Quality Improvements in Healthcare

Quality Improvements in Healthcare

Jay Garcia

Clayton State University School of Nursing

Organizational Transitions NURS 4601

October 25, 2012

Dr. Jennell Charles

Quality Improvements in Healthcare

Dear Ms. Haskell,

I would like to take this opportunity to say how sorry I am for the tragic loss of your son at our medical facility. The unexpected death of your beloved son Lewis, as a result of care in our facility, is both unacceptable and inexcusable. Due to this incident, a group task force was assembled at our hospital to analyze the structure, organization, and processes that led to the untimely death of Lewis with a goal of correcting the many levels of error. While this review does little to console you, perhaps it will help you to understand that we are searching for answers and implementing protocols that will ensure this type of accident does not occur in the future.

To promote a patient's safety and clinical improvement, implementation of evidence-based outcomes research is the critical factor we seek to emulate in daily practice. It was developed to examine the status of patients after they receive care and to explore the processes that obtained favorable/unfavorable results. We are hoping that a reworking of our patient-care ? conceptual framework under Donabedian's Model of Quality Health Care will facilitate the use of higher quality evaluation tools. We also seek to impact the formation of policies, guidelines, and procedures for improved safety and risk reduction. Although there are numerous facility changes underway, we will focus on the failures of patient-centered care and teamwork in this discussion, because it most appropriately addresses the failures of quality and safety that led to the death of your child.

The root-cause analysis of your case determined that we lost sight of our most basic priorities of patient-centered care. Clearly, our teamwork and collaboration efforts were disjointed, unresponsive, and dismissive of problems/requests of the family. Our review discovered that the biggest concern in your case is that the patient and the family appear to have been overlooked as a priority member of the healthcare decision-making team. The staff was repeatedly notified of family concerns that Lewis's condition had worsened, yet no serious escalation was attempted by personnel. This mistake, along with a lack of effective communication between the team members, allowed the situation to spiral out of control until it was too late to make the necessary clinical changes that might have saved your boy's life.

In addition, we believe that the skill mix of unit staffing was inadequate for weekend shifts at our hospital. We feel more senior/veteran staffing could have better guided the direction of care, or at least helped in identifying early signs of deterioration in your son's condition. We conclude that there was a distinct breakdown in communication between patient/family, nurses, doctors, and pharmacists which slowed delivery of care and thwarted communication of vital assessment data. Contacting an attending physician for advice regarding a patient's safety should never have been more than a one or two step process. If staff is not fully seasoned enough to deal with a situation such as yours, it is the role of the nursing supervisor and attending physician to address your concerns and be responsive to your requests for information and action. It is this multidisciplinary approach to quality management and risk reduction that leads to optimal outcomes (Hogan & Nickitas, 2009).

Finally, we feel that hospital staff followed a hospital protocol related to medication dosing and fluid control for your child to be in error. (reword) We are sorry for the loss of your loved one due to inappropriate and inadequate care. It is true that our team shares a common goal for all our patients - a positive, efficient, and effective outcome for everyone. We failed most miserably in not sharing that goal, its procedures, and its ongoing evaluation with the most important member of the healthcare team - the patient and the family.

According to Donabedian's model of quality assurance, the issues surrounding Lewis Blackman's death indicate failures at all levels used to measure health care system performance - structural elements, process elements, and outcome results. With regard to structural elements, they incorporate the characteristics of the institution, the provider, and the patient. They may be influenced by things such as the nurse-to-patient ratio, the availability of better technologies, hospital size, and physician training. In the case of Lewis Blackman, nurse and physician training repeatedly became a theme of incompetent care. Regardless of protocol (they were using an inappropriate protocol for procedures on this child), the seasoned physician or nurse may need to rely on clinical experience and the patient's status when the protocols are in question. At the very least, they should be checked with other knowledgeable staff to see if there are safety concerns. The fact that Lewis was receiving too little IV fluids for his size, that no nurse noticed his lack of urine output for many hours, and that the physician did not catch the inconsistencies in care parameters related to this patient, leads one to the belief that Lewis received inadequate, incompetent, and irrational medical care that lead to his death in a matter of four days. In this category we must include refusal or inability of medical team members to adequately communicate with others (nurses, doctors, family, attending). (would this be a breakdown in process?)

The process elements in Lewis's case are even more disturbing. Since process elements are associated with the treatment process, the stages of treatment, and appropriateness of treatment, one can recognize that Lewis' complications were inextricably tied to a general overall failure of process. Perhaps an extension of clinical incompetence within

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