Making the most of a JCAHO requirement
Making the most of a JCAHO requirement
Critical thinking makes the difference
Performance improvement gets a lot of press today. It is a mainstay of the revised Joint Commission on Accreditation of Healthcare Organizations (JCAHO) home care standards and a re-engineering buzzword. But sources say home care providers struggle with its implementation, bogging down in details or glossing over plans that could significantly impact patient outcomes rather than just meeting JCAHO intent.
"There is a lot of variability in what providers think is important and differing amounts of effort put into performance improvement," says Deborah Kranz, RN, MPH, a consultant with Kranz and Lamb Associates, an Oak Park, IL-based home care consulting firm. But an effective performance improvement plan can be a real competitive advantage, enabling agencies to better their patient outcomes and differentiate and quantify their care.
JCAHO standard PI.1 requires that "the organization has a planned, systematic, organization-wide approach to designing processes, and measuring, assessing, and improving its performance." This broad directive gives little guidance, but sources say you can design and implement an effective performance improvement plan with the following key actions:
o Determine organizational priorities.
The first performance improvement implementation step is determining what is important to your agency. Organizational priorities often fall out of the strategic planning and budgeting process, says Kranz. For example, new services or programs for payers are typically accounted for in annual budgets, although they may be implemented over the course of a hospital's fiscal year.
A home care provider should establish two to three broad objectives that can be accomplished within a year, suggests Kranz.
o Identify routine measures.
Routine measures are the day-in, day-out patient care and customer satisfaction gauges most hospitals use, such as chart audits, patient satisfaction surveys, incident reports, etc. In developing its performance improvement plan, an organization should review its already established measurements.
o Establish a steering committee.
The steering committee oversees the entire performance improvement process. It establishes the overall plan, identifying targets, determining process methodology, assessing individual team progress and determining board and executive management reporting frequency. Senior management and multidisciplinary staff representation on the committee is essential, says Kranz. As a resource gatekeeper, the senior manager should keep the committee pointed in the right direction, tying its activities with hospital system priorities, for example.
Most organizations have clinicians on the steering committee but may omit office-based staff.
Because "clinical staff lose focus on the impact of changes in the office," Kranz recommends including the office manager or someone familiar with the company's clerical procedures. Human resource and finance functions should also be represented.
o Designate improvement targets.
Organizational priorities may pre-determine improvement targets. They may surface from routine measurement trends. For example, an agency may expand its technology-dependent continuous care program. As many of the patients receiving such services require respiratory support, the agency may decide in advance that it should target improved ventilator management. Alternately, chart audits may reveal infections in several existing ventilator patients, thus prompting focus on improved ventilator management.
For Calvary Home Health, the home care arm of Bronx, NY-based Calvary Hospital, many improvement targets arise from its annual staff needs assessment. Each year, Calvary assesses professional staff members' perceived knowledge of various clinical and administrative functions and solicits input about new technologies or hot topics of concern, says Carol Townsend RN, BSN, MPA, director of patient services.
During a recent needs assessment, staff self-reported competency with the agency's advance directive policy. In compliance with the Patient Self-determination Act of 1992 and New York state regulations, it requires that staff members discuss advance directives with patients and document their preferences, such as do not resuscitate orders (DNR) or living wills. In addition to a regulatory requirement, the policy is particularly germane to Calvary's large elderly oncology patient population, says Townsend.
Though the agency does not provide formal hospice services, many patients have ultimately terminal conditions.
In a routine review of staff members' self-reported competencies, Calvary's quality improvement coordinator audited 50 patient charts to check advance directive policy compliance. The results were surprising, Townsend says.
Despite having advance directive information in case-opening paperwork, only five charts documented process completion.
Apparently, staff members discussed patients' advance directive rights, but were not following up to determine and record their desires.
o Determine process methodology; train staff.
Most organizations use one of two common performance improvement techniques, PDCA (plan, do, check, act) and FADE (focus, analyze, design, execute). Either approach works equally well, as long as staff members are properly trained "to understand organizational expectations and to be educated about ways they wouldn't have looked at the data," Kranz says. Many hospitals provide extensive performance improvement staff education resources. JCAHO also offers a number of home care-specific performance improvement education vehicles, including seminars, videos, and books.
o Establish performance improvement teams.
Individual performance improvement teams should include the people involved in the process being investigated. At Calvary, a multidisciplinary team discussed factors affecting the dissemination and completion of advance directive information.
o Outline and implement target improvement plans.
The team reviewing Calvary's advance directive procedures discovered that for the nursing staff, it was one more requirement in an already jam-packed case opening process. As a result, the advance directive discussion was usually pushed to the end of the visit and was then not subsequently followed up on, says Townsend.
Using a flowchart, the team then identified ways of better disseminating information and completing advance directives. As most of Calvary's largely Medicare patient population already had qualifying social service needs, team members developed several strategies to increase policy compliance using social work intervention.
First came staff education. Both social work and nursing staff were educated about the issue and the agency's planned corrective action.
Establish contact with social service
Next, a new policy was established requiring social work contact upon referral.
Intake now notifies social services about each new admission. Social services, in turn, makes phone contact with patients, usually shortly after nursing staff opens the case, and subsequently contacts the case manager about referring for social intervention.
Nine months after implementing the changes, Calvary's advance directive policy compliance skyrocketed. A recent chart audit found that 92% either had the patient's advance directive or documentation that the patient received information but had no directive.
While most providers perfect the structure of performance improvement, many fail to maximize its potential impact on their organization, says Kranz. Several factors make the difference between an effective plan and one that meets JCAHO intent but doesn't pack a punch.
o Attacking nonsubstantive issues.
Providers sometimes select insignificant improvement targets. The dividing line between a substantive and superficial issue is the degree to which it impacts patient outcomes and use of organizational resources. The more an improvement target can increase healing, decrease morbidity, or improve patient satisfaction while saving organizational time or resources, the more substantive it is. Smaller processes may make sense initially; early wins help gain buy-in needed to attack larger problems. But providers should rapidly move on, says Kranz.
In addition to bringing Calvary in compliance with federal and state regulations, Townsend says the agency's advance directive target also yielded increased social work utilization and helped better integrate social service and nursing efforts. And it significantly impacted patient care, saving patients from undesired medical interventions and educating them about treatment options, she adds.
o Applying quality assurance-like thinking.
Performance improvement requires critical thinking and problem solving, but this is where many providers miss the mark, Kranz says. "People have a tendency to come up with broad strokes and move right into action steps. They don't think about [variables impacting their improvement target]." Not just settling with the obvious conclusion is the heart of effective performance improvement, she adds.
o Including the wrong people.
Involving the right staff in your performance improvement process is critical, says Kranz. Without the appropriate leadership, the process can stagnate and lose focus, she adds. Team leaders in particular should be invested in the process under review and should be capable of helping the team address multiple issues, sources say.
o Doing too much too soon.
Selecting projects that are too large can stagnate the overall process, says Kranz. She cautions against tackling something overwhelmingly complicated, and instead, advises breaking the issue into more manageable - and correctable - components.
o Inadequately training staff.
Employees sometimes initially react negatively to the performance improvement process. Staff may first offer excuses about the agency's unique circumstances, but with education about performance improvement's curative vs. punitive goals, they usually enthusiastically participate, sources say.
Regardless of the targets selected, performance improvement is challenging and time-consuming, sources say. But agencies' efforts are amply returned, says Kranz.
"We get complacent on care. People focus on what outside organizations want, and they loose sight of actual care. [For example], why this wound took too long to heal. And this forces them to define why and how their care is different."
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