6 tips to set up functional improvement teams

Huron Valley Visiting Nurses of Ann Arbor, MI, switched from a quality assurance approach to a functional improvement team approach, pleasing both patients and staff.

Huron Valley employees meet in five different teams that together cover all of the agency’s jobs and functions. They discuss problems in their areas and work together to come up with solutions. Enthusiasm for the process has been contagious, and the changes are beginning to yield positive results, including higher scores on patient satisfaction surveys.

The agency’s quality manager and other employees say any home care agency could get functional improvement teams rolling. Here’s how:

1. Make sure the teams are diversified.

Employees from all sectors of the agency, from top executives to field nurses, serve on the teams, says Susan Johnson, acting director of quality management.

"We don’t force the field staff to get involved because it is a time commitment," Johnson says. "But they volunteered, and once they’re on it they like it enough that they continue to participate."

2. Have each team identify changes that need to be made.

Huron Valley asked the teams to identify only two changes they had made in 1996 to improve their processes. Their enthusiasm and ideas had made it difficult for them to limit the number of these, Johnson says.

"So we had 22 changes on our list and even more later," she says. "One of the exciting things about this is how quickly change can happen."

3. Consider adding outside experts to the team.

The ethical committee has recruited an attorney who is also a nurse and is active with a Michigan home health association, says Linda Taub, BSN, RN, director of clinical services.

"We also invited a medical ethicist from the University of Detroit to work on the ethics committee," Taub adds.

Outsider helps track legal trends

The addition of outside professionals has helped the committee stay abreast of state legal changes that affect health care ethics. "In Michigan, we had a change in law regarding do-not-resuscitate [DNR] orders in the home," Taub explains.

"Until the new law, the EMS was required to perform CPR on a patient in the home," she says. With the law’s passage, emergency crews are not required to perform CPR if there’s an original DNR order, signed by the physician, in the patient’s home. The patients initiate the orders.

The ethics committee decided its own DNR order would have to be revised. The old order was initiated by a physician and a copy was kept in the patient’s home. The new one could be initiated by a patient with a nurse’s assistance, and the doctor keeps the copy. The patient keeps the original at home.

Michigan’s new state law gave examples of DNR orders, and Huron Valley wrote its new order based on those examples, Taub says. Then the team hosted an inservice for all staff on the legislative changes.

4. Give the team free rein to make changes and adjustments in the agency’s current processes.

Huron Valley was having trouble with its documentation, so the care planning team did a chart audit. They found that some paperwork lacked signatures and dates, and that some nurses were careless in filling out assessment checklists.

One team member, Karen Zasada, RN, MSA, Huron Valley’s director of operations, spent about six months looking at how other home care agencies developed assessment tools. She also pored over standards of the Joint Commission on Accreditation of Healthcare Organizations in Oakbrook Terrace, IL.

With that information, she and the team first devised a 12-page form and then condensed it to seven pages. The new form has resulted in nurses being more consistent in how they assess patients, and it has more measurements than the old form, including a nutritional assessment.

5. Pilot-test the teams’ decisions.

Expect to go back to the drawing board often. "Don’t just create a tool and say this is it, and then make 1,000 copies," Zasada emphasizes. "There’s going to be some opportunity for improvement during the trial period, so set some realistic expectations for that."

The trial period should last as long as it takes the team to find a change that works. For example, the agency relied on a lengthy, 18-month trial period to develop a patient satisfaction survey.

After months of trial and error, the team developed a simple one-page form. The agency mailed the form to some patients, and surveyed others over the telephone. More patients responded to the new written survey than to the old one, and the team could have been satisfied with the results and stopped the process there. Instead, the team used the trial period to note any trends in the survey responses.

The team discovered that the written surveys produced more negative responses than the telephone surveys. Johnson surmises this was because "people were reluctant to say something negative to someone on the phone when the surveyor had a demeanor that the customer liked."

Also, "when they did the telephone surveys they would call people randomly from a list until they had X number of responses, and then they stopped. But the written surveys are sent to everybody," Johnson notes.

The team decided to switch to using only written surveys so the results would be more consistent and reliable.

6. Emphasize staff education.

Hold inservices that incorporate a review of employees’ work.

"Staff training is crucial," Zasada says.

Whenever a process is changed at Huron Valley, staff inservices are scheduled. For example, when the agency changed its assessment tool, it scheduled three inservices to educate staff. The first session focused on an overview of the new tool and how to complete it. The second session was scheduled two months later and included staff reviewing their own use of the tool to learn where improvements could be made.

"Then the last one was scheduled a month after the second inservice to provide feedback regarding how well the tool was working, share information regarding any areas still needing improvement, and answer individual questions," Zasada says.

Also, new staff are introduced to the assessment tool during orientation, and there is a follow-up to make sure they understand how to use it. Inservices may be scheduled in the future if chart audits reveal errors indicating that staff education is needed.  <