Oh yes you can go there - in fact, you must!

Imagine a quality improvement meeting at General Motors and the participants never even mention the cars? How about a Chef and her Sous Chef trying to improve the quality of the restaurant’s food, but they never talk about what the cooks are making? Absurd, right? Yet way too often, when we talk about improving quality and outcomes in Home Health, we avoid talking about the most important factor – the specific methods and care the clinicians actually provide in the visits.

Home Health leaders and Quality Assurance groups usually rely on a standardized set of steps - data is analyzed, charts are reviewed and assignments are handed out. Every organization has its own take on the process, but most of the steps are similar. Improvement plans – usually highly focused on documentation improvements and reports - are developed, training is conducted and we agree to check in at a later date. The closest we get to practice is usually shadow visits, but they usually focus on generalized principles (clean bag techniques, customer service, and maybe wound care). Don’t get me wrong, these tried and true steps are the distilled wisdom of years of practice and work. They work. Recent research has validated the importance structured and standardized care (for example, Atul Gawande’s Checklist Manifesto is a great read on this topic). But in home health quality assurance, they are rarely transformative, rarely challenge our practices and often allow us to avoid the elephant in the room.

Case conference is the closest most of us get to actually critically examining the actual care provided to the client. But time restraints, professional courtesy and event focused discussions (e.g. discharge planning, recert decisions, etc.) keep us from doing a deep dive into the place where the rubber really meets the road: the specific treatments, approaches, techniques and interactions between our clinicians and our clients.

Good documentation is absolutely critical. Process measures actually do measure things that make a difference to our clients’ recovery. But how our clinicians spend those precious few minutes we’re given in each visit has to be inspired, thoughtful, based on best practice and critically analyzed if we’re truly going achieve transformative care. And even the most skilled documenter can’t hide pedestrian or ineffective sessions.

So why are we so hesitant to jump right in the area we instinctively know is the most critical factor? A deeper study of current research and some focused questions for study are needed. But I’d like to share a few observations and theories:

·       “Our clinicians are the best and they know what they’re doing.” Maybe they are the best, and I hope your hiring and mentoring programs weed out at least the sub-standard. But the best of the best in any field not only constantly evaluate their own performance down to the micro level, but they also have coaches and mentors helping them break down their work, consider alternatives, critically think and suggest new ideas and approaches. It’s not only Pollyannaish to expect our clinicians to do this completely on their own, but it’s a huge burden to place on their already over-worked shoulders. They need us for more than documentation training. And ultimately, and unfortunately, you might have to make changes. There’s simply no room in home health anymore for the thin-skinned or the complacent. You might have some people on your team that just aren’t up to the challenges of the current environment.

·      " Medicare (or insert another all-powerful entity like “corporate” or “insurance”) makes us do so much we don’t have time for quality.” There’s no doubt that the requirements continue to increase, and the time allotted stays the same or decreases. These are truths, but they’re not insurmountable. These are the conditions of the playing field for all, not excuses for mediocrity. The best of the best overcome these obstacles. We need to help our clinicians figure this out. They need specific, practical training on the skills needed in his environment: point of service documentation, assessment tools, time management, inter-personal skills, etc.). They need to be skilled in these “soft skills” to free them to treat effectively. It’s also important to remind them that these required measures often are effective in guiding care, not just administrative irritants. For example, full vital sign checks help ensure we don’t miss subtle changes in condition, and unusual findings should focus our approach – potentially saving time. Mandatory triggers to notify a physician or collaborate with others on the team certainly require extra time. But they also serve as a critical time out to reassess at a potentially critical time in the clients’ recovery – or lack thereof. It costs time today, but makes the rest of the episode run more efficiently.

·       Clinicians as journalists. Nothing frustrates me more than an assessment that is actually just a summary of what the client or caregivers told us. Like a news report. Heck, if that’s all we had to do, we could have an administrative assistant call the client or send them a questionnaire. We are billing our payors for actual skilled, expert observations and assessments of ADL performance and medical condition observation and analysis. You didn’t do a head to toe assessment if you can’t tell me the color of your client’s underwear. You have no business turning in an assessment of toileting and bathing if you didn’t go in the bathroom. Unfortunately, and unbelievably, these practices are all too common. If you’re in a leadership position, you have to know these short-cuts are common in the field and you’d better be darned sure it’s not happening under your watch. I don’t care how many stars your agency has, if this happens in your agency your clients and payor sources are getting ripped off.

·       “I’m a nurse (or OT, or non-clinical, or whatever). I can’t question the skills of an OT (or PT, or nurse or whatever).” This common attitude requires a delicate response. How’s this: Male bovine feces! If you’re in a leadership position, you are expected to study up on best practices of all the elements of the services you provide in any industry. Health care is no different. Luckily there is a plethora of resources for you. The ANA, AOTA, APTA and ASHA are the best places to start. They all have websites that are treasure troves, but you can also pick up the phone and call them. You should have a posse of expert collaborators from all the disciplines you can turn to for advice. We have to read the professional journals. Call a professor at your local University that credentials the disciplines you oversee. Now when it comes time for counseling and coaching the clinicians to improve what they are doing in the visits you must use tact, excellent coaching skills and respect. Sometimes it helps to deliver the message with someone from the same discipline, but you must feel comfortable having these conversations solo as well. Make sure you’re role modeling best practice in leadership, strategic planning, agency improvement and other areas where your job requires you to be an expert.

·        Can’t see the trees though the forest. Often while we’re following our tried and true processes, and making sure we do all the things we’re supposed to do we become overly focused on our known and presumed solutions and we kill creativity and innovation. As healthcare quality and innovation expert Roy Rosin reminds us, “Fall in love with the problem, not the solution.” Don’t skip the tried and true, but don’t rely on it exclusively either. Meditate on the problem – break it down, look at it from different angles and brainstorm it before you pull out your checklists.
What have you seen? Please contact me or leave a comment about your thoughts and obeservations.

I’m lucky enough – and old enough - to have worked in leadership positions in many organizations from coast to coast. Here’s an almost universal truth I’ve discovered. You can’t truly improve quality unless you look at your episodes that demonstrate outcomes improvement, stabilization and decline, then drill down to the actual care provided. The majority of the time – not always, but usually – we record a stabilization or a decline, the area was either not fully assessed, not treated, treated through simulations or handouts, treated obliquely or haphazardly or the approach was never changed during the episode despite lack of progress. The physician is rarely brought in to discuss lack of progress in these poor outcome cases. I realize this is heresy in some circles – but I think this accounts for more poor outcomes than misunderstanding of OASIS scoring and intent or documentation.

Therapeutic exercises are valuable support to recovery, but to improve bed transferring, the clinicians have to spend a lot of time working with the clients on bed transferring – in bed! Skilled wound care is an art and a science – but what happens beyond the dressing is just as important. Therapy-only cases need just as much focus on the medical, medication and overall health issues as the most medically unstable episodes heavy on nursing visits. I promise you – look at what the clinicians are doing with their clients and the answers will unfold like a revelation.

Nothing in Home Health is more important than what happens in the home. We must look there for the answers. 

Leadership requires courage. We must rise to this challenge.

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