The Common Sense Guide to Improving Palliative Care > 1.4 How to Start Changing Practices
When Elisabeth Kübler-Ross set out to study dying people in the late 1960s in her own university hospital, clinicians responded that they had no patient known to be dying! Ignoring reality is often easier than acknowledging it or changing it. Today, many healthcare organizations tend to believe that they actually have little need to change: everyone else might need to change and improve, but we are doing just fine. However, many more groups now admit that they may not be doing a perfect job and want to do better.
The first thing you will need to do is to understand what is not working in your system and why. You will need a clear picture of the current situation and how you can improve practices. Take a close look at what your organization is already doing in any of the usual target areas: pain and symptom management, advance care planning, transfers and con-tinuity, and psychosocial/spiritual support for patients and families. Consider your current practices by asking a few pointed questions such as these:
These questions seem pretty straightforward. But when groups are asked to take a hard look at what is usual and routine in their settings, they tend to be shocked by what they find. Consider the following examples.
On the one hand, uncovering these shortcomings can make you want to throw in the towel. On the other, leaders intent on QI see these problems as opportunities to strive for excellence. Improvement starts with "What is wrong?" and "What if?" questions and then moves ahead when clinicians decide to take action on behalf of their patients.
The rapid-cycle QI method can quickly improve patient care. Such change does not require congressional action or discussion by the hospital's board of directors: improvement simply requires dedicated people working toward an aim that is important to patients and families.
Our work has most often engaged QI groups from hospitals (most often emergency rooms, intensive care units, and acute care), nursing homes, home health agencies, and hospices. Their patients, clients, and residents range from those in the early stages of a serious illness to those in their final days before death. Each of these situations requires different types of change, so we have varied our examples. Each chapter includes suggestions about adapting interventions to particular environments and to the specific needs of patients and families living with serious illness or of those passing through the hours and days just before death.
Once you have made improvements, you will want your colleagues to adopt these QI methods and to expand the scope of your intervention. This will lead to the next step in the improvement process: testing interventions on ever-larger groups or in different settings. Some teams have been so successful that their strategies have spread throughout their entire system or community. Of course, this is hard work. If it were easy, it would already be done. Sometimes, you may find that you have to go back a few times even to establish an aim that anchors the work.
QI teams like yours, nationwide, have discovered that their work in improving care for advanced chronic illness patients and those at the end of life has benefits for other patients and providers in their own healthcare system. Moreover, some improve delivery of healthcare throughout their region and among different care providers. As discussed at the beginning of this chapter, teams have achieved important goals within just a few months.
This manual features practical, hands-on skills and techniques to help you do just that. Each chapter features steps on how to get started; how to develop, test, and measure changes; and how to spread your ideas. Each chapter includes stories based on the experiences and achievements of the groups with which we have worked. These stories show you how others have accomplished improvement and inspire the confidence that you can change things for the better. This manual will also provide ready-to-use ideas for change, as well as tools with which to measure improvement.