Don't forget to look within to benchmark
Don't forget to look within to benchmark
Internal benchmarking better than nothing
Despite the dearth of huge data repositories, home health organizations can still reap improvement rewards by internal benchmarking, say benchmarking professionals in the fast-growing industry.
"By looking within your organization, you can determine which areas, functions, or departments may be performing similar activities," says Alexis Wilson, founder of Outcome Systems in Seattle. "Then you can outline the processes in each area to determine what is most effective and efficient."
Internal benchmarking can improve performance, which in turn boosts the bottom line, Wilson says. "If an organization can improve a core process by detailing the system and measuring the results, then it can improve its performance," she says.
In fact, this may be the perfect place to start because internal benchmarking successes can motivate home health nurses unaccustomed to performance measurements as well as paving the way for future external endeavors, adds Nancy Santucci, RN, MSN, quality management and education coordinator for Community Nursing Service (CNS), an agency in Oak Park, IL, that provides about 35,000 annual home visits.
"The entire field of home health is facing huge transitions, yet many field nurses don't even know what `benchmarking' means," Santucci says.
CNS learned first-hand the challenges and opportunities of home care benchmarking as they participated in Medicare's Prospective Payment System Demonstration Project for Medicare's Outcome and Assessment Information Set (OASIS).
"Our nurses were overwhelmed initially by OASIS," remembers Sally Behary, clinical director. "It took us about a year to fully implement it, yet they didn't fully embrace the benchmarking concept until we got back our first sets of results."
That tangible evidence helped change perceptions almost immediately. "It was the best thing that happened to our initiative. Until then, benchmarking meant one more piece of paper to process," Behary explains.
Part of the problem, she points out, is that health care has not had to be accountable to payers and regulatory bodies for outcomes until recently. "Nurses are simply not accustomed to thinking about comparing how patients fared over time," she says.
After CNS received its comparative data from HCFA, a team of field clinicians, including nurses, therapists, and aides, selected three areas in which they scored below the norm: rehospitalization rates, oral medication management, and ambulation.
The team then conducted staff interviews and chart reviews to discover more than 30 best practices in each area, says Santucci.
"We randomly selected 20 charts from those in which we felt the patient had potential for improvement, and then listed all assessments and interventions we felt were important to reaching good outcomes," she explains.
The team also asked staff members "what was done or not done" that could affect improvement.
For example, one of the key elements of improving medication compliance was whether or not the patient had the ability to self-administer the medicine. "Once we reinforced the importance of observation as well as a medication schedule that listed medication by time of day, patients showed improvement," she says.
Improvement in ambulation indicators came after therapists began reporting outcome results in the OASIS format rather than the Functional Independence Measure (FIM), an 18-item scale developed by Uniform Data Set in Medical Rehabilitation in Buffalo, NY.
"FIM, which uses a seven-point scale, considers improvement when patient goes from a walker to a cane, but OASIS, which uses a five-point scale, does not," she explains.
While CNS therapists still may use FIM for daily visit reports, they must use OASIS for outcome results.
The re-hospitalization indicator, the bane of home care benchmarking, proved more difficult to improve because of the complexities that make returning to the acute care facility necessary. "From the literature, we did find that many re-hospitalizations are due to congestive heart failure," she says. "Based on that fact, we knew that weight gain is the earliest indicator of CHF, even before ankle swelling, so we implemented a patient weight log."
CNS also supplies the scales if the patient can't afford them. "We can't control everything in benchmarking, but we control what we can," she says.
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