When we think about what makes a good healthcare agency, the magic "Q" word has to be part of the explanation.  To which "Q" word am I referring? To Quality.

We know what it feels like when we experience an agency providing a quality service. How would you describe that feeling?  How would you advise an agency to improve their ability to provide that feeling?

Quality can mean different things in hospice. It can be a quick response to referrals, the loving presence of a volunteer for companionship, or the timely assessment and management of symptoms.  One way to explain quality is to describe the processes involved through measurement of data. Time from referral to admission; fill rate of requests for volunteers; patient-reported symptom burden before and after interventions.  When we want to improve a part of this experience, we need to tap into the art and science known as "performance improvement."

The rest of this post illustrates the use of the Plan-Do-Check-Act model for performance improvement at Transitions HospiceCare.  The Plan-Do-Check-Act model includes:

  • cycles of data collection and planning (Plan)
  • testing of changes (Do)
  • analyzing results (Check)
  • deciding whether to keep the change or do something else (Act)

Most of hospice is provided at a lower billing level called Routine Home Care.  However, when a patient has uncontrolled symptoms and needs more care, a level of care called General Inpatient (GIP) is used to provide more services and bill at a higher rate.  Because of the higher billing rate, agencies need to be sure that the need for these services and the multi-disciplinary care given is documented clearly.  Hospices that don’t document this level of care well are at risk for having payment penalties.

Over the last year, a group of clinicians and leaders have been working on a performance improvement project called "GIP documentation" to look for potential areas to improve GIP documentation, develop education focusing on those areas for clinicians, and improve documentation as a result.

First the group met to discuss the problem, identify a way to measure current performance, and brainstorm ideas for how to improve.

Plan-Do-Check-Act cycles:

  • Developed a GIP-focused audit tool and conducted a baseline audit
  • Analyzed results and used them to develop in-person education events and written materials for clinicians (nurses, volunteers, Hospice Home staff)
  • Re-audited to check on results
  • Planned more targeted education events, incorporated a "pocket card" with GIP info for community partners
  • Refocus a third round of auditing on Hospice Field/Hospital GIP stays
  • Staffing change: Social worker liaison assigned to WakeMed
  • Shared successes achieved with staff
  • Continued education for staff about GIP documentation


The Hospice Home staff achieved 100% during the second round of auditing.  They are doing an excellent job documenting education provided about GIP, symptoms that cannot be treated in another setting, communication and support from the whole interdisciplinary team, and continued need for GIP! YAY!

The hospice field staff achieved 100% in the third round of auditing in documenting the education they are providing about GIP and discharge planning when relevant, symptoms that cannot be treated in another setting, communication with the whole interdisciplinary team, and continued need for GIP.   We are still looking to reach 100% in supportive notes from social workers and spiritual care counselors and anticipate that staffing with a wonderful social work liaison will help.  The improvements made have been dramatic and sustained! Way to go team!

In addition, the Education Department, Hospice Home staff, and Access Team have come together to create a new education program that will be provided twice yearly, in-person for liaison and Hospice Home staff in order to help keep GIP education current and provide time to share examples from our own patient experiences.

Next Step:

One more round of auditing is in progress to check that performance improvements have been sustained.

by Vicki Q., PI Coordinator
Note from Vicki:  This project represents the work of so many nurses, social workers, spiritual care counselors, auditors, and leaders who took a potential threat (increased focus of external auditors on GIP) and turned it into an opportunity to look at how to provide better education and support for our patients and our clinicians.  Thank you to ALL who have participated and keep up the good work!