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Logo of nihpaAbout Author manuscriptsSubmit a manuscriptHHS Public Access; Author Manuscript; Accepted for publication in peer reviewed journal;
Semin Oncol Nurs. Author manuscript; available in PMC 2011 November 1.
Published in final edited form as:
Semin Oncol Nurs. 2010 November; 26(4): 266–284.
doi: 10.1016/j.soncn.2010.08.006


Consensus Recommendations for Operational Features of Palliative Care Programs

DomainNQFaMust haveShould have
1. Program Administration
To effectively integrate
palliative care services into
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
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
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
2Monday–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,
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):
  • Operational Metrics: (number of consults, referring physician, disposition)
  • Clinical Metrics: (improvement in pain, dyspnea, distress)
  • Customer Metrics: (patient/family/referring physician satisfaction)
  • Financial Metrics: (cost avoidance, billing revenue, length of stay)
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
for helping develop and
coordinate educational
opportunities and resources
to improve the attitudes,
knowledge, skills, and
behavior of all health
3Palliative 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
17, 30, 31A bereavement policy and procedure
that describes bereavement services
provided to families of patients
impacted by the palliative care
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, 28Policies 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
A working relationship with one or
more community hospice providers.
12. Staff Wellness
The psychological demands
on palliative care staff are
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
4Policies 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