ABCD Exchange : Spring 2002 : Innovations--New Partnership to Improve EOL in NYC

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New Partnership to Improve End-of-Life Care Launched in New York City

The program is premised on the belief that health care providers can do better and can accomplish more by working together.--James Tallon

The United Hospital Fund (UHF), the RAND Center to Improve Care of the Dying (CICD), and the Institute for Healthcare Improvement (IHI) have launched a collaborative involving 21 New York City hospitals, nursing homes, hospices, and home health care agencies in breakthrough series to improve each organization's ability to care for people with advanced chronic illnesses at the end of life. The Palliative Care Quality Improvement Collaborative (PCQuIC) aims to achieve real, measurable change in how each of the participating organizations provides palliative care.

"PCQuIC aims to promote much-needed changes in the health care system related to the care of the chronically ill and dying," said James R. Tallon, UHF president. "The program is premised on the belief that health care providers can do better and can accomplish more by working together."

RAND and IHI have sponsored two previous national collaboratives to improve the quality of end-of-life care programs. "These series have shown that measurable changes can be achieved quickly and consistently across organizations when those organizations set ambitious goals and have the support of a network of faculty and other teams," said Joanne Lynn. "Our new program seeks to extend and enrich the process by engaging organizations from one geographic region in a collaborative effort. The potential for mutual support and teaching will be more easily realized than it has been in a national program."

Central to the program is IHI's pioneering "rapid-cycle" quality improvement process, which involves identifying goals, defining which practices are to be changed and how, and determining how to quantitatively measure the effectiveness of the change. The approach then is tested for a short period on a small scale, paying careful attention to measures of its effectiveness. Based on what is learned, the approach is expanded, modified, or scrapped.

Project participants have set goals to reduce pain in palliative care patients, improve advance care planning, improve continuity of care between hospital and nursing home, and provide better follow-up on referrals for hospice care (For specific goals, see below). Participating groups will work together over the year under the guidance of program faculty drawn from IHI, RAND, and local clinical leaders.

RAND's Center to Improve Care for the Dying specializes in research, education, and quality improvement activities used to shape practices to improve end-of-life care. IHI, headed by Donald Berwick, MD, is nationally renowned as a leading center for adapting the philosophy and techniques of quality improvement to health care providers. The United Hospital Fund is a health services research and philanthropic organization whose mission is to shape positive change in health care for the people of New York.

For more information, contact Sarah Myers at RAND/CICD, via e-mail: smyers@rand.org.

GOALS TO IMPROVE CARE IN NYC

Groups have already set several ambitious goals. Other health care organizations and providers interested in attempting similar changes can learn to do so by reading Improving Care for the End of Life: A Sourcebook for Health Care Managers and Clinicians, written by Joanne Lynn and Janice Lynch Schuster; download an excerpt from ABCD's website.

Pain and other symptom management

• 90% of patients and family members state that they are confident that pain, severe shortness of breath, or other symptoms near death would not last for long before being effectively treated
• Terrifying dyspnea, pain, or other symptoms are always relieved within an hour, no matter the time of day or where the patient is located

Advance care planning

• Most patients who want to die at home do so, and comfortably
• No more than 10% of patients have CPR at the time of death
• No one in the program ends up on a ventilator or with other supportive care after having made plans not to accept these supports
• All DNR orders written for a patient in any setting are continued in all other settings
• 90% of patients have an explicit decision about use of ventilators and resuscitation within a week of admission to a program

Continuity and coordination of care

• Rate of hospitalization is half of what patients experienced in the six months before enrollment
• No more than 10% of patients have an unexpected transfer to another setting

Patient and family education

• The average rate of use of "911" or emergency medical system is less than one per patient during the Collaborative
• 90% of patients understand the beneficial effects of proven strategies for self-care appropriate for their illness
• Pain scales and other important communication materials will be made available in each of the languages spoken by the organization's usual patients

Patient and family support

• 90% of families report that they felt that the care team was constant and available throughout the course of illness and for a few months after the patient's death
• Double the rate at which patients report that "this time of my life is especially meaningful, despite my illness"
• All patient and family phone calls to the provider team will be returned within 30 minutes
• All patients will be asked about their spiritual care needs and assisted in gaining access to supports that can meet these needs

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This content is provided by Americans for Better Care of the Dying. For more information, visit www.abcd-caring.org.