How can hospices join the outcomes revolution?

Start with formal relationship to existing data

While hospice initiatives continue to refine outcomes measures with industrywide applications (see related story, p. 109), hospices are urged to get up to speed on measuring outcomes in their own agencies. "The first thing you need to do is just go talk to patients and families and review your medical records," says Joan Teno, MD, MS, associate professor of community health at Brown University in Providence, RI. "One thing you could do is face-to-face interviews with 20 family members. You’d learn a tremendous amount, more than from satisfaction questionnaires. Does anything resonate out of them as an important opportunity for improvement? When I’ve done this, things always stick out," she explains.

"One of the first steps a hospice — or any health care provider — needs to take is deciding they want to measure their patients’ experience in a formal way," adds Sarah Goodlin, MD, a Project on Death in America faculty scholar at Dartmouth Medical School in Hanover, NH, and associate chief of staff for the Veterans Administration hospital in White River Junction, VT. "As much as everybody would like to comprehensively address outcomes, the only thing that really works is to pick a very few things important enough to measure and understand how these relate to the care they’re providing. Do that well, and then move on to something else."

Signing on to the outcomes revolution "has to do, in part, with changing the way they think about some of the things they already know well," says Melanie Merriman, MBA, PhD, director of quality and compliance services for the Miami-based Vitas Healthcare Corp. hospice chain. "To the extent that outcomes measurement sounds like something foreign or esoteric, you need to consider that the patient care chart already is a collection of data," she says.

"To begin looking at performance improvement requires only that you collect and look at the data in a slightly more formal way, for example re-collecting one or more assessment parameters a week after admission and formalizing these data on a chart or graph," she says. "The things organizations begin to discover when they do that will be eye opening. I believe it automatically begins to improve quality of care just because you’re paying more attention. Collecting and analyzing data in a more formalized way can also be a very comfortable adjunct to good clinical judgment and experience," Merriman says.

Eventually, however, hospices will need to get more serious about outcomes measurement. Both the Health Care Financing Administration and the Joint Commission on Accreditation of Healthcare Organizations have indicated that they will soon require formalized data reporting from providers, including hospices. To reach the required standard, "local programs will have to put up money, staff time, and commitment to learn how to do this right," says Bernice Wilson, RN, MS, executive director of the Ohio Hospice Organization in Columbus. "I find hospices have unrealistic expectations. The biggest misconception is this is some simple little matter, and once they get the form, they can just give it to a staff person. You need people in those positions with skills and ability to do the job," as well as the information technology and support.

"Finally, it’s not something you can do as a lone ranger," Wilson says. "People are hungry for someone to take the lead at the national level. Lots of people are calling and asking if they can participate in our study. I believe there is a role for the national, state, and local level. We all have to take our position. The role at the national level is to set the yardstick. The role of the state is to generate grass-roots consensus," she observes. "The problem for local programs is that they think they want to dance, and they’re just not ready. They don’t realize the commitment that’s required."

[For information on the toolkit of Instruments to Measure End-of-life Care, contact Joan Teno at Brown University. Telephone: (401) 863-1606. Web site:

For information on the NHO Research Committee or Kentucky’s benchmarking project, contact Stephen Connor at Hospice of Central Kentucky. Telephone: (502) 737-6300. Contact Patricia Gottfried at Hospice Organization of Wisconsin. Telephone: (608) 835-8184. Contact Bernice Wilson at the Ohio Hospice Organization. Telephone: (614) 274-9513. Contact New Hampshire Hospice Organization’s Quality Improvement Project at Dartmouth Medical School, 314 Strasenburgh Hall, Hanover, NH 03755. Telephone: (603) 650-1794. Connor also recommends that hospices contact their state organization, and if that body has not gotten involved, urge it to do so.

For information on the Missoula-Vitas Quality of Life Index, contact Melanie Merriman, (305) 374-4141.]