Use a new tool to track trends

Quarterly report is a better screwdriver

Sometimes it’s hard to find just the right tool to complete a QI job.

If the dusty old standbys don’t quite fit, then you might try tossing your QI toolbox aside and creating a new quality improvement and benchmarking tool, such as a quarterly summary report. Amicare Management Services of Novi, MI, did exactly that.

The company needed a tool to report QI data that could be used by the 24 Amicare home care and hospice agencies that the company manages. The tool had to track key safety and patient health issues. The tool also needed to meet standards by the Joint Commission on Accreditation of Healthcare Organizations in Oakbrook Terrace, IL, because the Amicare home care agencies are surveyed by the Joint Commission.

Tool time: Quarterly

The solution was a standardized quality improvement report, called the Quarterly Summary Report. Margaret Berkhousen, RN, BA, clinical specialist for quality improvement, worked with members of the AMS clinical services team to develop the report, which has been used by Amicare-managed agencies for about three years. Amicare Management Services manages 16 home care agencies and eight hospices that the company previously had owned. The agencies are located in six states.

Berkhousen says the report has improved reporting by the home care agencies’ staffs. The form is easy to use. Lines and cues are provided to help staff report data and results from other QI monitors, such as client concerns, unplanned occurrences, results of surveys, and infection tracking data. (See sample quarterly summary report, pp. 120-123.)

"But the most important feature of the standardized reporting format is that it provides data for comparison," Berkhousen says. "There are four or five indicators we look at across the system. The document may end up being four to five pages long, but they only have to turn it in once a quarter."

Each quarterly report includes the following information:

• results of systemwide indicators (such as congestive heart failure [CHF] readmission rates, or client satisfaction with pain control);

• customer complaint trends, and how these are addressed;

• infection rates for staff and clients;

• safety issues and disaster preparedness;

• educational needs identified during competency evaluation;

• other trends that are important to a particular agency.

The quarterly summary report has been well-received by the Joint Commission and the company’s primary insurers, Berkhousen says. It’s also allowed Amicare to track and improve several problem areas, including customer satisfaction and readmission rates for CHF patients. (See story on improving readmission rates for congestive heart failure patients, p. 125.)

‘Generally favorable’ not good enough

A problem area in customer service, for example, was that one home care agency’s management wasn’t satisfied with the agency’s "generally favorable" rating for the billing process. So the agency organized a process improvement committee and took the following actions:

— analyzed customers’ complaints to determine which specific issues could be addressed;

— enlisted help from the central billing department;

— assigned an employee to contact clients regularly about billing issues.

The result was that in the next quarter the agency didn’t have to rebill any clients because of inaccurate bills, Berkhousen says.

Here are her tips for quality managers who want to develop their own quarterly summary reports:

1. Develop the report according to the Joint Commission’s functions and dimensions of quality.

Amicare uses the Joint Commission’s five patient-centered functional areas and the six organizational functions, examining them according to the "dimensions of quality." Dimensions of quality include efficacy, appropriateness, availability, effectiveness, continuity, safety, efficiency, and respect and caring.

For example, one function is surveillance and control of infection, and a dimension of quality is effectiveness. So agencies measure their infection control effectiveness by tracking the number of infections. The indicator is to not have more than five days of infection per 1,000 days of time that patients have catheters inserted.

Berkhousen says the company’s average has been less than two days of infection per 1,000 days of catheter time.

The company also tracks whether an agency is receiving signed physician’s orders within 14 days. This indicator refers to the functional area of management of information services and the dimension of quality called efficiency.

2. Select measures of each function that need to be tracked.

"For instance, to look at the effectiveness of our treatment of clients with CHF, we measure readmission of clients to the hospital within 30 days of discharge," Berkhousen says.

Amicare’s QI plan includes four systemwide indicators for benchmarking. These indicators are revised and updated each year, depending on priorities and needs. The indicators are:

— Concerns are resolved to client satisfaction.

— CHF readmission rates are decreased.

— Client satisfaction is measured, and results used in organizational planning.

— Number of infections in clients with IV access devices is monitored.

3. Make sure the methodology is consistent.

Have each agency collect data in the same way, Berkhousen advises.

"Our hospice branches have pain management programs, so it’s important to them to determine how effective they are in relieving a patient’s pain," she says. "The first step was to make sure everyone was using the same methodology for rating pain."

A zero score meant no pain, and a score of 10 meant the patient was experiencing the worst kind of pain. So last year, one of the hospice indicators was: Pain is assessed and monitored using 0-10 pain scale per AHCPR guidelines.

"By the end of the year, all the hospices were using the same methodology for evaluating pain," Berkhousen says. "That enables us to look at a more meaningful indicator this year."

The new indicator is: Patients rate their pain as 3 or less within 1 week of nursing intervention.

"Because the branches are using the same methodology, they can compare results and call the best performers for help," she adds.

4. Computerize the process.

Amicare Management Services sends the quarterly report to agencies on both disk and hard copy. A few small branches do not have computers, so they fill out the report by hand.

The offices send Berkhousen the reports and she puts them together, evaluating and comparing the data. Chiefly she looks for trends.

"I can just report the figures as they’re reported to me, but when I go through the data analysis I typically come up with trends and can make recommendations," Berkhousen says.

"For instance, in 1995, we noted an increase in staff injury from slipping on ice and snow, mostly in clients’ driveways and walkways," she says. "The falls had not resulted in serious injuries, but the potential was there."

The clients often were unable to find help clearing snow and ice. "We can’t control their environment," Berkhousen adds. "So we are researching types of ice spikes or cleats that the staff can slip on over boots or shoes during the winter months."

5. Identify each agency’s problems.

Berkhousen discovered after one quarterly report that an Amicare agency had a 22% readmission rate for CHF patients with congestive heart failure. This was above the agency’s benchmark of 15% readmission for these patients.

"Most of the agencies are far below the benchmark," she says. This particular agency was having trouble, so Berkhousen began to investigate the cause. She called the agency and asked the following questions:

• Has the Hearts at Home Program been implemented?

• Have the nurses been checked off for cardiac care skills?

• Are the nurses teaching the clients to weigh themselves, and to call if their weight increases by two to five pounds in 24 to 48 hours?

• Are nurses implementing the protocol for management of weight gain?

6. Help the staff correct any problems.

Once a potential cause is identified, the office will make changes immediately, Berkhousen says.

"Sometimes they put these changes in place, and the very next quarter the readmission rate goes down," Berkhousen says.