Documentation of Advance Care Planning (ACP) is often driven by outpatient providers. However, inpatient hospitalization presents a unique opportunity to elicit and document endoflife wishes, and additionally strengthen communication between inpatient and outpatient providers. A chart audit of patients hospitalized on the medical service at our hospital revealed that housestaff did not document ACP discussions in a standard location or format in the medical record. Based on a review of the current literature, we believed that increasing rates of documentation would benefit patients by better aligning the care delivered with patient wishes, while improving housestaff exposure and experience with ACP. We describe here a residentled incentive program to improve both the rates and quality of ACP documentation in the inpatient setting.
To implement a yearlong residentled program using financial incentives and targeted interventions to increase rates and quality of ACP documentation in the hospital’s electronic medical record (EMR). By standardizing location and content, we aim to educate housestaff about key aspects of ACP discussions while making key information accessible to both inpatient and outpatient providers.
A group of residents at a 600bed academic medical center designed this project in 2011 as a submission to a medical center sponsored financial incentive program for housestaff guided quality improvement projects. We designed an ACP template integrated into the hospital’s electronic discharge summary (EDS), chosen for its easy accessibility to primary care providers (PCPs) and emergency room physicians. The template prompts inclusion of (1) expressed wishes for endoflife care, (2) mode of communication of the wishes, (3) whether the wishes represented a change from prior, (4) the name and contact information for a Durable Power of Attorney or Emergency Contact, and (5) PCP notification of changes in ACP. The incentive measured the completion of questions 1 and 4 within 48 hours of discharge for patients admitted to the medicine service. To meet the incentive goal, residents were required to have a 75% completion rate in at least three of four quarters from July 1st 2011 to June 30th 2012. Several cycles of continuous improvement focused on simplifying the template for easier use, providing real time feedback to housestaff about their individual rates of completion, and increasing education about the location and benefits of the template to inpatient and outpatient providers. To date, rates of ACP documentation have increased from initial rates of approximately 20% to greater than 80%.
A residentled quality improvement incentive program to improve rates of ACP documentation on the inpatient medicine service has led to significantly higher rates of standardized and accessible documentation. Further work will emphasize enhancing the quality of ACP discussions, assessing patient impact, and gauging the benefit to outpatient providers.
To cite this abstract:Dharia A, Goel A, Hoffman A, Le E, Dixson J, Lakin J, Bischoff K, Soni K, Mourad M, Ranji S, Mak Y. Improving Advance Care Planning Documentation Through a Residentled Incentive Program. Abstract published at Hospital Medicine 2012, April 1-4, San Diego, Calif. Abstract 97731. Journal of Hospital Medicine. 2012; 7 (suppl 2). https://www.shmabstracts.com/abstract/improving-advance-care-planning-documentation-through-a-residentled-incentive-program/. Accessed September 18, 2019.