Outcome-Based Quality Improvement (OBQI)

1 Outcome-Based Quality Improvement ( obqi ) Manual Revised: August 2010 Centers for Medicare & Medicaid Services obqi Implementation Manual August 2010 i Centers for Medicare & Medicaid Services Table of Contents Chapter Page 1. Introduction .. A. Understanding B Outcome-Based Quality Improvement ( obqi ) in Context .. C. Overview of This Table : Location of Learning Activities and Agency Strategies for outcome Enhancement Steps .. D. What This Manual Is and What It Is E. Benefits of Implementing 2. Outcomes and obqi .. A. What Is So Important About Outcomes? .. B. What Is obqi ? .. Figure : Two-Stage obqi Framework .. C. Reports To Be Used for outcome Enhancement .. Figure : Excerpt outcome Report .. Table : OASIS- based outcome Measures .. Table : Excerpt Agency Patient-Related Characteristics Report .. Figure : Excerpt Potentially Avoidable Event Report.

2 Figure : Excerpt Process Quality Measure D. Moving Toward outcome Management .. Figure : The outcome Model .. Frequently Asked Questions .. 3. Interpreting outcome Reports .. A. Introduction .. B. Data Analysis .. C. Reports Produced from OASIS Data .. D. Reviewing and Interpreting outcome Reports .. Figure : Illustrative Page from Sample All Patients Risk Adjusted outcome Report .. E. Risk Adjustment .. Table : Steps in Risk Adjustment .. F. Data Shock .. G. Presenting the outcome Report to Staff .. H. Report I. Summary .. Frequently Asked Questions .. Attachment A: Illustrative outcome Report for Faircare Home Health Services .. Attachment B: Exercises in Interpreting outcome Reports .. Attachment C: Overview of Risk Adjustment Methodology Used for Home Health Agency obqi Reports.

3 Attachment D: Agency Strategies to Facilitate Interpreting outcome Reports .. Table of Contents (Continued) Chapter Page obqi Implementation Manual August 2010 ii Centers for Medicare & Medicaid Services 4. Selecting Target Outcomes .. A. Introduction .. B. Selecting Outcomes for Further Investigation .. C. Using the Agency-Patient Related Characteristics Report to Assist in Target outcome Selection .. D. Who in the Agency Should Select the Target Outcomes? .. E. Timeline for Selecting Target Outcomes .. F. Summary .. Frequently Asked Questions .. Attachment A: Exercises in Selecting Target Outcomes .. Attachment B: Worksheet: Selecting Target Outcomes .. Attachment C: Agency Strategies to Facilitate Selecting Target Outcomes .. 5. Conducting the Process-of-Care Investigation .. A. Introduction .. B.

4 What Is the Process of Care Investigation? .. C. Benefits of the Process of Care Investigation .. D. Pitfalls to Avoid .. E. Planning the Investigation .. F. Identifying What Should Be Done in Providing Care .. G. Conducting the Investigation .. H. Selecting Cases for Review of Care Provided .. Figure : Excerpt Faircare Home Health Services Agency Patient-Related Characteristics and outcome Tally Reports .. Figure : Excerpt Faircare Home Health Services All Patients Risk Adjusted outcome Report .. 5-11 I. Drawing Conclusions .. J. Timeline for Completing the Process of Care Investigation .. Frequently Asked Questions .. Attachment A: Steps in Conducting a Focused Record Review .. Attachment B: Tools to Implement Quality Improvement .. Attachment C: Exercises in Investigating Important Clinical Attachment D: Agency Strategies to Facilitate Investigating Care Processes.

5 Table of Contents (Continued) Chapter Page obqi Implementation Manual August 2010 iii Centers for Medicare & Medicaid Services 6. Developing the Plan of Action .. A. Introduction .. B. What is the Plan of Action? .. Figure : Sample Plan of Action for the Target outcome of Improvement in Toilet Transferring .. C. Who Develops the Plan of Action? .. D. Statements of Problem/Strength in Care Provision .. E. Statements of Best Practices .. F. Timeline for Developing the Plan of Action .. Frequently Asked Questions .. Attachment A: Plan of Action for Quality Improvement Form .. Attachment B: Exercises in Evaluating Problem Statements and Best Practices .. Attachment C: Agency Strategies for Developing Statements of Problem or Strength in Care Provision .. Attachment D: Agency Strategies for Developing Statements of Best Practices .. 7.

6 Implementing and Monitoring the Plan of Action .. A. Introduction .. B. Fostering Behavioral Change in Care Delivery .. C. Planning the Implementation of the Action Plan .. D. Approaches to Change Clinical Practice .. E. Monitoring the Plan of Action .. F. Evaluating the Plan of Action .. G. Documenting the Quality Improvement Journey .. H. Summary .. Frequently Asked Questions .. Attachment A: Sample Action Strategies .. Attachment B: Exercises in Evaluating Action Attachment C: Broaden Your Options: Techniques to Foster Clinical Behavior Change .. Attachment D: Sample Monitoring Attachment E: Checklists for Your Agency's Plan of Action .. Attachment F: Strategies to Facilitate Writing Action Strategies .. Attachment G: Evaluating the Plan of Action .. Table of Contents (Continued) Chapter Page obqi Implementation Manual August 2010 iv Centers for Medicare & Medicaid Services 8.

7 Teamwork .. A. Introduction .. B. Why Teams? .. C. Examples of a Two-Team D. Team Development .. E. Team Leadership .. F. Team Members .. G. Progressing Through the Investigation and Planning .. H. Frequently Asked Questions .. Attachment A: Ground Rules for Group Discussion .. Attachment B: How to Recognize a Good Attachment C: Selecting the outcome Enhancement Teams .. Attachment D: Agency Strategies to Utilize Teams for outcome 9. obqi Education for Agency Staff .. A. Introduction .. B. Establishing the Atmosphere for Training: Why Change is Necessary .. C. Who Needs Training? What Training Do They Need? .. D. Overall Training Goal .. E. Planning and Scheduling the Training .. F. Who Should Conduct Training?

8 G. Training Approaches .. H. Learning Curve Expectations .. I. Assessing Staff Learning .. J. An Effective Timeline for outcome Enhancement .. K. Recap: What Can Be Done Early? .. L. The Most Important Factor in Training .. Frequently Asked Questions .. Attachment A: Identifying Training Needs of Staff .. Attachment B: Training Plan for Staff .. Attachment C: Training Tips .. Attachment D: Suggestions to Address Ongoing Training Needs .. Attachment E: Agency Strategies to Facilitate Training .. Attachment F: Comparison Overview of OASIS-Derived Reports .. 10. Establishing an Effective obqi System .. A. Introduction .. B. Agency Commitment to Quality Improvement .. C. Effects of Focus on Outcomes .. D. Expect Evolution in Your obqi System .. Table of Contents (Continued) Appendix Page obqi Implementation Manual August 2010 v Centers for Medicare & Medicaid Services A.

9 Guidelines for Reviewing obqi Reports outcome Reports, Agency Patient-Related Characteristics Reports, Patient Tally B. Definitions of Key Terms Related to C. All Patients Risk Adjusted outcome Report Section 5 0 8 Compliant CHAPTER 1 INTRODUCTION A. UNDERSTANDING obqi The Outcome-Based Quality Improvement ( obqi ) Manual is part of a series of four manuals produced by the Centers for Medicare & Medicaid Services (CMS). The obqi Manual describes the obqi outcome Report in detail and is intended to assist home health agencies use the data in the report and implement the steps in Outcome-Based Quality Improvement ( obqi ). The other three manuals are available on the CMS website and include: - The outcome and Assessment Information Set (OASIS-C) Guidance Manual, which introduces agencies to OASIS and the collection of uniform health status data on patients receiving home health care; - The Outcome-Based Quality Monitoring (OBQM) Manual, which focuses on understanding and using the information in the Agency Patient-Related Characteristics Report (formerly the Case Mix Report) and the Potentially Avoidable Event Report (formerly the Adverse Event outcome Report); - The Process- based Quality Improvement (PBQI) Manual, which describes the Process Quality Measure Report and discusses its use for Quality Improvement purposes.

10 B. Outcome-Based Quality Improvement ( obqi ) IN CONTEXT In 1999, all Medicare-certified home health agencies began collecting standardized patient status information through the use of the outcome and Assessment Information Set (OASIS). The OASIS items had been developed, tested, and refined over the prior decade through an extensive research and demonstration program funded largely by the Centers for Medicare & Medicaid Services (CMS, then known as the Health Care Financing Administration), the Robert Wood Johnson Foundation, and New York State. The items were designed to enable the rigorous and systematic measurement of patient home health care outcomes, with appropriate adjustment for patient risk factors affecting those outcomes. The current version of OASIS (OASIS-C) allows for the measurement of selected evidence- based process Quality measures as well. Home health agencies (HHAs) are provided with feedback reports from the OASIS data collected and transmitted to their respective state agencies in four unique reports -- Agency Patient-Related Characteristics Report (formerly the case mix report), the Potentially Avoidable Event Report (formerly the adverse event outcome report), the Outcome-Based Quality Improvement ( obqi ) outcome Report, and the Process Quality Measure Report (available 2010).