Documenting Quality Assurance

Those meeting minutes will improve your facility-and save it from survey grief

BY LINDA O’BOYLE ZANESKI, NHA, MHA, BSN, RN-C

Keep Statistics
The statistics you include can be not only your safety stats (resident/employee accidents/incidents and medication errors) but also other stats, such as infection control measures, skin status, psychotropic medication use, etc. When reviewing stats, be sure the committee looks for trends and problems in these areas. Should your numbers go up in a particular area, without a change in census, you may have a problem to focus upon (e.g., if more falls occurred on Hall B on the 3-11 shift, you may need to repeat an in-service for 3-11 staff in this area). Also, remember that the numbers don’t always tell the whole story. If you had three residents admitted with heavy wound care, you need to document this as the reason for the recorded increase in wounds in your facility for the month. Document the reasons for sudden fluctuations in the numbers, your plan for addressing those changes, and the results you expect at the next meeting.

Perform Audits
In doing this, each staff member, regardless of his or her discipline, has an important role. Continuous auditing will find problem areas before your state surveyors do. The key is to find the problems, document in the QA minutes that you have noticed problems, and describe what you are going to do about them. Then follow up at the next QA meeting to make sure that your corrective action has indeed helped to modify the problem or solve it completely. Often, if you can show the state survey team that you are already on top of a particular problem in this manner, they will respond favorably.

Each discipline should use audits to report on what it is doing to ensure quality care. For example, dietary may report its audits on recording of weights, calorie counts, and dietary recommendations. Perhaps resident weights and calorie-count audits resulted in 100% compliance, but the results of your dietary recommendations were recorded below your set threshold of compliance. The minutes should reflect your plans for changing the dietary recommendations and how you intend to monitor the results the following month. The next meeting minutes will (hopefully) record improvements in these areas.

Review Resident Surveys/Complaints
Don’t forget to include in your QA minutes your responses to resident questionnaires and resident council meetings. These can focus the QA committee’s attention on specific resident problems or complaints. For example, if your last 10 resident surveys indicated a problem with a high noise level on the 11-7 shift, you can ask staff on that shift to work quieter. If the residents complained of cold coffee at their last council meeting, that problem can easily be addressed. Of course, document your plan of correction and follow-up.

Address Survey Results
It’s a good idea to address your state survey issues separately. This will enable you to better focus on your specific survey problems and plans of correction. You certainly don’t want to be cited twice on the same issue.

Include Other Reports
There are other reports that you might want to have submitted at each meeting. They don’t necessarily fit under a specific department heading-for example, you might want to include reports reviewing policies and procedures, ethics issues, in-service training, hospital transfers, etc.

Remember to tailor your QA meeting to fit your facility’s needs. Be honest in recording these. Don’t be afraid to enter real problems into the QA minutes. When you discover a problem, document the discovery, the plan to correct it, the monitoring process, and the results. Your QA minutes will be the backbone of your quality improvement efforts. NH