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PALLIATIVE CARE: MEASURES AND OUTCOMES FOR PROGRAMS, INSTITUTIONS

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PALLIATIVE CARE: MEASURES AND OUTCOMES FOR PROGRAMS, INSTITUTIONS AND THE DPC. Jeff Myers MD, CCFP, MSEd. W. Gifford-Jones Professorship in Pain and Palliative Care – PowerPoint PPT presentation

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Title: PALLIATIVE CARE: MEASURES AND OUTCOMES FOR PROGRAMS, INSTITUTIONS


1
DPC Grand Rounds Sept 6, 2012
PALLIATIVE CARE MEASURES AND OUTCOMES FOR
PROGRAMS, INSTITUTIONS AND THE DPC
Jeff Myers MD, CCFP, MSEd W. Gifford-Jones
Professorship in Pain and Palliative Care Head
and Associate Professor - Division of Palliative
Care, Department of Family and Community
Medicine Faculty of Medicine, University of
Toronto
2
My one objective
  • Not my intention to represent myself as having a
    clear understanding of how performance measures,
    outcomes and quality indicators can and should be
    used by clinicians, palliative care teams, health
    care institutions and academic divisions
  • My objective is to make these concepts relatable
    and stimulate thought as to how they might apply
    in our clinical and academic settings

3
From State of the Division June 2012
  • Who are we?
  • What do we do?
  • Why do we matter?
  • Where are we going?
  • How will we get there?
  • What can each of us do?

4
From State of the Division June 2012
  • HOW WILL WE GET THERE?

Our initial strategy is to BUILD CAPACITY
through
INTEGRATION EDUCATION COMMUNITY BUILDING
5
DIVISION OF PALLIATIVE CARE
  • Who are we?
  • What do we do?
  • Why do we matter?
  • Where are we going?
  • How will we get there?
  • What can each of us do?
  • How will we know we are there?

6
DIVISION OF PALLIATIVE CARE
  • HOW WILL WE KNOW WE ARE THERE?

How will we know we have effectively
INTEGRATED? EDUCATED? BUILT A
COMMUNITY?
7
DIVISION OF PALLIATIVE CARE
  • Intuitively, anecdotally and through formal
    processes the sense is integration, education and
    building community are important
  • If each is in fact important, how will we KNOW if
    or when we have been effective and something is
    different?
  • What is improved because of the DPC?

8
DIVISION OF PALLIATIVE CARE
  • Its kind of like the field of palliative care
  • Intuitively, anecdotally and through formal
    processes we became aware of its importance
  • Only recently however has effectiveness been
    demonstrated
  • This required the elements (i.e. measures and
    outcomes) comprising effective to be defined
    and studied via rigorous design

9
DIVISION OF PALLIATIVE CARE
  • Its kind of like the field of palliative care
  • I imagine each of us having been in the position
    of feeling the need to defend the merit or
    purpose or role for the field









  • I imagine each of us believe it was worth the
    arduous process necessary to demonstrate
    effectiveness for the field
  • As a result, the field is becoming increasingly
    more visible, credible, valued and essential

10
DIVISION OF PALLIATIVE CARE
  • Intuitively, anecdotally and through formal
    processes the sense is integration, education and
    building community are important
  • If each is in fact important, how will we KNOW if
    or when we have been effective and something is
    different?
  • Define effective (has not been done for a DPC)
  • Define something

11
DIVISION OF PALLIATIVE CARE
  • We have the opportunity to define both
    effective and something for our context
  • Much like direct patient care, it is important to
    demonstrate our effectiveness as a Division
  • Measures and Outcomes are the tools to help us
    get there
  • There is even greater visibility, credibility,
    sense of being valued and considered essential

12
Measuring Performance
  • Measuring performancewhy the aversion?
  • We do this all the time clinically
  • eg. HgBA1C - a measure of effectiveness for a
    diabetes management plan
  • Dependent on executing a plan that has been
    tailored to an individual and incorporates the
    elements of personality characteristics, habits
    and abilities

13
Measuring Performance
  • Measuring performancewhy the aversion?
  • We do this all the time clinically
  • eg. a patients performance status
  • Routinely measuring PS generates data often
    essential to both effectively provide care and
    inform decision-making processes
  • qualification for services, treatment, clinical
    trials
  • survival estimation

14
Measuring Performance
These principles and elements combine to create a
framework that can be applied to different
contexts linking directly or indirectly to
patient care eg diabetes care tailored to an
individual STRUCTURE execution of a plan
PROCESS HgbA1C OUTCOME The team spent enough
time with me THE PERSONS EXPERIENCE
15
Measuring Performance
  • Another eg of a context is this presentation
  • STRUCTURE ppt, projector, room, video
  • PROCESS ensuring relevant info, order
  • OUTCOME of people who view it
  • PERSONS EXPERIENCE quan/qual evals
  • My objective is to make these concepts
    relatable and stimulate thought as to how they
    might apply in our clinical and academic work

16
How is performance measured?
  • STRUCTURE MEASURES
  • The right facilities, personnel, equipment and
    supplies to provide excellent X
  • eg. inpt consult service small group teaching
  • PROCESS MEASURES
  • The elements that outline the right thing that
    needs to be done at the right time for X
  • eg. referral process for consult service the
    tasks that must be completed during small
    group session (both learners and teachers)

17
How is performance measured?
  • OUTCOME MEASURES
  • Are an indication of the effect on X
  • eg. pts symptom severity ratings the learners
    ability to perform an abdominal exam
  • THE PERSONS EXPERIENCE
  • Perspective on and rating by the person for
    whom X has the greatest meaning and/or impact
  • eg. I find it difficult to ask for BTs Dr. C
    was helpful with practical tips about an abdo
    exam

18
WHO MEASURES PERFORMANCE?
  • Performance is expected to be measured by...
    individuals, clinical teams, research teams,
    teaching teams, institutions, organizations,
    departments, faculties etc.
  • We are part of the transformation currently
    occurring in health care whereby measures are
    becoming the foundation for healthcare reform

19
WHY MEASURE PERFORMANCE?
Choose to respond from one of two perspectives
  • Because someone or something in a
    position of authority tells us we must
  • OR
  • Because we believe palliative care to be
    important, can use measures and outcomes to carve
    out our own contribution to the field and become
    even more visible, credible, valued and essential

eg. Accreditation Canada, LHIN
20
Accreditation canada
  • External peer review process to assess and
    improve services care provided to patients
  • Assessments are based on standards of excellence
  • Decides which palliative care outcomes are
    important and expects them to be measured

21
Accreditation canada KEY palliative care
Measures
  • Development of a collaborative care plan
  • Immediate Access to staff (in person)
  • Immediate Access to staff (by telephone)
  • Immediate Access by Care Consultants (in person)
  • Immediate Access by Care Consultants (by
    telephone)
  • Management of Pain ESAS on Admission
  • Management of Pain Pain Burden on Admission
  • Documentation of Client and Family Service Goals

These arent so bad
22
Accreditation canada KEY palliative care
Measures
  1. of pts with 24/7 access to specialized pall
    care services - in person and by telephone
  2. of pts with documented care goals
  3. An IP pall care team follows a formal process
    to regularly evaluate its functioning, identify
    priorities for action and make improvements
    Includes a review of its services, processes and
    outcomes

These arent so bad either!!
23
LHIN Palliative Care mandate from the ministry
of health
  • Declaration of Partnership identifies four
    measures LHINs are to address
  • Decrease in caregiver burden
  • Increase in of deaths that occur in preferred
    setting
  • Increase in quality of life preceding death and
    quality of dying experience
  • Decrease in avoidable hospitalizations

Loftybut again, not so bad!!!
24
WHY MEASURE PERFORMANCE?
  • Preparing for this presentation has expanded my
    view and understanding of the potential role for
    performance measures
  • Because we believe the academic contribution of
    DPC members to be important, we will begin using
    measures and outcomes as a strategy to ensure the
    effectiveness and impact of DPCs contribution is
    clear
  • A palliative care team might also use this
    strategy to improve the of right patients
    families accessing specialized palliative care
    at the right time

25
OKI may have been avoiding the wordbut its
time
  • QUALITY of care is defined as the extent to which
    healthcare services for individuals and
    populations increase the likelihood of desired
    outcomes and are consistent with current
    professional knowledge
  • QUALITY INDICATOR (QI) is a measure designed to
    lead to improved quality of care
  • Avoidance was based purely on the reactions and
    expressions when mentioning the topic for today

26
quality indicators
  • A quality indicator is the same thing as a
    measure
  • A system of QIs should assess care in a
    population and compare against accepted standards
  • For palliative care, QI measures must be accepted
    by relevant stakeholders as truly measuring an
    important element of quality healthcare
  • Takes us back to the importance of being vigilant
    in our efforts to demonstrate the value of
    palliative care and begins with determining the
    necessary data elements and collect them!!!

27
quality indicators data domains
  • Operational
  • Does our program have the elements necessary to
    effectively provide quality palliative care?
  • What should be measured to demonstrate our
    program has these elements?
  • Clinical
  • Are we improving the clinical care of patients?
  • Experiential
  • Are we meeting the needs of pts/families/colleague
    s?
  • Financial
  • Does the work of our team save money for the
    institution?
  • Academic
  • What do learners learn and retain?

28
Palliative Care The quality challenge
  • Reminder We are part of the transformation
    currently occurring in health care whereby
    quality indicators and measures are becoming the
    foundation for healthcare reform
  • Palliative care cannot afford to ignore quality
  • Specialized palliative care has been directly
    linked to improvements in patient outcomes
  • However, current evidence is insufficient to link
    structures and processes to patient care outcomes
    for a number of key palliative care domains
  • Quality of life, communication, family burden,
    spiritual well being, bereavement, continuity,
    symptoms

29
Palliative Care The quality challenge
  • We now know that for certain pt populations who
    receive specialized palliative care, pts have
    better outcomes eg QoL, symptom management,
    survival
  • Specific structures within specialized palliative
    care and the necessary processes to ensuring
    effectiveness are not well known to maximize the
    likelihood desired outcomes
  • i.e. a widely accepted or standard set of QIs
    does not yet exist for palliative care,
    regardless of setting

30
As a clinician, team or program, ask yourselves
  • How will we KNOW if or when we have been
    effective and something is different?
  • Begin by identifying a problem or a process that
    could be improved
  • Examples include large of faxed requests for
    prescription refills, a service that notoriously
    does not refer, communication among team members,
    the educational experience of learners
  • An institution level example Sunnybrook Health
    Sciences Centres Quality Dying Initiative (QDI)

31
Sunnybrooks pcct
  • Our team is committed to improving EOL care for
    patients and their family members
  • Struggle with the questions, Could the PCCT be
    involved with the death of every pt in acute care
    setting? and Should the PCCT be involved with
    the death of every pt in acute care setting?
  • To make truly sustainable improvements, the
    required elements include institutional buy in,
    culture change and a commitment to addressing
    complex educational processes

32
QUALITY DYING INITIATIVE
  • First step was to collect some simple data
    elements and pose a question to key leaders in
    organization
  • As a tertiary Academic Health Sciences Centre
    with internationally recognized programs, death
    and dying are significant elements of our
    institutions overall patient and family care
    experience
  • 18 deaths per week occur in the acute care
    setting at Sunnybrook Health Sciences Centre
  • Could improvements be made in the care of
    patients for whom their death was in some way
    expected?

33
QUALITY DYING INITIATIVE
  • First step was to collect some simple data
    elements and pose a question to key leaders in
    organization
  • With very enthusiastic support from the Senior
    Leadership Team, second step was to articulate a
    Vision and Goals (not outcomesyet)

34
Quality Dying Initiative
  • Vision
  • Dying patients and their families
  • receive the highest quality of care
  • Goal
  • Sunnybrook will implement strategies that are
    patient/family, staff/clinician and
    institutionally focused to achieve the highest
    standard in quality of care for dying patients
    and families

35
Quality Dying Initiative
  • First step was to collect some simple data
    elements and pose a question to key leaders in
    organization
  • With very enthusiastic support from the Senior
    Leadership Team, second step was to articulate a
    Vision and Goals (not outcomesyet)
  • Third step was to populate a working group with
    individuals who share the vision and have
    expertise in Quality Improvement, expertise in
    EOL care, institutional and key stakeholder
    influence
  • Fourth step was to determine what needed to be in
    place before identifying a project

36
Quality Dying Initiative
  • QDI Working Group - Phase 1
  • Four main areas of focus
  • Literature Review/Best Practices/Evidence
  • Long Term Perspective Gathering data collection
    process i.e. Family Member Satisfaction Survey
  • Short Term Perspective Gathering patients,
    family members, staff and clinicians
  • Organizational Engagement Communications

37
QDI evidence
  • Objective Outline the specific care domains
    identified by dying patients and family members
    as being important elements of overall care
  • Product
  • Eight separate care domains identified as
    important by dying patients and their families
  • Serve as foundation from which future foci of
    related activities are to be defined, evaluated
    and improved

38
QDI evidence
Patient Family Member Identified Care Domains
  • Patient symptom management
  • Timely/clear communication
  • Information to prepare family for approaching
    death
  • Compassionate care/comfort/dignity/respect
  • Patient-Centred Decision making
  • Care of the Family
  • Family support
  • Caregiver satisfaction with hospital
    facilities/staff

39
QDI Long Term Data Collection Process
  • Family Member Satisfaction Survey
  • Objective Develop, pilot and implement a
    long-term strategy to effectively measure family
    satisfaction with the experience of the care of
    their dying family member
  • Purpose To prospectively collect data regarding
    the perceived quality of the dying experience by
    family members of adult patients who died at
    Sunnybrook
  • Collaborated with NRC Picker to develop survey
  • Survey addresses all quality dying domains
    identified by pts and families as being important
    in literature review
  • Distributed monthly to family members 4-6 weeks
    following the death of family member

40
Sample of survey data Details of death
41
Sample of survey DataOverall Satisfaction
42
Correlation with overall satisfaction
43
QDI Short Term Data Collection Process
  • Objective Gain an appreciation of the experience
    of family members of former patients
  • Product Family Member Focus Group
  • Pilot Family Member Satisfaction Survey
  • Seek contribution to and/or participation on a
    potential Family Member Advisory Committee
  • Initial collection of family member stories

44
QDI Short Term Data Collection Process
  • Family Member Focus Group
  • REB approved
  • March 28, 2012 11 participants
  • the dying experience forged a lifelong
    connection for me with SB and when I got the
    letter I thought - great you didnt forget about
    us

45
QDI Short Term Data Collection Process
  • Objective Gain an understanding of the
    experience and perspective of staff clinicians
    throughout the organization
  • Product Develop and implement institution wide
    clinical staff survey
  • Awareness marketing Identification of current
    initiatives and potential opportunities Baseline
    self-assessment of related skills Integrate an
    element that could serve as a corporate indicator

46
QDI organization engagement And communications
  • Objective Initiate institution wide awareness
    through communications
  • Product Finalizing slogan, visual, overall
    strategy for QDI Launch

47
Quality Dying Initiative
48
QDI launch
  • Communications Strategy
  • Clinical Staff Survey
  • Dissemination of findings from Family Member
    Focus Group
  • Further stakeholder engagement through follow up
    presentations to multiple leadership committees
    throughout the institution

49
QDI Clinical Staff Survey
  • 325 responses 12 response rate (on par with
    others)
  • 2/3 of respondents indicated profession
  • 60 nursing
  • 20 medicine
  • 5 social work
  • 5 pharmacy, dietician, OT, PT, SLP
  • 5 creative therapy, spiritual therapy, resp
    therapy and rad therapy

50
QDI Clinical Staff Survey
  • 98 agreed or strongly agreed with
  • I view the quality of the dying experience to
    be just as important as the quality of any other
    care element provided in the hospital setting"

51
QDI Clinical Staff Survey
  • 88 agreed or strongly agreed with
    I am able to recognize when a patient is dying
  • 76 agreed or strongly agreed with
    I am comfortable assessing the symptoms of a
    patient who is dying
  • 76 agreed or strongly agreed with I am
    comfortable discussing care elements unique to
    end of life with dying patients and their
    family members

52
QDI Clinical Staff Survey
  • 59 agreed or strongly agreed with a
    care plan addressing unique care needs of dying
    pts is routinely discussed by the IP team
  • 74 agreed or strongly agreed with
    I know when specialist palliative care input is
    necessary

53
QDI Clinical Staff Survey
  • 48 agreed or strongly agreed with
    care goals are clearly documented for dying
    patients
  • 76 agreed or strongly agreed with
    I am comfortable documenting care elements for
    dying patients

54
QDI Phase 2 Projects
  • Implement interventions that are specific,
    measurable and address the quality dying domains
    important to patients and families
  • Care Processes
  • Standardized EOL Order Set
  • Standardize Goals of Care Discussions
  • Integrate Patient Education resources
  • Family Meetings - routinely integrated into care
    and supported by staff/clinician education

55
measuring performance
  • How will we KNOW if or when we have been
    effective and something is different?
  • One option is to begin by identifying a problem
    or a process that could be improved
  • Another option is to begin by identifying a
    specific domain or element aligning with your
    values, priorities and/or interests
    (team or program)
  • This is the opportunity for the DPC

56
DIVISION OF PALLIATIVE CARE
  • Who are we?
  • What do we do?
  • Why do we matter?
  • Where are we going?
  • How will we get there?
  • What can each of us do?
  • How will we know we are there?

57
DIVISION OF PALLIATIVE CARE
  • HOW WILL WE KNOW WE ARE THERE?

How will we know we have been effective in
BUILDING CAPACITY through INTEGRATION?
EDUCATION? BUILDING COMMUNITY?
58
DIVISION OF PALLIATIVE CARE
  • HOW WILL WE KNOW WE ARE THERE?

How will we know we have been effective in
BUILDING CAPACITY through INTEGRATION? -
consider a focus eg. EOL, primary care,
geriatrics, critical care, oncology, CCACand
decide on one measure EDUCATION? - Who do you
wish you could teach something to? What do you
want them to learn? Be sure to measure this
before and after BUILDING COMMUNITY? - find a
local colleague who shares the same vision for a
product or an outcome and collaborate on a
project
From the perspective of building palliative care
capacity locally
59
Quality Dying Initiative
60
DIVISION OF PALLIATIVE CARE
  • HOW WILL WE KNOW WE ARE THERE?

How will we know we have been effective in
BUILDING CAPACITY through INTEGRATION? -
consider a focuslets not reinvent wheel
lets collaborate maximize both resources and
likelihood of effectiveness EDUCATION? - ensure
we consider appropriate educational measures and
outcomes in both projects and overall performance
strategy BUILDING COMMUNITY? - it is very likely
another DPC member has a shared vision for an
outcome just require a place to get
together
From the perspective of building palliative care
capacity as a division
61
(No Transcript)
62


63
DIVISION OF PALLIATIVE CARE
  • Intuitively, anecdotally and through formal
    processes the sense is integration, education and
    building community are important
  • If each is in fact important, how will we KNOW if
    or when we have been effective and something is
    different?
  • We have the opportunity to define both
    effective and something
  • DFCM Year 4 Implementation Priority

64
DIVISION OF PALLIATIVE CARE
  • Much like direct patient care, it is important to
    demonstrate our effectiveness as a Division
  • Uncover areas of ineffectiveness (use as
    leverage for local change)
  • Measures, outcomes and quality indicators are the
    tools to help us get there
  • There is even greater visibility, credibility,
    sense of being valued and considered essential
  • To help carry this further, both locally and as a
    division, Im pleased to announce a new role
  • DPC Quality Lead
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