There is so much change in current regulations that it’s easy to see how the home care industry’s strategic direction gets lost to the “tyranny of the urgent.” The new Home Health Conditions of Participation will place increased emphasis on Quality Improvement, yet agencies’ long-term success are not just dependent on their ability to improve quality. What will win in the end are care delivery systems that provide better outcomes for less money.
While we have not been told when Value-Based Purchasing (VBP) will be applied to Home Health Agencies outside of the pilot states, we shouldn’t be complacent. We know that providing better quality at less cost is what needs to be done. That requires restructuring care processes, and restructuring care processes takes time. While the VBP pilot is scheduled to continue for five more years, CMS is not required to wait until then to implement a general rollout. The successful organizations of the future will be the ones that begin re-shaping their care processes today to achieve better results for less.
Here are three things that organizations should keep in mind to be prepared to achieve success in the value based purchasing model.
It’s not all about the technology
After working in home care implementation during the 90s, my experiences convinced me that if there was an automated process in place, the quality of work being done would improve. So, in the 2000s, I was part of a team that created the vision for our next generation home care product that would focus on process-based automation and performance metrics. We thought we were going to revolutionize the industry.
Unfortunately, when we got the first actual performance measures back, we realized that we hadn’t achieved our goal. The reason? It’s not all about the technology. It’s about the people you want to achieve extraordinary performance.
A few years back, a physician told me that the aviation industry went through a similar awakening 40 years ago when a decision was made to start making people the top priority when discussing quality (safety). Why? Because it became clear to them that meeting the industry’s safety goal was dependent on people working closely together.
A core concept that came out of the initiative was Crew Resource Management, or CRM. He directed me to a book called “Why Hospitals Should Fly,” which explained the author’s vision of what a hospital might look like if it applied the lessons learned from Aviation. The next time I visited my son at Embry-Riddle Aeronautical University in Florida, I spoke with Dr. Scott Shappell, chairman of the Department of Human Factors and Systems. Ironically, Dr. Shappell earned his PhD from the University of Texas Medical School; while he wasn’t familiar with the book, he absolutely concurred with the author’s perspective as I explained it. In fact, in addition to working with the aviation industry, his department also covers the high-risk areas of mining and healthcare.
Another technology challenge that we will need to overcome is placing too much focus on the actual performance metrics themselves. That might sound odd, but let me explain. While performance metrics are an absolutely essential piece of the solution, they are the performance indicators, not the process needed to achieve them.
Think about a classmate back in school who always fought to get the “A” but cared very little about the knowledge that the grade was intended to represent. Sadly, I have heard anecdotes of agencies (thankfully not any that I have worked with) who focus intently on creating a process to achieve better scores on an outcome measure without really focusing on the process needed to truly achieve that outcome. We must strive to understand the performance metric and infuse that understanding into our processes of care so we truly achieve the desired end.
The lesson is clear. Technology has a key role in performance improvement, but the technology is ultimately a tool. Organizations that really shine are the ones that get the people part right and enable those people to use the tools available to them to maximize their results.
Time is everything
As it turns out, the way to decrease your turnaround time is not by working harder and faster, but by removing waste from your process. As a bonus, do that and you will increase quality!
Once we realized that we needed to focus on the people in the equation, we began to look at our methodologies and evaluate why we weren’t getting the results we wanted. We came across the Lean Education Academic Network (LEAN) methodology, which emphasizes finding what your customers value and figuring out how to create or adapt processes that eliminate waste.
We all kept wondering how you can effectively decrease cost and increase quality at the same time. Well, when you start eliminating waste, you may feel like you’re going faster. But in reality, you are taking your time and completing tasks more efficiently. So not only are you “increasing speed,” but you’re also improving on quality because you’re focusing on what’s important.
Using the LEAN methodology when it comes to documenting visit notes is a perfect example of eliminating waste while increasing speed and quality.
If you ask any nurse in home care, they will tell you that the longer you wait to do your visit notes, the more you forget about the visit. And studies confirm that documentation accuracy decreases the longer you wait.
An informal study by former California OASIS Coordinator Michael McGowan in 2011 had participants’ complete an assessment on him as a group in the morning. He then made them fill out the same assessment in the afternoon and a final assessment at the end of the day. The results showed that the group of participants were in 95 percent agreement with the notes in the morning, less than 80 percent in agreement in the afternoon, and by the end of the day, that percentage fell to 60.
Providing inaccurate clinical details can cause all sorts of problems. For instance, incorrectly answering any of the 100+ OASIS admission questions could result in erroneous outcomes, and that could lead a provider’s performance improvement initiative on a proverbial ghost chase. They could be identifying outcomes to focus on that in actuality they are doing well on, or worse yet missing serious issues that should be addressed. This, of course, can become a major patient safety issue. Plus, if you’re not documenting accurately, you might not be getting paid accurately either.
So how do we promote performance improvement while increasing quality and speed? By eliminating waste - in this case, wasted time. As it turns out, here’s where a process-based software shines, because it literally shines a light on where processes are failing or underperforming.
We began by looking at the data specifically based on the amount of time spent documenting a visit. We compared notes that were completed on the same day as the visit to those completed later. Our findings suggest that visit notes completed on the day of the visit take 30 percent less time to complete than those that get done later. For a regular nursing visit note, that’s approximately 10 minutes per visit of time saved if notes were completed on the same day as the visit. If you spread that out over a course of a typical day, which usually includes between five to six visits, you end up saving an hour’s worth of work. Imagine what your staff can do with an extra hour every day.
With those kind of time savings you have more time to think critically and you can really focus on the patient instead of scrambling to complete your paperwork. Yes, learning how to be quick is critical, but it’s also the quality that matters. Before you can deal with your clinical processes and your quality, you have to look at the time factor.
The devil is in the details
Let’s talk more about how the LEAN methodology makes sense in the context of a clinical process, particularly in home health. The key strategy of LEAN is to find out what the customer defines as value (e.g. what would they pay for) and to create the most efficient process possible to achieve it.
In home health, one of our largest customers is CMS, and it has defined very clearly one set of what it would pay for - in the form of Value Based Purchasing outcomes. With that in mind, we have set out to analyze the processes that drive successful outcomes for those measures. MEDITECH decided to first look at the process-based quality improvement (PBQI) measures.
To do well with these measures, you have to be very focused on specific details and really understand the objective of the outcome of interest and how it is evaluated. Once that is understood, you need to craft your processes so that it’s clear to clinicians what they need to do and make it easy for them to do it. Once you do that, it’s easy to evaluate if it’s really being done.
We wanted to make sure that clients had the tools to efficiently carry out the processes that lead to positive outcomes for those measures. We are putting together best practices and toolkits that can help agencies to ensure that assessments, planning and interventions are accomplished in a timely and effective way.
I know that the current pace of regulatory change can be staggering, but the changes are taking us in the direction of providing better care at reduced cost. The key to successfully meeting that challenge is to start soon. In fact, even without Value Based Purchasing, the new Conditions of Participation that will be in effect in Jan. 2018 emphasize the need for strong clinical processes and data-driven quality improvement. The sooner you start, the better off you will be!