Don't forget non-clinical indicators in QI

Monitor costs, staffing to ensure quality care

[Editor's note: This is the second of a two-part series that looks at quality improvement programs in hospice. Last month, the proposed requirements for hospice quality reporting were examined along with advice about how to prepare and examples of clinical quality indicators some hospices are using. This month, non-clinical quality indicators and their importance to the overall quality program are discussed.]

As hospice managers face the advent of quality reporting programs, Quality Assessment and Performance Improvement (QAPI) programs are being evaluated to ensure the capability to meet requirements for Medicare programs.

Although clinical indicators such as pain management, treatment of dyspnea, or management of anxiety are the most obvious measurements for hospice's that want to assess quality of patient outcomes, experts interviewed by Hospice Management Advisor recommend that quality measurement also address non-clinical issues.

Although clinical indicators come to mind first when asked to measure quality of care, there are many non-clinical issues that contribute to outcomes and quality of care, points out Karen Mikula, RN, BSN, CPHQ, senior director of quality initiatives at VITAS Innovative Hospice Care, Miami, FL. Her organization's quality improvement dashboard report used by all hospices within the network includes a variety of quality indicators that are reported throughout the hospice. "Of course we include data on patient and family outcomes such as patient comfort, patient safety, effective grief support, and family satisfaction or evaluation of care," she says. "But, we also include non-clinical indicators because they affect our ability to provide clinical care effectively."

Non-clinical indicators in the VITAS report cover the areas of stewardship and accountability, says Mikula. "We look at productivity to make sure we are using our financial resources effectively and we evaluate areas such as staff safety because we are responsible for staff members' safety as well as patient safety." Being able to provide a safe work environment not only ensures retention of employees but also the ability to continue recruiting new employees, she adds.

A quality improvement program is not complete unless you look carefully at your operations, points out Martha Lasseter, MBA, CHPCA, vice president of compliance for Treasure Coast Hospice in Stuart, FL. "You should look across your entire organization because every area impacts how you provide patient care," she says. Incident reports and patient or family complaints must be tracked carefully because they help you identify safety issues or potential service improvements, she points out. "Staff and physician satisfaction survey results are also important because they identify opportunities to improve retention and recruitment as well as referrals."

Other non-clinical indicators that are included in Treasure Coast's regular quality improvement reports include:

• Durable medical equipment costs per patient day

• Drug costs per patient day

• Billing/claim errors

• Human resource vacancy rate

• Percentage of salaries related to patient care

• Number of volunteers

• Number of volunteer visits to patients

• Continuing education units received by staff

Although quality patient care is the primary focus of all hospices, the only way to make sure your hospice is operating effectively and providing quality care is to track non-clinical indicators on a regular basis, points out Lasseter. "We have to know on an ongoing basis that we are positioned to meet regulatory requirements and to be financially efficient in order to continue providing quality care."


For more information about non-clinical indicators, contact:

• Martha Lasseter, MBA, CNPCA, Vice President of Compliance, Treasure Coast Hospice, 1201 SE Indian St., Stuart, FL 34997. Tel: (772) 403-4525; e-mail:

• Karen Mikula, RN, BSN, CPHQ, Senior Director of Quality Initiatives, VITAS Innovative Hospice Care, 100 South Biscayne Blvd., Suite 1300, Miami, FL 33131. Tel: (786) 318-5330; fax: (708) 478-5819; e-mail: