Noore-Sabah Khan (Johns Hopkins School of Medicine), Jacqueline Massare (Johns Hopkins School of Medicine), Naaz Hussain (Johns Hopkins Hospital), Maura McGuire (Johns Hopkins School of Medicine), Jessica Colburn (Johns Hopkins Hospital)
Advance Care Planning (ACP) documentation has been shown to improve quality of end-of-life care, increase compliance with patient preferences, and reduce costs of end-of-life care without increasing mortality. However, studies on barriers to ACP note a need for interventions that routinely integrate ACP into time-pressured clinic workflows.
The purpose of this study is to determine the ability of a Quality Improvement (QI) project focused on clinic workflow to increase rates of: (1) ACP documentation by ≥ 60% among patients 65 years or older, and (2) correct placement of the advance directive in the electronic medical record.
The ACP workflow improvement changes outlined by the QI project were implemented in a primary care practice over a three-month period from January to March 2016. We conducted a cross-sectional chart review with a pre-post analysis of 500 randomly selected charts, with 250 each before and after implementation of the QI project.
Overall, any ACP documentation (including Living Will, Health Care Agent/Power of Attorney, and/or 5 Wishes) increased from 11.6% before implementation of the workflow changes to 27.2% after implementation, representing a greater than 60% increase. MOLST documentation increased from 3.6% to 44% after the workflow changes were implemented, representing one of the largest improvements. Although overall, the percentage of charts with incorrectly placed documentation or documentation without dates was small, we did not find a decrease in these factors compared to charts from the pre-implementation period.
The QI project increased rates of ACP documentation by >60% and most documents (>90%) were entered correctly as outlined by the clinic workflow, but improvement is still needed to decrease the percentage of missing documents and notation without dates. This data presents encouraging results supporting implementation of the clinic workflow outlined by the QI project to other primary care sites in order to address barriers to ACP documentation.
Implications for Patient Care
The success of this QI project supports dissemination of this intervention to other sites. Future directions include implementing strategies to improve the return rate of blank ACP documents given to patients at the visit to be completed at home.