Incentivizing Residents to Document Inpatient Advance Care Planning

Discussing preferences for care near the end of life increases the likelihood that patients will receive care consistent with their preferences.^1-4 Recent work⁵ demonstrates that medical professionals infrequently ask about and document preferences for patients upon hospitalization. Because most end-of-life discussions occur in hospitals,⁶ we implemented a quality improvement program incentivizing resident physicians to consistently document key information about inpatient advance care planning discussions in a timely manner in an accessible location.

We conducted the project between July 1, 2011, and May 31, 2012, on the medical service at the University of California, San Francisco (UCSF), where the Medical Center and departments of medicine and graduate medical education collaborated to form the Housestaff Incentive Program. In this program, trainees choose quality improvement goals and faculty mentor trainee champions through design and implementation of projects. If goals are met, all trainees receive a financial incentive. Internal Medicine residents selected the goal of improving documentation of advance care planning discussions on the basis of pilot work and experience that inconsistent documentation was a barrier to honoring patients’ wishes on transitions of care. Input from key stakeholders, including emergency department, outpatient, hospital, and palliative care providers, informed the intervention, especially location and content of documentation. The project included 3 key elements; the details of each of these are included in the Table. To assess documentation rates, program residents reviewed charts of a random sample of recently discharged patients on a biweekly basis. The UCSF institutional review board approved the project.

The Figure shows implementation of key aspects of the intervention and the percentage of discharge summaries that included the required documentation by project month. Documentation rates are based on medical record review of 1474 patients, comprising 55.5% of those discharged from the medical service during the project period. Rates rose from 22.2% at the beginning of the program to more than 90% by October and remained near this level through May. In comparison, documentation rates for patients discharged from an attending-only service, which used the electronic template but did not receive the financial incentive or feedback, were 0% to 50% with a yearly mean of 11.7%.

We implemented a multifaceted intervention to improve resident documentation of advance care planning discussions in a consistent format and location. We believe that the discharge summary template and the financial incentive program provided the foundation for the observed increase in documentation rates. However, rates did not begin to increase until we implemented and refined performance feedback, indicating that this aspect was essential. Further work should be designed to demonstrate which specific interventions are most important.

Several limitations of this project warrant consideration. A key limitation was that we did not measure patient outcomes, and doing so will be critical in future work. In addition, we did not track documentation rates after the end of the project. Future programs should focus on sustainability, for example, by electronic medical record automation of audit and feedback. Finally, it is possible that factors other than the intervention contributed to the increase in rates that we observed during the course of the program.

In conclusion, our trainee-led quality improvement project, including a structured electronic medical record template, a financial incentive, and performance feedback, increased timely documentation of inpatient advance care planning discussions. Our results highlight the effectiveness of engaging residents in quality improvement activities. In addition, they present the possibility that such an incentive program could improve patient outcomes by ensuring that their wishes are available across care transitions.

Corresponding Author: Joshua R. Lakin, MD, Palliative Care Program, University of California, San Francisco, 2320 Sutter St, Ste 102, San Francisco, CA 94115 (jrlakin@gmail.com).

Published Online: July 15, 2013. doi:10.1001/jamainternmed.2013.8158.

Author Contributions: Dr Lakin had full access to all the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis.

Study concept and design: All authors.

Acquisition of data: Lakin, Le.

Analysis and interpretation of data: Lakin, Le, Mourad, Hollander.

Drafting of the manuscript: Lakin, Le, Mourad, Hollander.

Critical revision of the manuscript for important intellectual content: All authors.

Statistical analysis: Le.

Administrative, technical, and material support: Lakin, Hollander.

Study supervision: Mourad, Hollander, Anderson.

Conflict of Interest Disclosures: None reported.

Funding/Support: The University of California, San Francisco (UCSF), Medical Center and Department of Graduate Medical Education funded this project. The UCSF Clinical and Translational Science Institute Career Development Program, supported by National Institutes of Health grant KL2 RR024130, funded Dr Anderson.

Previous Presentation: Dr Lakin presented this work at the Annual Assembly of the American Academy of Hospice and Palliative Medicine; March 15, 2013; New Orleans, Louisiana.

Additional Contributions: Sumant Ranji, MD, Krishan Soni, MD, and Rebecca Sudore, MD, all from UCSF, provided leadership and guidance in managing this program. In addition, Ari Hoffman, MD, Jeffrey Dixson, MD, Ajay Dharia, MD, YinChong Mak, MD, Christopher Moriates, MD, Kara Bischoff, MD, and Aparna Goel, MD, also all from UCSF, built and refined this project and generated the required momentum to complete this incentive program.