Home agencies can benchmark internally
Get into OASIS early, use it to benchmark
Despite the dearth of huge data repositories, home health organizations can reap improvement rewards by internal benchmarking, say benchmarking professionals in the fast-growing industry. "By looking within your organization, you can determine which areas, functions, or departments may be performing similar activities," says Alexis Wilson, founder of Outcome Systems Inc. in Seattle. "Then you can outline the processes in each area to determine what is most effective and efficient." Internal benchmarking can improve performance, which in turn boosts the bottom line, she says. "If organizations can improve a core process by detailing the system and measuring the results, then it can improve its performance."
In fact, it may be the perfect place to start because internal benchmarking successes can motivate home health nurses unaccustomed to performance measurements and pave the way for future external endeavors, says Nancy Santucci, RN, MSN, quality management and education coordinator for Community Nursing Service (CNS), an agency in Oak Park, IL, that provides about 35,000 annual home visits. "The entire field of home health is facing huge transitions, yet many field nurses don’t even know what the term benchmarking means."
CNS learned firsthand the challenges and opportunities of home care benchmarking as it participated in Medicare’s Prospective Payment System Demonstration Project for Outcomes and Assessment Information Set (OASIS), a 79-question assessment tool administered at admission, discharge, and certification that will be required by the Healthcare Financing Administration this summer. "Our nurses were overwhelmed initially by OASIS," remembers Sally Behary, clinical director. "It took us about a year to fully implement it, yet they didn’t fully embrace the benchmarking concept until we got back our first sets of results."
That tangible evidence helped changed per-ceptions almost immediately. "It was the best thing that happened to our initiative. Until then, benchmarking meant one more piece of paper to process," she says. Part of the problem is that until recently, payers and regulatory bodies have not held health care accountable for outcomes. "Nurses are simply not accustomed to thinking about comparing how patients fared over time."
After CNS received its comparative data from HCFA, a team of field clinicians including nurses, therapists, and aides chose three areas in which they scored below the norm: rehospitalization rates, oral medication management, and ambulation. The team then conducted staff interviews and chart reviews to discover more than 30 best practices in each area, Santucci says. "We randomly selected 20 charts from those in which we felt patients had potential for improvement and then listed all assessments and interventions we felt important to reaching good outcomes."
The team also asked staff "what was done or not done" that could affect improvement. For example, one of the key pieces to improving medication compliance was whether the patient had the ability to self-administer the medicine. "Once we reinforced importance of observation as well as a medication schedule that listed medication by time of day, patients showed improvement," she says.
Improvement in ambulation indicators came after therapists began reporting outcomes in the OASIS format rather than with the Functional Independence Measure (FIM), an 18-item scale developed by Uniform Data Set in Medical Rehab-ilitation in Buffalo, NY. "FIM, which uses a seven-point scale, considers improvement when patient goes from a walker to a cane, but OASIS, which uses a five-point scale, does not," she says. While CNS therapists still may use FIM for daily visit reports, they must use OASIS for outcome results.
The rehospitalization indicator, the bane of home care benchmarking, proved more difficult to improve because of the complexities that make returning to the acute care facility necessary. "From the literature, we did find that many rehospitalizations are due to congestive heart failure," Behary says. "Based on that fact, we knew that weight gain is the earliest indicator of CHF, even before ankle swelling, so we implemented a patient weight log." CNS also supplies scales if the patient can’t afford them.
"We can’t control everything in benchmarking, but we control what we can," she says.
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