Quality assessment activities include the development of data sources and the analysis of information generated from these sources to identify and resolve problems as well as identify opportunities for improving care. Quality indicators are the measures that are collected and analyzed to assess performance and outcomes. We have listed at the end of this chapter all of the quality indicators used in Kaiser Permanente's Home Health Quality Management Program. While all of these indicators should and do reflect the broad goals of the TCPC Program (see Chapter 4), a few — those highlighted below — are especially sensitive to the program's unique focus on providing pain management and other comfort care in the patient's home and in accordance with the patient's wishes.
Two to three weeks after admission, patients or their family representatives are asked to complete a one-page satisfaction survey that evaluates quality of care and identifies areas for improvement (see Appendix for a copy). Results are tabulated and trends are analyzed quarterly. A quality staff member may contact patients or families regarding specific issues or concerns, if a name and contact person is provided on the survey. Aggregate results of the surveys and identified trends are presented quarterly to the agency quality committee. If the aggregate result falls below 4.5 (1-5 scale), a second level of analysis is done and an action planned developed.
Pain management is evaluated by: 1) monitoring the frequency with which pain is assessed and documented in the patient's chart, and 2) monitoring whether interventions and follow-up are implemented in accordance with pain standards established by the TriCentral Home Care Department (see Appendix). Random monthly audits of patient medical records are conducted to collect the data. Department goals are that pain ratings will be obtained and documented on at least 90% of all patient visits and at least 90% of all actions taken in response to pain ratings will meet the criteria defined in the pain standards.
Overall management of symptoms is evaluated by monitoring the number of:
The palliative care team discusses results at their weekly conferences to identify the reasons for use of the above services, identify missed opportunities, improve communication and appropriate service utilization, and avoid unnecessary emergency admissions.
The presence of an advance care plan for each patient is audited monthly as part of a random sample chart review. The review is comprehensive for key quality of care and compliance issues.
Service utilization is conducted through review of individual plans of care in team conference and through multidisciplinary peer reviews of medical records. Biweekly team conferences provide a venue for team members to evaluate care plans for individual patients and make changes as needed based on input from the patient, family, or team members. The plan of care is a fluid document that is adapted as needed to meet patient needs, with services increased, decreased, added, or deleted based on the principle of the right care at the right time.
Once quality indicators are established, data must be collected to assess performance with respect to each indicator. Because information gathering is so vital to quality assessment and performance improvement, the quality management plan should describe procedures for data collection and organization. This means identifying data sources, frequency of data collection, sample sizes, persons responsible for collecting data, report frequency, and to whom the information is reported. The plan also should present detailed procedures for data analysis.
The palliative care team should regularly review the data analyses to identify and resolve problems and to determine whether a more intensive analysis is required. Intensive analyses could be in response to "important single events; levels of performance or trends that vary significantly and undesirably from those expected; performance that varies significantly and undesirably from that of other organizations or recognized standards; and when a significant or sentinel event occurs (Kaiser Permanente, 2002)." For example, intensive analyses may be conducted on all confirmed transfusion reactions, significant adverse drug reactions, and significant medication errors.
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For more information about the TriCentral Palliative Care Toolkit visit www.growthhouse.org/palliative/. All content is Copyright © 2002, 2003 by Richard D. Brumley, M.D. All rights reserved. No part of this toolkit may be reproduced, stored in a retrieval system, or transmitted in any form or by any means, electronic, mechanical, photocopying, recording or otherwise, without written permission from the publishers. This guide to developing home-based outpatient palliative care services was developed through a grant to the Kaiser Permanente TriCentral Service Area from The Project on Death In America. The Kaiser Permanente TriCentral Palliative Care Program is a Sustaining Member of the Inter-Institutional Collaborating Network On End-of-life Care (IICN) which links major organizations internationally.
