Paths help home nurses improve quality of care
June 1, 1997 4 minutes read
Paths help home nurses improve quality of care
Lessons for hospitals planning home visits
One of the thorniest quality problems hospitals grapple with today arises when caregivers from an acute setting try to extend their care outside the hospital walls. But coordinating with outpatient and home care agencies is becoming easier as more adopt critical pathways as part of their quality efforts. Such was the case when Visiting Nurse Association (VNA) of Denver developed a set of critical pathways.
"Our payers in managed care were demanding this," says Stephanie Prock, RN, MSN, nurse manager at the agency and one of a team that developed the critical pathways program. "But for us, it was hard. We are a nonprofit stand-alone agency. We are not part of a system, and we have to have a program that can be adapted to the needs of both patients and multiple payers."
While much of the information that will determine the level of success in the program is still pending, Prock says the VNA has a sense it is doing well. "We are doing things the same way; we are getting consistent information; and we are tracking difficulties. It wasn’t that outcomes were bad before, but our information was just not consistent. Staff wasn’t sure of the sequencing of care, and I think that has changed."
Prock started with a team that included quality improvement managers, nurses, reha-bilitation staff, hospital discharge planners, administration from her VNA, and corporate representatives from the national VNA organization. "They had looked at disease management in the past, and we felt they could help us with the bigger picture."
Each of the participants has a vital role to play, Prock explains. Quality staff play a key role in conducting variance analysis and working to integrate the program into ongoing quality improvement initiatives. "They tell us that if the patient deviates from the plan, this is how to fix it," she says.
The admissions and hospital discharge staff can develop processes so that the appropriate pathway is chosen before the patient is admitted. The financial staff can outline the effect a decreasing number of necessary visits can have on the bottom line.
Set measurable goals
The group set goals of optimal clinical quality, easy access to care, and high patient satisfaction. But Prock admits those are "pie in the sky" indicators that sound pretty, but are hard to define. "We had to define our desired outcomes for specific populations. If they are patients with infections, then we have to look for a decrease in rehospitalizations."
For ease of access, the group decided to look at whether patients got appropriate treatment in a reasonable amount of time. Patient satisfaction would be evaluated with patient satisfaction surveys.
Once the goals were set, the paths were dev-eloped by the VNA’s clinical specialists. For example, the maternal child coordinator would develop paths associated with infant and child care. The pathways then were evaluated by an oversight group that included physicians from the payer organizations and taken to the users’ field staff, who were educated on how to use them.
"That’s where we had one of our biggest hiccups," Prock says. "We did group meetings at first, but we found compliance wasn’t really very good. Then we tried one-on-one training and re-education." The problem seemed to be a lack of involvement of managers at the start, she says.
That problem has been addressed by evaluating pathway use at weekly meetings held by each specialty group. For example, if a nurse talked about the progress of a certain patient, he or she was asked to explain where the patient was on the pathway in question.
"When people used the critical pathways, they understood their benefits and used them appropriately," Prock says. "But they were used less than half the time, and that was far below our goal."
Defining a successful’ outcome
Through an audit process that compares actual visits with an ideal situation, Prock also has found problems in the number of visits some paths allow. For example, if there is a peripheral intravenous-line patient who is independent in three visits, that progress fits the goal of that particular path. But the nurse still may go out every 72 hours to change the line. "That can skew the number of visits. We still have to change that."
Such problems raise questions about how to define a "successful outcome" and how to report the number of visits to customers, she says. "The same holds true for wound care," Prock explains. "You might have a wound which is healing and have provided appropriate education to the family, but the caregiver may still want to go out periodically and check on the patient’s progress."
Lessons to be learned
Those considering a critical pathways program for home visits can learn from the VNA’s experiences, she says. In particular, Prock advises to be aware of information system capabilities. "They just aren’t very sophisticated yet in home care. You can get information on cost accounting and outcomes, but it tends to be manual if you want to incorporate them both. We have a ways to go technically."
That said, Prock adds that developing critical pathways can still be worth the effort even if some reports can’t be generated easily on a sophisticated computer system.
She also advises that critical pathways be viewed as a purely clinical project. "It is a way of doing business," she says. "You have to have your admission people, your financial staff, and your quality people involved. It is not just about patient care services, but is an agencywide approach."
[Editor’s note: For more information, contact Stephanie Prock, Visiting Nurse Association of Denver, 3801 East Florida, Suite 800, Denver, CO 80210. Telephone: (303) 757-6363.]
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