Stanford University Medical Center Description

Stanford University Medical Center (SUMC) is an academic, 400+ bed tertiary care hospital located in northern California. A 1998 survey of our hospital staff indicated that the majority felt uncomfortable discussing end-of-life care issues and caring for these patients. A planning group in 2006 developed a 3-year business plan with hospital funding for an inpatient palliative care consultation team, a ½ day outpatient palliative care clinic, and a palliative medicine fellow. Major incentives for developing a palliative care service included the new status as a comprehensive cancer center and the hope that the service would help with patient flow, decrease lengths of stay, and decrease costs. The initial phase was implemented in August 2007 with an inpatient hospital-wide consult service; in conjunction with our affiliated VA program, fellows now routinely rotate on the service.

Description of Topic

Though palliative care was a new service to SUMC, there had been a robust palliative care program at our VA affiliate, the Palo Alto VA Health Care System (PAVA). PAVA had had an active inpatient consult service, an inpatient palliative care unit, and a palliative care clinic for 7+ years. Multiple physicians and house staff shared time between the two hospitals. For SUMC, we used CAPC formulas in the business plan to help "make the case" and create a framework for consult volume and staffing. This included a "ramp-up" phase in the first 6 months, during which there would be a gradual increase in the number of consults. We found that the actual consult volume for the first month was almost double what was estimated and has since regularly exceeded the expected volume for each month through the first year-i.e., there was no ramp-up in the traditional sense.

Impact on Program

Our fledgling team had to quickly learn to manage a larger-than-anticipated census and a steady stream of new consults, while developing operations and team-building for a brand new service. As we were in danger of not meeting consult requests and burning out even as we were just beginning, we met with our advisors and developed strategies to respond to this challenge:

• Utilization of daily multidisciplinary meetings for triaging and work flow.
• Incorporation of outside administrative staff to assist with metrics.
• Establishment of a comfort care order set as a tool to be used by primary clinicians.
• Periodic team-building sessions.

Lessons Learned

• The existence of a mature program at an affiliate hospital created a pool of clinicians who valued and already knew how to utilize a palliative care consult service.
• Our challenge was not how to "ramp up" but was how to manage strong demand from day one.
• While internal marketing was important for senior physicians and other clinicians, such marketing was not required for house staff, who initiated the bulk of the consults.
• The pool of house staff familiar with palliative care through their VA experience became allies in marketing to other clinicians and promoting palliative care. They modeled and taught other clinicians how to use our service.