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eHealth Data Solutions believes in using data for decisions, so we
have designed our products to help you convert data to action and
support continuous quality improvement.
Following the recommendations of the Institute of Medicine and
the guidance given to State and Federal SNF and ALF surveyors, and
incorporating themes from the PDCA cycle, eHDS proposes this general
process for affecting improvement in your facility.
1.
Ensure data
are complete and accurate.
2.
Identify
opportunities for improvement.
3. Look for root cause of the current state (and determine if the
process is stable).
4. Set measurable goals.
5.
Develop an action plan.
6.
Follow-up to evaluate the effectiveness of your action plan.
Below, we have detailed specific ways that you can implement these
six steps with CareWatch,
CareWatch and UB Watch, and
RiskWatch.
This plan will help move your data into action that results not only
in quality improvement and better care for your residents, but also
in attaining appropriate reimbursement for your efforts.
A. Quality Improvement and CareWatch
CareWatch uses the hundreds of data points found on the Minimum Data
Set (MDS) to populate Watch pages for quality and reimbursement, and
provides Statistical Process Control charts and other trend charts
to help you interpret these data. CareWatch extracts the quality
metrics from your MDS data that show how the care provided by your
staff is measured by CMS, including the 19 Quality Measures on Medicare
Compare and the 34 Quality Indicators / Quality Measures used by
surveyors. CareWatch also computes the RUG score for each assessment
using the MDS 2.0 RUGs 34, 44, 53 and 66 grouper algorithms.
1. Ensure data are complete
and accurate.
The first step in the process of using CareWatch to help convert
your data to action is ensuring your data are complete and accurate.
CareWatch can provide a roadmap to help you understand where you are
and see where you are headed. Just like you would not set off on a
cross-country trek with a map that is out of date or wrong, you should
not make decisions based on data in which you are not confident.
To
become more data confident, send all MDS assessments to CareWatch
before you send them to CMS. View logic flags and make corrections
as needed in your MDS entry product. Then re-submit to CareWatch,
viewing logic flags again if desired, and send to CMS.
CareWatch
logic flags will alert you to the presence of inconsistencies in the
MDS that could lead to inappropriate care, trigger QI/QMs or survey
tags, or could cause inappropriate reimbursement. Logic flags may
indicate spots where you may need to update care plans or check for
appropriate documentation. Checking for data integrity in CareWatch
helps solve the GIGO (Garbage In / Garbage Out) trap found in many
data collection efforts. By checking these flags prior to
transmission to CMS, you will ensure that the most accurate data are
sent to the state and that the data you use for decisions are the
best reflection of what is actually occurring in your facility. By
checking your data, you and your staff increase data confidence.
When embarking on any program for improvement, you should also be
sure that you know the rules so you are able to interpret the data
correctly (Loeb). For example, review the QI/QM technical
specifications to make sure that you understand how the measures are
calculated (Centers for Medicare & Medicaid Services).
2. Identify opportunities
for improvement.
Now that you are confident in your data, you may begin process
improvement by identifying your opportunities.
The CareWatch Home
page and the SPC Summary help you identify QI/QMs that are in the
red as compared to the state and national norm. Visit
the QI/QM Benchmark page to view a graphical comparison of all of your
indicators with state, national, facility, or organizational
averages. If any of your indicators are much higher than your chosen
benchmark, the next step is to learn the pattern of the indicator.
Establish the pattern or slope using the SPC Charts and review the
chart to determine:
1. What is the Gap; is this process predictable?
2. If the process is predictable, is it acceptable?
-What is your traffic light strategy (red, yellow, or green)?
-What is the distance from your mean to your benchmark?
3. Is any change normal variation, or are there real trends or
special causes?
-Use the control
limits to "filter out the noise" (Wheeler 30) and find out which
months or quarters need investigation.
You may also want to periodically scan through all of the QI/QM SPC
charts to look for any problematic trends; sometimes an indicator
may be in the yellow or green as compared to your benchmark, but
still show a definite unfavorable trend. The SPC charts give you a
chance to notice this trend and take action before the trend leads
to negative facility outcomes like survey tags.
When you identify some opportunities for improvement, choose a few
to pursue, but be careful of the silo approach. Recognize that many
problems have interdisciplinary causes and solutions. One example is
falls and pressure ulcers. On the surface, these may seem to be
clinically distinct areas. However, one cause of both may be
declining mobility.
3.
Look for the root cause.
Before you can improve a process, you need to identify the causal
factors of the current state. Causal factors are those
contributors that, if eliminated, would have either prevented the
occurrence or reduced its severity” of identified quality issue
(Rooney and Heuvel). Ask yourself and your staff, “What happened,
when, and how often? Which residents were affected? What are the
barriers to improvement? ” By asking these questions, you are on
your way to identifying the root cause.
“A root cause is an initiating cause of a causal chain which leads
to an outcome or effect of interest. Commonly, root cause is used to
describe the depth in the causal chain where an intervention could
reasonably be implemented to change performance and prevent an
undesirable outcome.” (emphasis added) (Wikipedia contributors)
When you are searching for root cause, do not rely on assumptions
and do not stop with one causal factor. Instead, look at the facts.
Drill down from QI/QM reports in CareWatch and use the Watch Pages
to help investigate. In this way, by drilling down to look at
individual residents and the cause of that resident triggering a QI/QM
factor, profound knowledge is gained. The places where a resident
triggers a QM indicate a potential failure in care or an unavoidable
circumstance in which a resident’s disease or condition is worsened.
Compassion may require both palliation and active treatment to stop
the decline. This too is a difference in the PDCA cycle, namely in
healthcare, the finding of an issue and the application of the
principle “first do no harm and when found eliminate harm” applies.
In effect one may view healthcare delivery as one enormous PDCA
cycle.
4.
Set goals.
When you have identified your opportunities for improvement and the
causal factors that need to be addressed, you may find it
helpful to set goals for your facility or organization. You should
be able to measure your progress towards these goals to determine if
your action plan is working. It is important not to choose arbitrary
or unreasonable numbers for those goals, as they may be detrimental
(Wheeler 18) (Carey, Improving Healthcare with Control Charts: Basic
and Advanced SPC Methods and Case Studies 104). Instead, examine the
process and engage your staff in setting achievable goals, then give
staff the support they need to meet it (Carey, Improving Healthcare
with Control Charts: Basic and Advanced SPC Methods and Case Studies
104).
For example, the organizational average for prevalence of high risk
residents developing pressure ulcers (QI/QM 12.1) is 17%. Their
lower control limit is 5%. The organization sets a goal of 0%. While
this is a great target, it is not achievable in their current
process. Furthermore, because some residents are admitted from the
hospital with ulcers and do not heal before their first quarterly
MDS measurement of ulcers, that goal may not be realistic and may be
very frustrating for facilities that are berated for not achieving
it.
Arbitrary goals may also lead to
under-reporting of issues (Wheeler) and subsequent problems on
survey. The Advancing Excellence national goal for high risk
pressure ulcers is 6% (Quality Partners). This value is included in
the organization’s process limits and meets the national standard,
so it may be a better goal.
Once you set your goals, you can record them on the Advancing
Excellence tracking reports in CareWatch and then monitor your
facility or organizational process towards these goals. Just go to
Advancing Excellence and click “Help This Page” for more detailed
instructions on using these features.
5. Develop an action plan.
As both Carey and Wheeler observe, goals by themselves do not cause
change (Carey, Improving Healthcare with Control Charts: Basic and
Advanced SPC Methods and Case Studies) (Wheeler). You, with input
from your staff, must develop an action plan and commit the
necessary resources to making the change (Carey, Improving
Healthcare with Control Charts: Basic and Advanced SPC Methods and
Case Studies 104). Remember, time is an important resource, so
consider how much time you plan to commit to a program and how your
staff can fit the program in with their current workflow.
First, ask how far you are from your goal: is your goal low-hanging
fruit that can be attained with small behavior changes, or does
meeting your goal require a fundamental process change? Your SPC
charts can help you address these questions and to make this
distinction. Remember, a QI/QM process that is in the red will, by
definition, require a fundamental change to drop below the state or
national norm.
Next, consider what corrective actions are needed to address the
root cause and include them in a plan of action. Each step should be
assigned to someone on the team, and you should plan follow-up to
ensure that each action is completed and assess its effectiveness.
As you develop your action plan, note that an interdisciplinary
approach may be essential. Communication among departments allows
you to use “all the expertise and knowledge of team members” to
improve resident care (Committee on Quality Health Care in America,
Institute of Medicine 83).
At the facility level, think about changes to policy, process,
oversight/enforcement of policy and process. Make sure that you know
both what the policy is and what staff is actually doing (Wurster,
Lichtenstein and Hodgeboom). If the policy is a good idea, but is
not followed, identify compliance barriers, such as confusion, and
remove them if possible (i.e. with additional training). If you
cannot remove the barriers or the policy is unrealistic, you may
need to change the policy.
Sometimes, changes must happen at the resident level as well as the
facility level. Use the clinical watch page (on the Analysis Menu)
associated with the clinical topic that you are trying to improve to
identify facility patterns and included residents. View the Resident
Summary Report of affected residents to identify related conditions.
Also view care plans and decide if added therapies, restorative
care, or other nursing services would help improve resident
condition or avoid further declines. Paradoxically, taking action on
behalf of individual residents sometimes starts with the
implementation of new facility processes of systematic review, such
as Resident Focused Review (Schmidt, Fedyk and Daniels).
Your action plan should include a test period. You must consider the
length of time needed to implement and validate action steps,
provide a system to track action steps, and decide who will verify
plan compliance. Determine evaluation criteria (your goals), and
schedule a time for an initial review of the action plan, or you may
delegate this review to your QA committee and/or to outside
consultants.
6. Follow-up.
A crucial aspect of any QI endeavor is follow-up. Now that you have
implemented a plan of action, you must ask yourself “is it working?”
To answer this question, do not guess, or you are managing by
‘superstition’ (Wheeler). Instead, track facility and
resident-specific interventions, monitor changes in condition of
affected residents, and code the MDS accurately so it best
represents resident condition.
Then, return to CareWatch and monitor
your SPC charts. Often a period of after five to seven weeks,
months, and/or quarters with improved results is required to have
passed to judge a change as an improvement. Do not assume that a
small change after one month indicates an overall improvement or
that no apparent change after one month means that the intervention
has failed. Remember, five to seven data points are needed to
indicate a trend. Use the rules outlined in the sections above to
determine if improvements have occurred and if any changes have been
coincidental (common cause) or if the intervention was successful
(special cause).
In evaluating the success of
your action plan, use data wisely: be careful not to let the data
wag the dog. A facility was reviewing their SPC charts during
CareWatch training, and staff was alarmed to see an increase in
falls. They attributed this increase to a change in staffing during
the affected period. After a few minutes of looking at the chart and
rationalizing the pattern, they discovered that they had been
looking at the pattern for Pain the entire time.
One other note, in
the example above, the DON tracked weight loss month to month. With
MDS data, you may also want to consider a trend of quarters because
every resident will have an assessment each quarter. However, use of
the Residents option in CareWatch allows viewing monthly data. Use
of quarterly data has greater application if your facility is small
or has a larger short-stay population.
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B. Attaining Appropriate Reimbursement with CareWatch and UBWatch
These process improvement steps can also be used to monitor and
improve case mix.
1. Ensure the data are complete and accurate by regularly submitting
MDSs to CareWatch, reviewing logic
flags, and responding as needed. Also submit Universal Billing
claims to UBWatch. UBWatch will look for coding errors (called
Exceptions) in the claims that could potentially result in delayed
or denied payment or recoupment of Medicare funds by RAC auditors.
You should also make sure you understand the factors that contribute
to your reimbursement. Review the Medicare Benefit Manual (Centers
for Medicare & Medicaid Services) and any state manuals regarding
Medicaid calculations.
2. Identify opportunities by viewing CMI Trend Charts to see if your
Case Mix is increasing or decreasing, if there are any exceptionally
high or low quarters, and if the acuity level represented in your
CMI process is consistent with both your knowledge of your residents
and the skill level of your staff. Also view your RUG Trends and Top
Exceptions in UBWatch to search for unintended billing patterns that
can be remedied.
3. If you decide that you need a change,
look for the causes behind
your current CMI. Consider the following questions: Is your facility
admitting the right mix of residents? Are resident deficits
care-planned appropriately? Is resident assistance appropriately
captured on the MDS (view Medicare RUG Tending or Medicaid RUG
Watch)? Are therapies and related diagnoses recorded on the UB claims? Does the facility have the staff and does staff have the
time to administer and document all planned services? Is restorative
staff pulled to the floor and unable to complete these tasks?
4. Set realistic and measurable goals. For example, average CMI will
increase by 5% over the next year, or CMI will stop declining, i.e.
stay above the lower bound set by the current process without that
boundary changing. Remember, goals do not cause changes.
5. Develop an action plan to address the issues identified in number
3 above. Use Medicare Watch and State Watch pages to identify
residents in RUG categories that are not appropriate for the actual
care the resident receives. Look for residents who could benefit
from restorative programming, added therapy, and other care.
Identifying residents who need therapy and restorative care helps to
improve the QM scores for ADL Decline and Mobility. Plan ahead for
assessments (Schmidt, Fedyk and Daniels) and re-educate staff on
coding.
6. Follow up on the initiative to make sure actions have been
completed, and measure whether your plan has been effective. Revisit
your CMI Trend Charts and UBWatch RUG Trends to see if the pattern
has changed, and view Medicare RUG Tending to assess if fewer
opportunities are missed.
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C. Role of RiskWatch
RiskWatch is also designed to be a repository of data that can be
analyzed and converted to action, and the program contains many tools
to aid you in reducing risk and improving resident safety and
quality of care. In the event of a resident experiencing an event, a
facility occurrence, such as a fall, facility staff enters relevant
details into RiskWatch. The event is then investigated, root cause
is assessed, and recommendations made. Finally each event is
reviewed for compliance and appropriate facility response. All of
the data collected during the process of report entry,
investigation, and review are then available for analysis.
The process of reducing risk in your facility or organization is
very similar to the process of improving quality. F-323 requires
facilities to complete similar process steps to ensure resident
safety including: “Identifying hazard(s) and risk(s); Evaluating and
analyzing of hazard(s) and risk(s); Implementing interventions…; and
Monitoring for effectiveness and modification of interventions when
necessary” (Centers for Medicare & Medicaid Services 232).
Therefore, you can employ the process improvement steps to reduce
the number of falls, medication errors, and other adverse events.
1. Ensure data are complete and accurate.
First, you must ensure your data are complete and accurate. This
means that you have a method, such as RiskWatch, of capturing
information about occurrences consistently and comprehensively and
tracking this information over time. This information should be
pertinent to the occurrence type and aid in quality improvement.
For example, if you are tracking pressure ulcers, you should record
whether each was present on admission or developed while the
resident was at your facility.
2. Identify opportunities.
Reviewing occurrence patterns on the RiskWatch Analysis menu is the
next step in converting RiskWatch data to action. Use your
Occurrence SPC charts to assess if each type of event is increasing
or decreasing and if there are any months or quarters that are
abnormally high or low.
Also compare your rate to an organizational
benchmark, if available. Think about what areas you would like to
target for improvement. For example, do you want to reduce the rate
of falls across the entire population, or the number of residents
that fall 3 or more times within a given period? Deciding what you
set for the target for improvement has definite requirements for the
steps and actions necessary to achieve the goal.
3. Look for the root cause.
Now, you are ready to look for the root cause. According to Crossing
the Quality Chasm, rather than blame specific individuals for their
failures, it is important to identify the system or process that led
to the error. In a culture where individual failure is the focus,
errors may be underreported due to fear of punishment (Committee on
Quality Health Care in America, Institute of Medicine).
Therefore,
when searching for a root cause, look below the surface for causal
factors that management has the ability to control, fix, change, or
care plan by developing actions for prevention. Use the Occurrence
Log and Watch pages to identify areas of risk that may be addressed.
What do your resident events have in common that could be the basis
for action? This should not be a one-person job. For example, you
should discuss the root cause of falls in your falls committee.
An increase in event/occurrence type or a high rate should have a
root cause, and each individual event/occurrence will also have a
root cause. For more information on selecting root causes in
RiskWatch, review your training document, RiskWatch Investigations:
Recommendations, Root Cause Analysis, and Conclusions. Some common
root causes that have been identified for event/occurrence causes
include: equipment failure, human error, internal risk factor
(medical condition), external factor, environment factor, staff did
not follow plan, process inefficiency, and resident action.
4. Set goals.
Now, set measurable and achievable goals for your facility or
organization. One goal might be to reduce average falls per month by
10%, but be sure to look at your SPC chart to evaluate your current
pattern and assess if this goal is appropriate.
5. Develop an action plan.
The action plan in RiskWatch goes beyond responding to an individual
event/occurrence. It should include interdisciplinary steps to
reduce the risk of future events/occurrences for individual
residents and all residents. If your root cause is at the facility
level, consider policy changes, re-education, and improved
communication.
If resident risk factors contributed to the area you
are targeting for improvement, view clinical information for
affected residents and consider intervention at the resident level.
Use the RiskWatch Resident Event/Occurrence Report and CareWatch
Resident Summary to identify resident risk factors. You may also use
the clinical Watch pages in CareWatch to identify residents who may
be at risk for an event/occurrence.
For example, the Falls Risk
Factors page identifies risk factors such as impaired standing
balance and unsteady gait; residents with these conditions may then
be screened for therapy and/or restorative care. The best action
plan may combine facility level changes with resident-level care
planning.
Make sure that your action steps are concrete and specific so you
will know they are done. For example, reminding staff to take care
during transfers may not address an increase in falls due to
improper transfers. Perhaps an in-service is needed on proper
transfer techniques. Perhaps a period for practice of proper
transfer techniques can help. Also include an evaluation period
during which you reinforce the action steps and check that they are
completed, and after which you follow-up to determine the
effectiveness of your plan.
6. Follow up.
After your evaluation period is complete, follow up to see if your
action plan improved the measure of risk that you chose. Do you have
a lower incidence of falls? Are fewer of your residents falling
multiple times? Refer to your Occurrence SPC charts and your Falls
Watch or other Watch pages in RiskWatch to make this determination.
However, beware of Time 1 to Time 2 comparisons. If you have fewer
falls in May than you did in January that may be a coincidence. By
looking at your process over time (5-7 periods where improvement is
recorded make a trend), you can learn whether changes mean your plan
was successful, or whether a lower value was a blip on the radar.
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