Quality Improvement in Healthcare: An ACO Palliative Care Case Study


mother and daughter “I didn’t expect to need palliative care so soon. But this summer I underwent cancer surgery. It was a huge relief to know my advance care planning was already done—and that my desires were understood by my family members. I’ve told everyone about the palliative care services OSF provides and how grateful I am for them.”

– Oncology patient

Quality improvement is essential for healthcare organizations as they transition to value-based care. Including palliative care in the planning and implementation of value-based care initiatives is more important than ever—especially for accountable care organizations (ACOs). Ensuring better health, better care and lowering healthcare costs across a community requires understanding and translating patients’ values into their medical decisions.

A recent study conducted by the Institute of Medicine (IOM) sheds light on the quality and cost of end-of-life care. The study highlights the fact that increased spending is not associated with higher-quality care, as measured by longevity, quality of life and patient satisfaction. In addition, the study shows that the cost of caring for individuals in their last year of life represents 13 percent of total annual health care spending. High-cost hospital-based treatment is often inconsistent with patient preferences and may contribute to patient suffering.

OSF HealthCare—one of the first Pioneer ACOs—has a strong history of supporting end-of-life and palliative care. In fact, OSF received the new 2014 Tim Philipp Award for Excellence in Palliative and End-of-Life Care, an IHA Quality Excellence Achievement Award for outstanding quality improvement in healthcare initiatives in hospitals and health systems in Illinois.

A key component of this Catholic health organization’s faith-based mission and palliative care program is to assist patients with advance care planning. OSF had spent almost a decade developing supportive care programs, but as a Pioneer ACO, they knew the need for advance care planning extended beyond the patients within their healthcare system. This ACO launched a community-wide supportive care initiative—enabled by technology—that has successfully spread advance care planning throughout their population.


For OSF, advance care planning involves much more than producing a documented plan. Rather, it involves understanding the patient’s value system and aligning his or her healthcare goals with these values. The service is available for free to all community members—including OSF patients, OSF employees and OSF employee family members—and involves a trained facilitator leading the patient through a series of questions to help discern personal values, beliefs and preferences for care at the end of life or in the event the patient is no longer able to speak for him or herself. It helps not only the patient but also the patient’s medical power of attorney understand what decisions the patient would want in a variety of circumstances.

Studies show that the vast majority of people at the end of their life are not able to express their wishes, nor are they able to give consent. Hence, it is wise for a person to engage in advance care planning, as the name implies, in advance of a crisis. According to Robert Sawicki, MD, Senior Vice President of Supportive Care, OSF Healthcare System, “It is widely understood that making advance healthcare plans for a future medical scenario, when a person cannot make decisions for themselves, is a critical step toward ensuring the patient gets the medical care they would want.”

Not only does going through the process of documenting an advance care plan prevent unwanted care; it can also be empowering for a patient. When patients know their care goals are documented—and they have shared their desires with their physicians and their family—they are more confident the care they receive will be aligned with their wishes.

However, advance care planning is not top of mind for many, especially those who are in good health or who do not feel that death is near. As a result, it is all too common for an advance care planning discussion to take place when a patient is already in crisis.


OSF’s supportive care team—which spearheaded the initiative— wanted to maximize the number of patients who had completed advance care planning. This meant that more advance care planning discussions and documentation of those discussions needed to occur. To achieve this goal, the team knew they need to engage physicians, nurses, care providers, facilitators, employees and patients. Most importantly, this effort needed to span the entire community covered by the ACO, not just OSF facilities.

An audience that OSF particularly needed to target was ambulatory care providers. Because care delivery is evolving into a continuum of care model, these providers—who already have many demands on their schedule—would be one of the linchpins in ensuring that advance care planning took place. OSF knew they would have to provide the training and tools to engage these providers and help them be successful.

Although OSF offers free advance care planning to all of its patients, the organization felt the process was particularly important for highrisk patients. As a Pioneer ACO, OSF had data from the Centers for Medicare and Medicaid Services, which contained information necessary to help identify the high-risk patients. They also had other payer claims data. In order to identify high-risk patients and focus their palliative care initiative, they needed to aggregate and analyze this data.

OSF also needed an effective method for documenting both advance care planning discussions and the advance care plans themselves.

They needed a solution that:

  • Could be implemented quickly—in days rather than weeks or months. This requirement eliminated their electronic health record (EHR) as a possible solution.
  • Was compatible with the community’s heterogeneous EHR environment. Since providers throughout the ACO community use disparate EHRs, OSF couldn’t rely on its own EHR as the solution.
  • Was easy for facilitators to access and enter data with minimal training.
  • Consisted of one common database to enable communitywide, customized reporting.
  • Could integrate the advance care planning information into OSF EHR patient records.


To drive quality improvement and to resolve these challenges, OSF’s supportive care team adopted a two-pronged approach. This approach involved establishing both the technological infrastructure and the community engagement programs in place to implement a successful advance care planning initiative.

Technology-enabled solution to drive community engagement

OSF had already implemented a healthcare enterprise data warehouse (EDW) from Health Catalyst to drive performance improvement initiatives. This EDW aggregates clinical, claims, financial and other data to create a consistent view of the ACO’s data—a single source of truth to inform decisions. On top of the EDW, OSF implemented Health Catalyst’s Instant Data Entry Application (IDEA). Together the EDW and IDEA enabled data aggregation, risk stratification, documentation and reporting across the ACO’s heterogeneous EHR environment…

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