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How to implement quality indicators successfully in palliative care services: perceptions of team members about facilitators of and barriers to implementation

Supportive Care in Cancer volume 23, pages 3503–3511 (2015)Cite this article

Abstract

Purpose

There is an increasing demand for the use of quality indicators in palliative care. With previous research about implementation in this field lacking, we aimed to evaluate the barriers to and facilitators of implementation.

Methods

Three focus group interviews were organized with 21 caregivers from 18 different specialized palliative care services in Belgium. Four had already worked with the indicators during a pilot study. The focus group discussions were transcribed verbatim and analyzed using the thematic framework approach.

Results

The caregivers anticipated that a positive attitude by the team towards quality improvement, the presence of a good leader, and the possible link between quality indicators and reimbursement might facilitate the implementation of quality indicators in specialized palliative care services. Other facilitators concerned the presence of a need to demonstrate quality of care, to perform improvement actions, and to learn from other caregivers and services in the field. A negative attitude by caregivers towards quality measurement and a lack of skills, time, and staff were mentioned as barriers to successful implementation.

Conclusion

Palliative caregivers anticipate a number of opportunities and problems when implementing quality indicators. These relate to the attitudes of the team regarding quality measurement; the attitudes, knowledge, and skills of the individual caregivers within the team; and the organizational context and the economic and political context. Training in the advantages of quality indicators and how to use them is indispensable, as are structural changes in the policy concerning palliative care, in order to progress towards systematic quality monitoring.

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References

  1. Bowman KW, Martin DK, Singer PA (2000) Quality end-of-life care. J Eval Clin Pract 6(1):51–61

    CAS  Article  PubMed  Google Scholar 

  2. Lorenz KA, Lynn J, Dy SM, Shugarman LR, Wilkinson A, Mularski RA et al (2008) Evidence for improving palliative care at the end of life: a systematic review. Ann Intern Med 148(2):147–59

    Article  PubMed  Google Scholar 

  3. Rosenfeld K, Wenger NS (2000) Measuring quality in end-of-life care. Clin Geriatr Med 16(2):387–400

    CAS  Article  PubMed  Google Scholar 

  4. Palliative care: a model for innovative health and social policies, 1649, Council of Europe (2009)

  5. Dy SM, Lupu D, Seow H (2012) Progress towards systems of quality measurement that capture the essence of good palliative care. Palliat Med 26(4):291–3

    Article  PubMed  Google Scholar 

  6. Ferrell B, Connor SR, Cordes A, Dahlin CM, Fine PG, Hutton N et al (2007) The national agenda for quality palliative care: the National Consensus Project and the National Quality Forum. J Pain Symptom Manag 33(6):737–44

    Article  Google Scholar 

  7. Eagar K, Watters P, Currow DC, Aoun SM, Yates P (2010) The Australian Palliative Care Outcomes Collaboration (PCOC)—measuring the quality and outcomes of palliative care on a routine basis. Aust Health Rev 34(2):186–92

    Article  PubMed  Google Scholar 

  8. Lundstrom S, Axelsson B, Heedman PA, Fransson G, Furst CJ (2012) Developing a national quality register in end-of-life care: the Swedish experience. Palliat Med 26(4):313–21

    Article  PubMed  Google Scholar 

  9. World Health Organisation (2006) Quality of care: a process for making strategic choices in health systems. WHO Press, Geneva

    Google Scholar 

  10. Campbell SM, Braspenning J, Hutchinson A, Marshall MN (2003) Research methods used in developing and applying quality indicators in primary care. BMJ 326(7393):816–9

    PubMed Central  CAS  Article  PubMed  Google Scholar 

  11. Ostgathe C, Voltz R (2010) Quality indicators in end-of-life care. Curr Opin Support Palliat Care 4(3):170–3

    Article  PubMed  Google Scholar 

  12. Shekelle PG, Maclean CH, Morton SC, Wenger NS (2001) Assessing care of vulnerable elders: methods for developing quality indicators. Ann Intern Med 135(8 Pt 2):647–52

    CAS  Article  PubMed  Google Scholar 

  13. Singer PA, Martin DK, Bowman K (2000) Quality end-of-life care: where do we go from here? J Palliat Med 3(4):403–5

    CAS  Article  PubMed  Google Scholar 

  14. Earle CC, Park ER, Lai B, Weeks JC, Ayanian JZ, Block S (2003) Identifying potential indicators of the quality of end-of-life cancer care from administrative data. J Clin Oncol 21(6):1133–8

    Article  PubMed  Google Scholar 

  15. Grunfeld E, Urquhart R, Mykhalovskiy E, Folkes A, Johnston G, Burge FI et al (2008) Toward population-based indicators of quality end-of-life care: testing stakeholder agreement. Cancer 112(10):2301–8

    PubMed Central  Article  PubMed  Google Scholar 

  16. Sato K, Miyashita M, Morita T, Sanjo M, Shima Y, Uchitomi Y (2008) Reliability assessment and findings of a newly developed quality measurement instrument: quality indicators of end-of-life cancer care from medical chart review at a Japanese regional cancer center. J Palliat Med 11(5):729–37

    Article  PubMed  Google Scholar 

  17. Seow H, Snyder CF, Shugarman LR, Mularski RA, Kutner JS, Lorenz KA et al (2009) Developing quality indicators for cancer end-of-life care: proceedings from a national symposium. Cancer 115(17):3820–9

    Article  PubMed  Google Scholar 

  18. Pastrana T, Radbruch L, Nauck F, Hover G, Fegg M, Pestinger M et al (2009) Outcome indicators in palliative care—how to assess quality and success. Focus group and nominal group technique in Germany. Support Care Cancer 18(7):859–868

    PubMed Central  Article  PubMed  Google Scholar 

  19. Claessen SJ, Francke AL, Belarbi HE, Pasman HR, van der Putten MJ, Deliens L (2011) A new set of quality indicators for palliative care: process and results of the development trajectory. J Pain Symptom Manag 42(2):169–82

    Article  Google Scholar 

  20. de Roo ML, Leemans K, Claessen SJ, Cohen J, Pasman HR, Deliens L et al (2013) Quality indicators for palliative care: update of a systematic review. J Pain Symptom Manag 46(4):556–72

    Article  Google Scholar 

  21. Leemans K, Cohen J, Francke AL, Vander Stichele RV, Claessen SJ, van den Block L et al (2013) Towards a standardized method of developing quality indicators for palliative care: protocol of the Quality Indicators for Palliative Care (Q-PAC) study. BMC Palliat Care 12(1):6

    PubMed Central  Article  PubMed  Google Scholar 

  22. Leemans K, Deliens L, Francke AL, Vander Stichele R, van den Block L, Cohen J (2015) Quality indicators for palliative care services (Q-PAC): mixed methods study testing for face validity, feasibility, discriminative power and usefulness. Palliat Med 29(1):71–82

    Article  PubMed  Google Scholar 

  23. Meiland FJ, Droes RM, de Lange J, Vernooij-Dassen MJ (2004) Development of a theoretical model for tracing facilitators and barriers in adaptive implementation of innovative practices in dementia care. Arch Gerontol Geriatr Suppl 9:279–90

    Article  PubMed  Google Scholar 

  24. Meiland FJ, Droes RM, de Lange J, Vernooij-Dassen MJ (2005) Facilitators and barriers in the implementation of the meeting centres model for people with dementia and their carers. Health Policy 71(2):243–53

    Article  PubMed  Google Scholar 

  25. Grol R, Wensing M (2011) Implementatie: effectieve verbetering van de patiëntenzorg. vierde herziene druk ed. Reed Business, Amsterdam

    Google Scholar 

  26. Grol R, Wensing M (2004) What drives change? Barriers to and incentives for achieving evidence-based practice. Med J Aust 180(6 Suppl):S57–S60

    PubMed  Google Scholar 

  27. de Vos ML, van der Veer SN, Graafmans WC, de Keizer NF, Jager KJ, Westert GP et al (2010) Implementing quality indicators in intensive care units: exploring barriers to and facilitators of behaviour change. Implement Sci 5:52

    PubMed Central  Article  PubMed  Google Scholar 

  28. Vasse E, Spijker A, Meiland F, Rikkert MO, Moniz-Cook E, Vernooij-Dassen M (2012) Barriers and facilitators in implementing quality indicators for psychosocial dementia care in European countries. In: Vasse E (ed) A stepwise process for developing and implementing quality indicators to improve psychosocial dementia care in European countries. Uitgeverij BOXpress, Nijmegen

    Google Scholar 

  29. Emanuel EJ, Emanuel LL (1998) The promise of a good death. Lancet 351(Suppl 2):SII21–SII29

    Article  PubMed  Google Scholar 

  30. Singer PA, Martin DK, Kelner M (1999) Quality end-of-life care: patients’ perspectives. JAMA 281(2):163–8

    CAS  Article  PubMed  Google Scholar 

  31. Steinhauser KE, Clipp EC, McNeilly M, Christakis NA, McIntyre LM, Tulsky JA (2000) In search of a good death: observations of patients, families, and providers. Ann Intern Med 132(10):825–32

    CAS  Article  PubMed  Google Scholar 

  32. Teno JM, Casey VA, Welch LC, Edgman-Levitan S (2001) Patient-focused, family-centered end-of-life medical care: views of the guidelines and bereaved family members. J Pain Symptom Manag 22(3):738–51

    CAS  Article  Google Scholar 

  33. Morgan D, Krueger R (1998) Planning focus groups. Series: focus group kit. SAGE Publications, Thousand Oaks

    Book  Google Scholar 

  34. Pope C, Ziebland S, Mays N (2000) Qualitative research in health care. Analysing qualitative data. BMJ 320(7227):114–6

    PubMed Central  CAS  Article  PubMed  Google Scholar 

  35. Addington D, Kyle T, Desai S, Wang J (2010) Facilitators and barriers to implementing quality measurement in primary mental health care: systematic review. Can Fam Physician 56(12):1322–31

    PubMed Central  PubMed  Google Scholar 

  36. Antunes B, Harding R, Higginson IJ (2014) Implementing patient-reported outcome measures in palliative care clinical practice: a systematic review of facilitators and barriers. Palliat Med 28(2):158–75

    Article  PubMed  Google Scholar 

  37. Duncan EA, Murray J (2012) The barriers and facilitators to routine outcome measurement by allied health professionals in practice: a systematic review. BMC Health Serv Res 12:96

    PubMed Central  Article  PubMed  Google Scholar 

  38. Hughes RG (2008) Tools and strategies for quality improvement and patient safety. In: Patient safety and quality: an evidence-based handbook for nurses. Agency for Healthcare Research and Quality, Rockville

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Acknowledgments

We thank all caregivers for their cooperation in the study. We thank Jane Ruthven for her help in language editing the manuscript. This study is realized with the support of Kom Op Tegen Kanker, a campaign of The Flemish League Against Cancer. The study is part of the Flanders Study to Improve End-of-Life Care and Evaluation Tools (FLIECE project), a collaboration between the Vrije Universiteit Brussel, Ghent University, the Katholieke Universiteit Leuven, Belgium, and VU University Medical Center Amsterdam, the Netherlands. Joachim Cohen and Lieve Van den Block are postdoctoral fellows of the Research Foundation Flanders.

Conflict of interest

The authors declare that there is no conflict of interest.

Author information

Affiliations

  1. End-of-Life Care Research Group Vrije Universiteit Brussel (VUB) and Ghent University, Laarbeeklaan 103, 1090, Brussels, Belgium

    Kathleen Leemans, Lieve Van den Block, Robert Vander Stichele, Luc Deliens & Joachim Cohen

  2. Department of Family Medicine and Chronic Care, Vrije Universiteit Brussel (VUB), Brussels, Belgium

    Lieve Van den Block

  3. Heymans Insitute, Department of Pharmacology, Ghent University, Ghent, Belgium

    Robert Vander Stichele

  4. Department of Public and Occupational Health, EMGO Institute for Health and Care Research, VU University Medical Center, Amsterdam, The Netherlands

    Anneke L. Francke & Luc Deliens

  5. NIVEL. Netherlands Institute for Health Services Research, Utrecht, The Netherlands

    Anneke L. Francke

Authors
  1. Kathleen Leemans
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  2. Lieve Van den Block
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  3. Robert Vander Stichele
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  4. Anneke L. Francke
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  5. Luc Deliens
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  6. Joachim Cohen
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Corresponding author

Correspondence to Kathleen Leemans.

Additional information

Luc Deliens and Joachim Cohen contributed equally as last authors

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Leemans, K., Van den Block, L., Vander Stichele, R. et al. How to implement quality indicators successfully in palliative care services: perceptions of team members about facilitators of and barriers to implementation. Support Care Cancer 23, 3503–3511 (2015). https://doi.org/10.1007/s00520-015-2687-8

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  • DOI: https://doi.org/10.1007/s00520-015-2687-8

Keywords

  • Quality indicators
  • Palliative care
  • Quality assessment
  • Quality improvement
  • Incentives
  • Disincentives
  • Qualitative research