A, B, or C — how do the nurses score?

How to create grade cards for case manager nurses

There has to be a good reason that most American school teachers still use the old standby scoring system of giving students scores from 0% to 100% on tests.

At least that’s what a Florida QI manager figured when she decided to use the same system to rate nurses on how well they filled out their case management files.

"I did this for feedback, and the nurses are getting more feedback than ever before," says Mary Lastinger, RN, QI coordinator for Community Home Health Care of St. Augustine, FL.

First Lastinger created 16 indicators or criteria to be used on a case management review tool.

Then she assigned five total points to each indicator, except for an indicator on teaching, which was broken down into five categories and is worth a total of 25 points.

The tool left a space to indicate "yes," the criterion was met, or "no," the criterion was not met.

This part of the tool was mostly objective. For instance, when Lastinger reviewed a nurse’s chart, she could easily see if a nurse provided a patient with "meds-specific teaching," as one indicator reads.

The nurse could receive a total score of 100 points for 100%. The form is used for each case file reviewed, and the scores are totaled and averaged to come up with an overall percentage and score.

Lastinger created the point scale because she wanted to give nurses some credit for partial compliance. It also makes it easier for the supervisors to evaluate a nurse’s progress. If she went strictly by the "yes" or "no" answers, the review might be too harsh.

For example, the agency has a policy that nurses must give the physician an update each week if the patient is visited by a nurse at least once a week. If the nurse visits the patient less frequently, then the nurse must give the physician an update after each visit.

"The problem is, if somebody missed one week of contact with the doctor, then technically that criterion would be a no. Or if somebody missed three weeks, the criterion would be no," Lastinger says, adding that the first nurse wouldn’t get credit for the times she did contact the physician.

"I wanted it to be done in a way to reflect that if something was done the majority of time, they’d still get some credit."

So she added some subjectivity into the measurement. Nurses could receive a "no" and still receive some points.

The scale is as follows:

• 5 — Highly consistent — 95%-100%

• 4 — Occasional inconsistencies — 90%-94%

• 3 — Fair to moderate compliance — 80%-89%

• 2 — Substandard compliance — 50%-79%

• 1 — Highly inconsistent — less than 50%

• 0 — Noncompliant with standard — 0%

If the nurse’s teaching was 80% complete, for instance, then the nurse would receive a score of three on that indicator.

Lastinger decides what constitutes the acceptable amount of teaching, and this also can be somewhat subjective, she admits. "If the patient has a multiple diagnosis, it makes it even more tricky."

Suppose a patient is being treated for cardiac problems, diabetes, and wound care. Then when Lastinger reviews the nurse’s chart, she sees that the nurse taught the patient about cardiac care and diabetes, but forgot about the wound care. "Then I might give the nurse a score of four points," she says.

"All I can do is draw on my own nursing experience and accepted standards of care: What are the priorities, and how would I go about teaching this?"

If a particular criterion doesn’t apply to that nurse, then it’s marked "N/A," and it’s subtracted from the total possible points before the percentage is determined.

So far, the individual scores have worked wonders.

"Subconsciously, they compare themselves to their peers," Lastinger says. "When they get a score of 84, they might not know what everybody else had, but they know where they stand and they might not like it."