JOURNAL OF PALLIATIVE MEDICINE Volume 16, Number 8, 2013 ª Mary Ann Liebert, Inc. DOI: 10.1089/jpm.2012.0492
Case Discussions in Palliative Medicine Feature Editor: Craig D. Blinderman
Assessing Patient Care in Palliative Care Using the Healthcare Matrix Joseph Arthur, MD,1 Jung Hye Kwon, MD, PhD,1,3 Suresh Reddy, MD,1 Doris C. Quinn, PhD,2 Eduardo Bruera, MD,1 and David Hui, MD, MSc, FRCPC1
Absract
The healthcare matrix is a novel assessment tool that facilitates systematic examination of patient cases using criteria established by the Accreditation Council for Graduate Medical Education and the Institute of Medicine. It is particularly useful for analyzing complex cases, although its use in the palliative care setting has not been documented. We describe here the use of the healthcare matrix to examine the healthcare encounters of a 63 year-old patient with advanced cancer. The healthcare matrix helped us to dissect the physical, psychosocial, logistical, professional, and ethical aspects of care, and to highlight multiple opportunities for quality improvement. In addition to the case example we will be discussing the advantages and disadvantages for using the healthcare matrix and its potential utility in palliative care.
Introduction
I
n 1999 the Accreditation Council for Graduate Medical Education (ACGME) introduced the six core competencies that physicians in training must be proficient in to ensure high-quality care. These competencies include patient care, medical knowledge, interpersonal and communication skills, professionalism, system-based practice, and patientbased learning and improvement.1 The American Board of Medical Specialties (ABMS) adopted these same competencies as the standards of certification and maintenance of certification for all specialty boards.2 In 2001 the Institute of Medicine (IOM) recommended six aims for improvement, emphasizing the need to ensure that care is safe, timely, efficient, effective, equitable, and patient centered.3 In 2005 Bingham and colleagues developed an assessment tool, the healthcare matrix, which provides a systematic method for examining complex care issues by combining the ACGME/ABMS Core Competencies and the IOM Aims for Improvement.4 This became an important aspect of the quality improvement (QI) training for medical students and residents at Vanderbilt University Medical Center.5,6 The healthcare matrix has since gained increasing popularity over time, and has been used to analyze various cases in psychiatry, anesthesiology, nephrology, neurology, pediatrics, obstetrics, and gynecology.6–8
The healthcare matrix is particularly suited for dissecting the complex cases in palliative care because of the multitude of physical, psychosocial, logistical, professional, interdisciplinary, ethical, and legal concerns in patients with advanced diseases. In addition to quality improvement, this could be a useful tool for palliative care educational programs by helping fellows to dissect the complexity of palliative care. There are no published reports on the use of a healthcare matrix in palliative care. In this article we aim to illustrate the versatility and utility of the healthcare matrix by applying it to analyze a complex case of a patient with advanced cancer. Case We present the case of a 63 year-old man with metastatic adenocarcinoma of the stomach. He initially presented to his primary care physician with worsening intermittent abdominal pain radiating to his sternum. He had a history of coronary artery disease, diabetes mellitus, and depression. He was married and lived with his wife. They had two children together. He used to work as a law enforcement officer. Further work-up with imaging, endoscopy, and biopsy revealed T3N0M0 signet ring cell carcinoma of the stomach. He was subsequently seen at our institution for further management. He received neoadjuvant chemotherapy with two cycles of oxaliplatin and 5-fluorouracil concurrent with radiation, and underwent total gastrectomy. The pathology report showed
1 Department of Palliative Care & Rehabilitation Medicine, 2Office of Performance Improvement, The University of Texas MD Anderson Cancer Center, Houston, Texas. 3 Department of Internal Medicine, Kangdong Sacred Heart Hospital, Hallym University, Seoul, Republic of Korea. Accepted November 9, 2012.
987
988
No
SAFE (Injury or potential for injury)
1
No
TIMELY (Delay in hrs, days, weeks)
2
No
Assessment of care
EFFECTIVE (Evidence-based care and outcomes)
3
No
EFFICIENT (Waste of resources)
4
Patient was instructed to Overuse of Initial ascitic fluid Differences in the revoke hospice, aggressive cytology was negative medical opinions returned to hospital measures and for cancer but the resulted in threat to and underwent many underuse of repeated test confirmed patient care. Surgeon aggressive, costly, and hospice as a recurrence. This caused recommended hospice probably unnecessary result of a delay in medical but medical oncologist procedures inaccurate decision and plan wanted more prognostication of care aggressive treatment INTERPERSONAL The lack of an earlier Miscommunication and AND pre-procedure misunderstanding COMMUNICATION discussion with patient between the intensivist SKILLS9 resulted in a delay and the palliative care of the procedure physician regarding (What must we say?) code status in the ICU resulted in significant conflict and patient’s family’s distress Lack of peer-to-peer communication between medical oncologist and surgical oncologist led to adverse changes to advance care plans and resulted in patient distress 10 PROFESSIONALISM Lack of timely discussion (How must we behave?) and informed consent prior to the procedure
PATIENT CARE7 (Overall assessment) Yes/No MEDICAL KNOWLEDGE and SKILLS8 (What must we know?)
Competencies
Aims
Table 1. Healthcare Matrix: Care of a Patient with Gastric Cancer
Yes
EQUITABLE5 (Gender, ethnicity, race, SES)
(continued)
Patient did not understand the meaning of ‘‘positive margins,’’ in the surgical report. Patient got mixed messages from different physicians regarding his cancer No check-up process during the transfer from one department to another
No
PATIENTCENTERED6 (Preference, needs, values)
989
SAFE (Injury or potential for injury)
1
3
EFFECTIVE (Evidence-based care and outcomes) Assessment of care
EFFICIENT (Waste of resources)
4
EQUITABLE5 (Gender, ethnicity, race, SES)
Improved communication is needed between patient and clinicians and among clinicians A thorough review of the informed consent should be done ahead of every procedure
PATIENTCENTERED6 (Preference, needs, values)
ª2004 Bingham, Quinn 1 Safe: Avoiding injuries to patients from the care that is intended to help them. 2 Timely: Reducing waits and sometimes harmful delays for both those who receive and those who give care. 3 Effective: Providing services based on scientific knowledge to all who could benefit and refraining from providing services to those not likely to benefit (avoiding underuse and overuse, respectively). 4 Efficient: Avoiding waste, including waste of equipment, supplies, ideas, and energy. 5 Equitable: Providing care that does not vary in quality because of personal characteristics such as gender, ethnicity, geographic location, and socioeconomic status. 6 Patient centered: Providing care that is respectful of and responsive to individual patient preferences, needs, and values and ensuring that patient values guide all clinical decisions. 7 Patient care: that is compassionate, appropriate, and effective for the treatment of health problems and the promotion of health. 8 Medical knowledge: about established and evolving biomedical, clinical, and cognate sciences (e.g., epidemiological and social-behavioral) and the application of this knowledge to patient care. 9 Interpersonal and communication skills: that result in effective information exchange and teaming with patients, their families, and other health professionals. 10 Professionalism: as manifested through a commitment to carrying out professional responsibilities, adherence to ethical principles, and sensitivity to a diverse patient population. 11 System-based practice: as manifested by actions that demonstrate an awareness of and responsiveness to the larger context and system of health care and the ability to effectively call on system resources to provide care that is of optimal value. 12 Practice-based learning and improvement: that involves investigation and evaluation of their own patient care, appraisal and assimilation of scientific evidence, and improvement in patient care.
Clear guidelines Clinicians need should be developed to be aware for hospice referral of evidence and revocation of disease progression and hospice referral criteria
Improvement
There was no system in place to ensure that all staff members are familiar with the pre-procedure policy The system did not ensure that the attending physician be notified when the patient enrolled in hospice
TIMELY (Delay in hrs, days, weeks)
2
Clinicians need to be PRACTICE-BASED We need to develop educated about the LEARNING AND educational 12 pre-procedure IMPROVEMENT interventions institutional policy for clinical care staff (What have we learned? regarding institutional What will we improve?) policies on informed consent and code status. Standards for clinicianclinician communication and patient-clinician communication should also be established
SYSTEM-BASED PRACTICE11 (What is the process? On whom do we depend? Who depends on us?)
Competencies
Aims
Table 1. (Continued)
990 ‘‘positive margins’’ but he understood this as no evidence of disease after the treatment. He remained in remission for 20 months and was under routine oncologic surveillance. Thereafter, his condition started to decline. He experienced a 10-pound weight loss over several months, poor nutritional intake, and deconditioning with difficulties ambulating. A computed tomography (CT) scan of the abdomen and pelvis prior to his last return visit showed ascites. On his return visit he met with three different physicians. First, his medical oncologist recommended percutaneuos jejunostomy tube placement to improve nutrition and paracentesis with ascitic fluid analysis to rule out recurrent disease. Next, he saw his surgical oncologist. Based on his clinical decline, the CT scan findings, and the history of ‘‘positive margins’’ of the pathological sample from the previous surgery, the surgical oncologist strongly suspected recurrent metastatic disease. He therefore recommended hospice and the patient agreed to it. He was then referred to the palliative care team to assist with a smooth transition to home hospice care. A week later he received a call from his medical oncologist stating that the ascitic fluid cytology was negative for malignancy. The medical oncologist was unaware of the patient’s enrollment in hospice until he called. The patient was instructed to revoke hospice, return to the hospital, and get a J-tube placement for nutritional support. On arrival at the hospital he was found during the preoperative evaluation not to be a good candidate for the surgical procedure and was then admitted with failure to thrive in the General Internal Medicine department. He was subsequently found to have pneumonia, pulmonary embolism, bilateral pleural effusion, and worsening ascites. His previous surgical oncologist who had recommended hospice in the past insisted on a repeat ascitic fluid analysis, which turned out to be positive for malignancy. Further work-up revealed significant metastasis to the colon with impending colonic obstruction. The oncology team consulted the gastroenterology service for palliative colonic stent placement without informing the patient. The gastroenterology service assumed that the General Internal Medicine team had already explained the procedure to him and therefore went ahead to schedule the procedure. The patient was transferred to the acute palliative care unit (APCU) on the eve of the procedure to focus on symptom control. He had agreed to a do-not-resuscitate (DNR) order. On the day of the procedure the patient refused to be sent down to the procedure room ‘‘until someone came up to explain the procedure’’ to him. The gastroenterology service came to the APCU to discuss the rationale, risks, and benefits of the procedure. The patient provided consent and was reversed to ‘‘full code.’’ After the procedure he developed aspiration pneumonitis with acute respiratory failure. He was sent to the intensive care unit (ICU) and intubated. The intensivist contacted the palliative care physician and requested the reversal of the code status back to DNR, despite the fact that the patient’s wife who was the surrogate decision maker wanted him to remain ‘‘full code.’’ The miscommunication and misunderstanding between the palliative care specialist and the intensivist resulted in significant conflict between the two physicians regarding the establishment of goals of care and care plans. The patient remained a ‘‘full code’’ based on the fact that the event was
ARTHUR ET AL. an acute and reversible complication, which was related to the procedure as well as the surrogate’s decision. He stayed in the ICU until his condition was stabilized. After two days of ICU stay his condition improved and he was transferred back to the APCU where he agreed to reinstitute the DNR order. He returned home five days later with the same hospice company that he had signed up with two months earlier. He died one week later. We presented this case at our palliative care morning rounds and reviewed the course of events. Representatives from intensive care, gastroenterology, anesthesiology, and quality improvement departments were present at the meeting. Using the healthcare matrix as a framework (see Table 1), we were able to clearly identify the deficiencies in the coordination of care and to discuss ways to improve our system to minimize recurrence of similar events. As a result of this meeting all attendees gained a better understanding of the institutional policy regarding informed consent and code status, and acknowledged the need to improve both peer-topeer communication and patient-physician communication. We also discussed the importance of educating our colleagues who were not present at the meeting about these issues, and using the healthcare matrix for future case analyses. The healthcare matrix provides a formative approach to the presentation of the core competencies. It allows one to systematically examine four key ACGME core competencies related to patient care, including medical knowledge and skills, interpersonal and communication skills, professionalism, and system-based practice, with the six IOM aims (i.e., safe, timely, effective, efficient, equitable, patient centered). Traditionally, the healthcare matrix is completed by an individual involved in the patient’s care, and then revised based on feedback from the interdisciplinary team. Users first complete the top row by assessing overall patient care based on each IOM aim. If the user answered ‘‘No’’ in any of the cells indicating a deficiency in care, then he or she should complete the remainder of the column to outline the specific gaps in care, and how practice can be improved (last row). Otherwise, the cells below could be left blank. Based on our patient’s history we completed the healthcare matrix and identified 12 major deficiencies and 5 opportunities for improvement. Discussion Miscommunication, misunderstandings, and misdiagnosis often happen among physicians, other health professionals, patients, and their family members, which may jeopardize patient care.9–11 As highlighted by the healthcare matrix, this patient experienced multiple mishaps during his encounter with the healthcare system, resulting in emotional distress, loss of his precious time, inappropriate use of resources, and distrust in the healthcare system. The healthcare matrix is useful for analyzing complex, interdisciplinary cases often seen in palliative care. The more complex the situation, the more challenging it is to capture the many essential issues and address them accordingly. The healthcare matrix facilitated our examination of this case in a systematic and comprehensive manner, and more importantly, allowed multiple specialties to work with each other toward improving patient care. The healthcare matrix revealed how safety was compromised because of the lack of communication between the
HEALTHCARE MATRIX IN PALLIATIVE CARE medical oncologist and the surgical oncologist regarding the patient’s prognosis and goals of care (see Table 1). Better communication would have enabled them to provide the patient with a unified message. The outpatient medical oncologist was the attending physician in charge of coordinating the patient’s care; however, the patient was under the direct care of the hospitalist, the palliative care specialist, and the intensivist when he was admitted under each service, making it confusing to know who was in charge. Patient care was not timely and efficient, because this patient was made to revoke hospice care, come to the hospital, and undergo many aggressive procedures that were costly and probably unnecessary. There was also miscommunication between the palliative care team and the G.I. endoscopy service. According to our institutional policy, the physician who had the primary responsibility for a patient’s treatment and care at the time of the event in question was responsible for obtaining the informed consent. However, this was not done ahead of time before the scheduled procedure. The matrix suggested the need for effective communication between patients and healthcare providers and a review of the institutional protocol regarding what must be done prior to any procedure. An analysis of over 200 matrices at Vanderbilt University with a focus on safety revealed that the most common issues were communication, teamwork, workarounds, and documentation.6 Care was not patient centered, especially when the patient had to ‘protest’ before someone came to explain the procedure to him. Good communication between the two services would have prevented this awkward scenario. Another issue was the misunderstanding between the intensivist and the palliative care physician regarding code status when the patient’s clinical condition deteriorated after the procedure. There is a need for a better understanding of code status under different scenarios among healthcare professionals. The healthcare matrix’s ability to elucidate the intricacies in patient cases makes it an appealing tool for optimizing care delivery in the clinical setting.12 One of the strengths is its versatility and universality, allowing it to be applied to almost all patient cases regardless of the discipline. As highlighted in this case report, it is useful for dissecting complex scenarios involving multiple professions. Thus, the healthcare matrix is a particularly attractive tool for palliative care. It helps to create a safe environment that focuses on the issues at hand and systems of care instead of individual deficiencies or shortcomings. Multiple institutions have already incorporated the healthcare matrix in their quality improvement initiatives.7,13 Recommendations from previous matrices can be used to generate new guidelines or to improve on existing ones. This can potentially help inform policy and system changes aimed at improving patient care outcomes, although the long-term impact has yet to be determined. Our department has started to use this tool routinely for ‘‘postmortem’’ analysis in Mortality and Morbidity rounds. The healthcare matrix also has the potential to serve as an educational tool for palliative care by enabling trainees to learn more about the specific ACGME core competencies, to critically assess patient care outcomes, and to identify strategies for improving patient care.6,14 By not bringing shame or placing blame on those involved in the case, the matrix promotes healthy learning and objective appraisal among train-
991 ees. By systematically analyzing each ‘‘cell,’’ the trainee can examine multiple dimensions of palliative care cases comprehensively without feeling overwhelmed. Thus, the healthcare matrix can be a useful tool for preparing Mortality and Morbidity rounds and case reports. This matrix can help trainees to learn from their patients in a more formal and methodical manner. Upon initial inspection, the healthcare matrix may appear to be a daunting table that requires a lot of information and time to complete. Some clinicians may also be concerned that it would take a considerable amount of time to be acquainted with its application. However, this matrix is designed to be easy to use. It typically takes less than 30 minutes to get familiar with this tool, and between 5 and 10 minutes to fill out a case once the essential information has been collected. Importantly, the matrix may help to highlight gaps of information needed to fully analyze a case. Another concern regarding the healthcare matrix is that it represents just another form to be filled out in a healthcare environment driven by superfluous documentation and an excessive number of forms. We argue that the healthcare matrix is a unique innovation that requires minimal amount of extra work and potentially useful practical applications. Furthermore, our institution has created a web-based interface for the healthcare matrix (inside.mdanderson.org/education/qualitycollege/hcmatrix.html), although this is not yet publicly available. It should be emphasized that the healthcare matrix has not been demonstrated to improve clinical outcome, nor has its reliability and validity been examined. Further research is needed to assess the barriers and satisfaction associated with the use of this tool. Quasi-experimental design or cluster randomized trials comparing the healthcare matrix to control educational interventions may allow us to assess its impact on quality improvement and patient safety. Conclusion We present the use of the healthcare matrix as a tool to analyze complex cases in palliative care. The matrix facilitates systematic, comprehensive, and critical appraisal of cases based on ACGME competencies and IOM domains, and helps to formulate ways to improve current practice. It has potential applications in the patient care, quality improvement, and educational aspects of palliative care. Further research is necessary to determine the full impact of the matrix. Author Disclosure Statement No competing financial interests exist. References 1. Stewart M: Core Competencies. www.acgme.org/acwebsite/ RRC_280/280_corecomp.asp. 2012. (Last accessed March 25, 2012.) 2. Nahrwold D: ABMS Maintenance of Certification. www.abms.org/Maintenance_of_Certification/ABMS_MOC .aspx. 2012. (Last accessed March 25, 2012.) 3. Institute of Medicine: To Err Is Human: Building a Safer Health System. www.iom.edu/Reports/1999/To-Err-is-HumanBuilding-A-Safer-Health-System.aspx. 2012. (Last accessed March 25, 2012.) 4. Bingham JW, Quinn DC, Richardson MG, Miles PV, Gabbe SG: Using a healthcare matrix to assess patient care in terms
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Address correspondence to: David Hui, MD, MSc, FRCPC Department of Palliative Care and Rehabilitation Medicine Unit 1414 The University of Texas MD Anderson Cancer 1515 Holcombe Boulevard Houston, TX 77030 E-mail:
[email protected]
