D'Anne Schick, MS

Steps for eva I ua t i ng patient care

Performing the process review meth- od for evaluating patient care in- volves 10 distinct steps. Process re- view is based on the actual observa- tion of patient care as it occurs. Each of the steps must be completed; how- ever, some can be done concurrently rather than sequentially. The follow- ing is a summary of the steps, with guidelines for their accomplishment. The first three steps are preparatory and usually require three to four months to complete.

1. Indicator selection. Not all of the indicators will be applicable to every situation. The key factors used in determining applicability involve selection based on philos- ophy, policies, and procedures (departmental, not operative pro- cedures). This first step is time- consuming because many details must be checked. Also, it is not un-

D'Anne Schick, MS, is the director of Northern New England Community Systems Foundation L t d , Augusta, Me. She is a graduate of Indiana Uni- versity and the University of Mich- igan. M s Schick spoke on nursing audit at the 1974 Congress.

usual to find that the staff is un- aware of some policies and pro- cedures.

2. Indicator revision. Once the selection step is complete, the in- dicators should be revised so that the wording, abbreviations, and reference terms correspond to those commonly used. In addition, depending on the staff mix (regis- tered nurse, licensed practical nurse, technician, aide), the indi- cators may require revision to cor- respond with job functions.

3. Indicator weighting. The items to be considered in indicator weighting involve decisions regard- ing priorities, importance in the overall suite functioning, and de- gree of sensitivity desired. AORN, following completion of current field testing of its methodology, will make a recommendation re- garding a weighting system. How- ever, despite recommendations, weighting systems should be re- viewed with administration (hos- pital and nursing), the OR staff, and selected surgeons.

Completion of these three steps is the most difficult and time-consum-

AORN Journal, August 1974, Vol 20, N o 2 237

ing portion of the process. The next two steps (4 and 51, involving the selection and training of observers, are education oriented.

4. Observer selection. The pri- mary decision involves whether only OR nurses or all available nurses should be considered as po- tential observers. Whichever de- cision is made, there are benefits and drawbacks. If only OR nurses are selected, an opportunity to in- terest other nurses in the OR is lost; however, outside observers will require additional training so that they can make accurate de- cisions. Certain prerequisites must be present in each observer. They should be involved with the proc- ess as early as possible, they must accept the validity of and need for evaluation, and they must be will- ing to support the system.

5. Observer training. All observ- ers need a training period, not only to assist them in developing confidence, but also to allow re- examination of their selection. Sometimes, observers have all the prerequisites “on paper,” but in practice they do not function as good observers. The problems may be those of confidence, interper- sonal relationships, or willingness to indicate a negative finding.

Steps six and seven are the final preimplementation activities; they in- volve the testing of the revised tool and observer monitoring.

6. Indicator testing. The indica- tors have previously been reviewed for applicability and revised as re- quired (step 1). During this testing step, the observers evaluate actual

operative procedures using the tool. They examine each indicator to determine if it is fair; that is, does the indicator correspond to policy and procedure? Is the data needed for decision making avail- able? Can the indicators be an- swered easily? The completed forms are then reviewed to ascer- tain whether or not the observers made appropriate decisions. Any form with all positive ratings or numerous negative or nonappro- priate ratings (more than 30%) requires followup.

7. Weighting system testing. The test evaluations are scored using the weighting system. During this step, a determination is made whether the weights are too high for certain indicators or too low for others. Indicators relating to environmental factors may carry a higher weight than indicators re- lating to direct patient care. If the philosophy is to place more em- phasis on patient-care factors than on environmental factors, the weights should be revised to reflect these priorities.

The completion of steps four through seven (selection, training, and testing steps) can be completed within one to two months. At this point, full implementation of the tool, which has been tailored to meet individual needs, may be instituted. The following and final steps are se- quentially performed.

8. ~ ~ ~ b e r of observations. The number of cases observed per month must be enough to assure reliability of the findings, but not so many that the process becomes a burden for the observers. It is

238 AORN Journal, August 1974, Vol 20, N o 2

neither necessary nor desirable to observe and evaluate every case. The key is to observe a sufficient number so that the results reflect the usual and not the unusual. As a start, evaluation of 10 to 12% of the monthly caseload should pro- vide reliable data. A precise meth- odology for determining the sample size will be available following the field- testing phase.

9. Analysis and presentation of findings. At the end of each obser- vation period, the results are thoroughly analyzed. Particular at- tention is directed to indicators answered negatively. A pattern sometimes emerges, that is, an in- dicator is frequently answered negatively. Any indicator answered negatively on 15% or more of the observations denotes a problem. The problem may be with phrasing of the indicator (ambiguity), the observers’ understanding of the in- dicator, or an actual deficiency in the case. Regardless of the reason, the situation requires a plan for corrective action.

10. Semiannual review and re- vision. Every six months, the tool should be re-examined. The indica- tors should be revised (if neces- sary) to reflect changes. In addi- tion, indicators which are always answered positively or as non- applicable can be deleted and new indicators added. Prior to being used, new indicators must be tested (step 6) and a weight developed

This final step is a return to step 1-thus the process is cyclical and

(step 7).

easily followed.

Lamberf awards group seeks enfries Innovative and imaginative ideas which have improved patient care or reduced health care costs are being sought for awards by the Gerard B Lambert Awards committee.

The 1974-1 975 awards will be presented in April 1975. Competition entries will be accepted through Oct 31, 1974. There are no application forms. Entrants need only answer the question, What is being done that i s different that should come to the attention of the awards Committee? All entries are read carefully and given equal consideration by research analysts, who last year read 342 issues of the industry’s professional publications and considered 1,718 ideas brought to their attention. Of these, 64 were examined by a panel of jurors, and through a series of eliminations, ten award-winning ideas were selected. Descriptions of these winning ideas are available upon request from the office of the awards committee.

The purpose of the awards i s to publicize solutions to widespread problems, to motivate others in the health care industry to implement these solutions, and to encourage health professionals to try innovative approaches.

The Gerard B Lambert awards were established in 1971 by Mrs Lambert in honor of her late husband, an innovator in government, business, and housing.

Entries should be sent to the Gerard B Lambert Awards, Dept 13A, 53 Bank St, Princeton, NJ 08540.

AORN Journal, August 1974, Vol 20, N o 2 239