Implementing a Care Planning System: How to Fix the Most Pervasive Errors in Health Care

  • Bernard J. Hammes
  • Linda A. Briggs
  • William Silvester
  • Kent S. Wilson
  • Sue Schettle
  • John R. Maycroft
  • Julie Sandoval
  • Ann E. Orders
  • Melissa Stern
Part of the Aging Medicine book series (AGME)


Serious errors can be made when health professionals do not know or fail to honor patients’ treatment preferences. Such errors are often avoidable when an effective advance care planning (ACP) system is in place. The design elements of a successful ACP model originating and implemented in La Crosse, Wisconsin, as well as large-scale rollouts of that system in Australia, Minneapolis/St. Paul, Kaiser Permanente in Northern California, and elsewhere in Wisconsin are described. Finally, the ways in which this ACP system improves care and how it aligns with other current efforts to improve care for patients and their families are explored.


Advance Directive Advance Care Planning Twin City Patient Education Material Planning Discussion 
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Copyright information

© Springer Science+Business Media New York 2014

Authors and Affiliations

  • Bernard J. Hammes
    • 1
  • Linda A. Briggs
    • 2
  • William Silvester
    • 3
  • Kent S. Wilson
    • 4
  • Sue Schettle
    • 5
  • John R. Maycroft
    • 6
  • Julie Sandoval
    • 7
  • Ann E. Orders
    • 8
  • Melissa Stern
    • 9
  1. 1.Gundersen Health SystemLa CrosseUSA
  2. 2.Gundersen Health SystemLa CrosseUSA
  3. 3.International Society of Advance Care Planning and End of Life CareMelbourneAustralia
  4. 4.Honoring Choices MinnesotaMinneapolisUSA
  5. 5.Twin Cities Medical SocietyMinneapolisUSA
  6. 6.Wisconsin Medical SocietyMadisonUSA
  7. 7.The Permanente Medical GroupOaklandUSA
  8. 8.Continuum of Care and Health Care ReformKaiser PermanentePasadenaUSA
  9. 9.Life Care PlanningKaiser PermanentePasadenaUSA

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