Rotation: Research and Quality Improvement

Over the course of fellowship, the fellow will be expected to design a quality improvement initiative for the Pediatric Palliative Care Service at Texas Children’s Hospital. Through mentorship, the fellow will conceive of an intervention as well as plan and execute several Plan-Do-Study-Act cycles and measure outcomes of their intervention. In addition, the fellow will learn about the role of clinical research in palliative care.

• The fellow will have four weeks dedicated time to work on the QI project (divided into two 2-week blocks), but will be able to use additional time on other rotations between activities to work on the project as well.
• Design a QI project of the fellow’s choosing. Implement the project and collect data from several PDSA cycles.
• The fellow will participate in calls for the Pediatric Palliative Care Research Network and engage in didactics related to research methods utilizing the scientific method in the care of patients.

Rotation coordinator: Dr. Jill Ann Jarrell. Contact: jajarrell@texaschildrens.org. Phone: (832) 826-8046.

Clinical experience: None.

Didactic experience: Directed readings about QI methodology and self-directed learning about research topic of choice. In addition, online modules by the Center to Advance Palliative Care outlining consensus recommendations for performance measures for all hospice and palliative care programs to use for program improvement.

Daytime: Independent work on QI project including readings, project design, and meetings with key stakeholders.

Call: No weeknight call. One weekend call per month. Weekend calls include daytime rounding as well as overnight home call.

• Timely verbal feedback provided by faculty throughout rotation.
• Structured written evaluation of fellow using American Academy of Hospice and Palliative Medicine evaluation tools at end of rotation.
• Fellow provides feedback to program director about rotation at end of rotation.

Goals and objectives based on Pediatric Hospice and Palliative Medicine Competencies, version 2.0

The fellow should demonstrate compassionate, appropriate, and effective care based on existing evidence base in pediatric palliative medicine and aimed at maximizing the well-being and quality of life for patients with chronic, complex, and/or life-threatening conditions and their families. The fellow should provide care in collaboration with other subspecialists and within an interdisciplinary team.

Objectives: Although the focus of this rotation is not direct patient care, clinical aspects will be addressed in the process of choosing an appropriate quality improvement project. Thus, at the completion of this rotation, the palliative care fellow will be able to:

• Consider healthcare delivery, management of specific disease processes, screening for palliative care needs, or other aspects of healthcare as an area to study.
• Formulate a complete care plan utilizing evidence-based palliative medicine and including all members of an interdisciplinary team.
• Utilize quality improvement methodology do improve patient care on the Pediatric Advanced Care Team, the pediatric palliative care consult service at Texas Children’s.
• The fellow will describe the problem they are seeking to address and how an improvement initiative would result in improved patient care.

The fellow should demonstrate knowledge about established and evolving biomedical, clinical, population, and social-behavioral sciences relevant to the care of patients with life-threatening conditions and to their families, and relate this knowledge to the hospice and palliative care practice.

Objectives: At the completion of this rotation, the palliative care fellow will be able to:

• Describe the scope and practice of pediatric palliative care including pain and symptom management, psychosocial stressors, spiritual distress, and grief.
• Recognize the role and importance of an interdisciplinary team in developing, conducting, and executing a quality improvement initiative in pediatric palliative care.
• Describe evidence-based quality improvement methodologies and demonstrate knowledge of their use.

The fellow should be able to investigate, evaluate, and continuously improve personal practices in caring for patients and families and appraise and assimilate scientific evidence relative to palliative care.

Objectives: At the completion of this rotation, the palliative care fellow will be able to:

• Utilize self-evaluation and feedback from interdisciplinary team to appraise his/her performance and continually improve.
• Demonstrate a habit of critical thinking, evidence-based decision-making, and continuous quality improvement.
• Identify and efficiently locate the best available information resources to address one’s question in developing a research project.
• Design and implement a quality improvement project related to a palliative care topic of their choosing.
  • Create list of potential topics
  • Delineate criteria for success
  • Establish list of required data
  • Plan an interventional strategy
  • Formulate a data review and analysis plan
  • Understand use of data analysis in QI
  • Conduct several improvement cycles to assess intervention
• Identify knowledge gaps in the course of providing patient care and cultivate the habit of continuous inquiry to expand one’s knowledge base.

The fellow should be able to demonstrate interpersonal and communication skills that result in effective relationship building, information exchange, emotional support, shared decision making, and collaboration with patients, patients’ families, and professional associates.

Objectives: At the completion of this rotation, the palliative care fellow will be able to:

• Utilize compassionate, effective communication skills to enhance interactions with patients and families, within the palliative care interdisciplinary team, and with other healthcare colleagues.
• Utilize learned communication skills to effectively navigate interactions with patients and families including information sharing, discussing concept of palliative care, discussing advance care planning and resuscitation status, discussing goals of care, and discussing symptoms and suffering.
• Demonstrate ability to communicate to team members the QI process.
• Demonstrate ability to effectively communicate QI interventions and outcomes to other healthcare providers as the project progresses.
• Upon the completion of the project, demonstrate the ability to formally present a quality improvement initiative to other healthcare providers.

The fellow should be able to demonstrate a commitment to carrying out professional responsibilities, awareness of his or her role in reducing suffering and enhancing quality of life, adherence to ethical principles, sensitivity to a diverse patient population, and appropriate self-reflection.

Objectives: At the completion of this rotation, the palliative care fellow will be able to:

• Demonstrate care that shows respectful attention to age/developmental stage, gender, sexual orientation, culture, religion/spirituality, disability, and family interactions.
• Demonstrate ability to balance the needs of patients, families, and team members with one’s own need for self-care.
• Recognize the role of self and the role of the system in prevention and disclosure of medical errors.
• Recognize his/her own limits and ask for help when needed.
• Discuss the ethics of research, including subject recruitment, informed consent, patient privacy and the role of Institutional Review Boards.
• In performing research that involves seeking information from patients and their families, respect privacy in obtaining such information.

The fellow should be able to demonstrate an awareness of and responsiveness to the larger context and system of healthcare, including hospice and other community-based services for patients and families, and the ability to effectively call on system resources to provide high-quality care.

Objectives: At the completion of this rotation, the palliative care fellow will be able to:

• Assess the value of care provided and advocate for care that is cost effective and represents best practices.
• Describe elements of the healthcare system relative to palliative care and constructs care plans that operate effectively within that system.
• Understand the costs of research.
• Determine the best methods of performing research within the constraints of residency and the medical system.
• Understand when research is appropriate and when it is not, considering the health of the patient, his/her understanding of the project, etc.
• Advocate for research to promote understanding of various disease processes or ways to deliver care.