NURS 6914 Week 9 program quality plan example

How Would We Know It Works? A Quality Plan for a Community Hospital's Palliative Care Consultation Program, From Consult Triggers to Bereavement Follow-Up

Student Name

College of Nursing, Walden University

NURS 6914: Advanced Palliative Concepts and Interdisciplinary Perspectives

Instructor Name

Month Day, Year

How Would We Know It Works? A Quality Plan for a Community Hospital's Palliative Care Consultation Program, From Consult Triggers to Bereavement Follow-Up

Executive Summary

This plan proposes how a composite 220-bed community hospital's palliative care consultation program would measure whether it is working, and three changes to make it work better. The program currently sees about four new patients a week, most with cancer, most referred in the last days of life. The plan proposes (1) a measurement set organized by structure, process and outcome, (2) revised criteria that prompt a consultation earlier and for more illnesses and (3) a bereavement follow-up process for families after a death.

Program Description

The team consists of a part-time palliative physician, one full-time palliative nurse practitioner, a social worker shared with the oncology unit and chaplaincy on request. Consultations are requested by attending physicians. A review of the past year's referrals showed three patterns: about four in five patients had cancer, although heart failure, lung disease and dementia account for many hospital deaths; the median time from consult to death was short, suggesting late referral; and no contact was made with families after a patient died.

Measurement Using Donabedian's Model

Donabedian (1988) argued that judging care calls for three kinds of evidence. For this program they become: who is on the team and what time and training they have (structure), whether the team reliably does the things a good consultation requires (process) and how patients and families fare (outcome). Each is needed, because good structure does not guarantee good process, and outcomes are affected by many things beyond the program. Table 1 sets out the proposed measures.

Table 1

Proposed Measures by Donabedian Category

Several process measures are adapted from the Measuring What Matters set, a list of top-ranked quality indicators for hospice and palliative care developed by the American Academy of Hospice and Palliative Medicine and the Hospice and Palliative Nurses Association, which includes comprehensive assessment, screening for physical symptoms, documentation of surrogate and care preferences and discussion of emotional or psychological needs (Dy et al., 2015). The structure measures reflect the first domain of the National Consensus Project guidelines, which describes an interdisciplinary team with appropriate training (Ferrell et al., 2018).

Revised Consultation Triggers

The current practice relies on physicians to think of palliative care, which produces late, cancer-heavy referrals. The plan proposes that the following prompt an automatic suggestion to consult, which the attending physician may accept or decline:

1. Two or more hospital admissions for the same serious illness within six months.

2. Admission to intensive care for a patient with advanced heart failure, lung disease, dementia, kidney failure or metastatic cancer.

3. A new diagnosis of metastatic cancer.

4. A family meeting about goals of care requested by any team member.

5. Uncontrolled symptoms after 48 hours of standard treatment.

The triggers name illnesses beyond cancer and moments earlier in the illness, which should shift both the diagnosis mix and the timing of referral. The process measures in Table 1 will show whether they do.

Bereavement Follow-Up

Hospital palliative programs often end their involvement at the patient's death, but the family's needs do not. Bereavement is associated with increased risk of physical and mental health problems, and a minority of bereaved people experience prolonged, disabling grief (Stroebe et al., 2007). Hospice programs provide bereavement support as a matter of course; hospital programs often do not.

The plan proposes a simple three-step process. A condolence card signed by the team within a week of the death. A phone call from the social worker or chaplain at about one month, using a brief screen for complicated grief risk. Referral to community bereavement services or a hospice bereavement program for families who screen at risk or ask for support. Every contact will be logged, which supplies the outcome measure in Table 1.

Implementation and Review

The program will collect baseline data on every measure for one quarter before setting targets, since targets without baselines cannot be judged. The trigger criteria will be introduced on two medical units first, then extended hospital-wide if the rate of declined suggestions is low. Results will be reported quarterly to the hospital's quality committee, and the team will review measures annually to retire those that no longer discriminate and add new ones. The plan requires a modest investment: protected chaplain hours, a part-time data analyst for chart audits and funding for condolence mailings. The quality committee is asked to approve these resources for one year, after which the program will present its results.

Risks and Limits

Three risks could undermine the plan. First, automatic consult suggestions may be ignored if physicians see them as alerts to click past; the referral log will track how often suggestions are declined, and the team will meet with the units where declines are highest. Second, a small team may be overwhelmed if earlier and broader referral succeeds; the plan asks for a review of staffing at six months, using the rise in consults as evidence. Third, outcome measures in palliative care are hard to interpret, since patients die whatever the quality of care and family ratings reflect many things beyond the team's work. The plan therefore treats outcomes as signals to investigate rather than grades, and it relies on process measures for accountability. None of these risks is a reason to delay; each is a reason to measure from the start.

References

Donabedian, A. (1988). The quality of care: How can it be assessed? JAMA, 260(12), 1743-1748. https://doi.org/10.1001/jama.1988.03410120089033

Dy, S. M., Kiley, K. B., Ast, K., Lupu, D., Norton, S. A., McMillan, S. C., Herr, K., Rotella, J. D., & Casarett, D. J. (2015). Measuring what matters: Top-ranked quality indicators for hospice and palliative care from the American Academy of Hospice and Palliative Medicine and Hospice and Palliative Nurses Association. Journal of Pain and Symptom Management, 49(4), 773-781. https://doi.org/10.1016/j.jpainsymman.2015.01.012

Ferrell, B. R., Twaddle, M. L., Melnick, A., & Meier, D. E. (2018). National Consensus Project clinical practice guidelines for quality palliative care guidelines, 4th edition. Journal of Palliative Medicine, 21(12), 1684-1689. https://doi.org/10.1089/jpm.2018.0431

Stroebe, M., Schut, H., & Stroebe, W. (2007). Health outcomes of bereavement. Lancet, 370(9603), 1960-1973. https://doi.org/10.1016/S0140-6736(07)61816-9