Spiritual needs are part of move to improve agency
Spiritual needs are part of move to improve agency
QI projects are for hospice and home care
Sometimes it’s not good enough to be average when compared with other agencies on a particular quality improvement indicator.
At least that’s the philosophy at the Community Nurse Association of Fairhaven Inc. in Fairhaven, MA, which instead compares itself to the top 10% performers nationwide on its customer satisfaction survey.
The agency uses a patient satisfaction tool to determine its indicators for the ORYX initiative, which is required of agencies accredited by the Joint Commission on Accreditation of Healthcare Organizations of Oakbrook Terrace, IL. The agency’s vendor, Fazzi Associates in Northamp-ton, MA, provides the tool and the benchmarking information along with a national patient satisfaction database for home care, and the hospice survey is the National Hospice Organization’s family satisfaction survey.
"We were receiving results we were happy with, but we could see some areas in service deliveries we could improve upon because we benchmark against similar-size agencies," says Diane Leclair, MSN, RNC, director of quality management for the agency.
For example, one of the home care indicators relates to how well staff explained how services were paid for. In the period of June-August 1998, the agency scored 88% on that question, while the top 10% of agencies included in the benchmarking comparison had an average score of 91%. "So, we thought this was an area we needed to improve," Leclair says.
Room for improvement
In the hospice area, the agency chose the indicators relating to pain management and satisfaction with spiritual needs. Results showed the agency had some room for improvement. For instance, on pain management, out of a perfect score of 6.0, the agency scored 4.62 in a survey conducted in 1997. The national hospice average was 4.74.
On meeting spiritual needs, the agency in 1997 scored 4.2, and the national average was 4.43.
"Meeting spiritual needs is a big part of hospice, and we had to do something about that," Leclair says.
Here’s how the agency came up with solutions to the various problems:
• Improving pain control.
The agency worked hard with a pain management task force to improve staff’s response to hospice patients’ pain. Its efforts paid off. By 1999, the agency scored 5.09 on the indicator for pain management, compared with a national average of 4.64.
"We had meetings to identify where nurses feel weakest in pain management assessment, and we developed a pain scale that is used uniformly," Leclair says.
Hospice staff also follow the guidelines on acute pain management that were put out by the Agency for Healthcare Research and Quality in Washington, DC. "We use that as our basis for pain management," Leclair adds.
Quality managers also conducted a needs assessment, looking at various medical references before creating a strategy to improve this area. Part of the strategy included creating staff awareness about pain management through the use of poster presentations, inservices, and equipment training.
• Helping patients better meet spiritual needs.
Spirituality is such an important part of hospice work that quality managers particularly were concerned about the agency’s poor standing in this area, Leclair says.
In 1998, the agency scored 4.36 out of a possible 6.0 on meeting patients’ spiritual needs, and the national average was 4.68. "We thought, Boy, we’re not doing good here.’"
Spirituality vs. religion
In response, Leclair created a competency tool that could be used by all disciplines. It was simple, with a selection of four articles about spirituality. She found the articles from magazines, nursing journals, and staff referrals. Employees would select one article to read and then write a brief essay describing what they learned from that article. Leclair made sure they had a quiet room with a comfortable chair in which to do the reading and writing.
"This was a real eye-opener for the staff," Leclair recalls. "What we found was a lot of our staff thought spirituality had a lot to do with religion, and it really doesn’t."
While spirituality might mean religion to some people, it also can involve nonreligious activities, such as yoga, meditation, reike, and aromatherapy, she adds.
Quality managers arranged for the staff to take inservices on spirituality, in addition to the competency test.
The staff began to understand that spirituality, as used in the hospice context, has less to do with religion than it does to helping a dying people feel connected to someone or something beyond themselves.
Family satisfaction surveys showed that the program worked. The hospice’s score in 1999 was 4.64, while the national average was 4.56.
• Providing better explanations about what will happen with reimbursement and improving discharge planning.
The home care agency aimed high in those areas, pushing staff to make its scores among the top 10% in national benchmarking of the patient satisfaction survey.
Since patients of recent years have been unhappy with what they perceive as cutbacks to home care services resulting from the Medicare changes prompted by the Balanced Budget Act of 1997, quality managers wanted to make sure patients understood the hows and whys of those changes, Leclair says.
Taking the blame
"People were getting upset and didn’t fully understand why Medicare wasn’t paying for more visits," she explains. Since Medicare insisted that it wasn’t cutting service or benefits, merely changing reimbursement through the interim payment system (IPS) led to much patient confusion, and blame sometimes was directed to the agency.
The agency’s patient satisfaction scores reflected this problem until after quality managers addressed reimbursement discussions and discharge planning as an important performance improvement project. For example, while the scores for the indicator about explaining reimbursement were off the mark in 1998, the agency achieved its goal in the first six months of 1999 with a score of 91% that was identical to the average score of the top 10% of agencies.
The agency’s score for discharge planning for June-August 1998 was 89%, and the top 10% was 93%. The agency’s last result from January-June 1999 was about 93%, the same as the national average for the top 10% of agencies.
Quality managers educated employees about reimbursement issues at staff meetings, and they provided an update on documentation. Consultants and other reimbursement experts spoke to the staff about Medicare and Medicaid regulations, explaining reimbursement from the business side of a home care agency, Leclair says.
New staff receive a self-learning packet and post-test on Medicare.
The agency also diverted two nurses to the role of case review nurse for which they review all patient records for accuracy in billing. These nurses do not have patient loads, Leclair notes. "They make sure the documentation is reflective of the appropriateness of service, which helps with all the indicators we have chosen."
Case review nurses also meet with clinicians and discuss their utilization patterns, she adds. "A case review nurse might say, I was looking at this and I think we could have kept a home health aide in there a little bit longer, so why did you keep the aide in three times a week for three weeks and then discharge?’"
Making positive change
The case review nurse might suggest the clinician follow a different utilization pattern, one that perhaps would be more satisfying to patients. For example, they could just decrease the aide’s visits, but keep the aide in a little longer, Leclair suggests.
Quality managers also held inservices with lectures and role playing on techniques for talking to patients about decreasing their services.
"We do not want to short-change patient’s care, so we make sure clinicians are aware of which community services are out there and who can provide a patient with services if we need to pull out," Leclair says.
For instance, a patient who has some difficulty preparing lunch might quality for a Meals on Wheels program.
"We also stressed to staff the importance of planning the end of service and making sure they are talking with patients about discharge at the admission visit," Leclair says. "No longer can you come in and say, I’m going to see you for nine weeks,’ because we can’t do that anymore."
• Diane Leclair, MSN, RNC, Director of Quality Management, Community Nurse Association of Fairhaven Inc., 62 Center St., Fairhaven, MA 02719. Telephone: (508) 992-6278.
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