Using QI to Improve Documentation Processes in the Maternal Infant Health Program

The team reduced staff time associated with office work from 53% to 36%. To measure the overall goal of reducing office-related work from 53% to 35% for MIHP staff members, the team used the agency’s electronic coding system. One of the reasons the team accomplished such a gain was partly because staff members coded in a standardized manner after the coding process was reevaluated. The standardization allowed the team to more accurately describe staff time usage in the program and reduced variance among staff members in their coding practices. Standardization should also help track progress and identify issues in the future because the data will be more accurate and reliable. By using the check sheets, the team saw an improvement in the average time to complete a progress note: from 14 minutes to 13 minutes, or a 9% improvement. By using this same check sheet, the team saw a negative impact on the average preparation time for a visit. Time increased from 9 minutes to 11 minutes, or an 18% increase. After seeing this information, the team will have to reevaluate some of the strategies that will focus on adapting or abandoning changes made to the process of preparing for a visit. As for the preexisting data, such as productivity rates and program financial information, the team did not see any measurable changes at this time. The team anticipated that these data would be negatively affected because staff would not be conducting as many visits because some of their time was being reallocated to QI within the program for this project. However, this was not the case, and staff maintained productivity rates that are in line with the 5-year trend data that were available for the program. Although the team saw gains and losses in the targeted areas, the final data collection cycle that it used for comparison had some flaws for this study. These flaws are directly related to the type of work staff members were conducting during this time frame, which included preparing for the MIHP state accreditation site visit. Because this is not a typical workload for staff members, it can be seen in the coding data provided (billable visits down, client no-shows down, assessments down, etc.). This is because staff members were not conducting as many visits during this period as they prepared for state accreditation. The team should have more reliable results next quarter because staff members will be coordinating their time more in line with their daily activities, and variance will decrease as staff become more familiar with the new processes.

The most important nonmeasureable outcome as a result of this QI initiative was increased communication among staff members with other staff members and among staff members with management. There was a great deal of growth in this area, and feedback was not always what the team may have wanted to hear, but the team definitely needed to hear feedback from both sides (staff and management) on the perception of the program and what needed to be addressed. There was a lot of tension as staff perceived this as an attack on their individual performance and passion for the program and that the program may have to be cut because of financial sustainability (jobs lost). After many meetings, the team established a certain level of trust between both staff and management that allowed them to work as a team and communicate while having team members feel that their input or feedback was valued. The team now continues to meet regularly, which allows it to continue addressing improvement efforts at a program level instead of the lackluster communication experienced at the beginning of this project.

The following information describes the strategies tested using the IF…THEN approach to address targeted goals and a narrative explaining those outcomes. 1. IF the team standardizes the equipment used by staff (new PC tablets), THEN that should help with staff training and allow staff to complete progress notes while conducting a home visit (smaller, more portable, fewer technical issues). 2. IF the team addresses technical issues in Insight, THEN that should allow staff to complete a progress note with fewer errors and in a shorter time frame (drop-down menus, character requirements, etc.). 3. IF the team provides staff with hotspots, THEN staff should be able to have connectivity in the field to complete progress notes while conducting a home visit. This strategy was tested and did not prove useful for staff because connectivity was an issue due to the rural communities the health department serves. 4. IF staff use Insight Anywhere, THEN they should be able to complete progress notes while conducting a home visit (prevents wireless connectivity issues). 5. IF the team puts a policy in place for progress note completion requirements, THEN staff will have the proper guidance to complete their progress notes in a way that is standardized for all MIHP staff members. 6. IF the team places an information rack in a centralized location for staff to pull necessary information (required charts and educational information), THEN that should help reduce staff time to locate the necessary information. 7. IF the team uses color-coded folders to distinguish between maternal and infant participants, THEN that should help staff identify what type of materials they should pull without searching through the clients’ charts (will also help with the chart review process). 8. IF the team revises and standardizes coding practices, THEN staff will more accurately depict their work being accomplished each day and code with fewer errors. By standardizing the equipment staff use, the team had all staff trained using the same tools, which assisted with consistency and ease of use while staff members were conducting home visits. This also made it easier for the management information system (MIS) staff to resolve technical problems on a program level instead of individually in a more timely manner. This was a major improvement because it enabled the team to address other issues later on in the QI project. The team also addressed many technical issues with the electronic health record (EHR) system (Insight) it uses to document client interactions. This allowed the team to decrease the frequency of errors associated with using the EHR system and made the system more user-friendly for staff, which improved timeliness and accuracy of the documentation. Because the team provides services for this program in a rural area, it tested a couple of strategies that would enable the MIHP staff members to document while they were out in the field using an electronic system instead of paper documentation (i.e., reduce duplication). The team first tested using hotspots to connect to Insight while staff were conducting home visits; however, this did not prove useful at this time because connectivity was an issue due to the rural environment of the communities served (i.e., no signal or frequently dropped signals). After realizing hotspots would not solve the issue of documenting electronically in the field, we tested Insight Anywhere and have had great success in documentation outcomes ever since. Using Insight Anywhere also allowed the team to develop a new process/policy for documentation procedures in the program. Staff members can upload their scheduled client’s information on Insight Anywhere at the beginning of each week and download their completed documentation at the same time. This has been a major improvement, because the team now has a 100% documentation rate within the specified time frame for progress note completion. This allows the team to have accurate and timely information when conducting visits, which improves the ability to address health concerns; each client has to have multiple staff disciplines coordinated throughout their enrollment in the program (e.g., social worker, registered dietitian, nurse). To help decrease the amount of time staff took to prepare for a visit, the team implemented two strategies to become more efficient. First, the team established a central area for staff to locate program documentation, in an effort to ensure all staff members were using the same standardized documentation or educational resources that were easy to access. After reviewing the data, the team will have to reevaluate this practice because it did not have the anticipated outcome. The team did see success in reducing staff time by implementing a simple color-coded file folder system, which distinguished between maternal and infant clients. This system allowed staff to identify appropriate materials just by glancing at the color of the client’s folder and also improved the chart review process conducted by the MIHP team. The final strategy that was implemented focused on the program's ability to accurately track staff time, which depicts their work being accomplished daily and coded with fewer errors. This was another major improvement that allowed the program to have accurate and reliable data consistently to monitor the program’s time usage. By having this information, the team can see how the changes implemented in the program have had a positive or negative impact on all aspects of the program. This also provided staff with standardized guidance on coding practices, which will reduce coding errors and have the ability to generate more revenue by instilling proper guidance on how to code for Medicaid outreach. The team realized many successes throughout this QI process, but it now has the tools, resources, and experience to continue to achieve greater gains as it moves forward with its efforts.

The team plans to continue QI efforts in MIHP to address many of the issues that it was not able to work on during this particular QI project. By conducting this project, the team discovered many other issues that it would like to address in the future, which it would not have been aware of otherwise. This will be accomplished by establishing regularly scheduled monthly meetings, which will focus only on QI within the program. The team believe that it will be able to maintain gains in MIHP through the improved communication and monitoring methods that have been put in place. As for QI in MMDHD’s other programs and services, the team will use the experiences gained in this project to benefit other projects, but each project presents different issues, concerns, and necessary resources, so replication may not be appropriate in most cases.