OBQM/Chart Audits and the New Survey Protocols: Tweaking and Streamlining Process for Real Improvement
From Outcome-Based Quality Improvement (OBQI) refresher training to Total Quality Management Agency Programs, the home health agency of today needs to define the level of programs needed to operationally and financially drive success. The home health agency needs OASIS stop, logic, and congruence edits to prompt clinicians and flag incongruence between M questions. But, that is just the start. The OASIS integrated assessment sets the stage for the plan of care created. From the plan comes the visits and they must support that plan and drive to expected outcomes.
Perhaps your firm would benefit from a third party quality clinical chart audit. Your Professional Advisory Committee, Board of Directors, and you may well see the merit of an independent view of clinical processes and care. Noting strengths and determining opportunities for improvement before a survey makes sense. Are you spending too much time and money internally for chart reviews? What does happen after those reviews? Do you educate personnel? How do you know if that education was successful?
Clinical chart audits can assist you to remedy issues, provide education and training, and improve efficiencies. Clinical audits can assist to streamline processes, determine areas of risk, and assist to improve the bottom line. Clinical audits can assist to identify quality customer service and improve patient care.
“Identifying ways that an outcome-based corporate culture fully extends to both internal and external customers is the responsibility of leadership. Developing and using simple tools can aid in the process. Once systems are implemented, maintaining a true commitment to TQM becomes a powerful challenge. But, to the persevering leader, the rewards of quality customer service can go hand in hand with a positive bottom line” (Carmichael, 2005)*
The new survey protocols mandate an outcome–oriented survey process, therefore, know that the surveyor will continue evaluating, per CMS, “the quality of care and services furnished by the agency as measured by indicators of medical, nursing, and rehabilitative care.” In addition, the new process will emphasize the clinical record of assessment and care, agency personnel interviews, and home visits. The new regulations provide clear guidance for expanding the survey, if needed.
Besides Process and Chart reviews, agencies should routinely use the Surveyor Worksheets to review agency data filed with the state, look at diagnoses and expected outcomes, monitor potentially avoidable event outcomes, and be certain there is adequate documentation for case mix indicators.
An evaluation of Level 1 indicators (see Select Data University April, 2011 article on New Survey Protocols, Survey Protocol Worksheets) includes standards under skilled nursing and therapies. If the agency is in compliance with Level 1 standards and no additional issues or concerns are identified, the survey is completed. If the expected outcomes are not met for one or more Level 1 standards, then the survey expands to become a partially extended survey.
At the very minimum, compliance with Level 2 standards is evaluated if deficiencies were identified with Level 1 standards. This is the partially extended survey. Be aware that surveyors may review additional non Level 1 or 2 standards under the same conditions during the partially extended survey at their discretion. (State Operations Manual, SOM, Appendix B). In an extended survey, all conditions will be reviewed. Appendix B and Survey Protocols provide specific recommendations for: citing condition-level deficiencies, extending the survey, and related conditions for further survey.
Now, more than ever, a thorough assessment must drive discipline specific care plans that drive the overall POC with every visit skilled and enhancing the process toward expected outcomes. Clinical record reviews, clinical interviews, and home visits drive the survey process. Documentation is essential. Good documentation starts with a thorough assessment. That assessment should be specific. Does your assessment tool set the stage for success? Is it detailed enough to gather data to allow the highest level of coding specificity? Does it cue the clinician with requests for detail to support a case mix diagnosis that may be assigned?
It is simple in the guidelines; a good POC starts with a solid clinically integrated OASIS assessment. That assessment drives the discipline specific care plan and those plans contribute to the overall POC. That POC has diagnoses present that require substantiation in the clinical record and the expertise of master coders. That very record supports the diagnoses sequences chosen. The visits can stand alone as to skill but reflect that they are a part of an individualized skilled plan of care.
Documentation takes time and thought. Clinicians are busy and require assistance and support. Consider a third party coding entity. Also consider an OASIS data collection service that was created by clinicians. The system should be reflective of what you expect and of what your clinicians need.
The new survey protocols are data driven. Agency leaders need real data daily, weekly, monthly to monitor clinical performance and patient care outcomes.
The Surveyors have the data when they arrive. Do you?
*Carmichael, S (2005). Total quality management and outcomes based quality improvement: revisiting the basics. In Home Health Care Management and Practice (17)(2),119-124