A Simpler Approach to Quality Assurance

Too many times when I speak about quality assurance, nurses can’t help but roll their eyes and sigh. To many nurses, the complicated procedures and less than timely findings of quality assurance activities are practically irrelevant to their patient care. When QA activities are relevant, they are often presented in a format that is not understood easily by clinicians who do not live in the world of Quality Assurance. And to be honest, I am not impressed with the typical quality assurance program in most agencies.

To be sure, we are great at finding deficiencies in our clinical records. We collect data for days. If every home health agency in the country pooled their data collection we could fill the National Library of Congress if the data were stored on flash drives. But usually what we do about the data falls into one of two categories. Daily we give the nurses ‘correction’ slips or some similar document so they can ‘fix’ the chart in question or we report aggregate findings at a quarterly meeting along with a complicated diagram and p values and n values and tell everyone we expect improvement by the next quarterly meeting. The meeting attendees who manage to maintain consciousness throughout the entire meeting have no idea how to go about adjusting the variables that factor into the equation without a statistics class.

It can and should be easier. Here is how QA works on Planet Julianne.

1. Do a few clinical record reviews. Write down your findings.
2. Discuss your findings with agency leadership and the staff and determine which three trends are affecting your care. There may 20 pertinent findings. But you are not that good. Focus on the big three.  Otherwise you will be busy for the rest of your career without ever accomplishing true change.
3. Bring the field staff into the QA meeting.
4. Pay very close attention to this step. ASK THE FIELD STAFF HOW THE QA TEAM CAN HELP THEM IMPROVE PERFORMANCE
5. This next step is even more important. LISTEN TO YOUR NURSES.
6. Design a simple plan. Simple as in, Problem, Plan of Action, Follow up. Leave fishbone diagrams and flow sheets to the artistically inclined. They have never hurt a QA process but other than looking good on survey, they don’t necessarily help.
7. Monitor progress – in the simplest manner possible. QA is not about data collection although you certainly can’t have QA without valid data. But if your focus is missed visits, look for missed visits. If you found no problems with timeliness of MD signatures, wait until the next quarter to look at them again. Focus, focus, focus.
8. Review findings with DON monthly.
9. At the quarter report on improvement.
10. This is another very important step. In fact, pay close attention because this is likely the most important step. IF THERE IS NO IMPROVEMENT, REALIZE THAT YOUR PLAN FAILED. YOUR NURSES DID NOT FAIL. YOU DID NOT FAIL. THE PLAN FAILED. Once you start blaming people you will lose focus and never achieve another positive result in your QA activities for the rest of your life.
11. Be willing to go back to the drawing board and try again. Being willing and able to recognize a failed plan is a huge success for anyone involved in QA activities.

Consultants like me like to go to an agency and tell everyone what worked in other agencies. Big deal. What works for your company is dependent on your staff, their talents, your problems, etc. Just as we design care plans to meet the individual needs of the patient, we should design QA activities to meet the unique needs of agencies.

So that’s my take on QA. Keep it simple. Make it work for your agency. Transform your QA staff from ‘chart police’ nobody likes into resources for the rest of the nurses. Have some fun with it.

I guarantee you success.