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Making Tough Conversations Easier When Facing Serious Illness

11/20/19

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Julie Cerese, PhD, RN, MSN, Group Senior Vice President, Performance Management Programs and Solutions Delivery

Historically, health care organizations in the United States have struggled with helping patients navigate their care choices when facing serious illnesses.

I wanted to share some work Vizient network members did over the past year within the Managing Serious Illness Collaborative, which focused on helping move palliative care further upstream to help more patients earlier in their illnesses.

The purpose of the collaborative was simple, but culturally, very difficult: make it easier for physicians and other providers to hold meaningful “goals of care” conversations with patients facing serious illnesses. Participants were encouraged to identify patients needing goals of care conversations using one simple question known as the “mandatory surprise question:”

Would I be surprised if this patient died in the next 12 months?

Literature shows the effectiveness of this question as a trigger for identifying patients who may need advanced care planning. Participants were encouraged to operationalize this process in order to establish goals of care and advanced care directives that could guide care choices. By identifying patients who needed these conversations earlier, palliative care services could be offered alongside any life-sustaining treatments they were already receiving. Palliative care, by definition, is medical care focused on improving the quality of life for people with serious illnesses. It is truly patient-centered care.

This collaborative project focused on overcoming these barriers and misconceptions:

  • Palliative care is the same as hospice care
  • Only palliative care providers can initiate goals of care conversations. This leads to conversations never happening because of a national shortage of palliative care providers.
  • Offering palliative care means you are giving up hope, and asking your patients to give up hope, too

The collaborative improved the documentation of goals of care conversations and the capture of advanced directives and advance care plans by 53%. Participants focused on operationalizing certain strategies in selected nursing units, but the results showed that broadening this approach organization-wide could have a significant impact.

As part of the collaborative, Vizient recommended the following strategies that can be deployed to help change the current culture of avoiding these critical conversations.

  • Incorporate the mandatory surprise question to serve as a lens to help providers determine who needs goals of care conversations
  • Train clinical staff on how to hold goals of care conversations. The Conversation Project has great toolkits available for educating clinical staff on how to engage in these discussions in an empathetic way.
  • Incorporate goals of care discussion notes, advance directives and other pertinent information within your electronic medical records, making the information easily accessible so that it can guide future decision-making between patients, their caregivers and physicians

When goals of care conversations are conducted with patients in the early stages of their serious illness journey, the patients, their families and caregivers are able to realize benefits like a greater focus on quality of life, higher patient satisfaction and an improved coordination of care.

To learn more about how Vizient Performance Improvement collaboratives bring together clinical, operational and quality leaders to work on the most critical aspects of health care performance, contact us today. 

About the author. Julie Cerese leads performance management programs and national networks for Vizient. In this role, she oversees quality, safety and clinical leadership programs, technical sales and solution delivery, and data science and member insights. She previously led the University HealthSystem Consortium extensive performance improvement products and services. Her substantial knowledge of clinical quality improvement was supplemented by her service as director of quality and infection control at Chicago’s Northwestern Memorial Hospital. Earlier she served as senior director of University HealthSystem Consortium’s clinical process improvement area. Cerese is the author of numerous journal articles on quality, performance improvement and other clinical topics.

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