QI medicine may cure documentation woes
MI agency creates Education at a Glance’
The staff at Oakwood Home Care Services in Allen Park, MI, continued to have difficulty in completing their Outcome and Assessment Information Set (OASIS) forms accurately even after multiple inservices, so managers devised a brief, attention-grabbing educational device that would provide weekly updates, reminders, and lessons.
"It seemed like what the staff needed was a follow-up, so we decided to give them a quick little education sheet that they could read at a glance, and that’s why we named it Education at a Glance,’" says Joyce Berry, RN, MS, BSN, manager of regulatory compliance and accreditation for the large suburban agency, which serves three counties in southeastern Michigan near Detroit. The agency had more than 6,300 unduplicated admissions last year and provides more than 50,000 visits a year.
Starting in August 2000, Berry and other managers created one-page educational sheets on bright orange paper. They gave the staff purple folders in which to store the sheets so that they would have them readily available if there was a question about OASIS or documentation that they needed to have answered, Berry says.
Each sheet took one small piece of a particular question or problem. For example, the Dec. 21, 2000, Education at a Glance focuses on the OASIS question M0032, and a Nov. 29, 2000, sheet is about how to use a discharge OASIS assessment form. (See samples of Education at a Glance sheets, p. 55.)
"Instead of looking at a four- or five-page handout, they were given the information in little segments, one segment at a time," Berry explains.
At first, the staff received the educational sheets twice a week, but that soon proved to be too time-consuming for managers and staff, so it became a weekly tradition in which the staff would find the sheets in their mailboxes on Fridays. On the same day, a compliance specialist at the agency will read a summary of the educational sheet into a voice mail message that is sent to all employees.
Education tips were played on voice mail
"If people feel like they’re too busy to read it, maybe they’ll listen to it on voice mail," Berry says.
The staff had positive feedback for the Education at a Glance initially, and managers noticed some improvement in documentation. However, some problems persisted, so managers had to move to the next phase of quality improvement.
One of the more persistent problems involved how the staff filled out the verification of change orders.
"At the top of the form, they have to write down the order date, and sometimes they didn’t fill that in at all," Berry says. "We have to enter that information into the computer, and the person doing the order entry had no idea what to enter."
Nurses also sometimes forgot to put down a physician’s phone number at the bottom of the form. Since the phone number was how the agency’s computer identified each physician, this also proved a major problem. A third problem involved the presumption of care form. Nurses would carelessly write that the care was resumed for nine weeks even when there wasn’t that much time remaining in the episode of care, Berry says.
"Before the prospective payment system [PPS], we weren’t resuming care; but now with Medicare patients, we have to keep them within the same 60-day episode and it doesn’t matter how many times they went into the hospital," Berry explains. "If they keep coming back to you, your payment is for the whole 60 days, unless there’s a significant change in their condition, such as a patient originally diagnosed with pneumonia returns to home care after having a stroke."
To solve the problem of documentation mistakes, mostly due to sloppiness, managers decided to follow up the educational sheets with supervisor auditing and oversight, Berry says.
The responsibility for entering data from the presumption of care and recertification forms was given to the team leaders. This has a twofold benefit: First, the managers are in a better position to determine what some of the missing data might be because they know these cases and, secondly, they now can see exactly what the problems are with their own team’s documentation and so they can easily fix the problem by having meetings with them, Berry says.
"Team leaders meet with their staff all the time, and they have closer access to them than we do, so it works better," she says. "Team leaders would say, yes,’ that it’s taking them time to do this, but at least it’s putting the problem back where it’s occurring, and we’re no longer asking a clerical person to try to guess or make determinations or track down a clinical person to find out the correct answer."
Although the most recent change to using team leaders was too recent to measure outcomes, Berry says it likely will show improvements in documentation, whereas the educational sheets weren’t enough.
"We had educated the staff all we could educate them, and we realized that the Education at a Glance was not causing enough of a change in their behavior with regards to the change in orders, so it was a performance issue," Berry adds. "We put the correction back with the people who actually monitored their performance."
Berry’s department had been auditing admission assessment documentation and then contacting individual nurses when errors were found. This did not seem to result in the necessary behavioral changes, so her department handed over the monitoring and auditing tasks to the nurse managers.
"This way, they look at all admissions, and if something is not done correctly, they can deal with the staff," Berry says. "It makes it a lot more effective if the person monitoring your performance knows what your problem is, and employees respond more to their managers."
M0150 question caused many problems
Some of the biggest documentation problems on the OASIS form have involved the M0150 question, which asks for the patient’s insurance. Nurses were failing to indicate that the insurance was Medicare if it was a Medicare HMO, and this type of omission results in inaccurate data being sent to the state office that handles Medicare data, Berry says.
The problem was that staff didn’t understand that they had to indicate both that it was Medicare reimbursement and that it was Medicare HMO reimbursement on the form, Berry explains.
The same problem cropped up later when patients were discharged to another facility because the discharge form also required that information, and staff would either forget or mark it incorrectly.
Since the managers began to review these forms and monitoring nurses’ documentation, those types of problems have improved, Berry says.
"The managers resented the extra work at first, but I think they found it enlightening. They have met with staff on a one-on-one basis to correct problems," she adds.
• Joyce Berry, RN, BSN, MS, Manager, Regulatory Compliance and Accreditation, Oakwood Home Care Services, 1633 Fairlane Circle, Suite 100, Allen Park, NY 48101. Telephone: (800) 757-7711.
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