Quality Improvement and The Veterans Health Administration’s Palliative Care National Clinical Template (QI812)

Abstract: The objectives of the study is to identify opportunities to use existing process level EHR data in their practice settings for quality assessment and to identify approaches to optimize quality efforts using process level data. Process measures provide evidence of care delivered at the bedside. The Veterans Health Administration’s (VHA) Palliative Care National Clinical Template (PC-NCT), writes process-level data from palliative care (PC) consultations to the Electronic Health Record (EHR) that are aggregated and used for quality improvement (QI). The aim of the study is to describe experience using the PC-NCT across facilities for QI. Process-level data generated during PC-NCT consults (7/1/2014 – 6/30/2017) were extracted from the EHR. We obtained user feedback and descriptively analyzed patterns of use for QI. 

The PC-NCT was used 32,566 times (34% of palliative care consultations) at 82 facilities (67% of facilities) to document care. At the domain level, Clinical Presentation was used in 97%, Social History 84%, Symptom Review 78%, Psychological Assessment 17%, Palliative Performance Scale (PPS) 77%, Care Planning 79%, Spiritual Concerns 57%, Physical Examination 87%, and Assessment and Recommendations 94% of PC-NCT consults. Facility culture, preferential use of locally developed tools, and challenges with note formatting are reported as reasons for non-use. PC-NCT data identify clinical questions for teams that are reviewed during twice yearly QI calls. Sites with low PPS scores are prompted with, “How are you collaborating with other services to promote earlier PC consultation?” Those with large numbers of patients reporting dyspnea are asked to consider how opioids are used in dyspnea management, and sites with sparse documentation of spiritual concerns are asked to consider what questions clinicians ask about spiritual concerns and whether they are comfortable addressing those needs. In addition to template use for quality assessment, it is used to educate new PC trainees on salient content for comprehensive consults and reduce inter-provider variability in PC delivery. Competition for scarce resources in healthcare necessitates optimizing use of existing data. Process-level data from a standardized PC note template can be used for QI, training, and standardization among staff.