Administrative Memos

199914

FROM: Theodore O. Will, Chief Executive Officer
DATE: Sep 22, 1999
SUBJECT: The Impact of an Advance Directives Quality Improvement Project in New York State
IPRO CONTACTS:

Marguerite Shaffer, R.N., Director Downstate, Improvement Strategies QI - Ext. 356 and Barbara Shields, R.N., Director Upstate, Improvement Strategies, (1-800-233-0360)

Enclosed is a copy of IPRO's report "The Impact of an Advance Directives Quality Improvement Project in New York State". This report describes the significant impact that was achieved after interventions were implemented by IPRO, various partnering organizations, and numerous hospitals across New York State. The purpose of these interventions was to improve the quality and quantity of patient education provided about advance directives as well as increasing the utilization of advance directives.

One particularly comprehensive intervention was the distribution of an "Advance Directives Quality Improvement Interventions Manual" which contained educational materials for both patients and staff, intervention suggestions, communication and public relation information, and best practice tools and protocols. Efforts were focused on two distinct patient populations, congestive heart failure (CHF) and elective surgery patients (total hip or total knee replacement). Statistically significant improvements in quality indicators were noted for each patient group.

Among the specific improvements noted in this project were the following:

• Statistically significant improvements in quality indicators reflecting patient involvement in advance directive decision making (increased from 31% to 39%) and statutory authority of advance directives prior to admission (PTA) in New York State (increased from 25% to 32%) were noted in the CHF patient group.
• Statistically significant improvements in quality indicators reflecting patient information provided about advance directives on admission (increased from 64% to 84%), and patient information provided about advance directives before discharge and death (increased from 70% to 86%) were noted in the elective surgery patient group.
• A statistically significant improvement in the quality indicator reflecting an opportunity for patient discussion about advance directives was noted in both the CHF group (increased from 34% to 47%) and the elective surgery group (increased from 18% to 55%).

Should you have any questions about this report or project, please feel free to call one of the above-mentioned contacts.

EXECUTIVE SUMMARY

Advance directives are written instructions relating to the provision of health care when adult individuals are unable to communicate their wishes regarding medical treatment. Relevant federal law under the Patient Self-Determination Act (PSDA) requires that a wide range of institutions maintain written policies and procedures about advance directives and provide required information to patients at the time of admission to the facility. Advance directives are also regulated under state law. New York State's Health Care Proxy law provides statutory immunity to providers who follow a proxy's directives in good faith.

To promote improved hospital compliance with the PSDA, increased patient understanding of advance directives, improved communication between health care workers and patients about end-of-life decision making, and improved access to advance directives, IPRO conducted a quality improvement study on advance directives. Fifty-eight hospitals collaborated on this study, of which 40 focused on CHF patients and 18 on elective surgery patients. Both individual and aggregate baseline reports emphasizing the measurements of 10 quality indicators were disseminated in 1998. This report represents the remeasurement of these quality indicators after a period of active intervention.

Interventions included the release of an "Advance Directives Quality Improvement Interventions Manual" authored by IPRO, partnering with the Hospital Association of New York State (HANYS) and the Voluntary Hospital Association (VHA) on a wallet card health care proxy form and physician survey, a multimedia educational campaign, conferences and presentations throughout New York State, and individual hospital-specific quality improvement plan recommendations and encouragement.

The remeasurement of the quality indicators took place for the time period of December 1, 1998 - February 28, 1999. In almost all cases quality indicators improved and many showed statistically significant improvement. Among the major findings of this impact study were the following:

• Statistically significant improvements in quality indicators reflecting patient involvement in advance directive decision making (increased from 31% to 39%) and statutory authority of advance directives PTA in New York State (increased from 25% to 32%) were noted in the CHF patient group.
• Statistically significant improvements in quality indicators reflecting patient information provided about advance directives on admission (increased from 64% to 84%), and patient information provided about advance directives before discharge and death (increased from 70% to 86%) were noted in the elective surgery patient group.
• A statistically significant improvement in the quality indicator reflecting an opportunity for patient discussion about advance directives was noted in both the CHF group (increased from 34% to 47%) and the elective surgery group (increased from 18% to 55%).