A Recipe for Success: The Joint Commission Advanced Certification for Palliative Care Programs

1. A Recipe for Success: The Joint Commission Advanced Certification for Palliative Care Programs Wednesday April 24, 2013 Audio Conference 1:30 – 2:30 PM EASTERN Renee Harvey, MPA, FACHEManager, Regulatory Affairs, Corporate ComplianceHackensack University Medical Center Hackensack, NJ Email: RHarvey@HackensackUMC.org Joe Contreras, MD, FAAHPMChair, Pain & Palliative Medicine InstituteHackensack University Medical CenterHackensack, NJ Email: JContreras@HackensackUMC.org

2. DISCLOSURE The speakers have nothing to disclose.

3. Establishing: Palliative Careat HackensackUMC • Hackensack University Medical Center; Hackensack, NJ • 775 bed Tertiary Teaching Hospital • Pain & Palliative Medicine Institute Established June 2008 • Clinical team - Palliative Care Physician, Nurse, Administrator • Interdisciplinary Team (IDT) – Pastoral Care, Bioethics , Case Management/Social Worker, Psychiatry, Nutritionist, Pharmacist, Hospice Coordinator • Making the Case – Identifying resources, Palliative Care Committee, identifying stakeholders, education, unit rounding, lunch and learns

4. Palliative Care Service History • HackensackUMC Palliative Care Service Gap Analysis • Policy • SW/psychosocial support • Chaplain documentation • Nursing Assessment eMAR • Nursing Care Plan • Metrics

5. Palliative Careat HackensackUMC Vision: Throughout the continuum of illness and treatments, all patients and their families will have access to quality palliative care. Mission: Increase the availability and understanding of palliative care services throughout Hackensack University Medical Center and the Northeast region.

6. The Journey to Certification • Assemble a team • Develop a plan • Implement the plan • Monitor the plan • Refine the plan • Celebrate success

7. The Certification Team • Interdisciplinary Team • Palliative Care independent practitioner • MD, APN • Social Worker • Chaplain • Registered Nurse Champion • Educator • Performance Improvement Advisor • Information Technology Representative • Administrator • Regulatory Expertise

8. Program Design

9. Palliative Care Policy HackensackUMC; Administrative Policy • Adult and Pediatric Palliative Care Purpose • To describe the components of palliative care. • To describe the procedure for obtaining a palliative care consult. • To define palliative care scope of practice.

10. Project Plan • Perform a gap analysis to identify where current practice is in or out of compliance with certification requirements • Joint Commission requirements are based on the National Consensus Project recommendations • Recommend using some type of tracking tool

11. Project Plan

12. Project Plan • There are 172 certification requirements called elements of performance (EPs)divided into five sections • Certification Participation Requirements • Information Management • Provision of Care, Treatment and Services • Performance Improvement • Performance Management

13. Project Plan • Advanced program requirements are very specific-example if the requirements states : “The interdisciplinary program team assesses and documents the patient’s anxiety, stress, anticipatory grief, coping, and other psychological symptoms and uses, when available, standardized scales”, • the expectation is every patient in the pool is assessed and it is documented.

14. Implement the Plan • How will you identify the patient population? • Paper Assessment Tool • Palliative Care Consult list • eMAR Assessment • Critical because care has to be delivered consistently to this population • Core care team members cooperate/share care responsibilities

15. Palliative Care Metrics • Growth • # consults/# admissions • Efficiency • # completed consults in 24 hours/# consults • Understanding • First PC consult > 30 day of death/# pts with PC consults prior to death • Patient Satisfaction • Are you satisfied with the palliative care team's discussion regarding its services? • # yes responses to survey question/# of surveys returned

16. Performance Improvement Activities • Development; PC Admission Assessment Tool • Population-specific screening tool placed within the electronic nursing admission assessment • Adult, Pediatric, NICU • Created a Best Practice Alert (BPA) to Admitting Physician • eMAR Pastoral Care Consult & Chaplain progress note • eMAR Palliative Care Nursing Care Plan • Development of an electronic report to monitor & capture data

17. Palliative Care Admission Assessment Tool ADULT: Does the patient have a chronic /serious medical condition? e.g. dementia, CHF, COPD, cancer Does the patient have uncontrolled symptoms from chronic disease? e.g. nausea, vomiting, pain and/ or SOB Is the patient technology or care dependent? Technology/care dependent is defined as patient who have inotropic infusions, oxygen dependent, hemodialysis, lives in nursing home or facility, cannot participate with ADL’s etc. Has the patient been involved with the Palliative Care Team previously? * Pediatric & Neonatal Admission Assessment Tool questions were also created and available for review.

18. Palliative Care Admission Assessment Tool

19. Implement the Plan • Assign sub work groups to begin to close the gaps identified in the gap analysis • Timeline will be determined by the nature of the gap • Err on the side of allowing more time to implement actions designed to correct practice

20. Strategies for Success • Communicate/Educate • Lunch & Learns • Patient Tracers • Screensavers • Organization’s newsletter • Care team visibility • Unit rounds • Practice dress rehearsals • Anticipate roadblocks

21. Post Certification Maintaining the Gains • Survey follow up • May have corrective action to submit • Hold a post survey “huddle” • Maintain the program infrastructure • Meet regularly as a team • Required data to collect, report • Recertify every two years

22. CELEBRATE

23. REVIEW • Assemble a team • Develop a plan • Implement the plan • Monitor the plan • Refine the plan • Celebrate success

24. Resources • Center to Advance Palliative Care www.capc.org • The Joint Commission www.jointcomission.org • Joint Commission Resources www.jcrinc.com • The National Consensus Project for Quality Palliative Care www.nationalconsensusproject.org

25. References Weissman, E. D. & Meier, E. D. (2011). Identifying patients in need of a palliative care assessment in the hospital setting. A consensus report from the Center to Advance Palliative Care. Journal of Palliative Medicine, 14(1) 17 – 23.

26. Question & Answer Period ABOUT CAPC The Center to Advance Palliative Care (CAPC) provides health care professionals with the tools, training and technical assistance necessary to start and sustain successful palliative care programs in hospitals and other health care settings. CAPC is a national organization dedicated to increasing the availability of quality palliative care services for people facing serious illness. Thank you for joining us today!

27. Continue the Discussion on CAPCconnectTM Forum! At the conclusion of this audio conference, we welcome you to continue the discussion with your peers and faculty on CAPCconnectTM Forum! Go to: http://www.capc.org/forums to post your message and comments within the “The Joint Commission Palliative Care Certification” discussion topic!