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CAPC Palliative Care Discussion Forum
Data Collection and Measurement

Next Reply: Re:Tool for Retrospective Review of Goals of Care
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Post Tool for Retrospective Review of Goals of Care
Author: pennyholt
Date: Apr 24, 2012 2:45 pm
I am looking for a quality measurement tool for retrospective chart review. We will be measuring the development, implementation and communication of the goals of care for our inpatient palliative care patients. Any help would be greatly appreciated.

Penny Holt, MSN RN
Clinical Coordinator
Winchester Medical Center
Winchester, Virginia
Replies: order by [Date] [Author] [Subject]
Re:Tool for Retrospective Review of Goals of Care (by sjcrump on 05/21/2012)
Dear Penny: The tool to use will largely depend on what you mean by goals of care. Is it assessment of expectations and hopes? Is it a prioritization of wishes? Is it a realization of self-determination? The research tools that I am aware of will vary based on what the researcher values. This is true of quality of life surveys as well. To state it provocatively, most of my patients have the same goals of care: longer life and better life. What our service is trying to do is realistically give expectations of the limits of medicine and care as best we can for our patients' needs.

Response on behalf of Ryan R. Nash, MD, MA
Assistant Professor
Palliative Care Leadership CentersTM
UAB PCLC Director
UAB Center for Palliative and Supportive Care
Posted per Sandra Joyce Crump, Program Manager
Re:Tool for Retrospective Review of Goals of Care (by sjcrump on 05/21/2012)
Dear Penny: It sounds to me like you have identified that you would like "goals of care" to be a quality indicator that you track and are trying to determine how to best do that? If you wish to assess the development of goals of care, the element that you can readily measure in a chart abstraction is documentation of goals of care discussion. For this, your chart abstraction tool should have queries that allow the abstractors to identify the presence or absence of documentation of these discussions. You may wish to achieve more granularity by discreetly querying regarding goals of care about "place of death" or "artificial nutrition and hydration". It will be easiest for you to enter and analyze the data if you create your tool so that your abstractor is entering numeric variables rather than string variables – in short, avoid "fill in the blank" questions on the abstraction tool. To assess "implementation" of goals of care you would need to measure something with regard to whether the goals of care and care plan match, or whether the care plan changed as new goals of care were documented. You would want to be as specific as possible with regard to what counts as a change in care plan. Documenting communication of goals of care is a little more straightforward. In a chart abstraction, your tool should query whether goals of care are explicitly communicated in the care plan, and you abstractor should be trained with regard to interpretation of the medical record in this regard. The project as you are proposing it is dauntingly complex. It would be simpler to utilize documentation of goals of care as an indicator, since you know they have to be developed before they can be documented. If you wish to do this as a formal QI project, you could 1. benchmark levels of documentation of goals of care, 2. offer training that focuses on the development, implementation, and documentation of goals of care, and 3. Measure the impact of this training on levels of documentation of goals of care with a post-training chart abstraction. The tool that you need develop to accomplish this will be much less burdensome. We do not have a chart abstraction tool specific to this question, but in most instances, unlike tools for measuring patient reported outcomes, chart abstraction tools are developed to meet the needs a specific project like the one you are proposing.
Response on behalf of Elizabeth Kvale MD
Assistant Professor
Med. Dir. UAB Palliative & Supportive Care Outpatient Services
Posted per Sandra Joyce Crump, Program Manager

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