A Meaningful Process

       Data and information have often been trended by department managers who develop the action plans. In and of itself, this may seem like the right way to do it, but what is trended is mostly poor performance associated with negative outcome incidents, which are only shared with the staff. A series of audits is undertaken with a limited amount of data or information. In-services and new forms are rolled out, and the focus is on people—not the process or root cause. An obvious question, then, needs to be asked: Did this process obtain anything that is meaningful?
       A facility should develop goals based on a target from a baseline, thus establishing thresholds that represent a set point that, if not met, will trigger further analysis. It should also set benchmarks (ie, an acceptable indicator range based on professional standards). With these steps taken, the facility and its quality assurance program can move toward much better resident outcomes and a more meaningful quality process. We have all seen and used quality measures (QMs) and, to a degree, measured our performance as being acceptable or not acceptable based on our overall percentile ranking. So, is a high percentile a bad thing and a lower percentile an effective measure of good performance? Not necessarily, and therefore the facility must establish goals, thresholds, and benchmarks in its efforts to measure quality outcomes for residents. The bases for the acceptable benchmarks are predicated on effective data collection in comparison to benchmarks. Quality improvement (QI) teams analyze systems and develop action plans with a focus on the processes as well as a consistent and routine sharing of the findings.

Data Collection

       A facility must collect a vast quantity of data to be able to trend and analyze the information. It should capture data over and above the demographic resident information and the event that happened (eg, a resident fall with the date and time and a follow up of the resident’s conditions completed and signed by the nurse involved or in charge). Event reporting and initial investigation should be a descriptive occurrence by incident and injury as to what was seen and observed. It should assess and identify contributing factors and risk factors tracked in increments of no more than two hours, such as day of the week, staff members assigned to the resident, location of staff members at the time of the incident or whether they were on break, and room environment with regard to safety.
       Other issues to track include whether items were on the floor, the location of walkers or wheelchairs, whether shoes were worn, the type of medication given and times along with changes of medications within the last two weeks, recent declines in activities in daily living (ADLs), weight changes, resident range of motion, restraint usage, recent care plan changes and new interventions, the last time of toileting, times of fluid and food intake, the use of side rails, whether a call light was on and for how long, and whether any alarms were on and/or operational. Interviews of staff and alert residents should also be included.
       Neither in this report nor in the medical record should a facility document fault or failure of care, equipment, or staff discipline. The medical record should contain a post-event, factual assessment and account along with immediate interventions to prevent reoccurrence. The initial information is completed at the time of the event or finding and forwarded to the interdisciplinary care plan (ICP) team the same or next day for a care plan update and interventions for prevention. The completed Event Reporting Form is forwarded to management to conduct a post-event assessment (logged for completeness and reported to all parties). Additional information, interviews, and assessments for interventions are completed at this time, along with a determination of whether the event was avoidable; the resident’s condition related to the occurrence was correctly assessed; reasonable interventions were planned; and the effectiveness of the implemented plan was evaluated.

The Monthly Event Tracking Log

       Once completed, the information is then transferred to the Monthly Event Tracking Log. After it is completed, the process of data analysis is conducted to determine trends and relationships to established goals, thresholds, and/or benchmarks. The log, properly completed with detailed information along with a tracking of the incident or event in increments of no more than two hours, helps facilities to assess information for trends and patterns. For example, it does not serve much purpose to know that most of the falls happens on the 3–11 pm shift. But if the information tracked shows that most of the falls happen between 7–9 pm, or that they happen on wing number two, or that they happen mostly on Mondays and Saturday and the days that Nurse Smith works, or that they happen when the residents are assigned to certified nursing assistant (CNA) Jones, then you have information that you can address and investigate further.
       A completed Monthly Event Tracking Log should also include specific statistical information (eg, the facility averages 15 falls per month, meals are served at the correct temperature as per diet orders 98.7% of the time, the facility’s medication error rate is 3.7%, etc.) to give the facility a start on establishing goals, thresholds, and benchmarks. For example, let us take a look at medication errors. Although a facility is within the federal certification mandated acceptance of less than 5%, it will want to do better. Right now, the baseline is 3.7%. The facility can establish a goal of 1.5%, which is the target from the baseline. The facility will then establish a threshold (eg, an error rate over 2%), which, if not met, will initiate further investigation, and the benchmark that the facility may establish is 1.50–1.95%.
       If the facility continues to strive for its goal and stays below the 1.95% rate, it will continue to believe that it is doing an acceptable job from a quality perspective in passing medications. Once the facility exceeds the 2% error rate, it will conduct a thorough investigation as to the cause and establish a possible solution. Assume for a moment that the facility cannot reduce its error rate between 1.95% and 2%. How does this process work? The event reports will be completed with as much detail as possible. This information will be monitored and analyzed for patterns, trends, and personnel to draw a conclusion and subsequent plan for addressing the solution. All appropriate personnel will be included in this analysis and decision, not just a selected few department managers. Once a decision and/or direction is established, it will be monitored monthly or as long as necessary until benchmarks are consistently met. Most facilities will stop the process there. But for a proper resolution, a facility must also continue to revisit this process periodically to see that the implemented protocols are still effective in the maintenance of the benchmark area.

Conclusion

       When it comes to surveys and survey issues, the facility will review its QMs along with other identifiable concerns. The purpose of the survey process is to assure that a high quality of care is provided to residents. Once the facility looks at its areas of concern and identifies potential QM areas that need improvement, the process is essentially the same: identify the area of concern and establish goals, benchmarks, and thresholds that the facility can work with. Once monitoring is in place, steps must be taken to work toward the goal. By making measurable improvements toward the goals established, the facility is, in essence, improving upon the quality of care provided to its residents.
       By way of analysis, most of the issues identified by the facility should be the ones surveyors will monitor during their inspections. The residents reviewed and monitored by the facility will in most cases be the higher-risk residents. This will ultimately result in showing the surveyors a proactive approach. More importantly, however, the efforts will result in improved resident care. Once the facility establishes benchmarks for acceptable ranges (based on industry standards, facility goals, etc.), the process is easily defended when questioned. The process of data gathering, analysis, and proactive goal setting with definitive steps for improvement will indicate that the facility is focused on providing a high quality of care to residents and taking the necessary steps to continue, maintain, and improve upon its overall services.