The Common Sense Guide to Improving Palliative Care > 1.1 An Orientation

This extract from the online edition of The Common Sense Guide to Improving Palliative Care is used with permission.

An Orientation

Healthcare is changing for the better for patients nearing the end of life. Changes being tested and tried by organizations nationwide demonstrate that we can and must make life better for people with advanced, and eventually fatal, illnesses. Using a rapid-cycle approach to quality improvement (QI), hundreds of teams have found that straightforward approaches to complex problems can actually lead to improvements for patients and families. In the midst of the physical and emotional suffering that often accompany dying, these teams have found that they can comfort the sick; that pain and a score of other symptoms can be managed; that advance care plans can be located and honored; that transfers can be almost seamless; and, certainly, that human relationships can be strengthened. Although it may take some time to design and implement a program of one's own, the process is easy to understand and follow; it is simple enough to try one or two changes with one or two patients and then go on from there, as other groups have. For instance, consider the following examples.

• A California skilled-nursing facility found that only 26% of their residents had a documented advance directive. An improvement team decided to do better. They gave patients and families very clear instructions about life-sustaining treatments and what it meant to use each of them. The team created a process to transfer records from the facility to other hospitals and clinics in its system, ensuring that advance directives went along. And they added completion of the advance directive to the weekly interdisciplinary team meeting, including it as a goal for every patient. Within six months, 70% of their patients had a documented advance directive at discharge; within 10 months, 91% did. Three months later, the level remained this high, and everyone at the facility had come to expect that a documented advance directive was simply part of good care.
• A volunteer meal-delivery program wanted to expand the scope of its work to offer prevention services along with hot meals. Its QI team aimed to reduce falls among its elderly clients by assessing homes for safety issues and ensuring that someone had made the necessary changes within six months. In the target group, only one client was hospitalized for a fall, compared to 36% of clients in a similar group who did not get the services. After that success, the group decided to add a two-hour visit with patients by a social worker to screen for depression. The social worker found that 60% of the clients reported feeling depressed; and, of these, 75% said they had no one to turn to in an emergency. The project recruited volunteers to make twice-weekly phone calls to their clients, using a discussion of menu choices for Meals on Wheels as the reason for the call. These calls provided regular social contact for the clients and current information about client needs to the program. The endeavor delighted both the homebound clients and the volunteers.
• A major urban hospital realized that many patients returned to their hospital beds without having completed scheduled diagnostic tests because they were in too much pain. At first, nurses were told to "try harder" to assess pain, but this brought about no real improvement. Then, the radiology department decided to give transport orderlies training in using a pain intensity scale. Orderlies were instructed not to transport a patient unless the nurse on duty had completed the form and, if necessary, had treated the patient's pain. This process resulted in huge changes: the number of patients assessed and treated for pain before undergoing a diagnostic test went from 16 to 92%. Within a few months, no patients were returned to the unit because they were in too much pain to undergo a test. Today, this process is standard procedure throughout the hospital. The hospital views it as an adverse event if a patient is returned because pain prevented a diagnostic test.
• Because of travel time, a hospice found that each nurse was able to admit only one or two patients per day. The hospice decided to train other staff to perform most of the admissions work, especially the duties of contacting and visiting families to explain the hospice benefit. This freed nurses to see three or four patients daily and increased by 37% the number of patients admitted to hospice within 24 hours of referral.

These groups sound so good, you might think that we made them up. But in fact, people like you, eager to improve how palliative care is done, created these stories with hard work and dedication. Like them, you too can use rapid-cycle QI methods to make substantial changes. You can use these methods in any healthcare setting, and you can do so quickly, effectively, and efficiently. This manual shows you how to jump start QI, no matter where you work, so as to improve your organization's practices. We focus on patients with advanced illness and those coming to the end of life, though the QI method works in other populations as well.

Everyone wants to improve healthcare, and many even have great ideas for doing so. Sometimes, the toughest part can be figuring out where to start and forging the will to get changes underway. We will show you how to develop a QI project, measure what you are doing, figure out whether what you have tried really leads to improvement, and sustain the improvements that you achieve.