Southern California CSU DNP Consortium California State University, Fullerton California State University, Long Beach California State University, Los Angeles ADVANCE CARE PLANNING IN A SKILLED NURSING FACILITY: A QUALITY IMPROVEMENT PROJECT A DOCTORAL PROJECT Submitted in Partial Fulfillment of the Requirements For the degree of DOCTOR OF NURSING PRACTICE By Dane Shoemaker Doctoral Project Committee Approval: Joy R. Goebel, RN, PhD, FPCN, Committee Chair Kholoud Hardan-Khalil, RN, PhD, CCRN, Committee Member May 2018 Copyright Dane Shoemaker 2018© ABSTRACT An increasing number of deaths in the United States are taking place in post-acute and skilled nursing facilities (SNF) and the trend is expected to continue. Demand for higher quality care at the end-of-life (EoL) calls for improvements in bedside nursing related to palliative care (PC) including advance care planning (ACP). In the state of California, a centerpiece of ACP is the completion of the Physician’s Orders for Life- Sustaining Treatment (POLST) form.
The purpose of the project was to improve ACP activities in a large post-acute care facility located in Southern California. The aims were (1) to describe the current state of ACP practices, (2) to develop and implement a PC-centered training program for licensed and non-licensed nurses, and (3) to evaluate the effectiveness of the intervention on ACP. The project employed an observational pre-posttest design. Nurses (licensed and non-licensed) were provided a class on PC concepts including EoL care and documentation.
A tool modified from the literature measured PC and ACP knowledge, skills and attitudes (KSA) of nurses (28 items, Likert scale, range 1-5). Pre-post- intervention chart audits evaluated POLST completeness. POLST forms from patient’s charts (n = 60), licensed registered nurses (n = 10), licensed vocational nurses (n = 26), and non-licensed clinical nursing assistants (n = 50) comprised the sample for this project. Post-intervention chart audits for POLST completeness increased from 52% to 62% (a 10-percentage point increase).
Licensed nurses and unlicensed CNA’s post-test mean scores on PC knowledge, skills and attitudes improved (mean 3. In addition, aggregated post-test scores for both groups improved (3. Twenty-two percent (n = 19) of the participants showed marginal KSA decrements (range differences -1. Implementation of PC-based trainings improves nursing KSA related to palliative and EoL care across nursing levels.
PC trainings may improve completeness of POLST documentation. The decrements in KSA scores suggest that trainings may sensitize nurses to challenges in providing palliative and EoL care. This project demonstrates the feasibility of implementing a facility wide PC educational program to a population who frequently lack access to evidence-based PC and EoL information. iv TABLE OF CONTENTS ABSTRACT.
iii LIST OF TABLES. vii LIST OF FIGURES. 7 Advance Care Planning and POLST Documentation. 18 Current Facility Procedures Related to POLST.
20 Educational In-service Intervention. 22 Analysis and Evaluation Plan. 24 Results Specific to the Palliative Care Educational Intervention. 26 Results Specific to the POLST Form Completeness.
42 APPENDIX A: SAMPLE DATA ABSTRACTION TOOL. 51 APPENDIX B: KNOWLEDGE SKILLS & ATTITUDES SURVEYS. 52 APPENDIX C: FACILITY LETTER OF SUPPORT. 66 APPENDIX D: IRB APPROVAL.
67 vi LIST OF TABLES Table Page 1. Total Combined Sample Knowledge, Skills and Attitudes Survey. RN/ LVN vs. CNA Knowledge, Skills and Attitudes Survey.
RN/ LVN Individual Questions Knowledge, Skills and Attitudes Survey. CNA Individual Questions Knowledge, Skills and Attitudes Survey. 30 vii LIST OF FIGURES Figure Page 1. Conceptual model: PDSA cycle for quality improvement.
Pre-post educational intervention: Completed POLST form items. 33 viii ACKNOWLEGEMENTS I would like to thank Drs. Kholoud Khalil, AJ Jadalla, Margaret Brady and Penny Weismuller for their support throughout the project and the doctoral program. I would like to give a special acknowledgement and thank you to my doctoral chair, Dr.
Joy Goebel, for her mentorship and guidance throughout the development of the doctoral project. Lastly, I would like to thank my partner, Paul Travis, for his care and patience as I worked to complete the doctoral degree. ix 1 BACKGROUND Although there has been an increased interest in improving advance care planning (ACP) over the last few decades, the topic is poorly understood by the general public (Silveira, DiPiero, Gerrity, & Feudtner, 2000). A small, unpublished survey conducted by an internist writing in the Journal of the American Medical Association (JAMA) suggested that, when queried, only two in ten of her patients understood what ACP was (Tinetti, 2012).
Several factors may play into this, including dated reimbursement mechanisms and a medical culture that has, until very recently, encouraged continuous and often aggressive treatments from birth to the final few months of life. Incessant politicization of the healthcare system by elected officials, policy makers and media outlets likely contribute to this knowledge deficit (for a current example, consider the characterization of ACP reimbursement discussions by some in Washington D. as “death panels”) (Rutenberg & Calmes, 2009). The United States congress moved us into a new era for ACP with the passage of the Patient Self-Determination Act (PSDA) in 1991.
The Act encouraged patients and families to participate in joint decision-making activities with their providers, including goals of care (GoC) and end-of-life (EoL) discussions. The legislation effectively rebranded American healthcare from a fully opaque, hierarchical and top-down system to a consumer-driven, “patient-centered” healthcare model with opportunities for patients and families to participate in all aspects of care (Teno et al. Further driving these ideas is a pervasive belief that by increasing ACP, late life experiences may be improved (Dying in America, 2015; Sopcheck, 2016; Lazenby, Ercolano, Schulman-Green, & McCorkle, 2012). 2 Problem Statement Americans today are living longer but with more chronic, life-limiting diseases, such as dementia, diabetes and congestive heart failure (Ji, 2016).
This has created an increased burden on patients, families, and the healthcare system (Center for Disease Control and Prevention [CDC], 2012). In fact, 50% of Medicare dollars are used by 5% of Medicare recipients (Joynt, Gawande, Orav, & Jha, 2013), most of which is spent in the last few months of life (Zhang et al. Evidence suggests that these expenditures do not translate into improved late life experiences. In a discouraging study by Singer, Lynn, Teno, Lunney, Meeker, & Lorenz (2014), symptom burden actually increased across disease states in the last decade.
One response to these disturbing trends has been a push by nursing and other healthcare thought leaders to more effectively focus on care that is consistent with patient and family preferences (Unroe, Hickman, & Torke, 2016). A similar push that is gaining more traction is for evidence-based treatments that improving quality of life (QoL) (Singer et al. The development and rapid implementation of the Physician Orders for Life-Sustaining Treatment (POLST) form is further evidence of a widespread attempt to improve care at the EoL by standardizing the documentation of patient care preferences (Wenger et al. Discussions of preferences are increasingly important in skilled nursing facilities (SNFs) as upwards of 29% of all deaths in the United States occur in this setting – and it is expected to increase to almost 40% by 2025 (CDC, 2014).
While broad uptake of ACP has seen positive gains over the last decade, arriving at specific care preferences that are durable across care settings has been problematic (Yung, Walling, Min, Wenger, & Ganz, 2010). Large numbers of patients admitted to 3 the SNFs continue to present with little or no documentation of care preferences (e. Moreover, the job of educating patients and families about ACP in these settings often falls on registered nurses (RNs), licensed vocational nurses (LVNs), and, potentially, even clinical nursing assistants (CNAs) working at the font-lines of care. Unfortunately, many of these individuals have limited education on these topics (Kelly, Thrane, Virani, Malloy, & Ferrell, 2011) which may lead to less optimal ACP implementation and untoward outcomes.
Purpose Statement The purpose of this Doctor of Nursing Practice (DNP) project is to improve ACP in the post-acute, SNF-based population. The specific aims of the project are fourfold: one, to describe current ACP activities in the SNF setting; two, to develop an education program targeted at bedside staff to support these efforts; three, to implement the educational program; and four, to evaluate the effectiveness of the intervention. Supporting Framework Evidence-based practice models and frameworks are necessary to help guide translation of research into real-world clinical practice settings (Schaffer, Sandau, & Diedrick, 2013). The framework chosen for this project is the Plan-Do- Study-Act (PDSA) learning cycle (see Figure 1).
Developed by the chief architect of the 4 QI movement, Walter Shewhart, the PDSA model is a widely cited ‘quality management’ tool that was originally designed to reduce variations in the production and delivery of goods and services. Shewhart’s central thesis - as relevant today for the healthcare industry as it was for American manufacturing more than seventy-five years ago - is that a constant, never-ending evaluation and assessment of management policies and procedures will lead to a culture of continuous process improvement and, by extension, better products or outcomes (Best & Neuhauser, 2006). The PDSA QI model identifies four stages: • Plan – identify the problem and figure out what changes are needed to fix it • Do – implement the change or intervention • Study – measure and analyze process outcomes • Act – evaluate, take stock and ask the question, “Does the process change or intervention result in measurable improvement?” According to Shewhart, the “Plan” stage should include an outline of objectives that clearly delineate a course for change. This can be done by first defining existing conditions, then posing a change idea, and finally planning for the change to be tested or implemented.
For the current DNP project, the Plan was to engage stakeholders in identifying the problem of incomplete or inaccurate POLST forms and to develop baseline data related to ACP practices in a large, stand-alone post-acute, skilled nursing facility (“Sunnyside”). This was done through two separate steps (a) resident chart reviews to assess for POLST form status and (b) pre-testing for licensed nursing and CNA staff to assess current levels of EoL experiences, attitudes and care preferences documentation/ POLST form knowledge. The pre-testing survey tool focused on whether staff possessed the skills necessary to engage patients and families in EoL and GoC discussions. 5 Shewhart’s “Do” stage requires specific strategies to carry out the proposed change and prepare it for launch.
Process analyses are conducted and new tools and protocols are developed to foster improvements (Van Tiel et al. For this project, an ACP education program was created and implemented for front-line clinical staff. The program was divided into two parts or groups. The first was for licensed staff, such as RNs and LVNs, and the second was for non-licensed CNA staff.
For the “Study” stage of the model, before and after intervention implementation variables are measured and data evaluated and stakeholders reflect on the “iterative” and continuous improvement process. For this DNP project, an education program post-test was done with the goal of measuring new knowledge and content acquisition related to GoC, EoL and POSLT form documentation and other related ACP activities. Finally, for the “Act” stage of the model, Shewhart suggests that stakeholders record the positive process changes that yield improvements and begin to standardize these across all levels of service (Barlog & Ginn, 1994). For the current project, the question asked, “Have ACP activities improved?” This was done through a post-intervention chart audit to assess whether greater numbers of completed and signed POLST forms were evident in patients’ charts.
Recommendations and a reflective “lessons learned” summary document was generated and submitted to stakeholders for review. Questions included: • Has the change added more costs? • Were mistakes made? • Has overall performance related to ACP activities improved? • What could have been done differently? 6 • How can we further enhance process flow and front-line staff education in ways that optimize quality indicators and improve patient outcomes? Stakeholders Identification of stakeholders is an important component to a QI project.