CPCS : Quality Improvement Services : 1997-1999 Collaboratives

To date, IHI and CICD have joined forces to implement two Collaboratives aimed at helping participating health care provider teams throughout the country develop high quality programs that blend the best of disease and medical management with the best of palliative care, including for patients who do not fit the current hospice model of end-of-life care. Funding from the Archstone, Robert Wood Johnson, Nathan Cummings, and other foundations has helped support the Collaboratives and related activities.

Prior to each Collaborative, participating health care teams formulated their aims using a charter that included seven patient promises and a matrix of key program elements. This planning and the implementation that followed help shape the intended results. The "Seven Promises" [ Read them at www.abcd-caring.org/tools/actionguides.htm ] encouraged teams to consider what they might be able to assure their patients that they could expect during their illness.

The first Collaborative began in July 1997 and focused on improving care in four specific areas related to end of life care: Pain and symptom management, advance care planning, continuity and coordination of care; and family support. The objectives of teams in this Collaborative included reducing the incidence of severe pain by 25 percent, increasing by 35 percent the number of patients who made their wishes known about end-of-life care, and reducing by 50 percent the number of patients with transfers in the last two weeks of life. Four-dozen health care organizations participated in this Collaborative and a number of interventions were found to be helpful in leading to improvements in the target areas. Successful interventions included:

• Instituting pain and symptom management protocols
• Initiating advance care planning discussions within 24 hours of admission and documenting the plan in a patient's chart
• Increasing 24-hour access to staff, using pagers and other communication devices to decrease hospital emergency room utilization
• Beginning bereavement assistance and support for the family and friends before patients die

Beginning in January 1999, IHI and CICD partnered with the Department of Veterans Affairs to lead a second Collaborative on Improving Care for Patients with Advanced Congestive Heart Failure and Chronic Obstructive Pulmonary Disease.

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