Barriers and Facilitators of Using Quality Improvement To Foster Locally Initiated Innovation in Palliative Care Services in India.

BACKGROUND: Quality improvement (QI) methods represent a vehicle for fostering locally initiated innovation cycles. We partnered with palliative care services from seven diverse practice settings in India to foster locally initiated improvement projects. OBJECTIVE: To evaluate the implementation experiences of locally initiated palliative care improvement projects at seven diverse sites and understand the barriers and facilitators of using QI to improve palliative care in India. PARTICIPANTS: We use a quota sampling approach to capture the perspectives of 44 local stakeholders in each of the following three categories (organizational leaders, clinic leaders, and clinical team members) through a semi-structured interview guide informed by the consolidated framework for implementation research (CFIR). We use standard qualitative methods to identify facilitators and barriers to using QI methods in seven diverse palliative care contexts. RESULTS: Across all sites, respondents emphasized the following factors important in the success of quality improvement initiative: leveraging clinic level data, QI methods training, provider buy-in, engaged mentors, committed leadership, team support, interdepartmental coordination, collaborations with other providers, local champions, and having a structure for accountability. Barriers to using QI methods to improve palliative care services included lack of designated staff, high patient volume, resources, patient population geographic constraints, general awareness and acceptance of palliative care, and culture. CONCLUSIONS: Empowering local leaders and medical personnel to champion, design, and iterate using QI methods represents a promising powerful tool to spread palliative care services in developing countries.

Early Referral to Palliative Care for Advanced Oral Cancer Patients: A Quality Improvement Initiative in Oncology Center at All India Institute of Medical Sciences.

OBJECTIVES: Oral cancers have high epidemiologic burden in India, and most oral cancer patients at the All India Institute of Medical Sciences present in advanced stages. Their symptomatic needs are often not adequately addressed and the referrals to palliative medicine clinic are for severe pain or terminal stages. Using quality improvement methods, we aimed to provide early referral to palliative care for advanced oral cancer patients. MATERIALS AND METHODS: Duration (number of days) between registration at the head-and-neck cancer clinic and referral to palliative medicine clinic at baseline and postinterventions. Interventions: Understanding current perceptions of oncologists for referral to palliative medicine clinic, educating them through departmental meetings, fostering clinician and patient-family awareness through pamphlets, defining process and screening guidelines for referral, including symptom burden charts in head-and-neck cancer clinic notes, soliciting regular feedback from oncologists at review meetings. RESULTS: The number of days for the referral to the palliative medicine clinic decreased from an average of 48 days to 13 days in 6 months. CONCLUSION: A multicomponent intervention included oncologists and patients and families, education, workflow modification, standardized assessment, documentation, and clinician feedback, and succeeded in improving the timeliness of palliative care referrals of advanced oral cancer patients.

Epilogue: Reflections from International Mentors of the Quality Improvement Training Programme in India.

The article collates the narratives of experiences of the international faculty who mentored the quality improvement teams from India since 2017.

Role of Early Palliative Care in Advanced Head-and-Neck Cancers Patients.

Head-and-neck cancers (HNCs) are significant in India. Poverty, illiteracy, lack of access to healthcare, and poor treatment infrastructure pose a major challenge in the management of these cancers. The majority of these patients present with advanced stage and are not amenable to curative treatment. The majority have the potential to benefit from palliative care (PC) interventions. Our experience has been that usually the referrals from HNC clinic for PC are at the end-of-life or terminal stage. Unfortunately, in the state of intractable suffering, it is difficult for patients to understand and fully benefit from the role of PC. Developing an effective working relationship and communication between the PC service and referring surgeons or oncologists is a key to foster more timely, appropriate referral, as both patients and clinicians often misunderstand or fail to recognize the role of PC. In preparation for a quality improvement project to improve access to PC for HNC patients at the All India Institute of Medical Sciences, we reviewed the needs, challenges, conceptual models, and potential of early integration of PC in advanced HNC patients.

Timely Assessment of Breathing-Related Distress in Community Palliative Care: A Multidisciplinary Collaborative Quality Improvement Project.

Background: Breathlessness is a common symptom for palliative patients that can cause distress and decrease function and quality of life. Palliative care services in Australia aim to routinely assess patients for breathing-related distress, but timely reassessment is not always achieved. Objective: To improve the timeliness of breathlessness reassessment in a home-based community palliative care service in New South Wales for people with moderate-to-severe breathing-related distress. Breathing-related distress was defined as a Symptom Assessment Score for "breathing problems" of four or more. Methods: This collaborative quality improvement (QI) project between SPHERE Palliative Care CAG, Stanford University mentors, and a Sydney metropolitan specialist palliative care service included a: (1) retrospective chart audit; (2) cause and effect analyses using a fishbone diagram; (3) development and implementation of key drivers and interventions; and (4) a pre-and-post evaluation of the timeliness of reassessment of breathing-related distress and changes in Symptom Assessment Scale scores for "breathing problems." Results: Key interventions included multidisciplinary education sessions to facilitate buy-in, with nurses as case managers responsible for breathlessness reassessment and documentation of scores, access and training in electronic palliative care data entry software, fortnightly monitoring and reporting of breathing-related distress scores, and development of an educational flowchart. The proportion of patients reassessed within seven days of an initial nursing assessment of moderate-to-severe breathing-related distress increased from 34% at baseline to 92% at six months. Conclusion: A local QI project increased the proportion of patients with a timely reassessment of their breathing-related distress in a community palliative care service.

The Palliative Care-Promoting Access and Improvement of the Cancer Experience (PC-PAICE) Project in India: A Multisite International Quality Improvement Collaborative.

Mentors at seven U.S. and Australian academic institutions initially partnered with seven leading Indian academic palliative care and cancer centers in 2017 to undertake a program combining remote and in-person mentorship, didactic instruction, and project-based learning in quality improvement (QI). From its inception in 2017 to 2020, the Palliative Care-Promoting Accesst and Improvement of the Cancer Experience Program conducted three cohorts for capacity building of 22 Indian palliative care and cancer programs. Indian leadership established a Mumbai QI training hub in 2019 with philanthropic support. In 2020, the project which is now named Enable Quality, Improve Patient care - India (EQuIP-India) focuses on both palliative care and cancer teams. EQuIP-India now leads ongoing Indian national collaboratives and training in QI and is integrated into India's National Cancer Grid. Palliative Care-Promoting Accesst and Improvement of the Cancer Experience demonstrates a feasible model of international collaboration and capacity building in palliative care and cancer QI. It is one of the several networked and blended learning approaches with potential for rapid scaling of evidence-based practices.