Implementing best practice in palliative care

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Palliative care and hospice focus on the relief of suffering and achieving the best possible quality of life, including ameliorating symptoms, relieving psychological distress, and promoting spiritual well-being for patients their caregivers. The growth of palliative care programs and services in the United States has paralleled the increased realization of the need for a rational, specialized approach to the care for people with advanced life-limiting chronic illness. A relatively new subspecialty, palliative care is building its evidence base supporting clinical practice. A new National Institute of Nursing Research funded national research network, the Palliative Care Research Cooperative Group (PCRC), is an efficient mechanism for evidence development including comparative effectiveness research. The fundamental next step is efficient implementation of new evidence and emerging clinical care guidelines into practice. Quality monitoring and performance improvement initiatives are an important approach to reinforce evidence implementation. Over the past 5 years, a regional point-of-care quality monitoring program called QDACT-PC has been developed and piloted in North Carolina; it has been demonstrated to be well-liked by clinicians, usable, feasible, and able to generate reliable information that can be used to benchmark conformance with palliative care quality metrics, drive continuous quality improvement (CQI) activities, and reinforce best practice. One example of low conformance with quality metrics identified in QDACT-PC was related to constipation management; data demonstrate that less than 50% of patients are receiving current best practice interventions to manage constipation and that the symptom is persisting at moderate to severe levels until death. We propose to introduce QDACT-PC within engaged research and clinical care footprint of the PCRC to create a national network for point-of-care palliative care quality monitoring, and demonstrate its capabilities for conducting CQI projects and reinforcing contemporary standards for clinical best practice. Specific aims of the project include: (1) To develop and nationally implement a PCRC specific version of QDACT-PC (named QDACT-PCRC). Upgrades planned for QDACT-PCRC include the addition of new data elements and question modules about caregivers, clinical sites characteristics, hospital-based palliative care, and questions relevant to Aims 2 and 3. (2) To demonstrate the use of QDACT-PCRC for CQI by conducting a network-wide CQI project in constipation management. QDACT-PCRC will be used to benchmark current conformance across all sites. PCRC clinical providers will develop a performance improvement program to address the symptom and its management. We will use QDACT-PCRC to monitor impact of the initiative, implementing iterative enhancements to the performance improvement program in order to achieve a goal of >90% conformance. (3) To test the use QDACT-PCRC as a mechanism for delivering clinical decision support that reinforces agreed best clinical practice. Palliative Medicine has recently proposed five clinical activities that should not be conducted as a part of ABIM's Choosing Wisely campaign (e.g. PEG tubes at end of life). We will use QDACT-PCRC to measure current rates of these activities being conducted at PCRC sites, to deliver a point- of-care real time education and clinical decision support module to reinforce best practice, and to monitor impact, with iterative cycles of system updates as needed based upon impact. The expected outcome of this project is a national system of real-time point-of-care quality monitoring for palliative care, with demonstrated capabilities to support CQI and implementation of best evidence. A corollary outcome is an aggregating dataset of quality monitoring and clinical implementation information, forming the PCRC Registry - intended to be a national resource to support quality monitoring, research and learning health care.