The process-of-care investigation is an extremely important OBQI component. Outcome measurement only reports the agency's current performance on specific outcomes. It is by systematically investigating the clinical actions contributing to outcomes and targeting those aspects of care delivery necessary to change or reinforce that outcome measurement becomes useful in improving patient care. That is, mere measurement of patient outcomes does not improve care-focused activity directed toward such improvement (or reinforcement) is necessary to see change in outcomes.
The process-of-care investigation is intended to be an integral part of the agency's quality improvement (QI) activities. If an agency is already using QI techniques or approaches, this investigation will involve many of these processes.
Benefits of the Process-of-Care Investigation
One significant benefit of the process-of-care investigation is its focus on identifying opportunities to improve patient care. Opportunities are found by selecting an outcome that is inferior to the reference group values (or to previous performance) and modifying specific aspects of patient care, or by selecting a superior outcome and reinforcing the positive care behaviors that influenced that outcome. Thus, the investigation's focus is on aspects of care delivery that are within an agency's direct control.
By selecting and acting on target outcomes, staff members are able to prioritize their QI activities and to maximize often-limited resources. Previously, patient care quality was measured in nonscientific ways by anecdotal information or by assessing rare events (e.g., falls). OASIS-based outcomes enable staff to more precisely measure the effectiveness of interventions as they influence patients. What better monitors than patient outcomes could an agency have to evaluate the effectiveness of its interventions?
Using a Team Approach to Investigate Processes of Care
Most agencies that successfully implement OBQI have found an interdisciplinary team approach is the most effective way to conduct the care investigation. Team members should include clinical field staff who are regularly involved in or affected by the work processes related to the outcome being investigated.
For example, if the target outcome is "Improvement in Ambulation/Locomotion," it would be important to include a physical therapist on the QI team. The size of the QI team should be relatively small to remain workable, probably no more than five to seven people.
Process-of-Care Investigation Goal
The goal of the process-of-care investigation is to examine the likely cause(s) of the outcome and to identify specific aspects of care that should be improved or reinforced. It is important to undertake the investigation in a systematic manner, avoiding the temptation to draw premature conclusions. Agencies have often found that QI team members who arrive with a predetermined idea of problems related to the target outcome can stall progress.
Another pitfall that agencies can encounter is to focus exclusively on paperwork instead of care delivery. Many QI teams presume that any problems found in clinical records are due to lack of documentation instead of inadequate care. If improving care is the goal of the QI team, the focus should be on discovering aspects of patient care that can be improved. Documentation should simply be seen as verification that specific aspects of care were (or were not) performed.
Conducting the Investigation
Identify Specific Aspects of Care
The first step is to identify specific aspects of assessment, care planning, interventions, evaluation, and coordination that should be provided for patients with conditions related to the target outcome. For example, if the target outcome is "Improvement in Pain Interfering with Activity," team members should identify aspects of care that should be provided for patients who have problems with pain.
* How should pain be assessed?
* How should pain be addressed in the care plan?
* What clinical interventions and teaching should be implemented for the patient (e.g., providing pain medication, teaching alternate methods for pain control, etc.)?
* How should the effectiveness of the interventions or teaching be evaluated?
* What should be communicated to the physician and other members of the patient's healthcare team about the patient's pain?
Most agencies have rather clear expectations of appropriate clinical actions to take in providing care to specific patient types. Some expectations are outlined in agency clinical policies or other documents; thus, identifying what should be done in specific situations is not an unusual occurrence for clinical staff.
QI teams often find traditional tools such as cause-and-effect diagrams can be particularly helpful at this stage of the process, guiding experienced clinical staff to identify the specific elements of care related to the target outcome. Other sources for information include agency protocols or standards, practice guidelines, standardized care plans or clinical pathways, research reports or journal articles, and expert consultation (Shaughnessy & Crisler, 1995;Leebov, 1991). Brainstorming sessions with QI team members and other clinicians can be helpful.
The final list of the aspects of care that are expected to be provided to patients, often referred to as the "Should Be Done" list, should be manageable, as that listing will be used in the next step of the investigation. QI teams should brainstorm and prioritize, using techniques such as multivoting to develop a final list.
Determine the Care Actually Provided
Determining whether the care identified was actually provided to the patients is the next step in the process. This means comparing the care patients should have received (as identified above) to the care patients actually received. Methods for conducting this comparison include:
* interviews with care providers,
* home visit observations,
* staff meeting discussions,
* case conferences, and
* clinical record review.
When using any of these methods, the final list of Should Be Done aspects of care will form the basis for the comparisons.
Develop a Care Review Criteria Form
The Should Be Done list can be used to develop a care review criteria form (see Figure 1). This allows reviewers to be consistent when evaluating the care provided. The QI team should determine the best method(s) for conducting the investigation, individuals responsible for completing specified activities, and time frames for completion.
The QI team can use the patient tally report to select patients for review. This report is provided along with the OBQI reports. The patient tally report (see Figure 2) provides information on outcomes and case mix characteristics on a patient-by-patient basis. In Figure 2:
* an "x" indicates the patient achieved the health status outcome and an "o" indicates the patient did not achieve the outcome.
* A "-" indicates the outcome was not calculated for the patient.
* For utilization outcomes, a "y" indicates the patient achieved the outcome.
* "n" indicates the patient did not achieve the utilization outcome.
Most QI teams find it helpful to review care provided to patients not achieving the outcome, comparing findings to care provided to patients achieving the outcome.
To facilitate drawing correct conclusions in the process-of-care investigation, it is important to include an adequate number of cases. Whenever possible, include approximately 30 cases in the review, whether conducting a focused record review, interviewing agency staff, or using another investigative method.
Summarizing Findings
Aggregate Data From All Forms
Once the investigation is complete, the QI team develops a summary of findings. In this step of the outcome enhancement phase, the team compiles information from all methods used for the investigation. If clinical records were reviewed, the team should aggregate results from all the review criteria forms (see Figure 3).
Draw Conclusions From Investigation
With the assistance of information from clinical records, interviews, or other investigational techniques, analytically and objectively think through the results of the care review based on the important care processes. To help staff summarize investigation results and establish priorities for process improvement, methods such as a checklist or Pareto chart can be used to answer the question, "How often are certain events happening?" Flow-charting processes can help to clearly identify redundant, inefficient, or insufficient steps in a problem process.
Using these tools can be very helpful because visual cues stimulate verbal exchange. Cause and effect diagrams assist in identifying relationships between a problem (an effect) and causative factors and in summarizing possible causes for specific outcomes that were identified through brainstorming, record review, or other methods. It is best to construct these diagrams in a meeting of the QI team, as a certain amount of brainstorming is needed to build the diagrams.
Identify Specific Clinical Actions
At the end of the summarization process, the team should clearly identify between one and three clinical actions it desires to change (or to reinforce, in the case of a superior outcome). Typically, the following three examples become apparent: 1) A Primary Problem, such as a lack of consistent assessment. 2) Delay in appropriate follow-up for patients whose conditions worsen. 3) Ineffective teaching.
The aspects of care that are inadequate will be developed as a statement of problem in care delivery, while those aspects that are superior will be developed as a statement of strength in care delivery. These statements of problem or strength will form the basis for the next step in outcome enhancement: the plan of action development.
Timeline for Completing the Process-of-Care Investigation
Although there has been some emphasis thus far on efficient completion of the process-of-care investigation, no specific time frame has been noted. It is important to understand the components of the investigation before discussing recommended timing. Agencies that have been successful in enhancing outcomes have demonstrated their ability to conduct the process-of-care investigation and to implement (at least some steps of) a plan of action within approximately 1 month of the agency obtaining the report. While this can seem like a short time interval, the importance of keeping the process moving is key to success.
Remember that staff will not be modifying their care delivery until after necessary changes have been identified from the process-of-care investigation and these changes are put in place with implementation of the plan of action. Until this occurs, patient care episodes and outcomes of care are likely to continue as they have been.
Only patients who have complete care episodes (start/resumption of care to discharge/transfer) after the plan of action is implemented are likely to show any difference in outcomes resulting from changes in care processes. The longer it takes to implement the plan of action, the less likely there will be a change in the outcomes that will be included in the next outcome report.
This timeline shows an agency should be prepared when obtaining its outcome and case mix reports. Agencies that begin the process-of-care investigation within 2 weeks of obtaining the outcome report have the best opportunity to move on to implementing the plan of action within 1 month.
Summary
Improving patient outcomes is one of the most important uses of OASIS-derived outcome data. After home care agencies access their outcome reports, the next step is using outcome data in QI programs. The process-of-care investigation is not complicated, nor is it a new concept for agencies that have experience with core QI principles. Agencies that conduct a thorough, systematic process-of-care investigation will be able to proceed to the next phase of outcome enhancement, development, and implementation of a plan of action to improve patient care.
Acknowledgments
The work that contributed to this article was funded by the Robert Wood Johnson Foundation (Grant #031950), the Centers for Medicare & Medicaid Services (Contract #500-94-0054), and the New York State Department of Health (Contract #C-015111).
tips for successful process-of-care investigations
[black small square] To select patients for review, the QI team can use the patient tally report.
[black small square] The final list of the "Should be Done" actions must relate to the target outcome and be manageable.
[black small square] Include at least 30 cases in conducting a focused review, interviewing agency staff, or using another investigative method.
[black small square] Conducting the process-of-care investigation and implementing at least part of a plan of action within 1 month of obtaining the report is key to success.
[black small square] The longer it takes to implement the plan of action, the less likely there will be a change in the outcomes to be included in the next outcome report.
REFERENCES