Complications paint incomplete quality picture
Too few details in most counting systems
By Patrice Spath, ART
Consultant in Health Care Quality and Resource Management
Forest Grove, OR
Complication counts are an example of how data gathered from a routine process can be deceiving when you are trying to improve the actual quality of care in your hospital. The shortcomings of such counting systems also show how easy it is to miss golden opportunities to improve processes in your facility.
Many hospitals count the number of complications that occur for a patient during a given hospitalization. This number is used to measure the "quality" of care provided. Although such counts may be easy to obtain, in many instances this raw number is not a meaningful performance measure.
The mere fact that something untoward happened to the patient is not, in itself, a gauge of quality because many factors can affect the patient’s development of a problem. Variables such as the patient’s clinical condition and predisposing health factors, expected complications of the treatment, natural course of the patient’s illness, and many other issues that may be outside the control of the health care provider can influence the development of a complication.
Many techniques are available to control for patient variables. The most well-known of these are the severity-of-illness classification systems. However, even the best patient risk adjustment methods cannot account for all the factors that affect patient outcomes. Because of these drawbacks, even the use of comparative data to benchmark patient complication rates can be futile.
How can providers make better use of complication rate data to improve the quality of patient care? The answer lies in closer review of significant events. Upon identification of a complication, physicians and other health care practitioners can evaluate the individual situation to identify issues that represent inappropriate patient management or system failures that contributed to the event.
When caregivers moved away from case-by-case review in the early 1990s, they began to rely more heavily on aggregate performance data for identifying improvement opportunities. Today, complication rates are reported, but individual cases are not investigated unless the overall rate exceeds a predetermined threshold of acceptability. However, the case-review experience, while more time-consuming, reveals much more than numbers alone.
The review of complications has traditionally been delegated to the medical staff and may occur in morbidity/mortality conferences or peer review committees. Unlike the medical staff, most hospital departments have not taken an active role in evaluating patient complications. Perhaps this is due to the nature of most complications, which may seem to be beyond the control of the nonphysician practitioner. However, review of patient complications by all members of the health care team can uncover recurrent system failures that must be addressed by the nonphysician providers. Improving business processes in the organization can help reduce or eliminate future patient care complications.
Without case-by-case review of significant complications, it may be impossible to recognize recurrent situations that contribute to untoward events. For example, consider the patient care situation described below:
A hospitalized patient with culture-proven bacteremia failed to receive parenteral antibiotics for three days. The antibiotics were started by the emergency department physician, who ordered a 48-hour course (allowing the attending physician to later make a decision regarding choice of antibiotic therapy based on the culture report).
The attending physician did not notice that the drug order stopped in 48 hours, and consequently the patient did not receive any parenteral antibiotics for three days. On the third day the patient’s nurse noticed the patient was not getting antibiotics and contacted the physician for orders. Antibiotic therapy resumed and the patient recovered, although the period of illness was longer than would have been expected if the antibiotics had been given continuously from admission.
This scenario might be reported to the Utiliza tion Management Committee as a discharge delay event, or might appear on a Risk Manage ment Report as a medication administration delay, but these performance measurement numbers don’t tell the whole story. This hospital has a system problem lack of communication between caregivers that is causing untoward events to occur. While this communication problem might cause another discharge delay or medication error, it is just as likely to cause a different type of untoward event to occur. And next time, the system problem might cause a much more serious event to occur.
If caregivers are only reviewing performance measurement data and not looking more closely at the situations surrounding the events, they are unlikely to notice when one root cause produces several different types of undesirable incidents.
Spot potential problems through case studies
To initiate regular review of complications by the multidisciplinary team, the quality management staff should identify cases that represent potential system problems. Using an existing multidisciplinary committee, the records of patients experiencing complications are evaluated by committee members. If no such committee exists, it may be necessary to form a task force for the sole purpose of complication review. The goal of the case review process is to identify system failures, not individual practitioner problems.
Case review forms are completed for each situation evaluated. (Shown on p. 83 is a sample case review form for the group to use.)
The group uses a consensus process to make final determinations of which system issues are root causes of complications. This "cause" information is integrated with performance measurement data. For example, in addition to reporting the number of complications that occur each month, the quality management department also reports the number found to be "preventable" or found to be caused by various types of system problems.
Multidisciplinary complication review must be promoted as educational, not punitive. The goal of the review is to identify the root causes of undesirable events and correct the problem. The findings of case-by-case complication review provide important information that supplements aggregate complication rate reporting. Complication review can also be an important learning experience for the committee members.
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