Home Health OutcomeBased Quality Improvement OBQI System

1
Home Health Outcome-Based Quality Improvement
(OBQI) System

• OBQI Training
• October 9-10, 2002
• Montgomery, AL

2
Why Quality Improvement Organizations (QIOs)?
3
Objectives for this Module

• Define what a QIO is
• Discuss QIO roles and responsibilities
• Identify QIO expertise
• Why the QIO and OBQI
• Understand the collaborative/educational approach
  used by QIO

4
Delmarva Foundation

• Mission
• Delmarva is a not-for-profit company committed
  to improvement in the quality and value of
  healthcare and human services by providing
  leadership, innovation and knowledge to the
  communities we serve.

5
QIO Mission

• Ensure the quality, effectiveness, efficiency,
  and economy
• of health care services provided to Medicare
  beneficiaries

6
QIO Responsibilities

• Improve health care quality
• The catalyst for community-wide health
  improvement activities
• Protect the Medicare Trust Fund
• Inform and protect Medicare beneficiaries

7
Who Benefits?

• Almost 40 million Medicare beneficiaries
• Health care providers
• All Americans

8
QIO Expertise

• Quality indicator development
• Data collection
• Statistical analysis
• Comparative analysis
• Provider feedback
• Performance measurement

9
QIO Expertise (contd)

• Process and system enhancement
• Benchmarks
• Facilitator/convener
• Information technology
• Training and education
• Communications

10
How QIOs Work

• Employ CQI techniques
• Work collaboratively with providers
• Form community partnerships
• Provide technical assistance
• Identify best practices and facilitate sharing
  among providers

11
OBQI On your marks, get set. . .

• Opportunity for Improvement
• Challenge
• Cutting edge
• Competitive advantage
• Learning process for all
• Collaboration is key

GO!
12
Overview of OBQI
13
Objectives for this Module

• Compare and contrast QA, QI/PI, and OBQI
• Describe current agency quality monitoring
  activities
• Explain CMSs evolving approach to quality
  monitoring activities
• Define a patient outcome
• Discuss the OBQI process

14
What Does My Agency Currently Do to Monitor
Quality of Care?
15
What Are the Differences Among Quality
Assurance,Quality Improvement, and
OBQI?Handout H.1
16
What Medicare Currently Requires for Quality
Monitoring?

• Annual Program Evaluation
• Quarterly Record Review
• A QA Approach

17
What Will Medicare Require for Quality Monitoring
in the Future?

• Use Measurable Outcome Data
• (OASIS-Derived Reports)
• Shift QI/PI Focus to Outcomes
• Public Reporting

18
What is So Important About Outcomes?

• What is the value of care?
• How does care affect patients?

19
OutcomesAre Why Care Is Provided
20
Patient Outcome
A Change in Health Status Between Two or More
Time Points
21
Outcome Characteristics

• Change intrinsic to the patient
• Positive, negative, or neutral
• Result from care, progression of disease, or both

22
What Is Outcome-Based Quality Improvement (OBQI)?
23
OutcomeAnalysis
collect transmitoasisdata
measurepatientoutcomes
monitoractionplan
interpretoutcomereports
implementaction plan
OBQIthe outcome-based quality improvement process
developaction plan
specifytargetoutcome(s)
identifyproblems/strengthsand best practices
investigatecareprocesses
24
Outcome Enhancement
collect transmitoasisdata
measurepatientoutcomes
monitoractionplan
interpretoutcomereports
implementaction plan
OBQIthe outcome-based quality improvement process
developaction plan
specifytargetoutcome(s)
identifyproblems/strengthsand best practices
investigatecareprocesses
25
Does OBQI Work to Improve Care?
26
How Does My Agencys Current Quality Monitoring
Relate to OBQI?
27
How Will I Know If Outcome Enhancement Works in
My Agency?
28
How Should My Agency Move Toward OBQI?

• Know you agencys current quality monitoring
  approach
• Learn the details of OBQI
• Obtain administrator support
• Prepare your staff to implement OBQI

29
Interpreting Outcome and Case Mix Reports and
Selecting Target Outcomes
30
Objectives for this Module

• Discuss purposes of the OASIS-derived reports
• Interpret reports
• Identify criteria for selecting target outcome(s)
• Select target outcome(s) according to agency
  context
• Experience emotional reaction to the outcome
  report

31
Basic Reports Produced from OASIS Data

• For OBQI
• Outcome Reports (risk adjusted and descriptive)
• Case mix report
• For OBQM
• Adverse event outcome report
• Case mix report

32
Outcome Report Excerpt
Improvement in Grooming
Cases Signif.
63.3 66.7
169 3183 .35
Current
Ref.
33
Sample Case Mix Report
All Patients' Case Mix Profile at Start of Care
Current Mean
Reference Mean
Inpatient DC within 14 Days of SOC

• From hospital ()
• From rehab facility ()
• From nursing home ()

• 69.1 68.4
• 7.2 6.4
• 1.8 3.3

34
Adverse Event Report Excerpt
Emergent Care for Wound Infections, Deteriorating
Wound Status
2.6 1.9
572 29983
Current
Ref.
35
(No Transcript)
36
Handout H.1, continued
37
Definition Improvement Measure
A Patient Improves in a Specific Outcome When the
OASIS Scale Value for the Health Attribute Shows
an Improvement in Patient Condition
38
Exclusions from Improvement Computation
Any Patient Whose Status at SOC is Optimal for
the Health Attribute Under Consideration
39
Definition Stabilization Measure
A Patient Stabilizes in a Specific Outcome When
the OASIS Scale Value for the Health Attribute
Shows Nonworsening in Patient Condition
40
Exclusions from Stabilization Computation
Any Patient Whose Status at SOC is at the Most
Severely Impaired Level for the Health Attribute
Under Consideration
41
Exercise 1
42
Data Shock

• Denial
• Defensiveness
• Our Patients are Different

43
Why Risk Adjust Outcomes?

• Assume your Agencys Outcomes Are Inferior to
  National Reference Sample
• Why?
• Explanation 1 Your Patients' Outcomes Are Truly
  Inferior
• Explanation 2 Your Patients Are at Greater Risk
  of Poor Outcomes

44
Purpose of Risk Adjustment

• Risk adjustment statistically accounts for
  differences in your agencys patients vs. the
  reference sample

45
Responses to Risk Adjustment

• Relief
• Bewilderment
• Doubt

46
Next Step Selecting Target Outcome(s)
47
Criteria for Selecting Target Outcome(s)
1. Statistical Significance
48
Criteria for Selecting Target Outcome(s)
2. Size of the Outcome Differences
49
Criteria for Selecting Target Outcome(s)
3. Number of Cases
50
Criteria for Selecting Target Outcome(s)
4. Actual Significance Levels
51
Criteria for Selecting Target Outcome(s)
5. Importance or Relevance to Your Agencys Goals
52
Criteria for Selecting Target Outcome(s)
6. Clinical Significance
53
SummaryApply the Criteria in Order
54
Exercise 2Practice Selecting aTarget Outcome
55
Adding Context to the Outcome Report The Case
Mix Report
56
Handout H3Sample Case Mix Report
57
How Does the Case Mix Report Help Me to Select
Target Outcome(s)?
58
Exercise 3Use Dependable Agency Report
59
Exercise 4Use Alternative Agency Report
60
Outcome EnhancementThe Process-of-Care
Investigation
61
Objectives for this Module

• Develop criteria to evaluate agency care
  provision
• Use critical thinking in reviewing care provided
• Identify areas to improve (or reinforce) care
• Identify potentially useful QI tools/ techniques

62
What is a Process-of-Care Investigation?
Systematic investigation of care contributing to
outcomes Targeting aspects of care to change (or
reinforce)
63
Focus of the Process-of-Care InvestigationSpeci
fic Aspects of Care Delivery Contributing to the
Outcome Results
64
Steps in the Process-of-Care Investigation

• Begin with the target outcome
• Investigate the likely cause(s) of the outcome
• Determine specific care aspects needing change

65
Pitfalls to Avoid

• Premature closure (jumping to conclusions)
• Involving only agency management
• Blaming data collection or analysis methods
• Not focusing on care delivery

66
Initial Steps in Investigating Care Provided

• Identify what should be done in providing care
• Determine what actually was done

67
Identifying What SHOULD Be Done
Which clinical actions/care behaviors have
relevance for the target outcome?
68
Identifying What SHOULD Be Done

• Specific assessments
• Specific care planning
• Specific interventions

69
GoalAn Inclusive List of Clinical Actions
70
Important Care Behaviors for Improvement in
Dyspnea

• Assessment
• 1. Patient weight is assessed at SOC
• 2. Patient weight is assessed every week

71
Important Care Behaviors for the Outcome of
Improvement in Dyspnea

• Care Planning or Interventions
• 1. Weight gain over 3 pounds is reported to the
  physician within the same day
• 2. Patient education regarding prescribed
  diuretics begins at SOC visit

72
Agency DecisionWho Should Develop the Should
Be Done List?
73
Most Important ConsiderationInclude Clinical
Staff
74
Make the Final Should Be Done List Manageable

• Brainstorm
• Prioritize

75
What Will the Should Be Done List Be Used For?

• Analysis of current care provision
• Constructing a tool to review care

76
How Specific Must the Should Be Done List Be?

• For consistency in reviewing care
• To facilitate drawing conclusions

77
Review Criteria Form
Target Outcome Measure Improvement in Dyspnea
78
Exercise 1

• Develop a Should Be Done List

79
Determining What Was Done

• What are we actually doing?
• How does this compare to our "should be done"
  list?

80
Agency Decisions

• Select the care review approach
• Determine the review format
• Determine who will conduct the review
• Determine the cases to be reviewed
• Determine the review time frame

81
Handout H.1

• Patient Tally Report Instructions

82
Potential Care Review Approaches

• Focused clinical record review
• Staff interviews
• Visit observation
• Staff meeting discussion
• Case conferences

83
Focused Clinical Record Review

• Familiarity with Process
• Select 30 Records for Review

84
Compare and Contrast

• This Clinical Record Review Approach
• Your Past QI or UR Activities

85
Drawing Conclusions

• Compile team member tally sheets
• Aggregate results
• Summarize problems (or strengths) in care
  provision

86
Clinical Record Review Grand Tally Sheet
Target Outcome Improvement in Dyspnea
87
Summarize Your Findings Clearly State a Limited
Number of Specific Clinical Actions/Care
Behaviors to Change (or Reinforce)
88
Exercise 2

• Investigate Care and Summarize Findings

89
Your Summary Produces a Statement of a Problem or
a Strength
90
Summarizing Findings and Developing the Plan of
Action
91
Objectives for this Module

• Synthesize information into the plan of action
• Practice writing (and reviewing) problem/strength
  statements
• Develop statements of best clinical practices

92
Ive Investigated the Care Provided to My
Agencys Patients that Contributed to the Target
Outcome-- Now What?
93
What is a Plan of Action?

• Corresponds to one target outcome
• Identifies recommended care processes
• Includes implementation approaches

94
Handout H.1Sample Plan of Action
95
Characteristics of Successful Plans of Action

• Focus on patient care
• Include specific aspects of care

96
Next Steps

• State problem (or strength) and
• Prioritize best clinical practices

97
The Statement of Problem (or Strength) describes
your target care behavior or process
98
Successful plans of action include specific,
clearly-worded statements of problem (or
strength) in current care delivery
99
Good Problem (or Strength) Statements

• Describe specific aspects of care
• Focus on patient care issues
• Use concrete and specific wording
• Address issues within the agencys control
• Focus on more than documentation
• Sometimes need boundaries

100
Criteria to Evaluate Problem/Strength Statements

• Clarity
• Specificity
• Overall Utility

101
Handout H2Problem/StrengthStatements
102
StatementCare plans for postoperative
orthopedic patients do not include teaching for
pain management during activity or exercise
103
StatementInadequate SOC assessment of speaking
ability in patients with neurologic diagnoses
104
StatementFor patients with pressure ulcers,
nutritional risk factors are poorly assessed
105
StatementInconsistent definition of anxiety, so
similar assessment data are not consistently
interpreted. When anxiety is present, no
specific interventions occur. Lack of continuity
of staff adds to patient anxiety.
106
Exercise E1 Writing Problem/Strength Statements
107
Moving from the Problem/Strengthto Best Clinical
Practices

• Exactly what should the clinician do?
• When and how should it be done?

108
Successful plans of action include specific,
clearly-worded best practices desired of clinical
staff

• Patient care focused
• Within agency control

109
Characteristics of Good "Best Practice" Statements

• Precise clinical activities or processes
• Specifically address the stated problem (or
  strength)
• Identify actions desired of all clinical staff
• Address activities beyond documentation

110
Criteria to Evaluate Best Practice Statements

• Clarity
• Specificity
• Clinical behaviors

111
Handout H3 Statements of Best Practices
112
Best Practices

• RN will include teaching for pain management
  during activity in all care planning for post
  operative orthopedic patients
• RN teaching content should include
  pre-medication, appropriate frequency and
  duration of exercises, deep breathing, prescribed
  warm-up and cool down

113
Best Practices

• At SOC, RN will request speech evaluations on
  patients with a primary neurological dysfunction
• Thorough evaluation for patients with
  long-standing diagnoses (e.g., CVA, Parkinsons
  disease, etc.)

114
Best Practices

• Nutritional risk factors for patients with
  pressure ulcers will be assessed at SOC and
  monthly until discharge
• Nutritional risk factor assessment will follow
  the Braden Scale guidelines

115
Best Practices

• Staff will use a consistent definition of anxiety
  in analyzing assessment data
• When anxiety is present, staff will intervene
• Continuity of nursing staff

116
Exercise E2 Writing Best Practice Statements
117
Exercise E2 (continued)Prioritizing Best
Practice Statements
118
Where Are We in Developing the Plan of Action?

• Target outcome selected
• Outcome for remediation
• Problem statement written
• Best practices specified

119
Implementing and Monitoring the Plan of Action
120
Objectives for this Module

• Identify appropriate intervention actions to
  change clinical practice
• Discuss importance of monitoring the plan of
  action
• Review timing for implementing intervention and
  monitoring activities

121
Review Your Status

• You Have
• Selected a Target Outcome
• Conducted the Process-of-Care Investigation
• Developed a Problem/Strength Statement
• Identified Best Practices for the Target Outcome

122
The Next Step in Outcome Enhancement

• To Foster Behavioral Change Within Your Agency

123
Focus on Intervention

• State the Actions to Occur
• Plan Their Implementation
• Follow Through

124
What Does "Intervention" Mean

• Relative to a Patient Care Plan?
• Relative to the Agency Plan of Action?

125
Plan of Action's Intervention Actions

• What Is to be Done
• When It Is to be Done
• Who Is Responsible
• How Action Is to be Monitored

Handout H-1
126
Handout H-2Review Intervention Actions
127
Relationship of Intervention Actions to Best
Practices

• Move the Best Practices "Off the Paper"
• Carefully Plan Change(s)
• Focus on Behavior Change

128
Recommended Approach to Develop Intervention
Actions

• Lay Out a Map to Implement Best Practices
• Keep Number of Actions to 4 or 5
• Each Action Has a Single Focus
• Plan to Implement within 1 Month

129
Evaluating Intervention Actions

• Related to Best Practices?
• Practical and Achievable?
• Adequate to Change Care?
• Scheduled to Begin Immediately?

130
Plan to Change Clinician Behavior

• Is an In-Service Sufficient?
• Will Changing a Form Do?
• Does Anything Work?

131
Changing Clinician Behavior Requires

• Recognizing Need for Change
• Identifying a Specific Change to Make
• Organizational Support for the Change
• Full Integration of the Change

132
Handout H-3 Changing Staff Behavior Techniques
133
Check-Up for Change

• Do Staff Know?
• Has Necessary Knowledge/Skill Been Conveyed?
• Do Organizational Processes Allow/Support Change?

134
Monitoring the Plan

• To Assure that Implementation Happens
• To Assess Extent of Behavior Change Occurring
• To Determine Potential Need for Modification

135
Sample Monitoring Approaches

• Quarterly Chart Review
• Peer Review
• Supervisory Visits
• Case Conferences
• Staff Meetings

136
Key Elements of Monitoring Activities

• Responsible Person(s) Identified
• Frequency Begins High, Then Tapers
• Provision for Feedback
• Integrated Into Routine Activities

137
Handout H-4Monitoring Approaches
138
Characteristics of Effective Monitoring Approaches

• Results Reviewed and Quickly Responded To
• Occur as Routine Activity within Agency
• Implemented as Planned

139
Evaluating the Plan of Action

• Quarterly Intervals
• When the Next Outcome Report Arrives

140
Handout H-5Checklist for Agency Plan of Action
141
Teamwork in the Outcome Enhancement Process
142
Objectives for this Module

• Identify most useful types of teams
• Discuss team roles and responsibilities
• Discuss key factors of team activity in OBQI

143
What Is the Work of Outcome Enhancement?

• Reviewing outcome and case mix reports
• Selecting target outcome(s)
• Conducting the process-of-care investigation
• Writing the plan of action
• Implementing the plan of action
• Monitoring the plan of action

144
A Team

• Starts with Individual Perspectives
• Commits to Work Interdependently
• Possesses a Common Objective and Focus

145
Key Factors of Team Activity in OBQI

• Involve agency staff
• Use time effectively
• Use group decision-making skills
• Document effective approaches
• Celebrate (food preferred)!

146
How Many People Need to Be Involved?
Large enough number to feel ownership Small
enough number to work efficiently
147
What Options Have Agencies Tried?What Worked
and What Didnt?
148
Suggested Approach Two Groups
Target Outcome Selection Process-of-Care
Investigation
149
Target Outcome Selection Group

• Reviews the outcome and case mix reports
• Selects the target outcome(s)

150
Possible Membership of This Group

• Director of Patient Services
• Quality Improvement Manager
• Data Processing Manager
• Rehab Supervisor
• Others as Indicated/Available

151
Care Process Group

• Conducts the process-of-care investigation
• Writes the plan of action
• Participates in implementing the plan of action
• Participates in monitoring the plan of action

152
Possible Membership of This Group

• Staff involved in care delivery related to
  outcome
• From across disciplines and functions
• Can utilize within-agency consultants

153
Team Roles

• Leader
• Facilitator
• Members

154
Responsibilities of Team Members

• Represent agency peers
• Represent a clinical discipline
• Actively participate in team functions
• Communicate with other agency staff

155
An Imperative Activity Communication with All
Staff
156
An Often-Overlooked Activity Closure
157
Training Agency Staff
158
Objectives for this Module

• Identify agency staff needing OBQI training
• Identify training topics needed by specific
  groups
• Plan appropriate timing for training
• Identify who should train
• Discuss materials to use in training

159
Which Agency Staff Need Training?

• Management Group
• Quality Improvement Groups
• Clinical Supervisors
• Clinical Staff
• Clinical Records Staff

160
When Should Training Occur?

• Just-in-Time Approach

161
Training Needed by Management Group

• Understanding Outcome Reports
• Selecting Target Outcomes
• Time and Resource Planning for OBQI Activities

162
Training for Management Staff Occurs

• Immediately After You Return to Your Agency

163
Training Needed forQI Groups/Clinical Supervisors

• Understanding Outcome Reports
• Plan for Selecting Target Outcomes
• Conducting Care Investigation
• Plan of Action Development and Implementation

164
Training for QI Groups Occurs

• Soon After You Return to Your Agency
• Once Target Outcomes Selected

165
Training for Clinical Supervisors Occurs

• When OBQI is Implemented
• Once Target Outcomes Selected

166
Training Needed by Clinical Staff

• Understand Outcome Reports
• Plans for Care Investigation
• Requests for Volunteers
• Changes in Care Delivery/ Processes

167
Training Needed by Clinical Records Staff

• Involvement in Care Investigation
• Steps in Outcome Enhancement

168
Who Should Conduct Training?

• Those Attending this Training
• Others?

169
How to Train Others in the Agency

• Use Sample Reports
• Use Exercises from this Training
• Use Handouts
• Use Existing QI Resources

170
Training Tips for Staff

• Include Context to Increase Motivation
• Start with Known and Proceed to Unknown
• Include Multiple Approaches
• Present the Administrative Support for Change
• Your Attitude is Contagious!

171
Evaluating Your Training

• Review Processes as You Go
• Review the Plans of Action You Develop
• Value of a Log (or Journal)

172
Retraining

• Expect to be Necessary for Next Reports
• Refer to Log/Journal
• Staff Turnover will Increase Need
• Approaches to Lower Need

173
Recap What Can Be Done Now?

• Orient Management Group and Quality Improvement
  Staff
• Plan Membership of Target Outcome Selection Group
• Identify Resources for Care Investigation
  Activities
• Schedule Agency-Wide Learning Activities

174
An Effective Timeline Maintains Momentum

• Within a Few Days After Accessing Reports
• Within Two Weeks of Accessing Reports
• Within One Month of Accessing Reports
• Three Months After Accessing Reports

175
Is There Support for OBQI?

• What Home Health Agencies Can Expect from the QIO?

176
Objectives for this Module

• Describe QIO resources
• Discuss how the HHAs can benefit from working
  with the QIO
• Identify the QIO contact person(s)

177
Outcome Enhancement isAgency-SpecificAgency-De
termined

• The QIO will provide ongoing training support and
  technical assistance

178
Where do we go from here?

• Next Step
• Orient and train appropriate staff in your agency

• The QIO Will
• Provide a training manual and resources
• Answer questions and provide assistance in
  planning training

179
Outcome Enhancement Process

• Reports
• Interpret reports
• Select Target Outcomes

• The QIO can help you
• Understand and interpret reports
• Identify appropriate areas for improvement

180
Outcome Enhancement Process

• QIO expertise available to you
• QI experts
• Chart review experience
• Identify and share best practices

• Process-of-Care Investigation
• Compare what should be done with what actually
  was done
• Identify areas to improve/reinforce

181
Outcome Enhancement Process

• Develop Plan of Action
• Implement
• Monitor

• QIO QI experience includes
• Interventions
• Changing care processes
• Documentation
• Communication

182
OBQI Resources

• State-wide list server administered by the QIO
• Interactive web-based OBQI Clearinghouse
• www.obqi.org

183
Contact Information

• Name(s)
• Phone
• Email address