Monday, October 30, 2017

Conference Review: 2017 Palliative and Supportive Care in Oncology Symposium - Day 1

by Christian Sinclair (@ctsinclair)

It is a testament to the growth and mainstream acceptance of palliative care, that there is a sub-sub-specialty two-day conference like the #PallOnc conference held in San Diego this past weekend. If you have not heard of this meeting yet, and the majority of your work in that intersection between oncology and palliative care, I would highly recommend considering it in the future. This is the 4th consecutive year the meeting has been held, and I applaud the commitment of the four co-sponsoring organizations (AAHPM, ASCO, ASTRO and MASCC). Kristina Newport and Shanthi Sivendran reviewed this conference for Pallimed in 2014 and it was one of our most popular posts. They went on to create the very popular Oncologist in Your Pocket pre-conference at the 2017 Annual Assembly of Hospice and Palliative Care. Clearly there is a hunger for this information!

With two-days of talks and over 150 posters, there is a lot to cover, but let me share some of my key takeaways and highlights of the symposium. For more detailed coverage you can check out the transcript at Symplur or the pallonc.org website (paywall).

The opening session focused on innovative models to integrate palliative care within oncology. Dr. Janet Bull (Four Seasons) made strong points about standardizing care, which starts by developing processes and procedures, collecting data and then using both to cycle through quality improvement. It can be difficult to take the loose, narrative approach commonly seen in palliative care and start to implement structure around the clinical visit. We want it to be patient-centered, and therefore often clinicians will allow the visit to be driven by the patient. Listening to Dr. Bull helped solidify the argument for allowing patient-centered approaches but using design-thinking to make sure that we are truly meeting all the needs of the patient, the system and ultimately ourselves (though efficiency and work-life balance)

The research presented Friday helped define what is involved with early integrated palliative care that makes it successful. Hoerger and colleagues presented analysis of palliative outpatient visits where the clinicians marked what they did immediately after the visit was done. Coping and symptom management were consistent through nearly all visits. Rapport and illness understanding were important early, where as treatment decisions and advance care planning were more important in later visits after trust had been established. While this may seem intuitive it is helpful to have more solid research behind what exactly palliative care that makes it effective.
Dr. Haider and his peers presented a detailed examination of how computers impact patient perceptions of empathy, communication and compassion. If you can take a wild guess, patients preferred the doctor in the vignette where they didn't use the computer. This seems intuitive, but again the research helps set the foundation for how we integrate point of care documentation (efficient, now bedtime charting), immediate access to scans and labs (to facilitate discussions with patients), while still being focused on the patient. Some people use scribes, other people do joint documentation with team members.
And it brought up a very palliative moment in the Q and A!
In the afternoon Sandra Mitchell (NCI) had a great session on fatigue during and following cancer treatment. While it is difficult to read some of the headers, I htink this is a smart approach to presenting data on symptom management, with green = good data, and red = less data. As you might see low-dose dexamethasone is on the red side. So maybe those of us seeing some good results from that, need to publish better data (or readdress on own biases).
One consistent theme was the importance of non-phamacologic management. What unfortunately was not routinely addressed was how to access CBT, acupuncture/acupressure, massage, psychology and others. I feel relatively lucky but occasionally frustrated at how to get my patients access to these services on a consistent basis to meet their needs. It is one thing to hear about how great they are at a conference, but another thing to get them implemented in your practice. If anyone has stories of success please share them with us!

More coverage on day 2 tomorrow!

Christian Sinclair, MD, FAAHPM is editor of Pallimed, and a palliative care doctor at the University of Kansas. He loves that next year's #pallonc conference will be in San Diego again, since that is his hometown!

Monday, October 30, 2017 by Christian Sinclair ·

Monday, October 23, 2017

Quality Improvement – The Science of Making Care Better for All

by Arif Kamal (@arifkamalmd)

It seems everywhere a person turns, there’s nonstop discourse regarding healthcare quality, particularly the relationship of meeting quality metrics to demonstrating lower costs and higher value. As palliative care further immerses itself into usual healthcare delivery, it behooves our workforce to adeptly apply quality improvement skills to translate our sense of “what is right” into the usual practice of “what is done.” Meeting these demands takes skills and practice, rooted in an evolving evidence base around quality improvement science.

It may confuse some to hear that quality improvement is derived from science. For some, quality improvement is what you call things when there’s not grant money, not a protocol or consent, the project is not publishable or meaty enough to face the feedback or scrutiny of your peers, or when there’s a high likelihood of failure. Quality improvement and “pilot” study can sometimes seem synonymous, and it’s certainly the former and not the latter when results are negative or there’s “more to learn.”

In fact, quality improvement is just as time and resource intensive as pure research, a reflection of rigor that started from the very beginning. The formative years of quality improvement science originated from the factory setting, where observers painstakingly monitored outcomes at the individual and systems level, quantified opportunities for improvement at the outcome (number of widgets) side, and changed how products are made through incentives and modifications to the environment. The origin of the term the “Hawthorne Effect” comes from just such study.

In the 1920’s, the Hawthorne Works, a telephone products manufacturing plant just outside of Chicago, commissioned investigators to experiment how to increase productivity among assembly line workers. The studies continued on for almost a decade, with small changes in lighting (brighter lighting led to more productivity), changes in cleanliness of facilities, and moving work stations around, all leading to small, time-limited upticks in production. In the end, the investigators concluded that the changes in production were ultimately more a result of the workers knowing their production numbers were being observed, than the actual interventions themselves. Though different than what the investigators had originally thought, the Effect is a powerful tool used today to motivate change. The Hawthorne Effect is why highway signs that announce the monitoring of speed by an increased police presence and overhead aircraft reflectively lead to drivers slowing down. Knowing you’re being watched changes your behavior.

From the early part of the 20th century moving forward, a robust science regarding process control, change management, and behavior change built upon the early lessons from the Hawthorne factory. We now have approaches like Failure Mode and Effects Analysis (FMEA) that try to anticipate errors or understand when future breakdowns of the system will occur. Much of this is built upon knowledge that comes from the fields of human factors engineering and industrial engineering, far away from the settings where healthcare is delivered. We also discuss the concept of “high reliability organizations” that anticipate and address opportunities for improvement within increasingly complex environments. It’s the idea that healthcare could become like nuclear power plants and the airline industry; extraordinarily rare errors, that when they occur, are industry-wide learning events. Getting there involves a focus on quality improvement science that is no less robust or meticulous than generating our evidence through clinical trials and the like. And importantly, palliative care through its entrenched ethos and culture around shaping the system to maximize patient-derived wishes, can lead the way in getting there.

To get a taste of quality improvement and its implementation in palliative care, my colleagues and I recently published an article “Quality Improvement Pearls for the Palliative Care and Hospice Professional” which the publisher of the Journal of Pain and Symptom Management has made available for complimentary download for the next few weeks.

Also, there are webinar-based opportunities to learn more about the quickly-evolving environment in palliative care quality. For example, the community-based palliative care quality improvement collaborative I co-chair with AAHPM President Janet Bull, the Global Palliative Care Quality Alliance, is hosting its Third Annual Quality Matters in Palliative Care Conference.

This free, virtual, webinar-based, half-day conference will offer complimentary CME/CNE and feature speakers covering topics related to principles of quality measurement, population health and palliative care, and what CAPC, AAHPM, and HPNA are doing to further the quality agenda in our field. The conference is this Thursday, October 26th in the afternoon. Please register at www.gpcqa.org/qmc. Even if you can’t attend live, please register to receive a copy of the slides and a recording of the presentations.

Arif Kamal MD, MBA, MHS is an Associate Professor of Medicine and Business Administration at Duke University and Physician Quality and Outcomes Officer of the Duke Cancer Institute. He is the father of two beautiful children and has learned (as the younger one is 6 months old) that sleep is a precious, precious thing and should be appreciated whenever (if ever) it occurs.

Monday, October 23, 2017 by Christian Sinclair ·

Monday, October 2, 2017

Building Certification for Hospice and Palliative Care Social Workers - Take the Survey!

by Megan Mooney

(Take the Hospice and Palliative SW Job Analysis survey before October 5th if you are a social worker. If you are not a social worker, encourage social workers in hospice and palliative care that you know to take it!)

What is Evidence Based Practice?
The Institute of Medicine (2001) defines evidence-based medicine as “the integration of best researched evidence and clinical expertise with patient values” (p. 147). According to Social Work Policy Institute (2010) evidence-based practice (EBP) is defined as the combination of research interventions, clinical experience, values, and client preference that aids practitioners in treating individuals. In social work, the consensus is that EBP is a way of practicing, assessing, intervening, and evaluating based on empirical support, which helps practitioners become more effective (Mullen et al., 2008). This approach assures that the treatments and services offered to clients will have the most effective and beneficial results mirroring what the research shows.

Why is it Important for Social Workers to Participate in Research?
To ensure the effectiveness of the social work profession, standards of social work education have been applied and implemented into accredited programs. The Council on Social Work Education (CSWE), states “Social workers use practice to inform research, employ evidence-based interventions, evaluate their own practice and use research findings to improve practice, policy, and social service delivery” (CSWE, 2008, p. 5).

Additionally, the National Association of Social Workers (NASW) Code of Ethics 4.01 Competence, states “social workers should base practice on recognized knowledge, including empirically based knowledge, relevant to social work and social work ethics” (NASW 2013, para. 39). As you can see, the Social Work field has started to increase its emphasis on EBP, by putting these standards of education and practice into place.

Has someone ever asked you how do you know that intervention that you’re doing is effective and the best one available? As competent Social Workers, we must be able to provide that answer and the answer is always “through evidence based research or practice”. As Social Workers, we make a commitment to better ourselves, the communities we serve, and to help improve the knowledge base of our field. We need to help contribute to the developing of evidence based practice. Research is vital to social work because it helps us to be effective and to provide the best services possible to our communities!

How Do We Participate in Research?
Social Workers have many opportunities to be involved in research. The NASW outlines this in their Evaluation and Research section. If you’re near an institution (University or Hospital), see if they need any help with the research they’re conducting. We can participate in online surveys (quantitative data) that helps contribute to the knowledge base of our field. We can also agree to be interviewed for qualitative data that will help researchers identify the needs of our work. This all helps to provide the best interventions needed in our areas of expertise!

We Have a Great Opportunity for Hospice and Palliative Care Social Workers to Help Right Now!
A great opportunity that social workers in the hospice and palliative care field have right now is to participate in the Hospice and Palliative Social Worker Job Analysis Survey! We do hope that you will help with this and invite your other HPM friends too. This is a wonderful opportunity to help improve our field! We only have until October 5th to complete this survey! It only takes about 30 minutes and you get entered into a drawing to win a chance to go to one of the SWHPM conferences. Here is the link: http://louisville.edu/medicine/departments/medicine/divisions/internalmedicine/hp-ja-survey

If you are a practicing hospice and/or palliative social worker, you are invited to complete the Hospice and Palliative Social Worker Job Analysis Survey, the first step in creating the certification program. Please invite other social workers you know to do so too!The survey will be open September 5 - October 5.

Megan Mooney, MSW is a researcher with the University of Missouri and leads the Pallimed Facebook efforts. She also started Death Cafe in St. Joseph, MO.

Monday, October 2, 2017 by Pallimed Editor ·

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