Five Tips for Effective Quality Improvement in Palliative Care (#3 will blow you away)

by Arif Kamal

Apologies for the “clickbait” title to the blog post; scouring the internet it seems that hyperbole works to get readers’ attention, certainly among entertainment sites and maybe increasingly within presidential politics. But it seems I had little choice; the fifth word of my title is “Quality”, which excites very few people. Bear with me, I promise this will get good.

Quality improvement is critical for palliative care organizations to build and sustain success within their clinical missions. Those who are watching and evaluating us, including patients, caregivers, health systems, regulators, and payers, are increasingly expecting a consistent product, delivered in close alignment with our growing evidence base. Further, rapid evolutions in the health care delivery and payment ecosystem require palliative care organizations to masterfully deploy quality improvement initiatives to solve problems. This requires a facile understanding of key steps needed to transition from identifying a problem to sustaining the change.

I’ve spent much of the past five years working as a Quality Improvement Coach for the American Society of Clinical Oncology’s (ASCO) Quality Training Program and ASCO/AAHPM Virtual Learning Collaborative and have come away with a few pearls that may be helpful. I also highly recommend “The Improvement Guide” by Langley et al., seen by many as the definitive textbook for healthcare quality improvement.

Below I offer Five Tips, by no means an exhaustive review, but a decent place to start.

Tip #1: Define the problem – Have a problem statement. This is one or two sentences that covers the Who, What, When, and Where of the problem (but not Why or How). Add a Harm to this statement to give it some punch. For example, “At the Mustard Clinic, from January through July 2016 the outpatient palliative care clinic no-show rate was 40%, missing critical opportunities for patients to receive timely symptom management, goals of care discussions, and possibly reduce time in the hospital during an unwanted readmission.”

Tip #2: Define the problem, again – Quality improvement committees are like family meetings, everyone’s inherently and not unexpectedly on different pages. When starting a quality improvement committee meeting, go around the room and ask everyone what they think the problem is you’re trying to solve. Marvel at the variation, and the “scope creep” and “scope drift” that occur over time. And then insert your excellent family meeting skills to get everyone on the same page. Lack of consensus on the specific problem will sink you.

Tip #3: Problem first, solutions (much) later – If your problem statement sounds something like this, “Because of high 30-day readmission rates at our hospital, we need more palliative care” then you’ve put the cart before the horse. All quality improvement starts with a specific, agreed-upon problem – not a solution. Starting a palliative care clinic, growing a palliative care service, applying disease-based triggers for consultation, etc. are all solutions. Implementing your solution is not the point of quality improvement, it’s solving a problem. Our practice is to not speak of solutions until at least the fourth meeting of our quality improvement committee.

Tip #4: Have an aim statement. What is the goal of your quality improvement project? Be specific, and think of the Who, What, When, and Where (but not How). For example, “By July 2017 we will decrease the outpatient palliative care clinic no-show rate to 25% at the Mustard Clinic.” You cannot yet know the “How”, because it’s dependent on the “Why”. And you can’t understand the “Why” without exploring the drivers of the problem, and the process by which the problem occurs.

Tip #5: Explore the “Why”. Be curious, open-minded, and solicit opinions of all stakeholders. The above fictitious problem of clinic no-show rates is complex, and not easy to solve (or people would have solved it already). If any part of your brain is saying, “Isn’t it obvious, what they need to do is….” then you’re like the 99% of us (very much including me) who must practice exploring the process, and getting input from all stakeholders. I could imagine this committee would solicit input from patients, caregivers, front desk staff, phone triage personnel, appointment schedulers, nurses, physicians, and financial counselors. Can you think of others? Drawing the process from start to finish is also very helpful. How does a patient go from being referred to the clinic to successfully coming? Where are all the places the process could go wrong? What data is needed to quantify the shortfalls? The point here is try not to go down a path of implementing solutions until you’re confident of the problem, have an understanding of where the process is breaking down, and have tailored the solution to that breakdown.

I’ll be speaking more about this topic, and will be joined by several other national leaders including Drs. Diane Meier, Steve Pantilat, and Phil Rodgers during the 2nd Annual Palliative Care Quality Matters Conference on October 20th from 12-5PM EST. The Conference is hosted by the Global Palliative Care Quality Alliance (www.gpcqa.org), a multi-site, volunteer collaboration of healthcare organizations with a passion for improving quality in palliative care.

The virtual conference presented via Webex is open to all colleagues with complimentary registration and CME/CNE. Register at www.gpcqa.org/qmc

Additionally, this Wednesday evening October 5th at 9PM EST/6PM PST I’ll be hosting a Tweetchat. Would love your input on the following questions:

T1: What makes performing quality improvement challenging in palliative care and hospice?

T2: Most quality improvement projects don’t work. Name an epic failure you were part of. What did you learn?

T3: Change my Top Five to a Top Ten list. What tips could you add?

T4: How could we help each other in our field do better quality improvement? What’s the role of AAHPM, HPNA, NHPCO and other membership societies?

What: #hpm (hospice and palliative med/care) chat on Twitter
When: Wed 10/5/2016 - 9p ET/ 6p PT
Host: Dr. Arif Kamal @arifkamalMD

Follow @hpmchat and go to www.hpmchat.org for up to date info.

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Arif Kamal MD MBA MHS is the Physician Quality and Outcomes Officer and Assistant Professor of Medicine (Oncology and Palliative Care) at Duke University. He is a diehard Kansas City Chiefs football fan, which has prepared him for discussions regarding futility and complicated grief with his patients.