More than 500 professionals, including doctors, nurses, social workers, chaplains, and healthcare administrators, gathered to learn from the 48 organizations that participated in the yearlong IHI Breakthrough Series on Improving Care at the End of Life. Participants represented hospitals, hospices, community-based organizations, and public and private programs. Each had used the IHI model for rapid change to improve care in one or more of four critical areas: pain and other symptom management, advance care planning, continuity of transfers, and meaningfulness and spirituality.
What is the smallest measurement you need to persuade yourself you've made a difference?Some organizations undertook large-scale projects - building statewide coalitions among competing organizations or establishing palliative care units and consults. Others pursued patient-centered programs, such as creating comfort/hospitality rooms for families in ICUs or assembling emergency resource kits for home use. And many organizations worked on including "Pain As a Fifth Vital Sign," aiming not only to have pain assessed, but to have it reduced quickly.
Donald Berwick, M.D., President and CEO of IHI, praised collaborative participants by noting that their work has been used to improve the work of other breakthrough collaboratives focusing on different healthcare issues. The applicability of end-of-life work to other realms of health care stems, in part, from the fact that all of health care touches on the end of life in one way or another, Berwick said. "Your work is leading edge, in part because it deals with every aspect of healthcare," Berwick told Congress attendees. "In your meetings, I have been struck by the cooperation among groups - and cooperation is the hallmark of improvement."
IHI collaborative participants described just how powerful cooperation can be in changing end-of-life care routines. For example, three competing healthcare groups in Minnesota have combined to set up the Minnesota Partnership to Improve End-of-Life Care. Allina Health, Fairview, and Health Partners have submitted a proposal to Robert Wood Johnson to create a statewide improvement effort. "There may be competition at the corporate level," said Health Partners' Barry Baines, M.D. "But at the care level, collaboration is essential."
Others talked about specific instances in which they knew their work had paid-off for patients. Kay Cherry of North Carolina’s Albemarle Home Care, which covers 12 counties, described what happened when a 44-year old mother of four appeared in a home care agency for her regular physical therapy appointment.
"Something about her chart alerted the home care agency to call the hospice and say that the woman appeared to be in a great deal of pain," Cherry said. "Because home health picked up on it, we were able to get someone out to her house, where we learned that her pain was at a level 10. She’d been afraid to get medications because she couldn’t afford them. We were able to get the medication and to work with her." Cherry urged others "not to wait until we perfect our ideas, but to drive forward with an imperfect product and perfect it along the way."
Some participants described how imperfect systems are now - but how hopeful they are that they will overcome barriers and change the way things are done. Barbara LeZotte, System Vice President for Provena Health in Illinois, said her group would use the flight home to develop ideas to put in place immediately, following IHI's motto, "What can you do by next Tuesday?" In the next month, LeZotte said, she will survey providers throughout the system, and develop rapid-cycle changes according to the IHI model.
Andrea Kabcenell, R.N., M.P.H., IHI’s Collaborative Director, said, "I heard many plans to get started quickly on changing the way that pain and other symptoms are managed, and how to talk to patients about planning. Also notable was how readily people took to the 'just enough' measurement strategy that would be useful, but did not require so much time and energy."
Many collaborative participants will continue their work, despite the end of this year's series. Most, like Wayne Bottner, M.D., of Gundersen-Lutheran Hospital in Wisconsin, say they can no longer imagine not focusing on end-of-life care improvements.
One especially telling moment came when Joanne Lynn, M.D., chairperson of the collaborative, asked several hundred people to stand if they could go home and do something about pain management in the next week. Everyone in the room stood. Most remained standing when Lynn asked if they had a champion for this area in their institutions.
"The hardest thing is to make people think in a new way," Lynn said. "We tend to turn our blinders on certain problems. But if you have at least one idea, and one champion, you can do it. We will all gain if everyone does a better job."
Other organizations interested in participating in the second IHI Breakthrough Series should contact IHI at 617.754.4800 or visit the web site at www.ihi.org for details and an application form.
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