When a Medicare beneficiary with stage 5 chronic kidney disease (CKD) entered hospice in early 2016, the beneficiary’s family was concerned to learn that the necessary medications used for comfort care (known as a Comfort Kit) were not available when the patient had an increase in pain and shortness of breath the day after admission. The beneficiary's family member subsequently contacted Livanta – the Beneficiary and Family Centered Care-Quality Improvement Organization (BFCC-QIO) for that state – with a complaint about the lack of availability of the Comfort Kit and the resulting delay in comfort care. Livanta confirmed the quality of care concern and referred the case to Qualis Health – the Quality Innovation Network-Quality Improvement Organization (QIN-QIO) serving Idaho and Washington – to help the hospice provider review the case and evaluate its improvement plan.
After performing a root cause analysis and a retrospective audit to identify any similar delays in medication access for comfort measures, the hospice quality team determined that the complaint represented a single isolated occurrence of a family’s dissatisfaction with the symptom management provided. The team consulted the Medicare Conditions of Participation and the state’s hospice and palliative care association, and determined that their organization was meeting national standards and its own standards of care. Yet, despite the absence of a systemic process problem, the team took the complaint seriously and assessed additional opportunities for quality improvement.
“One complaint opened a window to identify and implement fundamental process revisions, and to share improvements in medication ordering and delivery within the whole system.”
As they examined the process to acquire the Comfort Kit, hospice quality team members looked for opportunities to shorten the length of time between admission to hospice and the family’s receipt of a Comfort Kit. Originally, specialists and primary care physicians within the health care system ordered medications for hospice patients – a decentralized process that led to communication gaps and delays. Under the new streamlined process, the hospice physician group began ordering all scheduled drugs for hospice patients to improve efficiency. The hospice quality team also identified an alternative process for delivery of the Comfort Kit, using the health network’s transportation system to enable delivery within hours.
Improvements in acquisition and delivery processes further enabled the hospice provider to help families receive all medications in a timelier manner – not just Comfort Kits, but any medications urgently needed before the kit arrives or once drugs are initiated. Once hospice nurses assess the need for any urgent medications at the initial visit (and all ensuing visits), they can implement different delivery options based on need. Using a courier service, pharmacies close to the family's residence, and volunteer staff, urgent medications can be processed and delivered in as little as one to two hours.
The hospice provider sent the QIN-QIO monthly reports monitoring patient complaints and has registered no complaints related to delays in receiving medications or concerns with symptom management for hospice care since the implementation of their plan.
“It’s important to recognize how a single complaint led to looking at an overall process – the process of ordering, receiving and delivering medications for all patients, beyond the Comfort Kit and beyond one family’s concern,” says Evan Stults, Communications Director for Qualis Health. “One complaint opened a window to identify and implement fundamental process revisions, and to share improvements in medication ordering and delivery within the whole system.”