Using The Joint Commission's Certification for Advanced Palliative Care to Improve Quality

The Palliative Care Service (PCS) line at our 731 licensed-bed metropolitan based facility recently received our first recertification for Advanced Palliative Care (APC) from The Joint Commission (TJC). It was through our initial designation of this specialty certification that facilitated the growth of our well-established adult PC program and our newly developed neonatal program (weeCARE). Seemingly counterintuitive, these two diverse populations served by our service have become a unified structure over the previous two years. Quality improvement opportunities were identified and structural homogeneity was achieved through a more stringent implementation of evidence-based guidelines within our PCS. This has led to a number of improvements within our service, from formalizing the structure of our service line, to improving the quality of care provided to patients and families, and most notably to our recent success in achieving our first recertification for Advanced Palliative Care from TJC.

Initial APC certification was obtained in the latter part of November 2012. Our overarching goal for seeking this scrupulous designation was to provide patients and families with the augmented care PCS offers. In the years that followed our initial certification, it became clear that the novelty of marrying 2 diverse teams has been a worthwhile effort. Our approach to providing high quality PC has evolved and our ability to critique our services has become an integral process in the PC cogwheel and has been successfully incorporated into the culture. Upon applying for APC certification from TJC, a team is charged with identifying 4 performance measures in which to collect and analyze data, 2 of which must be clinical measures that are consistent with processes or outcomes described in the Clinical Practice Guidelines for Quality Palliative Care (National Consensus Project for Quality Palliative Care, 2013).

With this, the members of the PC Steering committee, who drive our data analysis and quality improvement, determined it would behoove our service to collect and analyze the following data: determine the percentages of deaths in the adult ICUs with and without PCS. This measure did cause some ambivalence and spark meaningful conversation among the Steering Committee because conceptually, all end-of-life care is PC however; not all PC is end-of-life care, a key point to differentiate PC from hospice. Ultimately, we concluded that our interdisciplinary team (IDT) members are experts regarding end-of-life care and determined that those who die in the ICU should become beneficiaries of this service. This data was itemized by each of the 5 adult ICUs and taken to our Critical Care Committee quarterly. Providing this information was always insightful and propagated some friendly competition within. Furthermore, this was the most pervasive measure impacting administrative support because it proved to be the most impactful regarding judicious financial use for our healthcare system.

Second, we implemented a PC specific patient satisfaction tool to determine the “likelihood to recommend” PCS. Because patient satisfaction is rapidly becoming linked to reimbursement and continues to reign as a gold standard outcome, it was vital that this data be collected. Because the vast majority of our PC population is ineligible to receive the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) survey, instead the PC-specific patient satisfaction survey is mailed to patients or their family who are HCAHPS ineligible. This has provided invaluable insight into not only our PCS but also how other hospital staff and physicians are perceived by hospitalized patients and families. We noticed that the percentage of surveys returned were rather low and brainstormed methods to increase the response rate, such as including a picture of the IDT along with a personalized letter explaining why the feedback is important. Moreover, we have amended the original survey to clearly segregate our adult and neonatal populations, further guiding the feedback to the correct IDT.

Next, we wanted to determine the percentage of family conferences that established goals, were multidisciplinary, and had both elements. We spent time thoughtfully differentiating family meetings from family conferences, complete with a literature review to form the foundation of the definitions. Because advanced care planning is a concept inherent to PCS, it remained important that we continue to measure both. A meeting is an impromptu conversation with family and a conference is a pre-scheduled event requiring care coordination attempting to bring the entire healthcare team together to discuss prognostic information with the family to help them establish realistic healthcare goals for their loved one. The family meeting measure became an important internal quality measure for our team.

Lastly, we developed, implemented, and determined the use of triggers to appropriately identify weeCARE patients. Initially, a number of diagnoses were included to identify our target neonatal population however; through our data analysis, we have refined our diagnoses and have even added 2 more triggers that were not originally identified. We have also distinguished what constitutes failed trigger identification through defining the time the infant spends in the neonatal ICU, which must be at least 72 hours.

Preparing for and maintaining APC certification is contingent upon ongoing education of not only the core IDT but also the entire hospital staff. Hospital-wide staff education and preparation continues to be a challenge we encounter. A number of methods have been employed to continually educate more than 3,300 hospital clinical staff and nearly 1,200 hospital privileged physicians within our institution. Dependency on our PC Champion Committee, which is comprised of a representative from each of the inpatient units and departments within the hospital, is pivotal. The Champions meet monthly and take information back to their respective units to help define PC, differentiate between PC and hospice, and help identify appropriate patients in their unit that would reap benefits from PCS. We challenged our Champions to create posters for their unit that would not only highlight the PCS in our facility but also would identify how PC can be applied to that unit’s specific population. For those Champions that chose to complete a poster, an education activity credit for the nursing career ladder was awarded. After the posters were completed, we had a poster contest that the Champions voted to decide which poster was the most aesthetically appealing and which one displayed the application of PC information the best. Another approach that was deployed was creating a PC specific binder for each of the 26 inpatient units along with a number of ancillary departments. The content within contains an overview of PC, defines what types of patients are appropriate for PC, outlines information specific to our PCS, identifies our core IDT members and their role within the team, and showcases the electronic medical record documentation requirements for both nursing and physicians. The Champions along with our TJC surveyor raved about this binder. It has demonstrated its utility as a readily available resource to the staff.

In our efforts to disseminate PC specific education to encompass all disciplines, we offer contact hours through our monthly “Palliative Care Pearls” and quarterly “weeCARE Wisdom” education series. These lectures are done by guest speakers who are typically specialists within their fields and are open to all hospital staff. Each week, despite the inability to provide contact hours, the adult IDT continues to meet for PC Pearls, to review new literature, prepare for PC certification within their discipline, and collaborate with other experts to facilitate learning. We have also composed and uploaded an online PC learning module that is required for all new hires and recommended for all current employees. For staff who choose not to complete this online training,

Though the opportunities for implementing and nurturing a PCS are seemingly endless, we have ceased a number of opportunities to share what we have learned on both the national and international forefronts. A number of our team members have presented our efforts to improve across the globe, giving us the ability to network with and learn from other PCS lines. Members of our team have been invited to present at a number of national and international conferences including: American Hospice and Palliative Medicine, Hospice and Palliative Nurses Association, National Association of Neonatal Nurses, Nurses Improving Care of Healthsystem Elders, our system’s Quality Conference, Geriatricks Conference, Gravens Conference, Sigma Theta Tau International, International Perinatal Bereavement Conference, and Congress on Paediatric Palliative Care. Most notably, for the past 2 years, someone from our team has presented at the Center to Advance Palliative Care national conference, which serving as a national organization providing governing advice for PC. We have also participated in a number of research studies, some of which are spearheaded by our very own, serving as the principle investigators. Finally, as we continue evolving as a service, the APC certification has instilled a sense of empowerment amongst our team. This will only continue to augment our efforts of continued refinement.