Use of the quality improvement process in assessing end-of-life care in the nursing home

To report on the process and effect of a quality improvement project on end-of-life (EOL) care in a state veterans' home.

The design uses survey data from representatives of the deceased, continuous quality improvement (QI) techniques, and interdisciplinary team activities. Representatives of the deceased were surveyed using a tool that assessed symptom management, emotional states, hospice use, and satisfaction with the care provided by the home and the hospice. Using the results of the survey, the interdisciplinary EOL care team used continuous QI methods to improve EOL care.

Representatives of the deceased of the Thomas Fitzgerald State Veterans Home (TFVH) and the interdisciplinary EOL care team of TFVH, which included staff of TFVH and the hospices serving TFVH.

The compiled survey results were compared from year to year to assess trends in the following areas: overall quality of care, pain, dyspnea, other uncomfortable symptoms, emotional need, and spiritual needs. We also assessed the degree of depression, agitation and anxiety, loneliness, and preparation and preparedness of the member for death. We surveyed for ratings on the satisfaction with staff, clergy and hospice, clarity of explanations and information provided by TFVH staff, what disciplines provided the emotional and spiritual support for the resident, whether discussions were held about advance directives, if they would recommend TFVH to other families, and use of/satisfaction with the hospice that served their loved one.

The survey return rate was 8 (38%) (2000), 22 (73%) (2001), and 25 (55%) (2002). The specific areas that were improved per the survey results (which also correlated with staff perceptions) were the following: overall quality of care, spiritual care, distribution of work load, and patients' preparedness for death. The prevalence of symptoms was reduced by 22% (pain), 25% (dyspnea), and 30% (uncomfortable symptoms of dying). A marked improvement of involvement of clergy in the spiritual care was also noted. The survey process also identified areas that did not improve or worsened such as management of depression, agitation, anxiety, loneliness, family education, and discussions. During the 2000-2002 time period, an average of 83% of the representatives responded that they would recommend the TFVH to another family.

EOL care in nursing homes is rated lower than care in all other venues and must be improved. EOL care can be improved using patient representative surveys as the springboard for staff and hospice interdisciplinary team QI processes. The interdisciplinary team must include the care staff of the home along with hospices serving the institution. We present here one process that we have found effective in improving EOL care. The critical issue is the dedication of the institution and staff to improve EOL care rather than the manner in which it is accomplished.