Using Quality Improvement Science to Create a Navigator in the Electronic Health Record for the Consolidation of Patient Information Surrounding Pediatric End-of-Life Care

Cultural or Spiritual End-of-Life Practice Preference Assessment and Documentation: Identifying Current Practice in Pediatric Hospice

Communities use rituals at end of life to foster a peaceful death, ensure passage to the afterlife, and grieve their lost loved ones. Studies report fear of misunderstanding or impeding rituals as a barrier to accepting hospice care. However, there has been little research on cultural and spiritual rituals in the setting of hospice care or how patient preference should be assessed, documented, and supported by hospice staff. This project sought to identify the current practice for assessment of cultural or spiritual end-of-life practice preferences, and the documentation of those preferences, within pediatric hospice programs in a Midwestern state. In surveys of 2 pediatric hospice programs, employee respondents reported routine assessment (97.3%) and routine documentation (70.3%) of cultural or spiritual end-of-life practice preferences. Most respondents reported documentation was written by various disciplines and in various locations in the medical record. Additionally, a retrospective chart review was performed including decedents of 1 pediatric hospice program over a 5-year period. Documentation affirming familial spiritual beliefs was identified in 75.9% of charts, of which, only 12.2% had documentation regarding end-of-life-specific spiritual needs. Standardized documentation practices may help foster equitable hospice care for all patients by ensuring care providers are aware of the patient and/or family's end-of-life spiritual needs.

Preoperative Code Status Discussion Workflows: Targets for Improvement in Multidisciplinary Pathways

CONTEXT

Discussion of perioperative code status is an important element of preoperative care and a component of the American College of Surgeons' Geriatric Surgery Verification (GSV) program. Evidence suggests code status discussions (CSDs) are not routinely performed and are inconsistently documented.

OBJECTIVES

Because preoperative decision making is a complex process spanning multiple providers, this study aims to utilize process mapping to highlight challenges associated with CSDs and inform efforts to improve workflows and implement elements of the GSV program.

METHODS

Using process mapping, we detailed workflows relating to (CSDs) for patients undergoing thoracic surgery and a possible workflow for implementing GSV standards for goals and decision-making.

RESULTS

We generated process maps for outpatient and day-of-surgery workflows relating to CSDs. In addition, we generated a process map for a potential workflow to address limitations and integrate GSV Standards for Goals and Decision Making.

CONCLUSION

Process mapping highlighted challenges associated with the implementation of multidisciplinary care pathways and indicated a need for centralization and consolidation of perioperative code status documentation.

Top Ten Tips Palliative Care Clinicians Should Know About Leveraging the Electronic Health Record for Data Collection and Quality Improvement

As palliative care (PC) programs rapidly grow and expand across settings, the need to measure, improve, and standardize high-quality PC has also grown. The electronic health record (EHR) is a key component of these efforts as a central hub of care delivery and a repository of patient and system data. Deliberate efforts to leverage the EHR for PC quality improvement (QI) can help PC programs and health systems improve care for patients with serious illnesses. This article, written by clinicians with experience in QI, informatics, and clinical program development, provides practical tips and guidance on EHR strategies and tools for QI and quality measurement.

Low rates of structured advance care planning documentation in electronic health records: results of a single-center observational study

BACKGROUND

Proper advance care planning (ACP) documentation both improves patient care and is increasingly seen as a marker of high quality by governmental payers. The transition of most medical documentation to electronic health records (EHR) allows for ACP documents to be rapidly disseminated across diverse ambulatory practice settings. At the same time, the complexity and heterogeneity of the EHR, as well as the multiple potential storage locations for documentation, may lead to confusion and inaccessibility. There has been movement to promote structured ACP (S-ACP) documentation within the EHR.

METHODS

We performed a retrospective cohort study at a single, large university medical center in California to analyze rates of S-ACP documentation. S-ACP was defined as ACP documentation contained in standardized locations, auditable, and not in free-text format. The analytic cohort composed of all patients 65 and older with at least one ambulatory encounter at Stanford Health Care between 2012 and 2020, and without concurrent hospice care. We then analyzed clinic-level, provider-level, insurance, and temporal factors associated with S-ACP documentation rate.

RESULTS

Of 187,316 unique outpatient encounters between 2012 and 2020, only 7,902 (4.2%) contained S-ACP documentation in the EHR. The most common methods of S-ACP documentation were through problem list diagnoses (3,802; 40.3%) and scanned documents (3,791; 40.0%). At the clinic level, marked variability in S-ACP documentation was observed, with Senior Care (46.6%) and Palliative Care (25.0%) demonstrating highest rates. There was a temporal trend toward increased S-ACP documentation rate (p < 0.001).

CONCLUSION

This retrospective, single-center study reveals a low rate of S-ACP documentation irrespective of clinic and specialty. While S-ACP documentation rate should not be construed as a proxy for ACP documentation rate, it nonetheless serves as an important quality metric which may be reported to payers. This study highlights the need to both centralize and standardize reporting of ACP documentation in complex EHR systems.