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Reforming Care for Persons Near the End of Life: The Promise of Quality Improvement

Joanne Lynn, MD; Kevin Nolan, MA; Andrea Kabcenell, RN, MPH; David Weissman, MD; Casey Milne, RN, BSN, CCM, CMC; Donald M. Berwick, MD, End-of-Life Care Consensus Panel*
[+] Article, Author, and Disclosure Information

From the Washington Home Center for Palliative Care Studies, Washington, D.C.; Associates in Process Improvement, Silver Spring, Maryland; Cornell University, Ithaca, New York; Medical College of Wisconsin, Milwaukee, Wisconsin; and Institute for Healthcare Improvement, Boston, Massachusetts

This paper is based on a longer paper developed by the authors for the ACP–ASIM End-of-Life Care Consensus Panel.

Acknowledgments: The End-of-Life Care Consensus Panel thanks the Greenwall Foundation for its support of the development of the original paper and Dr. Joan Teno and Ms. Jean Brontoli for permission to use the figures that report their work.

Grant Support: By the Greenwall Foundation.

Requests for Single Reprints: Lois Snyder, JD, Center for Ethics and Professionalism, American College of Physicians–American Society of Internal Medicine, 190 N. Independence Mall West, Philadelphia, PA 19106-1572; e-mail, lsnyder@mail.acponline.org.

Current Author Addresses: Dr. Lynn: The Washington Center for Palliative Care Studies, 4200 Wisconsin Avenue, NW, Washington, DC 20016.

Mr. Nolan: Associates in Process Improvement, 1110 Bonifant Street, Suite 420, Silver Spring, MD 20910.

Ms. Kabcenell: Institute for Healthcare Improvement, 13 Eagle's Head Road, Ithaca, NY 14850.

Dr. Weissman: John Doyle Hospital, Medical College of Wisconsin, Box 133, 9200 West Wisconsin Avenue, Milwaukee, WI 53226.

Ms. Milne: 4461 Westover Place, NW, Washington, DC 20016.

Dr. Berwick: Institute for Healthcare Improvement, 375 Longwood Avenue, 4th Floor, Boston, MA 02215.

Ann Intern Med. 2002;137(2):117-122. doi:10.7326/0003-4819-137-2-200207160-00010
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Most people in developed countries will live with a serious, eventually fatal, chronic condition for months or years before dying; yet, the delivery of health care services has only just recently begun adapting to this reality. Quality improvement methods have been effective in helping clinical services to make substantial changes quickly.Quality improvement requires stating an aim, measuring success, and testing possible improvements. The testing of changes requires a clinical team to Plan, Do, Study, and Act on new insights (the “PDSA cycle“). Repeated PDSA cycles generate deep understanding of complex systems and make sustainable improvements rapidly.This paper discusses a composite case study in a nursing home setting, which builds on experience with multisite collaborative efforts and introduces quality improvement methods in the context of end-of-life care.

*For members of the End-of-Life Care Consensus Panel, see the Appendix.


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Figure 1.
Response time to pain by quarter-years and split by time from assessment to orders and time from orders to administration.solid line, circlesdotted line, squares

Shown are the average time elapsed from assessment to orders ( ) and the average time elapsed from orders to treatment ( ). Used with permission from Jean Brontoli, St. Mary's Health Center, St. Louis, Missouri.

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Figure 2.
Rate of dyspnea that persisted for more than one hospice care shift.barssolid line

Shown are the quarter-year rates ( ) and 2-month moving average ( ) of severe dyspnea not relieved by end of shift. Used with permission from Joan Teno, MD, Brown University, Providence, Rhode Island.

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