Anthropometric Measurements

QAPI PROGRAM
PERFORMANCE IMPROVEMENT PROJECT (PIP) #3
LOCATION: Alpine Hospice DATE INITIATED: 2/1/10
PIP TITLE: Anthropometric Measurements
Statement of the Problem and Supporting Data: Routine medical record audits have
revealed that clinicians do not always record patient body measurements (e.g., height &
weight and mid-upper-arm circumference) during their assessments. Anthropometric
measurements may be useful in demonstrating decline in the patient’s condition. Without
documentation of patient body measurements over time, it may be difficult to determine if a
patient is declining and qualifies for hospice services.
Rationale for Conducting the PIP: The hospice wants to ensure that the patients it
serves are terminally ill with a life expectancy of six months or less if the terminal illness
runs its normal course. Decreasing weight, mid-upper-arm circumference, and/or
decreasing abdominal girth, not due to reversible causes such as depression or use of
diuretics, may be predictive of disease progression.
Goals and Objectives
(1) Nurses will measure and document mid-upper-arm circumference or
abdominal girth for each hospice patient within 48 hours of admission to the
agency.
(2) Nurses will document the hospice patient’s height and weight (if patient
ambulatory) within 48 hours of admission to the agency.
(3) Nurses will measure and document mid-upper-arm circumference or
abdominal girth for each hospice patient every two weeks.
(4) Nurses will document each hospice patient’s weight (if patient ambulatory)
every two weeks.
Project Activities
(1) Data from mock surveys and quality audits over the past quarter were
analyzed to determine trends in nursing documentation of anthropometric
measures.
(2) Results of the data analysis and the quality improvement plan will be
presented to the QAPI Committee.
(3) The plan will be implemented in all hospice agency locations; results will be
monitored monthly and reviewed by the QAPI Committee quarterly.
(4) The plan will be revised as necessary.
Project Progress/Findings:
Data: Over the 4 th quarter, 44 medical records from the Brigham City, Heber, Logan,
Ogden, Orem, and Salt Lake City offices were reviewed. Of the 44 records audited,

18% (8/44) contained nursing documentation of mid-upper-arm circumference within
48 hours of admission to the agency, and 18% (8/44) contained documentation of the
patient’s height and weight within 48 hours of admission.
Plan for Improvement
Threshold
(1) The Clinical Director or designee from each office site will be responsible for
collecting data related to the measuring and documenting of mid-upper-arm
circumference or abdominal girth and height and weight on the nursing
assessments.
(2) The Clinical Director or designee will educate his/her nursing staff on the
requirement for the routine measuring and documenting of anthropometric
measurements.
(3) The Quality Improvement Manager will provide in-service training to the
Clinical Director or designee (i.e., auditor) on audit procedures and use of the
audit tool.
(4) The auditor will randomly select medical records to review each month. The
quantity chosen will equal at least 25% of the office’s average daily census
(ADC). For example, if the ADC for the previous month was 30, the auditor
would review 8 medical records.
(5) The auditor will submit completed audit tools to the Quality Improvement
Manager by the 7 th day of the following month.
(6) The Quality Improvement Manager will collect and analyze the data,
observing for trends or patterns, and report findings and recommendations
for improvement to the QAPI Committee each quarter.
(7) The QAPI Committee will review findings and recommendations each quarter
and revise the plan as needed to improve outcomes.
(8) The Clinical Directors and Quality Improvement Manager will collaborate to
ensure auditors and clinical staff members receive ongoing feedback on
compliance findings and information on any revisions to the performance
improvement plan.
90% for all criteria
Methodology
Data Sources: Initial Nursing Assessment, Recertification Nursing Assessment, Nursing
Progress Note
Data Collection: Quality assurance audit tool
Process: Clinical Record Review of 25% of average daily census (ADC)
Frequency: Monthly