ABCD Exchange : March - April 2001 : Upfront - 2nd National Congress

President's Letter - Stretching Limits
QuickScan - News In Brief
Meet the Board - Introducing Members
Lunch Bunch - First Meeting of 2001
Gatherings - Searching for Spirituality
Caregiving - Volunteer Teams in AL
Innovations - MD Training in EOL Care

Second National Congress on Improving End-of-Life Care : Health Care Professionals Remain Dedicated to Issue, Patients
by Janice M. Lynch

The complex history of Birmingham, AL, gave an ideal context for the Institute for Health Care Improvement (IHI) and Center to Improve Care of the Dying/RAND (CICD) National Congress on Improvements and Innovations in End of Life Care. Birmingham, once known as the Magic City for its Southern-flavored cosmopolitan life, is more notorious for its tumultuous role in civil rights movement. Birmingham became the scene of years of bitter struggles to right wrongs. One need not stretch the analogy too far to know that America's health care system is far from being a "Magic City" to people with serious, chronic illness. Hundreds of wrongs must be corrected, and patients at the end of life remain in desperate need of better treatment. Amos Bailey, M.D., leader of the award-winning Balm of Gilead Center, has participated in other IHI/CICD programs. He told his colleagues, "I am a change junkie. This conference can put change junkies together with people who know how to provide a fix." Bailey explained that just four years ago, Cooper Green enrolled in a Breakthrough Series Collaborative to improve end of life care. Last fall, the program they developed was featured in Bill Moyers' PBS series, "On Our Own Terms."

Approximately 150 people attended the two-day congress, which included a pre-conference session on hospital-based palliative care sponsored by the Center to Advance Palliative Care (CAPC). Participants ranged from medical directors of small community hospices to leaders at Veterans Affairs Medical Centers, from researchers to CEOs. Several had participated in two earlier Breakthrough Series collaboratives, and attended to share what they had learned and to discuss the current status of their projects. Other sponsors included the Agency for Healthcare Research and Quality (AHRQ), the National Coalition on Health Care (NCHC), The Fan Fox and Leslie R. Samuels Foundation, the United Hospital Fund, the CAPC, and the National Hospice and Palliative Care Organization.

Several sessions focused on helping participants understand the rapid-cycle model of change that has proven so successful in improving care for patients nationwide. That model (which can be read online at ABCD's website by clicking on the icon for Improving Care), urges groups to start with one problem and work toward its solution-quickly, with some data gathering but with a greater focus on solving the issue. From there, groups must refine the solution or choose another problem. Andrea Kabcenell, RN, MPH, compared the process to having watched her young son struggle to conquer his fear of the water. He had come up with many strategies for how he might learn to swim without ever having to get in the water. Finally, he agreed with his mother that if he could try just one class, he might convince himself to try another. He did, and continued until he was confident in his ability. This is precisely the model many health care organizations follow when trying to overcome inertia, the status quo, and the natural fear of change.

For first-time participant Pat Schoeni, director of public affairs for the National Coalition on Health Care, the program was rewarding. "The dedication to improving the quality of care at the end of life, which was demonstrated by all those participating, gives hope that the full meaning of 'care' is alive and well in today's health care system, "Schoeni said. In breakout sessions, several groups described their own experiences with trying changes, failing at them, and trying again. In "Building on Strengths: Innovations in Coalition Efforts," Jean Brontoli, RN, Kate Payne, RN, JD, and Rick Warren, ANP, RN, described the progress they have made since first participating in a 1997 breakthrough series. Brontoli, clinical director for SSM St. Mary's Health Center, explained how her group had decided to improve patient satisfaction by improving assessment and treatment of pain on inpatient medical surgical units. The group made many changes, including use of "Pain As a 5th Vital Sign," use of a "Stop Pain" logo, and development of standards and forms. The group made steady process, which it has maintained, and continues to review and improve its work.

Payne discussed improvements still underway at Nashville's St. Thomas Health Services, where she described "Culture Change in an Acute Care Setting," as "The kitchen sink approach to improving end of life care." Among the group's successes are its compassionate non-discharge policy, which prohibits discharging patients from the ICU if they appear to be near death; links with other initiatives, such as EPEC; and a formal structure focused on improved care. Although Payne has participated in the rapid-cycle program, she heard new ideas at the Congress. "The most provocative information came from Joanne Lynn about safety issues, and how many errors in end of life care should be considered as safety problems. She is at the cutting edge of improvement, and I have since used this notion in several talks." Warren described how Providence Health System (OR) used a breakthrough series to improve care for patients with congestive heart failure (CHF) or chronic obstructive pulmonary disease (COPD). After developing a program that focused on patient education and support, the group found that study patients had an average daily cost of $1.86/day, compared to a control group whose costs were $14.70/day.

The work will continue beyond the Congress. Sarah Myers, M.P.H., research associate for CICD/RAND, said, "The initiative will continue to look at novel ways to get quality improvement started. We are working on a regional collaborative to improve palliative care in New York City, as well as a collaborative with nursing homes in Pittsburgh."

In two days of sessions, many successes were described, and participants benefited from what they heard. During lunch, people discussed what they planned to do in their hospice or hospital or practice as soon as they got home. Kabcenell said, "There was great enthusiasm for trying new things. It was clear that the devotion and will are there, and that everyone needs to be a little more determined to try things on a small scale so that the learning begins more immediately."

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