Quality Improvement in Healthcare: An ACO Palliative Care Case Study

Engaged and educated community resources

The supportive care team placed considerable focus on training physicians, nurses, care providers, facilitators and other employees to talk with patients about advance care planning. They delivered education on how to understand the patients’ values, how to translate those values into medical decision-making and how to document stated preferences for care.

A particularly important target for the team was care managers. A care management program had previously been established in OSF ambulatory practices. Since this group of care managers was already reaching out to high-risk patients, the team leveraged that opportunity and encouraged them to conduct advance care planning discussions with those patients.

In addition to education, OSF adopted several strategies to encourage care teams to meet advance care planning targets. One such strategy was healthy competition. Monthly leadership reports generated from the EDW clearly indicated how different entities (such as hospitals and clinics) were performing against each other and against targets.

The supportive care team also worked diligently to sign up OSF employees for advance care planning. The reasoning behind this strategy was straightforward. Not only did the team believe that advance care planning is important for everyone, but they also viewed OSF employees as important advocates of the process. If a patient were to ask a care provider whether they had completed advance care planning, the team wanted the answer to be “yes” as often as possible to give the concept more validity.

Finally, OSF hosted community events. In one region, where OSF is the smallest of three hospital systems, OSF facilitators engaged physicians and nurses from two other systems to jointly lead an awareness effort that involved co-sponsoring the screening of a film called “Considering the Conversation” to the public. Producers ofthe film, along with the CEOs from each of the three hospitals, were united on one stage. The event was very well attended, and advance care planning rates increased across the community as a result.


Developed and deployed a community-wide palliative care program—completing advance care planning with more than 16,000 patients and engaging more than 980 physicians and community facilitators

OSF’s initiative has been embraced by the entire community, including the OSF healthcare system and other systems and providers. In fact, OSF exceeded its targets. Here are highlights of the team’s achievements:

  • They established a target of completing advance care planning with 1,200 high-risk patients within the year. In just nine months, they completed the process for 1,243 patients.
  • Previously, OSF had a total of 1,952 high-risk patients who had completed advance care planning. They have increased this figure now by 64 percent.
  • For patients who were not high risk, the team documented over 4,300 (annualized) advance care plans in 2014, bringing the total number of patients completing advance care plans to 16,000.
  • To date, 980 physicians and community facilitators have been trained to help guide patients through the process and document their advance care plan.

Leveraged their EDW platform in a heterogeneous EHR environment

The EDW enabled multiple sources of claims data to be aggregated. Then, using this rich, community-wide view of data, OSF was able to stratify its patients to target those at high risk.

In addition, all community resources were trained on and given access to Health Catalyst’s easy-to-use IDEA application, which enabled them to document advance care planning and to access patient information. Users are able to collect such information as type of visit, region, advance care planning completion date and facilitator name. The EDW platform also captures information about when facilitators reached out to the patient to talk about advance care planning, ensuring patients don’t receive multiple outreach calls.

For patients within the OSF healthcare system, the EDW integrates advance care planning information directly into the patient’s clinical record in the EHR. The EDW updates the advance care planning data in near real-time, requiring no manual effort to transcribe information from paper to the EHR or other systems. This automation improves data integrity.

Data exposure at all levels: Reporting and visualizations

The solution automatically generates customized reports and delivers them to facilitators, medical group offices, CEOs and other executives. Reports include the following:

  • Medical group staff receive a report on a daily basis showing them who the high-risk patients are so that facilitators can reach out to them. They also can see how many patients in each location have completed advance care plans to date.
  • The supportive care team receives a weekly report of patients who have completed advance care planning.
  • On a monthly basis, the executive leadership team receives a dashboard report to show trends and progress against the target.


OSF is continuing to expand the initiative throughout the community by on-going engagement with physicians, care providers, facilitators, patients and families—including employees and their family members. As the initiative progresses, OSF plans to measure how well the care that was delivered to a patient aligned with that patient’s stated goals. They also plan to perform further analyses; for example:

  • Correlating how well the patients’ care goals were met and the timing of the advance care planning discussion. So far, OSF’s experience has shown that the sooner patients have the discussion, the more likely the patients’ goals will be met and the more likely effective, high-quality care will be delivered.
  • Comparing readmissions rates for patients with advance care planning versus those without. The team hypothesizes that readmissions will be lower because patients generally specify the desire to be cared for in the comfort of their home.
  • The number of hospice referrals for patients with advance care plans. Hospice is associated with higher-quality, effective care and high levels of family member satisfaction.


Health Catalyst is a mission-driven data warehousing and analytics company that helps healthcare organizations of all sizes perform the clinical, financial, and operational reporting and analysis needed for population health and accountable care. Our proven enterprise data warehouse (EDW) and analytics platform helps improve quality, add efficiency and lower costs in support of more than 30 million patients for organizations ranging from the largest US health system to forward-thinking physician practices. Faster and more agile than data warehouses from other industries, the Health Catalyst Late- Binding™ EDW has been heralded by KLAS as a “newer and more effective way to approach EDW.” For more information, visit healthcatalyst.com, and follow us on Twitter, LinkedIn, Google+ and Facebook.

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