Implementing Goals of Care Notes in a Statewide Health System: A Quality Improvement Initiative.

Abstract

Background: Goals of Care (GOC) documentation for seriously ill patients is integral to patient-centered care but not standardized. Collaborative efforts within the health system to improve the frequency and documentation of GOC to communicate patient preferences and values are essential to ensure both quality of life and quality of death.

Measures: We created a standard GOC note type and location in the electronic medical record (EMR) for a large, statewide health system in the Midwest. Utilization and note content for all unique GOC note types documented in the first year were reviewed. A framework of GOC topics including treatment plan, prognosis, patient preferences and values, and quality of life was used to review the note content. Demographic data and outcomes including death during the observation period and hospice enrollment were also collected.

Outcomes: In the first year, 934 GOC notes were documented. Palliative care (PC) clinicians addressed more GOC fields compared to other clinicians (70% v. 31%, p <.0001) and had earlier discussions (median 19 days before death v. 4 days, p<.0001). Hospice was discussed more by PC (50% vs 27%, p=.0001) and PC discussions were followed by higher hospice enrollments before death (50% vs 35% p=.0166).

Conclusions: We successfully implemented a standard EMR location for GOC notes which improved GOC documentation across a state health care system and found variations and gaps in fields addressed by all clinicians as well as key differences between PC clinicians vs other clinicians.