The problems in end-of-life care, having received so much media attention that a Sunday "Doonesbury" featured the issue, have reached a crisis point - and a turning point. In 1996, the Institute for Healthcare Improvement (IHI) recognized that the end-of-life field might be ripe for substantial quality improvement using a collaborative approach: the Breakthrough Series. Experts in the field knew something about how to improve care, but there was a chasm between the best available knowledge and everyday practice. Some organizations, true innovators in the field, had begun to respond to problems in care of the dying and were models for improvement. IHI leaders and faculty were convinced that improving care at the end of life would certainly achieve better clinical outcomes and, might additionally reduce health care costs while improving patient and family satisfaction.
From July 1997 to July 1998, 47 health care organizations, including hospitals, hospices, home health agencies, long-term care facilities, Veterans Affairs medical centers, and community-based organizations, participated in the Breakthrough Series Collaborative on Improving End-of-Life Care. Brainstorming sessions among leaders, experts, and faculty identified four target areas that could be improved immediately if an organization set out to do so:
As the project got under way, participants and others found alarming problems in what they were doing as part of their "usual" care:
The 47 organizations in the Breakthrough Series focused on quick changes, often starting by trying new programs or ideas on one or two or a dozen patients. They worked toward rapid breakthroughs, important improvements that could be done on a small scale "by next Tuesday." When these tests worked, they were tested with larger groups of patients, or in new settings. Organizations abandoned ideas that did not lead to improvement - and then came at the problem from a different angle.
Many participants found broad institutional support for their work - and others discovered that their work in improving end-of-life care had benefits for other units and providers in their systems. Some encountered unexpected obstacles. And others found that measuring change - and whether or not change amounted to improvement - was essential but largely uncharted territory.
Teams achieved many of their goals, often within just a few months. Examples are:
By the end of the year, most were satisfied with the progress they had made, and many were committed to continuing their work to improve care. Here are some of the results. We'll tell their stories later; here we are just showing the kinds of gains made.
|Franciscan Health Systems
Compared to a control group of patients in a different site in the same care system (located in Washington State), a group targeted by Franciscan's Supportive Care Services had significantly fewer hospitalizations in the last year of life.
|Community Memorial Hospital
In September 1997, 13 out of 20 dying medical/oncology patients at Community Memorial Hospital in Menomonee Falls, Wisconsin, had their pain management goals met. By March, that number had increased to 100 percent.
|Veterans Affairs Healthcare System
When the project began, 15 percent of patients at Veterans Affairs Healthcare System in Dayton, Ohio, had documented advance care plans; within 12 weeks, 90 percent of randomly sampled medical records had plans documented.
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This online version of the book Improving Care for the End of Life: A Sourcebook for Health Care Managers and Clinicians is provided with permission of Americans for Better Care of the Dying [ www.abcd-caring.org ] and Oxford University Press. All rights reserved.
For further information on quality improvement in end-of-life care visit The Palliative Care Policy Center [ www.medicaring.org ].