As we read the technical knowledge and practical wisdom that industry experts have presented in this and last month's OBQI-focused issues of Home Healthcare Nurse, we are no doubt brimming with a variety of feelings. From excitement and possibility to apprehensiveness and sheer exhaustion, the commitment to the principles and practices of OBQI can appear daunting.But not so for those of us who are "Lover's of OBQI."
There are some among us, albeit a definite minority, who have since the first whisper of OASIS longed for the day that we could see the miracles of OBQI become reality. Ah, yes...objective and standardized data on which we could evaluate the care we've provided and identify areas of improvement...it would be a good thing!
So, What's Different?
I distinctly recall the first time I was presented with an overview of the two-stage OBQI Process. I remember thinking, "take measurements, analyze the findings, select a problem to work on, develop a plan, implement the plan, monitor and evaluate the change. And this is different than my daily approach to patient care in what way?"
The OBQI framework was the model I used to conduct my clinical practice as a physical therapist. I assessed my patient, compiled objective measurements of physiologic signs, range of motion, strength, pain, level of assistance required, etc. I analyzed my assessment findings and determined those key problems that I could address to improve or resolve the patient's condition. I then selected specific problems on which to focus, developed and implemented a treatment plan to fix the problems, and monitored the patient's progress.
If improvement occurred, I continued to reinforce the interventions. If improvement did not occur, I developed and implemented a new treatment plan. This model had proven successful in achieving my patient-centered goals, and the resemblance of my practice model to OBQI felt familiar, natural, and promising.
Stumbling Blocks
Because a standardized body of data was requisite for OBQI, in the absence of anything else, I made the natural progression from a "Lover of OBQI" to a "Lover of OASIS." As word spread of my "condition," I was frequently confronted by those who had less than affection for my beloved "MOOs." While most of these neigh sayers presented criticisms and complaints that I could easily dismiss with a simple explanation or correction, I was occasionally presented with a criticism that allowed doubt to enter my mind.
Could What They're Saying Be True?
These thoughtful criticisms made me uncomfortable, and I found myself justifying them away. "Just continue to collect the data the best you can...there is a learning curve for all of us...the data will get better...I know that some of the data collection rules challenge clinical reason-but standardized data collection is paramount...just obey the data collection instructions!"
The PPS Distraction
The year 2000 brought implementation of the home care Prospective Payment System (PPS). My MOO friends were finally being given the attention they deserved! But, only 23 of them. I was quick to notice a trend. There was a deluge of requests for training programs on the 23 important OASIS items. At first I balked, "I will not be a party to this blasphemy!" Then I reconsidered. Maybe the heightened concerns for accuracy on these 23 items will carryover to the others?
After repeatedly conducting training on these 23 items, I could no longer ignore the degree of data collection practice inconsistencies on this subset of 23 and the entire OASIS data set.
* How can five different clinicians possibly interpret the same item and instruction in five different ways?
* If I'm consistently seeing this concern with agencies seeking training, how much worse could the inconsistency be for agencies that do not receive focused item-by-item instruction?
* How much worse could the inconsistency be for the non-PPS items?
These questions gnawed at me. How could I, a confessed OASIS lover, even suggest that reliability problems existed? I consoled myself by rereading the OASIS Q&A's and documents that assure me that the data set has demonstrated acceptable reliability, and I kept my concerns to myself.
OBQM Reports-Good News and Bad News
In 2001 the adverse event outcome reports and the case mix profiles were released. Months passed and some agencies still demonstrated no interest in even accessing these invaluable reports. I wondered, "How can they face themselves in the mirror? I wouldn't let my grandmother's dog be treated by these slothful agencies!"
Yet, as I immersed myself in these reports, strange findings emerged. I asked myself:
* If I am to answer "yes" on M0440 for any area of pathologically altered tissue, including moles, bruises, and old scars, shouldn't the national average be much higher than 30%?
* Why does a "yes" response on this broadly defined MOO item land a patient in a category defined as "Acute wounds/lesions"?
* Is the category appropriate for a patient with a 40-year-old appendectomy scar?
Another seed of doubt is planted. I realize that following the standardized data collection instructions of not reporting the stage of an unobservable pressure ulcer at start of care will result in a patient's inclusion in the adverse event outcome of "increase in pressure ulcers," if the ulcer is observable at discharge. The patient didn't really have a negative outcome, but the demands imposed by the standardized instructions make it appear otherwise. Ughhhh!
How can this be? I must be overanalyzing. Surely there are many people who are a lot smarter than me in the ways of such things. Best not create a problem where one obviously doesn't exist! Besides, I love the idea that I can now access objective reports that alert me to the unique characteristics of my agency's patients and to specific cases of poor outcomes.
Could these negative outcomes have been occurring all along without my knowledge? I shudder to think! But no more! I will faithfully access my OBQM reports and systematically investigate each adverse outcome.
OBQI Reports-Finally the Holy Grail?
In 2002 the release of the risk-adjusted outcome reports occurred...the moment we all have been anticipating. Now everyone will "see the light"! We OBQI lovers will get our risk-adjusted reports and rapidly plow through the steps we have so diligently prepared to take! The improvement that will result will be proof to the skeptics that we have been right all along! I can hardly sleep awaiting their arrival!
But wait! Not all of the outcome measures are risk adjusted? I'm a follower! I'm a believer! I've recited the mantra "Risk-adjusted outcome reports are the cornerstone of OBQI...risk-adjusted outcome reports are the cornerstone of OBQI..." How can it now be suggested that I can conduct OBQI on nonrisk-adjusted outcome measures? I don't get it. I'm in conflict again!
Sure, I love my 29 new risk-adjusted outcome friends. I cannot imagine only picking a couple! How can I possibly let the rest just sit there? But listed there, in black and white, the descriptive report shows 12 outcomes (including several personal favorites related to oral medications and pain), just sitting there with their little nonrisk-adjusted heads hanging. I move ahead with my commitment to OBQI, with discord lingering in the back of my mind.
What's Next?
I cannot predict what lies ahead for OBQI. (Even as we speak there are apostates meeting, plotting, and scheming to abolish the very tool that currently serves as the "rock" for the OBQI process.) I have learned a great deal developing these special OBQI issues for Home Healthcare Nurse. Through these efforts I have experienced my own epiphany that is beginning to replace turmoil with harmony. I now believe that a true lover of OBQI would experience conflict, would continuously question, would seek proof, would demand answers where answers exist, and would demonstrate persistence where answers do not exist.
We who embrace the doctrines of OBQI often feel a need to accept and preach the instructions and guidance without question. After all, questioning is for the nonbelievers! So, in an effort to not feed the fires of the opposition, and to demonstrate loyalty to a process in which we place our faith, we accept too much, and question too little.
By its very nature QBQI demands systematic evaluation and analysis in efforts toward continual improvement and refinement. The OASIS data set, outcome reports, measures, and processes are so new to home care. To assume that the OBQI process has been introduced in its national debut in its perfected form would be ironic.
Just as we are encouraged to critically evaluate the patient outcomes we achieve and the care practices that contribute to them, we should not hesitate to also critically evaluate the reports and outcome measures used in the OBQI process, and the OASIS data that contributes to them.
Just as systematic and thoughtful analysis of our patient outcomes will lead to refined care practices, systematic and thoughtful analysis of the OBQI reports and outcomes will lead to a refined data set, data collection instructions, and outcome reports.
My enlightenment has been cathartic and liberating. I feel freer to consider recommendations and positions that previously invoked feelings of abomination and guilt. I can now ask:
* Do the OASIS items measure what we want them to measure?
* Is our data collection consistent enough between clinicians and agencies nationwide to provide reliable comparisons?
* Are the current 41 outcome measures the most valuable indicators of changes in patient health status?
* Do these outcome measures adequately represent the most significant patient outcomes that can be influenced by the provision of high-quality home care services?
* Given the current demands on agencies, do the tasks required by OBQI represent a reasonable and realistic resource investment to voluntarily accept?
* Will the return on the investment be worthy of the costs?
I can now ask these questions aloud! Not because I'm an agitator, but because, as an OBQI lover, my expectations demand continuous improvement. Just as I rejoice in my adverse event report because it shows me a potential area for improvement, I am now able to rejoice in the discovery of possible OASIS and OBQI-related imperfections. Through these weaknesses we will find the course to the eventual evolution of OBQI in home care.