Identification of Local Problem
The Heart Hospital Baylor Scott and White - Plano (THHBP) needed to enhance their current case review for mortalities and morbidities to improve patient care and offer an ongoing educational opportunity for case management.
Context of the QI Activity
To establish a multidisciplinary team for case reviews within a safe, non-punitive, and educational environment, aiming to identify the root causes of mortalities and complications, enhance patient care, and prevent future complications.
What were the interventions?
A new process, the Phase of Care Mortality/Morbidity Analysis (POCMA), was implemented based on a model adopted from an external facility. (See image 1.1)
- This approach broadened discussions of adverse events to uncover the root cause rather than focusing on the immediate cause, by examining the patient's entire hospital experience ranging from the pre-operative planning and considerations through admission, intervention and recovery, to discharge.
Key enhancements included:
- Facilitation by the Quality Department for every meeting.
- Clearly defined meeting and case review criteria to ensure focus and consistency.
- Standardized case identification using Midas, STS, VQI, NCDR, and staff referrals.
- Fostering a culture of trust and safety within the review environment.
- Mandatory physician and fellow attendance to meet credentialing requirements while earning CMEs.
- Developed a standardized Phase of Care Analysis form to track and document case review findings. (See image 1.2)
- Record phase-of-care details for every case in a structured format to enable future review and trend analysis.
- Offer real time consistent and immediate feedback for physicians who have cases undergoing review and discussion.
Costs and Funding Sources
Full-Time Equivalent (FTE) Allocation:
- Physicians, fellows, and quality staff provide time for physician case review prior to meetings, collaborative discussion during sessions, meeting facilitation, and implementation of follow-up items.
- Time and resources from quality staff for facilitation of case reviews, compiling case review data, generating reports, and tracking outcomes.
- Initial effort to design standardized criteria, workflows, and templates for case reviews.
Overall Results and Analysis
The enhanced case review has demonstrated the necessity of establishing a high-risk conference. Additionally, it has emphasized the need for implementation of numerous new protocols to enhance patient care.
As a result of POCMA, we have introduced several new protocols and guidelines:
- Implementation of Enhanced Recovery After Surgery (ERAS) for all vascular and cardiothoracic surgical procedures
- Creation as well as review and updates of vascular order sets with a pre-checked antiplatelet and statin
- A reduction in the stroke rate and length of stay for patients having carotid procedures
- Identification for the need of an enhanced assessment of high-risk patients and offering case review for discussion and consensus recommendations prior to intervention being done
- Incorporation of a dedicated high-risk case conference into the POCMA process
- Highlighted the importance of specialized training for staff involved in high-risk care
Annual analysis of adverse events by phase of care demonstrated ongoing shifts across phases, reflecting continuous process improvement. (See image 1.3)
Limitations
Historically low attendance:
- To promote an active and robust discussion, attendance is monitored, and CMEs are offered to encourage participation. Our institution also factors in attendance at POCMA as a standard for credentialing requirements.
Physician Engagement:
- Challenges in fostering consistent participation and commitment
- Requires creating and sustaining an environment that promotes transparency, trust, and collaborative dialogue among all team members
Lessons Learned
To sustain continued improvement, the quality department acts as the facilitator for the meetings, following up on action items with all parties involved with process improvement initiatives and promoting a culture of success with the physician champion.
To quickly implement new standards and protocols, it is essential to have diverse perspectives from multiple different service lines and areas of patient care contributing to the review and improvement discussions.
