Practice English Speaking&Listening with: Understanding PBQI

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One benefit of the new OASIS-C data items is the ability to generate a new

quality report for home health agencies to supplement the currently-available

OBQI and OBQM reports. As you know, OASIS-C includes data items to collect

information on an agency' s use of specific best practices. New process data

items allow measurement of care processes that are particularly relevant for

home health care and under agency control. OASIS-C process measures focus on

high-risk, high-volume, problem-prone areas for home health care.

Process data items will be used to generate a Process Quality Measure Report,

which will contain information on multiple process quality measures, measuring

specific best practices for clinical activities including assessment, care

planning, care coordination, clinical interventions, education and prevention.

Some of these measures will pertain only to patients with certain conditions,

for example, diabetes and heart failure. Others will apply to all patients.

Beginning in late 2010, Process Quality Measure report will be available on

CASPER. A smaller set of measures has been endorsed by the National Quality

Forum, and beginning in late 2010 will be reported on Home Health Compare.

The measures on the Process Quality Measure Report can be used in HHA

performance/quality improvement programs for assessing clinician adherence to

evidence-based practices and providing guidance to agencies on how to improve

quality of care and reduce acute care hospitalizations.

This presentation provides an overview of how HHAs can use the new process

quality measures in a quality or performance improvement system. The process

that will be discussed today is Process Based Quality Improvement, or PBQI. We

will provide a big picture overview of PBQI, spend some time discussing how to

read the Process Quality Reports, and then show a simulation of a Quality or

Performance Improvement Coordinator using the report to initiate a PBQI activity

in her agency.

To get started, let's briefly review why it is important to measure care

processes. There are several important reasons, including:

Evaluate elements of care under an HHA' s control,

Promote the use of specific evidence-based care practices,

Evaluate the impact of use of best care practices on patient outcomes,

For use in agency-level performance improvement activities,

For public reporting to assist consumers in cross-agency comparisons,

For potential use in future quality-based purchasing systems, and

Promote improvements in patient care across settings

Home Health Conditions of Participation do not require that HHAs adopt the

processes included in the OASIS-C data items; however, agencies are encouraged

to implement evidence-based care practices to promote optimal patient care and

increase the likelihood of positive outcomes.

Process-Based Quality Improvement is a systematic process for using process

quality measures in quality/performance systems. While many similarities between

PBQI and Outcome-based Quality Improvement (OBQI) processes exist, the primary

difference is the starting point. OBQI starts with outcome measures and attempts

to identify processes of care leading to outcomes. In contrast, PBQI starts with

specifically identified processes, and the investigation is focused on the

extent to which the best practices are being implemented during patient care.

PBQI consists of four phases

Selecting Process Quality Measures for Investigation

Investigating the Process Quality Measures

Developing a Plan of Action to improve rates of use of best practices

Implementing and evaluating the Plan of Action

Selection of Process Quality measures includes interpretation of the Process

Quality Measure Report, and identification of a small number of process measures

to focus on. The Investigation phase uses performance/quality improvement

approaches to identify the extent to which the specific best practices are being

routinely implemented as part of patient care activities. As with OBQI, a plan

of action to improve care by increasing use of best practices is developed,

implemented, and evaluated.

This is only a brief overview of PBQI. Detailed information can be found in the

PBQI manual, available on the CMS web site, along with the OASIS-C, OBQI, and

OBQM manuals. The PBQI manual provides step-by-step instructions on interpreting

the Process Quality Measure Reports, along with guidance on implementing PBQI.

Process Quality Measure Reports can be accessed from the CMS CASPER reporting

system, along with the OBQI and OBQM reports. As with the other types of

reports, agencies will request the report for specified time intervals.

Branch-specific reports also will be made available for those HHAs that have

multiple branches. Detailed instructions for accessing the reports are posted on

the CMS Web site.

Process Quality Measure Reports can be accessed from the CMS CASPER reporting

system, along with the OBQI and OBQM reports. As with the other types of

reports, agencies will request the report for specified time intervals.

Branch-specific reports also will be made available for those HHAs that have

multiple branches. Detailed instructions for accessing the reports are posted on

the CMS Web site.

Process Quality Measure reports will include measures on the rate of adherence

to the evidence-based practices included in OASIS. Some of the measures are

calculated for all patients, while others are specific to groups of patients.

For example, the falls risk measure is only calculated for patients 65 and

older. Care planning, implementation, education, and prevention measures are

calculated for the subset of home health patients for which each measure is

indicated. For example, pressure ulcer prevention applies to patients assessed

to be at elevated risk of developing a pressure ulcer. There may also be

patients who are excluded. For example, calculation of measures for depression

interventions in the plan of care and depression interventions implemented

exclude non-responsive patients.

As with the OBQI and OBQM reports, national comparisons will be provided. Of

course, the first report you receive will not have a prior comparison because

all available data will be considered current data. However, after the first

reporting period, a comparison of the adherence rate to the previous reporting

period will be provided. A list of measures and OASIS items used to calculate

the measures can be found in the PBQI manual. One difference between the Process

Quality Measure report and the OBQI and OBQM reports is that there is no risk

adjustment. If you recall, risk adjustment is a statistical technique that is

used when making comparisons between groups that takes into account baseline

differences between the groups. Risk adjustment is not necessary for process

quality measures because the expectation is that the process should be followed

for every patient for whom it applies.

Let?s review a sample report. The header information is very similar to other

quality reports that CMS provides. Agency information is provided on the left,

and dates covered by the report (requested and actual) are shown on the right.

The number of cases is the number of quality episodes that occurred during the

actual time periods under consideration. Quality episodes start with start or

resumption of care and end with discharge or transfer, so one patient may be

represented by one or more quality episodes. Remember that prior cases will be

zero for your first report, as all available cases will be considered current.

The number of cases in the reference sample reflects all quality episodes

available from Medicare-certified home health agencies nationally.

Process quality measures are listed on the left side of the report. For each

report, the current rate of patients for whom the best practice specified within

the quality measure is represented by the white bar, with the actual rate noted.

The black bar is the rate reported for the national data. The gray bar is the

rate for your previous time point. The number of eligible cases next to each bar

is the number of care episodes for which the process measure applies. For

example, for the measure "Multifactor falls risk assessment conducted for

patients 65 and older," the number of eligible cases for the agency current

period is 418. The number of eligible cases included in the national reference

rate is 2,127,921, and the number of eligible cases for the prior time period is

389. This number is specific for each measure. Some measures are relevant for

all patients, while others are relevant to specific groups of patients. This

measure, for example, is only relevant for patients 65 and older.

As with the OBQI and OBQM reports, statistical significance is also reported.

Statistical significance is important when comparing groups, and indicates the

probability that the difference between groups would have been observed by

chance. When significance values are .10 or less, you can be more confident

about the differences between groups. Plus signs are used to indicate low

statistical significance values between current and prior groups and asterisks

are used to indicate low statistical significance values between current and

reference groups. You may want to focus more on those rates than with

significance values marked by asterisks or plus signs. For more information

about statistical significance, refer to the OBQI manual on the CMS web site.

One more point should be made about the Process Quality Measure Report. Some

measures will be calculated and reported separately for short-term episodes,

defined as home health episodes in which the quality episodes, from the start or

resumption of care to the transfer or discharge, are 60 days or less, and

long-term episodes in which the quality episodes exceed 60 days. This

calculation will be made for measures that identify whether a process was

implemented since the prior OASIS assessment based on data collected at

transfer/discharge. For these measures, only the short-term episodes will be

reported on the Home Health Compare website. You can find more information about

the process quality measure calculations in the Process Quality Measure manual

that we discussed earlier.

Agencies may consider each measure individually (e.g., a potential problem with

clinicians not following agency policy) or consider the measure as it

potentially affects specific related outcomes (e.g., the process quality measure

may shed light on related outcome results). For example, the rate of

multi-factor falls risk assessments may be related to the number of acute care

hospitalizations for falls where more risks assessments completed are associated

with fewer hospitalizations related to falls.

The next part of this presentation will illustrate how an agency might use the

report in their quality or performance improvement programs. Although there is

no CMS requirement for such a staff position, many agencies have chosen to

create a position to oversee quality or performance improvement efforts. The

title for this position varies across agencies. At this agency, the staff member

overseeing performance improvement efforts is the Performance Improvement

Coordinator. She has convened a work group, including the clinical coordinator,

a nurse and a physical therapist, to discuss their Process Based Quality

Improvement efforts.

I want to start this meeting by thanking each of you for being part of our

Process Based Quality Improvement workgroup. We really need your ideas and input

as we begin this performance improvement activity. I?ll just quickly go over

what our purpose and plan is for this workgroup.

As you know, many data items on the OASIS-C forms are quality indicators. These

indicators are provided in data reports so we can benchmark our agency against

the nation, the state, and even our competitors. And most importantly, we can

use these reports to monitor our own progress. In addition, the public can also

see some of our quality indicators on Home Health Compare.

Really? ? You mean that my patients and their families can look up information

concerning our agency?s quality measures on the internet?

Yes they can. On the website the public can see how we rate on

quite a few measures, including several ADLs, medications, acute care

hospitalizations, and some of the new process measures like Fall Prevention.

Many process measures are related to high-risk, high-volume, problem-prone areas

for home health care. Process Based Quality Improvement, or PBQI, starts with

taking a look at the care processes we have identified as being significant for

our agency, and the investigation is focused on whether the best practices are

being implemented during patient care.

So let's get started. There are four phases to Process-Based Quality

Improvement, also called PBQI for short.

Phase 1 is Selecting Process Quality Measures for Investigation. We're going to

think about our agency priorities and look at some data to assist with selecting

a measure to focus on.

Phase 2 is the investigative phase. Digging deep into what's behind the issue.

Phase 3 is Developing a Plan of Action to assist us with improving rates of use

of best practices for our agency, including how we'll address anticipated


The 4th Phase is Implementing and Evaluating the Plan of Action.

The first step of Phase 1 is actually already done, selecting the team. The

team needs to be interdisciplinary and more than just managers or PI team

members. I invited each of you to be part of the team, because we really need

and value your opinions as clinicians. We may need to ask a few more people to

join us as we progress, including a home health aide - they need to be actively

involved with these quality improvement efforts too.

Once the team has been selected, we need to think about agency priorities and

look at data available to us so that we can select a measure or two to focus on.

We?ve been talking about working on fall prevention because we?ve found falls to

be a serious problem in the population that we see. We have a high percentage of

elderly patients.

And we?ve seen how important fall prevention is, not only for reducing harm or

injury, but also to sustain quality of life, and let elders remain in their


But we implemented a fall prevention program last year. Right now we?re doing a

fall screening assessment and the Timed Up and Go. Why should we be focusing on

falls again? Maybe we should do medications or something else?

Well, let's look at the PBQI report. Based on what I?ve seen so far, it looks

like falls prevention is an area we need to look at more closely, but I'd like

the group to take a look at the data and see if you all agree.

I have been reviewing the data reports each month as they are posted and have

noticed trends that indicate we may not be doing as well as we should be, or

could be, with our fall prevention. Let me show you our reports. I've taken some

of the key fall prevention data and put it into a table.

The red and yellow coloring show how well we are doing related to our prior

rates and national references to help identify our areas of need.

We're completing multi-factor fall assessments on about 80% of our Medicare

patients, which doesn't sound that bad, but we need to look at the other data to

see the bigger picture. We're having problems with including fall prevention

steps in our plan of care orders as well as implementing our fall prevention


I agree that we?re doing OK, but we definitely have room to improve. Also, I

know that our agency prides itself with providing excellence in care, and we've

been working on reducing avoidable falls for years. I've provided educational

sessions for all of our clinicians in the last year or so.

I'm glad to help out, but fall prevention is more of a therapy role isn't it?

Actually I think there's an equally important role for nursing because there are

so many reasons for falls beyond weakness, balance issues, and such. Medications

can impact falls greatly.

Actually I think there?s an equally important role for nursing because there are

so many reasons for falls beyond weakness, balance issues, and such. Medications

can impact falls greatly.

Great points. Yes all disciplines can affect fall prevention, and really, many

of our outcomes. So, do we agree that, based upon the data and our agency's

goals, we should create a formal PBQI Plan of Action?

Based on our agency priorities and the PBQI reports, I'm in agreement with

focusing on falls.

I also agree. Now what do we do?

OK - Now that we have identified the Process Quality area to focus on, we can

move to Phase 2, the investigative phase. Let's discuss what problems or issues

we may be having with our established fall prevention program. Just brainstorm

and give me as many reasons as you can think of about why we're having problems.

No idea is stupid. Once we get them all down we can go back and we'll talk

about them.

I'm not sure all the nurses know how to accurately perform the Timed Up and Go.

It isn't very hard to do, but I know some staff that could use a refresher. I?ve

had significant deviations in the Timed Up and Go compared to other clinicians.

We're also growing and have a lot of new staff.

Good points. So you're saying we're unsure of the competency of all of our

staff. How was the staff tested for competency with the roll-out? And do we

include fall assessment competency testing in our orientation?

I demonstrated the Timed Up and Go at staff meetings at all of our offices last

year. One of the Coordinators reviewed the Missouri Alliance for Home Care fall

assessment at the same time.

Did the staff have to demonstrate the Timed Up and Go?

No we weren't tested. We were just given our stopwatches after the education

session. As for orientation, I do go over the fall assessment tests and watch

the new orientee complete 1 or 2 assessments. I?m not sure if everyone does. I

did have trouble finding stop watches for the last few new nurses. They were

back ordered. I wonder if they ever came in?

These comments are exactly what we need. We have to find out if our established

processes or the best practices that we've established are working or not.

So, you both identified that no formal competency was completed initially and no

formal process established with orientation, including obtaining the equipment

necessary to perform testing.

I was only asked to demonstrate the Timed Up and Go. No one ever mentioned

doing competency testing.

Please understand that we are not blaming you. Many times, problems with quality

improvement efforts are related to care processes or best practices being put

into place without having a formal plan of action in place first. As part of

Phase 4, we'll make sure that we can implement, and continually evaluate, the

plan. We'll look for how we can measure improvement, including doing competency

testing and adding to our orientation checklist, etc. Right now we need to just

come up with as many possible problems as we can, and then we'll decide which

problems we'll work on to find solutions.

I'm not sure staff members are consistently providing patients with educational


And we can see that we aren't always including interventions on the plan of care

once we've identified that the patient's at risk, and we're not succeeding in

implementing interventions at the level we desire, either.

Ok, great; we've identified a lot of potential problems with our current fall

prevention best practices. Now we need to prioritize them and discuss which ones

we feel we need to work on first. It's best if we only pick a couple to work on

to begin with and then add more as we progress.

I want each of you to select the top 5 issues that you think we should work on.

Then we'll discuss all of our lists and pick two that we'll start with. Then

we'll actually write problem statements.

Thanks for all your great input! We now have our first 2 problem statements to

work on.

Evidence-based fall risk assessments are not being completed consistently on all

patients without physical or cognitive impairments.

No consistent fall prevention education is being provided to patients.

The next step is to think about key barriers to addressing these problems.

Many of my peers feel that fall prevention is the role of the therapist, not the

nurse. Some therapists don't feel nurses should perform fall assessments because

the patients may be at more risk for falling during these assessments if the

nurses aren't properly trained.

We did provide training during the roll-out on how to perform the test, what

patients not to test due to functional or cognitive factors and how to score

patients. These assessment tests aren't hard to administer.

I agree, but that is a barrier we have to overcome.

Exactly, so what can we do to overcome this misconception?

We need to re-educate staff on our fall assessment process. Could I include

other therapists to help with the training that would work one-on-one with our

nurses to increase their skills and competence? That would allow therapists to

feel more confident.

Great idea! Actually that addresses 2 barriers we have. First, the

misconception about whether the nurses should be performing the TUG test, and

second, assessing competency of all staff. What other barriers do you think we


Now that we know our problems and some of the barriers, what do we do next?

Now we begin to determine which best practices we should implement to help solve

the problem statements and overcome barriers. That sounds a lot easier than it

is. We need to use evidence-based practices, or interventions, tools or

strategies that are recognized as best practices.

Isn't Timed Up and Go an evidence-based tool?

You raise a good point. There is no reason to reinvent the wheel if there is

evidence-based care available. Yes, the Timed Up and Go is a good example of an

evidence-based tool and combined with the Missouri Alliance fall assessment it

does meet OASIS-C criteria for conducting a standardized, validated,

multi-factor assessment. So, if the TUG and Missouri Alliance tool are

completed, we can answer yes to M1910 Fall Risk Assessment. But we've been

seeing a high number of falls where the patients were not identified as at risk

for falls using our current assessments. One thing that we're looking at is

possibly modifying our fall assessment tools. We need to evaluate if we should

change or add additional fall assessment tools.

My understanding is that CMS isn't going to require us to use any specific


Correct. CMS doesn't plan to endorse any specific tool. It's up to each agency

to select a tool that's been validated, which means tested on community

dwelling elders, and it's also standardized, meaning it has a standard rating

scale. It's our responsibility to watch for new assessments and evaluate them to

see if they meet the criteria in Chapter 3 of the OASIS Manual.

Is there one test that can be used alone?

I've used many different fall risk assessments in both hospital and homecare

environments. I can research more on different fall assessments. My clinical

coordinator also told me about the Connecticut Collaborative for Falls

Prevention, or CCFP. I wasn't familiar with it but I did research it the other

day and found that it had been published in numerous peer-reviewed journals, and

the developers have provided documentation saying they believe it does meet the

CMS criteria. There are also many other falls assessments available, but we

would need to look at each assessment against the definition in Chapter 3 of the

OASIS Manual to determine if we could use it as a multi-factor fall assessment.

I'd be happy to do the research, and as a team we could determine if they meet

CMS criteria.

Excellent - thanks. We've been researching this issue and would consider

changing to a different falls risk assessment tool if that is what our work

group decides. We should talk about the benefits and possible barriers of the


assessment tools.

The work group continued to meet and discuss what possible Best Practices would

work best for their agency and their population, as well as meeting CMS

requirements for being standardized and validated. Note that when the OASIS-C

Guidance manual states that a screening or assessment tool must be validated

through scientific testing, this can be interpreted to mean that:

The predictive ability of the tool to identify patients with a need for further

follow-up or intervention for the health problem of concern, for example,


falls, pressure ulcers, and pain, has been the subject of one or more research

studies whose subjects reflect the home health/community-dwelling elder

population; and

The study or studies have been subjected to a peer review process which found

that the study rigor such as design, sampling, sample size, statistics and the

results such as external validity and generalizability were adequate and are

associated with desired outcomes. They then investigated new falls assessment

programs as well as looked at

their current practices related to best practices in the home care industry.

They've decided to begin working on two best practices - "Multi-factorial Fall

Risk Assessment Conducted For Patients 65 and Over" and "Fall Prevention Steps

Implemented for All Episodes of Care" - and will continue to research different

fall assessments tools. They plan to trial any new tool they select with a small

group of champion clinicians to allow for evaluation before they go to full

implementation and modification of their current fall prevention program.

The team next moved into discussing their Action Strategies. The physical

therapist requested an occupational therapist to join the team as they begin to

plan the implementation and evaluation phase. A home health aide was also

invited to join in the brainstorming meetings.

Today the original team is meeting to finalize their action strategies. Let's

listen in?

OK, today let's review our draft Action Strategies from last meeting and finish

our planning.

I really like our Action Plan and I think it will make a difference. Also, I

think it's important that we continue to research and find assessment tools that

work best for our agency's population.

I agree, the process of improving our fall prevention practices is ongoing, just

like all other quality improvement. We have to continue to modify and refine our

plans to strive for better patient outcomes. We must have a way to measure

improvement and that includes monitoring. Monitoring is a crucial step that can

easily be overlooked. How are we going to know it's being done if we don't

measure it?

I totally agree. We also need to make sure new orientees are trained or tested

for fall assessment competency.

Yes. Monitoring also provides us a chance to highlight successes and provide

rewards and reinforcement as needed. We can't just wait until our reports come

out to decide if our best practices are working. We need to watch our data, but

it will take months to begin to see any change and really 6-12 months to see

results. We can't wait that long, so doing chart reviews and looking at our

OASIS-C audits is essential.

So, how can we monitor to see if all patients who aren't functionally or

physically impaired are receiving fall assessments?

Is there a way our computer system can run a report of all patients at Start of

Care and Resumption of Care to see if there is a completed fall assessment?

But how would you tell if the patient has a functional or cognitive impairment

so we can exclude them from the analysis?

Since we're computerized we can work with our vendor to run reports that show

patients that didn't received the fall assessments and we can select specific

OASIS-C item responses that would give us a better picture of functional or

cognitive impairments. This would give us a good start to looking for staff

non-adherence or education needs. We can run reports by individual clinicians

and compare staff within a team or office. This is a good strategy to improve

clinician adherence to best practices - it's called "academic detailing."

Clinicians who are less adherent to recommended practices generally improve when

they have the opportunity to compare their performance to other clinicians who

are more adherent.

What about monitoring ideas for successful competency with fall assessments?

When we do the agency wide competency testing, would that not be enough to


What about new orientees?

Yes, we can track everyone who has completed competency testing within a

spreadsheet or on their annual skills checklist. The annual skills checklist

option is a great way to also make sure orientees are tested by their preceptors

or coordinators. We can have clinical coordinators monitor their teams to ensure

all staff are tested competent or are provided remedial education and additional

face-to-face testing.

The team concluded their meeting by agreeing that a realistic goal would be to

increase the percent of patients that receive falls assessments by 5% each

quarter until reaching 100% of patients without functional or cognitive

impairments. They also determined their Evaluation Process, when they would

review and revise their Plan of Action and when they would review the next

Process Quality measures. The team will continue to monitor and document their

findings on the Plan of Action and modify and refine the plan as needed.

For continuous process improvement, HHAs should identify performance problems,

develops a remediation plan to improve performance, and monitor the results of

the plan and modifies the plan as needed.

The Description of Understanding PBQI