it relates to different disciplines.
The teams were given one basic guideline: Base everything on Texas regulations, Medicare Conditions of Participation, and Joint Commission standards.
"We presented some forms from other places, tools we were using, and we cut and pasted," O’Connell says.
O’Connell used a basic format she helped develop at a different agency. The result was a comprehensive, four-page tool that is used for every clinical record reviewed. The same tool is used on each client’s chart, and it covers all services provided by the agency. (See clinical record review, inserted in this issue.)
The tool has exact details for every clinical record function. Under the heading "Medicare Screening Form," for example, the tool lists:
a. Header completed
b. Questions 1-6 answered as appropriate/ Retirement date must be documented
c. Medicare card visualized and information completed for each space
d. Patient/representative signature
e. Date and RN signature
Each detail is documented as a "Yes," "No," or "N/A," and a space is left for comments.
The reviewer includes patient information, the nurse’s name, and discharge date at the bottom of each page of the form, and then each page is signed by the reviewer.
"We maintain patient confidentiality by writing only medical record number and initials," O’Connell says. Then the agency saves the tool after reviews in case a state surveyor asks for proof that the quarterly review was conducted.
Lastly, the agency generates a quarterly report from each clinical record review with its findings.
The entire QI restructuring program has boosted not only the agency’s quality of care, but also its quality of internal functions, O’Connell says.
"We’ve noticed a great improvement in office efficiency and communication," she notes. "It’s made the office run much more smoothly."
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