TRANSFORM THE CULTURE OF ST. ALEXIUS MEDICAL CENTER TO INCREASE PALLIATIVE AND/OR HOSPICE CARE Betty Skonieczny,

1. TRANSFORM THE CULTURE OF ST. ALEXIUS MEDICAL CENTER TO INCREASE PALLIATIVE AND/OR HOSPICE CARE Betty Skonieczny, BCC, MPS ACE Project - Course 3 St. Alexius Medical Center – Hoffman Estates, Illinois 60169

2. VISION STATEMENT INCREASE THE OPTION OF PALLIATIVE AND/OR HOSPICE CARE FOR PATIENTS AT ST. ALEXIUS MEDICAL CENTER

3. BACKGROUND • Changing the culture of an institution is an enormous, multi-layered, complicated task. Why would a chaplain, new to St. Alexius, away from hospital chaplaincy since her residency over 30 years ago, want to take on a monumental task of “transforming the culture of a 250-bed community hospital?” • The answer is simple – NEED! • 50 to 60% of palliative care patients live longer, with better quality of life, in LESS resource-intensive settings (home, nursing home, hospice) (S. Morrison, Hertzberg, Palliative Care Institute, Mt. Sinai Medical Center, NYC) • Hospitals can save between $500 to $2,300 per day for each patient using palliative care services (White, K., Journal of Health Care Management) • Palliative Care can lead to more appropriate use of resources: patient, family, hospital, medical (CAPC, 2010)

4. OBJECTIVES Form a multi-disciplinary team to develop palliative care 2. Educate physicians, nurses, and multi-disciplinary staff about palliative care 3. Improve communication between patient, physician, and family 4. Increase the option for patients to receive palliative and/or hospice care earlier

5. FULL LIFE COMMITTEE MEMBERS Seated, Left to Right: Bonnie Kochan, Quality Manager, Kathy Montalbano, Recording Secretary, Linda Gump, Vice President of Operations, Dr. Jenny Kang, Co-Chair of Committee, Betty Skonieczny, Co-Chair of Committee, Rebecca Davis Mathias, Phd, Ethicist Standing, Left to Right: Rev. Domingo Hurtado-Badillo, Chaplain, Midge Hellmer RN, Oncology Nurse, Mark Kosla RN, Nurse Educator, Dr. Scott Neeley, Medical Director ICU, Dr. Barry Bikshorn, Neurologist, Dr. Edwin Priest, Oncologist, Dr. Teo Alvia, Internist, Sandy Kraus, Director of Risk Mgmt, Chris Johns, VP of Patient Safety and Quality Missing: Dr. Elizabeth Schupp, Pulmonologist, Denise Iberle, Case Mgr. Oncology, Barbara Wallace, RN, Director of ICU, Lonnie Hicks, Mgr. Social Services

6. KEY LEADERS IN CHANGING THE CULTURE OF ST. ALEXIUS MEDICAL CENTER Left to Right Linda Gump: VP of Operations – Communication link to CEO and corporate offices Dr. Jenny Kang: Co-Chair of Full Life Committee and Communication link to Physicians on Med Ex Committee Betty Skonieczny: Co-Chair of Full Life Committee - Plansagenda, all around resource person and passion behind the project

7. An indirect approach to increase and improve communication between physicians, patients, families and nurses

9. Evidence of Culture Change - Pre-Arrest Order Form approved from tie-breaking vote on 12/3/09 to an affirmative 12-4 vote on 3/3/10

10. METHODS • 1. Administrative support from VP and CEO • 2. End-of-Life (EOL) Committee is multi-disciplinary • 3. Recruited six key physicians to EOL Committee (oncologist , pulmonologist,intensivist, • hospitalist, neurologist, internist) • 4. Monthly report to Med Ex Committee of Physicians to solicit their support, approval, and • ownership ofpalliative care • 5. Agenda for Full Life Committee monthly meetings includes education, discussion, and debate. • 6. Created Pre-Arrest/DNR Order Form to increase physician communication with patients and • families about end-of-life care • 7. Small test of change for Pre-Arrest/DNR Order Form on med/surgical unit • 8. Education for nurses and physicians about form • 9. Offered two educational opportunities using well-known leaders in palliative care: Rev. Dr. • Myles Sheehan and Dr. Martha Twaddle • 10. Study hospital palliative care models and choose model to fit our hospital culture • 11. Chaplain provides education to 16 clergy of Ministerial Association and 46 Ministers of Care • about palliative care

11. RESULTS • Develop and implement Pre-Arrest/DNR Order Form with all physicians – August, 2010 • Educate and train physicians and nurses to use form • Committee changes name changes from End-of-Life to Full Life Committee to reflect • goals of palliative care • Choose Palliative Care Nurse Practitioner Model to continue changing the culture of • St. Alexius • CEO approves hiring Palliative Care Nurse Practitioner 18 months after Full Life • Committee begins • 6. Creating patient video for in-house television

12. DISCUSSION • STRENGTHS • VP and CNO support palliative care • Respected staff on Full Life Committee • Intensivist physicians role model good communication with patients and families • CHALLENGES • 1. Failed attempt to begin palliative care 2 years earlier soured physicians attitude • 2. Physicians resist change • 3. Physicians don’t attend education programs • 4. Poor communication between physicians and patients

13. ADJUSTMENT 1. Sought support from Medical Director from the beginning 2. Physician Co-Chairs Committee 3. Used various ways to have physicians take ownership of culture changes 4. Hopeful Pre-Arrest / DNR Order will significantly influence delivery of care 5. Attend local conferences and report back to Full Life Committee 6. Research journal articles and provide monthly article for committee to read 7. Provides committee with monthly research data from Illinois Health Institute (IHI)

14. NEXT STEPS • 1. Hire Palliative Care Nurse Practitioner • 2. Involve Palliative Care Nurse Practitioner on Full Life Committee • 3. Complete patient video for in-house TV • 4. Need Palliative Care Physician to join hospital staff • 5. Continue educating physicians and nurses • 6. Continue speaking about palliative care at area churches • 7. Create way to track palliative care and hospice statistics

15. IMPLICATIONS FOR PATIENTSThe project is much like a snow ball rolling downhill; slow at first, gradually picking up momentum. In August, 2010, it became mandatory for any patient in ICU for 5 days that a multi-disciplinary care conference with family will occur on day 5. As physicians have grown in their understanding and realization that palliative care positively impacts their patients, the direct implication for patients has begun to be seen. Since the Pre-Arrest/DNR Form was initiated on August 3, 2010 early data reveals that patients are going on hospice 1 to 5 days sooner. Change is happening. This next year will be exciting. Solid data will be available as the Palliative Care Nurse Practitioner begins developing a patient case load.

16. The Legend of the Starfish A vacationing businessman was walking along a beach when he saw a young boy. Along the shore were many starfish that had been washed up by the tide and were sure to die before the tide returned. The boy walked slowly along the shore and occasionally reached down and tossed the beached starfish back into the ocean. The businessman, hoping to teach the boy a little lesson in common sense, walked up to the boy and said, "I have been watching what you are doing, son. You have a good heart, and I know you mean well, but do you realize how many beaches there are around here and how many starfish are dying on every beach every day. Surely such an industrious and kind hearted boy such as yourself could find something better to do with your time. Do you really think that what you are doing is going to make a difference?" The boy looked up at the man, and then he looked down at a starfish by his feet. He picked up the starfish, and as he gently tossed it back into the ocean, he said, "It makes a difference to that one”. -Author Unknown