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Chapter 3

Mary Maven Chapter 3

We Can Do This!

End-of-Chapter Questions


1. Knowing that each system is designed to get the results it gets, can you identify procedures or processes in your organization that lead to variability in results?

Answer: Question 1

If you hear yourself or others saying, “why doesn’t this ever happen to Mary”? or “sometimes it works, sometimes it doesn’t”, you may need to do a little investigating and see where there are variations in practice that don’t always lead to the desired outcome.  Reducing variations in practice and processes leads to consistency in practice and consistency in outcomes. Think about your own area of influence in your hospice, where do you see variation in the ways things get done? Do these practices lead to differences in outcomes? Try not to limit your vision with thoughts like, “we have always done it this way”, or “nobody will want to change this”,  or “administration insists that we use  x-y-z”. This will stifle your creativity and imagination to recognize where change could be really useful.

2. Identify your QAPI committee “dream team.” Who in your organization should be on the committee and why. What roles and responsibilities would each person have? How would membership on this committee change depending on the improvement project?

Answer: Question 2

Depending on the size and complexity of your organization, there may be an organization-wide QAPI committee responsible for the 360 degree review, developing a “dashboard” (manageable number of indicators to tell you how your organization is performing); suggesting the QAPI agenda for board approval; acting as liaison and supporting improvement teams; and providing timely information to the senior leaders and the board. This committee might include: board member, medical director or designee, QAPI Coordinator, clinical representative, business representative, perhaps a family member(s). If an individual improvement project is related to contracted services (durable medical equipment, pharmacy, etc.) you may want to invite a senior representative from that service provider to meet periodically with the QAPI Committee. In addition, there may be times when expertise beyond the scope of the team is needed to help guide the work of the committee. In these cases technical experts and/or consultants may be ad hoc members of the team.

PIP teams should include stakeholders (if the project is to improve Hospice Aide practice then Hospice Aides should be part of the improvement team), QAPI coordinator, technical experts as needed and other staff members and/or volunteers. Depending on the size and resources of your hospice, and the complexity of the performance improvement project, teams may have 3 people or have as many as 7-8 members.  Improvement teams can decide amongst themselves or be assigned the following roles:

  • Team leader: Keep team focused on goal, set, attend and run meetings smoothly and efficiently (don’t waste time, adhere to the agenda). Hold team members accountable for their deliverables. Use the model for improvement to guide team activity. Provide assistance with tasks as needed. Communicate work and results of team beyond the team. Keep senior leadership informed of progress, request help when needed. Communicate and post results of project for other hospice members.
  • Team members: Take an active role (ask, answer questions, offer suggestions, use model for improvement) and display a positive attitude for improvement project participation. Attend meetings regularly, come with assignments done, keep team leader informed of any barriers to completing tasks on time or other problems.Support the testing of changes and stay attuned to undesired effects on staff and patients when testing change, report to team leader.

Usual team responsibilities that will be assigned:

  • Planning project: aim statement, outcome measures, changes to be tested based on best practices,
  • Researching for best practices, process measures,
  • Planning PDSA cycles, gathering data, analyzing data, graphing results, testing change(s), Encouraging others to test change,
  • Helping with staff education,
  • Finding a root cause for a problem,
  • Writing meeting notes and keeping track of changes tested and outcome measure,
  • Keeping focused on timeliness of project.

It is better to pick a smaller more focused and time-bound project than to chose a large hospice-wide project while you are learning the model for improvement and getting staff involved in the process.  

3. List as many sources of “best practices” that you can think of. Why would you want to test best practices in your organization? Why not just implement them?

Answer: Question 3

Best practices may be found in the palliative care literature or something used in the hospice next door. You may find a practice that works well in another location but doesn’t work in your hospice. That’s why all changes need to be tested. You may also ask your own “in-house” experts to help identify best practices; they may have used other procedures/interventions in previous roles, or have discovered something that would work well through journal reading or attending conferences. NHPCO has several listserves available to you as NHPCO members and this is another place to solicit advice for a particular problem you are facing. . Many people will ask for and give assistance and share tools/protocols they have used successfully. Contact membership services for info on joining a listserve or visit the Quality Partners homepage for more information - www.nhpco.org/quality.

You can use a small test of change – work with one patient, one doctor, one nurse - and see if you achieve the desired outcome for that one patient using the “new” procedure/intervention. If the test turns out to positively affect the outcome, then you will want to try it with a few more patients. If something works from  8-4 -M-F, will it work for on call staff? Does it work with nursing home patients as well as homebound patients and/or those in an extended care facility? Avoid implementing anything until the new assessment tool or procedure- intervention-change- has been tested under different circumstances in different situations.