Spread the QI gospel among branches

Get consistency in a multifacility organization

With over 500 offices around the country, Columbia HCA is probably one of the biggest players in the home care market. But for Elaine Davis, CPHQ, chief quality officer of the Columbia Homecare Group in Dallas, being so large means it takes extra effort to make sure all quality improvement (QI) programs are implemented uniformly.

"If you have 500 people in a room and ask three to count the blue shirts, you’re going to get three different answers," Davis says. "It’s the same in my job. If you are vague, you will get different interpretations of what a particular policy will look like when it’s implemented. The key to success is to narrow, narrow, narrow."

Davis has three recommendations for people trying to bring a baseline, standardized level of quality to a large organization:

1. Be objective in your instructions.

"You can’t use subjective language," she explains. "If I say to a home health aide that I expect quality care, that doesn’t mean anything to her. I have to personalize it. I have to define what I mean by quality." Telling the aide that quality means being on time, for example, is a more concrete statement, Davis says. "If you tell her that you expect her to be where she says she will be within 15 minutes on either side, you are more likely to get the result you want."

2. Standardize policies.

Some people think standardizing means having the same policy in every office. Not so, Davis says. While having the same rules is important, that is only one aspect — the technical aspect — of standardization. More important, and more difficult, is "relational" standardization, or ensuring that policies and programs are appropriate to the particular relationships involved, be they client/caregiver or administrator/nurse.

Davis explains: "We say, ‘Here is how you schedule,’ and we write a thick manual that sits on a shelf. Standardization is about how to do your job, but it has to separate the significant from the trivial. There are 35 or 45 different steps associated with scheduling. If I wrote about each, no one would read it." Instead, it is more important that she enumerate the most important elements of a particular task.

For example, if a home health aide breaks something in a client home, the old procedure would be a long document that would outline all the steps the aide would have to take. These would likely include, among others:

— Apologize.

— Ask for an estimate.

— Take that estimate back to the home care office.

— Explain the situation to the manager.

— Get approval for coverage from the manager.

— Return to the client and tell the client that if they buy a new object and send the bill to the home care agency, the client will be reimbursed.

"That’s nine or 10 steps," she says. "Meanwhile, you have inconvenienced a sick patient and put the onus on them." By concentrating on enumerating the steps needed to correct a situation quickly and easily for the client, Davis says the whole procedure can be shortened. "Now we can have the staff member call to have a check sent immediately or even purchase a replacement for the client and put the cost on his or her expense sheet."

3. Performance monitoring.

Monitoring both internal and external criteria enables Davis to determine if her policies are being implemented. There are five internal criteria Davis looks at:

Financial performance.

This is fairly self-explanatory, covering costs, income, expenses, etc.

Clinical quality performance.

Also straightforward, this indicator relates to how well patients do under care.

Human relations performance.

This section describes staff relations and performance.

Service capabilities performance.

Davis says this indicator tells how well the agency meets the needs of its patient base.

Development performance.

This relates to how the agency is positioned in the market.

External indicators are more objective. "People have their own biases, so we have to make sure we can monitor performance based on more objective criteria, as well," she says. For example, under clinical quality performance, Davis tells her nurses to look for a way to prove there has been a positive outcome. They can look through their clinical notes to find something objective that reinforces their opinion, such as improved ability of the patient to care for him- or herself or improved range of motion. "You have to find a way to take how they feel out of it."

Another external monitor is customer surveys. "You can make a customer satisfaction survey say whatever you want by asking the right questions, so we ask questions that require specific answers, like, ‘What do we do that you particularly value?’ Such questions generate specific answers."

Quarterly meetings foster key cooperation

While Davis finds that these steps help her control quality programs across 500 facilities, smaller organizations make use of smaller programs.

Mary Ann Rae, MN, RN, PHN, is operations manager at Alliance Home Care Management in Walnut Creek, CA, a home care company that manages five hospital-based home care agencies in California.

"We find that the best way to ensure a program is put in place uniformly is to communicate regularly," says Rae.

Each operations manager deals with two quality improvement coordinators at the various home care companies. The managers and coordinators meet quarterly to share information, talk about problems, and find solutions. There are also monthly conference calls, and daily telephone communication between the operations managers and their QI coordinators. This communication fosters a great deal of cooperation, says Rae.

She was reminded of the importance of communication recently when she realized there was no systemwide policy on patients who do not wish to be resuscitated.

By discussing the problem with her counterparts and their QI coordinators, Rae was able to pull together pieces from every office’s policy — however informal it was. She developed a procedure that was implemented last month. (See DNR policy, p. 8.)

"We have two procedures — one for DNR patients who let us know prior to start of care, and one for those who decide after care begins," she says. "The issue is addressed again with both patient and doctor at every recertification." The policy will be field-tested, and discussed at the next quarterly meeting.

Rae says the best way to get uniform quality programs and policies is to allow staff the freedom to provide input into them. "If you mandate a policy and it doesn’t work for them, they have no incentive to put it into place," she says. "But if you make it a realistic policy, one they can work with because they helped develop it, then they will all work with that policy. Cooperation keeps the agencies from straying away from your standards. It instills trust and a better working relationship."