Improving Care for the End of Life, Online Edition The Palliative Care Policy Center

Sourcebook : Improving Care for the End of Life : 2.10 Troubleshooting: Ways to Avoid Common Traps

All teams encounter the same pitfalls, and some fall right in. The key is knowing what the problems are. Teams that recognize when they are stuck can often climb right back out.

Problem 1: Studying the Problem Too Long without Acting

Teams that spend more than four weeks collecting baseline information are stuck. If discussions about data collection dominate team meetings, the team has fallen into an information abyss.

Solution: Collect Just Enough Data

Problem 2: Getting Everyone's Agreement First

The entire nursing staff need not agree to treat pain differently. Start with the staff members who will be trying the new assessment approach. In health care, we sometimes seek consensus around changes before agreement is needed or warranted, missing the opportunity to try new approaches. Participants need not agree "for all time," only for a while. Most people can make this commitment just to be cooperative.

Solution: Start with Small Groups and Gradually Add People Working on the Change

Problem 3: Educating without Changing Structures or Expectations

The most common tool for change in health care is an education program. It is also the least effective if done without other system changes. Education is very useful for helping people adopt new changes that they are motivated to adopt, but education alone does not create lasting change. If your massive education campaign leads to no real behavior changes, you are going nowhere.

Solution: Focus on Powerful Changes

Problem 4: Tackling Everything at Once

A team may be eager to tackle it all - pain management, advanced care planning, and meaningfulness and spiritual support - aiming to improve every problem in patient care at once. However, starting changes in each area simultaneously takes a tremendous amount of staff time and requires tolerance of uncertainty and disruption in many areas at once. If team members feel that they cannot pay attention to all the changes the team wants to make, then the team has taken on too much.

Solution: Focus and Sequence the Changes

Problem 5: Measuring Nothing - or Everything

Having no data is a problem. Unfortunately, good work will not stand on its own merits. If the team cannot describe the effect of the changes it has made, it will not be able to continue with the good ones - or recognize the bad ones. And, as mentioned above, teams need to avoid the comfortable niche of measuring so much that they don't have time to make much happen. We find it a useful rule of thumb to allocate energy this way: "If you have five units of energy to spend on making improvement, use four on change and one on measurement." Be sure not to use much less on change or much more on measurement.

Solution: Just Enough Data (again)

Problem 6: Failing to Build Support for Replication

If a team has great results for a few patients, but no one else adopts the changes, it has not made much headway. Early in the process, team members need to tell others about what they're doing - to make colleagues curious to know more - so that others will be more willing to try the team's changes. In this way, teams do good work for their patients while laying the groundwork for further improvements.

Solution: Promote the Project and Engage Senior Leaders

Problem 7: Assuming That the Status Quo Is OK

In health care, we have come to accept some very troubling practices. Think, for instance, about patients in the last phase of life who receive futile CPR or doctors who keep prescribing meperidine. Some aspects of the status quo never set off the alarms that they should. If a team cannot think of anything to improve about the way it cares for dying patients, team members are not looking critically at the status quo. Sometimes, under scrutiny, the status quo actually becomes shocking. Sometimes, just measuring the dysfunction in the status quo is so embarrassing that it motivates a readiness to change.

Solution: Think about How It Could Be

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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 ].

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