How to start a quality improvement project

Hospice directors discuss their strategies

Hospices beginning performance improvement projects for the first time, or those revising existing programs, could learn a few pointers from their peers' experiences.

Here are examples and advice from hospice leaders who have been working on quality assessment/performance improvement measures as anticipated under the new conditions of participation (COPs) proposed by the Centers for Medicare and Medicaid Services (CMS):

  • Improve medication delivery and medication safety: "We looked at incidence reports for the previous two years, and like most organizations across the country know, medication is a high volume, high risk area," says Tamara Royse, RN, BS[Ed], MSQA, director for performance improvement and training for Alive Hospice Inc. of Nashville, TN.

"So, we wanted to reduce our medication error rate, and while we were doing this, we were implementing new medication lockers and a computerized medication administration system," Royse says.

The hospice put together teams who reviewed the medication administration process, specifically identifying factors that caused medication errors, she notes.

"We held brainstorming sessions with staff about what they thought were the causes of the mistakes," Royse says. "And we implemented a do-not-disturb zone in the medication room to prevent interruptions."

The goal was to reduce the medication error rate by 50 percent, and that goal has been achieved, she says.

"We've had two months this year where there were no medication errors," Royse says.

The focus was on inpatient beds, and the next step will be to use the same performance improvement process when more beds are added to the inpatient unit, Royse notes.

"We didn't tackle the medication error rate at home because it's a whole different setting, and you have less control over the medication there," she says.

  • Measure outcomes during audits: "One thing, we've begun to do in performance improvement is measuring outcomes in our audit," says Virginia Valentine, MS, RN, CHPN, director of performance improvement for Family Hospice and Palliative Care in Pittsburgh, PA.

"We've done a lot of process auditing in the past," Valentine says. "Now, we are shifting our focus and looking at outcomes auditing versus process auditing."

Valentine defines the two this way:

- Process auditing is when you make certain certifications are signed, pain assessments are conducted, advanced directives are reviewed, etc.

- Outcomes auditing is when you focus on whether or not the outcome identified has been achieved, such as pain being kept under control, caregivers expressing confidence, safety achieved, etc.

"We look at the results we get from the family survey we send out, and we use that to say, 'I think we're doing a good job in these areas,'" Valentine says.

The hospice's performance improvement committee documents outcomes and conducts ongoing audits, including audits of discharged patients, she says.

"We collect data, collate it, and look at it for analysis," Valentine explains. "We use the family survey data that the National Hospice & Palliative Care Organization (NHPCO) has developed."

Also, the hospice's clinical managers conduct ongoing audits in terms of actual documentation and tabulation of data, she adds.

  • More effectively audit pain control outcomes: "We used to audit the pain assessment at every visit, but not now," Valentine says.

Now, the hospice audits whether a patient's pain is contained within zero to 3 on a zero to 10 scale at 48 hours, 72 hours, and one week after admission, she says.

The pain assessments still are obtained regularly, and so there also is an audit of what the patient's pain was like within six hours of his or her death if the patient is an inpatient, and perhaps within less than 24 hours if the patient is not, Valentine explains.

"We want to make sure patients are comfortable," Valentine says. "We want to see whether the patient was having a lot of pain."

For part of this audit, hospice professionals look at the pain medications the patient has been taking, and how they're delivered, she says.

"We want to know what percentage of patients are on IV, oral, or a combination in administering pain medication," Valentine says.

"We also look at how many after-hours calls for pain problems occur, and this also helps us look at how well we're doing."

Other audit questions are as follows:

- Are after-hours calls handled by a triage nurse or do they require an on-call nursing visit?

- What type of complementary therapies are used to help the patient feel comfortable (i.e., music therapy, art therapy, massage, therapeutic touch)?

"Complementary therapies release a lot of anxiety, and sometimes anxiety can lead to greater pain or more difficulty in controlling it," Valentine says.

  • Measure caregiver confidence, safety, and advanced directives: "In terms of caregivers, we look at confidence data from the hospice survey," Valentine says. "We're involved with several research projects that deal with comfort and caregiver confidence, but we've just begun this."

The overall outcome would be to have the patient and family understand what their own expectations are about death and about the patient's care during the end of life, she notes.

"We look at some of the things we do like increasing phone monitoring during visits and whether the patient has used volunteer services," Valentine says. "When we look at the patient's chart, does the documentation reflect that the family understands how to care for the patient who is dying?"

With safety quality issues, the main goal is to look at the risk of falling, Valentine says.

"We conduct fall risk assessments and home safety assessments on patients living in their homes," she says. "We look at interventions that are appropriate for their level of risk, and the outcome is how many falls they are having, and we track that."

For advanced directives, the hospice has looked closely at the discussions employees have with families about advanced directives and living wills. Here are some questions reviewed:

- Has the patient identified actual end-of-life wishes?

- Have the end-of-life wishes changed from the time the patient was admitted to the time the patient is discharged?

- Does the patient wish to have hydration and nutrition?

- Does the patient want a do not resuscitate order or not, and what are the outcomes?

- If a patient has a living will that says he or she doesn't want to have feeding tubes, is the staff honoring this request?

"We want to have the discussion about advanced directives with the patient and family, and we want people to feel they are able to identify the patient's wishes," Valentine says. "We want to make sure when those wishes are identified that we are honoring those wishes, and the best way to honor them is to know what they are and have it documented."

  • Even emotional states of mind can be measured: "Quality is even more important at the end of life than it may be at other times," says Janet L. Jones, RN, BSN, chief executive officer of Alive Hospice.

"Quality is not about a cure; it's about whether their pain is being managed," Jones says.

It's also about these existential issues:

- Is the patient living in the kind of setting he or she wishes to live in?

- Are there issues regarding the patient's human existence that he or she is struggling with, such as issues involving meaning and purpose in life?

"Those are things we measure, and they're extremely important so people can finish their lives in a manner that's meaningful to them," Jones says.

"We're very fortunate to have resources and a board of directors who understand our mission of supporting quality," Jones says. "For hospice organizations that may not have as much support as we do, I think there still are very simple and easy and clear ways they can target and measure their organization to evaluate their quality and how they're performing."