Improving Healthcare: One Man's Story
Note: Details regarding the patient and nursing home discussed in this article have been changed to protect confidentiality.
People with Medicare coverage like Ohio’s James Wilson, 77, are changing America’s healthcare system for the better.
Wilson, a retired pipe fitter, may not seem like the kind of person you would suspect would be helping healthcare providers improve the quality of their care. In a life filled with grandkids and hobbies, Wilson hadn’t given much thought to what ails America’s healthcare delivery system—until his hip surgery.
Wilson called 1-800-MEDICARE (1-800-633-4227) because he “just didn’t feel good” about the care he received at Blue Skies Nursing and Rehabilitation Center following his hip surgery.
Wilson was especially bothered that no one at the nursing home told him whether his hip incision was infected. His doctor said that this was something that needed to be checked. He wondered if other “balls were being dropped” by the busy nursing home staff.
Wilson was right to voice his concerns. Experts have long advised that patients, and their loved ones, must be their own advocates if they want to ensure that they are getting quality care.
Wilson saw on the paperwork he signed when he was admitted to Blue Skies that he should call 1-800-MEDICARE if he had a complaint about the quality of his care. So he did.
Medicare referred him to the Quality Improvement Organization (QIO) in his state. (Every state has a QIO; Qualis Health performs this role in Idaho and Washington.) The call was handled by an experienced professional. Wilson could tell she had been doing this work for some time because her questions went right to the heart of the matter: “What concerned you? Did you tell your doctor, or any of the staff at Blue Skies, about your concerns? Have you or your family talked to the nursing home’s staff about your concerns?”
Wilson had no way of knowing how important his call could be. “Red flags” like this often lead to real improvements in healthcare delivery.
The QIO requested Wilson’s medical record from Blue Skies and reviewed it to see whether he received appropriate care: Did he have a care plan? Had his incision been checked for infection?
It was found that, despite the doctor’s order, there was no record of Wilson’s hip incision having been checked for infection. Also, the QIO’s staff could not find any evidence of his care plan. A care plan is a basic document that every nursing home should complete for each patient.
The information in the medical record led the QIO staff to request that Blue Skies submit a quality improvement plan showing how they would work to prevent this type of concern from happening to other patients.
You might think that a healthcare provider would be unhappy to learn that an outside organization was checking on the quality of the care it delivers. However, the opposite is usually true. In fact, healthcare providers often welcome outside help on quality issues. They understand that even the best healthcare provider has to constantly check the way that things are done to ensure that quality stays high.
At Blue Skies, the staff welcomed the QIO’s offer to assist them in building a quality improvement plan. It helped them set up a system to ensure that a care plan is created for all Blue Skies patients when he or she is admitted, and that every care plan is updated at least quarterly. In addition, the quality improvement plan also required that doctor’s orders (like the one telling Blue Skies’ staff to check Mr. Wilson’s hip incision for infection) be checked daily.
Soon after the quality improvement plan was put in place, the QIO checked patient records and found that doctors’ orders were being followed 98% of the time. Also, care plans had been created for 89% of patients. A check three months later resulted in an A+ for the nursing home: all doctors’ orders were being followed and all patients had care plans.
The QIO staff are no longer reviewing Blue Skies’ patient charts, but work with the facility is ongoing. The staff members at the nursing home owe a debt to James Wilson. He brought to light his quality of care concerns and helped Medicare improve healthcare.
To contact the QIO in your state, call 1-800-MEDICARE (1-800-633-4227).
Learn how to file a Medicare quality-of-care complaint in Idaho or Washington.
Adapted by Qualis Health from materials provided by the Communications QIOSC and prepared under a contract with the Centers for Medicare & Medicaid Services (CMS), an agency of the U.S. Department of Health and Human Services. The contents presented do not necessarily reflect CMS policy.