OASIS Alert

One agency improved 11 percent in one year -- here's how you can too.

When Washington-based Assured Home Health and Hospice saw the agency's outcome "Pain interfering with activity" moving in the wrong direction, they decided it would be the target outcome for their first outcome-based quality improvement project. A year later they had improved this outcome by more than 11 percentage points.

The challenge: In the winter of 2003, the agency's score on pain interfering with activity was two percent worse than the previous year and five percent below the national reference, explains Carrie Knittel, Assured's director of clinical services. "Fewer of our patients were improving in this outcome than the national reference, and we were concerned that this meant we were not addressing pain as well as we could," adds Joanna McGeoghe-ghan, the agency's OBQI expert.

The strategy: In choosing this target outcome, Knittel and McGeogheghan involved staff from the start, so they understood the selection process. Then they did behind-the-scenes preparation for some of the more time-consuming activities.

Using journal and Internet research, they prepared a rough draft of possible best practices to assess and treat pain related to this target outcome. They attended staff meetings at each of the three offices to get staff input. This allowed them to "whittle down the statements" to four best practices that became the plan of action, McGeogheghan explains.

Having the staff talk while Knittel and McGeogheghan took notes made the process seem easier, Knittel reports. And when staff realized that OBQI was not just theoretical, but actually affected patient care, "they jumped on the bandwagon," she says.

The POA was twofold: answer M0420 accurately and improve staff awareness of pain assessment and pain management.

What they discovered: Clinicians didn't always know how to answer questions correctly. For example, it was very hard to get clinicians -- especially therapists -- to distinguish between the presence of pain and pain interfering with activity when answering M0420, Knittel reports. "Clinicians really struggled with marking '0' (no pain interfering with activity) when the patient was having pain," she explains.

Even more surprising, the computerized system allowed clinicians to use different pain scales, so nurses were using a 0-10 scale and therapists were using a 1-5 scale. When they were both seeing a patient, the assessments didn't match, McGeogheghan adds.

The next step: Discussing the item in staff meetings allowed staff to share insights and techniques with each other, rather than having it all come from supervisors, McGeo-gheghan says. And choosing one pain scale for everyone to use improved consistency.

Because Assured uses a computerized documentation system, they were able to include clinical pathways the clinician was to access if the patient scored "2" or higher on M0420. This way on every visit the clinician was reminded to assess the pain, assess the medication regime for effectiveness and notify the doctor if it wasn't effective.

"It's not that the staff weren't doing these things," Knittel says, but they weren't documenting them consistently. This system greatly improved the documentation. And it reminded clinicians of the importance of assessing chronic pain as well as acute pain on each visit.

The agency also included pain questions on the quarterly peer chart review form both to monitor progress and to indirectly reinforce the new approach, Knittel says.

The results: After six weeks a chart review showed that over 80 percent of patients were having pain accurately assessed and appropriately followed up. The charts also showed greater consistency between nursing and therapy notes.

After a year, the agency achieved a score of 63 percent on improvement in pain interfering with activity, up from 51.9 percent a year earlier, Knittel reports. Not only was it higher than the year before, but also it was above the national reference, she says.

An unexpected result was finding that clinicians were taking a fresher look at chronic pain and at what they could be doing for these patients.

The positive experience with OBQI helped clinicians understand why it was important to collect accurate data, Knittel notes.