OBQI in Home Health

HealthyNurse · May 1, 2011

What specific questions did you have? I have a good deal of experience in this area.

KateRN1 · Jun 3, 2011

I am prepping documents for upcoming state and accreditation survey. One of the requirements is that we have documented "an ongoing performance improvement program." We don't. So I am starting our first Performance Improvement Project. I met with the clinical managers today and got a good feel for the OASIS issues they're seeing, confirmed with OASIS edits that I receive, and they were the same issues I was seeing when I was a clinical manager. So the issues are identified. I've identified the specific policies and procedures as well as OASIS item guidance that is involved. Now I need to formulate the plan to improve. This is where I get stuck.

1) What is the best method to improve employee documentation in terms of accurate OASIS data collection? Group teachings? Individuals? Combination of both? I know that some of it will depend on the persons involved.

2) Suggestions for how I document the interventions so that survey criteria are met? Or will they just look at the fact that there is a program in place but not the content?

3) Any strategies for increasing staff buy-in?

HealthyNurse · Jun 9, 2011

1.) The best way to improve employee documentation in terms of accurate OASIS data collection would probably be a combination of group and individual education. How much time and resources are you being given to put into this project? Are you addressing several OASIS items or are there just a few that you are choosing to focus on? How you approach this project will depend on how much support you have from upper management.

In a previous role, I was in charge of the "OASIS Integrity Program", which sounds similar to what you are trying to implement. This was around the time of the transition to OASIS-C, so it involved a great deal of education for all clinicians We had group trainings that used a combination of lecture, role playing, and small group sessions. I found that the role playing and small group sessions were the most effective. Clinicians actually said afterwards that they felt it was very educational and FUN- which is unheard of during staff trainings! All clinicians were required to take a test after the trainings. If they didn't get a passing score on the test, they had one-on-one remediation.

An OASIS Integrity Program should also involve in-field competency assessment on a regular basis (yearly if possible). After the education, schedule some in-field time to check them off in the field as they complete an OASIS assessment. If it's not possible for you to do the competency assessments, this could be incorporated into their performance evals. There should also be some form of on-going chart audits.

2.) There are several ways that you could organize the content of your Performance Improvement Program to meet standards. It is important that you are able to produce written evidence if asked, so I would suggest keeping a binder where you can organize all of the supporting documentation for your program. Make sure you keep the agendas and meeting minutes for any meetings that you have related to a PI issue. This could be one section of the binder. As another section, you could have a written PI plan for the agency in place. This would be a document that is revised and updated yearly and helps you to focus your goals for the year. You could also have a separate section for each PI project that you undertake- the first one being your OASIS project. For example, keep any sign-in sheets for trainings, educational materials that you pass out in the trainings, blank copy of the test, copy of the in-field check-offs, and chart audit form for your project. You also want to be able to demonstrate that your project has improved care- so results of chart audits before the project versus after implementation.

3.) Staff often need to be reminded why quality measures on the OASIS are important- make sure they understand that some of the measures are publicly reported. In group trainings, I would take them to the Home Health Compare website and compare a few competitors to our agency. Also, discuss how CMS is on the road to link quality measures with reimbursement...and why the staff should care (viability of the agency where they receive their paycheck from, etc). Be sure to mention how health care reform will impact home health care with the onset of ACOs and why it's important for home health agencies to be at the top of their game.

Another way to ensure buy-in may be a bit controversial, but effective. We used a program that allowed us to view the quality outcomes by team or specific clinician. We used this to give the clinician a "quality report card". You could break it down by team or clinician. It allowed them to see directly how their care (or answers on OASIS items) impacted the quality outcomes. In real life, of course, it is not just the care of one clinician that impacts the quality measures.

Good luck to you! Let me know if you have any other specific questions!

KateRN1 · Jun 15, 2011

Have started the OASIS re-education, but not having a great deal of luck with buy-in from staff. In fact, I was ever-so-politely accused of Medicare fraud last week because I suggested that the RN use the actual CMS guidance to score ADLs/IADLs. This may be a point of contention that will drive some of our nurses away--the expectation that they will actually conform to published guidance vs. whatever they feel like doing in the moment. Currently, I'm doing 1:1 education based on scrubbed edits to show clinicians where the discrepancies lie and how to rethink the tool.

Have also started a QI Committee withfirst meeting this morning to meet survey requirements and hopefully get buy-in from field staff. I truly believe that shared governance is a better way to go than the autocratic methods that have been used in the past. Sadly, I don't find many folks who want to "own" the issues, but rather want to blame--the process, the paperwork, management. It gets old. If you don't want to be the best damn home health nurse you can be, get outta my agency.

We have the scorecards, but I find them very ineffective. Because the clinical managers get the edits and make appropriate updates, the employee's scorecard is really a reflection on the effectiveness of the clinical manager, not the fied staff. Hence me keeping track of the edits to use for education. I've asked the clinical managers to stop using the scorecards for the time being. The other issue with the scorecards is that they are tied to the SOC RN, regardless of who continues to see the pt or does the discharge, so I am not thrilled with that particular product. I can't find a way to make it consistently relevant to one person.

I'm sure I'll have more questions after his morning's meeting. Thanks for your help!