Kaiser Permanente Tri Central Continuing Care

Kaiser Permanente Tri- Central Continuing Care

2002 PERFORMANCE ASSESSMENT AND IMPROVEMENT PLAN (QUALITY IMPROVEMENT PLAN)

TRI-CENTRAL HOME HEALTH & PALLIATIVE CARE

PURPOSE

 To organize and integrate performance assessment and improvement activities through an ongoing program.  To objectively and systematically monitor and evaluate the quality of patient care.  To pursue opportunities to improve patient care, provide continuous quality improvement, and resolve identified problems

OBJECTIVES

 To systematically measure performance; assess performances; improve performance by (1) designing new systems and processes, or (2) improving the functioning of existing systems and processes; and maintain the stability of existing systems and processes that are functioning well.

 To document evidence of a planned, systematic, ongoing Performance Assessment and Improvement Program that includes effective mechanisms for reviewing and evaluating the processes and outcomes of patient care.

 To establish priorities for the improvement or resolution of known or suspected problems that impacts directly or indirectly on important aspects of patient care.

RECOGNIZED STANDARDS/ GUIDELINES

The JCAHO Ten Step Quality Improvement Process, Juran Quality Improvement, Quality Control and Quality Planning process, and PMAI model (appendix A) will serve as guidelines for the QI process.

RESPONSIBILITY

 The Board of Directors, Area Medical Director, Assistant Area Medical Directors, and the Chiefs of Medical Staff Departments are responsible for overseeing the design and ensuring the implementation of the performance assessment and improvement process. (appendix F)

 The Physicians-in-Charge of the Home Care Department, Assistant Medical Center Administrator and SA Administrator of Home Health/Hospice are responsible for the department's overall performance assessment and improvement program, and to assure that it is consistent with the overall Tri- Central Continuing Care quality improvement programs.

 The ADA Home Care-Regulatory Affairs/Compliance is responsible for the ongoing Quality Management monitoring activities.

 Each clinical department or Service Line, as specified in the definition of the scope of services provided in (appendix B) is responsible for the supervision and review of all matters relating to Pg. 2 Kaiser Permanente Tri-Central Continuing Care 2002 Performance Assessment and Improvement Tri-Central HH PC QM Plan that department or service line including planning, designing, measuring, assessing and improving patient care and related services. Department clinical staff will participate in the Pg. 3 Kaiser Permanente Tri-Central Continuing Care 2002 Performance Assessment and Improvement Tri-Central HH PC QM Plan

Development of indicators, mechanisms for triggering evaluation, data collection, review, analysis of care, plans of action, and evaluation.

 In coordination with the Continuing Care Quality Improvement program, this performance assessment and improvement plan takes into account the strategic goals of the Continuing Care service line (appendix C).

SCOPE OF SERVICE

Please see appendix B for a description of and the scope of services for Tri-Central Home Care

KEY FUNCTIONS

The focus of quality improvement is on understanding and improving the processes that compose key functions -- those functions that have the greatest effect on the quality of care the patient ultimately receives. These functions include clinical, support, managerial and governance activities. Key functions for Home Health/Palliative Care/Hospice include:

 Patient Rights and Organizational Ethics  Assessment of Patients  Care of Patients  Invasive Procedures  Medication Use  Nutrition Care  Special Treatment Procedures  Patient and Family Education  Continuum of Care  Leadership/Governance  Management of the Environment of Care  Management of Human Resources  Management of Information  Surveillance, Prevention, and Control of Infection  Improving Organizational Performance

DATA COLLECTION AND ORGANIZATION

Data will be collected and organized for review by the Tri-Central Home Care Continuous Quality Improvement Department and other designated Home Care team members. This will include the data source, frequency of data collection, sample size, person responsible for collecting data, Report frequency and whom the information is reported to. This will be reflected in the Indicator Profile Flow Sheet. All negative variance in auditing will have Interator Reliability performed and signed off by another Quality Management Coordinator.

The frequency of data collection for each indicator used in monitoring is determined by the frequency of the process or outcome monitored, it’s significance, the extent to which performance is meeting objective internal and external expectations, and/or the extent to which performance is stable. This will also be reflected in the Indicator Profile Sheet. This data will be reported to the QI committee, which will meet no less than quarterly or as directed by the committee. Pg. 4 Kaiser Permanente Tri-Central Continuing Care 2002 Performance Assessment and Improvement Tri-Central HH PC QM Plan ANALYSIS OF CARE/ PERFORMANCE ASSESSMENT

The Continuous Quality Improvement Department systematically assesses the collected data and information to determine: (1) the level of performance and stability of existing processes; (2) areas for possible improvement of processes; (3) actions to maintain stability in or improve the performance of processes; and (4) whether changes in the processes resulted in improvement. Quality Improvement tools may be utilized to determine the symptoms and causes of the identified problem/effect.

Data will be displayed in an appropriate format to enhance analysis though the use of graphs and charts as needed. The identification of the root cause(s) is imperative to the selection of the appropriate action plans. The root cause(s) may be determined utilizing a variety of approaches.

PLAN OF ACTION/ PERFORMANCE IMPROVEMENT

When problems are identified through monitoring activities, action plans will be enacted to solve the problems or improve care. The department will systematically improve its performance by (1) designing new processes to support performance improvement objectives; or (2) improving the functioning of existing processes.

Federally mandated data collection process is being required for all certified Home Health Agencies, which has been implemented. Outcome Assessment Information Set (OASIS) is a predetermined set of questions and observations that are required from a clinical provider at certain designated points of time during a patient’s tenure on Home Health. This data set drives the plan of care for the Home Health patient. It is discipline neutral and provides objective outcome data for the Home Health Agency and HCFA. Monthly or more frequently as designated by the Home Health Agency reports are transmitted to a Kaiser Permanente Divisional Contracted Vendor. The encrypted data is analyzed for KP Divisional benchmarking and then submitted to HCFA, by the contracted vendor. Benchmarking of data will be shared through the Regional and Divisional Home Care QI Committee for sharing of best practices. Opportunities for improvement are to be incorporated into the performance improvement process.

ORYX identified indicators have been identified as Kaiser Permanente divisional indicators. The are listed as the following: 1. Improvement in the health status of the cardiac patient 2. Improvement in the overall patient's functional management of dyspnea 3. Improvement in the decline of pain impacting the activity 4. Transfer or return to an inpatient facility within 30 days of discharge 5. Improvement in the patient's ability to transfer 6. Improvement in the management of oral medications

ORYX data is currently collected off of the OASIS data sets and reported Divisional to each agency.

Adverse Event Reporting from OASIS data is printed quarterly from the CMS data web-site and charts are reviewed based upon the assessment of the data. Opportunities for improvement in care delivery are assessed and summarized for education, clinical competency enhancement, documentation education, and service delivery issues. Results will be presented to the Quality and Professional Advisory Committees for recommendations.

ASSESSMENT OF ACTIONS AND DOCUMENTATION OF IMPROVEMENT

The QI committee and the Administrative Team of the Home Care Agency will assess actions for effectiveness. Continued monitoring will take place with adjustments to the action plan if needed Pg. 5 Kaiser Permanente Tri-Central Continuing Care 2002 Performance Assessment and Improvement Tri-Central HH PC QM Plan until the desired outcome is realized. Root cause analysis will be utilized to determine the best course of action. These may include the following:  Change in policy and /or procedure  Education and training programs  Referral to other appropriate departments, committees, council and /or administrative structure  Chartered teams to facilitate problem resolution  Counseling and discipline  Change in work assignments/ privileges  Elimination of duplication  Clarify unclear steps  Eliminate needless steps  Minimize steps with no added value  Improve efficiency in materials, job assignments, or work environment  Best current method  Design an error proof system  Other actions as indicated

EFFECTIVENESS OF ACTION

The Continuous Quality Improvement Department reviews effectiveness of actions taken and documentation of improvements. Additional analysis and actions will be necessary when the desired state of performance is not achieved.

COMMUNICATION OF INFORMATION

The Continuous Quality Improvement Department meets at least quarterly to discuss quality improvement issues, perform peer review, analyze data and discuss conclusions, recommendations and actions to be taken based on that analysis. The Quality Improvement Chairperson will evaluate quality improvement issues that arise between meetings. The Physician in Charge or Quality Improvement Chairperson may convene additional department meetings to respond to specific quality of care issues as necessary.

Summaries of quality improvement activities will be reported to the Home Health/Palliative Care/Hospice QI Committee, the Continuing Care QI Committee, and Kaiser Foundation Hospitals Quality Improvement Committee at the Bellflower Medical Center, or other appropriate medical staff committee as scheduled by that committee, and to the Medical Executive Committee and Board of Directors.

Qualities Improvement issues identified which relate to ambulatory care are communicated to the SCPMG Quality Improvement Structure and Process.

The Continuing Care Leadership Team is ultimately responsible for the Tri Central Home Care Quality Improvement Program. The tentative dates of the 2002 quarterly reporting are:

 February 06, 2002 (fourth quarter 2001)  May 01, 2002,(first quarter 2002, annual review of 2001, QM Plan 2002)  August 14, 2002, (second quarter 2002)  November 13, 2002, (third quarter 2002)

2002 MONITORS/PERFORMANCE IMPROVEMENT INDICATORS Pg. 6 Kaiser Permanente Tri-Central Continuing Care 2002 Performance Assessment and Improvement Tri-Central HH PC QM Plan Listed are the proposed monitors/performance indicators for 2002 based on the 2001QI results or ongoing quality maintenance standards (indicator profiles can be seen in appendix D):

Indicator Reported Ownership

DME Issues Quarterly Agency Specific Member Satisfaction Quarterly Agency Specific Adverse Drug Reactions Quarterly Agency Specific Utilization Review Statistics Quarterly Agency Specific Infection Control Quarterly Agency Specific  CLBSI  Employee Exposure/Infections  Patient infections Unusual Occurrences Quarterly Agency Specific Member Concerns/Complaints Quarterly Division Specific Frequency and Duration Quarterly Division Specific Initial Assessment within 24 hours Quarterly Agency Specific Management of Pain Quarterly Division Specific Additional Services Assessment Quarterly Agency Specific Significant Changes are Reported Random Agency Specific Communication of Multidiscipline Quarterly Division Specific Assessment reflects OASIS Data Quarterly Division Specific Primary Diagnosis for OASIS correct Quarterly Division Specific OASIS AND ICD-9 Accurate Random Agency Specific CHHA Supervision Compliance-14 day Random Agency Specific Wound Care Random Agency Specific

Regional/Divisional Home Care Quality Management Committee

The Regional HCQM Committee was established in 1998. They have established indicators and a reporting format. The following are the divisional indicators:

Indicator Reported Ownership

Member Concerns/Complaints Quarterly Division Specific Frequency and Duration Quarterly Division Specific Management of Pain Quarterly Division Specific Communication of Multidiscipline Quarterly Division Specific Assessment reflects OASIS Data Quarterly Division Specific Primary Diagnosis for OASIS correct Quarterly Division Specific OASIS AND ICD-9 Accurate Quarterly Division Specific

CONFIDENTIALITY

Records, reports, studies and minutes reflecting quality improvement actions and follow-up will be maintained in the Tri-Central Home Care Department /Quality Improvement office and are confidential. Quality reviews are legally protected under the California Health and Safety Code Section 1370 and P.L.1157. This information is to be maintained in a manner that will preserve its character as not discoverable or admissible in a court of law as specified by P.I 1157. Subject to the foregoing, the data shall be available only to those who are responsible for evaluating and participating in the quality improvement program and those organizations responsible for the effectiveness of the program for accreditation and licensing. Pg. 7 Kaiser Permanente Tri-Central Continuing Care 2002 Performance Assessment and Improvement Tri-Central HH PC QM Plan ANNUAL EVALUATION

The Tri-Central Home Care Department Quality Improvement Program will be reviewed redesigned or improved annually, and as necessary. Reassessment includes feedback from staff who perform the activities based upon review of the objectives, scope and organization and effectiveness as evidenced by:

 Comparison of the written plan with the quality improvement activities that were performed.  Determination of whether quality improvement information was communicated to the Home Care Department, Continuing Care Service Line, Quality Improvement Committee, and other appropriate committees/persons.  Determination of whether identified problems were resolved or improved.  Determination if the improvements assisted in achieving the organization's objectives.  Determination of need for retention or revision of indicators for the upcoming year.  Determination of need for educational presentations based on the annual review.

An annual evaluation of the quality Improvement program of 2001 will identify and prioritize areas for improvement for 2002. The calendar of QI Activities (appendix E) will outline these years' activities. The year will be defined as activities performed from January to December. The report is to be filed with the First Quarter reporting data of the next calendar year.

COMMUNICATION OF INFORMATION

The Tri-Central Home Care Department meets not less than quarterly to discuss quality improvement issues, perform peer review, analyze data and discuss conclusions, recommendations and actions to be taken based on that analysis. The Quality Improvement Chairperson will evaluate quality improvement issues that arise between meetings. The Physician in Charge or Quality Improvement Chairperson may convene additional department meetings to respond to specific quality of care issues as necessary.

Summaries of quality improvement activities will be reported to the Home Health QI Committee, Continuing Care QI Committee, and Kaiser Foundation Hospitals Quality Improvement Committee or other appropriate medical staff committee as scheduled by that committee, and to the Medical Executive Committee and Board of Directors.

Records, reports, studies and minutes reflecting quality improvement actions and follow-up will be maintained in the Quality Improvement office and is confidential. This information is to be Maintained in a manner that will preserve its character as not discoverable or admissible in a court of law as specified by Evidence Code 1157. Subject to the foregoing, the data shall be available only to those who are responsible for evaluating and participating in the quality improvement program and those organizations responsible for the effectiveness of the program for accreditation and licensing.

Quality improvement issues identified, which relate to ambulatory care are communicated to the SCMPG Quality Improvement Structure and Process.

SCOPE OF CARE

DESCRIPTION OF HOME CARE SERVICES

Home Health: These services are provided to home bound eligible Medicare and Kaiser Permanente members who require short term intermittent skilled attention to health care needs. These members must require a skilled service to maintain health and wellness Pg. 8 Kaiser Permanente Tri-Central Continuing Care 2002 Performance Assessment and Improvement Tri-Central HH PC QM Plan such as occurs in the exacerbation of chronic illnesses, infectious diseases, instabilities or new or chronic illnesses.

Care is provided in the patient's home. A multidisciplinary approach is utilized in the planning, delivery and oversight of patient care. Team members providing services include Physicians, Nurses, Social Workers, Registered Dietitian, Certified Home Health Aides, Speech, Occupational and Physical Therapists.

The patients serviced are primarily adults. Infants, children and adolescents may be Admitted on a case by case basis in collaboration with their pediatrician.

Ancillary services may be provided by the patients identified Medical Center or Clinic. The patient's referring medical center in concert with the hospice physicians provides pharmaceutical services. The hospice staff performs treatments and procedures previously indicated as provided on a case-by-case basis. These treatments and procedures may be provided when the hospice physician deems it necessary to significantly improve the patient’s quality of life. Pain or symptom control may also be Provided by the special departments at the patient’s designated Medical Center. The exception to this is IV therapy, which is provided by the home care staff.

AVAILABILITY OF SERVICES

Hospice: Nursing triage services and after hour visits are available via telephone twenty-four hours a day, seven days a week. Other discipline specific appointments are made with the patient/family at mutually convenient times. The regular hours of office operation are Monday through Friday, 8:30 a.m. to 5:00 p.m. After hour and emergency calls are handled and triaged, and calls to the doctor as appropriate or as ordered. This after hour staff may direct the “on call nurse” to make home visits as deemed necessary.

Home Health: Tri-Central Home Health department provides Nursing and other extensive multidisciplinary services for all eligible members and their families. A wide range of health care needs are provided on a short term intermittent basis in the patient’s home during the hours of 8:30 a.m. to 5:00 p.m. daily.

III. HOME CARE MODALITIES OF SERVICE

Treatments and services provided on a case-by-case basis:

Catheterization (urinary) Counseling Durable medical equipment Establishment of a bowel regime Nutritional/Counseling (RD) Ostomy care Oxygen therapy via nasal cannula (face mask or trach collars) Skin/decubitus Suctioning Suture removal Medication administration Intravenous Administration Pg. 9 Kaiser Permanente Tri-Central Continuing Care 2002 Performance Assessment and Improvement Tri-Central HH PC QM Plan Music therapy Patient/family instruction Palliative radiation therapy Speech/language therapy (Contracted services) Occupational therapy Physical therapy (identified as core discipline) Referral to physician consultation Chemotherapy, palliative Pacemaker maintenance Diagnostic tests Chaplains services Volunteer services Wound Care Instruction/Management Diabetic Instruction/Management Enteral Nutrition Therapy Home Infusion Therapy Long Term Catheter Insertion (Central Lines and PIC/PICC) Antibiotic Therapy Steroids Diuretics Hydration CADD/PCA Pump Management Chemotherapy (Including Amphotericin and Ganciclovir administration) Total Parental Nutrition Narcotics Anticoagulation Treatment Pain Management Phlebotomy Nursing Care/Case Management Medical Social Worker Home Personal Care (in conjunction with skilled care) Palliative Care (Under the services of Management & Evaluation) Pediatric Neonate Services High Risk Referrals Hyperbilirubin/Phototherapy Perinatal Services Hyperemesis Gravidarum High Risk Antepartum Preterm Birth Prevention At-Risk Postpartum Care Rehab Services-Adults and Pediatrics (OT/PT/ST) Surgical Rehab Stroke Rehab CPM Protocol Heat/Cold Ultrasound Therapy Low Back Pain Program Home Exercise Program Energy Conservation Instruction Activities of Daily Living Safety Instruction Communication Disorders Pg. 10 Kaiser Permanente Tri-Central Continuing Care 2002 Performance Assessment and Improvement Tri-Central HH PC QM Plan

IV. ANCILLARY SERVICES PROVIDED BY OTHER DEPARTMENT OR ORGANIZATIONS

AIDS/HIV/Infectious Disease Case Management Sickle Cell Case Management Wound Care Instruction/Management ESRD Case Management Asthma Case Management Diabetes Case Management CHF Case Management COPD/Respiratory Case Management Palliative Care Research End of Life Care Palliative Care Services Geriatric Depression Research

SIGNIFICANT ACTIVITIES AND PROCESSES PERFORMED

Assessment, Planning, Implementation, and Evaluation Intermittent Skilled Services Patient Education and Training Coordination of Care Counseling and Referral Drug: Preparation and Administration Equipment: Preventative Maintenance, Delivery and Training Supportive Care