Early efforts give company head start on OASIS
Home health branches use data to improve care
When it comes to introducing the Outcome and Assessment Information Set (OASIS) to home health staff, Nurses Calling, a Cincinnati-based company, has given its branches a head start.
Thanks to early recognition of the importance of the OASIS data collection, Nurses Calling began devoting staff to the project nearly three years ago. Now, with some early data already collected, the company is using it to suggest quality improvements at local branches, say Sheila Heck, RN, C, MS, vice president for clinical services for Nurses Calling/Health Force, and Sue Blockberger-Miller, RN, BSN, the company’s national director of quality improvement.
Heck says the initial buy-in by field nurses, already overburdened and short of time, took some work. "Once they began to use the form, it began to dawn on them how it would provide them with a more complete assessment. In the spring of ’98, when it became pretty clear that OASIS was going to be the way to go, and many folks had never even heard of it, we’d already operationalized it in our branches and our nurses had a comfort level with it."
Furthermore, Heck adds, it’s an effort that can be duplicated fairly inexpensively, with help from a good information services staffer. Although vendors now offer software specifically designed to handle OASIS data collection and analysis, her company accomplished its project with the use of Microsoft Word and Excel.
"While software systems are very nice and they do make your life easier; if you don’t have the funds or the resources for that, you can still get the job done," Heck says.
Assessment grows to 14 pages
The company began working with OASIS in April 1997. Blockberger-Miller says a team was organized to carefully comb through the OASIS assessment alongside the company’s existing assessment tool.
"We sat down with our four-page nursing assessment and OASIS B, which was 10 or 11 pages," Heck says. "We went by body systems, plucking out of the OASIS the issues that addressed IADLs [instrumental activities of daily living] and sort of plugging them in."
The original nursing assessment was in Microsoft Word, so OASIS additions were pasted into the file. When the group finished, after about six meetings, the new assessment form was 14-pages long. It was put on floppy disks, and distributed to branches.
"They had the forms printed at Kinko’s or [other places]," Heck says. "The reason we did that was that we knew OASIS was going to change. We didn’t want to go into heavy-duty printing and template manufacturing when we knew this was not the final form."
Thinking ahead paid off. "When the changes did come — because we had it in our word processing program — we were able to incorporate the changes very, very simply," Heck adds.
Once the form was completed and distributed, there still was a substantial hurdle to clear in implementation — educating nurses on how to use it. It wasn’t just the length of the new assessment that proved daunting. Because they weren’t allowed to change any of the wording from the OASIS assessment, much of the new terminology was difficult for nurses to understand, Heck recalls.
"Nurses sometimes take things very literally and the whole concept behind OASIS is, Where is your patient at this moment in time as you sit there with them?’ Not where they were two weeks ago or where you think they might be this afternoon, but what’s going on right now."
Blockberger-Miller says her group distributed tip sheets to help explain how to answer certain tricky OASIS questions.
For example, there was one question in the personal care section that dealt with bathing, asking whether a patient was able to bathe himself independently in the bath or shower. The range of answers didn’t address patients who could independently bathe themselves while seated on the toilet near the sink in the bathroom.
After much discussion, Heck and Blockberger-Miller advised nurses to interpret the OASIS language literally — answering the question no, even though the patient could accomplish certain independent bathing functions. "It was just getting used to the language, figuring out where it didn’t quite seem to fit the particular patient situation," Blockberger-Miller says. "Once we provided the tip sheets, that did seem to help them in evaluating patients and being able to fill out the assessment form more correctly."
The new forms originally were rolled out in August 1997 in two midwestern branches of Nurses Calling. In January 1998, it went out to the rest of the company’s 12 branches.
Along the way, the company used train-the-trainers-style teaching at monthly meetings of directors of clinical services. They, in turn, educated field staff.
Blockberger-Miller says nurses who used the new form began to realize its advantages. "Once the nurses got past the initial shock (of the longer form), they learned they didn’t have to sit in front of the patient and ask every single question," she says. "It’s more of an effort to evaluate the patient, knowing what’s on the form, so you can fill it out. They started to see that the OASIS and the assessment together could really validate the care they are providing for the patient."
From data collection to analysis
Throughout 1998, Nurses Calling was collecting information from the new forms. The company chose five indicators that it would track, based on what it found to be high-volume, high-risk, or problem-prone areas:
1. Management of oral medications. "Because most of our patients are on medication, we figured that was a high-volume area to measure," Heck says.
2. Ambulation. This was a logical choice, she says, because it is a basic activity of daily living, and most Medicare home care patients have some sort of ambulatory compromise.
3. Bathing. Chosen as a way to measure the effectiveness of home health aide services.
4. Pain and dyspnea. "We included those because we service a significant number of heart failure patients," Heck says. "We have clinical models for heart failure and COPD [chronic obstructive pulmonary disease], so we used those two criteria to help us with those two outcomes."
Nurses were provided with an outcomes worksheet they were to fill out in addition to the OASIS assessment. (See "Individual Patient Outcomes," inserted in this issue.) Numbers for the five indicators were copied from the assessment and put on the worksheet, which was sent back to the company. The sheets were filled out for admissions, recertifications, and discharges.
Results were gathered for branches and were plugged into an Excel spreadsheet created for the project. (See "Branch-Level Global Outcomes," inserted in this issue.)
Those results pointed to few areas of immediate concern, but just as importantly highlighted a much larger problem with the entire data analysis.
In comparing data, Nurses Calling did not separate patients on chronic waivers. The peculiar characteristics of that patient group created problems in analysis, Heck says. "Because of the chronic nature of these patients who are on our chronic waivers, they never got better, they never got worse. They either stayed the same or they died. It skews all the data."
Despite that obstacle, Heck and Blockberger-Miller did manage to extract some data that pointed to areas where quality could be improved.
For example, in the area of medication, results showed that out of a total of 1,230 patients, only 504 had the potential to improve medication management at start of care. The others already were managing their medications properly or were not taking meds.
Of that smaller group, only 107, or 21%, actually improved. Heck says she believes it was because the patients lacked good medication teaching tools, a point the company is in the process of addressing. Likewise, in the area of ambulation, 790 patients had the potential to improve, and only 133, or 17%, did improve.
"We are implementing restorative nursing at our locations to get these people up and moving," Heck says. "I believe again, our data was skewed by collapsing our chronics and our acutes together. With the addition of restorative nursing and separating out our data, we should have more finite data by the end of the year."
An agency implementing OASIS needs to spend a lot of time training nurses in how to fill out the forms and the purpose of the data collection.
Blockberger-Miller says her group ran into problems in the beginning, because nurses believed they would be graded based on the responses. As a result, documentation didn’t always support the numbers they were presenting on their patients.
Heck says nurses had to learn that the numbers were only being used as a baseline against which to compare later progress. "We had to get past that learning curve that this was not really a report card on how well you applied your nursing skills. This was a measurement we were trying to gather."
Choosing which indicators to study will depend upon the agency’s patient population, and what kind of information the agency is seeking.
"The first thing you do is describe or write the [improvement] program," Heck says. "What is it you’re trying to do? Are you trying to improve your clinical practice? First you decide that, then you decide what monitors you’re going to use."
The indicators chosen should be tracked for a while to allow collection of enough results to be useful, Blockberger-Miller says.
"You can’t collect it for two quarters and say, OK, we’ve improved and that’s it,’" she says, noting that there are several directors of clinical services who would like to see Nurses Calling’s indicators expanded to include items they have a particular interest in. The first order of business, however, is to sort out the chronic waiver patients, she and Heck say.
"We feel that we first need to extract that out and see how we end up by the end of this year before we change the indicators we are collecting at this point," Blockberger-Miller says.
Heck says that for a project like this one to work, it should involve the lead clinical staffer and at least one other person, and must have the cooperation of the director of nursing.
She suspects that cooperation will be easier to secure, now that OASIS is a sure thing. "When we were doing this, I kept getting comments such as Why are we even doing this? Nobody is making us.’ Well, now you can say, HCFA made us.’"
• Sheila Heck, Vice President for Clinical Services, and Sue Blockberger-Miller, National Director of Quality Improvement, Nurses Calling/Health Force, 4700 Ashwood Drive, Suite 200, Cincinnati, OH 45241. Telephone: (800) 989-7337. Fax: (513) 530-1694. E-mail: [email protected] or sblockberger@ chs-corp.com.
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