Medical Examiner

A Hospital’s Most Important Secret System

What happens after something bad happens.

Delivery room.
When something goes wrong here, Quality Improvement Committees are there to find out why and try to make sure it doesn’t happen again.

Photo by Mariusz S. Jurgielewicz/Shutterstock

Every two weeks, the Quality Improvement Committee meets in a windowless room. Some people’s names are called; they leave because they were involved in the adverse event. Everyone else stays. They hear the story. They ask questions. They look at the documents. They make a decision.

Most people don’t know that some version of a QI committee exists for every department of every accredited hospital in this country. The committees are one of the most important safety features in medical care today. I’ve been lucky enough to serve on these committees, both as a trainee and as more senior staff.

You may not know about QI committees, the way you don’t know how the surgical instruments used in the operating room are sterilized, or how the biohazard garbage is taken away, or how the blood tubes used for testing are zipped to the lab. The hospital is made up of a thousand secret systems, most of them behind walls and curtains, and most of them don’t matter to patients in any immediate way.

But then something bad happens, and this particular system becomes important. That’s because QI committees mean that when something bad happens, everyone is looking to see what happened: looking back, but also looking forward, to try to make sure it doesn’t happen again.

We have a long way to go until hospitals are as safe as we want them to be. Quality improvement programs have been working, slowly and steadily, for a long time to improve outcomes as diverse as reaction time to heart attack, appropriate antibiotic treatment of pneumonia, and of course care in pregnancy. This kind of work—iterative, incremental, numbers-heavy—is the slower story behind many exciting headlines about outcome improvement. But very few people outside of medicine know how this work is begun.

So what does a QI committee talk about? In most hospitals, certain types of cases require QI investigation and generate an automatic referral. For example, an unexpectedly low Apgar score in a newborn, or a very large amount of blood loss in a surgery. But in most institutions, any hospital employee can refer a case to QI at any time, for any reason, and that’s a large part of its effectiveness. Because sometimes something bad didn’t happen—but it almost did—and the staff wants to make sure there’s no near-miss next time.

Here’s one example, referred for low Apgar scores: Patient X is admitted in labor. Everything seems OK, but she ends up pushing for a long time before delivering Baby Z. Baby Z requires resuscitation by neonatology in the delivery room, admission to the neonatal intensive care unit, and a breathing tube to help it breathe. By Day 2 of life, Baby Z quickly recovers, and the breathing tube is removed. Baby Z goes home, healthy, on Day 3.

But even so—even though Baby Z went home, with Mom, on schedule, without lasting damage—the committee still needs to figure out what happened.

This doesn’t mean there’s blame, or even that things could have been done differently. Sometimes stuff just … happens. As one of my best medical teachers said: “The human body doesn’t always follow the textbook.” But did the medical staff cause harm? Were they ready for foreseeable problems? They have to figure that out. That’s what QI does.

The committee starts with the timeline. The bare facts of the case are collected, but that timeline is just the beginning. The QI committee member assigned to the case then has to go through the record to look at everything—everything—not just the happenings close to the adverse event. The member brings the records to the committee so all the questions can be asked: Was prenatal care appropriately administered in the months before this admission? Was the decision to admit or induce or augment Patient X’s labor a reasonable one? Was the admission note properly documented by an attending physician, within two hours of admission? Was the fetal heart tracing reviewed appropriately by both nursing and medical staff? Was appropriate lab work ordered, drawn, reviewed?

It’s not easy work.

At the end, the committee members discuss. Was this avoidable? Would another reasonable provider have made the same decisions? Do any of the providers need to be educated, or counseled, or (very rarely) disciplined?

And then the committee moves its attention up a level from the individual; this is where most of the important work is done. Is there a system problem here, one that needs to be sent to an administrative level, to be fixed by policy change or educational initiatives? Does the hospital or department need to change the physical location of supplies, or make certain medications more accessible? Does it need to rethink communication: between nurses and doctors, or between obstetrics and pediatrics, or obstetrics and anesthesia?

QI is not your grade-school principal’s office. The committee members know that they are watching the work of highly skilled, devoted, competent people who want only the best for their patients. So it’s not their role to yell, or shame. It’s their role to figure out what could have been different, what could have changed what happened. Sometimes, the hardest answer may be “nothing.” But it’s important that the question is asked.

Now it’s Tuesday night, and you’re staffing the labor floor. You have a patient who is fully dilated, now pushing, and it’s been a while, almost three hours of pushing. Has it been too long? You think back to Baby Z. You ask yourself: Am I making the right decision here? You flip through the chart to review the labor curve again; how big did we think this baby was? Maybe you ask your partner on call with you that night to double-check that you’re making reasonable decisions. She looks at the fetal heart tracing and agrees with you. Together you make the plan to reassess the labor progress in 30 minutes; as much as you’d like to avoid it, you’ll give serious thought to offering a cesarean section if progress is not occurring as it should.

Twenty minutes later, a beautiful baby is born. You are prepared for difficulty, with pediatricians in the room and extra nursing help at the ready outside, but there are no low Apgars, no neonatal resuscitation, no NICU. A beautiful, chubby baby is curled on her mother’s bare skin, clenching tiny fists; her mother can’t look away from her. The father is folding his tall frame over the bed rail, making inarticulate phone calls while holding her tiny foot.

This, too, can be the result of the QI committee’s work.