Sometimes the quick fix is the best QI process

Agency makes several fast improvements

A lengthy quality improvement process often is not needed to solve a particular problem. The best solution might be the "quick fix," a sensible approach that uses the philosophy of the QI process without spending months of committee time on it.

St. Margaret Mercy Home Care of Hammond, IN, has solved several problems this way. The hospital-based agency, which serves northwestern Indiana and the southern Chicago area, has a QI process that tracks any trends, says Karen Wade, RN, MS, director of home care services.

The agency has a quality improvement program that tracks and trends the following:

· that patients are achieving maximum potential from whatever therapy they receive;

· that there's no evidence of infection during wound healing, and the most cost-effective treatment was utilized with an emphasis on prevention;

· that patients are assessed when hospitalized to determine the reason for hospitalization and to analyze whether the hospitalization could have been prevented;

· that patients are achieving established personal care goals with home health aides.

In addition to this formal QI process, the agency also tracks clinical pathway and program variances and minor problems that are discovered through its occurrence reports.

"We turn everything into a performance improvement," Wade says. "Even something so minor as if a physical therapist comes in late, or if the patient states any concern, the nurse might fill out an investigation report."

By tracking every issue so closely, Wade has noticed a correlation between patient satisfaction, returns to the hospital, and trends of complaints and problems.

For example, if the agency's congestive heart failure (CHF) patients were being readmitted to the hospital for treatment, then the agency would monitor hospitalization rates and track which staff members were involved in patient care. Wade and other managers would ask these questions:

· Was there one particular nurse or physician involved with the patient?

· What were the reasons for the patient being admitted to the hospital?

· Was the patient on the agency's CHF program, and if not, why not?

· What prohibited the patient from staying home?

This way, the managers can quickly arrive at explanations and possible solutions to the problem. St. Margaret Mercy Home Care has successfully followed this quick and simple process with the following problems:

· Some oncology patients were hospitalized needlessly.

A physician noticed that four of his oncology patients had been needlessly admitted to the hospital. The physician thought the home care nurse had been sending the patients to the emergency room.

So the agency's management team checked the patients' charts and saw that each patient had that same physician, but a different nurse. The problem was that the patients would panic and go to the hospital without informing the nurse or their primary care physician. Then, whichever physician happened to be on call would admit the patients because the patients didn't inform the doctor that they were receiving home care services.

"So we took copies of the patients' charts over to their main physician," Wade says.

The patients were instructed on what to do at home, but some of them still would go into the emergency room when they felt worse. So the primary physician notified the on-call physicians that he wanted to be called about certain patients before they were admitted to the hospital. Since then, there hasn't been a problem with these patients being hospitalized, Wade says.

· The agency received too many phone calls.

The agency's clerical staff reported that they were receiving too many phone calls and needed some more employees to help handle them.

"We sat down with them and said,'What are the phone calls about? Are they referrals?'" Wade says.

The employees said the calls weren't referrals, so the agency's management became concerned and decided to track these calls to see what the problem was.

The clerical employees were given a log report form and told to write down each call that came in and what it was for. At first the staff complained about the extra work, Wade recalls.

"But we said,'Listen, when we collect this data we'll find out what the problem is and eliminate the problem,'" Wade says. "So they would only have to do the extra work for a limited period of time."

Aide lateness worried patients

After staff completed the log reports for a few weeks, Wade and other managers analyzed the information and created a pie chart. The chart showed that most of the calls were from patients who were worried when their aides were late, Wade says.

"We found that over half of the time, the aides would tell a patient,'I'll be there by 8 o'clock,' and if the aide wasn't there by 8:15, then the patient panicked," Wade says.

Once the agency's managers learned this was the problem, they met with the aides and asked them why this was happening.

The aides thought they were doing well with their schedules, Wade says. But whenever something came up to keep them at one home, they often failed to call the next patient to let the patient know they were running late.

"So we had them start giving the patient an hour range, saying they would be there between 8 a.m. and 9 a.m., for example," Wade says.

"Then they tell patients,'If something happens in your home, I want to take care of you so I may be a little late to the next person, and this is why I'll give you this time range,'" Wade explains.

Once this minor change was made, the complaints and phone calls decreased. Also, the agency's employee and patient satisfaction increased, Wade says.

"We saw an improvement in our next customer satisfaction survey," she says.

· Patient education was too confusing.

Many patients had difficulty absorbing all the information being thrown at them. This was because the agency's patients often have more than one major diagnosis, and nurses would place patients on one of the agency's new care pathways for each of their diseases. Nurses would then teach the patients about each of their diseases.

This became a problem simply because of the way the nurses were telling patients about it, Wade explains.

"They were telling the patient,'We're putting you on a program for these diseases,'" Wade says. And this frightened the patients, who felt they couldn't possibly learn all of this new material at one time.

"The patients were afraid they were going to get too much information, and it was going to be confusing," Wade says.

The solution was to not tell the patient that they would be expected to learn about three or more diseases as part of a pathway initiative.

Nurses still could teach patients everything they needed to teach them for various diseases. But they would no longer label it a "program." Instead, the teaching material would be a natural part of the nursing visit.

The change seemed to work. "We've been doing the pathways this year, and now they're applied to all diagnoses," Wade says. "Patient satisfaction is continuing to climb each quarter."