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Application of OBQI Principles & the Acute Care Hospitalization Improvement Matrix for Plan of Action Development. Part 2 October 27, 2005. Objectives. Review the Areas for Improvement incorporated in the ACH Improvement Matrix

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Application of OBQI Principles & the Acute Care Hospitalization Improvement Matrix for Plan of Action Development

Part 2

October 27, 2005

  • Review the Areas for Improvement incorporated in the ACH Improvement Matrix
  • Identify evidence-based strategies to reduce avoidable hospitalizations
  • Describe how to incorporate evidence-based strategies and corresponding actions into outcome-based quality improvement (OBQI) process for POA development
the challenge
The Challenge
  • Multidimensional issue across provider settings
  • Evidence that hospitalization rates can be decreased
  • Gap between science and practice
the mission
The Mission
  • Implement care delivery systems that prevent deterioration resulting in need for hospitalization and emergent care

The Goal

  • Reduce avoidable hospitalizations and emergent care for home health patients
the solution
The Solution
  • Multi-dimensional
    • Improve care processes
    • Lead & influence improvements across provider settings
  • Focus improvement on
    • Coordinating care transitions
    • Identifying patients at risk
    • Stabilizing & managing complex/chronic conditions
    • Supporting patient/caregiver self-management
    • Improving communication/collaboration w/physicians
    • Creating systems/using health information technology to support these practices
the plan
The Plan
  • Use OBQI process to systematically identify problems driving agency ACH rate
  • Use strategies and actions identified in the Change Binder to help build POA
  • Engage in a quality improvement community to share lessons learned (HHAs & other providers)
  • Continuously strive to improve quality
resources to assess the ach issues
Resources to Assess the ACH Issues
  • Risk-Adjusted Outcome Report (page 3)
  • Agency Case Mix Report
  • Case Mix Analysis Tool
  • Patient Tally Workbook
  • Process of Care Investigation
    • ACH Chart Audit Tool
case mix analysis tool
Case Mix Analysis Tool

Purpose ― Allows HHAs to obtain a better understanding of the characteristics of their hospitalized patients

what does it do
What does it do?
  • Computes case mix values for “hospitalized” and “non-hospitalized” episodes
  • Calculates differences in case mix values between “hospitalized” and “non-hospitalized” episodes
  • Produces a report that shows the differences in case mix values of hospitalized and non-hospitalized patients
what value does it provide
What value does it provide?
  • Extends the review of the Case Mix Report to examine case mix differences between patients who are and are not hospitalized
  • Can help focus process of care investigation to identify true cause(s) for ACH rate
patient tally report workbook
Patient Tally Report Workbook
  • Excel-based tool
  • Contains raw OASIS data for all of the patients included within your OBQI report
  • Combines your Case Mix Tally and Outcome Tally Reports into one tool
  • Allows you to query your OASIS data to determine case mix & patient outcome information
patient tally report workbook16
Patient Tally Report Workbook
  • Open up Patient Tally Workbook
  • Select 4th option on menu – View existing spreadsheet data
  • At bottom of page select tab labeled Case Mix Query 1 – provides list of the hospitalized patients for your agency
  • At bottom of page select tab labeled Case Mix Query 2 – provides list of the non-hospitalized patients for your agency
patient tally report workbook17
Patient Tally Report Workbook
  • From Case Mix Query 1, select 30 patients to perform a record review utilizing the Audit Tool included in the ACH Planning Packet
process of care investigation
Process of Care Investigation
  • Identify a list of "should be done" care processes
  • Narrow the "should be done" list to the MOST IMPORTANT
  • Utilize the ACH chart audit tool or clinician interview guide
  • Randomly select up to 30 patient care episodes
  • Review the care episodes
  • Summarize findings
what is a process of care investigation
What is a Process-of-Care Investigation?
  • Systematic investigation of care contributing to outcomes
  • Targets Specific Aspects of Care Delivery Contributing to the ACH Outcome Result
pitfalls to avoid
Pitfalls to Avoid
  • Premature closure (jumping to conclusions)
  • Involving only agency management
  • “Blaming” data collection or analysis methods
  • Not focusing on care delivery
initial steps in investigating care provided
Initial Steps in Investigating Care Provided
  • Identify what should be done in providing care
  • Determine what actually was done
agency decisions
Agency Decisions
  • Determine the review format
  • Determine who will conduct the review
  • Determine the cases to be reviewed
  • Determine the review time frame
drawing conclusions
Drawing Conclusions:
  • Compile team member tally sheets
  • Aggregate results
  • Summarize problem area(s)
problem statements
Problem Statements
  • Describes specific aspects of care that demonstrate inadequate care (or excellent care)
  • Contains specific, concrete wording to which clinical staff can relate
  • Address issues within the agency’s control
  • Focuses on patient care delivery instead of documentation
  • Contains a sufficiently narrow focus to keep a plan of action manageable
  • Change Framework – entire set of change concepts organized into Areas for Improvement and Stages of Care
  • Improvement Matrix – “big picture” of the organization and high-level strategies
  • Strategy – high-level change concept; represents a series of actions designed to achieve a specific objective
  • Action – specific change idea that can be tested and implemented at the agency level
  • Tool – a form, instrument, or manual that can be used as is or modified to support strategies and actions
  • Resource – a reference for more information related to implementing specific strategies and actions
ach improvement matrix areas for improvement
ACH Improvement Matrix:Areas for Improvement
  • Promoting Patient Self-Management
  • Implementing Evidence-Based Practices & Guidelines
  • Using Systems and Technology to Promote Effectiveness and Efficiency
  • Improving Care Delivery Systems & Mobilizing Community Resources
  • Creating a Culture of Quality
promoting patient self management
Promoting Patient Self-Management
  • Focus on problem-solving skills and self efficacy
  • Role of homecare nurse in assessing, motivating, and empowering patient self-management
  • Evidence that effective self-management associated with better outcomes
implementing evidence based practices and guidelines
Implementing Evidence-Based Practices and Guidelines
  • Strong foundation of evidence-based guidelines and tools exists
  • Demonstrated impact on hospitalization for selected interventions
  • Guidelines and tools need to be adapted for home care
  • Focus on getting clinicians to know and use the evidence base
using systems and technology to promote effectiveness and efficiency
Using Systems and Technology to Promote Effectiveness and Efficiency
  • Systems and technology key to supporting and sustaining use of guidelines and tools
  • Systems range from simple to complex
  • Key functions:
    • Identification and tracking
    • Internal/external communication
    • Decision support and “just-in-time” information
improving care delivery systems mobilizing community resources
Improving Care Delivery Systems& Mobilizing Community Resources
  • Delivery systems problems lead to avoidable hospital admissions
    • Poor planning
    • Poor communication
    • Insufficient information transfer
  • Growing body of research demonstrates effectiveness of better discharge planning and improvements in transitions across settings
  • Effective changes include
    • Collaborative planning with hospitals
    • Use of transition protocols
    • Use of interdisciplinary teams/ APNs
creating a culture of quality
Creating a Culture of Quality
  • Quality improvement is a complex process
  • Requires top-down/bottom-up involvement
  • Commitment of senior leaders key at every stage: launching, implementation, and sustainability
using the change binder with obqi
Using the Change Binder with OBQI
  • Comprehensive Framework
    • Represents excellent system of care required to make transformational change
    • Not intended to do everything
    • Add strategies over time
  • Issues not the same in every agency
  • The OBQI process along with some additional diagnostic tools can help HHAs narrow their focus
identify problems strengths and best practices
Identify Problems/Strengths and Best Practices
  • Identify the problem or strength
  • Specific Actions from the Change Framework can be considered for clinical best practices, especially those from
    • Promoting patient self-management
    • Implementing evidence-based practices and guidelines
develop action plan
Develop Action Plan
  • Specific Actions can be considered for intervention activities to implement clinical actions (best practices), especially system changes
    • Using systems and technology
    • Improving care delivery systems
    • Creating a culture of quality
intervention actions
Intervention Actions
  • What is to be Done
  • When it is to be Done
  • Who is Responsible
  • How Action is to Monitored
strategy combinations
Strategy Combinations
  • Identifying patients at risk and implementing Actions to address the risk
  • Disease management
  • Transition from hospital to home health care

Identifying Patients at Risk of Hospitalization and Implementing Actions to Address the Risk Factors

implement the action plan
Implement the Action Plan
  • Clinical staff informed
  • Responsible persons carry out intervention activities
  • Specified activities occur as planned
monitor the action plan
Monitor the Action Plan
  • POA is a dynamic tool
  • Monitor
    • Intervention actions occurred
    • Best practices are used consistently
    • Outcome
  • Measure outcome and process
    • Measurement strategy
tips for internal monitoring
Tips for Internal Monitoring
  • Monitor your measures over time
  • Assign responsibilities for data collection
  • Establish a schedule and process for data collection
  • Consider real-time data collection
  • Integrate data collection into ongoing work
next steps
Next Steps
  • Discuss with Team
  • Further investigation?
  • Finalize POA
  • Implement POA
  • Conduct Small Tests of Change
  • Measure & Monitor
  • Work Collaboratively with IPRO and other HHAs

November Regional Workshops

  • Need to conduct Process of Care Investigation prior to attending
  • Bring problem(s) identified from POCI
  • Will review tools to assist in internal monitoring

November Regional Workshops

Afternoon Breakout Sessions

  • Focus on POA development utilizing ACH Improvement Matrix
  • Provide opportunity for LTHHCP & Special Needs agencies to collaborate on issues related to their specific patientpopulation
  • Leave workshop with POA constructed
  • Return to agency to consult with clinical staff on tool selection
  • Submit final ACH POA to IPRO no later than 12/30/05, for review and comment


  • Change Binder
  • Shared learning
  • Collaboration
  • IPRO Home Health Project Team
contact information
Contact Information

Sara Butterfield , RN, BSN, CPHQ, CCM / Project Director

Phone: 518-426-3300 ext. 104


Christine Stegel RN, MS / Performance Improvement Coordinator

Phone: 518-426-3300 ext. 113


Susan Hollander MPH, CPHQ / Assistant Director

Phone: 516-326-7767 ext. 241