Sick To Death > Chapter 3 > Quality Improvement
Recognizing the shortcomings in end-of-life care, many organizations have undertaken rapid-cycle quality improvement (Phillips, Sabatino, and Long 2001; Lynn, Nolan, et al. 2002). Almost one hundred organizations from an array of health-care facilities and programs have participated in year-long improvement collaboratives. In 1997, forty-seven teams representing hospitals, nursing homes, and veterans hospitals joined in a "Breakthrough Series Collaborative" to improve four key aspects of end-of-life care: to improve pain and other symptom management; to reduce the number of transfers and increase continuity of care; to improve advance care planning; and to attend to the spiritual needs of patients and enhance opportunities for meaningfulness in their lives and in the lives of their loved ones (Lynn, Schuster, and Kabcenell 2000). The forty-seven teams were successful in most of the initiatives that they attempted, although improving continuity of care proved to be a difficult task.
When the collaborative series began, participating teams reported significant problems in how their institutions dealt with end-of-life care (Lynn, Schuster, and Kabcenell 2000). One hospice found that half of the patients it admitted reported pain scores greater than five (on a scale of one to ten). A hospital team found that it took almost an hour from the time pain was assessed until orders were issued and another 115 minutes before medication was actually delivered.
By applying rapid-cycle improvement methods, groups reversed these and other problems. For instance, many teams began to assess pain as a fifth vital sign, a strategy that has since become part of JCAHO standards ( Joint Commission on Accreditation of Healthcare Organizations 2001). One team developed what I earlier called the "no surprise" question. The team asked physicians at a Franciscan Health System clinic in Tacoma, Washington, to review lists of their patients - and ask themselves if they would be surprised if particular patients were to die within the next year. Patients whose death would not be a surprise were referred to supportive-care services, including advance care planning. Doing this eventually led to greater satisfaction, more use of supports in the community, earlier referrals to hospice, and much longer stays in hospice care. The program has already expanded to six other facilities in that health-care system and won a national award for its efforts (National Coalition for Health Care and Institute for Healthcare Improvement 2000).
Another team launched an in-patient palliative-care unit in its city's public hospital. That award-winning program relied on community and faith-based volunteer networks to support patients who would otherwise have been ineligible for hospice services (Last Acts 2000).
Building on the success of this model, the U.S. Department of Veterans Affairs, the Institute for Healthcare Improvement, and the Center to Improve Care of the Dying cosponsored a program focused on improving care for patients with advanced congestive heart failure and chronic obstructive pulmonary disease. Regional collaboratives in New York City and in Pittsburgh have demonstrated that the model can be used to move an entire region to improve care for people near the end of life. The Veterans Health System coordinated a quality-improvement collaborative among seventy teams, which drove serious pain rates down by one-third (Cleeland et al. 2003). In these and other projects (Bookbinder 2001), the methods of quality improvement have shown their merit in creating systems that support good care (Lynn, Nolan, et al. 2002; Joint Commission on Accreditation of Healthcare Organizations 2001).