Hospital Palliative Performance Profiles

Since 1996, the Dartmouth Atlas of Health Care has tracked patterns of health care delivery, practice and quality across the country. Its massive pool of national, regional, local and provider-level health care utilization and cost data, derived from the Medicare database, has documented striking geographical variations in the delivery of health care services. But it has also changed our understanding of the efficiency and effectiveness of health care delivery and demonstrated that more medical care does not necessarily mean better care—that the wide disparities in health care spending and utilization do not track with measurable improvements in health care quality. In fact, higher utilization at the end of life may represent both harm to patients and billions of dollars in wasteful and unnecessary health care spending.

The Dartmouth Atlas Project, founded by Dr. John E. Wennberg, is based in the Dartmouth Institute for Health Policy and Clinical Practice at Dartmouth University. Its databases are used by health care policy-makers, analysts, health care executives, researchers, and, increasingly, palliative care advocates seeking to plan or justify the need for palliative care services to help their hospitals better manage these high-need, high-cost, high-utilization patients.
“Concern about overly aggressive care for patients at the end of life has sparked increased interest both in palliative care and in aligning the kinds of services provided to dying patients with their well-informed preferences,” the report states. “Patient wishes may have less influence on intensity of care than the practice patterns of the hospital where the care is given.”

Taken together, these figures start to sketch a picture of how much potentially futile or ineffective care a hospital or a region provides to patients during their final months of life or during the hospitalization in which death occurs—as well as creating an opportunity to compare performance on these variables among peers.

Our analyses show there is great variation in end-of-life care across regions and states. Digging deeper, our research group has identified that those hospitals with high performance scores (100 or above) have adopted advanced palliative care organizational (APCO) principles in which there are what we refer to as “learning communities”. This learning community is essentially a group of palliative care stakeholders who "join" together and are driven by a desire to share problems, knowledge, experiences, insights, templates, tools, and best practices around palliative care.

I'm interested to hear from those involved in learning communities sponsored by APCOs.

Role Definition and Advanced Palliative Care Organizations

I'm asked from time to time why I consider palliative care to be two parts accomplishment for three parts potential. I offer many reasons in reply, but none (in my opinion) have a greater impact on the success of palliative medicine programs than role confusion.

The highly collaborative nature of palliative care services (and by extension, advanced palliative care organizations) requires sharp role definition. Ideally, what a person thinks his or her job is, what others expect of that job, and how the job is actually performed are all the same. Role confusion, however, is a common byproduct of the service/program launch process. Role perception “drift” is natural, especially as insufficient resources are strained to meet growing demand for the service.

So that fledgling programs can better identify and eliminate such drift, program sponsors should, up-front, clearly delineate roles and expected results. Most program developers do this through job descriptions, yet, for all of the benefits that accrue from traditional job descriptions, role definition is rarely one of them. I've successfully used a management tool known as Responsibility Charting to systematically identify decisions and activities that must be accomplished and to pinpoint the functions (positions) that will take on roles relevant to those results. Among the benefits that may flow from this process:
-increased productivity through well-defined accountability
-increased capacity through elimination of overlaps and redundancies
-streamlined organizational structure achieved by collapsing unneeded layers and placing accountability closest to the decision
-improved communication and collaboration.
In other words, a strong performance management program for the palliative care service that will guide leadership and palliative care specialists.

Defining the Role of Medical Leadership in Successful Palliative Programs

The keys to success, we've found through study and experience, are to align expectations and to create an organizational structure that enables easy scaling to accomodate growth.Job specifications based upon program metrics generally produce the best results , that is to say, the role of program director is best determined by identifying and incorporating into the position profile the program expectations from at least three and not more than five "stakeholders', including the CEO. This can best be done done by an outside consultant who will not inject "bias" into the assessment.

Removing Barriers to Success

I'm often asked what keeps programs from reaching their potential? Several factors, but one stands out.
A program can be successfully STARTED with less than 1.0 FTE - the challenge becomes in sustaining the program with such limited staffing. The shortage of palliative care specialists makes timely scaling of the program one of, if not the greatest, management challenges. Those that have been able to SUSTAIN the program with limited staffing have done so because they've effectively brought infrastructure (intellectual capital) to the program at the right time and in the right amount. Yet , as one might surmise, doing so demands management agility and acumen and, most precious of all, time. These are resources in short supply at most fledgling programs.
In future posts, we'll examine several other barriers to program growth, and how successful programs have surmounted those obstacles. Most of all, I'm curious to learn experiences of readers of this blog.

Two Parts Accomplishment, Three Parts Potential

Two parts accomplishment, three parts potential. That, to me, describes the current state of palliative medicine.
How can that be, you ask? After all, palliative medicine is now a recognized subspecialty. And the clinical domains of good palliative care are being adopted widely.
So why is the promise of palliative medicine yet to be realized, and what will it take to translate potential into accomplishment? While palliative medicine practices are delivering exceptional care to those with life-limiting illnesses, many demonstrate unfilled potential. Why? Because they’re undercapitalized; not financially, but intellectually. The bulk of each practice’s intellectual capital has been invested in the clinical knowledge residing in the physician’s head. And that’s the way it should be. But what about other intellectual capital—efficient workflow processes, coding expertise, knowledge of palliative medicine reimbursement nuances, practice analysis intelligence, software, and marketing know-how—so essential to the achievement of a high-performing practice? Most palliative medicine programs labor without this intellectual capital, and find themselves a year or two later scrambling to justify continued viability either of the practice itself or the palliative program associated with it.
Sponsors of palliative care programs, usually hospitals and hospices and most surely all well-intentioned, discover that sustaining (and growing) a program requires a different set of skills and expertise than developing the program. They also underestimate the importance of organizational structure in the success of the program. My aim is of this forum is that we'll examine the key elements of APCOs, the barriers to success and how they might best be removed, and why the shortage of palliative care specialists threatens to stifle the progress of end-of-life care.