Don’t get tripped up by the ‘No. 1 trouble spot’
Don’t get tripped up by the No. 1 trouble spot’
Step-by-step guide to resolving problems with QI
Accreditation associations say that health care facilities often struggle the most with the standards that examine quality improvement/performance improvement (QI/PI) measures.
"That is the No. 1 trouble spot," says Mary M. Fogel, RN, president of Fogel and Associates in Lindenhurst, IL, and surveyor for the Accreditation Association for Ambulatory Health Care in Skokie, IL. Why? "Many times when we go to survey, the actual format of the study is one of the problems," Fogel says.
Many facilities follow a format they created themselves or obtained from another facility, but the format isn’t as user-friendly as it needs to be, she maintains. For example, it should allow for documentation of the QI process. Evaluate your format, she advises, "and don’t try to make it real fancy."
Consider these other suggestions from the accreditation groups:
If you’re hospital-based, don’t develop a separate QI plan. Ann Kobs, MS, RN, former director of the department of standards and current sentinel event specialist for the Joint Commission on Accreditation of Healthcare Organizations in Oakbrook Terrace, IL, says organizations need to have a "planned, systematic, organizationwide approach" to performance improvement."You do not need a separate quality improvement plan. You never did," she says of hospital-based ambulatory surgery programs. "You don’t have to have 57 indicators," Kobs says. "If you do, stop."
Often, organizations that have such a large number of indicators have several that are 100% or zero consistently. "Drop those," she advises. "What a waste of time. Instead, be enmeshed in the organization’s quality improvement activities. That’s what we’ll look for."
Measure patient satisfaction. The Joint Commission is examining measures of patient needs, expectations, and satisfaction, Kobs says. For example, did patients say they were prepared for the surgical episode? Did they feel like they knew enough? Did they have a pleasant experience coming out of the anesthesia? Did they understand the teaching that you did? Expect such questions from surveyors, she advises. Quantify. When you evaluate your problem, indicate how often it is happening, Fogel says."Give either percentages or numerals," she says. "When you [go] back and re-evaluate, then you actually have something to measure it against."
Track and trend. Health care facilities tend to do a good job of data collection, Kobs acknowledges. "The place where we all fall apart is that you have sheets and sheets of numbers, but you never take them to the next step and make them tell you a story," she says. "And telling the story is the turning point because telling the story is when you get employees’ attention, management’s attention, so that they say, This is something we need to watch and track and trend over time.’"Fogel recommends that facilities demonstrate the format of the study by identifying the problem, evaluating the problem (frequency, source of the problem, and severity of the problem), and showing solutions or corrective measures implemented. "After that, you must go back and re-evaluate the problem and the measures you took to correct the problem," she says.
Each QI study needs to have a re-evaluation, but each QI study doesn’t necessarily need a restudy, Fogel emphasizes. A restudy is only done when you’ve re-evaluated the measures that were implemented and you think the problem might reoccur, she says.
Benchmark against other programs and/or internally. According to Kobs, the critical question is: Has the problem improved? "One of the things that the surveyors do with any performance improvement activity is they will take a particular problem and go through the minutes or memos or whatever you have about that particular issue and see if it ever was resolved or did it just fall through the cracks," she says.To prepare for a survey, identify a challenging area in performance improvement and look at your 1998 records to follow it through to resolution. "And then six months later, check it out to see if the fix was holding," Kobs says. "That’s a big piece: Are you tying it all into a big bundle?"
Conduct an internal comparison of processes and outcomes to ensure a continual process of performance improvement, she advises. "One of the things that you want to look at is where were we a year ago, and where are we today? Are we improving as we go along over time? What are you able to demonstrate that you improved?"
Refer to current literature and to other organizations to compare your performance if that’s possible, Kobs suggests. However, "if you’re measuring apples and they’re measuring oranges, that’s not really a useful measure. Your best measure is measuring against yourself."
Close the loop. Report your results to the appropriate group, such as the QI committee, the governing body, or the medical executive committee, Fogel says."And once you have done that, you’re closing the loop," she says. "Everybody has been made responsible, has been accountable, and has heard about what has happened in solving this problem."
[Editor’s note: Do you have an accreditation tip you’d like to share or a question for the surveyors? Contact: Joy Daughtery Dickinson, P.O. Box 740056, Atlanta, GA 30374. Fax: (404) 262-5447. E-mail: [email protected].]
Subscribe Now for Access
You have reached your article limit for the month. We hope you found our articles both enjoyable and insightful. For information on new subscriptions, product trials, alternative billing arrangements or group and site discounts please call 800-688-2421. We look forward to having you as a long-term member of the Relias Media community.