QI overhauls care plans to please JCAHO

A survey consultant told officials at a Georgia home care agency that they should scrap their care plans because the forms would not pass muster with the Joint Commission on Accreditation of Healthcare Organizations in Oakbrook Terrace, IL.

The care plans merely duplicated the Medicare 485 form, when instead they needed to focus on updating changes to the patient’s care and listing treatment goals, says Deborah Jennings, RN, standards and regulatory coordinator for Advantage Home Health and Quality Home Health in Savannah, GA. The agency, which is affiliated with St. Joseph/Candler Health System of Savannah, conducts about 20,000 visits a month in six counties and two South Carolina offices.

So the agency started an extensive quality improvement project, using the Continual Improvement Principals and Tools, published in 1993 and developed by Executive Learning Inc. in Brentwood, TN. (See note at end of story.)

The project resulted in new care plans for each discipline, which the Joint Commission approved during a survey. The care plans also have helped staff provide more specific, detailed, and consistent documentation, Jennings says.

For instance, the social workers previously only used narrative-style notes and didn’t list time frames for accomplishing goals that were set. Now the medical social worker plan of care has been tightened to include these specifics, and the medical social work initial evaluation has become more focused, as well. (See medical social work initial evaluation form, inserted in this issue.)

The initial evaluation, which is two pages, still allows space for a narrative, but it asks the social worker to describe and assess these specifics:

• description of patient and history;

• support systems and family information;

• patient’s current living status;

• sources and amounts of income and insurance coverage;

• whether patient owns home;

• any major outstanding bills;

• patient’s status regarding advance directives, durable power of attorney, and legally authorized representative;

• current legal situation;

• patient’s and caregiver’s attitude/feelings concerning the illness and present condition;

• patient’s and caregiver’s feelings about what is needed to improve situation.

Quality managers who would like to revise their agencies’ care plans could follow these guidelines, Jennings suggests:

1. Find a process to improve.

The team developed an opportunity statement, which reads as follows:

"An opportunity exists to improve the interdisciplinary care planning beginning with patient admission and ending with patient discharge. This effort should improve continuity, efficiency, effectiveness, timeliness for the patient and health care providers. The process is important to work on now because the agency can improve the quality of patient care through enhanced communication and coordination of services."

2. Organize a care planning team.

Members would include every discipline that performs care planning, such as the nurses, social worker, home health aide, physical therapist, speech therapist, respiratory therapist, and occupational therapist.

"We have a durable medical equipment [DME] company and an infusion company, and they have care plans too. So we had a DME representative and a pharmacist on the team," Jennings says.

Advantage Home Health’s care team had 12 members. The team members worked on revising the care plan pertaining to their disciplines and enlisted help from their peers. For instance, the home health aide team member asked for input from other staff aides. The social workers worked on their form, the therapists worked on their forms, and so on.

Jennings says it was important to involve other staff members for two reasons: First, the people who would be using the forms would have the best ideas of how to put them together; second, the staff’s involvement helped with their eventual buy-in to the new forms.

3. Clarify process with a flowchart.

The team wrote a flowchart to clarify the entire process for each of the disciplines. (See Advantage Home Health’s flowchart, p. 37.)

It starts with the patient being admitted and assessed by the nurse, and then leads to the choice of whether nursing services are needed. If the answer is yes, the next question is whether the physician has given a nursing evaluation order; if the answer is no, then the next questions are:

• Is physical therapy service needed?

• Is speech therapy service needed?

The flowchart ends with "implement care plan," and the statement, "Patient status review in team conference — every 60-62 days and in Ground Rounds Monthly," which are team meetings held in all branches for the purpose of discussing patient care.

The team also made sure everyone on staff understood the current process and what changes were needed to improve it by holding inservices for each discipline and asking for staff input on any problems they might have with the forms.

4. Plan and implement the revisions.

Team members were given checklists to use in writing their care plans. The plans basically had to include categories for problems identified, onset date, date resolved, and room to write interventions and goals. (See sample medical social work plan of care, p. 38.)

"We told them we wanted the problem listed, the interventions very clearly stated, and we wanted the goals stated with time frames," Jennings says. "We said, ‘However you want to develop the form, these are the items we need to really clarify.’"

The team decided that the nurses’ care plan needed to have a priority problem list, and the form name was changed to Care Plan Update, Jennings says. "At the top of the form, you could number your problems in order of priority," she explains. "Then there’s a section below where you can state what the problem is, the intervention, and goal."

For example, the nurse could write down actions that do not require a physician’s order, such as if the patient is weighed or if fluids are increased. (See sample Care Plan Update form, inserted in this issue.)

Jennings was in charge of editing the revised care plans. She made sure all of the components required by different regulatory sources were met. "They brought back their suggestions, and we discussed them and assessed what was needed on the forms."

5. Check to make sure it’s working and act when needed.

The process began in August 1996 and continued through December 1997 because the team wanted to be sure all snags were ironed out.

Some forms have been changed as far as data collection, and a few problems have arisen in terms of compliance and documentation, Jennings notes.

For example, one problem on the home health aide care plan was that the form had a place for staff to update the care plan, but it didn’t have a place to say which specific items were updated. So there was no way of knowing how long ago a particular activity was checked.

[For additional information, contact: Deborah Jennings, RN, Standards and Regulatory Coordinator, Advantage Home Health and Quality Home Health, P.O. Box 24177, Savannah, GA 31403. Telephone: (912) 692-7543.

Executive Learning, 7101 Executive Center Drive, Suite 160, Brentwood, TN 37027. Telephone: (800) 929-7890 or (615) 373-8483. Fax: (615) 373-8635. Web site: www.elinc.com. The Executive Learning handbook has been revised. The 1997 edition is titled Handbook for Improvements, 2nd Edition; A Quick Reference Guide for Tools and Concepts.]