Quality Measures Framed For Palliative Medicine


The National Quality Forum has published a comprehensive quality measurement and reporting system for the new subspecialty of hospice and palliative medicine.

“A National Framework and Preferred Practices for Palliative and Hospice Care Quality” crosses all health care settings and establishes minimum preferred practices.

Published in December by the National Quality Forum (NQF), the framework is intended to be the first step in a process through which rigorous, quantifiable internal and external quality indicators are developed. The document is based on an extensive set of clinical practice guidelines published in 2004 by the National Consensus Project (NCP) for Quality Palliative Care.

The NQF is a private, not-for-profit membership organization created to develop and implement a national strategy for health care quality measurement and reporting. NQF was assisted in this project by the Robert Wood Johnson Foundation.

The NCP is a consortium of the American Academy of Hospice and Palliative Medicine, the Center to Advance Palliative Care, the Hospice and Palliative Nurses Association, and the National Hospice and Palliative Care Organization.

“Together, these two documents define the state of the art in palliative care practices,” according to the NQF report. Of particular importance, palliative care services are indicated across the entire trajectory of a patient's illness; their provision should not be restricted to the end-of-life phase.

The field of palliative care “is escalating dramatically in response to an aging population and an overburdened health system. People are eager for direction in terms of palliative care,” said NCP chair Betty R. Ferrell, Ph.D., of the City of Hope National Medical Center in Duarte, Calif.

More than 2,000 U.S. hospitals have palliative care programs of some kind, but the interdisciplinary care outlined in the NCP guidelines remains confined mostly to large, metropolitan hospitals, Dr. Ferrell said in an interview.

“What we have to do now is catch up the practice. A family practice doctor may say he takes care of dying patients, but now we have to make sure that that doctor knows what to do, that he's competent in pain management, knows how to break bad news, and holds family conferences in the ICU. The culture has changed, but there's still an enormous amount of work to be done to translate this change in attitude into action,” she said.

According to the NCP, palliative care should be integrated into all health care for debilitating and life-threatening illnesses. The NCP framework for quality assessment emphasizes these goals:

▸ Address pain and symptom control, psychosocial distress, spiritual issues, and practical needs with patient and family throughout the continuum of care.

▸ Offer patients and families the information they need in an ongoing and understandable manner, so they may grasp their condition and treatment options. Elicit their values and goals over time; regularly reassess the benefits and burdens of treatment; and remain sensitive to changes in the patient's condition during decision-making process about the care plan.

▸ Ensure genuine coordination of care across settings with regular, high-quality communication, particularly at times of transition or changing needs. Use case management techniques to provide effective continuity of care.

▸ Prepare both the patient and family for the dying process and for death, when it is anticipated. Explore hospice options; allow opportunities for personal growth; and offer bereavement support for the family.

“These quality indicators will advance palliative care in all disciplines to improve the quality of life of people facing life-threatening and chronic, debilitating diseases,” said Judy Lenz, R.N., chief executive officer of the Hospice and Palliative Nurses Association.

The NQF preferred practices will help to lay the foundation for all hospice and palliative care services as well as to maximize the quality of care in a cost-effective manner, said Dr. Ronald S. Schonwetter, executive vice president and chief medical officer of LifePath Hospice and Palliative Care in Tampa.

Medicare reimbursement for hospice and palliative care will likely be influenced by pay-for-performance quality measures at some point, Dr. Schonwetter said in an interview.

A technical report to identify appropriate evidence-based quality indicators for the specialty is being worked on by researchers at the University of North Carolina, at Chapel Hill, who will turn over the findings to the Centers for Medicare and Medicaid Services in the next year.

“The NQF and the development of preferred practices are crucial steps in that process,” explained the internist, who is the immediate past president of the American Academy of Hospice and Palliative Medicine.

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