Measuring quality of care in palliative care services.

Professor Irene J. Higginson, B.Med.Sci., B.M.B.S., F.F.P.H.M., Ph.D., is a palliative medicine physician who has been researching audit and outcome measures in palliative care for more than 15 years. For the past 3 years she has been based at King’s College School of Medicine and Dentistry and St. Christopher’s Hospice in London, England. In this interview with Innovations associate editor Anna L. Romer, she discusses the purpose of audit and the evolution of two quality of care measures she has designed: the Support Team Assessment Schedule (STAS) and more recently the Palliative Care Outcome Scale (POS). The STAS includes nine core items: Pain Control, Other Symptom Control, Patient Anxiety, Family Anxiety, Patient Insight, Family Insight, Communication between Patient and Family, Communication between Professionals, and Communication Professional to Patient and Family. Staff members grade each of these domains using a forced-choice severity scale of zero to four. The instrument lists the item, for example, “Pain Control” and a few words to cue the person using the form (i.e., “Effect of his/her pain on the patient”). The POS is a new tool that represents an evolution in practice. A key difference between the two tools is that the POS has two parallel instruments—one for a staff member to complete and the other for the patient to complete. In terms of content, the POS includes many of the same domains, but frames the questions with more specificity. The POS staff questionnaire has 10 items and each includes a specific question with a clear time period (the past 3 days). This tool unpacks broad terms such as “communication” into particular questions, for example, about how much information is given, or whether patients have been able to share feelings. The final two items in the POS inquire about how much time has been wasted on appointments and on whether practical matters resulting from the illness have been addressed. In addition to the forced-choice items, there is an open-ended question asking staff or the patient to list the main problems over the past 3 days. Staff also complete a performance status question. In the following interview, Dr. Higginson describes the evolution of the two measures and reflects on the interface between quality of care (i.e., a measure of the care palliative care teams provide based on their own assessments of patient needs and experience) and quality of life (a term grounded in patients’ subjective experience). Dr. Higginson details her hopes for the POS, a tool that attempts to address this gap between health care professionals’ perspectives and patients’ perspectives. This interview is excerpted from a thematic issue, “Measuring Quality in Palliative Care,” Volume 2, Number 1, 2000 of the online journal Innovations in End-of-Life Care at http://www.edc.org/lastacts/.