The Common Sense Guide to Improving Palliative Care > Advance Care Planning > 3.3 Identifying the Problem and Setting an Aim

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

Advance Care Planning: Identifying the Problem and Setting an Aim

You may know that most of your seriously ill patients do not have good advance care planning (ACP), but you are not exactly sure where to start an improvement project. Do families always just want "everything done?" Are staff "afraid" to have these conversations earlier in the resident's stay because they "don't know what to say" or are afraid that they might "upset" the resident or family? Do patients really want to avoid these discussions? Before you act on your hunches, be sure that you know the problem well. Others on your team need to agree about what the problem really is. Your team might ask staff about their perceptions or ask residents' survivors. Do you have data that can clarify which are the most important areas or resident populations to start with? Even asking a few of your team members such questions can help identify the problem.

Team Delta

After a few brainstorming sessions, Team Delta talked to a few family members whose loved ones had recently been hospitalized or had died in the facility. They identified the following problem areas:

Once Team Delta identified key problem areas, the team needed to set one or more aim statements that it could measure and toward which it could work. Team Delta developed the following aim statements to reflect its broad sequential goals:

Aim 1: Within six months, 80% of the facility's professional caregivers will have participated in an educational seminar on ACP, treatment choices, and disease progression.

Aim 2: Within three months, 95% of new and "at risk of death" residents will have an ACP discussion documented in their medical records.

Aim 3: Within six months, 95% of new and "at risk of death" residents who have had an ACP discussion will have a completed advance care plan documented in their charts.

The team then came up with this overarching aim statement.

Aim statement: Within six months, 90% of new and "at risk of death" residents will have a completed ACP documented in their record (95% with discussion, and 95% of those discussions documented = 90% overall completion rate).

What will improve: Documented ACPs.

By when: Within six months.

By how much: Ninety percent (instead of the current occasional).

For whom: New and "at risk of death" residents.

How to have comprehensive discussions with patients and families, how to document the patients' decisions and later changes in those decisions, and how to transfer patients' information to other healthcare settings are all part of a good ACP program. Common problems related to ACP include the following:

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