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Stand Up Stand Out: Baylor Scott & White

Posted By Joanna Carmona, Tuesday, June 27, 2017

Stand Up Stand Out is an occasional feature on the blog highlighting the work of organizations that belong
to the NPSF Stand Up for Patient Safety program. In this post, read about what one Texas health system 

is doing to improve palliative care. 


Baylor Scott & White Health, a not-for-profit health system based in Texas, is a founding member of the IHI/NPSF Stand Up for Patient Safety program and has recently partnered with Ariadne Labs to roll out their Serious Illness Conversation and Care Planning Program across their system. Robert L. Fine, MD, FACP, FAAHPM, Clinical Director, Office of Clinical Ethics and Palliative Care at Baylor Scott & White Health, spoke to us about the genesis of the palliative care movement and how the program has initially influenced patient safety across their health system. 


Why did Baylor Scott & White partner with Ariadne Labs to implement their

Serious Illness Conversation and Care Planning Program?

The easy answer is that they had a complete, scalable, evidence-based product ready to go to help improve communication between patients and providers.


The deeper story, however, is the collective cumulative experience that led to the development of palliative care in first place. One of the earliest studies to suggest such a need was the SUPPORT study, published in JAMA in 1995. This study involved 9,000 seriously ill patients with a six-month mortality rate of 50% admitted to five major teaching hospitals. These weren’t hospice appropriate patients—at least not on admission—these were people with a 50% chance of survival and, in fact, half did survive. However, for the 50% of patients who died, the study revealed glaring care deficiencies leading to significant confusion about goals of care (with much unwanted treatment provided) and significant suffering. The SUPPORT study thus revealed a special sort of patient safety concern and care deficit.


At the root of this care deficit was poor communication. Many of us focusing on end-of-life care via ethics or hospice consultation came to understand that hospice could not serve patients in common circumstances like those found in the SUPPORT study until very late in the patient’s journey, and ethics consultation could largely work on only the moral dimensions of care. Some other sort of service not necessarily tied to definite terminal illness or ethical uncertainty/discord was required.


The notion of palliative care as distinct from hospice was just starting to evolve at that time and the SUPPORT study lent great credence to the need. In fact, I attempted to start a small palliative care program at Baylor University Medical Center in 1995, but the program was terminated before we could serve our first patients. It would be several more years before we could get our palliative care service line established. Palliative care as a specialty is now growing rapidly, but we’ve all realized that we can’t train palliative care doctors, nurses, and other professionals fast enough to serve every seriously ill patient who might benefit. We must help non-palliative care professionals develop better primary palliative care skills, such as better communication skills.


So, how can we do that? The reality is that busy physicians aren’t going to take a multi-day training to do it and non-palliative care specialty training will never include the intense communication training that is so much of the focus of a palliative medicine fellowship. However, non-palliative care professionals can and will participate in shorter training with role-play exercises over a few hours accompanied by ongoing coaching. BSWH chose the program from Ariadne Labs because they had the evidence-based solution we were looking for.


What does the Serious Illness Conversation and Care Planning Program consist of?

There are three basic components:

  • Tools that provide a scripted checklist approach to guide the clinician who isn’t comfortable with having these types of serious conversations;
  • Education for health care professionals using the tools; and
  • Systems change to help identify appropriate patients and to build the tools into the EMR so that any practitioner can look at the chart and be both guided in the conversation and see what has been previously discussed by others following the same conversational script.

It has been demonstrated that patients and doctors like the tools, it helps make conversations more complete, and the data are retrievable. This is a pretty big systems change and Ariadne has never taken it to a system as big as ours—this will be the first.


How are you rolling the program out across your system?

Systems change and EMR implementation is critical. It would frankly be easier in a system that has one EMR, but at Baylor Scott & White we have two different major EMRs. Another challenge is our sheer size and geographic spread. We are also one of the larger nonprofit systems in the country, the largest in Texas, and we have thousands of physicians, advance practice nurses, and others to be trained.


At the same time that we have been building the necessary tools into our EMRs, we are also training our palliative care experts to train others in the use of the SICP tools and process. I’ve observed that just because a palliative care professional is an expert communicator with patients of families, that doesn’t guarantee they will be an expert trainer, so the notion of “train the trainer” is very important. Each trained facilitator can then train three learners in three hours. Of course, the trainer needs to be available going forward to provide ongoing coaching when needed. It is a bit daunting given our size, but we see it as a perpetual task that we are slowly and deliberately weaving into the fabric of our organization. It is a project in perpetuity and we want this program to be self-sustaining.


What has been the reaction among team members to the new program?

We don’t teach much about end of life in medical school, especially not the differences in communication between those with less serious illnesses versus more serious illnesses, and this training is benefiting both palliative care professionals and those who may not be as comfortable having these conversations. The palliative care professionals, even though already skilled in serious illness conversation, are very excited. Some have said that it has actually shortened their goals-of-care conversations because the script helps to focus the conversations. We are also starting to hear from some early adopter non-palliative care professionals we have trained saying that they don’t need the palliative care team as often to have these conversations. I think some palliative care professionals might see that as a threat, but at BSWH we don’t!


Out in the community of doctors, there are those who haven’t been trained but are excited to be trained ASAP. There are others who feel they don’t have time to learn this right now, but we are working on how to encourage everyone to take the time for trainings.

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How do you think this program will impact patient safety across your system?  

It has already. When it comes to the structural impact, you see it by being able to open up the EMR and having a link at the top of the patient banner directly to the SICP script and answers. All you have to do is click to see what answers the patients gave. This is the beginning of real cultural change.


It is so vitally important because a lot of programs from the mid to late 1990s on have emphasized preventing  bad death, meaning a patient who received unwanted treatment, was separated from their family at death, experienced emotional and spiritual distress, had poorly treated pain, and experienced many other treatment deficits as well. That is a patient safety problem. If death comes, we should ideally provide what I refer to as “safe passage.” For example, if someone says ‘When I die, I want to go to heaven without your machines’ then we ought to be able to know that and offer them a safe passage to heaven or whatever their wishes may be. We use the idea of safe passage frequently with patients and families facing mortality because it is an idea that people get.


We recently had a palliative care physician say to us, "I found all this information that I normally don’t have when I’m consulted. It was in the SICP section of the EMR.  When I was called in as a consultant, the information present allowed me to sit down with the patient and family and say 'Based on the information you gave to your oncologist, I can suggest we do the following…'" The information not only gets to the right person at the right time, but it also gets dispersed to the whole team. We see this program continuing to influence patient safety as time goes on and the amount of trainers and trainees grows.


Read other Stand Up Stand Out stories.


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How does your organization encourage conversations with patients who are experiencing serious illness? Comment on this post below.

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