"Miracle on the Hudson" - Are There Lessons for Hospice Quality Improvement Programs?

Captain Sullenberger’s experience and leadership skills were key components in landing Flight 1549 with 155 survivors safely in New York’s icy Hudson River last month. In his biography portraying his 40+ years of experience in the aviation industry, he is described as having a history of achievement in safety, innovation, crew training, operational improvement, productivity improvement and customer service, and proven ability to maximize crew performance and flight safety. He is described as a strong communicator, effective negotiator and motivational team builder (http://safetyreliability.com/profiles). His company, Safety Reliability Methods, Inc., provides consulting to businesses, including health care companies that want to adopt the strict quality concepts used in aviation to their own settings. We have all heard on the news lately that an essential key to success in aviation safety is the integration of people, procedures and equipment. These essential components seemed to come together in perfect harmony on January 15th under Captain Sullenberger’s focused leadership.

So What Do Hospice QAPIand Aviation Safety Have in Common?
Hospice’s overall mission is to ensure the well-being, dignity and comfort of a patient and family facing life’s last physical journey, with a patient and family-centered plan of care ("POC") guiding the way. Because the POCis such an important navigating instrument for hospice staff, it’s no surprise that failure to adhere to the POCcontinues to be one of the leading deficiencies found by hospice surveyors. Successful integration of hospice’s "people, procedures and equipment" (or resources in our case) is as essential in hospice care as in aviation safety and is the key to avoiding deficiencies based on the POC. 

Because CMS wants to ensure that hospice patients and their families have the best care at journey’s end, the hospice CoPs have specific new requirements, including what must be included in the patient assessment and POC. Hospices must also reassess, review and revise the POCat set frequencies. Under the revised CoPs, the POCmust be an evolving document based on the ongoing assessment of patient needs and not just a paper exercise. Under the revised CoPs, the registered nurse plays an important role in "piloting" the hospice toward compliance with these new requirements and in ensuring that the interdisciplinary POCis implemented.

In the November 2008 surveyor training on the new hospice CoPs, CMS included examples of common survey findings related to the POC. In the CoPs, CMS states that quality assessment performance improvement ("QAPI") efforts should be focused on high-risk, high-volume, problem-prone areas affecting palliative outcomes, patient safety and quality of care (Basic Hospice Agency Surveyor Training, November 2008 — Lesson 6: slides 6–10). So it follows that surveyors will focus heavily on the POCin evaluating compliance with those mandates.

In Scenario 5 of the training (Basic Hospice Agency Surveyor Training, November 2008 — Lesson 4: page 12) a patient is admitted to hospice with a diagnosis of bladder cancer. The initial assessment notes blood in the Foley catheter bag, but the POCand subsequent interdisciplinary group reviews of the POCover several weeks fail to note any interventions related to the hematuria or care of the Foley catheter. The situation deteriorates to the point where the patient has abdominal pain and the nurse tries to irrigate and replace the catheter that is now occluded by large clots. Asubsequent ERvisit ensues. During a survey, the surveyor notes that the record contains no documentation that the nurse had physician orders to irrigate or replace the Foley catheter. The hospice now faces a condition-level deficiency based on harm to the patient.

How Should the Hospice Use Its QAPI Program to Avoid This Situation? 
Patient-level data, after several chart reviews, might reveal that the hospice has a problem incorporating all pertinent assessment data into the POC(including interventions and goals related to the medical care needs of the patients), does not follow standards of practice (related to acquiring physician orders and implementing appropriate medical interventions) and fails to achieve specific goals (avoiding emergency admissions). 

In considering how the CMS Cycle of Care Model integrates with the CMS QAPI Loop Model, we could see the hospice broadening patient-level data into a full-blown Performance Improvement Plan leading to subsequent changes in patient care policies and procedures.

Now, consider if the following hypothetical information were found once the hospice started digging into the data looking for common threads: Most patients with incomplete plans of care with or without emergency admissions occur when patients are admitted on the weekend by an on-call nurse without accurate and/or timely discharge information from the hospital or referring physician.

It’s clear to see which policy and process improvements need to be adopted, implemented and then reevaluated to see if the improvements are sustained. As is the case with aviation safety, the CMS concept models for QAPI provide schematic, integrated approaches toward achieving and sustaining quality care and operations.

For more information about this article, please contact Cindy Morgan of AHHC of NC at 919.971.8731 or cindymorgan@homeandhospicecare.org.