PROMISE Performance Reporting and Outcomes Measurement to Improve the Standard of care at End-of-life

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PROMISEPerformance Reporting and Outcomes
Measurement to Improve the Standard of care at
End-of-life

• The PROMISE team
• HPC meeting, St Louis
• May 12, 2009

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Objectives

• To introduce the PROMISE center
• To explain PROMISE
• Methods
• Reports
• To describe where PROMISE is going and
• To identify ways in which well need your help

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PROMISE goals

• To identify and reduce unwanted variation in the
  quality of end-of-life care for veterans.
• To define and disseminate processes of care that
  contribute to improved outcomes for veterans near
  the end of life and their families.

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What is PROMISE?

• The quality measurement center for the CELC
  Initiative
• Based at the Philadelphia VAMC Center for Health
  Equity Research and Promotion
• Funded through the CELC to provide
• A voice for veterans/families
• Actionable data that can guide facility- VISN-
  and national-level planning and strategy.

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What does PROMISE deliver?

• Data for facilities about the quality of
  end-of-life care they provide
• Timely feedback
• Understandable reports
• Meaningful benchmarks
• Practical guidance for HPC programs
• Useful evaluations for CELC Initiative leadership

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Framework for PROMISE data Domains of care
(from NCP guidelines)

• Physical aspects of care
• Social aspects of care
• Spiritual, religious, and existential aspects of
  care
• Cultural aspects of care
• Care of the imminently dying patient
• Psychological and psychiatric aspects of care
  (including bereavement)

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Framework for PROMISE data Aspects of care

• Processes of care (from chart reviews)
• Outcomes (Families perceptions of care)
• Currently (Q1 FY09) 43 facilities
• 800 interviews/quarter
• 1600 chart reviews/quarter

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Processes of care Chart review

• Sample
• Inpatient deaths
• Excluding unexpected deaths (e.g. ER, suicide,
  homicide, OR for outpatient procedure)
• Deaths identified using VISN data (multiple
  overlapping samples)
• Remote chart reviews via Global CPRS

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Processes of care (examples)

• Pain assessment within 24 hours of last admission
• Palliative care consultation note
• Documentation of a surrogate or that a surrogate
  could not be found
• Chaplain contact with veteran/family
• Social work note
• Documentation of a bereavement contact

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Processes of care Documentation of a surrogate
decision-maker
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Outcomes of care The Bereaved Family Survey

• BFS OMB-approved survey derived from the Family
  Assessment of Treatment at End-of-life (FATE)
• 14-item telephone survey administered to the
  veterans NOK 6-10 weeks after death
• Procedure
• Predefined algorithm for contacts (NOK first
  choice)
• Initial letter with opt-out provision
• Telephone contact
• Opportunity for family members to refer to
  alternate

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Outcomes of care 12 multiple-choice BFS items

• Pain management (1)
• Communication (Providers gave enough information
  in an understandable way and took time to listen)
  (3)
• Veteran didnt receive unwanted treatment (1)
• Providers were kind, caring, and respectful (1)
• Family was told what to expect in the veterans
  last hours of life (1)
• Veterans personal care needs were met (1)
• Spiritual support, emotional support (pre/post)
  (3)
• Enough help with funeral arrangements (1)

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Outcomes of care BFS scoring

• All items are either dichotomous or
  frequency-based
• Did you receive as much help as you needed with
• How often did the health care providers who took
  care of veteran
• Responses dichotomized (Best possible response
  vs. all others).
• BFS and item scores reflect a proportion of the
  time that the veteran/family received the best
  possible care.

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BFS scores 43 facilities
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Families perceptions of bereavement support 43
facilities
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Quarterly VISN-level reports

• Categories match NCP domains
• Reports broken down by facility (Process and
  outcome measures)
• Compared to sample benchmark (pooled mean of top
  facilities)
• Hypertext links to
• Best Practices on PROMISE website
• SharePoint tools (Luhrs)

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Additional dataresponses to 2 open-ended
questions

• The hospice unit was the best part of the care
  that veteran got in the whole 14 years that he
  was going to the VA.
• We really depended on the palliative teamthey
  were wonderful.
• Everyone was very helpful, but especially NP on
  PCCT. She was always there, always available.
  We wouldnt have made it without her.

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Additional datareferrals for unmet needs

• Unmet needs identified in interviews
• Bereavement
• Questions about care
• Questions about benefits
• Referred to VISN coordinator and/or facility
  patient advocate (with family permission).
• Gives us
• An opportunity to meet needs and to leave
  families with a good impression of the VA
• Valuable data about needs for improvement

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Can you give us even more data?
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Additional data

• Aggregate (broken down) data available to each
  VISN
• Raw data available on request
• Menu-driven custom reports online (at PROMISE
  website)
• Mean BFS score in our ICU, with and without
  palliative care
• Mean bereavement score in our VISN, with and
  without a bereavement contact

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Using the PROMISE report 6 rules

• Dont panic
• Focus! (Look at individual items)
• Ask Do you have enough data? (Two quarters
  worth)
• Use common sense (does this score make sense?)
• Select one item to improve that has
• A low score
• An obvious action plan
• Be skeptical about changes

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Interpreting changesWhat happened in these
facilities?

• A facility improves its BFS score from 45 to 60
  in 3 months
• Answer Nothing
• A facility improves its bereavement score from 49
  to 65 in 3 months
• Answer A social worker dedicated to bereavement
  calls educational materials for family a
  condolence letter for all deaths.
• Lesson Be critical about scores and changes

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Closing the loop Bringing the veterans and
familys voice back to the bedside
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Help us close the loop (1-2)

• 1. Success stories solicited from field
• Structured description via web-based form
  (Through PROMISE website)
• Submit descriptions of
• Good scores
• Improvements
• How youre using PROMISE data
• 2. QI Registry tracking single-facility
  interventions
• Structured description of goal, intervention, and
  expected outcome submitted via web-based form
  (Through PROMISE website)

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Help us close the loop (3)

• 3. QI Collaboratives that track
  multiple-facility interventions
• Best Practices reviewed/selected by advisory
  panels (Carol Luhrs and Therese Cortez)
• Designated leader
• Organized schedule
• Technical assistance
• Measurement/analysis by PROMISE
• Tailored feedback

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PROMISE Implementation
Guidelines/ Expert opinion
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PROMISE goals

• To identify and reduce unwanted variation in the
  quality of end-of-life care for veterans.
• To define and disseminate processes of care
  (Best Practices) that contribute to improved
  outcomes for veterans near the end of life and
  their families.

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Progress and next steps

• Rollout
• 7 VISNs on board FY08
• Goal 12 in FY09 21 in FY10
• Dissemination PROMISE website coming online
• Measurement
• Refine process measures
• Implement Success Stories QI registry
  Collaboratives

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PROMISE websitewww.cherp.research.va.gov/PROMISE

• (Non-VA site www.caringforveterans.org)
• Find out more about PROMISE
• Register a QI initiative
• Brag about a success story
• Join a QI collaborative
• Learn about best practices (coming soon)