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The implementation of a collaborative, communitywide advance directive education program has yielded significant QI dividends: a policy for recording and tracking advance directives that produced a 99% success rate. The program, "Respecting Your Choices," was launched in 1991 in LaCrosse County, WI. It involved patient education; training and continuing education of nonphysician educators; access to educators at all health care organizations; common policies and practices; and documentation. Two major health systems participated — Franciscan Skemp Healthcare and Gunderson Lutheran LaCrosse, as well as an ambulatory care hospital, nursing homes, and other health organizations.
"One problem we had to think about early was, once we had developed our plans, how could we really make sure they were being followed by all of the physicians?" recalls Bernard J. Hammes, PhD, director of medical humanities at Gunderson Lutheran La Crosse and creator of the task force. "So we created practices and policies that both systems adopted as standards of care."
The task force addressed specific questions and arrived at practical answers. For example:
• How would the document be kept so it was available when needed? "What worked here was for healthy adults to keep their advance directives in the medical records of the hospital, where they were likely to go in case of an emergency," says Hammes.
• How can we make sure an advance directive is in the medical record and that the doctor knows it’s there? How will other staff know where to put it? The task force assigned a specific place in the records for advance directives.
• What if a person has never been hospitalized and has no record? "We decided that a record should be created specifically for that purpose," he says.
These and other questions, he observes, "led to important QI work." The task force not only created a system for putting the advance directive in the record, but a system to identify it so it was there when needed. "We also felt the file we keep on a patient should go up to the unit when he’s hospitalized — that it should be physically taken out and put into the unit record at time of hospitalization," says Hammes. Now, when a doctor in our community visits the patient and opens the chart or binder, he will always see the advance directive if the patient has one." The task force also had to determine whose responsibility it was to move the document upon admission. It was decided it would be the unit secretary’s job.
"A year later, we did a QI project," Hammes reports. The issue addressed by the project: Does the advance directive always get moved to the right place? The task force looked at the unit records and saw that it did not get moved as often as 40% of the time. "This was bad, so we interviewed people to find out why," he relates. "We found the secretaries did not have a common understanding of how the policy worked. Many felt they needed a physician’s order to move the document. We rewrote the policy, re-educated the secretaries, came back two months later, and found we had a 99% success rate."
What the task force learned, says Hammes, was that it wasn’t enough just to have a good program. "It needed not only to be developed, but to be continually monitored," he explains. "The real key to our success was that when we found poor results, we developed an improvement project to make it better."
Other results of the "Respecting Your Choices" program were equally impressive. While the program’s primary goal was to make sure that 50% of the adults in the community had advanced care planning before a major medical crisis, it was reported in a 1998 study of 540 decedents in the community that 85% of them had written advance directives.1
While the study did not demonstrate with statistical significance any cost savings, the group who had advance directives were significantly less likely to die in the hospital. "Those patients with advance directives used $2,000 less of physician and hospital resources in the last six months of life, but the population was not yet big enough to show statistical significance," Hammes observes.
However, Hammes concedes that at its best, "Good advance care planning can improve the quality of end-of-life care in a way that is basically cost-neutral."
1. Hammes BJ, Rooney BL. Death and end-of-life planning in one Midwestern community. Arch Intern Med 1998; 158:383-390.