Sourcebook : 6.2 Improve Clinicians' Communication Skills : 6.2.1 Case Study - St. Thomas Health Services:

As many innovators discover, not every health care provider is ready for change or understands quality improvement in end-of-life care. The Breakthrough Series team from St. Thomas Health Services in Nashville, Tennessee, encountered a physician who was reluctant to engage in any of the team's change cycles. However, one day he called the team leader to ask for "the packet," something to help him talk to dying patients. The team quickly wrote and began to distribute a collection of documents they titled "The Packet: Communication Guide for Care of the Patient with Life Threatening Illness," which featured checklists to guide clinicians through the steps involved in providing good end-of-life care. The checklists are a "care map" to protocols and policies and describe the role of each care team member. The requesting physician's "packet" was assembled in a day.

With "The Packet," the team aimed to improve communication between physicians and patients or their surrogates. To measure initial success, the team planned to track increased patient/family/physician/caregiver satisfaction with care, although the patient may have died. As the project continued, the team found that families gave consistently high satisfaction ratings - even when communication was poor, pain was not controlled, and other factors were less than ideal. It changed its measures to include:

• Increased end-of-life ethics consults
• Data collection about elements of a good and bad death
• Decreased costs of dying, without an increase in mortality rates
• Increased patient comfort, competency, confidence, and satisfaction

The checklist encouraged continuity of communication among providers and with patients - helping everyone to sing from the same sheet. Information in "The Packet" became the basis for a communications flowchart now used as a teaching instrument. The focus on communications created the expectation that doctors would discuss end-of-life issues with patients, gave nurses more direct authority in communicating with patients and clinicians, and highlighted the need to focus on spirituality.

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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 ].