Sourcebook : Improving Care for the End of Life : 2.0 How to Make Improvement Happen

"Whether you think you can, or whether you think you can't, you're right."
- Henry Ford

For most people most of the time, what is easy and routine is what happens - until that easy routine comes apart. One case in point is how the health care system treats dying patients. In some instances, of course, it is not that the system is coming apart but that it was never developed. Readers seeking to fix or change this system may feel like loose cannons in their own organizations. This book shows how to test creative ideas and solutions with small groups of patients and, then, how to improve on those ideas to foster even more improvement. The model used is called the Plan-Do-Study-Act (PDSA) cycle; it is a practical and proven quality improvement tool. With this model, teams can start at virtually any point in the routine and change it for the better. This model is meant not to replace change models that organizations may already be using but to streamline and accelerate improvement. Most important, health care providers can apply the model in their daily routines to improve how they care for dying patients and families.

The PDSA model requires teams to set aims, measure changes, and decide whether or not they represent an improvement. The model has two parts that teams must use in order to make it work. The first part requires asking (and answering) three fundamental questions: General approach to sequential PDSA cycles.

What are we trying to accomplish?
How will we know that a change is an improvement?
What changes can we make that will result in improvement?

The second part requires taking action, using the PDSA cycle to test and implement changes in real work settings.

The questions are simple and straightforward, but answering them takes thought and analysis. The answers to these questions are the basis for improvement efforts.

Sample Case Study
Staff at Unique Hospice and Palliative Care Unit might think that they outperform the national average on pain management. After all, they reason, families and loved ones never complain. Even so, the group's Grade A Improvement team decides to examine the unit's performance, with the aim of showing that all patients on one unit are assessed for pain and that pain intensity levels will be at or below a 3 (on a scale of 0 to 10). How will the group know that its change - reviewing charts for pain assessment and follow-up - is an improvement? Because the team has set a goal known to be part of good practice, for instance, that patient pain intensity levels will be below a 4. After reviewing five patients each week for one month on pain assessment, the team discovers that only three-fourths of patients have documented assessment and follow-up procedures and that more than half report pain intensity scores greater than 5. These data are very revealing to this team, who felt, like others, that no improvement was needed in their pain management program. What changes can the team now do that will lead to improvement? The team begins a second improvement cycle and decides to measure "Pain as a Fifth Vital Sign." (This project is described in chapter 3.) Ongoing data collection will help them determine whether the team has reached its goal of 100 percent of patients being routinely assessed for pain and the appropriate intervention for pain relief being undertaken.

Sample Case Study

Staff at Unique Hospice and Palliative Care Unit might think that they outperform the national average on pain management. After all, they reason, families and loved ones never complain. Even so, the group's Grade A Improvement team decides to examine the unit's performance, with the aim of showing that all patients on one unit are assessed for pain and that pain intensity levels will be at or below a 3 (on a scale of 0 to 10).

How will the group know that its change - reviewing charts for pain assessment and follow-up - is an improvement? Because the team has set a goal known to be part of good practice, for instance, that patient pain intensity levels will be below a 4. After reviewing five patients each week for one month on pain assessment, the team discovers that only three-fourths of patients have documented assessment and follow-up procedures and that more than half report pain intensity scores greater than 5. These data are very revealing to this team, who felt, like others, that no improvement was needed in their pain management program.

What changes can the team now do that will lead to improvement? The team begins a second improvement cycle and decides to measure "Pain as a Fifth Vital Sign." (This project is described in chapter 3.) Ongoing data collection will help them determine whether the team has reached its goal of 100 percent of patients being routinely assessed for pain and the appropriate intervention for pain relief being undertaken.

Innovators Need to Know
The PDSA model provides a framework for beginning changes on a small scale and increasing their scope as they prove successful. Look to frontline staff for ideas on what to improve. Recruit a team that can provide day-to-day leadership, has the necessary technical expertise, and has the support of system leadership. Groups must collect the data to know when a change is actually an improvement. Most groups can do something to improve care "by next Tuesday." Barriers to change can be overcome. Consider an external ethics review for some CQI projects.

Innovators Need to Know

The PDSA model provides a framework for beginning changes on a small scale and increasing their scope as they prove successful.
Look to frontline staff for ideas on what to improve.
Recruit a team that can provide day-to-day leadership, has the necessary technical expertise, and has the support of system leadership.
Groups must collect the data to know when a change is actually an improvement.
Most groups can do something to improve care "by next Tuesday."
Barriers to change can be overcome.
Consider an external ethics review for some CQI projects.

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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 ].