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Hospice of the Bluegrass • Lexington, KY
Hospice of the Bluegrass made
an early commitment to hospice
quality reporting. As part of
our strategic goals for 2012, we
provided updates to the board of
directors as well as our executive
management team. With the tone
at the top set, our next challenge
was to educate clinicians on
the NHPCO Comfortable Dying
Measure (NQF 0209) and what
it means to their practice and
workflow.
The quality team (Compliance
Analyst Tim Shockley; Patient
Safety and Infection Control
Nurse Kim Whisman; and
Compliance Coordinator Gale
Hankins) and I were charged
with project implementation, but
success couldn’t be accomplished
without help from the clinical
team, led by Chief Clinical
Officer Deede Byrne. But really,
there isn’t a clinical director,
supervisor, team leader, or
clinician that wasn’t part of the
team. As the saying goes, it takes
a village.
We discussed the measure
regularly at quality meetings,
but also at our clinical director
meetings, team leader meetings
and staff meetings. It was also
part of the annual quality
presentation that was conducted
at each office. That was round
one. Round two was a “train the
trainer” PowerPoint that was
used in each office leading up to
the October 1 deadline.
Additionally, we supplied staff
with cheat sheets, flowcharts,
decision trees, electronic
medical record screenshots and
internally-developed FAQs.
Since communication about
patient needs is handled
differently in our rural offices
which have fewer staff,
leadership chose not to be
prescriptive about each office’s
“hand-off communications”
process. Instead, we encouraged
each office to use its established
communications system—why
change it if it already works?
In the month prior to the
October 1 deadline, we tested
our electronic forms, reports and
clinical processes. A centralized
tracking tool was maintained
in the quality department.
Reminder e-mails and voice
mails were spearheaded by our
compliance analyst. Through
these communications, it
became evident that each
office was using some sort
of tracking system to keep
up with admissions and the
measure’s questions, so the
quality department created an
individualized tracking tool for
each office’s use.
Eugenia Smither,
RN, BS, CHC, CHE, CHP
Corporate Compliance Officer
Vice President of Compliance
and Quality Improvement
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