Summary of Suggested Additions or Revisions to Policy and Procedures Manual

Recommended new policies added to the agency’s Policy and Procedures Manual

• Establish an LGBTQ-friendly environment of care, including sensitivity to gender identity.• Define “family” inclusively for non-traditional circles of care.• Create a hospice medical futility policy.• Create agency guidelines on terminal sedation and patient requests for information on voluntarily hastening death by withholding food, hydration, antibiotics or hoarding medications.• Create agency guidelines on the 2016 CA End of Life Option. • Define explicit rules and procedures for employing a certified medical interpreter.• Educate families on federal and state guidelines for proper disposal of medications, including controlled substances.• Create special protocols for veterans, political asylees and refugees from countries at war, people with PTSD, and families exposed to violence in order to provide trauma-informed care.

Recommended revisions and additions to the agency’s Policy and Procedures Manual

Human Resources Policies• Economic of Care: Personal safety in the community guidelinesRecommendation: Petition Hayward City Council to create a new parking ordinance that would grant hospice employees to park everywhere (except in front of fire hydrants) from 10:30pm through 6am in order to increase employee safety.

• Employee Security and safety: Managing undesirable behaviorRecommendation: Offer non-violent communication training to employees; teach critical incident debriefing to supervisors and senior clinical staff

• Violence in the Workplace Prevention Policy Recommendation: expand the concept of violence to include verbal bully; put handouts on bullying in the workplace into an appendix of the New Employee Handbook.

• Hospice Aide SupervisionRecommendation: If supervision is part of the nurse’s tasks, prior to hire assess nurse’s competence in mentoring. If needed, provide continuing education on how to provide collaborative and supportive supervision and mentoring.

• Inservice Education

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Summary of Suggested Additions or Revisions to Policy and Procedures Manual

Recommendation: Replace vague promise to offer inservice to staff with the specification of topics covered such as bioethics, the CA 2016 End of Life Option, cultural competence, interdisciplinary team communication, health literacy; record the inservice and make available the video record, power point slides, and handouts to all agency employees.

• Spiritual ServicesRecommendation: Revise the definition of spiritual care, including tasks and scope of care to encompass “psycho-social-spiritual” continuum of care.

• Bereavement ServicesRecommendation: Create a line item in the annual hospice budget to pay for assembling a lending library on grief and bereavement for hospice clients.

• Employee OrientationRecommendation: Assemble a web-page for new employees and volunteers which includes online resources about medical condition, resources for grieving, communication, self-care.

• Staff Competency ProgramRecommendation: Align agency competency assessments of clinical staff with standards for palliative care established by professional associations; create a staff webpage/web portal with links to competencies specified for Hospice & Palliative Nurses Association for certification examinations for Nursing Assistant, Licensed Practical/Vocational Nurse, Registered Nurse, Advanced Practice Nurse, Nurse Practitioner, Hospice and Palliative Care Administrator; NASW Standards for Social Work Practice in Palliative and End of Life Care; The California State University Institute for Palliative Care and HealthCare Chaplaincy Network specialty certificate program in Palliative Care Chaplaincy; The California State University Institute for Palliative Care and Coalition for Compassionate Care of California continuing education course on Palliative Care for Certified Case Managers (CCMs); consider offering grants and paid days off for employees to cover cost of travel to sit for certification examination.

• Volunteer Recruitment and Retention ActivitiesRecommendation: Reconfigure recruitment activity chart to better reflect goals of reaching out to local organizations.

• Volunteer training programRecommendation: Add SBAR training for volunteer communication protocolduring emergency; add module on dangers of proselytizing, necessity of using certified medical interpreter.

• Employee Orientation ChecklistRecommendations:

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Summary of Suggested Additions or Revisions to Policy and Procedures Manual

• RE infection control and prevention: sensitize all new employees about dangers of cross-national disease vectors; add links to CDC Health Alert, Travelers’ Health Travel Notices, Earthquake sites.• RE community resources: Invite new employees to add to community resources on webpage and various referral directories.• ADD short introductory communication skills training during

orientation• teach SBAR format so information passing is efficient• develop process for raising ethical concerns to ombudsperson•  ADD materials for how cultural bias affects care• Create handouts and curriculum for multidisciplinary communication• ADD introductory to hospice clinical staff’s attachment and

bereavement • ADD curriculum on resilience and revitalization for hospice

employees• ADD short modules on following topics to new employee orientation: fears of narcotic addition at end of life, health literacy, cultural sensitivity and humility

Infection prevention and controlRecommendation: Nursing Director or Hospice Administrator subscribe to CDC newsletters and require adjustments to initial patient assessments to adapt to emerging health alerts, (domestic and international). Leadership• Disruptive and Inappropriate BehaviorRecommendation: Substitute specific descriptions of inappropriate and disruptive behavior for general description in policy; require 2-hour inservice on workplace verbal bullying of every new employee; require an inservice on group problem-solving dealing with difficult/challenging patient or family behavior.

• Leadership assessment of contributions to quality assessment/performance improvement (QAPI) and safety improvement activitiesRecommendation: The self-assessment of leadership should be concrete, specific, with dates or measurable outcomes or indicators or the equivalent, e.g., successful mentorship, effective intervention.

• Compliance ProgramRecommendation: The Compliance Officer is not specified in the policy. CO should not be the Owner or Hospice Administrator.

• Continuous CareRecommendation: The Volunteer Director should create a No One Dies Alone and/or a weekend Tuck-in program staffed by volunteers to assist anxious family members who need extra support.

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Summary of Suggested Additions or Revisions to Policy and Procedures Manual

Medication Management (MM)• Treatment modalitiesRecommendation: Develop a protocol and handouts about artificial hydration and nutrition, terminal sedation for agitated patients, voluntarily refusing food and drink to hasten death, fear of addiction to pain medication, allow natural death

Provision of care, treatment, and services• Assessment and reassessment guidelinesRecommendation: Add spiritual care counselor’s standards of practice to clinical team’s parameters of care; add assessment responsibilities of spiritual care counselor to list of which member of the multidisciplinary performs which part of the assessment; add core competencies of social workers and spiritual care counselors to this section. • Initial assessment/Comprehensive AssessmentRecommendation: Add more screening tools for psycho-social-spiritual assessment including: social determinants of health, cultural assessment, family dynamics, health literacy, health information needs, distress, coping and adjustment, trauma history, drug and alcohol screening, veteran status, spirituality, fear of opioid misuse, spiritual-existential assessment, quality of life assessment, caregiver assessment.

• Pain assessment and reassessmentRecommendation: Teach clinical staff and volunteers how to facilitate guided meditations with patient and family; offer pet therapy to anxious patients and families, if appropriate.

• End-of-life careRecommendation: Unless you have an RN board-certified by the Hospice and Palliative Nurses’ Association, instead of having the RN to perform the entire initial assessment, it would be better to have the spiritual care counselor assess the patient and family’s emotional and spiritual state, and the social worker assess the patient and family’s psychosocial status.

• IDG Care Planning ProcessRecommendation: Outcomes-orientation should be explicit and be part of every IDG meeting; create an IDG outcomes form so that there is general agreement about outcomes for each treatment plan.

• Coordination of hospice internal communicationsRecommendation: Assign responsibility and create mechanism for providing regular updates about patient deaths and bereavement milestones so the staff are current about the people they cared for.

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Summary of Suggested Additions or Revisions to Policy and Procedures Manual

• Plan for patient/family educationRecommendation: • Require every member of the patient care team read the federal government’s Universal Precautions Health Literacy Toolkit; provide training and supervision to staff on assessing health literacy and health information.• Require the RN as well as the spiritual care counselor or the social worker assess the patient and caregiver’s health literacy, including questions, confusions, concerns.

• Patient and family educationRecommendation: Add to list of topics: Allow natural death, DNR, artificial hydration and nutrition, dementia, delirium and seeing spirits, voluntary death, the specific issues pertaining to caregivers: ie burnout, family conflict, communicating; what to expect in the last 48 hours of death; natural decreased thirst and hunger at end of life.

In light of the National Quality Forum’s recommended measure for Pain management (#209), include in patient and family psychoeducation about fear of narcotic addition and make this central to standard practice and documentation of pain management.

• Withholding resuscitationRecommendation: • Before the patient signs or refuses DNR, several things ought to happen first:

i) patient is screened for health literacyii) cultural sensitive assessment is madeiii) values worksheet is completediv) patient is educated about the effects of resuscitation and ventilation

• This text should include patient education regarding the other topics typically involved in Advanced Care planning• Text should be discussed in terms of patient’s religious and cultural values• In addition to DNR, please consider adopting Five wishes in addition to POLST and instead of DNR – use “allow natural death”

• Spiritual Care CounselingRecommendation: I would like to revise the text so that it reflects the competences of board certified chaplains.

• Limited English proficiency or impairments in communicationAt present the policy reads: “In order to ensure competency of translators, family members or friends may be used as the translator only if specifically requested by the patient.”

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Summary of Suggested Additions or Revisions to Policy and Procedures Manual

I have concerns about requests to have family or friends interpreting. This practice runs counter to professional standards among certified medical interpreters.

Recommendation: • If hospice cannot find certified translators when needed, I recommend recruiting community-based volunteers who will undergo specific medical interpretation training.

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