Utilization of EHR to Support Joint Commission Advance Palliative Certification Performance Measures

Topic: Leveraging Technology


Trinitas Regional Medical Center (TRMC) received the initial Joint Commission Certification in Advanced Palliaitve Care in 2013 and redesignation in 2015. As a Joint Commission certified program, we are held to a set of standards and is required to collect and analyze data. The performance measure selected have to be evidence-based, relevant valid and reliable (www.jointcommission.org).

The Palliative Care Team collaborated with the Informatics Nurses of TRMC to explore our EHR in designing clinical documentation that will support the Palliative Care (PC) performance measures.

There are four performance measures that the program has to monitor.

  1. Documentation of family meetings
  2. Documented decrease in pain score
  3. Improvement in the dyspnea assessment of patients, and
  4. Patient satisfaction-this measure was excluded in this EHR project.  Patient satisfaction is measured by evaluating the survey responses received from discharged patient who had PC consult

A family meeting template was designed as a structured note that meets the needs of PC team. TRMC adapted two evidence-based tools; (1) The Adult Non-Verbal Pain Scale (ANVPS), and (2) the Respiratory Ditress Observation Scale RDOS (Campbell & Walch, 2010). The clinical documentation in the EHR was modified and designed to accommodate these clinical assessment tools..

On July 2013, the documentation of family meeting in the EHR was piloted in the intensive care unit (ICU).  The family meeting template was initially used by the PC Nurse, and eventually expanded to the medical residents, physicians, and the ICU nursing staff.  The project rolled out to the oncology and geriatric unit first, then to the rest of the medical surgical units. Our data showed the progressive increase in the documentation of family meetings from our inception to present time. Our baseline data was 20%% in 2009. After the implementation, the initial documentation rate was 43%, 3rd quarter 2013

TRMC adapted an evidence-based tool to assess respiratory distress for patients who are unable to self-report. On August 2013, RDOS was first implemented in ICU. RDOS enables the clinician to assess and document patient's respiratory distress using a standardized tool. Review of documentation enables us to analyze and monitor symptom improvement.

Ongoing monitoring of pain assessment and documentation is a hospital wide performance improvement activity. TRMC adapted the ANVPS and retired the previous scale used for non-verbal patients. On August 2013, the ANVPS was first utilized in the ICU for non-verbal incubated/sedated patients.


  • Campbell,  M.L.. & Walch,,,  J.  (2010). A respiratory distress observation scalefor patients unable to self-report dyspnea. Journal. Of Palliative Medicine. Vol 13,, No. 3.
  • Performance Measurement Requirements for Palliative Care.  Retrieved on July 28, 2016 https://www.jointcommission.org/certification/performance_measurement_requirements_palliative_care.aspx



  • Clare Cruz, MSN, RN, BC
  • Geraldine Cruz, MSN, CHPN, CCRN
  • Hana Baudendistel, MS, BSN, NE-BC

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