[Outcome based quality-improvement methods in visiting nursing services (VNS) in Japan: practical report and...

For the execution of the nation's public long-term care insurance in the year 2000, and Quality Improvement (QI) of visiting nursing services (VNS) will become extremely important in Japan. Some standard methods to evaluate structure or process in VNS have been published but there is no report of actual QI performance based on outcome measurement in each VNS institution. Modifying the method introduced by JCHO in USA, we performed QI using one negative outcome "unexpected cessation of home care" as a monitoring outcome measurement. In three VNS institutions variously located in Japan, cases of unexpected-cessation in one year were monitored retrospectively, then blindly assessed by nurses. Cases were categorized into "avoidable cessation" or "unavoidable unexpected-cessation", and for the "avoidable" cases the kinds of improvement that would be necessary to avoid this type of unexpected-cessation in the future were discussed. Depending on the situation of the facility, some of the suggested improvements were executed within possible ranges. The numbers of unexpected-cessation of home health care in each institution were 89, 58 and 15 with incidences from all the cases in one year of 46%, 40% and 42% respectively. In these cases, 47, 39 and 15 cases were categorized as "avoidable". Generally, improper nursing assessment in changes of patients' physical condition was the biggest cause of home health care unexpected-cessation. Although some institution were not able to accomplish any part, each institution were able to capture their unique problems and made a detailed specific QI plan to avoid cessation of home care in the future. The two main problems in feasibility were "the analysis took too long (8-9 hours)" and "part-time staff member could not participate". This simple modified QI method provides useful Quality Improvement of Japanese VNS with a limited staff. However, to facilitate execution, a much fairer recognition of the importance of QI, computerization or the partial consignment to a third party, and investigation over a shorter period were considered to be effective.