Quality Assurance, Quality Assesment/Performance Improvement, Quality Improvement, Whatever You Call It or “A Rose By Any Other Name”

Several recent plans of corrections for CHAP and some recent software demo’s put me in mind to rant a bit about the monster that home health and hospice agencies call QA (or QI or QAPI, etc). These monsters were conceived when the industry started to utilize technology and it is out of hand, folks!

It doesn’t matter if you are in manufacturing, retail, restaurant, dry cleaning, or consulting (like me) every industry utilizes quality assessment functions. In other words, they gather data that indicates the health of their company. Some of this data is financial, some is customer experience data, some is regulatory but any business owner worth his salt understands that they need data to indicate the health of their business.

Let’s compare and contrast a typical home health QA process to a manufacturing QA process:

ping pong ball

Let’s say your company manufactures ping pong balls. Does their QA process require someone to look at EVERY SINGLE PING PONG BALL for defects? and just THROW OUT THE DEFECTIVE PING PONG BALL DATA? (that’s in CAPS because believe it or not that is what most home health agencies do!)

The process is fairly standardized. They look at a SAMPLE (say, I don’t know, 10% like Medicare requires of home health) and then they discern from that sample if there is a problem that would benefit from some intervention. Then comes the most important QA function of all, they analyze what is causing the discovered problem (a machine? a process? packaging? a person?)

So, lets compare the common practice we find in home health  of scrutinizing every single visit note (this is a step created, even forced by some software applications) Results include

  1. missing all the golden opportunities to determine where the defects are and the analysis to actually improve the sample (overall quality);
  2. causing abysmal morale in an industry where turnover and burnout are already tragic;
  3. costing  WAY more money than our shrinking margins can afford; and
  4. NOT moving the quality needle one fraction! (because you don’t get a needle in this type of so-call quality assessment)

Imagine if your QA program actually followed a manufacturing type QA or say,  the Medicare and CHAP recommendations of reviewing 10% clinical records (not individual notes mind you–because one at time does not provide context). Results would include:

  1. Data that can be analyzed to identify root cause analysis (typically its “people, paper, or process” Hint: almost always “process”
  2. Ability to compare one month or quarter to another month or quarter to effectively MOVE the needle (because now you have one)
  3. Improved morale as staff can look at (and assist in improving) overall statistics of the company rather than individual and daily professional failures.
  4. Much lower costs and in line with the reimbursement that is expected in this industry.

This is especially interesting because Medicare looks at less than 10% of all the claims in the nation (probably closer to 5%) The odds that they will EVER look at that note that does not have fall precautions in light of peripheral neuropathy are next to nothing! (literally, less than .000%

Have you heard “Medicare won’t pay for that if this [insert demand of QA Queen here] isn’t in the record” Um, yes they will. We use the prospective payment system. Operative word “prospective”. Medicare will pay for ALL your claims regardless of what is in the record (that’s another rant too) because remember that they don’t look at your record, they just look at your claim.

Now, I’m not saying that we should not have processes in place to ensure that we are following Medicare Conditions of Participation. I’m just saying that we should not have THAT process in place because it doesn’t ensure compliance with the COPs and the costs are prohibitive and all the other reasons listed above.

I am aware that the OASIS is a bit different, certain elements of the OASIS determine the payment you receive for the episode, deserves a look-see (preferably via a scrubber like PPS Plus) but other than those elements, it is not reviewed unless the chart is selected for ADR (Additional Documentation Request).

So, what the heck am I suggesting? If you want to know, I recommend that your agency:

  1. utilize a monthly or quarterly QA process whereby you look at a sample of records (just like the surveyors do) isn’t it incredible how much you can learn about an entire operation by looking at the smallest of samples!
  2. From that sample, figure out where you have opportunities to improve or flat out failures.
  3. Perform a root cause analysis
  4. Develop a plan of correction based on the analysis
  5. Provide the education to clinicians about the metric that was found and get their assistance in improving it.
  6. Evaluate it again to see if it worked (Hint: If it didn’t, you may need to look at your root cause analysis again) CELEBRATE when it moves the needle in even the tiniest bit in the right direction.
  7. STOP, Please stop paying for someone to QA every single note, turn that button OFF if it is on your EHR. I’m not saying fire your QA staff. Assess if they understand the difference between finding mistakes and solving problems. Some folks are excellent at finding mistakes but they just simply cannot help you improve the data and usually have no vested interest in doing so. (because you are paying them to find mistakes)
  8. Invest in high quality orientation and on-boarding clinicians to understand the expectations of Medicare and CHAP. Include them in record review so they can see how their charting will be reviewed in context.

I mentioned software didn’t I?

I’ve been watching software development in home health and hospice since I beta-tested Misys in 1999 (now Allscripts) and I’m so disappointed that I have yet to come across a solution that considers the role of quality assessment.

However, I actually got a little excited about a relatively new player to the home health and hospice software arena. (Although a long standing and proven track record in private duty) The EHR is Kantime. www.Kantime.com I’m especially excited about the QA features. For instance, every time a nurse enters an antibiotic, it prompts an infection surveillance report. Every visit has an option to start a complaint or incident report.

Then I got a little perturbed when I saw 2 other software applications, both of which had each note go through an “approval process” that required human intervention (costly and ineffective). I won’t mention their names, but you know if you use them.




  1. Kelly Kavanaugh-Branam says:

    Great rant Carol!!!! Loved it and agree with you 100%. I hope everyone in the industry reads it and takes notes!!
    Would love to get together and catch up one of these days!!

  2. Love the rant! Will be using the “QA Queen” a lot at the office after this post!

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