In February 2012, HSAG Arizona, the state’s QIO, completed a review of care for a 91-year-old patient who had surgery for a hip fracture at a Phoenix-area hospital and experienced unnecessary pain and suffering due to the hospital’s inappropriate management of postoperative pain.
After HSAG contacted the facility regarding appropriate quality improvement activities to address this issue, the 400-plus bed hospital saw an opportunity for facility-wide improvement. The hospital’s pharmacy department developed a system for generating automated reminders to nursing staff regarding pain management, while the hospital met with nursing staff to alert personnel to this incident and reinforce education regarding analgesia. The hospital also reached out to the beneficiary’s daughter, who attended a staff meeting about the profound impact that care decisions make on patients and their family members.
HSAG was the catalyst for this innovative approach toward the delivery of better care and active engagement.