Module 5: Audit Cycle Begins

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Module 5 Audit Cycle Begins
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This training session contains information
regarding

• Audit Cycle Begins
• Questionnaire Administration
• Institution Level Data
• Patient/Family Member ACP Questionnaires
• Interview Tips
• ACP Questionnaire Walk-through

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Audit Cycle Begins
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Audit Cycle 2 Begins Jan 2, 2013

• Participating institutions may begin to recruit
  patients/family members and conduct the study
  before or after the start date, as long as they
  have the necessary resources and training to
  begin.
• There are 2 types of data collection to be
  conducted during each Audit Cycle
• Institution Level Data
• Patient/Family Member Data

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Questionnaire Administration

• Institution Level Data

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Degree of System Implementation

• Collection of institutional data will allow for a
  comparison between those institutions with low
  and high degrees of system level implementation
  to determine if there is a higher prevalence of
  ACP and greater satisfaction of EOL communication
  and decision-making in institutions with higher
  degrees of system level implementation.
• This is done by completing the Degree of System
  Implementation questionnaires

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• There are 2 versions of the Degree of System
  Implementation Questionnaire
• Acute Care Units
• Health Administration Level

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To be completed at the beginning of the audit
cycle. The ACUTE CARE UNIT version of the
questionnaire should be completed by interview
with the hospital staff member (Patient Care
Coordinator, Manager) with responsibility for
overall unit or specific involved program(s) from
which the patients are recruited.
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To be completed at the beginning of the audit
cycle. The HEALTH CARE ADMINISTRATION LEVEL
version of the questionnaire should be completed
by interview with the individual (who is
knowledgeable regarding ACP activities in the
health region/authority/zone. This may be the
palliative care team. Smaller institutions may
not have an ideal respondent for this version of
the questionnaire.
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Questionnaire Administration

• Patient Family Member ACP Questionnaire

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Enrollment

• A total of 60 enrollments are expected at each
  participating institution during each Audit
  Cycle.
• There should be a minimum of 20 patients and 20
  family member respondents.
• For example, a site may enroll 22 patient
  respondents and 38 family member respondents.

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Enrolling Patients Family Members at Different
Times

• It may be difficult to enroll family members
  since they often have other obligations that take
  them away from the hospital during regular
  business hours.
• An option is to make initial contact with family
  members by telephone to arrange for a mutually
  agreeable time to meet.

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• We suggest you
• Identify yourself as a member of the patients
  healthcare team.
• Indicate the patient/family member is eligible
  for a study we are conducting about hospitalized
  elderly patients.
• Indicate you would like to make an appointment
  with them to further discuss.
• We are not suggesting that consent be obtained by
  telephone rather we are proposing to make the
  initial contact by telephone.
• Ensure you check with your ethics committee to
  ensure this strategy is acceptable

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Interview Tips

• Have the appropriate version of the ACP
  Questionnaire on-hand (i.e. Pt or FM)
• Use the respondents name
• Introduce yourself and your role
• Ensure the respondent is ready and try to have a
  private location to conduct the interview
• Ensure comfort and put the respondent at ease

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• 60 minutes
• May be conducted over a few shorter sessions
• The questionnaires should be administered
  in-person with the respondent.
• Do not give the questionnaires to the respondent
  to fill out at their leisure.

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• Read each question to the respondent. If the
  respondent does not understand, repeat the
  question.
• The researcher administering the questionnaire
  should not interpret the questions for the
  respondent.
• When the question is open-ended, do not
  paraphrase or change the respondents answer.
  Record the answer verbatim.

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• If the respondent says I dont know provide
  them with the applicable laminated reference
  card.
• Ask the respondent to look at the options
  presented on the card.
• If the respondent declines to respond to a
  particular question, make a note in the margin.
  You will be able to note this when entering the
  data into the database (see REDCap training
  module).

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• If both the patient and family member are
  enrolled, conduct the interviews as close to each
  other as possible.
• If the interview is started, then part way
  through the respondent withdraws their consent to
  continue do not discard the questionnaire.
• Questionnaires that are gt 50 complete should be
  included.
• Questionnaires that are lt 50 complete can not be
  included. Another patient will need to be
  enrolled to replace this respondent.

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Reference Cards

• Reference card templates are provided to
  participating institutions to assist with the
  administration of the questionnaire.
• These can shown to a respondent to assist them
  in answering a question.
• Ensure you use the correct card set for the type
  of respondent.

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ACP Questionnaire Walk-Through
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Questionnaire Breakdown
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Enrollment
Duration of interview
Interview Date
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Section 1 Patient Demographics

• Enable us to adequately describe the patients
  involved in this study
• Will help us explain if certain types of patients
  are or are not involved in ACP

ACP pg. 2
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Section 1 Demographics, Health Literacy

• Health Literacy is a key determinant to
  preferences for EOL treatment. We are using a
  validated short item questionnaire to measure
  health literacy, the REALM tool.
• Provide the respondent with the reference card
  (CARD 1)
• Ask them to read down the list, pronouncing aloud
  as many words as they can.
• Interviewer scores the number of correctly
  pronounced words

ACP pg. 2
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Section 1 Demographics, Ethnicity Language

• Impact of ethnicity on access to healthcare
  resources
• Disparities are most related to whether you
  appear as a visible minority and speak another
  language, other than the 2 official languages of
  Canada.
• Categorize patients/family members as to whether
  they appear to be Caucasian (by appearance) and
  by asking the patient/family member if the are
  proficient in another language other than English
  (or French if in Quebec).

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• We will want to be able to categorize
  patients/family members into one of the 4
  quadrants

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Section 1 Frailty Index

• Consider the patients overall condition two
  weeks prior to admission to the hospital
• Some interviewers have noted that the patients
  response to this question differs from the family
  members response to this question. In the cases
  where there is a discrepancy between the
  respondents answers, always use the patients
  (self-report) response.

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ACP Questionnaire Family Member

• Section 1
• Family Member Demographics
• Patient Demographics
• Frailty Index
• Section 2
• Section 3
• Section 4
• Section 5
• Section 6

Complete if patient not enrolled in study
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Section 2 Determinants of Decision Making

• Questions that may relate to the respondents
  preferences for EOL care
• We will analyze and to see if we can better
  understand the key determinants to preferred care
  at EOL.

ACP pg. 4-5
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Lifetime Line - Question 6

• Patient indicates where they see themselves
  between life and death.
• Measure the distance from the Birth anchor to the
  patients mark. Round to the nearest millimeter.

ACP pg. 5
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• This is a particularly difficult question for
  respondents to answer.
• You can ask this question at a different point in
  the interview.
• Some respondents are not able to make a mark but
  indicate verbally their response (e.g. 3 years
  left to live) or they simply can not provide a
  response. Please make note of this responses on
  the questionnaire
• Mark a line on the page, measure the distance
• Enter a verbal response
• Respondent could not answer

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Section 3 Decisions About Your Health Care Prior
to Hospitalization

• In this section, we are trying to ascertain
  whether the respondent has engaged in ACP PRIOR
  to hospitalization.

ACP pg. 6-10
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Section 3 Question 3

• It is important that the respondent understand
  the meaning of the term life sustaining
  treatments first mentioned in questions 2, 3
  and in subsequent questions.
• Before asking question 3 give the respondent
  CARD 3 which explains life sustaining treatment
  options, so we can be sure they know to what we
  are referring.

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Section 3 Question 7

• If the respondent has answered yes they have
  discussed their preferences for using or not
  using life sustaining treatments with someone,
  proceed with asking the questions presented in
  the table.
• Each table row asks whether the respondent
  engaged in these with a specific individual (e.g.
  Family doctor, nurse, lawyer, etc).
• If the response is yes, follow-up questions are
  asked regarding some of the details surrounding
  the discussion (e.g. how often, when they last
  spoke about this matter and under what
  circumstances).

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Section 3 Question 9

• Part a) of this question has a blank contained
  within to allow for the participating institution
  to apply the relevant document to their
  province/region/institution.

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Section 3 Question 9

• This question has a blank contained within to
  allow for the participating institution to note
  the relevant type of document for their
  province/region/institution.

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Section 4 Goals of Your Health Care During the
Current Hospitalization

• This section is trying to determine the
  respondents perspective on communication and
  decision making about the use of life sustaining
  treatments while in hospital (during current
  hospitalization, not prior to hospital or
  previous hospitalization).
• If respondents refer to previous conversations
  outside the current hospitalization, please keep
  directing them back to conversations and events
  during the current hospitalization.

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• For each question in this section, you are asking
  the respondent Did this happen, yes or no?
• If no, we want to know how important that issue
  is to the respondent.
• If yes we want to know both how important and
  how satisfied they are with the issue.

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Section 5 CANHELP

• The CANHELP questionnaire is a formal, validated
  satisfaction with EOL care measurement tool.
• We are using the validated subscales pertinent to
  ACP
• Literally read the instructions at the beginning
  of the questionnaire.
• Also, explain that you are asking about their
  rating of care over the past month, regardless as
  to where the care occurred (at home, hospital or
  other location).

ACP pg. 15-16
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Section 6 Barriers Facilitators

• Section 6 offers the respondent an opportunity to
  share any barriers and/or facilitators they
  experienced concerning discussions with health
  care professionals about ACP.
• Record their responses verbatim.

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Parting words to the respondent

• You have now completed the respondent interview
  portion of the ACP questionnaire.
• At the conclusion of the interview please thank
  the respondent for their time and candor in
  sharing information about this important topic.
• If the respondent requests more information
  regarding ACP please refer them to the
  appropriate individual on the ward (e.g. Social
  Worker).
• It is also advisable to make a Progress Note
  entry into the patients medical chart to alert
  any other members of the patients care team that
  an interview regarding ACP was conducted.

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Section 7 Documentation of ACP/AD in Medical
Chart

• The purpose of this section is to record any
  ACP/AD documents found on the medical record at
  the time of the interview.
• This data collection can occur either immediately
  before the interview or immediately after.

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• If both the patient and family member are
  interviewed, section 7 should be completed at the
  point of first contact.
• (i.e. after the first interview).
• If blank documents are found in the medical chart
  (e.g. goals of care form, tracking record or My
  Voice workbook) they should be indicated as not
  present in Section 7 of the questionnaire.

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• Some interviewers have noted that responses
  provided to them during the interview are not
  consistent with what is found documented in the
  medical chart.
• E.g. a patient indicates that they do not have
  any advance directives but a DNR form is found on
  the medical chart.
• This is an observational study, our role is to
  collect data and see what happens over the course
  of the patients stay. Do not intervene with the
  respondent and try to correct any
  inconsistencies.
• The only reason a study team member should
  intervene is if the patient experiences
  emotional/psychological trauma, induced by our
  interview, and help from the clinical team is
  required to deal with the situation.

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Documentation Requirements

• Hard copies of all study documentation should be
  retained and filed
• Consent form
• Completed ACP Questionnaire
• Case Report Form (i.e. Chart Abstraction form).
  See Module 6.

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Training Module 5 Complete