The PROMISE team HPC meeting, St Louis May 12, 2009

1. PROMISEPerformance Reporting and Outcomes Measurement to Improve the Standard of care at End-of-life The PROMISE team HPC meeting, St Louis May 12, 2009

2. Objectives: • To introduce the PROMISE center • To explain PROMISE: • Methods • Reports • To describe where PROMISE is going; and • To identify ways in which we’ll need your help

3. PROMISE goals: • To identify and reduce unwanted variation in the quality of end-of-life care for veterans. • To define and disseminate processes of care that contribute to improved outcomes for veterans near the end of life and their families.

4. What is PROMISE? • The quality measurement center for the CELC Initiative • Based at the Philadelphia VAMC Center for Health Equity Research and Promotion • Funded through the CELC to provide: • A voice for veterans/families • Actionable data that can guide facility- VISN- and national-level planning and strategy.

5. What does PROMISE deliver? • Data for facilities about the quality of end-of-life care they provide • Timely feedback • Understandable reports • Meaningful benchmarks • Practical guidance for HPC programs • Useful evaluations for CELC Initiative leadership

6. Framework for PROMISE data: Domains of care (from NCP guidelines) • Physical aspects of care • Social aspects of care • Spiritual, religious, and existential aspects of care • Cultural aspects of care • Care of the imminently dying patient • Psychological and psychiatric aspects of care (including bereavement)

7. Framework for PROMISE data: Aspects of care • Processes of care (from chart reviews) • Outcomes (Families’ perceptions of care) • Currently (Q1 FY09) 43 facilities: • ~800 interviews/quarter • ~1600 chart reviews/quarter

8. Processes of care: Chart review • Sample: • Inpatient deaths • Excluding “unexpected” deaths (e.g. ER, suicide, homicide, OR for outpatient procedure) • Deaths identified using VISN data (multiple overlapping samples) • Remote chart reviews via Global CPRS

9. Processes of care: (examples) • Pain assessment within 24 hours of last admission • Palliative care consultation note • Documentation of a surrogate or that a surrogate could not be found • Chaplain contact with veteran/family • Social work note • Documentation of a bereavement contact

10. Processes of care: Documentation of a surrogate decision-maker

11. Outcomes of care: The Bereaved Family Survey • BFS: OMB-approved survey derived from the Family Assessment of Treatment at End-of-life (FATE) • 14-item telephone survey administered to the veteran’s NOK 6-10 weeks after death • Procedure: • Predefined algorithm for contacts (NOK first choice) • Initial letter with opt-out provision • Telephone contact • Opportunity for family members to refer to alternate

12. Outcomes of care: 12 multiple-choice BFS items • Pain management (1) • Communication (Providers gave enough information in an understandable way and took time to listen) (3) • Veteran didn’t receive unwanted treatment (1) • Providers were kind, caring, and respectful (1) • Family was told what to expect in the veteran’s last hours of life (1) • Veteran’s personal care needs were met (1) • Spiritual support, emotional support (pre/post) (3) • Enough help with funeral arrangements (1)

13. Outcomes of care: BFS scoring • All items are either dichotomous or frequency-based • Did you receive as much help as you needed with… • How often did the health care providers who took care of [veteran]… • Responses dichotomized (Best possible response vs. all others). • BFS and item scores reflect a proportion of the time that the veteran/family received the best possible care.

14. BFS scores: 43 facilities

15. Families’ perceptions of bereavement support: 43 facilities

16. Quarterly VISN-level reports • Categories match NCP domains • Reports broken down by facility (Process and outcome measures) • Compared to sample benchmark (pooled mean of top facilities) • Hypertext links to: • Best Practices on PROMISE website • SharePoint tools (Luhrs)

17. Additional data…responses to 2 open-ended questions • “The hospice unit was the best part of the care that [veteran] got in the whole 14 years that he was going to the VA.” • “We really depended on the palliative team—they were wonderful.” • “Everyone was very helpful, but especially [NP on PCCT]. She was always there, always available. We wouldn’t have made it without her.”

18. Additional data…referrals for unmet needs • Unmet needs identified in interviews: • Bereavement • Questions about care • Questions about benefits • Referred to VISN coordinator and/or facility patient advocate (with family permission). • Gives us: • An opportunity to meet needs and to leave families with a good impression of the VA • Valuable data about needs for improvement

19. Can you give us even more data?

20. Additional data… • Aggregate (broken down) data available to each VISN • “Raw” data available on request • Menu-driven custom reports online (at PROMISE website) • “Mean BFS score in our ICU, with and without palliative care” • “Mean bereavement score in our VISN, with and without a bereavement contact”

21. Using the PROMISE report: 6 rules • Don’t panic • Focus! (Look at individual items) • Ask: Do you have enough data? (Two quarters’ worth) • Use common sense (does this score make sense?) • Select oneitem to improve that has: • A low score • An obvious action plan • Be skeptical about changes

22. Interpreting changes:What happened in these facilities? • A facility improves its BFS score from 45 to 60 in 3 months • Answer: Nothing • A facility improves its bereavement score from 49 to 65 in 3 months • Answer: A social worker dedicated to bereavement calls; educational materials for family; a condolence letter for all deaths. • Lesson: Be critical about scores and changes

23. Closing the loop: Bringing the veteran’s and family’s voice back to the bedside

24. Help us close the loop (1-2) 1. “Success stories” solicited from field • Structured description via web-based form (Through PROMISE website) • Submit descriptions of: • Good scores • Improvements • How you’re using PROMISE data 2. “QI Registry” tracking single-facility interventions • Structured description of goal, intervention, and expected outcome submitted via web-based form (Through PROMISE website)

25. Help us close the loop (3) 3. “QI Collaboratives” that track multiple-facility interventions • Best Practices reviewed/selected by advisory panels (Carol Luhrs and Therese Cortez) • Designated leader • Organized schedule • Technical assistance • Measurement/analysis by PROMISE • Tailored feedback

26. PROMISE Implementation Guidelines/ Expert opinion

27. PROMISE goals: • To identify and reduce unwanted variation in the quality of end-of-life care for veterans. • To define and disseminate processes of care (“Best Practices”) that contribute to improved outcomes for veterans near the end of life and their families.

28. Progress and next steps • Rollout: • 7 VISNs on board FY08 • Goal: 12 in FY09; 21 in FY10 • Dissemination: PROMISE website coming online • Measurement: • Refine process measures • Implement Success Stories; QI registry; Collaboratives

29. PROMISE website:www.cherp.research.va.gov/PROMISE • (Non-VA site: www.caringforveterans.org) • Find out more about PROMISE • Register a QI initiative • Brag about a success story • Join a QI collaborative • Learn about best practices (coming soon)