PURPOSE: The purpose of this paper is to explore and examine attitudes and perceptions of leaders on application of quality improvement (QI) strategies in a palliative and hospice care organization.
DESIGN/METHODOLOGY/APPROACH: This study employed qualitative research methodology where leaders working in a hospice and palliative care organization were invited to participate in 45-60-min-long semi-structured interview. Interviews were recorded and transcribed verbatim. Qualitative content analysis was utilized to analyze the data collected during participant interviews.
FINDINGS: Seven leaders participated in the interviews. Five themes were developed from data analysis: patient-centered care; continuous QI; leadership involvement and commitment; communication as a foundation for QI; and perceived barriers. Data analysis suggests that use of QI approach in palliative and hospice care enhances the quality of care provided for patients, and can help improve patient satisfaction.
PRACTICAL IMPLICATIONS: Because there is a paucity of research on implementation of QI strategies in hospice and palliative care settings, this research can have wide practical implications. This research can provide useful practical tips to leaders as they work on implementing QI projects in their organization.
ORIGINALITY/VALUE: This manuscript can be of value to leaders, administrators and academicians who are interested in applying QI principles to healthcare processes especially in palliative and hospice care settings. Ability to work with others, solid communication and involvement of employees from all levels can help in streamlining current systems of care.
BACKGROUND: We sought to increase intensive care unit-family meeting (ICU-FM) documentation in the electronic health record in Veterans Affairs (VA) hospitals.
MEASURES: Primary outcomes were proportion of VA decedents with ICU-FM and Bereaved Family Survey-Performance Measure (BFS-PM) scores of "excellent".
INTERVENTION: Quality Improvement (QI) project, clinical champion and ICU-FM templates, were implemented in nine participating VA facilities. ICU-FMs and BFS-PM were determined in decedents between 2011-2018.
OUTCOMES: ICU-FM increased from 3% to 28% in participating vs. 5% to 6% in non-participating facilities over time. Participating facilities were 5-fold more likely to have ICU-FMs among ICU decedents (OR=5.69, [4.45-7.28]). Facility-wide excellent BFS-PM scores increased by 19% in participating vs. non-participating facilities at the end of the observation period (OR=1.19, [1.10-1.30] but no difference between groups was observed in patients who died in the ICU.
CONCLUSIONS: Increasing ICU-FMs is necessary but not sufficient to improve family-reported satisfaction following an ICU death.
BACKGROUND: To enhance the quality of hospice care and to facilitate consumers' choices, the Centers for Medicare and Medicaid Services (CMS) began the Hospice Quality Reporting Program, in which CMS posted the quality measures of participating hospices on its reporting website, Hospice Compare. Little is known about the participation rate and the types of nonparticipating hospices.
OBJECTIVE: To examine the factors associated with hospices' nonparticipation in Hospice Compare.
RESEARCH DESIGN: We analyzed data from the CMS 2016 Hospice Compare. "Nonparticipants" were those who did not submit any quality measure. With the data of the Provider of Service file, the Healthcare Cost Report Information System, and the Area Health Resources File, multivariate logistic regressions estimated the association between nonparticipants and hospice and market characteristics, including ownership, size, nurse staffing ratio, and market competition intensity.
RESULTS: Among the 4123 certified hospices subject to penalty from nonparticipation, 259 did not participate in Hospice Compare. California, New Mexico, Texas, and Wyoming had participation rates lower than 80%. Hospices that were for-profit, had no accreditation, had few nurses per patient day, provided no inpatient care, and were located in competitive markets were less likely to participate than other hospices.
CONCLUSIONS: Hospice Compare successfully motivated hospice in participating in the quality report program in most of states. For-profit hospices, hospices with less quality, and hospices located in competitive markets were less likely to participate. Further research is warranted to examine the quality of these nonparticipants, especially in the 4 states with a lower participation rate.
Experience-based design, co-design, and experience-based co-design can be used within healthcare to design services that improve the patient, carer and staff experience of the services. As palliative and end-of-life care centrally value person-centred care, we believe that service designers, commissioners and those tasked with making quality improvements will be interested in this growing field. This paper outlines these approaches-with a particular emphasis on experience-based co-design-and describes how they are and can be used within palliative and end-of-life care. Based on a rapid review and several case studies, this article highlights the key lessons learnt from previous projects using these approaches and discusses areas for improvement in current reporting of service design projects.
INTRODUCTION: A structured and intentional approach to quality improvement is critical for clinicians specializing in palliative care and is a required component of training programs.
METHODS: We present a multimodal, comprehensive curriculum for teaching quality improvement to interdisciplinary trainees in palliative care.
RESULTS: The curriculum consists of 4 sessions, one and half hours long a piece, that focus on the purpose and practice of quality improvement and guide learners through a team-based project implementation experience. Course assessments demonstrate satisfaction with the course and improvement in targeted skills, knowledge, and attitudes.
DISCUSSION: Several key learnings stand out from our experience with this curriculum as central to the experience of students: project work completed as interdisciplinary teams, varying teaching methodologies over a longitudinal curriculum, and the opportunity for formal presentation of their work.
OBJECTIVE: Quality communication is an important aspect of advance care planning (ACP). This study evaluates a certification program that trains lay people in communication skills to support community-based ACP conversations.
METHODS: The program was developed with an emphasis on communication skills training. The testing of the program included ACP Guides and conversation partners, who were hospice volunteers, to assess the use of communication skills in ACP conversations. The evaluation used direct observations of conversations between trained ACP Guides and conversation partners as well as semi-structured interviews with those trained to become ACP Guides and those participating in the conversation.
RESULTS: Twenty-two ACP Guides participated in the testing phase with a retention rate of 100% completing all 4 sessions. The RELATE model of communication emerged during program development and testing. Evaluation of 15 ACP Guides having ACP conversations found that trained ACP Guides could use the RELATE model of communication to support ACP conversations.
CONCLUSION: A community-academic partnership developed an ACP Community Guides Program that trained individuals to have community-based ACP conversations. Next steps include additional testing of the program and RELATE in small numbers, especially among minority populations, to evaluate acceptability and usability of this approach.
PRACTICE IMPLICATIONS: Laypersons with concrete communication skills can facilitate effective peer-to-peer ACP conversations.
Background: Dementia is a terminal illness making the palliative and hospice approach to care appropriate for older people with advanced dementia.
Objective: To examine clinical and health services outcomes of a quality improvement pilot project to provide home hospice care for older people with advanced dementia.
Study design: Twenty older people with advanced dementia being treated in the Maccabi Healthcare Services homecare program, received home hospice care as an extension of their usual care for 6–7 months (or until they died) from a multidisciplinary team who were available 24/7. Family members were interviewed using validated questionnaires about symptom management, satisfaction with care, and caregiver burden. Hospitalizations prevented and medications discontinued, were determined by medical record review and team consensus.
Findings: The findings are based on 112 months of care with an average of 5.6 (SD 1.6) months per participant. The participants were on average 83.5 (SD 8.6) years old, 70% women, in homecare for 2.8 (SD 2.0) years, had dementia for 5.6 (SD 3.6) years with multiple comorbidities, and had been hospitalized for an average of 14.0 (SD 18.1) days in the year prior to the project. Four patients were fed via artificial nutrition. During the pilot project, 4 patients died, 2 patients withdrew, 1 patient was transferred to a nursing home and 13 returned to their usual homecare program. The home hospice program lead to significant (p < 0.001)improvement in: symptom management (score of 33.8 on admission on the Volicer symptom management scale increased to 38.3 on discharge), in satisfaction with care (27.5 to 35.3,), and a significant decline in caregiver burden (12.1 to 1.4 on the Zarit Burden index). There were five hospitalizations, and 33 hospitalizations prevented, and an average of 2.1(SD 1.4) medications discontinued per participant. Family members reported that the professionalism and 24/7 availability of the staff provided the added value of the program.
Conclusions: This pilot quality improvement project suggests that home hospice care for older people with advanced dementia can improve symptom management and caregiver satisfaction, while decreasing caregiver burden, preventing hospitalizations and discontinuing unnecessary medications. Identifying older people with advanced dementia with a 6 month prognosis remains a major challenge.
Background: The Centers for Medicare & Medicaid Services (CMS) Hospice Quality Reporting Program (HQRP) introduced the requirement that hospices nationwide begin collecting and submitting standardized patient-level quality data on July 1, 2014.
Objectives: This study examined whether this requirement has increased hospice total costs, general costs and visiting services costs.
Research Design: We conducted a cross-sectional study using data from the 2012 and 2014 Medicare hospice cost reports linked to hospice claims. We measured total costs per patient day (PPD), general costs PPD and visiting services costs PPD for freestanding hospices. We estimated the incremental costs of operating in 2014 vs. 2012 using hierarchical random effects models and adjusting for year, wage-index, care volume, case-mix and hospice and market characteristics, stratified by hospice ownership type.
Results: Both for-profit and nonprofit hospices reported higher total costs PPD and general services costs PPD in 2014 compared with 2012. Nonprofit hospices also reported higher general costs PPD in 2014 compared with 2012. In adjusted models, the total costs PPD in 2014 were $10.55 higher than in 2012 for non-profit hospices and $6.43 higher for for-profit hospices. The increase in general costs PPD and visiting services costs PPD ranged from $3.15 to $5.87 by ownership and type of costs. Both for-profit and non-profit hospices showed lower costs PPD for all types associated with more patients and longer length of stay.
Conclusions: Hospice costs increased following the CMS HQRP quality data collection/submission requirement. Complementary studies need to understand whether increased costs brought additional benefits.
BACKGROUND: Physician Orders for Life-Sustaining Treatment (POLST) can help ensure continuity of do-not-resuscitate (DNR) decisions and other care preferences after discharge from the hospital.
OBJECTIVE: We aimed to improve POLST completion rates for patients with DNR orders who were being discharged to a nursing home (NH) after an acute hospitalization at our institution.
DESIGN: We implemented an interprofessional quality improvement intervention involving education, communication skills, and nursing and case manager cues regarding POLST use. The intervention was later augmented with performance feedback and financial incentives for resident physicians who completed a POLST at NH transfer.
MEASURE: Whether patients with DNR orders at hospital discharge have a POLST at NH transfer.
RESULTS: The intervention resulted in increased POLST use for patients with DNR orders discharged to NH: baseline 25/65 (38%), intervention 36/71 (51%), and augmented intervention 44/63 (70%) (p < 0.01).
CONCLUSIONS: An interdisciplinary intervention can increase POLST use for patients with DNR orders transitioning to NH. Multiple components, including financial incentives and performance feedback, may be needed to effect statistically significant change.
PROBLEM: Despite acknowledged benefits, the impact of advance care planning on usual care is inconsistent.
DESIGN: Quality improvement study.
SETTING: A Western Australian regional hospital.
KEY MEASURES FOR IMPROVEMENT: This project aimed to create a system for storing, accessing and incorporating advance care planning documents in clinical care.
STRATEGIES FOR CHANGE: Interventions over 18 months addressed four areas: medical records processes for receiving and processing advance care planning documents; information technology solutions for electronic storage and alerts; clerical staff duties in regards advance care planning documents; and clinician education.
EFFECTS OF CHANGE: There was a 12-fold increase in advance care planning documents stored electronically and 100% of audited notes had correct filing of advance care planning documents with an alert in place at follow-up audit. Clinician recognition of the presence of an advance care planning document improved. Detailed examples of interventions are described.
LESSONS LEARNT: Repeated exposure to different forms of advance care planning education, in conjunction with simple but effective system changes can make a difference in changing established hospital practice. Final impact of these changes on end-of-life care requires further audit.
Anticipatory planning for end of life requires a common language for discussion among patients, families, and professionals. Studies show that early Palliative Care (PC) interventions based on a problem-oriented approach can improve quality of life, support decision-making, and optimize the timing of medical treatment and transition to hospice services. The aim of this quality-improvement project was to develop a pragmatic structure meeting all clinical settings and populations needs. Based on the Medical Research Council (MRC) framework, a literature review identifying approaches commonly used in PC was performed. In addition, more than 500 hospital-based interprofessional consultations were analyzed. Identified themes were structured and compared to published approaches. We evaluated the clinical usefulness of this structure with an online survey among professionals. The emerged 'SENS'-structure stands for: Symptoms patients suffer from; End-of-life decisions; Network around the patient delivering care; and Support for the carer. Evaluation among professionals has confirmed that the 'SENS'-structure covers all relevant areas for anticipatory planning in PC. 'SENS' is useful in guiding patient-centered PC conversations and pragmatic anticipatory planning, alongside the regular diagnosis-triggered approach in various settings. Following this approach, 'SENS' may facilitate systematic integration of PC in clinical practice. Depending on clearly defined outcomes, this needs to be confirmed by future randomized controlled studies.
BACKGROUND: Given the limited ability of hospice patients to assess, monitor, and respond to substandard care, quality oversight has an important role to play in the hospice sector. The IMPACT Act of 2014 required that agencies be recertified at least every three years, but it did not otherwise alter hospice quality oversight.
OBJECTIVES: To illuminate the current hospice quality oversight process and discuss its role alongside other government monitoring and public reporting efforts.
METHODS: Retrospective analysis (2006-2015) concerning hospice accreditation status, deficiency trends, survey frequency and deficiency outcomes, and termination from the Medicare program.
RESULTS: The proportion of privately accredited hospice agencies increased from 15% to 39%, a trend driven largely by its increased use among for-profit agencies. The combined rate of deficiencies per agency increased 35% over the past decade, with issues around care planning, aide and homemaker services, and clinical assessment featured most prominently. Nearly half (45%) of all surveys resulted in deficiency citations; however, less than one-in-four hospice agencies were surveyed in a given year. Over the past decade, 28 agencies were terminated from the Medicare program; most of these agencies were unaccredited and operated on a for-profit basis.
CONCLUSIONS: The IMPACT Act addressed one of the biggest shortcomings in hospice oversight. Our findings highlight additional reforms that could be considered. First, reporting inspection results from private and public recertification surveys could promote greater transparency and accountability. Second, making a wider range of intermediate sanctions available to oversight agencies could enhance enforcement efforts and, ideally, incentivize agencies to improve quality of care.
Despite the established benefit of advance care planning (ACP), achieving and sustaining high rates of ACP completion continue to be a challenge in many health care settings. A palliative care champions committee has targeted improving the ACP process through quality improvement initiatives at an academic medical center. To understand the impact of multiyear efforts to improve ACP, surveys of registered nurses, care coordinators, and medical assistants from inpatient and outpatient settings were conducted in 2013 and 2017 to explore comfort level with ACP, barriers preventing completion of ACP in daily practice, and suggestions for overcoming these barriers. The findings suggest strategies to further integrate ACP through interdisciplinary teams, including outpatient staff education, inpatient and outpatient quality improvement initiatives, and dedicated staff for ACP.
BACKGROUND:: The goal of Palliative Day Services is to provide holistic care that contributes to the quality of life of people with life-threatening illness and their families. Quality indicators provide a means by which to describe, monitor and evaluate the quality of Palliative Day Services provision and act as a starting point for quality improvement. However, currently, there are no published quality indicators for Palliative Day Services.
AIM: To develop and provide the first set of quality indicators that describe and evaluate the quality of Palliative Day Services.
DESIGN AND SETTING:: A modified Delphi technique was used to combine best available research evidence derived from a systematic scoping review with multidisciplinary expert appraisal of the appropriateness and feasibility of candidate indicators. The resulting indicators were compiled into 'toolkit' and tested in five UK Palliative Day Service settings.
RESULTS:: A panel of experts independently reviewed evidence summaries for 182 candidate indicators and provided ratings on appropriateness, followed by a panel discussion and further independent ratings of appropriateness, feasibility and necessity. This exercise resulted in the identification of 30 indicators which were used in practice testing. The final indicator set comprised 7 structural indicators, 21 process indicators and 2 outcome indicators.
CONCLUSION:: The indicators fulfil a previously unmet need among Palliative Day Service providers by delivering an appropriate and feasible means to assess, review, and communicate the quality of care, and to identify areas for quality improvement.
Palliative care delivery is shifting to the home, yet data are limited on symptom assessment tools and protocols for that setting. A quality improvement project was done in a home-based palliative care program to imbed the Edmonton Symptom Assessment System into the electronic health record. The purpose of the quality improvement project was to track symptom severity and collect utilization data. Baseline data were collected on 35 patients for symptom presence and severity as well as hospital utilization and readmission. The most common symptoms were tiredness, pain, and a lack of feeling of overall well-being. The most severe symptoms, those with a rating of 6 of 10 or higher, were pain, drowsiness, and anxiety. Seventy-seven percent of the symptoms within the Edmonton Symptom Assessment System showed an improvement over the 3-month QI project per the electronic health record data. Hospitalization rates also went from 4.2% to 2.6% and 30-day readmissions were reduced from 15% to 0%. The results suggest that the palliative care program was able to improve symptoms through the use of Edmonton Symptom Assessment System and that that may have affected hospital utilization.
Objective: To improve outpatient advanced care planning (ACP) for adults with congenital/pediatric heart disease followed in a pediatric heart failure (HF) and transplant clinic through quality improvement (QI) methodology.
Design: A one-year QI project was completed. We conducted quarterly chart reviews and incorporated feedback from the providers to direct subsequent interventions.
Patients and Setting: Patients =18 years of age seen in the HF and Transplant Clinic for follow-up visit were included in analysis.
Interventions: Interventions focused on five main areas: identifying and training providers to have ACP discussions, standardizing the ACP discussion, standardizing ACP and advance directive (AD) documentation in the electronic medical record, preparing providers to have ACP conversations, and preparing patients to engage in ACP and AD completion.
Outcome Measures: The outcome measure was percent of adults seen in the HF and Transplant Clinic per month with documented AD (goal 50%). The process measure was percent of adults seen in the HF and Transplant Clinic per month with a documented ACP discussion (goal 100%).
Results: At baseline, no patients had a documented ACP discussion or AD. Fifty-eight adults (mean age 20.4 ± 2.1 years) were seen from March 2016 to February 2017 for a total of 130 visits. In the final month of our study, 75% of adult encounters had a documented ACP discussion and 42% had a documented AD.
Conclusions: The percentage of documented ADs in adults seen in the HF and Transplant Clinic at a quaternary children's hospital improved through a QI initiative. Over 50% of patients who were engaged in an ACP discussion completed an AD, suggesting this population is receptive to ACP and AD completion.
BACKGROUND: Benefits of palliative care have been extensively described; however, reports on adherence to national quality indicators are limited.
OBJECTIVES: This study focuses on describing the characteristics of patients who were seen at an urban academic hospital and their care team's adherence to 5 out of 10 Measuring What Matters (MWM) quality indicators.
DESIGN: Retrospective chart review Setting/Subjects: Patients seen by inpatient palliative care service from January 2014 to December 2015 in an urban academic hospital.
MEASUREMENTS: Patient age, gender, ethnicity, disease category, discharge end point, life-sustaining preferences, surrogate decision-maker documentation, and initial palliative assessment were analyzed using descriptive, parametric, and nonparametric statistics.
RESULTS: During two years, 1272 patients were seen by the inpatient palliative care service. Fifty-one percent of patients were male, with an average age of 68 years. The majority were Caucasian (57%) and African American (41%). Life-limiting illnesses included were cancer, complex chronic illnesses, and gastrointestinal illness. Adherence to comprehensive palliative care assessment was measured at 64%; initial visit assessment for physical symptoms was 38%; code status preference was 99%; care consistent with preference in vulnerable elders was 99%; and surrogate documentation was noted at 33%. Compared to hospital patients discharged without hospice, patients discharged with hospice care had consults with higher adherence to comprehensive assessment and surrogate documentation quality standards (p < 0.05).
CONCLUSIONS: Adherence to MWM measures was variable. Subjects discharged with hospice services were more likely to receive comprehensive assessment within 5 days of admission and surrogate documentation compared to those subjects without hospice care.
BACKGROUND: Despite substantial efforts to integrate palliative care and improve advance care planning, both are underutilized. Quality improvement initiatives focused on reducing mortality may offer an opportunity for facilitating engagement with palliative care and advance care planning.
OBJECTIVE: In the context of an initiative to reduce acute myocardial infarction (AMI) mortality, we examined challenges and opportunities for engaging palliative care and improving advance care planning.
METHODS: We performed a secondary analysis of qualitative data collected through the Leadership Saves Lives initiative between 2014 and 2016. Data included in-depth interviews with hospital executives, clinicians, administrators, and quality improvement staff (n = 28) from 5 hospitals participating in the Mayo Clinic Care Network. Focused analysis examined emergent themes related to end-of-life experiences, including palliative care and advance care planning.
RESULTS: Participants described challenges related to palliative care and advance care planning in the AMI context, including intervention decisions during an acute event, delivering care aligned with patient and family preferences, and the culture around palliative care and hospice. Participants proposed strategies for addressing such challenges in the context of improving AMI quality outcomes.
CONCLUSIONS: Clinicians who participated in an initiative to reduce AMI mortality highlighted the challenges associated with decision-making regarding interventions, systems for documenting patient goals of care, and broader engagement with palliative care. Quality improvement initiatives focused on mortality may offer a meaningful and feasible opportunity for engaging palliative care. Primary palliative care training is needed to improve discussions about patient and family goals of care near the end of life.
OBJECTIVE: Numerous studies have characterized the pain reported by patients with advanced illness in terms of descriptors such as severity, but few have measured pain-related distress. Distress may be important in the clinical approach to pain. To evaluate pain-related distress among adult patients with advanced illness and pain following enrollment in an urban, specialist-level, community-based palliative care program.
METHOD: In a retrospective cross-sectional analysis, data were extracted from the electronic health records of all patients who were able to complete the pain item from the Condensed Memorial Symptom Assessment Scale at the start of care. Bivariate and multivariate analyses evaluated the associations between distress and both sociodemographics and disease-related information.
RESULTS: The 506 patients completing the pain item had a mean (SD) age of 70.7 years (13.8); 64.2% were women, 32.1% were Hispanic, 32.6% were white, and 27.7% were black. Of the 503 patients who indicated some level of distress on a 0–4 scale, 221 (43.7%) had high distress, defined as a score =3 (“quite a bit” or “very much”). Cancer diagnosis and poor performance status (unable to care for self) were predictors of high pain-related distress (both p < 0.05).
Significance of results: Among patients with advanced illness who reported pain at the start of care by a specialist palliative care program, high pain-related distress was common, particularly among those with cancer or poor physical function. Further studies are needed to explore the extent to which pain-related distress should inform the assessment and management of pain.
CONTEXT: Best supportive care (BSC) is often not standardized across sites, consistent with best evidence, or sufficiently described. We developed a consensus-based checklist to document BSC delivery, including symptom management, decision making, and care planning. We hypothesized that BSC can be feasibly documented with this checklist consistent with consolidated standards of reporting trials.
OBJECTIVE: To determine feasibility/acceptability of a BSC checklist among clinicians.
METHODS: To test feasibility of a BSC checklist in standard care, we enrolled a sample of clinicians treating patients with advanced cancer at four centers. Clinicians were asked to complete the checklist at eligible patient encounters. We surveyed enrollees regarding checklist use generating descriptive statistics and frequencies.
RESULTS: We surveyed 15 clinicians and 9 advanced practice providers. Mean age was 41 (SD = 7.9). Mean years since fellowship for physicians was 7.2 (SD = 4.5). Represented specialties are medical oncology (n = 8), gynecologic oncology (n = 4), palliative care (n = 2), and other (n = 1). For “overall impact on your delivery of supportive/palliative care,” 40% noted improved impact with using BSC. For “overall impact on your documentation of supportive/palliative care,” 46% noted improvement. Impact on “frequency of comprehensive symptom assessment” was noted to be “increased” by 33% of providers. None noted decreased frequency or worsening impact on any measure with use of BSC. Regarding feasibility of integrating the checklist into workflow, 73% agreed/strongly agreed that checklists could be easily integrated, 73% saw value in integration, and 80% found it easy to use.
CONCLUSION: Clinicians viewed the BSC checklist favorably illustrating proof of concept, minor workflow impact, and potential of benefit to patients.