Improving Care for Patients At the End of Life

In 2006, SVMC launched a special Lean Six Sigma project to improve care at the end of life. We knew that our patients didn't always receive end of life care in the most clinically appropriate, cost effective, and desirable setting.

SVMC had observed among its patient population a trend that was similar to what's been observed across the country. Patients are admitted to acute care when alternate levels of care may be more desirable; their lives are prolonged without effective pain and symptom management; and they receive costly and sometimes ineffective interventions that contribute to, rather than decrease, pain and suffering.

Focusing on patients who die in the hospital from chronic disease and illness, SVMC found that the total hospital-related costs to care for these patients in the last 12 months of life average some $1.5 million annually. Although cost was an important component of the project, the goal of the project was to provide patients and their families the opportunity to experience a more meaningful death as defined by improved coordination of care, increased referrals to alternate levels of care such as hospice and palliative care settings, and reduced emotional, physical, and spiritual pain.

In its analysis of why care at end of life is both costly and not always well managed, the End of Life Care team identified several key issues related to poor communication and coordination of care, ineffective pain and symptom management, late referrals to hospice and inadequate advanced care planning. Root causes of these issues included time constraints on the part of providers to have meaningful discussions with patients about end of life care planning, difficulties coordinating care when multiple physicians are managing specific medical problems, and widespread misconceptions about the benefit of hospice and options for palliative care.

The team developed and implemented solutions to address these issues. These included establishing a Palliative Care Nurse Practitioner in the hospital, educating providers on how to talk to patients about death and dying, clarifying insurance regulations and benefits of hospice, and revising the palliative and comfort care guidelines to improve relief of pain and suffering for patients who choose to remain in the hospital.

Hospitals that have implemented a formal palliative care service have seen dramatic cost-savings achieved by reduced hospitalizations, readmissions and length-of-stay; improved pain and symptom relief for patients; increased hospice utilization; reduced telephone calls to primary care providers; and increased family, patient and caregiver satisfaction.

Results to date have shown an average monthly increase of 100 patient days in hospice, reduced costs in acute care, improved pain management and patient and family satisfaction with their care at SVMC.

As with all Six Sigma projects, a team of individuals from across the health system continues to monitor the success of the project to hold gains made. As such, there are a series of indicators the team monitors and reports on quarterly to the SVHC's executive management team.