Data Analysis and Quality Improvement Initiative Proposal

The main driving force in improving overall healthcare is quality. Quality at all levels needs to be addressed on a continuous basis. In order to achieve high quality, changes should be based on data, a multidisciplinary approach, supported by evidence base measures (Hulbert-Williams et al., 2019). 

In this paper we are going to review current workflows at Vila Health Hospice and if improvements can be based off of the data that is available. Hospice is defined as a service that provides medical care with a multifaceted approach at the end of life (Blackburn-Penhollow, 2020). This multifaceted approach also provides emotional and spiritual support for not only the patient but the family as well. The focus is on symptom management and is not curative and usually is provided in the patient’s home although there are times when inpatient admissions are warranted to provide respite relief to family and manage symptoms of the underlying disease (Blackburn-Penhollow, 2020). In order to achieve the highest level of hospice care, patients should be referred earlier in their disease journey than they historically have been. 

At Vila Health we interviewed many levels of professionals involved in the decision making when it comes to quality. Based off of the interviews the opportunities to look at are length of stay, pain levels and symptom relief, as well as inpatient admissions (Capella University, 2020). The dashboard below reflects that from 2014 to 2015 the length of stay less than seven days decreased from 50 to 46, inpatient admissions decreased from 47 to 27, and pain management rating 7-10 for more than 24 hours increased from 13 to 17, while symptom control rose from 13-22 all of which have room for improvement. In 2014 overall adverse events was 123 and decreased in 2015 to 112 (Capella University, 2020).  This data shows relative factors to providing high quality of care at end of life and in hospice. 

Healthcare dashboards like the one above are known as clinical dashboards and can be used by clinicians. Dashboards provide clinicians with access to relevant and timely information which assist them in their decision making and thus improve the quality of patient care (Buttigieg, et al. 2017). One limitation that the dashboards may have is limited information for a clinician to make an informed decision. Thus other ways of gathering information should be used when rolling out a quality initiative. 

The multidisciplinary approach of doctors, nurses, social workers, and spiritual or bereavement counselors who provide the holistic approach will help achieve the highest quality of care. The earlier the patient referral is into the hospice program will allow this multidisciplinary team to provide the most benefits to the patient and family. These benefits include symptom control while it is manageable, improved quality end of life for the patient, and more satisfied family members (Nakagawa & Garan, 2018). Looking at the above data gives us enough information to focus on management of pain, symptom relief, and inpatient admissions for our quality initiative however other information may be needed. 

For this quality initiative the focus will be on improving end of life care to hospice patients. To do this, process changes to increase quality improvement for current workflows in pain and symptom relief and to reduce inpatient admissions need to be evaluated. Based off of the interviews at Vila Health, communication, enhanced charting processes and assessment tools are key areas to hone in on for improving. Nurses can have the best assessment tools but if they do not do anything once the information is gathered, the tools are useless. Referrals into appropriate programs are essential in the quality of end of life care for a patient in hospice. For example, the distress screening tool from the National Cancer Center can assess if a patient is feeling overwhelmed related to their diagnosis or other areas of their life (Swanson, 2021). If the distress tool is positive a referral can be made to the social or behavioral worker on the hospice team. If pain isn’t controlled, the pain management team can be consulted. These referrals can be placed through live charting for quicker interventions to be initiated thus resulting in better patient satisfaction and likely decreased admission to an inpatient setting to control pain and symptoms rather than phone call, email, or faxed referrals. 

The Plan-Do-Study Act method of evaluating the proposed initiatives will allow for quick assessment of the proposal and implementation of needed changes (McNicholas, 2019). In an effort to communicate the quality improvement initiative the acute hospitals and hospice staff will need to be educated on the assessment tools and how the referrals to various support programs may increase. This education will need to be done in a variety of ways to meet all learner’s needs. For example online virtual training meetings, team meetings, updates to procedure and process books, PowerPoint presentations, and ongoing education are suggestions to the quality initiative team rolling out the changes. Once referrals start happening and appropriate support staff are pulled into the care plan of the patient, the nurses may get some relief in their caseload thus reducing burnout and employee stress. Communication of the real time referrals can be done through electronic medical records and the use of mobile data. Through implementing these proposed initiatives the end result will result in improved care of the patient during their end of life. 

Adverse or Near Miss Data Factors in the Quality Initiative

Chief Executive Officer (CEO) Owen Welch was interviewed. He would like to see alerts to hospice nurses improve, especially with stress on the staff with traveling, high census, and burnout. In addition the inter-collaboration of staff and family or patients through video conferencing can improve care and communication standards. Jacky Sandoval, Chief Nursing Officer feels late referrals into the program decreases the benefits offered for both the patient and the family including length of stay and effectiveness of pain and symptom management (Capella University, 2020). 

The use of video conferencing can greatly improve communication between staff. This type of virtual or telehealth can help patients and families connect with health care providers in remote situations like hospice (Reed et al., 2017). The main concern with using technology that may not be secure is patient privacy. The use of electronic medical record access through laptops for live charting at a patient’s home allows for better multidisciplinary communication and thus better outcomes however at times internet access isn’t always readily available in all homes. The use of mobile hotspots or mobile data on their computers will help enhance that piece of communication real time. 

Data collected by Vila Hospice includes near misses as well as actual events. To show overall quality improvement in the areas identified we would need additional information to show the differences between the near miss and actual events. The information is limited by not including specific details about factors leading to uncontrolled symptom and pain management, inpatient admissions, and length of stays and thus drawing a conclusion based on the available data would limit the ability to provide a clear goal of any new initiatives. It is important to note that the data indicates improvement in inpatient admissions and length of stays less than seven days however the pain and symptom management showed less favorable outcomes. This could be related to high acuity census and lower staffing ratios based off of the interview with Owen Welch, CEO (Capella University, 2020). One way to determine stress levels of patient’s having symptoms is to complete a distress screening to indicate levels of stress an individual in hospice may be experiencing. Health insurer Cigna completed a study that integrated the national comprehensive cancer network distress screening tool into assessments (Swanson, et al, 2019). This tool allowed for direct referrals into other programs that may benefit a patient thus taking some of the work off of the already stressed nurse providing care. With the use of the live charting the referrals could be started more quickly leading to quicker services for the patients and families needing them. This transition into hospice can be a time of uncertainty and can cause anxiety, and there is a need for effective interventions to meet the overall care needs of people with cancer that cannot be cured (Hulbert-Williams et al., 2019). Live charting, distress screening, pain assessment, symptom assessment, and telehealth can help to ease that transition period for both the patient and family. 

Distress can lead to stress and decreased outcomes because symptoms can be exacerbated. One practice most hospices require, including Vila Hospice, are pain and symptom assessments. The dashboard shared early shows opportunity to improve outcomes related to pain and symptom management. The National Palliative Care Research Center (NPCRC) provides hospice providers with multiple assessments to choose from including verbal scores, Wong Baker Faces, and nonverbal indicators (NPCRC, 2020). If new therapies such as pain medication adjustments or non-pharmacology interventions are started, the nurse must reassess the pain and or symptom. There is evidence showing these assessments are not always completed timely due to a variety of reasons which could be from opportunities previously stated earlier in this paper. For example while 95% of a group of patients received an opioid pain medication, only 69% of hospice patients received a pain or symptom assessment upon admission and only 54% in a final assessment before end of life (Cea et al., 2016).  This may be because of lack of charting due to staff burnout and stress levels. 

Interprofessional Communication with the Multidisciplinary Team

Communication is the key to get quality outcomes in hospice. Early communication between the referring provider, the patient and family, and the interdisciplinary team are essential to improve the quality of life and end of life care (Mullville, 2019). Determining which way to communicate with the multidisciplinary team is one thing that CEO Owen Welch feels would be key to having optimal outcomes at Vila Health (Capella University, 2020). In addition, late referrals into hospice have shown poor quality of life, unmet spiritual needs, and less patient and family satisfaction (Mullville, 2019). Hospice providers need to develop rapport and good partnerships with local doctors and facilities to educate, screen, and get referrals in earlier. How to communicate those referrals in a timely manner can led to improved outcomes as discussed above however the communication strategy can be difficult to decide. Email is one option but isn’t always secure, multidisciplinary team meetings is another option however direct clinical care staff may have already started their day and be in the field with patients and families. Another way is to utilize whatever electronic health record (EHR) is being utilized and to ensure communication with local health facilities’ EHR. The details of the communications should include all pertinent information needed for the person who will be viewing the protected data. One way to do that is utilizing the SBAR model. SBAR stands for situation, background, assessment, and recommendation. This model allows for pertinent information including the assessment, recommendations of care, and plans for the next person providing care (Agency for Healthcare Research and Quality, n.d.). Utilizing a communication model such as SBAR would provide the necessary information to the next care taker, whether clinical or non-clinical, to provide the most optimal care for the hospice patient and family. 

Conclusion

In a concerted attempt to reduce the number of adverse events related to length of stay 

inpatient admissions, pain and symptom management, it is important to keep in constant and 

early communication with the patient, family, and interdisciplinary team. Having timely referrals

to hospice is shown to improve quality of life during end of life care. National studies indicate 

hospice referrals are not made in a timely manner, causing end of life patients to have needs that 

are not met and poor quality of life (Mulville, 2019). Education with providers in the 

community setting and local health facilities on what hospice does and the best way to achieve 

optimal outcomes is imperative to reduce the delay in referrals to hospice and palliative 

programs.

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