Quality Improvement in Palliative Care

  • Joanne Lynn MD
  • Sarah Myers MPH
  • David E Weissman MD

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Introduction   How do you change the status quo?  What can you do when the system of care does not support best practice?  There are relatively easy ways to test new ideas and solutions for improving care on a small scale and to improve upon those ideas to foster even more improvement.  Continuous Quality Improvement using the Plan-Do-Study-Act (PDSA) cycle is a successful model to move a care system closer and closer to the desired change.  The PDSA process reveals insights into a care system and how it can work better. This model requires a team of change agents to set an aim, implement a change, measure the effect, study what they have learned, try another change, and repeat the process. There are three key questions to answer in the PDSA process:

1) How do you know there is a problem? 2) What changes can you make that will result in improvement? 3) How will you know that a change is an improvement?  An example of using the PDSA cycle is presented below.

  1. PLAN: Demonstrating that a problem exists and defining the goal.  The residency program director feels that all residents out-perform the national average on pain management, however, the nursing staff disagrees and has brought their concern to the program director.  Working together, the program director, two nurses and two residents decide to gather data on the oncology unit, starting with pain assessment documentation. After first reviewing national pain assessment guidelines, five patient charts were reviewed for pain intensity and physician assessments.  The initial data confirm the nurses’ impression and convinces the program director that a change is needed. The team sets a goal that, within one month, all patients will have physician pain assessment notes and <10% will report pain intensity scores greater than 5 for more than 2 hours. 
  2. DO:  Defining the necessary changes.  The team begins an improvement cycle that includes three changes: 1) daily reminder of the goals at morning report; 2) scheduling a one-hour pain assessment lecture for residents; and 3) weekly e-mail reminders of the goals to the attending physician.
  3. STUDY:  Measuring the effect of change.   Reviewing charts over the following month reveals no improvement in pain assessments or scores.  The team reviews the data and decides they need more information to plan the next change.
  4. ACT:  Make changes based on what is learned.  A portion of a future morning report and faculty meeting is used to gather information from residents and faculty as to why they believe pain intensity scores are not improving. They find that pain assessment is just too easy to skip over in the press of other issues.  Thus, no one is able to confirm that physician pain assessments are being done or that patients are comfortable. 
  5. PLAN:  The team develops a new strategy: over the next month the team will make pain a 5th vital sign and residents will learn new pain assessment skills through an experiential education program.
  6. DO:  The nurses start checking pain as a 5th vital sign and a resident completes a pain assessment skills training program.  Subsequently, the STUDY-ACT part of the cycle finds substantial improvement. Once a change strategy has led to documented improvement, the team can choose to incorporate it into regular practice, spread it to other units within the institution and set additional aims for quality improvement using the PDSA model.

‘By Next Tuesday’   Most improvement efforts fail because excessive time is spent considering, studying and meeting. Teams should ask, “What is the largest, most informative change we can make by next Tuesday?” This will not be the only change a team should make, but by making a change “by next Tuesday,” teams can break the inertia that keeps many improvement efforts from getting off the ground.

References and Resources

  1. Lynn J, Nolan K, Kabcenell A,  Weissman DE, et al. Reforming Care for Persons Near the End of Life: The Promise of Quality Improvement.  Ann Int Med. 2002; 137: 116-122.
  2. Langley GL, Nolan KM, Nolan TW, Norman CL, Provost LP.  The Improvement Guide: A Practical Approach to Enhancing Organizational Performance.  San Francisco, CA: Jossey-Bass; 1996. 
  3. Lynn J, Schuster JL, The Center to Improve Care of the Dying, and The Institute for Healthcare Improvement. Improving Care for the End of Life:  A Sourcebook for Clinicians and Managers.  New York, NY: Oxford University Press; 2000. 
  4. RAND Center to Improve Care of the Dying.  Currently known as Palliative Care Policy Center.  Available at http://www.medicaring.org.
  5. Healthcare Quality Improvement Resources.  Americans for Better Care of the Dying.  Available at:  http://www.abcd-caring.org/resources.htm.

Version History:  This Fast Fact was originally edited by David E Weissman MD.   2nd Edition published June 2005; 3rd Edition September 2015. Current version re-copy-edited April 2009; then again September 2015 by Katherine Recka MD.