Quality and quality improvement in end-of-life care: Perceptions of hospice providers
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Hospice is both a philosophy of care and a system for delivering care to patients near the end of life. The goals of hospice are to provide comfort care around the process of dying and to support the dying individual and his/her family members. Hospice care focuses not only on physical aspects of care, but also on social, emotional, spiritual, cultural, and ethical aspects. In recent years, there has been increasing interest among clinicians, researchers, and others to improve the quality of care provided through hospice. Yet relatively little research has focused on the perceptions of quality improvement (QI) among hospice staff, even though such perceptions may influence both their engagement in, and the ultimate success of, agencies? QI efforts. The goal of this study was to examine how hospice staff perceive efforts to improve quality of care in the hospice setting. This qualitative study employed an ethnographic and phenomenological approach to elicit narratives and meanings of end-of-life (EOL) care quality and its improvement from 19 directors, nurses, chaplains, and social workers from five hospice agencies in Maryland. Study participants articulated five interrelated meanings of QI: formal processes, learning on the part of hospice providers, changes in documentation to support compliance, ?doing better,? and activities that positively impact patients and families. They agreed that the quality of EOL care can be improved, and, for the most part, their views of QI were positive. Yet they also expressed skepticism about QI efforts. Front-line hospice workers had fairly broad, generalized knowledge regarding the QI efforts of their agencies, but limited familiarity with how those efforts were chosen. Participants reported engaging in improvement activities, although not all of those activities were part of their agencies? formal QI efforts. Furthermore, they identified education as a key mechanism to help them more effectively improve the quality of care they provide. Finally, this study found that participants? perceptions of quality EOL care and QI were linked to their occupational roles, but not to the characteristics of their agencies. Implications of these findings for hospice policy and practice are discussed, as are ideas for future research.