PROMISE Performance Reporting and Outcomes Measurement to Improve the Standard of care at End-of-life The PROMISE team

How well are we doing?  “Our facility delivers the best possible end-of- life care.”  “Our palliative care team has a significant impact on the care of veterans.”  “Veterans who die in our hospice unit get much better care that they would elsewhere.”  How do you know?

You don’t know “ When hearing something unusual, do not pre-emptively reject it, for that would be folly. Indeed, horrible things may be true, and familiar and praised things may prove to be lies. Truth is truth unto itself, not because people say it is.” -Ibn al-Nafis

“In God we trust. All others must measure outcomes.” -Anonymous

PROMISE: Measuring successes and identifying opportunities  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.

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

What is PROMISE?  The quality measurement center for the VA’s CELC Initiative  Based at the Philadelphia VAMC Center for Health Equity Research and Promotion  Funding through CELC for: »A voice for veterans/families »Actionable data that can guide facility- VISN- and national-level planning and strategy.

Meet the PROMISE Team Dawn Kim Monica Jennie Matt Sean Tiffany Hien Megan Fiona Maysa Katie Anushree Christine Nicole Elena Wei Charlotte Daisy Joan

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

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)

Framework for PROMISE data: Aspects of care  Outcomes (Families’ perceptions of care)  Processes of care (from chart reviews)  Currently (Q4 FY09) 96 facilities: »~5800 interviews »~11,000 chart reviews

Step #1: Chart review  Deaths identified by Program Managers using VISN data (multiple overlapping samples)  The PROMISE sample: »We identify inpatient deaths »We exclude “unexpected” deaths (e.g. ER, suicide, homicide, OR for outpatient procedure)  Remote chart reviews via Global CPRS

Step #2: 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

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.

Overall BFS scores

Individual items: (Bereavement support)

Step #2: Processes of care from chart review: (examples)  Pain assessment in the last 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 within 2 weeks after death

Processes of care: Documentation of a bereavement contact

How do we use process of care data?  Not performance measures  Process of care data give diagnostic tools that can: »Identify potential problems »Find opportunities for improvement »Guide improvement strategies  Process of care data give evidence of impact that can: »Demonstrate the value of what you do »Help to justify (continued) funding

Using process of care data as a diagnostic tool  Example: Families at facility X feel they didn’t get enough bereavement support.  Ask: »Are we contacting families? »Or maybe the PCCT is contacting families, but other providers aren’t?

Pitfalls of using process of care data as a diagnostic tool  But: »“We make all our calls at 1 month” »“We document our calls in a collateral note” »“We don’t have time to document our calls”  Only you can decide whether a process measure is useful in your facility.

Using process of care data to show impact: One facility’s example  Good: “We were able to offer bereavement support to 60% of families of veterans who died as inpatients.”  Better: “Those contacts resulted in a 17-point increase on our facility’s bereavement score.”  Best: “Those contacts resulted in a 17-point increase in our facility’s bereavement score, compared to a national average 10-point increase.”

Getting data from PROMISE  Reports: »BFS data (outcome measures) »Chart review data (process measures) »Open-ended responses  More data…

Quarterly VISN-level reports  De-identified reports broken down by facility  Available at the end of the next quarter (Q1 deaths reported at the end of Q2)  Compared to a goal (pooled mean of top facilities)  Hypertext links to: »Success Stories on PROMISE website »SharePoint tools (Luhrs)

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.”

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

Can you give us even more data?

Additional data…  Aggregate (broken down) data available to each VISN  “Raw” data available on request  Menu-driven custom reports online (to be at the 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”

VISN “Hotseat calls”  Opportunity to get immediate answers to data questions: »What effect is our chaplain having on families’ perceptions of spiritual support? »What is the impact of palliative care in facility X? »What is the value of a hospice unit in facility Y?

Using the PROMISE report: 6 rules 1.Don’t panic 2.Focus! (Look at individual items) 3.Ask: Do you have enough data? (Often two quarters’ worth) 4.Use common sense (does this score make sense?) 5.Select one item to improve that has: 1.A low score 2.An obvious action plan 6.Be skeptical about changes

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

Help us close the loop (1-2) 1. “Success stories” disseminated on the PROMISE website and in monthly e-newsletter »Structured description via web-based form (through PROMISE website) »We need 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)

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 from the Implementation Center »Measurement/analysis by the PROMISE Center »Tailored feedback

PROMISE Implementation Recommendations Dissemination (PROMISE newsletter, etc) Implementation (Sharepoint, technical assistance, etc) QI registry QI Collaboratives Evaluation: BFS Chart review Guidelines/ Expert opinion

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.

Progress and next steps  Rollout: »21 VISNs currently on board  PROMISE website »Methods »FAQs »(Success Stories)  Monthly E-newsletter

PROMISE website:  Find out more about PROMISE  Register a QI initiative  Read about others’ success stories  Brag about your own success story  Learn about best practices  Join a QI collaborative (Carol Luhrs and Therese Cortez)