Incontinence management
::
::
::
::
::
::
::
::
::
::
|
|
Modules - Incontinence Management
STEP 4: MONITOR THE PROMPTED VOIDING PROGRAM
| Conduct periodic control checks to monitor the prompted voiding program and ensure quality of care. Share results with nurse aides to elicit their help with improvement efforts and strengthen their commitment to the program. |
QUESTIONS?
If you have any questions about the procedures we've presented in this training module or need assistance with implementing a prompted voiding program, please contact us or check out these other pages:
QUALITY INDICATORS FOR INCONTINENCE CARE
We worked with researchers at RAND, a southern California think tank, to develop a series of nine quality indicators (QI) related to incontinence care for nursing home residents. Presented as a series of if/then statements, these QIs outline minimally acceptable care for the assessment and treatment of incontinent residents. QIs, writes RAND, "set a minimal standard for acceptable care-standards that, if not met, almost ensure that the care is of poor quality."
Based on expert opinion and existing best-practice guidelines, all of our QI-associated assessment and treatment tasks are both related to positive outcomes for residents and feasible for nursing home staff to implement. Use them to evaluate incontinence care in your facility.
CONTINUOUS QUALITY ASSESSMENTS HELP ENSURE PROGRAM SUCCESS
When writing training modules like this one, it seems that the more likely your audience is to skip an implementation step, the more important that step becomes. From this standpoint, Step 4-monitor the prompted voiding program-appears very, very, VERY important indeed.
All kidding aside, it truly is very important. Here's why: Having accomplished Steps 1, 2, and 3, your facility now has a significant investment in improving the quality of incontinence care for residents. All that time and money will go to waste, however, unless supervisors conduct regular "wet" checks to make sure nurse aides continue to provide quality care. Most nursing homes forego this step only to pay a price for their negligence: studies show that in the absence of quality control assessment, nurse aides backslide and fail to consistently implement prompted voiding with incontinent residents (1).
Evidently, old habits are hard to break and new ones are hard to maintain if you don't get timely feedback about how you're doing, including reinforcement for doing things right and recommendations for improvement if you're doing things wrong. This feedback loop is a hallmark of continuous quality improvement programs. Commenting on the proven effectiveness of these programs, geriatrician John Morley and his colleagues observe (2): "It does not take the wizardry of Harry Potter to curb errors, but rather the 'magic' of data collection, analysis, and self-correction in a timely way (2003; pg. 809)." Step 4 is all about this kind of magic.
START BY SETTING WETNESS WARNING LIMITS
The primary tool used to monitor prompted voiding programs is a control chart, which graphically displays expected versus actual outcomes. This chart compares the percentage of incontinent residents found wet at any given point in time to the percentage who should be wet if the prompted voiding program is working as expected. If the "actual" percentage exceeds the "expected" percentage, there's a problem, and it needs further analysis if you intend to resolve it. Typical problems stem from changes in a resident's status or break-downs in the prompted voiding work process.
Before you can construct a control chart, you need to establish your program's performance goals; that is, you need to calculate the percentage of residents who should be wet if the program is working well. This calculation is based on data collected during the prompted voiding trial (Step 2. Only the data for "responsive" residents is used. Recall that during the assessment trial, these residents were checked for wetness four times a day for two or three days. These 8 or 12 "data points" per resident, recorded on the Prompted Voiding Trial form, can now be used to establish program performance goals as follows:
- Calculate the wetness rate for each responsive resident: Divide the total number of checks on which the resident was found wet by the total number of checks in all (8 for a two-day trial; 12 for a three-day trial), then multiply by 100 to convert to a percentage.
- Calculate the average wetness rate for all residents and the standard deviation by using a simple program at this web address: www.physics.csbsju.edu/stats/cstats_NROW_form.html. (Alternatively, some calculators can also compute averages and standard deviations.) Where this web-based program prompts you to enter the "Number of Items," enter the number of residents for which you have wetness rates, then click "Submit." In the boxes that appear next, enter the wetness rates for residents, one per box. Then click "Calculate Now."
- The program returns a "results" page (see sample) that reports both the mean, or average, wetness rate for all residents and the standard deviation. Use these results to set a warning limit two standard deviations above the mean. In the example below, the mean wetness rate for five residents was 18.8% and the standard deviation was 2.86. With these results, we would set the warning limit at 24.52% [18.8 + 2(2.86)].
Sample "Results" Page from Web-based Program (our highlights for emphasis)
Descriptive Statistics: Results
The results of some basic statistical tests performed at 10:26 on 8-DEC-2003.
5 data points were entered:
15.0 17.0 19.0 21.0 22.0
Mean = 18.8
95% confidence interval for actual Mean: 15.24 thru 22.36
Standard Deviation = 2.86
Hi = 22.0 Low = 15.0
Median = 19.0
Average Absolute Deviation from Median = 2.20
|
CONDUCT CONTROL CHECKS
The warning limit defines acceptable performance. As long as wetness rates during weekly control checks fall under the limit, the program is meeting its goals. If wetness rates exceed the limit, the program is considered to be "out of control" and further analysis and corrective action are needed to bring it back in line.
How do you calculate wetness rates? To start, supervisory nurses should randomly check at least 10 residents for wetness each week. Take the number of residents found wet and convert it to a percentage of the total checks conducted. This percentage is the wetness rate. If two of 10 residents are found wet, for example, then the wetness rate for that week is 20%. We estimate that supervisors will spend 20-30 minutes a week conducting control checks.
Guidelines for Scheduling Random Control Checks
Above all, do not be predictable. Put the names of all eligible residents in a hat, for example, and draw 10 names to determine who you will check that week. You can also draw from the hat the day of the week and the shift on which you will conduct checks.
Do not impose anything like order on the schedule. Do not, for example, always conduct control checks on Mondays, or check this hall first, then that one, or check the day shift, followed by the evening and then the morning shifts.
|
CREATE A CONTROL CHART
Creating a control chart, like the one below, that displays your data graphically will help you analyze trends over time and facilitate improvement efforts.
Sample Control Chart
As illustrated in the above example, the mean percentage of residents who were found wet on the most recent 36 control checks was 15%. Bars represent the percentage of residents who were found wet on each control check. On three occasions (checks number 12, 29, and 36), the percentage of residents who were wet exceeded the warning limit. This is a red flag to staff that corrective action may be needed.
Further analyses of control check results should help you pinpoint the problem. Consider, for example, whether out-of-control results indicate a change in a resident's status, a breakdown in care during shift changes, or a staffing problem on a particular hallway. All these are common occurrences that can skew program results.
SHARE RESULTS WITH STAFF, ELICIT THEIR HELP WITH IMPROVEMENTS
To truly experience the "magic" of continuous quality improvement, you must share results of the control-check evaluations with the nurse aides who perform the lion's share of the work for the prompted voiding program. As we noted at the start of this step, staff members need feedback-both good and bad-to help them establish new work routines. Simply posting an updated control chart each week, for example, will enable nurse aides to make connections between their work and the impact it has on their residents. If these direct care providers can see tangible evidence of the prompted voiding program's benefits, then they are less likely to view the intervention as an additional burden and more likely to work to sustain its positive effects.
Sharing performance results also gives nurse aides the opportunity to help supervisors correct any problems that arise. Often the aides are the first to know if a resident's status has changed or if there's been a break-down in the work process. Involving these staff members in improvement efforts will also help strengthen their commitment to the program.
In addition to posting control charts, you can complete the "circle of communication" by presenting and discussing program performance results at in-service trainings and during regular staff meetings.
Consider rewarding the staff for consistently good results. The most powerful motivators are job advancements and salary increases. If these are beyond your budget, a staff pizza party every quarter for outstanding performance can't hurt.
REFERENCES
The articles cited below, plus others, are summarized on our Related Studies.
- Schnelle JF, McNees P, Crooks V, & Ouslander JG. The use of a computer-based model to implement an incontinence management program. The Gerontologist, 1995; 35(5):656-665.
- Morley JE, Flahaerty JH, & Thomas DR. Geriatricians, continuous quality improvement, and improved care for older persons. J Geron: Med Sci, 2003;58A(9):809-812.
(prev | next)
|
|
|
