TABLE 2
Consensus Recommendations for Operational Features of Palliative Care Programs
| RECOMMENDATIONS | |||
|---|---|---|---|
| Domain | NQFa | Must have | Should have |
| 1. Program Administration To effectively integrate palliative care services into hospital culture and practice, so that the program’s mission is aligned with that of the hospital, the program must have both visibility and voice within the hospital management structure. This can best be accomplished by (1) ensuring that a program has a designated program director, with dedicated funding for program director duties and (2) a routine mechanism for program reporting and planning that is integrated into the hospital management committee structure. | Palliative care program staff integrated into the management structure of the hospital to ensure that program consideration of hospital mission/goals. Processes, outcomes, and strategic planning are developed in consideration of hospital mission/goals. | Systems that integrate palliative care practices into the care of all seriously ill patients, not just those seen by the program. | |
| 2. Types of Services The three components of a fully integrated palliative care program are an inpatient consultation service, outpatient practice, and geographic inpatient unit. All three serve different but complementary functions to support patients/ families through the illness experience. Because a consultation practice has the ability to serve patients throughout the entire hospital, this is typically recommended as the first point of program development. | A consultation service that is available to all hospital inpatients. | Resources for outpatient palliative care services, especially in hospitals with more than 300 beds. An inpatient palliative care geographic unit, especially in hospitals with more than 300 beds. | |
| 3. Availability Patients, families and hospital staff need palliative care services that are available for both routine and emergency services. | 2 | Monday–Friday inpatient consultation availability and 24/7 telephone support. | 24/7 inpatient consultation availability, especially in hospitals with more than 300 beds. |
| 4. Staffing The following disciplines are essential to provide palliative care services: physician, nursing, social work and chaplaincy. In addition, mental health services must be available. Depending on the institution and staff, basic mental health screening services can be provided by an appropriately trained social worker, chaplain, or nurse with psychiatric training. Ideally a psychologist or psychiatrist are also available for complex mental health needs. Social work, chaplaincy, and mental health services can be provided by dedicated palliative care fulltime equivalent positions or by existing hospital staff, although their work in support of the palliative care program will still need to be accounted and paid for, and not just “added on” to their existing job responsibilities. | 1, 5, 19, 20, 21, 22, 23 | Specific funding for a designated palliative care physician(s). All certified in hospice and palliative medicine (HPM) or committed to working toward board certification. Specific funding for a designated palliative care nurse(s), with advance practice nursing preferred. All program nurses must be certified by the National Board for Certification of Hospice and Palliative Nursing (NBCHPN) or committed to working toward board certification. Appropriately trained staff to provide mental health services. Social worker(s) and chaplain(s) available to provide clinical care as part of an interdisciplinary team. Administrative support (secretary/ administrative assistant position) in hospitals with either more than 150 beds or a consult service with volume >15 consults per month. | |
| 5. Measurement Providing evidence of the value of palliative care programs to patients, families, referring physicians and hospital administrators is critical for program sustainability and growth. Key outcome measures can be divided into four domains (examples provided):
| 12, 13, 14, 15, 16 | Operational metrics for all consultations. Customer, clinical and financial metrics that are tracked either continuously or intermittently. | |
| 6. Quality Improvement Palliative care programs must be held accountable to the same quality-improvement standards as other hospital clinical programs. | 12, 13, 14, 15, 16 | Quality improvement activities, continuous or intermittent, for (a) pain, (b) non-pain symptoms, (c) psychosocial/spiritual distress and (d) communication between health care providers and patients/ surrogates. | |
| 7. Marketing As a new specialty, the palliative care program is responsible for making its presence and range of services known to the key stakeholders for quality care. | Marketing materials and strategies appropriate for hospital staff, patients, and families. | ||
| 8. Education As a new specialty, the palliative care program is responsible for helping develop and coordinate educational opportunities and resources to improve the attitudes, knowledge, skills, and behavior of all health professionals | 3 | Palliative care educational resources for hospital physicians, nurses, social workers, chaplains, health professional trainees, and any other staff the program feels are essential to fulfill its mission and goals. | |
| 9. Bereavement Services There are no currently accepted best practice features of bereavement services to recommend. Common elements present in many programs include telephone or letter follow-up, sympathy cards, registry of community resources for support groups and counseling services, an remembrance services. All programs are encouraged to develop a bereavement policy and make changes as needed through quality-improvement initiatives. | 17, 30, 31 | A bereavement policy and procedure that describes bereavement services provided to families of patients impacted by the palliative care program. | |
| 10. Patient Identification In most hospitals, palliative care consultations originate from a physician order. To facilitate referrals for “at-risk” patients, many hospitals have begun adopting screening | A working relationship with the appropriate departments to adopt palliative care screening criteria for patients in the emergency department, general med/surgical wards and intensive care units. | ||
| 11. Continuity of Care Coordination of care as patients move from one care site to another is especially critical for patients with serious,often life-limiting diseases, and is a cornerstone of palliative care clinical work. | 7, 8, 28 | Policies and procedures that specify the manner in which transitions across care sites (e.g., hospital to home hospice) will be handled to ensure excellent communication between facilities. A working relationship with one or more community hospice providers. | |
| 12. Staff Wellness The psychological demands on palliative care staff are often overwhelming, placing practitioners at risk for burnout and a range of other mental health problems. Common examples of team wellness activities are team retreats, regularly scheduled patient debriefing exercises, relaxation-exercise training and individual referral for staff counseling. | 4 | Policies and procedures that promote palliative care team wellness. |
aNQF column numbers represent the specific National Quality Forum Hospice and Palliative Medicine Preferred Practice. (SEE TABLE 1) Data from10, 18, 24