Breakthrough’ initiative inspires participants
Clarifying role in end-of-life improvements
The first three-day intensive learning session of the Boston-based Institute for Healthcare Improvement’s (IHI) Breakthrough Series on Improving Care at the End of Life was held July 20 to 22 in Landsdowne, VA. (See Hospice Management Advisor, July 1997, p. 82.) Hospice participants in this project are excited about the possibilities it offers to influence how the larger health care system goes about improving care for dying patients, as well as expanding their vision of vertical integration.
IHI sponsors breakthrough collaboratives on health quality issues, such as cesarean rates and adverse drug events, which offer opportunities to match best science with actual practice. The goal is to achieve significant reductions in cost and improved outcomes in a short period of time. The hospice group has proven to be one of the most popular, drawing teams from 48 different communities, representing hospitals, home health agencies, hospices, or combinations of providers.
The range of projects was impressive, says Gretchen Brown, MSW, president and CEO of Hospice of the Bluegrass in Lexington, KY, who attended in partnership with staff from St. Joseph Hospital in Lexington and the Sisters of Charity of Nazarus system in Louisville. "A lot of systems, maybe they had hospices or maybe they didn’t, but they had as an aim to get more patients into hospice and to get them there sooner. There are a whole lot of people interested in end-of-life care these days, and that’s great," Brown says. "I also think there was a realization that we in hospice do a good job of taking care of folks with terminal illnesses."
Two more meetings are planned for the participating teams, and a national congress will present results from the collaborative sometime next year. The program’s focus is on identifying the best available ideas for rapid change and improvement in end-of-life care, emphasizing comfort, quality, dignity, satisfaction with care, optimal patient transfers, and reductions in unwanted, nonbeneficial care.
The challenge of institutional change
Collaborative chairwoman Joanne Lynn, MD, director of the Center to Improve Care of the Dying at George Washington University in Washington, DC, says she was awestruck by participants’ commitment to improvement. "There are 48 teams, each hoping to go back home and fix things. All different kinds of folks, from different settings, noting that they’re all serving the same kinds of people. The first session was to clarify team membership, goals, and measures that will tell them that they have reached those goals," Lynn explains.
"Change is not easy to accomplish; those who have been through SUPPORT find that easy to believe," says Lynn, who was co-principal investigator of the widely publicized Study to Understand Programs and Preferences for Outcomes and Risks of Treatment (SUPPORT), documenting the unhappy realities of end-of-life medical care in this country. "Some teams will get farther, because they have smaller dragons to slay. Others are in more rigid organizations, but all can start where they are today and start working toward a better tomorrow," she adds.
For its first meeting, the project assembled the best ideas and techniques for improving end-of-life care quickly. "Finding things to try out is not as hard as finding ways to measure the results, but the hardest part is doing things that make more than just a ripple in the stream," Lynn says. Examples of the kinds of things health systems can implement quickly include getting all providers within an inter-referring care network to agree to honor each others’ do-not-resuscitate orders on transfers or implementing pain assessment as a fifth vital sign.
Where does hospice fit?
As to where hospice will best fit in the evolution of end-of-life care, Lynn says she is of two minds. "Hospice can improve itself in its niche and be the preferred provider for those patients with relatively predictable terminal prognoses," involving solid organ tumors, while other types of providers learn to adapt hospice principles to their own settings, Lynn says. "Or hospice can try to do it all itself. Even if the care is given by today’s hospice providers, they may have to call themselves something else and learn new methods of delivery. Patients with uncertain prognoses will have trouble carrying the symbolic baggage of hospice for longer periods just because of how this society defines hospice," she says. "Some hospice programs are trying to go outside and address new approaches."
The breakthrough series on end-of-life care has proven so popular that it may be repeated, Lynn says. But in the meantime, how can HMA readers start applying the same principles? "You start by sorting out your shortcomings, identifying what is the right team to address them, and then how you know if it was successful. Start gently cycling your ideas through the system," she says. "Then try something new."
Hospices also need to be active in the public policy arena surrounding end-of-life care. "At least half of the states will be tackling end-of-life issues in the next year, either through legislation, ballot initiatives, or blue-ribbon panels. Hospices need to make it clear they don’t want stupid things going on in this area. States have a responsibility to deal with this issue not just as a matter of [individual] rights but as a reflection of how the community supports its members who are terminally ill."
[For more information on the collaborative, contact IHI at 135 Francis St., Boston, MA 02219. Telephone: (617) 754-4800.]
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