QIO helps hospital achieve dramatic results
QIO helps hospital achieve dramatic results
From sanction to JCAHO Gold Seal of Approval
In late 2002, a hospital-based cardiac surgery center in Florida received an initial sanction notice from the Florida Medical Quality Assurance, Inc. (FMQAI), the state’s QIO. Today, it is the proud recipient of JCAHO’s Gold Seal of Approval for coronary artery disease care.
What led to such a dramatic turnaround? It was a combination of help and advice from FMAQI, along with a desire on the part of the hospital’s quality staff to go above and beyond the recommendations of the QIO.
"We became involved through a request from CMS’s regional office in Atlanta," recalls Cheryl Cook, RN, FMQAI beneficiary protection community of practice leader, who notes that the hospital would only share its story under condition of anonymity. "We had received specific information about the facility, and concerns about the quality of care being delivered to open-heart surgery patients." Following the request from CMS, FMQAI, as it does in all such cases, reviewed the facility’s records in order to give guidance on prevailing standards of care regarding the complaints. "In the course of our review and research, we discovered some medical record cases that we considered outliers — where patients had to be returned to surgery for complications," Cook reports. "We also identified opportunities where they could improve."
What FMQAI saw
These opportunities included, for example, improvements in documentation. "They had an automated system in place for the recording of their lab studies, but they did not have a paper copy on the charts," Cook notes. "Potentially, a patient could go to the OR, and if their system were down, they could go to surgery without an anesthesiologist looking at lab values. While that may be very unlikely, it showed an opportunity to improve by always having a paper copy."
In addition, these particular patients had an unusual amount of weight gain post-op — in excess of 20 pounds on post-op day one. "This raised a bit of a red flag, because in my past experience as a clinical nurse, this had not happened," notes Cook. This weight gain, which was water weight, could have been due to the use of a lot of IV fluids during surgical procedure, or a lot of blood products.
"In addition," says Cook, "documentation itself could have been improved — in several cases, it was hard to decipher from the medical record exactly what had happened."
The action plan
After reviewing the charts and identifying opportunities for improvement, the QIO asked the facility for its input on the findings. "Then, it went back to our physician reviewers for final determination, and they felt as though these were quality issues that were significant and needed immediate attention," says Cook. "That was the point at which the sanction was issued."
Sanctions, Cook further explains, are justified if a significant number (three or more) of cases are discovered that raise important quality issues. But the sanction, while it can potentially lead to loss of accreditation, "allows for an action plan to be created," she notes. It is then up to the hospital to work with the plan and improve its performance.
"We discussed our concerns with the facility and asked them to go back and do some root cause analyses, and bring back to our organization a proposed action plan," says Cook. "Then, it was reviewed internally, some suggestions may have been made to tweak it, and final approval was given."
Improvement plans included:
- completion of nursing assessment;
- physician’s orders completed within a defined timeframe;
- management of the patient’s post-operative weight gain with a goal of no more than 19 pounds;
- documentation of pre-operative laboratory studies on the patient’s chart.
Policies and interventions
The first two items, says Cook, also relate to documentation. For example, in terms of nursing assessments, all hospital have policies that say nursing assessments will be completed and done in "x" hours upon admission and repeated every so often. "This may differ based on the level of care provided," says Cook. In any event, the hospital held inservices on the policy and then conducted follow-up audits to ensure compliance.
A similar tack was taken with physician orders, with staff being re-inserviced, and an audit following.
In terms of the overweight patients, certain interventions were instituted in the OR to monitor IVs more closely. Anesthesia staff and CRNAs received inservice education, and a new look was given to the tools being used to document the amount of fluids being administered. "They also put in place a new QI team," says Cook. "If any patient comes out of the OR and gains 20 pounds, they will go back as a team and look at where there might have been opportunities to prevent it."
For the final item, a new policy was adopted that required a hard copy of lab studies on every chart.
Above and beyond
Three to six months after such an action plan is instituted, the QIO pulls medical records to validate whether the actions the facility stated it would take were actually in place. In this instance, they were.
Simply adhering to the QIO’s recommendations, says Cook, would not in and of itself have led to the Gold Seal award. "In several cases this facility went a step beyond," she says. "For example, they put together a QI team that looked at the entire surgery process. And the Gold Seal was not just for surgery; they looked at AMI care, cardio interventional services, and open heart surgery."
Continuum-based approach
According to JCAHO, organizations that attain this certification "stand apart from the rest" because they have demonstrated a "continuum-based approach to chronic condition management" that:
- supports a patient’s self management activities;
- utilizes a standardized method of delivering or facilitating integrated and coordinated clinical care based on clinical guidelines or evidence-based practices;
- tailors treatment and intervention to individual needs;
- promotes the flow of patient information across settings and providers, while protecting patients’ rights, security and privacy;
- analyzes and uses data to continually improve treatment plans;
- evaluates ways to improve performance and clinical practice, thereby improving patient care.
While a process like this may not be something quality managers would actively seek, if it does happen they should view it as an opportunity, Cook advises.
"I think it’s an opportunity for quality managers to take a look at their processes and work problems out with their QIOs," she says. "When you work with an outside person, sometimes you get a more objective viewpoint and see more opportunities to improve."
Need More Information?
For more information, contact:
- Cheryl Cook, RN, FMQAI Beneficiary Protection Community of Practice Leader, Florida Medical Quality Assurance, Inc., 5201 W. Kennedy Blvd., Ste. #900 Tampa, FL 33609. Phone: 813-865-3255. Fax: 813-354-0737.
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