Spring cleaning? Throw out QA, add FI’ to clean quality house

Start with small, staff-championed problems to gain buy-in

The staff of Southern Home Care in Jeffersonville, IN, didn’t expect huge changes when the agency switched from quality assurance to a function-based process improvement program.

But there were small changes, and these were enough to convince the staff that functional improvement (FI) would work. For one, nurses talked about how much better the program was at staff meetings. And patient complaints dropped off from four in the third quarter of 1996 to zero in the fourth quarter of 1996, says Lorraine Waters, RN, BSN, MA, director. Waters also has a certification in community health.

The agency, which is part of Clark Memorial Hospital, covers seven counties in south-central Indiana.

Although the changes weren’t dramatic, Southern Home Care managers found that it was better to choose smaller problems to fix when first tackling process improvement. The staff could see how well these changes were going, so they became more invested in the process improvement concept.

Southern Home Care created teams to work on each of the four processes it wanted to improve. Waters says they kept the list small at first. The first process on the list, patient satisfaction, was a natural choice because of the complaints in that area, Waters says.

Then the agency asked nurses to identify other areas that should be priorities for improvement. Waters says this process was informal. No charts or reports were used to find trouble spots. The nurses simply sat down to discuss which problems needed to be addressed, and they decided which should be part of the process improvement program. The other three problem areas nurses identified were the on-call process, interdisciplinary communications, and bag carrying.

"They didn’t just give us a list and then we picked them out," Waters says. "The nurses decided which were most important."

Here’s how they addressed the problems in each of the areas:

The on-call process.

The on-call team was successful in rectifying problems with nurse scheduling on the weekend.

"They only had to make a few small changes to the process to make it function a lot better, but it made a big difference in how the staff felt about it," says Vicki Vallejos, BSN, RN, manager of support services

Previously, the nurses might have been given a weekend on-call schedule they didn’t want. "There was a lot of trading of days and a lot of panic to make sure everything was covered," Vallejos recalls.

After an on-call team focused on how to make scheduling fair for all nurses, they decided to include the nurses in the scheduling process. The team decided to rotate which office begins working on weekends, and to give outlying areas the first chance to sign up, she says.

"That has really increased their satisfaction. It seems to be more organized and the nurses have a better feeling about what they’re doing," Vallejos adds.

The on-call team also addressed ways to visit patients more quickly when they call in during the weekend.

The nurses had been carrying beepers. When a patient called, they’d visit that home. But if a second patient called while they were making a visit, that patient might have had to wait hours for a response, Waters explains. Waters says this was especially true when nurses were answering calls in rural areas.

Keep an on-call scheduling nurse

The solution was to have one nurse work the weekend as an on-call scheduling nurse.

The scheduling nurse no longer makes calls unless everyone else is busy. Instead, that person coordinates which on-call nurse will visit which home. Now patients are seen soon after they call into the agency, Vallejos says.

No formal surveys were taken of employees’ satisfaction before and after the changes, Waters says. But the staff repeatedly mentioned during staff meetings how much happier they were with the changes. Anecdotal evidence suggests patients also were pleased, she adds.

Patient satisfaction.

Another successful change was in how the agency addressed a frequent patient concern: too many different nurses visiting a home. (See related story on how the teams improved patient satisfaction, p. 55.)

"That team took a random survey of 10 charts to see how many nurses were going in, and they worked with the nursing teams to change that process," Waters says.

The nurses had always set their own schedules, Waters says. "But they were trading patients, and that was identified as one of the problems."

So the nurses talked about ways to make the process more consistent in the staff meetings. The major change was that the nurse manager more carefully scrutinized and reviewed the schedules, making sure there was less trading of patients.

It worked. Before the process improvement, an average of five nurses were visiting each patient during weekdays. Within six months after the change, the average was reduced to three nurses visiting each patient.

A discharge patient satisfaction survey showed that patient complaints about the number of nurses visiting their homes stopped completely for the four months after the change, Waters states.

Give discharged patients follow-up calls

Another patient satisfaction change was for Southern Home Care’s staff to provide follow-up phone calls after patients were discharged, Waters says.

"We want to let them know we’re still available if they need help," she explains.

This change was made to prevent patients from ending up in the hospital after they were discharged from home care, she says. "We were wondering if we could catch any problems early because maybe there’s something we could do to intervene."

No outcomes are yet available to show if the follow-up phone calls are working.

Interdisciplinary communications.

The interdisciplinary team has been working on trying to improve documentation and communication by all staff, including the rehabilitation employees, Vallejos says.

Waters says one successful improvement in interdisciplinary communications is having nurses send patients’ chart information to the main office by e-mail. That information is downloaded into the main computer server, printed out automatically, and put in the patient’s chart, she adds.

But the team has gone back to square one to solve the problem of undocumented discussions about patients.

"We have a lot of hallway conferences that never get documented, so we’re trying to figure out a good method for communication to take place and be documented," Waters says.

Bag carrying.

The fourth process improvement also has been slowed down. The team needed to find the best way for field nurses to carry their supplies and a new laptop computer, says Vallejos.

Waters says the team first looked at how to make it easier for nurses to carry their supplies without causing back strain. But when the agency began to use laptop computers, the team had to go back to the drawing board.

"It is an issue for some staff to carry that much equipment, and we may need to use a different type of laptop bag," Waters says.

These types of setbacks are to be expected with process improvement, Waters states.

"That’s the whole purpose of process improvement," Waters emphasizes. "If you have a process improvement team, you have to set a goal, but it’s not an ongoing process."

Waters says the main objective is to reach a goal, but changes will continue until then. Under the agency’s old quality system, she says, "people got really focused on the activity and they never reached a goal."  <