In September 2023, Kathie Zhang, MD, Chief Resident for Quality and Safety in the Department of Internal Medicine at University of Iowa Health Care and physician in the Iowa City Veterans Affairs Health Care System (ICVAHCS), and the rest of her quality improvement (QI) team—called the Narcan Improvement Team—received a HeRO award, an honor in the VA system, which is used to recognize notable strides toward sustaining the VA as a high reliability organization (HRO).

The ICVAHCS is a part of a regional group of VAs that together make up a Veteran Integrated Service Network (VISN). The national VA entity hosts a quality improvement competition among VISNs every quarter. This competition honors one team from each region with a HeRO award, with the winning project then being elevated to the national competition.

Zhang’s winning team is composed of Internal Medicine residents Jeremy Zhang, MD; Tommy Robinson, MD; Michael Sauer, MD; Sarah Von Dorin, MD; Lauren Zabel, MD; VA employees Emily Peters, RN, and Yvonne De Sloover Koch, PharmD. The team published their results in the American Journal of Medical Quality, titled Preventing Opioid-Related Toxicity at a Regional VA Medical Center: A Resident-Led Interprofessional Quality Improvement Project. Clinical Assistant Professor Matthew Soltys, MD, served as senior author and faculty facilitator.

“There are three pillars to high reliability organizations,” Soltys said. “One is leadership commitment, one is culture of safety, and another is continuous process improvement. At the local level, you can be nominated for the HeRO award in different clinical and non-clinical categories. I’ve had the privilege to work with Dr. Zhang, and it’s been an amazing experience being the mentor of this team.”

Soltys nominated the team for the HeRO to recognize their project’s success and their overall contribution to veteran care. “I would say 75% of the care provided at the VA comes from trainees in some form or the other, and a lot of times there isn’t visibility into what they’re doing because they’re not VA employees. One way we can share the great work they are doing is through these HeRO awards.”

The Narcan Improvement Team was established to increase naloxone prescriptions at the ICVAHCS. The drug, known widely by the brand name Narcan, reverses opioid overdoses with no major side effects to the patient.

The Narcan Improvement Team kept the project within their small QI group in its first year, working with approximately 300 patients. Before the team’s intervention process began, the prescription rate for qualified patients was around 30% for this group; by the end of the first year of the project, it had risen to 90%.

“When we saw we were able to get our own group to 90 percent, we really wanted to expand our efforts to the forty residents serving the VA, because combined, the panel size is closer to 3000 patients, meaning we could have more of an impact outside our own group,” Kathie Zhang, MD, said. “So, the second year of our project, Dr. Jeremy Zhang led the expansion component. We were then able to grow, with Emily’s and Yvonne’s help, from a forty percent prescription rate for the large panel to a percentage in the mid-sixties.”

Emily Peters, RN, nurse educator for the VA, and Yvonne De Sloover-Koch, PharmD, clinical pharmacy specialist, were the two VA employees who played an important role in the success of the project. The duo led an education series for residents on how to recognize when to prescribe this crucial medication to a patient, including bringing demos to the group and discussing how to provide assistive education to the patients. Once the group of residents was trained, Kathie Zhang’s QI team proactively sent messages to the rest of the residents to help identify which of their patients may have qualified for Narcan.

In addition to receiving the local and VISN level HeRO Award for their project, the QI team received regional and national recognition in other spaces: they won accolades at the regional Society of General Internal Medicine (SGIM) conference, the national SGIM conference, took first place at the University of Iowa’s Graduate Medical Education (GME) Innovation Day, and shared the project at the Quality and Safety Symposium.