NSG/577 Week 1: Quality Frameworks and Quality Markers, sample paper

What Good Care Looks Like When the Nurse Leaves After an Hour: Quality Frameworks and Markers for a Four-County Home Health Agency

[Student Name]

University of Phoenix

NSG/577: Continuous Quality Monitoring and Outcomes Improvement

Week 1 Assignment

[Instructor Name]

[Date]

The agency, its service area and all figures are a composite written for a model paper.

Our nonprofit home health agency serves four counties, admits about 1,450 patients a year and employs 38 registered nurses, 14 therapists, 11 home health aides and 3 social workers. A nurse spends perhaps an hour in a patient's home and then leaves. Between visits, patients take their own medications, manage their own wounds and decide whether to call the agency or 911. As the agency's new director of quality, my first task is to decide what good care means here and which signs of it to measure.

Two Frameworks

Donabedian (1988) offered three lenses for judging care. Structure covers the settings in which care takes place: staff, equipment, money and the way an organization is arranged. Process covers the work itself, the things clinicians and patients do together. Outcome covers what happens to the patient's health as a result. In his account the three form a chain, since sound resources make sound practice more probable and sound practice makes better results more probable. For an agency that has tended to report only its outcomes, the model is a reminder that a result is always produced by something upstream, and that the upstream conditions are where a manager can act.

The Institute of Medicine (2001) defined six aims for health care: care that is safe and effective, centered on the patient, timely, efficient and equitable. The aims describe what quality should achieve and are a useful check on whether a set of markers is balanced.

What Each Framework Adds

The two frameworks answer different questions. Donabedian's model tells the agency where to look, at resources, at actions and at results, and suggests how they connect. The six aims tell the agency what to look for, reminding it that a measure set concentrated on safety alone would miss timeliness or equity. Used together, they work like the two axes of a grid: every proposed marker should sit in one of the three Donabedian columns and serve at least one of the six aims. A marker that fits nowhere on the grid is probably measuring something convenient rather than something important.

Why Home Care Challenges the Frameworks

Home care differs from hospital care in ways that shape quality. In a hospital, quality is largely what staff do; in home care, quality is largely what patients and families are able to do after staff leave. The environment is not controlled; the agency cannot fix a steep staircase or an empty refrigerator by itself. Coordination with physicians, pharmacies and hospitals happens across organizations. And outcomes depend strongly on patients' social resources, such as a caregiver at home or money for medications, which raises questions of fairness when outcomes are compared.

Structure Markers

Structure markers describe the agency's capacity to provide good care. Four are proposed: registered nurse caseload per nurse, since high caseloads shorten visits; the proportion of nurses with home health certification or specialized wound or cardiac training; after-hours telephone access with a nurse answering within 15 minutes; and the proportion of patients whose records are shared electronically with their primary care provider.

Process Markers

Process markers describe what the agency does. Five are proposed: timely initiation of care, the percentage of patients seen within two days of referral or of leaving the hospital; medication reconciliation completed at the start of care; teaching for high-risk conditions, such as heart failure or diabetes, documented with teach-back; fall risk assessment and home safety intervention; and communication with the physician when a patient's condition changes, documented within 24 hours.

Outcome Markers

Outcome markers describe results for patients. Five are proposed: acute care hospitalization during the home health episode; emergency department use without hospitalization; improvement in mobility and activities of daily living; improvement in management of oral medications; and patient experience, from the home health patient experience survey.

Checking Against the Six Aims

The markers cover the six aims: safety through falls and medication measures, effectiveness through functional improvement and hospitalization, patient-centeredness through experience and teach-back, timeliness through initiation of care and after-hours response, efficiency through avoided hospital use and equity through a plan, discussed in Week 5, to compare results across patient groups (Institute of Medicine, 2001).

Markers the Agency Considered and Set Aside

Several candidate markers were discussed and not adopted. The number of visits per patient was rejected because more visits are not better in themselves and the count rewards volume. Documentation completion within 24 hours was set aside as a structure-like compliance marker that says little about the patient. Wound healing rates were deferred because only about one patient in six has a wound and the numbers each quarter would be too small to read. Recording why these were set aside matters, because staff will ask, and because the reasons show that markers were chosen for what they reveal about care rather than for how easy they are to count.

What Staff Said

Before finalizing the list, I met with nurses and aides from each team. Their comments changed two markers. Aides pointed out that falls often happen on the first night home, before the first visit, which strengthened the case for measuring how quickly care begins. Nurses said that teaching is often documented as done when the patient was too tired to absorb it, which is why the teaching marker requires teach-back rather than a checkbox. Staff who give the care usually know where the gaps are before any data show them.

Sources of Data

Many of the markers can be built from the standardized assessment that Medicare-certified agencies complete at the start of care, at transfers and at discharge, supplemented by visit records, telephone logs and survey results. The standardized assessment has known limits: a review of studies found its reliability and validity ranged from low to moderate and varied by item (O'Connor & Davitt, 2012). Markers built from it must be interpreted with that in mind.

Choosing a Focus

Measuring everything at once dilutes attention. The agency's board has asked for a focus. Acute care hospitalization will be the lead measure for three reasons. A return to the hospital is hard on patients and expensive for payers. It appears in public reports that referral sources read. And it sits at the end of many processes at once, from the timing of the first visit to the quality of teaching, so a change in it tells the agency something about the whole system. The processes most likely to affect it will be developed alongside.

Conclusion

Quality in home care means what patients and families can do safely after the nurse leaves, as well as what the nurse does in the visit. Donabedian's model and the six aims yield a balanced set of structure, process and outcome markers suited to the agency, with acute care hospitalization chosen as the focus for developing a measure. Week 2 will define that measure precisely.

References

Donabedian, A. (1988). The quality of care: How can it be assessed? JAMA, 260(12), 1743-1748. https://doi.org/10.1001/jama.1988.03410120089033

Institute of Medicine. (2001). Crossing the quality chasm: A new health system for the 21st century. National Academies Press. https://doi.org/10.17226/10027

O'Connor, M., & Davitt, J. K. (2012). The Outcome and Assessment Information Set (OASIS): A review of validity and reliability. Home Health Care Services Quarterly, 31(4), 267-301. https://doi.org/10.1080/01621424.2012.703908