Project improves peer review, documentation

Agency creates thorough form

Homecare quality managers often encounter gremlins soon after starting a peer review process. They include redundancy, inefficiency, and complexity. Often they can be eliminated by creating a thorough, clear peer review tool.

St. Joseph’s Visiting Nurse Association in Mishawaka, IN, recently completed a peer review chart that has 109 questions. It covers everything from whether the 485 worksheet is complete; to whether the clinical notes are current, signed, and dated; to what the net amount is over or under reimbursement. (See sample peer review tool, inserted in this issue.)

The agency, led by its quality improvement team, embarked on a lengthy effort to improve documentation and its peer review process by creating the new chart. Although it’s too early to say whether the new process and chart have improved clinical outcomes, the change already resulted in a streamlined and much more efficient documentation process, says Mark Guzicki, RN, MBA, CPHQ, director of clinical and quality services for the hospital-owned agency, which serves northern Indiana and southwestern Michigan with 8,000 nursing visits a month.

"Historically, we’ve lacked a sound performance improvement process and have never taken a systematic approach to PI projects," Guzicki says.

QI managers found about 40% of the information collected in some charts were redundant and too complex. "We spent so much time on the insignificant part of charting and documentation that we had no time or resources to focus on what’s important, and the important information got buried in the myriad of paperwork people were trying to chart," Guzicki says. In addition, the old documentation system and charts were too difficult to track for trends and sentinel events.

Guzicki and other QI managers decided to revamp the agency’s documentation through a formal peer review process. Here’s what they did:

1. Refer to the experts.

They plowed through a manual by the Joint Commission on Accreditation of Healthcare Organizations in Oakbrook Terrace, IL, looking for high priority indicators that should be a part of the agency’s medical record, Guzicki says.

"We wanted to build our tool around the Joint Commission requirements and to include those things we might want to look for that the OIG [Office of Inspector General in Washington, DC] might want to look for," he adds.

Quality managers had several important goals:

• Keep it simple.
• Make the peer review tool user friendly.
• Make sure the tool differentiates between clinical aspects of chart review and clerical aspects of chart review.

For example, a clerical aspect might be the question of whether there is a signed advanced directive in the chart. "It doesn’t require a clinician’s skills to look for that," Guzicki explains.

The clinical aspect includes asking whether a discharge plan is appropriate, or whether there is evidence that clinical care is reasonable and necessary.

Guzicki and another quality improvement manager created a draft of the peer review tool. "We let people tear that apart and put it back together," he says. "We have since modified the form and it continues to evolve, but it’s working fairly well."

2. Form a performance improvement team.

The agency included Guzicki and all disciplines on the team. Team members included therapeutic staff, nurses, nurse leaders, home health aides, clinical manager, medical record specialist, and a representative from the human resources team.

The team’s role was to look at trends and problems that appeared as the peer review process collected data. Guzicki built an Excel data base for the peer review charts, so tracking trends is now much easier.

"If we analyze the clerical component and find we have an inordinate amount of failures to get the bill of rights signed, then we’ll focus on that," he says.

3. Begin improved peer review process.

Each month, a quality improvement clinical employee and a clerical employee review a total of 5% of the agency’s total charts. This amounts to about 40 charts a week. They match the visit frequency with that of billing to make sure the agency had new verbal orders when providing treatment.

For example, they’ll answer these questions:

• Was the physician order returned and in the chart on time?
• If the agency delivered pharmaceutical supplies, was there a copy of the delivery on file?
• Was the LPN supervision completed at least one time per month?
• Is there evidence the nurse or therapist provided appropriate teaching? Is the patient response to teaching evident?

Each peer review chart takes about 30 minutes to complete, Guzicki estimates.

The peer reviewers are looking for exceptions, which may be omissions or errors. For instance, an exception might be that a nurse’s note for July 11, 1998, is not on file. "Sometimes the clinician has it in her travel file, but it has not been properly filed, so the peer review serves as a good prompter," Guzicki says.

Another exception might be that the medication sheet was not updated at the time of the last new medication. When ever these problems are found, the nurse involved and the nurse’s clinical manager are given a report, and they have seven days to correct the problem.

4. Use the peer review data for PI projects.

The peer review process has shown the redundancy in many of the agency’s forms. "Whenever a regulation or business requirement changed, the agency would simply add something to existing forms," Guzicki says.

"By incrementally adding onto our package, we’ve created a monster that’s designed to fail," he adds. "For example, we have forms that ask five to six times for the medication record."

The agency plans to tackle the project of revamping and simplifying documentation.

"Our next step is to make contact with a number of benchmarking organizations about documentation to form a needs analysis for the facility," Guzicki says. "We’ve gone as far as to investigate a point-of-care documentation system."

The peer review chart database also makes it a simple matter for Guzicki or other quality managers to run a report that lists the findings down into groups, according to the types of problems. This gives a clear-cut look at trends, and helps the agency’s performance improvement team set goals and priorities for future projects.


Mark Guzicki, RN, MBA, CPHQ, Director of Clinical and Quality Services, St. Joseph’s Visiting Nurse Association, 810 E. Park Place, P.O. Box 5006, Mishawaka, IN 46546-5006. Telephone: (219) 271-2142.