In early 2016, a Medicare beneficiary's family member contacted KEPRO – the Beneficiary and Family Centered Care-Quality Improvement Organization (BFCC-QIO) for that state – with a complaint regarding the patient’s postoperative care. Following hip surgery, the patient had received medication and, a few days later, was found in the hospital room not breathing. The hospital called a Code Blue and transferred the patient to the intensive care unit (ICU), where the patient recovered before being discharged. Afterwards, KEPRO reviewed the case and determined that the standard of care delivered by the hospital needed to be improved. The BFCC-QIO notified the hospital and transferred the case to Alliant Quality – the Quality Innovation Network-Quality Improvement Organization (QIN-QIO) for Georgia and North Carolina – to help the hospital perform a root cause analysis and work through the quality improvement process.
This BFCC-QIO and QIN-QIO collaboration enables complementary steps towards improving quality of care. "The BFCC-QIO’s case review at the national level provides a standardized intake and review process," says Dr. Adrienne Mims, Vice President and Chief Medical Officer at Alliant Quality QIN-QIO. "Then, when QIN-QIOs work with facilities on quality improvement cases at the local level, we can truly focus on changing processes of care. Facilities are really receptive and engaged with us."
Alliant Quality guided the hospital's review process, beginning with a root cause analysis to determine what went wrong, whether the case reflected a pattern, and how the quality of care could be improved. Upon review of the full patient chart, from admission through discharge, the hospital review team found several issues regarding prescription dosage and timing, duplicate ordering of similar medications, and monitoring for slowing of respiration. Further, the hospital performed a retrospective chart review of 30 similar cases and found many instances of these issues.
"We often talk about narcotic abuse, but there's a whole other area of appropriate and safe use of opioids that's important to seniors," says Dr. Mims. "Many seniors are opioid naïve and extra sensitive to opioids, so we unwittingly put them in danger when we treat them the way we would treat a younger person with pain."
"We often talk about narcotic abuse, but there's a whole other area of appropriate and safe use of opioids that's important to seniors."
Realizing that they were at risk of endangering patients repeatedly, the hospital stepped up to make big changes. It implemented new process improvements and training for each problem area, including the purchasing of smaller opioid dose volumes, improving pharmacy communication and alerts, and requiring medication instructions and nurse respiration monitoring.
The hospital sent the QIN-QIO quarterly reports on its improvement progress throughout 2016, assessing 30 charts on the same four measures. By the third quarter, the hospital had achieved 98 percent success on three of their four measures, and the potential for improvement didn't stop there. The hospital looks forward to promoting its findings to all 67 medical facilities (hospitals, clinics, urgent care, rehabilitation centers) in their system.