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OBQI Process Can Be The Key To Preventing Adverse Events

Published on Fri Aug 29, 2003

When adverse event reports indicated problems with surgical wound healing, St. Elizabeth's Home Health in Belleville, IL began asking why.

"This was the one area where we fell below the national norms, although our impression was that our patients' surgical wounds usually healed well, so we were concerned," explains Grace Grider, who leads the process improvement activities for the agency.

Now - less than a year into the quality im-provement project - the agency is seeing dramatic improvements. Currently, almost all patients who stay more than a few days show improvement of surgical wounds at discharge.

How They Did It

St. Elizabeth's process improvement committee was beginning the transition to outcome-based quality improvement in October 2002 and used the step-by-step process outlined in the OBQI manual, Grider tells Eli.

After the committee audited the charts of patients identified in the adverse event reports, they found two main problems: definitions and documentation.

The agency excluded patients seen for three days or fewer, leaving 150 charts for patients whose surgical wounds failed to show improvement, Grider reports. Of these, only 63 percent had complete documentation to match the OASIS assessment, and it also became clear that staff had differing interpretations of the status of a surgical wound.

During the months that followed, the committee worked on what nurses and therapists should document at every visit; reviewed the Wound, Ostomy, and Continence Nurses Society (WOCN) guidelines and the literature to define wound healing; began staff inservice presentations on wound care; reviewed sample standards and best practices for ideas and sent two committee members to a wound care conference.

Following these preliminary efforts, the committee instituted changes including:

  • Nursing visit forms that include a space for wound assessment. Documentation of wound status was inconsistent, so the committee added a section to the visit form where the nurse must indicate wound observations (the agency's form is shared - see chart pages 1 & 2). "We require them to measure wounds weekly unless there are significant changes," Grider says, "but we require observation and documentation at every visit."

  • Revised wound care plan. The committee found the current wound care plan disorganized and developed one basic plan with space for individualization. It includes a space where the admitting nurse can put wound status information to be updated at each visit so everyone can see the changes, Grider explains.

  • Basic patient instruction sheets. This innovation has significantly increased consistency in documenting instructions given to the patient and family. The instructions given now are more uniform.

    The agency found the basic information was the same for all types of wound care - symptoms to watch for, who to call, nutrition suggestions, what not to do. The HHA left a space on the form for the nurse to customize instructions for each patient, Grider says. "The nurses really liked [the instruction sheets] and have asked us to create them for other topics," she adds.

  • Regular inservice presentations. As it developed new procedures, the agency provided staff inservice instruction. "We have regular monthly meetings that include all nurses to review progress, introduce changes and present proposals," Grider says.

    One crucial inservice instructed the clinicians on the definition the agency uses for a healed surgical wound. Agreeing on how to determine the status of the wound is a vital step in OASIS accuracy, she emphasizes.

    Patients admitted from a nursing home after surgery may be a month or two post-op, Grider notes, and after a month of gait training or other home care, their surgical incision may be no more than a scar. "At that point it could be that it's a scar  and a lesion for OASIS purposes, but no longer a surgical wound," she suggests.

    The next phase involves monitoring results. Because it seemed too long to wait for the OBQI reports after one year of effort, Grider has recently enlisted the help of the staff member who audits OASIS assessments. Two extra questions - M0488 at start of care and at discharge - give Grider the information she needs. If the patient shows no improvement, she then can check the chart for further information.

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