Benefits and challenges in use of a standardized symptom assessment instrument in hospice.

BACKGROUND Hospices are now mandated to perform routine quality assessment under the final Medicare Hospice Conditions of Participation, creating an opportunity to explore standardized approaches to monitoring hospice quality. OBJECTIVE We report hospice staff experiences using a standardized symptom assessment instrument, the Edmonton Symptom Assessment System (ESAS), in a pilot study designed to develop and test quality measures on symptom management. Use of the ESAS illustrates the benefits and challenges arising with standardized symptom assessment for quality monitoring in hospice. METHODS We interviewed 24 individuals representing 8 hospices involved with the National Association for Home Care & Hospice Quality Assessment Collaborative, which pilot tested the ESAS as a source of standardized data for quality assessment. Transcripts were analyzed using the constant comparative method. RESULTS Participants reported benefits and challenges with the ESAS. Benefits were that the ESAS was a brief and easy tool that identified areas of concern, engaged patients in symptom assessment, and monitored symptom changes over time. Additionally, the ESAS was viewed as a useful teaching tool for less experienced staff. Challenges included lack of clarity about inclusion rules and frequency of assessments; difficulty interpreting the numeric symptom rating scale, difficulty incorporating patient preferences with symptoms, and a sense that the use of standard assessment instruments was "unnatural." DISCUSSION Recommendations to promote effective use of ESAS data for quality monitoring of hospice care include standardizing implementation procedures, adding patients' preferences to the ESAS form, and staff education to enhance comfort with the instrument before implementation.