Implementing patient-centered treatment planning at the Anoka Metro Regional Treatment Centre (AMRTC)
The purpose of this paper is to investigate the implementation of a quality assurance project at AMRTC to support a system change. In a 2015 review of the patient treatment plans at the AMRTC by The Centre for Medicare and Medicaid Services (CMS), it was reported that the facility was not adhering to CMS standards and guidelines for developing treatment plans.
According to the CMS deficiency report, “treatment plans were generic in nature” (CMS, 2016, para. 5). CMS standards and guidelines outlined in the state operation manual expect all inpatient comprehensive treatment plans to be individualized, i.e., tailored to the patients’ specific needs for treatment. Furthermore, treatment plans development should be a collaborative effort between the patient and the interdisciplinary team (CMS, 2016).
Summary
This summary addresses my proposal to investigate the implementation of a quality assurance project for the advanced nursing practice field experience. The organizational change I am investigating is the Implementation of Patient-Centered Treatment Planning at the AMRTC. The population affected by this change is adults who have a diagnosis of mental illness and receiving inpatient treatment. My change leader is my nursing supervisor.
My plan for conducting this investigation is to assess all relevant data available at the facility and share points on how to review the project portfolio, validate data, and use the data-tracking system to ensure that the project is implemented to increase quality care outcomes. The study’s findings will be shared with the QAPI change leader.
Activity Selection and Methodology
This section of the Quality Improvement Activity (QIA) form addresses activity selection and methodology. The reason this project is important to my organization relates to the deficiency of AMTRC’s treatment plans based on the CMS report. A CMS survey conducted in September 2015, revealed that the AMTRC was not adhering to CMS standard guidelines # 482.61 (c) (i) Treatment plan, as outlined in the State Operations Manual.
The CMS surveyors reported that Treatment Plans were generic, thereby not meeting individual care needs and treatment of the patients. The CMS allowed the facility to develop a plan of correction for this deficiency. The CMS standard and guideline outlined in the state operation manual expect all inpatient comprehensive treatment plans to be individualized, i.e., tailored to the patient’s specific needs for treatment. Furthermore, such plans should be developed in collaboration with the patient and the interdisciplinary team providing treatment to the patient (CMS, 2016).
The quantifiable measure used in this project was for the AMRTC to comply with the CMS standards and guidelines by developing individualized and patient-centered treatment plans for all their patients. Benchmarking was used in this project to ensure that all impatient had individualized treatment plans that would meet their treatment needs. This benchmark was established by following the standards and guidelines established by the CMS.
The baseline goal established by AMRTC was that 100% of treatment plans would be individualized to patient-centered goals and measurable interventions as recommended by the CMS. The basic methodology was to gather data by auditing a random selection of patient’s charts from different units. The information reviewed included progress notes, group attendance reports, and comprehensive treatment plans. Also, data were gathered by interviewing patients and staff to obtain their opinion on treatment modality currently in use by the facility. Treatment plan experts were also required to audit treatment plans for patients in their units weekly using the Person-centered Treatment Planning Fidelity Audit tool as a guide.
At the end of weekly audits, coaching recommendations are sent to the Unit Supervisors and the Director of Nursing who then reviewed the recommendations for accuracy and followed up with the treatment plan writer as needed to provide an opportunity for improvement.
Data collection from a random selection of patients in different units eliminates the opportunity for a biased study. In this project, data sources included medical and treatment records, patient and staff interviews, and observation during focus groups. Data were collected from patient medical and treatment records every week. The sampling technique used was a random selection of patients from different units.
Data Collection and Results
Section two of the form describes the actual data collected and results. An initial or baseline rate of 10% was established in September 2015 when the CMS Surveyors visited AMRTC. The first re-measurement was in October 2015 when the facility contracted with two treatment plan consultants for 6 months. The treatment plan consultants were responsible for training the management and clinical staff in Patient-centered Treatment Planning. At this time, the re-measurement rate was still at 10%, as training did not start until early November.
Re-measurement at the end of November showed significant improvement. Progress was also noted in subsequent re-measurements. There were rate increases of 10% in November, 40% in December, 60% in January, 80% in February, and 90% in March. In the month May, the facility met its goal of 100%, which was also maintained in June 2016.
The Analysis Cycle of rhe Project
Section 3 addresses the analysis cycle of the project. The analysis cycle took place over 9 months from September 2015 to June 2016; this cycle covers all quantifiable measures except the statistical tests and significance, which did not apply to this study. In comparison to the baseline goal, the actual rates were 10% in September, 10% in October, and 20% in November. Rates continued to improve over the next seven-month reporting period. This trend demonstrated an improvement in implementing individualized treatment plans in this facility. There were no changes to the goal of this project during the period of this study.
The Implemented Interventions
Section four of the QIA form addresses the interventions that were implemented to effect change. The interventions that had the most impact on this change project were the hiring of Treatment plan consultants to train the management and clinical staff in Patient-Centered Treatment Planning. The training was able to address the knowledge barrier, as treatment plan writers at AMRTC did not have the expertise to write patient-centered treatment plans.
Also, training staff from each unit on individualized Patient-Centered Treatment Plans made a huge impact on the change project by empowering the staff to provide the patients with adequate tools for their treatment and recovery. The trainers addressed the knowledge barrier by providing education to staff who will become the treatment plan auditors on how to use the Person-Centered Treatment Plan Fidelity Audit tool.
Data Collection Methods Used
Data for the implementation of individualized Patient-Centered Treatment plans were collected using the random sampling method. The source of data was from patient medical and treatment records. A random sample of 10 patient charts out of a population of 100 was selected and audited. Data collection was done once a week and analysis were done monthly.
The unit supervisor, registered nurses, and social workers had the responsibility of collecting data and analyzing such data using the Person-Centered Treatment Plan Fidelity Audit tool. At the end of the Audit, recommendations, and audited treatment plans were submitted to the unit manager and the director of nursing who reviewed the result and provided feedback as needed.
Appropriateness
The data collection measures were appropriate for this change project. The data collection was not biased because both the unit manager and the director of nursing reviewed treatment plan audits and results to ensure accuracy and correctness. Additionally, data were collected from all relevant areas, including patient medical and treatment records, progress notes, interviews, observation of the patients during groups, and participating in treatment planning meetings.
Treatment plans were audited to measure compliance by using The Person-Centered Treatment Plan Fidelity Audit tool. Baseline data supported the need for a change due to 10% percent compliance, which was below the CMS standards and regulations on treatment planning. A compliance rate of 10% revealed that treatment plans developed by the facility for its patients were generic, thereby not meeting the individual treatment needs of these patients.
Improvement of Data Collection Measures
I strongly believe that the data collection measures used for the study to implement Patient-Centered Treatment Planning at AMRTC were adequate and rigorous. They met the standards outlined by The National Committee for Quality Assurance (NCQA). According to Sebastian-Coleman (2013), organizations must use appropriate data sources, including medical records and other encounters to ensure reliable evaluation and benchmarking.
For this study, data sources included patient medical and treatment records, observing patients during group participation, and interviews with staff and patients. The method of data collection for this study was reliable as data was collected via interviewing staff, patients, and site visitor reviewers visiting the facility to audit the patients’ treatment plans. This correlates with the data collection method outlined by (NCQA) which states that reliable data can be collected through visits and interviews. There were no barriers to data collection noted as patients’ medical records were readily available to the auditors.
The data collection measures could have been improved through an independent reviewer trained to validate the program variables. AHIMA prescribes that the quality of the process of data collection, warehousing, and analysis should be evaluated based on data quality management aspects of accuracy, consistency, currency, and precision, among others (Kuhl, 2012).)
Using a dedicated clinical data reviewer familiar with the AMTRC’s treatment plans would have minimized bias and enhanced the validity and accuracy of the collected data. Further, an initial interviewer training on the program variables, information pertinent to the project, and data entry could have improved the qualitative data collected through the interviewing of staff and patients. The training could also have enhanced the reviewer’s clinical judgment of the program variables.
Another approach involves continuous monitoring of data integrity for data quality management. In this project, the use of tools such as automated checks could have enhanced data integrity by limiting aberrant entries. The use of EHRs by providers to collect structured data (patient health information) in line with the meaningful use requirements would have improved data integrity measures (Dolansky & Moore, 2013). Comparing the collected data on the AMTRC’s treatment plans against federal benchmarks on readmissions and length of hospital stays could be a SMART way of ensuring data integrity in line with the QSEN’s systems thinking.
Improvement of the data collection measures could also have been achieved with inter-rater reliability audits. Potential reporting errors could have been identified through auditing the patient charts selected for this project. Also, the program variables could have been audited to identify agreements or disagreements with the reviewer’s findings. The difference would determine the reliability of the data collection measures and program variables.
Evaluation
The effectiveness of the change project in this facility was evaluated based on the length of inpatient admission. After the implementation of individualized patient-centered treatment plans, patients can identify their goals and objectives and contribute to the development of their treatment plans. This in return allows the treatment team to tailor treatment towards the patient’s need, which ultimately promotes recovery and discharge to nursing homes or community.
Before the study to implement patient-centered treatment planning, the patient’s goals and objectives were generic; the treatment team had the sole responsibility to make decisions on the goals and objectives they believe will be in the patient’s best interest. One of the challenges the facility had during the implementation process was that some severely mentally ill patients were not able to participate in their treatment plan meetings. This was a challenge for the facility, as the team had to develop treatment goals and objectives based on the patient’s medical history or current diagnosis without his/her input.
The change could be considered successful due to a decrease in the patient’s length of stay (LOS) at the facility. The LOS was calculated as the number of days a patient admitted to AMTRC stays hospitalized before being discharged to nursing homes or community settings taking into account the nature of illness or injury. The mean LOS was taken as an inpatient stay of 14 days since admission. A percentage reduction or increase in the number of patients with a 2-week hospitalization period was used as a benchmark for determining the success of the project. Overall, there was a 25% decrease in the population of inpatients with a LOS of 14 days at the facility.
Implementation Effect
Implementation of this project affected the organization and quality care outcomes positively. It decreased the length of stay of the patients and improved the quality of care provided by the facility. This improvement was achieved by providing adequate treatment and working with the patients to identify individual goals and objectives. Implementation of this project also helped the organization meet its strategic goals of correcting the deficiency outlined by CMS on treatment planning.
Stakeholder Roles
According to IHI 2015, having the right people on an improvement team is very important to yield an effective improvement result. Such teams differ in size and configuration based on organizational needs. Organizations build their teams to suit their needs. The stakeholders in this project included the Chief Medical Director, Director of Nursing, Director of Social Work, RN Supervisor, Social Work Supervisor, Quality Improvement Specialist, Staff Nurse, Staff Educator, Social Worker, Behavioral Analyst, and Occupational Therapist.
The roles of these individuals were as follows: the Chief Medical Director serves as the clinical leader, Director of Nursing and director of social work serve as the technical experts in this area of study, and RN Supervisors and Social work Supervisor serve as the Day-to-Day Leadership team members. Team members were successful in their roles for this project as evidenced by a successful implementation of individualized patient-centered treatment plans. The team also ensured that the facility was able to correct its deficiency as outlined by CMS.
Improvement
To increase overall quality care outcomes, I believe the change project could have been improved by increasing the number of trained staff from each unit as treatment plan experts from six staff to ten professionals. This approach would help to educate and empower more staff to achieve the facility goals in a shorter period. Techniques and data used in the data analysis were appropriate. The focus of the study and the population used for this study were also appropriate to help the facility meet its goals.
Involvement
My involvement in this organization was as an employee. I was involved with the stakeholders in this change project as a treatment plan expert and auditor. My best experience in this project was learning how to write individualized and patient-centered treatment plans. Also, auditing treatment plans written by my colleagues and providing feedback was challenging as I ensured that my results were accurate and unbiased.
In conclusion, participating in this implementation project has widened my horizon on how effective adequate treatment or care can promote patient recovery and wellbeing.
References
Centre for Medicare and Medicaid Services [CMS]. (2016). Appendix AA- State Operations Manual. Web.
Dolansky, M. & Moore, S. (2013). Quality and Safety Education for Nurses (QSEN): The Key is Systems Thinking. Online Journal of Issues in Nursing, 18(3), 113-121.
Kuhl, J. (2012). Health Story Data Standards Included in Meaningful Use Program. Journal of AHIMA, 1(2), 12-19.
Sebastian-Coleman, L. (2013). Measuring Data Quality for Ongoing Improvement: A Data Quality Assessment Framework. Burlington: Morgan Kaufmann.