Hospices need to embrace the challenge of measuring quality

Start small, but measure something that matters

By Larry Beresford

Experts have repeatedly warned America’s hospices that they need to elevate quality as a priority at both the organizational and the industrywide levels. Hospices must find ways to quantify, measure, compare, and improve the quality of care they provide to terminally ill patients.

This is because quality measurement, report cards, benchmarking, and the use of quality data to make comparisons among providers to guide consumers’ choices are becoming standard practice throughout the health care system. Hospices that receive third-party reimbursement shouldn’t expect to be exempt from such trends. Experts say that if the industry doesn’t act to define and implement its own meaningful measures of hospice quality — admittedly a significant methodological challenge — then measures are likely to be imposed from without. And externally imposed measures, like home health care’s OASIS, may not be a good fit with hospice’s mission and values.

Hospice quality measurement already under way

The challenge of quality measurement will be familiar to anyone who has attended a hospice conference presentation in the past six years on the Missoula-VITAS Quality-of-Life Index, a multifaceted measure of the experience of terminally ill hospice patients. Another attempt to measure hospice quality is the National Hospice and Palliative Care Organization (NHPCO) National Data Set, a collaborative effort to validate usable measures of previously identified outcomes of hospice care (safe and comfortable dying, self-determined life closure, and effective grieving).

However, the urgency of demands for quality is rising at the same time that many providers seem not to be keeping pace. Anecdotal concerns about hospices providing inconsistent or inadequate care are increasingly discussed whenever hospice professionals get together. But without some universal, quantifiable, comparative definitions of quality, how will the industry get a grip on quality and protect its good name?

To give just two current examples of the accelerating pace of quality demands, NHPCO will be working with a consultant this summer to develop a Quality Advisory Council with the aim of promoting a broadly based quality initiative that builds on existing quality programs and measures. And the California Hospice and Palliative Care Association (CHAPCA) earlier this year empaneled a Quality Initiative Work Group to study the issue and propose a statewide quality program in response to growing consumer complaints reaching the state body.

"As a board, we needed to get a better picture as to what was happening out there," explains former CHAPCA president Laura Miller, of Elizabeth Hospice in Escondido, CA, who spearheaded the state initiative. "With more and more new providers entering the industry, we have a responsibility not only to set the standard of care, but to see that it is delivered."

Moving too fast?

Melanie Merriman, a Florida-based quality measurement consultant and co-author of the Missoula-VITAS Index, is one of the experts who have been warning hospices to jump on the quality bandwagon. She says she wonders why the industry has made so little progress on quality measurement, when six years ago there seemed to be so much promise.

In retrospect, she says, "we tried to go too far too fast. We started on a different plane than most providers. I thought hospices were standing at the bus stop waiting for the quality bus to arrive, and I was 100 percent wrong. So I’ve been backing up and backing up ever since. I woke up one day and said, A lot of these organizations aren’t measuring anything.’"

Too many hospices, Merriman adds, haven’t made the necessary cultural transformation to recognize their ethical responsibility to measure quality. They still want to know why they should have to prove that they provide high-quality care. Others participate in the Joint Commission on Accreditation of Healthcare Organizations or other accreditation programs, but they fail to appreciate how these externally imposed requirements are relevant to their own expectations about the quality of their services. For some of these hospices, accreditation becomes just a paper exercise.

There also is a mistaken impression among some hospices that something as subjective as a terminally ill patient’s quality of life cannot be measured, Merriman says. In fact, researchers are making steady progress on crafting tools to do just that.

"What’s important for hospices is to put a stake in the ground around quality," Merriman says. "Decide each year what your three most important quality indicators are. Start small, but create an organizational culture where it becomes part of how you talk about your organization." Indicators should be simple, workable, and meaningful to everyone in the organization. Results can’t just sit in the computer, but should be discussed at every staff meeting, with bar charts posted on the bulletin board in the lunchroom.

Imagine the headline in the local newspaper a year from now announcing your hospice’s commitment to measure the quality of its care, what it’s learning, and how it’s acting on that information to raise the quality bar, Merriman says. What do you want that newspaper story to say about your quality? What would a billboard advertisement say about the hospice’s commitment to quality? How do you translate the hospice’s vision of what it offers to dying patients into measurable outcomes?

Pain management is often chosen as the first target for hospice quality measurement. What is the patient’s pain level (on a self-identified scale of 1 to 10) on admission and then 48 or 72 hours later? Is pain assessed and recorded in the chart on every nursing visit? If pain is above a certain threshold, is there evidence that the hospice team took steps to remedy it? In hospice care, there is an additional wrinkle, which is that the patient should get to define how much pain he or she is willing to live with, Merriman notes. The hospice’s quality score should reflect whether the patient’s actual pain level matches his or her desired pain level.

Tips for quality improvement

 What else can hospices do to get serious about quality?

  • Recognize that a commitment to quality is essential to the business of hospice care in the 21st century.
  • Commitment should extend from the board level, with a feedback loop for reporting quality data back to the board for its careful review.
  • Professional consultants are available to help hospices design quality approaches, but there also should be a staff champion or cheerleader for quality, whose job is to make sure everyone in the agency feels responsible for its quality.
  • Small, ad hoc, multidisciplinary groups of veteran staff can come together around specific quality concerns, propose improvements, and devise simple measures to see if they made a difference, thereby moving the organization forward in small steps.
  • Understand how all of these quality efforts (including those externally imposed by certification and accreditation bodies) relate to the agency’s mission, values, and beliefs about care for the dying. If they don’t connect, go back to the drawing board. But measure something that your agency believes is an important indicator of its actual performance.
  • Network with other quality professionals in the community, including those at the local hospital. Propose a communitywide "Pain as a Fifth Vital Sign" initiative.
  • Participate in NHPCO’s new "Family Evaluation of Hospice Care" survey process to report standardized family satisfaction data to a national pool.
  • Take fuller advantage of the potential for existing hospice charting and billing software programs to provide actionable performance data to the management team.

The formal approach to quality

For hospices large and small that want to take quality improvement to the next level, one way is to participate in a more formal benchmarking program. An example of this is Perforum of Lyme, NH, an integrated benchmarking service explicitly designed for hospices. Participants, one-fourth of whom have an average daily census of fewer than 40 patients, submit and exchange data in standardized reporting formats and receive back reports charting how they compare to peers in such areas as revenues, costs, profitability, case mix, visits, productivity, and outcomes of care.

"All of them have made a commitment to performance improvement, which demands performance measurement and open-minded collaboration," explains Perforum president Martha Tecca. "They agree to discuss the data, as well as the agency practices and structures that lie behind them." The hospices participate in technical assistance teleconferences, share practices, and learn from each other, while Perforum helps them develop operating performance targets and measure their improvement over time.

"First, you can compare yourself to overall averages," Tecca notes. "Then find two or three peers who are achieving a level of performance that you would like to achieve, and contact them to find out how they did it," she says.

[Editor’s note: Larry Beresford, a former editor of HMA, is an Oakland, CA-based freelance writer specializing in hospice and end-of-life care. Contact him at (510) 536-3048 or larryberesford@hotmail.com.]