Application of OBQI Principles

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Application of OBQI Principles the Acute
Care Hospitalization Improvement Matrix for Plan
of Action Development

• Part 2
• October 27, 2005

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Objectives

• Review the Areas for Improvement incorporated in
  the ACH Improvement Matrix
• Identify evidence-based strategies to reduce
  avoidable hospitalizations
• Describe how to incorporate evidence-based
  strategies and corresponding actions into
  outcome-based quality improvement (OBQI) process
  for POA development

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The Challenge

• Multidimensional issue across provider settings
• Evidence that hospitalization rates can be
  decreased
• Gap between science and practice

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The Mission

• Implement care delivery systems that prevent
  deterioration resulting in need for
  hospitalization and emergent care
• The Goal
• Reduce avoidable hospitalizations and emergent
  care for home health patients

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The Solution

• Multi-dimensional
• Improve care processes
• Lead influence improvements across provider
  settings
• Focus improvement on
• Coordinating care transitions
• Identifying patients at risk
• Stabilizing managing complex/chronic conditions
• Supporting patient/caregiver self-management
• Improving communication/collaboration
  w/physicians
• Creating systems/using health information
  technology to support these practices

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The Plan

• Use OBQI process to systematically identify
  problems driving agency ACH rate
• Use strategies and actions identified in the
  Change Binder to help build POA
• Engage in a quality improvement community to
  share lessons learned (HHAs other providers)
• Continuously strive to improve quality

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Resources to Assess the ACH Issues

• Risk-Adjusted Outcome Report (page 3)
• Agency Case Mix Report
• Case Mix Analysis Tool
• Patient Tally Workbook
• Process of Care Investigation
• ACH Chart Audit Tool

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Case Mix Analysis Tool

• Purpose ? Allows HHAs to obtain a better
  understanding of the characteristics of their
  hospitalized patients

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What does it do?

• Computes case mix values for hospitalized and
  non-hospitalized episodes
• Calculates differences in case mix values between
  hospitalized and non-hospitalized episodes
• Produces a report that shows the differences in
  case mix values of hospitalized and
  non-hospitalized patients

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What value does it provide?

• Extends the review of the Case Mix Report to
  examine case mix differences between patients who
  are and are not hospitalized
• Can help focus process of care investigation to
  identify true cause(s) for ACH rate

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Patient Tally Report Workbook

• Excel-based tool
• Contains raw OASIS data for all of the patients
  included within your OBQI report
• Combines your Case Mix Tally and Outcome Tally
  Reports into one tool
• Allows you to query your OASIS data to determine
  case mix patient outcome information

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Patient Tally Report Workbook

• Open up Patient Tally Workbook
• Select 4th option on menu View existing
  spreadsheet data
• At bottom of page select tab labeled Case Mix
  Query 1 provides list of the hospitalized
  patients for your agency
• At bottom of page select tab labeled Case Mix
  Query 2 provides list of the non-hospitalized
  patients for your agency

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Patient Tally Report Workbook

• From Case Mix Query 1, select 30 patients to
  perform a record review utilizing the Audit Tool
  included in the ACH Planning Packet

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Process of Care Investigation

• Identify a list of "should be done" care
  processes
• Narrow the "should be done" list to the MOST
  IMPORTANT
• Utilize the ACH chart audit tool or clinician
  interview guide
• Randomly select up to 30 patient care episodes
• Review the care episodes
• Summarize findings

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What is a Process-of-Care Investigation?

• Systematic investigation of care contributing to
  outcomes
• Targets Specific Aspects of Care Delivery
  Contributing to the ACH Outcome Result

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Pitfalls to Avoid

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

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Initial Steps in Investigating Care Provided

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

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ACH Clinical Record Review Tool
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Agency Decisions

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

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Drawing Conclusions

• Compile team member tally sheets
• Aggregate results
• Summarize problem area(s)

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Focused Clinical Record Review Grand Tally Sheet
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Problem Statements

• Describes specific aspects of care that
  demonstrate inadequate care (or excellent care)
• Contains specific, concrete wording to which
  clinical staff can relate
• Address issues within the agencys control
• Focuses on patient care delivery instead of
  documentation
• Contains a sufficiently narrow focus to keep a
  plan of action manageable

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Change Binder
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Definitions

• Change Framework entire set of change concepts
  organized into Areas for Improvement and Stages
  of Care
• Improvement Matrix big picture of the
  organization and high-level strategies
• Strategy high-level change concept represents
  a series of actions designed to achieve a
  specific objective
• Action specific change idea that can be tested
  and implemented at the agency level
• Tool a form, instrument, or manual that can be
  used as is or modified to support strategies and
  actions
• Resource a reference for more information
  related to implementing specific strategies and
  actions

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ACH Improvement MatrixAreas for Improvement

• Promoting Patient Self-Management
• Implementing Evidence-Based Practices
  Guidelines
• Using Systems and Technology to Promote
  Effectiveness and Efficiency
• Improving Care Delivery Systems Mobilizing
  Community Resources
• Creating a Culture of Quality

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Promoting Patient Self-Management

• Focus on problem-solving skills and self efficacy
• Role of homecare nurse in assessing, motivating,
  and empowering patient self-management
• Evidence that effective self-management
  associated with better outcomes

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Implementing Evidence-Based Practices and
Guidelines

• Strong foundation of evidence-based guidelines
  and tools exists
• Demonstrated impact on hospitalization for
  selected interventions
• Guidelines and tools need to be adapted for home
  care
• Focus on getting clinicians to know and use the
  evidence base

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Using Systems and Technology to Promote
Effectiveness and Efficiency

• Systems and technology key to supporting and
  sustaining use of guidelines and tools
• Systems range from simple to complex
• Key functions
• Identification and tracking
• Internal/external communication
• Decision support and just-in-time information

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Improving Care Delivery Systems Mobilizing
Community Resources

• Delivery systems problems lead to avoidable
  hospital admissions
• Poor planning
• Poor communication
• Insufficient information transfer
• Growing body of research demonstrates
  effectiveness of better discharge planning and
  improvements in transitions across settings
• Effective changes include
• Collaborative planning with hospitals
• Use of transition protocols
• Use of interdisciplinary teams/ APNs

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Creating a Culture of Quality

• Quality improvement is a complex process
• Requires top-down/bottom-up involvement
• Commitment of senior leaders key at every stage
  launching, implementation, and sustainability

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Using the Change Binder with OBQI

• Comprehensive Framework
• Represents excellent system of care required to
  make transformational change
• Not intended to do everything
• Add strategies over time
• Issues not the same in every agency
• The OBQI process along with some additional
  diagnostic tools can help HHAs narrow their focus

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Identify Problems/Strengths and Best Practices

• Identify the problem or strength
• Specific Actions from the Change Framework can be
  considered for clinical best practices,
  especially those from
• Promoting patient self-management
• Implementing evidence-based practices and
  guidelines

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Develop Action Plan

• Specific Actions can be considered for
  intervention activities to implement clinical
  actions (best practices), especially system
  changes
• Using systems and technology
• Improving care delivery systems
• Creating a culture of quality

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Intervention Actions

• What is to be Done
• When it is to be Done
• Who is Responsible
• How Action is to Monitored

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Strategy Combinations

• Identifying patients at risk and implementing
  Actions to address the risk
• Disease management
• Transition from hospital to home health care

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Identifying Patients at Risk of Hospitalization
and Implementing Actions to Address the Risk
Factors
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Small Tests of Change
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Implement the Action Plan

• Clinical staff informed
• Responsible persons carry out intervention
  activities
• Specified activities occur as planned

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Monitor the Action Plan

• POA is a dynamic tool
• Monitor
• Intervention actions occurred
• Best practices are used consistently
• Outcome
• Measure outcome and process
• Measurement strategy

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Tips for Internal Monitoring

• Monitor your measures over time
• Assign responsibilities for data collection
• Establish a schedule and process for data
  collection
• Consider real-time data collection
• Integrate data collection into ongoing work

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Next Steps

• Discuss with Team
• Further investigation?
• Finalize POA
• Implement POA
• Conduct Small Tests of Change
• Measure Monitor
• Work Collaboratively with IPRO and other HHAs

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Assistance

• November Regional Workshops
• Need to conduct Process of Care Investigation
  prior to attending
• Bring problem(s) identified from POCI
• Will review tools to assist in internal monitoring

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Assistance

• November Regional Workshops
• Afternoon Breakout Sessions
• Focus on POA development utilizing ACH
  Improvement Matrix
• Provide opportunity for LTHHCP Special Needs
  agencies to collaborate on issues related to
  their specific patient population

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Goals

• Leave workshop with POA constructed
• Return to agency to consult with clinical staff
  on tool selection
• Submit final ACH POA to IPRO no later than
  12/30/05, for review and comment

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Assistance

• MedQIC
• http//www.medqic.org
• Change Binder
• Shared learning
• Collaboration
• IPRO Home Health Project Team

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Contact Information

• Sara Butterfield , RN, BSN, CPHQ, CCM / Project
  Director
• Phone [phone] ext. 104
• Email sbutterfield_at_nyqio.sdps.org
• Christine Stegel RN, MS / Performance Improvement
  Coordinator
• Phone [phone] ext. 113
• Email cstegel_at_nyqio.sdps.org
• Susan Hollander MPH, CPHQ / Assistant Director
• Phone [phone] ext. 241
• Email shollander_at_nyqio.sdps.org