Quality improvement in hospice: adding a big job to an already big job?

"Goals of Care Conversations Don't Fit in a Box": Hospice Staff Experiences and Perceptions of Advance Care Planning Quality Measurement

CONTEXT

With rising concerns about quality of care in hospice, federal agencies recently began mandating quality measurement in hospice, including measures of advance care planning (ACP).

OBJECTIVES

To characterize hospice providers' experiences with ACP quality measurement and their reflections on ways to improve it.

METHODS

Semi-structured in-depth interviews of fifty-one hospice providers from various clinical backgrounds and organizational roles in four geographically diverse non-profit, community-based hospices in the U.S. Participants were queried about their experiences with and barriers to ACP quality measurement processes in their organization, opinions about the impacts of federally mandated quality measures, and ideas for improvement. Data were analyzed using thematic analysis with an interdisciplinary team, facilitated by ATLAS.ti and Excel.

RESULTS

Four key findings of the ACP quality measurement experience for hospice staff included variation, barriers, attitudes, and recommendations for improvement. 1) Variation: Within and across organizations, participants applied a variety of processes to measure ACP quality, and exposure to and experiences with quality measurement varied based on organizational role. 2) Barriers: ACP quality measurement was impeded by limited resources, technological problems, and measurement challenges. 3) Attitudes: Participants' opinions of recently implemented federally mandated requirements for ACP quality measurement highlighted numerous downsides, unintended consequences, and few upsides. 4) Recommendations: improvements included personalizing ACP quality measures, elevating the importance of quality measurement, and streamlining processes.

CONCLUSION

Hospice staff take ACP quality measurement seriously, but insufficient organizational resources and regulatory bureaucracy create challenges. Efforts to enhance ACP quality measure nuance and assess outcomes are needed to improve care.

Improving Care Experiences for Patients and Caregivers at End of Life: A Systematic Review

BACKGROUND

End-of-life care is increasing as the US population ages. Approaches to providing high-quality end-of-life care vary across setting, diseases, and populations. Several data collection tools measure patient and/or caregiver care experiences at end of life and can be used for quality improvement. Previous reviews examined palliative care improvements or available measures but none explicitly on improving care experiences. We reviewed literature on improving patient and/or caregiver end-of-life care experiences.

DESIGN

We searched U.S. English-language peer-reviewed and grey literature after 2000 on adult end-of-life care experiences. We followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines for quantitative studies, Enhancing Transparency in Reporting the Synthesis of Qualitative Research approach for qualitative studies, and Assessment of Multiple Systematic Reviews tool for the literature reviews.

SETTING

Palliative and hospice care.

POPULATION

Full-text abstraction of 84 articles, identifying 16 articles.

MEASURES

Patient and/or caregiver end-of-life care experiences (captured through administrative data or direct report).

RESULTS

Articles examined palliative care experiences across settings; none studied hospice care experiences. Patients and/or caregivers assessed overall care experiences, clinician-staff interactions, provider communication, respect and trust, timeliness of care, spiritual support, caregiver knowledge of care plans, or bereavement support. Efforts aimed at improving end-of-life care experiences are limited and show mixed results.

CONCLUSIONS

Literature on improving patient and/or caregiver end-of-life care experiences is emerging and focused on palliative care experiences. Evidence on improving hospice care experiences is lacking. Research on strategies for improving end-of-life care experiences should go beyond overall care experiences to include specific aspects of palliative and hospice care experiences.

Quality improvement in hospice settings: perceptions of leaders

PURPOSE

The purpose of this paper is to explore and examine attitudes and perceptions of leaders on application of quality improvement (QI) strategies in a palliative and hospice care organization.

DESIGN/METHODOLOGY/APPROACH

This study employed qualitative research methodology where leaders working in a hospice and palliative care organization were invited to participate in 45-60-min-long semi-structured interview. Interviews were recorded and transcribed verbatim. Qualitative content analysis was utilized to analyze the data collected during participant interviews.

FINDINGS

Seven leaders participated in the interviews. Five themes were developed from data analysis: patient-centered care; continuous QI; leadership involvement and commitment; communication as a foundation for QI; and perceived barriers. Data analysis suggests that use of QI approach in palliative and hospice care enhances the quality of care provided for patients, and can help improve patient satisfaction.

PRACTICAL IMPLICATIONS

Because there is a paucity of research on implementation of QI strategies in hospice and palliative care settings, this research can have wide practical implications. This research can provide useful practical tips to leaders as they work on implementing QI projects in their organization.

ORIGINALITY/VALUE

This manuscript can be of value to leaders, administrators and academicians who are interested in applying QI principles to healthcare processes especially in palliative and hospice care settings. Ability to work with others, solid communication and involvement of employees from all levels can help in streamlining current systems of care.

A Descriptive Study of California Hospice Providers’ Perceptions of Public Reporting of Quality Data Using the Family Evaluation of Hospice Care Survey

The Affordable Care Act requires US hospices to report quality data to the Centers for Medicare and Medicaid Services (CMS) in 2013 with data eventually being made public. There may be some benefit to participating in a voluntary public-reporting program prior to public disclosure by CMS; therefore, we developed and conducted an electronic survey exploring California hospices’ perceptions of public reporting. The majority (78.1%) of respondents reported current use of the Family Evaluation of Hospice Care tool and a willingness to consider voluntary participation in a public-reporting program outside of what is being implemented by CMS (58.6%). Tax status of responding hospices was not predictive of a willingness to participate in a statewide public-reporting program of hospice quality in our study.

Development and preliminary testing of the quality of spiritual care scale

CONTEXT

The provision of spiritual care is considered a key element of hospice and palliative care, but there is a paucity of empirically developed quality-of-care measures in this domain.

OBJECTIVES

To describe the development and reliability and validity of the Quality of Spiritual Care (QSC) scale in family caregivers.

METHODS

We conducted analyses of interviews conducted that included the QSC scale with family members of residents who died in long-term care settings taken after the resident had died. To determine reliability and validity of the QSC scale, we examined internal consistency, concurrent construct validity, and factor analysis with promax rotation.

RESULTS

Of 165 family caregivers of decedents who were asked whether they received spiritual care, 91 (55%) responded yes, and 89 of these (98%) completed at least 80% of the QSC items. Two items (i.e., satisfaction with and value of spiritual care) were perfectly correlated so the latter item was dropped in scale development. Factor analysis identified two factors, personal spiritual enrichment (mean pattern matrix loading = 0.77) and relationship enrichment (mean pattern matrix loading = 0.72). Reliability analysis yielded a Cronbach's alpha of 0.87, and item-total correlations for all items were in excess of 0.55. Preliminary validity of the QSC was supported by significant and expected correlations in both direction and magnitude with items from validated instruments conceptually associated with the quality of spiritual care.

CONCLUSION

Preliminary testing of the QSC scale suggests that it is a valid and reliable outcome measure of the quality of spiritual care at the end of life.

Teaching communication skills to hospice teams: comparing the effectiveness of a communication skills laboratory with in-person, second life, and phone role-playing

INTRODUCTION

Communication skills are critical in hospice care but challenging to teach. Therefore, a hospice agency developed a communication skills laboratory for nurses and social workers.

METHODS

Learners role-played 3 common hospice scenarios. The role-play modalities were in-person, Second Life, and telephone. Learners were scored on 4 communication aspects.

RESULTS

Learners in all modalities rated the laboratory as very effective. However, learners in the Second Life and phone modality showed greater improvements from scene 1 to 3 than those in the in-person modality. There were no significant differences in improvement between the Second Life and phone modalities.

CONCLUSION

Results support the effectiveness of this communication skills laboratory while using different teaching modalities and show phone and Second Life role-plays were more effective than an in-person role-play.

Methods for improving the quality of palliative care delivery: a systematic review

BACKGROUND

The effectiveness for improving the outcomes across palliative care domains remains unclear. We conducted a systematic review of different types of quality improvement interventions relevant to palliative care.

METHODS

We searched PubMed, CINAHL, PsycINFO, and Cochrane for relevant articles published between 2000 and 2011.

RESULTS

A total of 10 randomized controlled trials and 7 nonrandomized controlled trials were included. Of the 5 studies using relay of clinical information, 1 reported significant improvement in patient quality of life. Of the 5 studies targeting education and self-management, 4 found significant improvements in quality of life or patient symptoms.

CONCLUSION

A minority of quality improvement interventions have succeeded in improving the quality of palliative care delivery. More studies are needed on specific quality improvement types, including organizational change and multiple types of interventions.

A health services framework of spiritual care

AIMS

To introduce a health services framework of spiritual care that addresses the empirical and applied issues surrounding spirituality and nursing practice.

BACKGROUND

Despite over 20 years of study, the concept of spirituality is still under development, which limits application to nursing practice.

METHODS

Three studies using a health services framework are reviewed: (1) a survey study of dying patients and family that describes the providers, types and outcomes of spiritual care; (2) an exploratory study of the process of spiritual care; and (3) a multi-level study of the structure and outcomes of spiritual care in long-term care facilities.

RESULTS

Spiritual care recipients identify family or friends (41%), clergy (17%) and health care providers (29%) as spiritual care providers. The most frequently reported type of spiritual care was help in coping with illness (87%). Just over half (55%) were satisfied with the care that they received. The processes of spiritual care involved: (1) presence, (2) opening eyes, and; (3) co-creating, which was a mutual and fluid activity between patients, family members and care providers. In long term care facilities, decedents who received spiritual care were perceived as receiving better overall care in the last month of life, when compared with those decedents who did not receive spiritual care.

CONCLUSIONS

A health services framework provides a holistic view of spiritual care, one that is consistent with integrated nursing models.

IMPLICATIONS FOR NURSING MANAGEMENT

By focusing on the structure, process and outcome elements of spiritual care within organisational settings, nursing management can develop feasible approaches to implement, improve and evaluate the delivery of this unique type of care.