PCQN QI Collaborative

Screening for Spiritual Needs September 20, 2016

Agenda

• Data review • Screening questions review & discussion • Updates from teams • Next steps

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Data Review

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Data Review

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Percent screened:7/25/16 – 9/16/16 (numbers represent # of patients screened)

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28 16 15

38 29

13 31

40

68 13 34 33

21 18 41 35

156 81 27 88

17 97 55

25 53 61

22 81

48 89 25

53 64 33 76 54 74 28 44

37 38 20

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Example Screening Questions

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Hoag Providence Little Co. of Mary

1. Where do you draw your strength? 2. What are the most important

issues that have been raised for you by your illness?

3. In the past, what has helped you cope during the challenging moments of your life?

4. Are there particular beliefs or faith practices that give meaning to your life?

1. In difficult times, what brings you meaning or hope?

2. How have you felt connected to that during this illness/hospitalization?

**Optional question if not already addressed: Do you have any religious beliefs or practices that are important to you?

Mapping of Screening Questions

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HOPE FICA SPIRIT Providence Hoag UCSF PCQN NOS Coping/Strength/Values ● What is there in your life that gives you

internal support? ● Do you have spiritual beliefs that help you cope with stress?

● In difficult times, what brings you meaning or hope? How have you felt connected to that during this illness or hospitalization?

● Where do you draw your strength? ● What gives you strength in difficult times?

● What gives you strength/comfort in difficult times? How is that working?

● What are the sources of hope, strength, comfort and peace?

● Is there a group of people you really love or are important to you?

● What are the most important issues that have been raised for you by your illness?

● What are the most important issues that have been raised for you or your loved ones by your illness?

● What gives your life meaning?

● What do you hold onto during difficult time?

● In the past, what has helped you cope during the challenging moments of your life?

● Are you at peace? ● How are you holding up?

● What sustains you and keeps you going? ● How are your spirits? ● Are you at peace? ● How do you feel you are coping?

Reglion/Spiritual practices ● Do you consider yourself part of an organized religion? How important is that to you?

● Do you consider yourself spiritual or religious?

● Do you have a formal religious affiliation? Can you describe this? ● Do you have any religious beliefs or

practices that are important to you? ● Are there particular beliefs or faith practices that give meaning to your life?

● Do you have a faith tradition or spiritual belief system? How is it helping or not helping now?

● Do you belong to an organized religion?

● What aspect of your religion are helpful and not so helpful to you?

● What importance does your faith or belief have in your life?

● Do you have a spiritual life that is important to you?

●Do you have a faith tradition?

● Are you part of a religious or spiritual community? Does it help you? How?

● Are you part of a spiritual or religious community? Is this of support to you and how?

● Describe the beliefs and practices of your religion that you personally accept.

● Is faith or spirituality important to you?

● Do you have personal spiritual beliefs that are independent of organized religion? What are they?

● Describe those beliefs and practices that you do not accept or follow.

● Would you like a prayer?

● Do you believe in God? What kind of relationship do you have with God?

● In what ways is your religion or spirituality meaningful to you.

●How do you get spiritual comfort?

● What aspects of your spiritual practices do you find most helpful to you personally?

● Do you belong to any religious or spirtiual communities? How do you participate in them? What importance do they have for you? What types of support and help does or could they provide for you in dealing with health issues?

● What specific practices do you carry out

as part of your religious or spiritual life?

● What lifestyle activities or practices do your religion encourage, discourage or forbid? To what extent do you follow those guidelines?

Application to medical care ● Has being sick affected your ability to do things that usually help you spiritually?

● Have your beliefs influenced how you take care of yourself in this illness?

● Are there specific elements of medical care that your religion discourages or forbids? To what extent do you follow them?

● What do I need to know about you (culture, family, religion) to give you the care you need?

● As a doctor, is there anything that I may do to help you access the resources that usually help you?

● What role do your beliefs play in regaining your health?

● What aspects of your religion or spirituality would you like me to keep in mind as I care for you?

● Are you worried about any conflicts between your beliefs and your medical situation/care decisions?

● How would you like me, your healthcare provider, to address these issues in your healthcare?

● Are there particular aspects of medical care that you would wish to forgoe or have withheld because of your religion/spirituality?

● Are there any specific practices or restrictions I should know about when providing your medical care?

● Are there religious or spiritual practices or rituals that you would like to have available in the hospital or at home?

● Are there religious or spiritual practices

that you wish to plan for at the time of death or following death?

● As we plan for your medical care near the end of life, in what ways will your religion or spirituality influence your decisions?

PDSA Updates

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PDSA Updates: ZSFG

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Baseline data: Unable to determine baseline information for patients screening positive from PCQN database for 2013 – 2015 {64.9% of patients screened “positive”}

SMART goal: Short term: • Develop and begin using standardized screening questions within PC by

October 2016 • Develop card on spiritual screening for broader dissemination November 2016 Long Term: Screen 90% of palliative care patients for spiritual care needs by June 2017

Current barriers and/or opp. for improvement:

• Lack of real time data entry into PCQN and difficult to evaluate impact of QI interventions

• Developing questions that are authentic to team members which are appropriate for patients and families from a literacy perspective and for diverse cultural and ethnic backgrounds with a high prevalence of LEP

• Varied background/comfort level of providers with spiritual care and screening

Describe first test of change:

• Developing questions and finding agreement among the team • Vetting the questions with literacy review and with the Interpretive Services

Department • Developing screening questions and card delineating positive answers to

screens

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PDSA Updates: HOAG

PDSA Updates: HOAG

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What are you currently doing to execute the plan? Describe what happened when you carried out the test of change.

Observations, issues encountered. We have updated the data sheets and created pocket cards for the clinicians to use. Our chaplains have developed a documentation code that they use to allow our admin to easily pull the screening data onto our data sheet. We have discussed the same type of change with our physicians. Not sure anyone is actively using the pocket cards, but we have had a significant increase in discussion at daily IDTs and the focus on ensuring patients are screened has definitely increased.

PDSA Updates: HOAG

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Provide up-to-date data for your site. 7/1/16-8/31/16 Screened 46.9% Screened Pos 28.1% Intervened 96.8% Baseline screened positive: 19.1%

Act

How is this plan working for you? Changes to your plan? Next steps? Additional tests of change? • Physicians adding the screening to their symptom documentation

template • Looking at ways to partner with Chaplain Interns outside of CARES

Program to expand the spirituality screen across the hospital • Reallocating SW interns to assist in our Irvine location to increase

breadth of screening

PDSA Updates: UCSF Baseline Data: 65% of patients screened positive for spiritual needs between 7/1/2015 and

6/30/2016. We don’t know what percentage of patients were screened. SMART Goal: Screen 75% of patients for spiritual needs during the course of the inpatient palliative

care consult (excluding patients who refuse the screening and who we are unable to screen).

Current barriers and/or opportunities for improvement:

Clinicians of disciplines other than spiritual care don’t consistently recognize it as their responsibility to screen for spiritual needs, and they also don’t always feel confident knowing how to screen for spiritual needs. Clinicians pressed for time don’t prioritize spiritual screening. Some clinicians feel concerned that a spiritual screen could reveal issues that they aren’t able to address. Some clinicians worry that patients or family members might not be receptive to a spiritual screen, or that primary teams aren’t interested in them doing this work.

Describe first test of change:

1. Keep track of every instance when we do a spiritual screen, rather than simply when patients screen positive for spiritual needs, per revised PCQN data element

2. PC team uses 4 sample spiritual screening questions to standardize spiritual screening, lower barrier to spiritual screening, and bolster providers’ confidence in their ability to screen.

PDSA Updates: UCSF

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What are you currently doing to execute the plan? Describe what happened when you carried out the test of change.

Observations, issues encountered. • We have updated our PCQN “yellow cards” with new PCQN

data element • We have decided on suggested spiritual screening questions

to ask • We have incorporated them into our note templates in the

EMR • We have made a pocket card for clinicians • We have made posters to help with awareness • We scheduled time during our October team meeting to

“launch” this project and seek input from all members of our team

UCSF Card (Front)

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Screening for Spiritual Needs • A simple probe to identify patients or family members with spiritual needs

and/or distress who would benefit from further assessment or intervention. • Can be done by any member of the palliative care team. Example of screening questions include, but not limited to: • Do you have a faith tradition or spiritual belief system? If yes, how is it helping

(or not helping) now? • What gives you strength in difficult times? • What are the most important issues that have been raised for you (or for your

loved ones) by this illness? • Are you at peace? • How are your spirits? • How do you feel you are coping?

UCSF Card (Back)

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SCREEN POSITIVE: Themes expressed by patient/family warrant further assessment and intervention by a spiritual care provider. Themes include but are not limited to: • Religious/theological themes • Hopelessness or despair • Inability to accept losses • Feelings of abandonment by religious group or God, or anger at God • Questioning meaning or purpose of illness, suffering, or life itself • Feelings of guilt - feel self to be bad, sinful or unlovable • Asking “Why me?” • A history of broken relationships or need for reconciliation/forgiveness • Evidence of poor coping • Excessive guilt, regret or remorse Document on consult card and refer to chaplain if screen ‘positive’.

Palliative Care Service Goal: Screen ≥75% of patients or their family for spiritual needs (excluding those who can’t participate or decline screen) Example screening questions:

How are your spirits? How are you coping? What gives you strength in difficult times? Do you have a faith tradition or spiritual belief system?

If yes, how is it helping (or not helping) you now? What are the most important issues that have been raised by your illness?

Themes that warrant further assessment by a spiritual care provider: Religious/theological themes Questioning meaning or purpose of illness or life itself Hopelessness Guilt Feelings of abandonment, need for reconciliation/forgiveness Asking “why me?”

PDSA Updates: UCSF

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Provide up-to-date data for your site.

• Starting after our October launch, we will review our spiritual screening data with our team every month:

• At our monthly meetings • Via e-mail • On posters in our rounding room and the bathroom across the

hall ;-)

Act

How is this plan working for you? Changes to your plan? Next steps? Additional tests of change? • We are saving time during our December team meeting to reflect on

this project and update our plans

Additional Updates?

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Next Steps

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1. Continue to build & implement plans 2. In-person conference - report out? 3. Continuing spiritual screening project AND adding new project on anxiety screening & improvement

Thank you!

See you at the upcoming conference: October 13-14

OR on the next QI collaborative call: November 15 at 12:00pm PST

Kara Bischoff: kara.bischoff@ucsf.edu Angela Marks: angela.marks@ucsf.edu

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