New Mexico's Health Quality Improvement Organization

Home Health Agencies

Tally Reports Can Assist in OBQI Efforts

Selecting a Target Outcome
Assessing and Using Patient Tally Report Data
System Requirements and Installation Instructions
Performing Queries to Select Cases with Specified Characteristics
Printing Reports

During recent Outcome-Based Quality Improvement (OBQI) training conducted by the New Mexico Medical Review Association (NMMRA), home health agency personnel were taught how to train other agency staff in OBQI processes. When agencies download their outcome reports, they should be conducting a process-of-care investigation and writing a plan of action for improving patient care in one or two areas.

Plans of action are to be submitted to NMMRA for review and feedback. Agencies are expected to review and monitor their plans of action for progress throughout the year, making updates where necessary with assistance from NMMRA. A tool has been created to assist agencies in honing in on potential areas of improvement. Once a target outcome is selected, agencies can use the Patient Tally Report workbook tool to further examine specifics related to groups of patients with the same outcome or case mix characteristics. Identifying and examining attributes of these patients can make it easier to discover potential areas for process-of-care adjustments.

Selecting a Target Outcome
Prior to using the Patient Tally Report tool, agencies should review their outcome reports and select one or two specific target outcomes for OBQI activities. NMMRA recommends that agencies involve several key staff in making this decision. Some agencies form a team consisting of administrative, managerial, and clinical field staff members to evaluate potential target outcomes.

It is important to limit the number of target outcomes selected to one or two (or a maximum of three). This allows in-depth review of the care processes that affected the target outcomes and implementation of outcome enhancement activities within one month. The one-month time frame will maximize the possibility of seeing changes in target outcomes (as a result of outcome enhancement activities) reflected on the next outcome report.

Most agencies may select a target outcome that is unfavorable in comparison to the reference group or prior outcome. Some agencies, however, select a favorable outcome for outcome enhancement activities to identify and reinforce excellent care practices.

As potential target outcomes are evaluated for OBQI enhancement activities, the following selection criteria should be applied:

First select outcomes that have statistically significant comparisons to either prior outcomes or reference group outcomes (noted by the double or single asterisk). Potential target choices in the absence of statistically significant outcomes may be those with a "signif" calculation no higher than .25.
Next select statistically significant outcomes that have a large magnitude of difference (e.g., greater than a 10 percent difference) between current values vs. adjusted prior values or current values and reference values.
Select outcomes that were calculated for at least 30 patients.
Select outcomes that have particular relevance for your agency's goals or program objectives.
Select the outcomes that have clinical significance for your agency.

Outcomes that meet the selection criteria should be considered potential target outcomes. If there are a limited number of outcomes remaining, the choice is easier than if there are several. If there are several outcomes remaining as potential choices, achieving consensus on the target outcome(s) is an important step. Analyzing outcome results can support an agency's process-of-care investigation. The Patient Tally Report is a useful tool in analyzing outcome results and generating discussion about potential target outcome choices.

Accessing and Using the Patient Tally Report Data
The Patient Tally Reports tool is a workbook that makes it easy to examine outcome results. The tool and instructions are available at http://www.cms.hhs.gov/HomeHealthQualityInits/downloads/HHQIOASISOBQIRevisedPatientTally.zip. The workbook is a set of spreadsheets that contain raw OASIS items, case mix, and outcome data along with associated macros, or programs, for querying and printing these data.

The four components of the Patient Tally Report workbook are:

A spreadsheet (or "worksheet") containing start of care and resumption of care (SOC/ROC) raw OASIS item data for all patients,
A spreadsheet (or "worksheet") containing start of care and resumption of care (SOC/ROC) Case Mix data for all patients,
A spreadsheet containing Outcome data for all patients, and
A set of macros that automate the processes of querying the spreadsheets to select cases with specified characteristics and printing of reports.

System Requirements and Installation Instructions
A copy of Microsoft Excel (version 97 or later) in Windows 95 or 98 environments is recommended to read these data files and run the query and print macros. This software is not provided. There should be very little difference for users working with Excel 97 in Windows NT or 2000. Agencies using another current Windows-based spreadsheet or database program should be able to import data from the Excel workbook, but likely will not be able to run the associated macros.

If your agency has a copy of Microsoft Excel (or a similar Windows-based program) and can use it with relatively large amounts of data, your computer hardware is probably sufficient to handle the patient tally workbook. Agencies with extremely large numbers of cases (in the thousands) may require more memory (RAM) than smaller agencies to load the data and run the macros.

Before you can utilize the Tally Report workbook, obtain both the OBQI case mix tally report and the OBQI outcome tally report for your agency from CASPER System in a spreadsheet format. The reports are accessed using the same system used for submitting your OASIS data to the state, as described in the Home Health Care Agency System User's Guide at http://cms.hhs.gov/apps/hha/usermanu.asp [large .zip file]. Refer to Appendix A - Casper Reporting. After requesting and viewing the reports, you must save both reports in spreadsheet (.xls) format, to a folder on your computer's hard drive. Make sure you request the same date range for both reports.

The instruction document found at http://www.cms.hhs.gov/HomeHealthQualityInits/downloads/HHQIOASISOBQIRevisedPatientTally.zip provides detail on working with the Patient Tally Report workbook, but to get you started, here are some basic guidelines:

Run your case mix and outcome tally reports and save them to your desired location.
Open the Excel workbook file named "CMSTallyTemplate.xls". From the "Options" menu, choose "Enable Macros." To import the case mix and outcome tally report data, select the "Import New Data" button and click "Go".
On the Patient Tally Data Selection form, click the "Browse" button to locate the spreadsheet file in which you saved the case mix tally report. Repeat this process for the outcome tally report file. You will need to select both the case mix and the outcome reports in order to import your data. The full path and filename for each file will appear in the dialog box.
When both files have been selected, click the "Finished" button. Both files will then be imported into the Patient Tally Report Workbook. It is recommended that you save this workbook under a unique name immediately after import. It is also recommended that you protect the workbook with a password to prevent unauthorized access to confidential patient data.

Performing Queries to Select Cases with Specified Characteristics
The first step in the process-of-care investigation is to select patients who achieved a target outcome and compare them to patients who did not achieve that outcome. As part of this investigation, it may also be desirable to further subdivide these groups of patients to focus on key secondary outcomes. The Excel patient tally workbook can assist in this process by providing the capability to query the tally reports to quickly zero in on patients with selected characteristics. This is accomplished with several query macros that are provided as part of the workbook.

The program allows the user to select and view patients by outcome and case mix criteria. Selections can be "filtered" even further using additional outcome and case mix criteria. Results from different queries can also be combined allowing agencies to focus on only those patients with specific attributes and outcomes and avoiding manual review of lengthy printed reports.

A concrete example will best illustrate this procedure. Suppose an agency selects "Improvement in bathing" as its target outcome. Obviously, the agency will want to compare patients who improved in bathing with those who did not improve. To list the patients who improved in bathing, follow the steps below:

Open the patient tally workbook file in Excel.
From the "Tools" menu, select the "Macro..." option. You will see a list of available macros. Find the macro named "QueryOutcomes" on this list and click on it. Click on the "Run" button to run this macro.
You will be asked if you want to "Specify (more) selection criteria?". Click on the "Yes" button.
You will then see a series of prompts asking whether you want to select cases based on each outcome measure. The first outcome is "Improvement in grooming," which you are not interested in at this time. Click on the "No" button to skip this outcome and proceed to the others.
Continue to click on "No" until the outcome you are interested in, "Improvement in bathing" appears. Click on "Yes" when you are prompted to add "Improvement in bathing" to the selection criteria.
You are now asked whether you want to select patients who did improve in bathing or those who did not improve. Enter the number "1" and click on "OK" to select patients who achieved the outcome Improvement in bathing.
Note that the "Outcome Query" specification box now indicates that you have specified "Improv in bathing = Yes" as a selection criteria. Also, an "X" appears under the "Improv in bathing" label in the first query definition row (row 8991). Since you do not want to specify any other selection criteria at this time, click on "Cancel" to exit from the specification step.
You will now return to the prompt asking if you want to "Specify (more) selection criteria?". Click on "No".
Excel will now perform the requested query and list all outcomes for only those patients who improved in bathing. Note that the Outcomes spreadsheet is now active, regardless of which spreadsheet was active when you ran the macro. Note also that the selection criteria you specified are listed at the top of the screen (in row 8999). Cases that met the selection criteria are listed starting in row 9001. NOTE: If you explore the spreadsheets, you will notice that the data for all of your patients start in row 4 in the Outcomes spreadsheet and row 3 in the Raw Data and Case Mix spreadsheets. The spreadsheets for most agencies will contain a large number of blank rows and some additional header information prior to row 8999. These rows allow the query macros to operate regardless of the number of cases an agency may have.
Although you may be interested in whether these patients achieved other outcomes, you will almost certainly want to look at the start of care case mix characteristics and possibly the raw OASIS data for these patients. There are additional macros that will apply the selection criteria (i.e., patients who improved in bathing) to the Case Mix and Raw Data spreadsheets. To see Case Mix data for patients who improved in bathing, select the "Macro..." option from the "Tools" menu. From the list of available macros, click on the macro named "CaseMixQuery" and click on "Run". You should now see case mix data for all patients who improved in bathing. Note that the Case Mix spreadsheet is now active, regardless of which spreadsheet was active when you ran the macro.
To see raw OASIS data for the same patients, select the "Macros..." option from the "Tools" menu. From the list of available macros, click on the macro named "RawDataQuery" and click on "Run". You should now see OASIS data items for all patients who improved in bathing. Note that the Raw Data spreadsheet is now active, regardless of which spreadsheet was active when you ran the macro.

This example demonstrates how to select patients based on a single criterion. The "QueryOutcomes" macro allows you to specify up to seven levels of selection criteria, and each level can contain selection criteria for any of the outcomes (i.e., 46 selection criteria). The criteria that you specify within a given level must all be true for a case to be listed. If multiple levels of criteria are specified, any case that satisfies at least one level will be listed. Cases that satisfy more than one level of a query will only be listed once.

Printing Reports
The tally workbook also includes macros that allow you to print the entire contents of a tally report as well as the results of a query. There are separate macros for printing all cases in a tally report and for printing only those cases that satisfy the selection criteria of a query. The macros for printing entire reports are called PrintCaseMixReport, PrintOutcomeReport, and PrintRawDataReport. The macros for printing the results of a query are PrintCaseMixQuery, PrintOutcomeQuery, and PrintRawDataQuery.

You must have specified a query (using the QueryOutcomes macro) and, in the cases of case mix and raw OASIS data reports, applied the query (using CaseMixQuery or RawDataQuery) prior to running the macros that print query results. This caveat aside, the procedure for printing is virtually identical using any of the print macros. The steps involved in printing the entire Outcomes Tally Report are as follows:

Open the patient tally workbook file in Excel (if it is not already open).
From the "Tools" menu, select the "Macro..." option.
You will see a list of available macros. Find the macro named "PrintOutcomeReport" on this list and click on it. Click on the "Run" button to run this macro.
Next, you will see a prompt that tells you how many cases are on the report and approximately how many pages the printout will take. If you want to send the report to the printer, click on "Yes." If you want to preview the report on screen, click on "No." If you want to cancel the macro and the print job altogether, click on "Cancel."

In addition to the need to specify and apply queries prior to printing their results, keep in mind that the macros were designed to work with a laser printer using legal-size (8.5 by 14 inches) paper in a landscape orientation. Your printer must be able to support this mode of printing for the macros to paginate and print the reports properly. Use the printed reports for further process-of-care examination to help guide and determine plans of action.

It is important that you use your clinical judgment to determine what criteria to select. Consider what would make a difference when examining processes of care. The Patient Tally Report workbook is a work in progress. One problem that has been identified is the "filter by age" feature. Users also may experience difficulties when accessing CASPER through Netscape rather than Internet Explorer. These issues should be worked out with the next version of the program.

Home Health Outcomes Based Quality Improvment (OBQI)