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Continuous Improvement in a Home Care Quality Management Program

By Gordon Raup

The goal of quality improvement programs in home care is to improve patient outcomes while minimizing resources. Outcome analysis, in particular, is used to measure the success of these programs. Outcome measures such as re-admission rates for diabetes, mellitus, or satisfaction of clients with breast cancer, provide a valuable yard stick to compare the effectiveness of different agencies and allow each agency to compare current performance against past performance.

In the new environment of health care reform and managed competition, many home care agencies are seeing the importance of improving their results in key outcome measures. They see that the ability to show better outcomes with the same or fewer resources will offer their agencies a competitive advantage in the coming era of prospective pay and managed care contracts.

Forward-looking agencies are adopting, or already have adopted, continuous improvement programs. With such programs, they systematically collect data at each step of the care process and analyze it to find areas for possible improvement. Hypotheses are formed about what procedural changes could improve outcomes and/or reduce costs in the identified area of interest. Studies are set up to test these hypotheses. The best procedures identified in these studies are adopted and the cycle is repeated in another area of interest. These agencies have found that a major source of improved outcomes is a never ending program of finding what works best in their own situation.

One example may help to illustrate. A new wound management program may be introduced, backed by studies showing a 40% reduction in the time necessary to heal wounds at a cost of $50 per treatment. In the past, it may have been sufficient to accept this result at face value. But in the competitive environment of today, agencies wishing to survive the coming shakeout in home care will likely want to test this for themselves. How fast does the new program heal wound? Are more or less planned and unplanned visits required? What is the total cost of using the new program compared to the total cost of the current method?

Speed and Cost

A continuous improvement program within each home health agency may well be advisable for the long term viability of the agency, but many agencies are hesitant. Adding additional data collection forms to the already overburdened nursing staff is not only costly, but a source of considerable job dissatisfaction. And the cost of manually pulling and reviewing charts for a retrospective study is often prohibitive.

On the other hand, most agencies know that they cannot afford not to institute a continuous improvement program. With the probable shift from reimbursement for care provided to prospective pay and to managed care contracts, the key to profitability will shift from capturing billable charges to controlling costs. Furthermore, the key to controlling costs is an active continuous improvement program in which there is a constant search for better methods of care at reduced cost.

This situation may appear to be a Catch-22 between the apparent cost of a continuous improvement program and the high cost of not having such a program, but several lessons from manufacturing may help eliminate the conflict. In the mid 1980's, manufacturing faced a similar need for a continuous improvement program to improve product quality. After many stops and starts, most manufacturing companies have now adopted extensive programs in this area.

One of the most important tools in many of these programs is Statistical Process Control (SPC). Using this tool simplifies data collection by numerically coding all the data, even qualitative data. This not only makes the data easier and quicker to collect, but easier and quicker to analyze as well. SPC then predicts when product quality standards are being threatened by comparing limited amounts of new data with previously collected data.

Prior to SPC, manufacturing was typically done in batches where the parts were first produced and then taken to inspection for data collection and analysis. If any parts were bad, then often the whole batch had to be re-worked. With the introduction of SPC, manufacturers took data collection and analysis out of the inspection department and integrated it with the manufacturing process itself. They found that once people got used to the idea that data collection and analysis were a part of everyone's job, the additional cost of checking one more feature or dimension was negligible.

Manufacturers soon found, however, that the cost of managing and analyzing all of the newly acquired data was exploding. Files full of data collection sheets analyzed by expensive statisticians threatened the gains made from the improved quality. Computerization was the answer. By distributing PCs throughout the manufacturing process, the paper flood was greatly reduced and the statistical analysis was done and presented immediately. Manufacturers found that data accuracy also jumped dramatically once the data was directly entered into the computer at the job site.

Much of this history is not directly applicable to home care. SPC, for example, requires processes which behave, or at least can behave, exactly the same each time they are performed. Nevertheless, two central lessons from industry may be useful in home care:

1). Coding the data numerically makes it is easier to collect and easier to analyze.
2). Computerizing data collection and analysis speeds data entry, reduces errors, and provides analytical feedback faster, cheaper, and more accurately.

Once the twin steps of coding the data numerically and computerization were taken, manufacturing organizations found they could be much more flexible in their continuous improvement programs. New studies could be defined and implemented in hours instead of weeks. Past data could be re-analyzed quickly by letting the computer do the searching and sorting.

Standardized Language and Computerization

Home care can achieve the same low cost and flexibility in its continuous improvement programs through the use of standardized nursing languages and computerization. Standardized languages such as the Omaha System and the Iowa NIC Taxonomy were developed, in part, to provide a numerical coding system for nursing data so that it could be statistically analyzed. These standardized languages, and the Omaha System in particular, also simplify the data collection process itself by replacing text entry with short pick lists of standard terms.

Computerization of clinical data collection in home care is just beginning to take hold and many clinical data collectors and report generators are currently on the market. What separates CareFacts HC from these other products is that it has been designed from its inception to facilitate and incorporate statistical analysis of the collected data. It is designed to be the backbone of a home care agency's documentation system and quality improvement program by combining data collection and data analysis in an integrated package. By allowing retrospective studies to be performed within minutes by the computer and prospective studies to be easily incorporated into the normal visit documentation, CareFacts HC gives home care agencies the flexibility needed to adopt a continuous improvement program without a large research staff, and with less effort than current documentation systems.

Citation: Raup, G. (1993). Continuous Improvement in a Home Care Quality Management Program. The Quality Messenger, 1(1), 1, 2, 6.

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