Background Advance care planning (ACP) enables patients’ end-of-life wishes to be better known and followed, reduces caregiver burden in decision-making, and reduces use of invasive interventions at the end of life.
A baseline audit showed that the average ACP completion rate among inpatients of our acute palliative care unit who had no prior ACP done was 4.9%.
Surveys performed suggested a realistic target goal of 40%. The aim was to increase new ACP completion rate among Palliative Medicine inpatients from 4.9% to 40% over 6 months.
Methods Inpatients under the Department of Palliative Medicine with no prior ACP done were included, while patients under the department for 3 days or less were excluded.
A flowchart of the baseline work processes was developed. Root causes for poor ACP completion rates were elicited through brainstorming and root cause analysis. The top root causes were identified via multi-voting based on the Pareto principle. Interventions were implemented in a stepwise fashion and studied using the Plan-Do-Study-Act framework. Results were studied in 2-weekly intervals.
Results The top root causes that accounted for 80% of the votes were: (1) No organized system to initiate ACP; (2) Goals of care discussion deemed sufficient; (3) Inadequate staff knowledge about ACP; (4) No protected time.
Interventions included staff education to correct misperceptions and clarify work processes, introduction of documentation templates indicating whether ACP has been done/offered with senior staff to oversee the screening process, and introduction of protected time for staff to conduct ACP discussions.
Over 6 months, the average rate of new ACP completion increased from 4.9% to 44.4%.
Conclusions It is feasible to improve ACP completion in an acute palliative care unit using targeted interventions, via a systematic approach to quality improvement.
Further work will be done to ensure sustainability and explore potential spread of the interventions.
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