Guide staff toward sterling documentation
Guide staff toward sterling documentation
Here’s how to create case management review tool
The QI manager at Community Home Health Care in St. Augustine, FL, created a tool that has worked wonders with the agency’s nursing staff.
Their documentation improved, an achievement that was noted during a recent survey by the Joint Commission on Accreditation of Healthcare Organizations of Oakbrook Terrace, IL.
The agency has tabulated no statistics on the improvements so far, but anecdotal evidence shows the documentation is improving, says Mary Lastinger, RN, QI coordinator.
The tool is used to measure each nurse/case manager’s documentation compliance, and to compare compare compliance among all the nurses. Nurses are given quarterly reports that provide an average score for how well they documented their care plans and other case charts.
Here’s how Lastinger created a CQI Ongoing Monitors Worksheet and a Case Management Review Tool:
1. Identify problems with current documentation tool.
Lastinger studied the old documentation tool and easily found its weak spots. One problem, she notes, was it didn’t give much feedback to staff about the positive or negative elements in their charting.
"When we were getting ready for staff evaluations, the supervisors would come to me and say, How is so and so doing with their paperwork?’ And I’d have a vague recollection that a nurse tended to be behind in those areas, but I didn’t have objective criteria," Lastinger recalls.
So she wrote that problem down on a case management review tool outline that she used to help her stay focused on goals, as follows:
• "Inadequate to provide really useful data."
• "Essentially Quality Assurance orientation rather than Quality Improvement."
Another glaring problem was the indicators were too vague. So she jotted down, "Indicators nonspecific and open to wide interpretation by auditor."
The indicators were so lacking in details that Lastinger "didn’t think they would yield any useful information."
For example, one indicator said, "Care plans updated at least every two months." Lastinger changed this to read, "Care plans are updated to reflect change in plan of treatment as indicated and/or progress toward goal achievement at least every two months."
2. Create goals for new tool.
Lastinger quickly identified this partial list of goals:
• Promote concept of case manager.
• Help staff become more efficient in delivery of care.
• Develop tools that meet Joint Commission and Medicare guidelines, and that provide meaningful feedback to staff.
Each goal was created to solve a problem Lastinger had identified when she was working with nurses on their documentation. For example, she wanted to encourage nurses to refer to the Medicare 485 form to guide their documentation, and they were not doing so. So she made that part of the delivery of care goal.
In promoting the concept of case manager, Lastinger decided to show staff how they needed to document so they could take credit for all the things they are doing, according to another goal. "They were doing a lot of different things, but if they didn’t put it on paper, they didn’t get credit for it," she explains.
3. Develop indicators for case management review tool.
Lastinger took the original indicators, which again were too vague, and made these more specific. Then she added more indicators, mostly ones that related to patient teaching.
She gleaned ideas from the Quality Assurance/ Risk Management Peer Group of the Florida Hospital Association, Home Care Division. And she read assorted textbooks on quality improvement.
Lastinger also met with Betty Poyner, RN, MBA, director of Community Home Health Care, and solicited input from other nurses at the agency.
Each indicator needed to refer to a specific QI goal. For example, Lastinger was concerned about how the nurses were updating patients’ charts on medications.
Nurses needed to review the medication list periodically and make sure the patients’ listed medications were still correct.
So she wrote this indicator: "Medication list is reviewed and updated at least every two months."
After Lastinger came up with an idea for an indicator, she rewrote it to make it more narrow and specific. She wanted it to be as specific as possible to eliminate her own subjective interpretation when she scored nurses’ case management charts.
"It was to help limit my interpretation and limit it for anyone else who uses the tool," Lastinger explains. "The less vague the indicator, the easier it is to make a determination. Plus, since these forms are going back to the nurses, I want them to understand as clearly as possible what our expectations are."
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