Background:
Palliative care (PC) patients are among the sickest in our hospitals. Determining how best to care for these patients is imperative. Pain is a common and distressing symptom for PC and many other hospitalized patients. Improving pain management is an important target for quality improvement (QI). Collaborating across sites can synergize QI efforts.
Purpose:
The Palliative Care Quality Network (PCQN) is a consortium of 28 PC teams committed to improving the care of seriously ill patients and their families. PCQN members collect a standardized dataset with 23 data elements for each patient they see. Data are entered into a web-based database that generates automated reports showing trends over time and comparisons across sites. To date, 14 teams have entered data on over 8300 patient encounters. In 2014 the PCQN launched a QI Collaborative to improve pain management. Seven PCQN teams are participating in this coordinated QI project with the goal of learning from and motivating each other to achieve greater gains than any team could make alone.
Description:
PCQN data shows that at baseline only 69% (range for participating teams: 62%-80%) of patients with moderate or severe pain on the day of initial PC assessment had an improvement in their pain by the second PC assessment within 72 hours.
We implemented a multipronged intervention to promote collaboration including a 3-hour, interactive session to introduce QI methods such as fishbone diagrams, process mapping, and root cause analyses; monthly conference calls; and ongoing mentorship. During the calls, teams review current data, present their progress, discuss stumbling blocks and generate assignments to test new strategies and advance the QI project.
PC teams have identified specific strategies for improving pain management include seeing patients with pain early in the morning, contacting primary teams with recommendations or writing new orders immediately after seeing a patient in pain, and conducting a follow up visit in the afternoon to ensure the plan has been implemented and pain improved so that the plan can be revised if pain persists. Teams are monitoring these processes, with plans to alter them as needed, as well as daily pain scores.
There is great variability by month. The data since full implementation of QI efforts show that 68% (range: 50%-79%) of patients improved. Engagement with the project is high.
Conclusions:
The PCQN QI Collaborative aims to improve pain management for PC patients at multiple sites. The use of standardized data collection provides common outcomes. PC teams have identified a unified set of interventions to improve pain management and are monitoring progress. Collaboration and regular feedback of individual data with comparisons to others is motivating teams to improve, however improvement has been difficult to achieve quickly. This QI Collaborative can be generalized to other PC teams and Hospital Medicine groups.