CLINICAL UPDATE
USE OF POINT OF CARE OUTCOMES DATA FACILITATES QUALITY IMPROVEMENT IN PALLIATIVE CARE Sarah Aranha, Claire E Johnson, Jane Healey, Pippa Blackburn, Sam Allingham, Ann Yeomanson and Margaret Bird Overview The Supportive and Palliative Care Unit (SPCU), Eastern Health is the largest in-patient palliative care unit in Victoria, with 32 beds and a diverse interdisciplinary team. The unit provides specialist palliative care for an average of 800 patients with a life-limiting diagnosis annually. In 2016, the Supportive and Palliative Care Unit (SPCU) at Eastern Health identified an opportunity to review the SPCU’s clinical assessment processes and utilise the benchmarked reports provided by the Palliative Care Outcomes Collaboration to report patient outcomes. The Palliative Care Outcomes Collaboration (PCOC) is a national, voluntary quality improvement program that supports individual person-centred care through point-ofcare data collection. Regardless of the care setting, patient measurements define the quality of care. PCOC supports continuous improvement in palliative care through using standardised, validated, clinical assessment tools to systematically measure, report and benchmark patient and family outcomes (Clapham and Holloway, 2014). Patients are systematically assessed using five assessment tools: • the Palliative Care Phase (PC Phase)- a measure of the clinical need of the patient and their family and carers (Masso et al. 2015); • the Palliative Care Problem Severity Score (PCPSS) - clinician assessed severity of problems in each domain (ie. pain, other symptoms, psychological/spiritual and family/ carer) (Masso et al. 2016); • the Symptom Assessment Scale (SAS) - used to capture the patient’s perspective on the degree of individual symptom distress (Aoun et al. 2011); • the Resource Utilisation Group Activities Daily Living (RUG-ADL)measures motor function with activities of daily living (ie. bed mobility, toileting, transfer and eating) (Fries et al. 1994), and; • the Australian Karnofsky Performance Scale (AKPS)- overall performance or ability to manage activities of daily living (Abernethy et al. 2005). 20 February 2018 Volume 25, No. 7
Each service collects and reports data biannually to PCOC and receives a consolidated report of outcome measures for the preceding six months. Reports describe how each service has performed against nationally agreed benchmarks to help identify areas where improvements are needed (Currow et al. 2015). PCOC provides training in the use of the tools and support services to embed their use in routine practice. A quality improvement facilitator helps services to interpret their reports and respond to the issues raised. A PCOC quality improvement facilitator, working collaboratively with the SPCU in April 2016, provided structured feedback on benchmarking outcomes from the 2015 reports. Four areas for improvement were identified: • levels of distress across three indicators (pain, dyspnoea, family/ carer stress); • discord between clinician and patient rated scores of key symptoms; • higher than average rate of deaths outside the terminal phase; and • inconsistent application of clinical tools. Although the SPCU had been undertaking clinical assessments for more than four years using the tools provided by PCOC, there were several process issues identified in relation to the way in which the assessments were conducted, data were entered and a lack of interdisciplinary engagement with the use of PCOC assessments (nursing led). Nursing staff had completed education during the initial implementation of PCOC into the service, though no ongoing education had occurred for either nursing or interdisciplinary staff. This in turn led to assessments being undertaken inconsistently. The PCOC assessments and language were not embedded throughout the interdisciplinary team and the focus was to collect and enter the data rather than using the clinical information the assessments provided, in real time, to inform and plan patient care.
The SPCU leadership team identified that there needed to be a shift in focus for staff to understand the clinical assessment tools, and have systems and processes in place to use the information these assessments provided to plan care and improve outcomes. A further requirement was for the systems and processes used to collect and record the assessment for benchmarking purposes to be enhanced to improve data integrity. The SPCU responded by planning a quality improvement project which aimed to embed the PCOC clinical assessments throughout the interdisciplinary team. An important factor was to improve clinician knowledge and use of the assessment tools across the interdisciplinary team and to integrate these assessments into clinical practice to facilitate decision making and care planning. It was anticipated that these changes would lead to improved patient assessment, earlier recognition of changes in patients’ condition and prompt action to manage moderate or severe symptoms for our patients and their families.
Method
The SPCU leadership team used a PDSA (plan, do, study, act) continuous improvement methodology to implement changes (Gillam and Siriwardena 2013). The work was further enabled by a connection with a formal inter-professional project to revise the SPCU model of care that was occurring simultaneously. The project was guided by use of ‘A3’ process improvement tools, (Kimsey 2010) as well as Eastern Health’s improvement methodology and performance excellence systems. The Model of Care project’s scope extended to all phases of the inpatient journey, and included: 1. access 2. initial needs identification and assessment 3. consent and goal-setting 4. care-planning and implementation 5. transition and discharge
References Abernethy, Amy P., Tania Shelby-James, Belinda S. Fazekas, David Woods, and David C. Currow. 2005. The Australia-modified Karnofsky Performance Status (AKPS) scale: a revised scale for contemporary palliative care clinical practice [ISRCTN81117481]. BMC Palliative Care 4 (1):7. doi: 10.1186/1472684x-4-7. Aoun, Samar M., Leanne Monterosso, Linda J. Kristjanson, and Ruth McConigley. 2011. Measuring Symptom Distress in Palliative Care: Psychometric Properties of the Symptom Assessment Scale (SAS). Journal of Palliative Medicine 14 (3):315-321. doi: 10.1089/jpm.2010.0412. Australian Council on Healthcare Standards (ACHS). 2012. EQuIPNational Guidelines Standard 12. Sydney, Australia. Bausewein C, Daveson B, Benalia H, Simon ST, and Higginson IJ. 2011. Outcome Measurement in Palliative Care: The Essentials. King’s College https:// www.kcl.ac.uk/ nursing/departments/ cicelysaunders/ attachments/ Guidance-on-OutcomeMeasurement-inPalliative-Care.pdf
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