OASIS Alert

When you think about OBQI, does the phrase "what have you done for me lately" come to mind? What if you knew that one agency took a  close look at its data,and was able to vastly improve patient outcomes in just two steps?

Many home health agencies see outcome-based quality improvement as nothing more than a cloud hanging over them as the government moves forward with the agency report card pilot project.But a more positive approach to OBQI focuses on the value it brings in terms of improving patient care.

That's the approach Personal Touch Home Care inTowson,MD chosetotake,using OBQI data to dramatically improve results for patients with congestive heart failure.

Personal Touch worked with the Delmarva Foundation, Maryland's quality improvement organization, to decrease the percentage of CHF patients needing emergency room care from 50 percent to 17 percent, explains Personal Touch's National Quality Director Susan Niewenhous. "And the effects went well beyond the CHF patients we were focusing on," she tells Eli.

When Personal Touch looked at the OBQI reports the agency discovered "a lot of people going back for emergent care," Niewenhous says. And because the case mix report showed at least 60 percent of patients were heart patients, the agency looked to see if most of the people seeking emergent care were also cardiac patients. Chart review confirmed that more than 50 percent were, she notes.

By using the data available and changing only two activities, the agency dramatically decreased the number of patients needing emergent care. Here's how Personal Touch worked its magic:

First, the agency looked within the charts for underlying problems and found that many CHF patients' charts contained an initial weight for the patient, but no weights noted on subsequent visits. Monitoring daily weights "is one of the best ways to tell if a CHF patient is getting into trouble," Niewenhous explains, so the agency decided one action it could take was to monitor and record CHF patients' weights consistently.

To make this change happen, Personal Touch incorporated a weight chart into the patient's record, teaching the patient and caregiver how to take and record weights and explaining the importance of consistently doing this, Niewenhous reports. Clinicians also documented these actions in the chart.

"The fun part of this was finding that not only the nurses but also the therapists got really involved," Niewenhous marvels, with therapists monitoring the weights as well, rather than viewing that as a nursing duty. Knowing that this action clearly could make a difference, therapists would check the weight when they visited and call the office if they saw a gain, she explains.

Second, the staff reviewed the on-call log and found that patients were not calling the agency before going to the hospital.

In response to this realization, the agency began explaining more carefully to the patient who to call and when to call. Clinicians documented this instructioninthechartonboththeinitialvisitandthe third visit to be sure the patient remembered and added "a big sticker on their home chart reminding the patient when to call and providing the number," Niewenhous reports. Although some patients and some physicians preferred using emergent care, most were able to detect problems at an earlier stage and avoid unplanned visits.

Agencies beginning their OBQI problem-solving take away the following nuggets of wisdom from Niewenhous' experiences:

1. Don't expect instant success. Plan on several months of continuous reinforcement before the staff employs the new approach consistently. Use multiple educational approaches such as verbal presentations, written material and bulletin boards and repeat until employees internalize the new habit.

2. Applaud and demonstrate.Consistently reinforce desired behavior. Talk about the issue in every staff meeting. Point out instances where the new approach has been successful. But don't expect perfection, Niewenhous encourages.

3. Problem solve. If people are not doing what they are supposed to, talk to them about it and figure out why. Does the patient need a scale in the home? Is the patient having trouble getting on the scale? Emphasize why the change is important and what you expect staff to do.

4. Use the data to reinforce success. Give the data a few months to register an improvement and then monitor your results. "When we audited charts after the first two months we realized we needed to do more staff education,since we still weren't seeing the desired behavior," Niewenhous explains, but after four months her agency was beginning to see results. By the end of six months, "we were really getting there," she tells Eli.

5. Remember new nurses and therapists. Orienting new staff in the best practices you've decided to use is critical to continued success.

6. Build on staff enthusiasm. Once people see what you can do with data, you'll find them approaching new problems by suggesting that the agency take a look at the data, Niewenhous reports. Even clerical staff on the team start looking at charts differently, she adds.

And don't just involve the most gung-ho staff in your efforts,Niewenhous suggests.Sometimes staff who aren't compliant with expectations about documentation and teaching change their approach once they see from the data that these activities can make a real difference in patients' lives, she concludes.