Quality improvement in end-of-life care: Small-scale innovations can make a dramatic difference

• Published in: Postgraduate medicine 2002-03, Vol.111 (3), p.21-26
• Main Authors: Blanchard, Janice, McCann, Elizabeth, Lynn, Joanne
• Format: Article
• Language: English
• Subjects: Aged; Aged, 80 and over; Humans; Quality Assurance, Health Care - methods; Terminal Care - standards; United States
• ISSN: 0032-5481; 1941-9260
• DOI: 10.3810/pgm.2002.03.1143

Acceptance of the status quo is an important barrier to quality improvement in healthcare. Physicians may assume that because they cannot change the entire healthcare system, they can do nothing to improve patient care. Any attempt at quality improvement requires a supportive environment. CEOs, physician colleagues, and other clinicians must recognize that improvement is possible, necessary, and deserving of support--even though changes may cause some disruptions. Rapid, visible change and distinct leadership are essential. Once improvements are initiated, change can become infectious. As members of the healthcare community see improvements in end-of-life patient care, they will notice other areas that need attention. Physicians are familiar with the model of the large-scale randomized controlled trial; indeed, they sometimes consider it the only acceptable method for improving medical care. However, this model is not ideal for improving healthcare delivery systems. Small- scale efforts in quality improvement achieve results more rapidly and reliably. In the small-scale model, change is implemented by the PDSA cycle--Planning, Doing, Studying consequences, and Acting on lessons learned from those consequences.4 (Reference) Evidence of success can be provided in a relatively fast and approachable manner by repeatedly applying change on a small-scale level and comparing the results to the baseline. Once patients have been identified, energetic and sustained efforts at quality improvement can be made. Rapid-cycle quality improvement teams throughout the United States have made enormous changes in short intervals. For example, one team virtually abolished severe and persistent dyspnea in a hospice population.7 (Reference) Initially, half of the hospice patients under the team's care had had dyspnea lasting more than 8 hours. The team's new approach included prioritizing quick responses, creating a physician- endorsed treatment protocol, and ensuring that appropriate medication was available in patients' homes (and ready to be administered upon a phone call from a physician or nurse). Within 6 months, the rate of dyspnea lasting more than 8 hours in the hospice population fell to zero.