Sample Plan of Action for Continuous Quality Improvement

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					                 Sample Plan of Action for Continuous Quality Improvement
                              BEST QUALITY HOME HEALTH

                           QUALITY IMPROVEMENT TEAM MEMBERS

1. Sally Smith, Director               4. Mary Miller, RN                  7. Fancy Flowers, LPN
2. Bobby Brown, LPN                    5. Jackie Jackson, RPT              8.
3. Randi Rowland, RN                   6. Johnnie Johnson, RN              9.

Outcome Report time frame 03/02-02/03                  Plan of Action Date 05/15/03

 1. Target Outcome Addressed by Plan of Action: Improvement in Dyspnea

 2. Action Plan for (circle one): a. Remediation          b. Reinforcement
 3. Identified Problem or Strength: The nurses are not performing in-depth respiratory assessments
     or providing instruction to decrease dyspnea on patients scoring a 2 or above on MO490 at the start
     of care.
 4. Care Behaviors or Processes Selected as Best Practices (Prioritized):
         a. On all patients scoring a 2 or higher on MO490 at the start of care, the nurses will perform
              an in-depth respiratory assessment utilizing the Respiratory Assessment Tool.
         b. On all patients scoring a 2 or higher on MO 490 at the start of care, the skilled nurse will use
            the assessment information to determine need for a Respiratory Therapy referral as per the
            protocol set forth on the Respiratory Assessment Tool.
         c.   On all patients scoring a 2 or higher on MO490 at the start of care, the nurses will provide
              teaching on ways to decrease dyspnea utilizing the Improving Dyspnea Teaching Tool at the
              start of care visit
         d. On all patients scoring a 2 or higher on MO490 at the start of care, the nurses will provide
            teaching on ways to decrease dyspnea utilizing the Improving Dyspnea Teaching Tool at
            each subsequent skilled nursing visit until the patient verbalizes complete understanding.
            (Revised 12/4/03)
         e. On all patients scoring a 2 or higher on MO490 at the start of care, the nurses will provide
            teaching on ways to decrease dyspnea utilizing the Improving Dyspnea Teaching Tool once
            per week throughout the care episode until the patient verbalizes complete understanding.
            (To begin December 7, 2003.)


 5. Agency Intervention Actions (Prioritized):
                                            Time Frame     Responsible    Monitoring Approaches
                  Action                   Start   Finish   Person(s)         (and Frequency)
 a. In-service clinical staff to educate 04/25/03 04/25/03 Sally Smith Education of all clinical staff
    on OBQI process and POA.                                           completed as evidenced by
                                                                       signatures of all staff on in-
                                                                       service sign-in sheet.
 b. Develop Respiratory Assessment 04/21/03 05/09/03        Jackie         Respiratory Assessment Tool is
    Tool with which the nurses can                          Jackson,       developed and approved for
    carry out in-depth respiratory                          Randi          use by the agency director.
    assessment and make decisions as                        Rowland,
    to the need for respiratory therapy                     Mary Miller
    referral.
 c. Develop a teaching tool that the      04/21/03 05/09/03 Jackie         Teaching tool for ways to
    nurses can use to carry out                             Jackson,       improve dyspnea is developed
    teaching on ways to improve                             Johnnie        and approved for use by the
                                                                                                   1/8/2007
   dyspnea.                                                Johnson,    agency director.
                                                           Bobby Brown
d. In-service clinical staff on use of 05/12/03 05/12/03 Sally Smith,     Education of all clinical staff
   new Respiratory Assessment Tool,                      Jackie           completed as evidenced by
   new Improving Dyspnea Teaching                        Jackson          signatures of all staff on in-
   Tool, and Best Practices to be                                         service sign-in sheet.
   carried out.

e. Include education on assessment 5/12/03 5/30/03 Jackie                 Tool teaching included in
    tool and teaching tool in orientation                   Jackson       orientation program.
    program
f. Repeat inservice and include           03/05/04 03/05/04 Sally Smith   Education of all clinical staff
    information in new employee                                           completed as evidenced by
    orientation packet to educate new                                     signatures of all staff on in-
    nursing staff on OBQI process and                                     service sign-in sheet.
    POA, Best Practices to be carried
    out, and correct usage of
    Respiratory Assessment Tool and
    Improving Dyspnea Teaching Tool.
 6. Evaluation:

Review of Plan:                                   b. Next Outcome Report: May 2004
                                                     Date:
       Date: September 1, 2003                       Result:
       Responsible Person(s): Sally Smith, Jackie    Next Step(s):
       Jackson, Randi Rowland
       Results: The plan as a whole was reviewed
       by the OBQI committee.        The group
       consensus was that the plan needs no
       revisions at this time.

       Date: December 4, 2003
       Responsible Person(s): Sally Smith, Jackie
       Jackson, Randi Rowland
       Results: The plan as a whole was reviewed
       by the OBQI committee. It was decided that
       Best Practice “d” was too cumbersome due
       to the high frequency of the action; therefore,
       it was replaced with Best Practice “e” to
       reduce the frequency, scheduled to start
       December 7, 2003. A memo was sent to the
       nurses advising of the frequency change.

       Date: March 2, 2004
       Responsible Person(s) Sally Smith, Jackie
       Jackson, Randi Rowland
       Results: The plan as a whole was reviewed
       by the OBQI committee. It was decided that
       because of high nurse turnover, a repeat
       inservice on OBQI, the POA, the best
       practices and usage of the assessment and
       teaching tools was needed; therefore,
       intervention action “f” was added. The
       information was added in written form to the
       new employee orientation packet.

 Monitoring Activities: Chart review
                                                                                                    1/8/2007
(1)   Activity: On all patients scoring a 2 or higher on MO490 at the start of care, did the
      nurses perform an in-depth respiratory assessment by utilizing the Respiratory
      Assessment Tool (RAT)?

      Date Completed: June 15, 2003
      Finding: In 10 of 12 (83%) charts audited, the nurses performed the activity as specified
      in the POA. It was noted that on the two charts that should have had assessments, but did
      not, the same nurse that had seen both patients had not attended the in-services and had
      not performed an assessment on either patient.
      Response: The nurse who failed to perform the assessments as specified was in-
      serviced. A double check of the attendance sheet was performed and three staff members
      had not been educated. In-service completed with all staff. Will re-audit in approximately
      two weeks.
                                               **********
      Date completed: July 1, 2003
      Finding: In 12 of 12 (100%) charts audited, the nurses performed the activity as specified
      in the POA.
      Response: Posted results. Will re-audit in one month.

                                               **********
      Date completed: August 1, 2003
      Finding: In 12 of 12 (100%) charts audited, the nurses performed the activity as specified
      in the POA.
      Response: Posted results. Will re-audit in three months.

                                                 **********
      Date completed: November 1, 2003
      Finding: In 7 of 12 (58%) charts audited, the nurses performed the activity as specified in
      the POA.
      Response: Posted results. Will increase frequency of chart audits and re-audit in two
      weeks.
                                                 **********
      Date completed: November 15, 2003
      Finding: In 6 of 12 (50%) charts audited, the nurses performed the activity as specified in
      the POA.
      Response: Posted results. Upon polling the nurses, discovered that with staff turnover,
      the new nurses did not know where the RAT assessment tool is stored. Memo sent to all
      staff. Will re-audit in approximately two weeks.

                                              **********
      Date completed: November 30, 2003
      Finding: In 9 of 12 (75%) charts audited, the nurses performed the activity as specified in
      the POA.
      Response: Posted results. Will keep frequency of chart audits high until stabilized; if
      improvement doesn’t occur, will address possible causes/solutions at the upcoming
      quarterly review of the POA.
                                              **********

      Date completed: December 15, 2003
      Finding: In 10 of 12 (83%) charts audited, the nurses performed the activity as specified
      in the POA.
      Response: Posted results. Will re-audit in two weeks.

                                                **********


      Date completed: December 30, 2003
                                                                                           1/8/2007
      Finding: In 14 of 14 (100%) of charts audited, the nurses performed the activity as
      specified in the POA.
      Response: Posted results. Will re-audit in two weeks.

                                              **********
      Date completed: January 15, 2004
      Finding: In 7 of 10 (70%) charts audited, the nurses performed the activity as specified in
      the POA.
      Response: Posted results. Will re-audit in two weeks.

                                              **********
      Date completed: January 30, 2004
      Finding: In 6 of 10 (60%) charts audited, the nurses performed the activity as specified in
      the POA.
      Response: Will re-audit in two weeks.

                                                **********
      Date completed: February 15, 2004
      Finding: In 10 of 16 (62%) charts audited, the nurses performed the activity as specified
      in the POA.
      Response: Posted results. Will re-audit in two weeks. If problem persists, will address in
      quarterly review that will occur next month.

                                              **********
      Date completed: February 28, 2004
      Finding: In 8 of 15 (53%) charts audited, the nurses performed the activity as specified in
      the POA.
      Response: Will address causes/solutions in quarterly review of plan scheduled for March
      2, 2004.
                                              **********

(2)   Activity: On all patients scoring a 2 or higher on MO490 at the start of care, did the
      nurses make respiratory therapy referrals per the protocol set out in the Respiratory
      Assessment Tool?

      Date Completed: June 15, 2003
      Finding: In 6 of 12 (50%) charts audited, the nurses performed the activity as specified in
      the POA.
      Response: Discussed the issue with the staff and discovered that many staff did not
      know how to make an RT referral. Flow chart developed and given to all staff. Will re-
      audit in approximately two weeks.

                                               **********
      Date completed: July 1, 2003
      Finding: In 7 of 12 (58%) charts audited, the nurses performed the activity as specified in
      the POA.
      Response: Discussed the issue with the staff and discovered that the RT had recently
      had a baby and would not return for four weeks. Contract established with alternate RT.
      Will re-audit in two weeks.
                                               **********
      Date completed: July 15, 2003
      Finding: In 12 of 12 (100%) charts audited, the nurses performed the activity as specified.
      Response: Posted results. Will re-audit in one month.

                                                **********

      Date completed: August 15, 2003

                                                                                            1/8/2007
      Finding: In 12 of 12 (100%) charts audited, the nurses performed the activity as specified.
      Response: Posted results. Will re-audit in three months.

                                              **********
      Date completed: November 15, 2003
      Finding: In 14 of 15 (93%) charts audited, the nurses performed the activity as specified.
      Response: Posted results. Will re-audit in three months.

                                              **********
      Date completed: February 15, 2004
      Finding: In 10 of 16 (62%) charts audited, the nurses performed the activity as specified.
      Response: Posted results. Will increase the frequency of the chart audits and re-audit in
      two weeks.
                                               **********
      Date completed: February 28, 2004
      Finding: In 16 of 17 (94%) charts audited, the nurses performed the activity as specified.
      Response: Posted results. Will address causes/solutions in quarterly evaluation
      scheduled for March 2, 2004.
                                               **********

(3)   Activity: On all patients scoring a 2 or higher on MO490 at the start of care, did the
      nurses provide teaching on ways to decrease dyspnea at the start of care visit by utilizing
      the Improving Dyspnea Teaching Tool?

      Date Completed: June 15, 2003
      Finding: In 10 of 10 (100%) charts audited, the nurses performed the activity as specified
      in the POA.
      Response: Posted results. Will re-audit in two weeks.

                                              **********
      Date completed: July 1, 2003
      Finding: In 10 of 10 (100%) charts audited, the nurses carried out the activity as specified
      in the POA.
      Response: Posted results. Will re-audit in one month.
      .
                                               **********
      Date completed: August 1, 2003
      Finding: In 10 of 10 (100%) charts audited, the nurses performed the activity as specified
      in the POA.
      Response: Posted results. Will re-audit in one month.

                                              **********
      Date completed: September 1, 2003
      Finding: In 16 of 16 (100%) charts audited, the nurses performed the activity as specified
      in the POA.
      Response: Posted results. Will re-audit in three months.

                                              **********
      Date completed: December 1, 2003
      Finding: In 6 of 14 (42%) charts audited, the nurses performed the activity as specified in
      the POA.
      Response: Posted results. Upon posting results, several nurses verbalized that they
      were not aware of the teaching tool. The nurses who stated this were all new, so it was
      surmised that the problem was due to staff turnover. A memo was sent to all staff. Will re-
      audit in two weeks.


      Date completed: December 15, 2003
                                                                                           1/8/2007
      Finding: In 16 of 16 (100%) charts audited, the best practice was carried out as specified.
      Response: Will re-audit in two weeks.

                                              **********
      Date completed: December 30, 2003
      Finding: In 16 of 16 (100%) charts audited, the best practice was carried out as specified
      in the POA.
      Response: Will re-audit in one month.

                                              **********
      Date completed: January 30, 2004
      Finding: In 10 of 14 (71%) charts audited, the best practice was carried out as specified in
      the POA.
      Response: Will re-audit in two weeks.

                                              **********
      Date completed: February 15, 2004
      Finding: In 9 of 15 (60%) charts audited, the best practice was carried out as specified in
      the POA.
      Response: Will re-audit in two weeks.

                                              **********
      Date completed: February 28, 2004
      Finding: In 10 of 15 (66%) charts audited, the best practice was carried out as specified in
      the POA.
      Response: Will address causes/solutions in upcoming quarterly review of the plan
      scheduled for March 2, 2004.

                                                **********
(4)   Activity: On all patients scoring a 2 or higher on MO490 at the start of care, did the
      nurses provide teaching on ways to decrease dyspnea at each visit after the start of care
      by utilizing the Improving Dyspnea Teaching Tool?


      Date Completed: June 15, 2003
      Finding: In 5 of 10 (50%) charts audited, the nurses performed the activity as specified in
      the POA.
      Response: Will discuss the need for ongoing education at next staff meeting. Also will
      post in restrooms and in nursing newsletter. Will re-audit in two weeks.

                                              **********
      Date Completed: July 1, 2003
      Finding: In 9 of 10 (90%) charts audited, the nurses performed the activity as specified in
      the POA.
      Response: Posted results. Will re-audit in one month.

                                              **********
      Date Completed: August 1, 2003
      Finding: In 10 of 10 (100%) charts audited, the nurses performed the activity as specified.
      Response: Posted results. Will re-audit in three months.

                                                **********
      Date Completed: November 1, 2003
      Finding: In 4 of 10 (40%) of charts audited, the nurses performed the activity as specified.
      Response: Questioned some of the nurses, who said it is too time consuming to do this
      activity at each visit. Reminded nurses of importance of doing activity at each visit. Posted
      results and reminders. Will re-audit in one month.

                                                                                           1/8/2007
      Date completed: December 1, 2003
      Finding: In 3 out of 11 (27%) of charts audited, the nurses performed the activity as
      specified.
      Response: Re-questioned the nurses, who said that the patients are refusing to accept
      the teaching on every visit, citing that it is too time-consuming and too overwhelming to do
      on every visit. Will explore causes and solutions at quarterly review of plan later this week.

                                                **********

(5)   On all patients scoring a 2 or higher on MO490 at the start of care, did the nurses provide
      teaching on ways to decrease dyspnea utilizing the Improving Dyspnea Teaching Tool
      once per week throughout the care episode until the patient verbalized complete
      understanding? (Begun December 7, 2003)

      Date Completed: December 30, 2003
      Finding: In 8 of 10 (80%) of charts audited, the nurses performed the activity as specified.
      Response: Will keep frequency of monitoring high and re-audit in two weeks.

                                              **********
      Date Completed: January 15, 2004
      Finding: In 12 of 12 (100%) of charts audited, the nurses performed the activity as
      specified.
      Response: Posted results. Will re-audit in two weeks.

                                               **********
      Date Completed: January 30, 2004
      Finding: In 15 of 15 charts audited, the nurses performed the activity as specified.
      Response: Posted results. Will re-audit in one month.

                                              **********
      Date Completed: February 28, 2004
      Finding: In 14 of 14 (100%) charts audited, the nurses performed the activity as specified.
      Response: Posted results. Will re-audit in three months.




                                                         Provided by the Oklahoma Foundation for Medical Quality, the
                                                         Medicare Quality Improvement Organization for Oklahoma, under
                                                         contract with the Centers for Medicare & Medicaid Services, US
                                                         Dept of Health & Human Services. The contents do necessarily
                                                                                                   1/8/2007
                                                         reflect CMS policy. 1B-095-SPOA-OK-010807