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

Sourcebook : Improving Care for the End of Life : 17.7 Start to Test Changes with a Limited Number of People

The sooner a team tries changes, the more confident it will be that accelerating change is possible. The greatest pitfall in improvement is delaying the test for one more round of data collection, or for the next committee meeting to receive approval for rolling out the change to the entire organization. Begin testing on a small scale.

The best way to start is to try changes on one or two patients, during one afternoon or one shift. This kind of change is something that can be done “by next Tuesday.” Willing team members can test the change on their own patients.

When teams begin to test changes, they also need to make plans: what is likely to happen, what the results might be, how these results can be measured and described. For example, if the change involves an advance care planning process, and the measure is family statements that their wishes were known and followed, ask the first family right after the first discussion whether or not they feel their wishes are known to the staff. Continue to study the results. Ask the physician and nurse who participated how the process went and how it could be improved in the future. Do not wait until the process has gone badly for six patients to modify the intervention!

Teams can then continue testing on ever larger samples and begin to study their results. Along the way, teams can document what they are learning and share it with others: Post a graph on the staff bulletin board to document the number of advance care planning discussions held in the clinic that week. Tell others about the results of interviews with family caregivers. Even if the changes tested show no result in the first few weeks of a project, resist the temptation to abandon the work or hide the results. Instead, use this as a chance to do a little detective work to determine whether the changes are really taking place (Is the protocol being used? Are the discussions really occurring?), then modify the plan as needed. If, over a month or six weeks, the indicators remain unchanged, then the team should consider trying other changes or using another measure or indicator to test for improvement.

Learning to test on a small scale is an unfamiliar concept in health care. Be patient and keep trying. Rapid-cycle change is a convincing and safe way to bring innovation into health care organizations.

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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 [ ] and Oxford University Press. All rights reserved.

For further information on quality improvement in end-of-life care visit The Palliative Care Policy Center [ ].

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