This material was prepared by the Great Plains Quality Innovation Network, the Medicare Quality Improvement Organization for Kansas, Nebraska, North Dakota and South Dakota, under contract with the Centers for Medicare & Medicaid Services (CMS), an agency of the U.S. Department of Health and Human Services. The contents presented do not necessarily reflect CMS policy. A FRAMEWORK FOR IMPROVING END-OF-LIFE CARE: FIVE CONVERSATION READY PRINCIPLES # PRINCIPLES PROMISING CHANGE CONCEPTS DATE COMPLETED GETTING STARTED 1. COLLECT baseline data a. % of individuals with accessible healthcare directive or documented healthcare agent 2. UNDERSTAND current process b. Conduct chart review of the last patient deaths in facility 3. SET an aim c. “How good by when” 4. IDENTIFY a subpopulation d. Consider age, e.g., 65 years or older, or health characteristic, e.g., end-stage disease A Framework for Improving End-of-life Care 5 . ENGAGE with patients and families to understand what matters most to them at the end of life a . Develop standardized advance care planning materials for conducting and documenting advance care planning conversations b . Train advance care planning facilitators c . Community involvement 2 . STEWARD information about each patient’s end-of-life care wishes as reliably as we do allergy information a . Understand the current fields in your EHR to identify opportunities to capture and store end-of-life care information in the system b . Create the architecture for the EHR that accounts for entry, storage, and retrieval of end- of-care wishes; consider how allergies are documented and retrieved 3 . RESPECT people’s wishes for care at the end-of-life by partnering to develop a patient-centered plan of care a . Create workflows to support entry and retrieval of end-of- life care information b . Identify patients needing end- of-life care c Assess and affirm known end-of-

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A FRAMEWORK FOR IMPROVING END-OF-LIFE CARE: FIVE CONVERSATION READY PRINCIPLES

# PRINCIPLES PROMISING CHANGE CONCEPTSDATE

COMPLETED

GETTING STARTED1. COLLECT baseline data a. % of individuals with accessible healthcare

directive or documented healthcare agent

2. UNDERSTAND current process b. Conduct chart review of the last patient deaths in facility

3. SET an aim c. “How good by when”

4. IDENTIFY a subpopulation d. Consider age, e.g., 65 years or older, or health characteristic, e.g., end-stage disease

A Framework for Improving End-of-life Care5. ENGAGE with patients and families to

understand what matters most to them at the end of life

a. Develop standardized advance care planning materials for conducting and documenting advance care planning conversations

b. Train advance care planning facilitators

c. Community involvement

2. STEWARD information about each patient’s end-of-life care wishes as reliably as we do allergy information

a. Understand the current fields in your EHR to identify opportunities to capture and store end-of-life care information in the system

b. Create the architecture for the EHR that accounts for entry, storage, and retrieval of end-of-care wishes; consider how allergies are documented and retrieved

3. RESPECT people’s wishes for care at the end-of-life by partnering to develop a patient-centered plan of care

a. Create workflows to support entry and retrieval of end-of-life care information

b. Identify patients needing end-of-life care

c. Assess and affirm known end-of-life care wishes

d. Maintain an end-of-life care plan across organizational boundaries

4. EXEMPLIFY the work in our own lives so that we fully understand the benefits and challenges

a. Prioritize and segment staff for engagement through their own advance care planning

b. Provide the right tools at the right time

5. Connect in a manner that is culturally and individually respectful of each other

a. Recognize the effects of different cultural influences and connect with communities and leaders to help smooth the path

Reference: McCutcheon Adams K, Kabcenell A, Little K, Sokol-Hessner L. “Conversation Ready”: A Framework for Improving End-of-Life Care. IHI White Paper. Cambridge, Massachusetts: Institute for Healthcare Improvement; 2015. (Available at www.ihi.org.)

http://www.ihi.org/