A palliative approach to care benefits clients in any setting, including complex continuing care. The early identification of clients who would benefit from a palliative approach to care means patients can access services to meet their physical, psychological, social, spiritual, and practical needs as they cope with their life-limiting illness.
Ontario Health had a chance to catch up with Shanna Anness, Nursing Professional Practice Leader and BPSO Lead, and Hilary Mettam, Community Development Lead, North West Regional Palliative Care Program, to learn how they are working to improve the early identification of clients who would benefit from a palliative approach to care at St. Joseph’s Care Group.
Can you describe your initiative?
St. Joseph’s Care Group decided to focus on the early identification of clients for a palliative approach as part of our Quality Improvement Plan (QIP) and designation as an RNAO Best Practice Spotlight Organization. RNAO’s palliative care best practice guideline aligns directly with the QIP palliative care indicator, which has been helpful for combining resources.
St. Joseph’s Hospital provides end-of-life care for clients on the hospice palliative care unit. Still, the organization wanted to focus on palliative care throughout the hospital as clients can benefit from palliative care early on in their illness. Research shows it can decrease anxiety and depression, improve quality of life, and improve symptom control.
What were your first steps?
To start the project, we partnered with our regional RNAO best practice consultant to complete a gap analysis based on RNAO’s best practice guideline for A Palliative Approach to Care in the Last 12 Months of Life. From the gap analysis, we identified that the early identification of clients for a palliative approach to care should be the focus of improvement. With any gap analysis, there is usually more than one area a team could focus on, however, to ensure success, we zeroed in on what was our highest priority.
We invited a mix of frontline staff and management from across the hospital to participate in the initial gap analysis, ensuring representation from various disciplines (nursing, social work, Indigenous support, spiritual care, OT/PT, and our palliative care consultant).
How did you use data to inform your work?
One challenge we have faced is access to relevant data. We overcame this challenge by collaborating with our organization’s RAI coordinators and Decision Support consultant to determine what data is available and how it can be used to support our project. We were then able to collect baseline data from our EMR related to the number of deaths throughout the hospital, transfers to hospice, and referrals for palliative care consults.
The Medically Complex Care Unit was then identified as our focus area given the client population and readiness for change. It was also more manageable to scope our project down to one unit versus trying to make improvements across the whole hospital. We collected baseline data on this floor as our first Plan-Do-Study-Act (PDSA) cycle.
Now, on a regular basis, the Decision Support consultant pulls reports for us and we present this data back to the team. Over time, we’re hoping to present the data in a more sophisticated way, but for now, simply having the right data to inform our work is wonderful.
We are now in the process of 1) selecting and testing out a tool for early identification and 2) engaging frontline staff to become champions who can generate change ideas and support implementation. We’re also planning broader staff education and engagement to promote the palliative approach to care and raise awareness about this work and why it’s important.
Who else are you collaborating with?
This project is a joint effort between our Collaborative Practice team, Regional Palliative Care Program, and In-Patient Rehabilitative Care division within our organization.
We have also connected with Ontario Health experts in CQIP to seek guidance on the process and advice from their experiences supporting organizations who have done similar work. We’ve benefitted greatly from working with palliative care experts such as the palliative care consultant nurse.
As our project has progressed, we have reached out to others within our organization who have expertise in certain areas such as Clinical Learning and Decision Support. Our leadership team/executive sponsors have been integral to connecting us to these other resources.
We are also working with the leadership team at St. Joseph’s Care Group’s long-term care division, which is completing similar initiatives related to the early identification of clients who would benefit from a palliative approach. They have helped support us throughout this process.
Did you have any challenges or barriers?
Many of our bumps along the way are related to the pandemic. This has slowed our initiative significantly, but we have been innovative in moving forward with what we can.
In addition to the data challenge mentioned earlier, staff engagement has also been a challenge due to the pandemic that has caused stress and burnout among healthcare workers. We have overcome this challenge by having staff provide feedback from the nursing quality practice council and identifying champions who have protected time to contribute to our initiative. We also continue to reach out to other organizations in our region who are doing similar work to share ideas and learn from their experiences.
What advice would you give to other organizations looking to take first steps?
Make sure to set aside time at the start of your quality improvement journey to gain a fulsome understanding of the current state and where the gaps/barriers are – gather baseline data, ensure communication with leaders and frontline staff, and listen to client and caregiver stories.
Be open to the process as assumptions regarding gaps may not end up being your project's focus once you've engaged stakeholders and gathered their feedback. There may be uncertainty at first, but eventually, the direction will become more apparent. Start small, learn about what works and what doesn't, and grow from there.
Take the time to gather your team together and identify those who have done similar work. Often, we work in silos and we may not know who is working on similar initiatives, both internally and externally. Spending the time to identify these resources is greatly beneficial and will make your work more efficient.