Practice Changes

• Overview
• Quality
• QAPI
• PDSA
• Collecting Measures
• Performance Improvement Project
• Interventions
• MedQIC
• Cultural Diversity
• Additional Resources

Overview

This section provides an overview of the processes for quality and performance improvement, suggestions for interventions and cultural diversity in hospice and palliative care. 

Quality

The Institute of Medicine identified six aims for healthcare quality improvement.  They are:

• Safe - avoiding patient injuries from care given;
• Effective - evidence based with neither underuse or overuse of available techniques;
• Patient-centered - patients/families active in their plan of care;
• Timely - providing prompt attention benefits patients/families;
• Efficient - reducing waste;
• Equitable - racial and ethnic patients receive equitable care.

Since quality is everyone's responsibility, this means quality is an attitude and orientation that encompasses an entire agency leading toward excellence and continuously improving processes throughout the system.

QAPI

Quality Assessment and Performance Improvement (QAPI) is a way of assessing quality and improving performance.  It provides hospice and palliative care agencies with a structure to improve outcomes for their patients and families.  The diagram below, from the Center for Medicare and Medicaid Services, illustrates the structure using this feedback loop.



You may want to consider using the structure and providing your staff with an in-service.  This may help define and assist your staff in understanding QAPI and their role in the process.     

Quality Assessment and Performance Improvement (Staff In-service)

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PDSA

The PDSA (Plan, Do, Study, Act) Cycle is a medium for learning and action.  One way to use the cycle is to follow The Model for Improvement (Langley, et.al. 2009) by asking these three fundamental questions:

• What are we trying to accomplish?  
• How will we know that a change is an improvement?  
• What change can we make that will result in improvement?   

The PDSA cycle informs your staff on how your current systems are operating and where problems may exist.  Read the following self-study reference to learn about the PDSA Cycle.

Quality Improvement: The Process and PDSA Method Fitting the Pieces Together

Collecting Measures

The process of quality assessment begins with your quality team determining measures, collecting data, reporting and focusing on data to improve quality.  Conduct an in-service for your staff explaining the components for collecting, analyzing and reporting data as part of a QAPI program.  You can ask staff to review clinical records using an agency specific data location tool that includes the AIM questions.

Quality Assessment: Data collection, recording and reporting (Staff In-service)
Agency Specific Data Location Tool

Performance Improvement Project

Once your quality team has selected measures and data are collected, the results of the information are used to improve the quality of your care, services and operations.  Your quality measure report may identify areas in need of improvement.  You should investigate which organizational factors may be contributing to low performance in certain areas (root cause analysis), and then implement strategies to improve. For example, if your data show low rates for comprehensive assessment completed within five days of admission, you may want to gather a team of people to analyze why this is the case, and then develop an intervention to help achieve the goal. This would be considered a Performance Improvement Project (PIP).  Show your staff how to identify areas for improvement and support attendance of those interested in quality with regularly scheduled performance improvement meetings and keeping the team on track by completing QAPI Program Performance Improvement Project forms.   

Performance Improvement Projects: Improving outcomes and sustaining progress (Staff In-service)
Essential Elements of a PIP
Outline for PI Team Meeting Schedule, Agendas and Notes
QAPI Program Performance Improvement Project Template

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Interventions

The following are examples of performance improvement interventions implemented by Hospice AIM Project participating agencies for problems identified by quality measure performance scores.


Problem #1:    
Did not achieve performance level wanted in quality measures score for M1 and M2 due to either symptoms not assessed or symptom ratings not quantified in the clinical record.
Intervention #1:     
Developed a Hospice Symptoms Review Form (Modified Edmonton Scale) to be used with responsive patients/family members at the time of admission.  This tool scored six of the symptoms that comprise M1 and M2 (pain, shortness of breath, nausea, constipation, anxiety, and depression).

Hospice Symptoms Review Form (Modified Edmonton Scale)

Problem #2:    
Did not achieve performance level wanted in quality measure scores for M1, M2, and M7 due to anxiety and depression screenings frequently not documented or completed within acceptable timeframes.
Intervention #2:     
Developed nursing - social work interaction process for use with patients with anxiety on admission: social worker to be contacted within 24-48 hours of admission and social work visit scheduled within three days of notification.

Problem #3:    
Did not achieve performance level wanted in quality measure scores for M2 and M7 due to anxiety and depression screenings frequently not documented or completed within acceptable timeframes.
Intervention #3:     
Developed a "red flag" process to use when the professional nurse on the Initial/Comprehensive Assessment identifies patient/family who need a social work visit within 24-48 hours.

Clinical Intervention Examples (professional nurse and social worker)

Problem #4:    
Did not achieve performance level wanted in quality measure scores for M1, M2, and M3 due to not consistently assessing pain in nonresponsive patients.
Intervention #4:     
Implemented the additional use of the FLACC scale to measure pain in nonresponsive patients.

Problem #5:    
Did not achieve performance level wanted in quality measure scores for M1, M2, M3, M4, and M7 due to either symptoms not assessed or symptom ratings not quantified in the clinical record.
Intervention #5:     
Initiated reactivation of pain, dyspnea, nausea, and anxiety scales in the electronic clinical record. Scales had been available in the software but were shut off prior to data collection.

Problem #6:
Did not achieve performance level wanted in quality measure scores for M1, M2, M3, and M7 due to either assessments not completed or symptom ratings not quantified in the clinical record.
Intervention #6:   
Developed clinical staff user friendly key chain hole punched laminated 5"x7" cards for reference during patient assessments.  One card contains selected questions from the Edmonton Symptom Assessment Scale and on the back the PAINAD (Pain Assessment in Advanced Dementia) scale.  The other card contains the Palliative Performance Score V.2 and on the back the FAST (Functional Assessment Staging of Alzheimer's Disease).   

Clinical Practice Laminated Cards 

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MedQIC

Materials designed to help healthcare organizations develop quality improvement strategies are available on the Internet. One good source of information is the Centers for Medicare and Medicaid Services (CMS) MedQIC Web site: www.medqic.org. Materials developed for the home health and nursing home settings may be of particular value. 

Cultural Diversity

Hospice and palliative care serves many different populations.  The varied beliefs and attitudes held by people about cultural diversity can affect care delivery and patient outcomes.  Creating an environment of inclusion for staff and patients can be complex. Diversity training, mentoring of staff and leadership development are some ideas for an agency to implement to address some of the challenges that your agency may encounter.

There are questions on the AIM DATA Collection Tool that ask for patient's race and ethnicity.  You can refer to the HRET Disparities Web site www.hretdisparities.org for information on speaking with patients about race and ethnicity or use the toolkit's tip sheets for suggestions on how to ask patients about race, ethnicity and preferred language. The Toolkit also includes a document containing discussion points to assist primary care and other health care providers with discussing end-of-life care options with their patients and families.

Awareness of Minorities and Other People Groups
Asking Patients about Race, Ethnicity, and Preferred Language
Health Care Provider Tips for Increasing Hospice and Palliative Care Admissions


We thank the following agencies and organizations for sharing their resources in this toolkit.  We hope you find them helpful.

Additional Resources

Hospice Hawaii

• 2011 Quality Improvement Program
• Nausea/Vomiting Management Audit Tool
• Bowel Care Audit Tool
• Death Visit Audit Tool
• Eligibility Audit Tool
• Nurse POMR Audit Tool
• CNA POC r/t Care Given Audit Tool
• Narcotic Orders Audit Tool
• On-Call Visit Audit Tool

Oregon Hospice Association/Willamette Valley Hospice

• Fall Prevention Program
• Self Assessment for Caregivers
• WVH Fall Form
• WVH Fall Safety Checklist
• Plan of Care_Safety

New York State Department of Health (Material prepared by Weatherbee Resources, Inc. under contract with the New York State Department of Health, Office of Long Term Care for its Hospice Quality Assessment and Performance Improvement Initiative. December 2009)

• Tool for Evaluating Quality Indicators or Instruments
• Indicator Description Template and Example
• QAPI Report to Hospice Governing Body

References

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IPRO Staff Access