IHI faculty member Lauge Sokol-Hessner, MD, is Associate Director of Inpatient Quality and Conversation Ready Team Leader at Beth Israel Deaconess Medical Center. He is also faculty for the IHI Virtual Expedition: Is Your Organization Conversation Ready?
Q: How would you describe the Conversation Ready concept?
There are two parallel and intersecting initiatives. One is The Conversation Project, which is focused on helping patients and families start to have conversations about end-of-life wishes. But the founders of that project realized it wouldn’t be sufficient. It will be hard to improve the care we give to patients if we, the providers in the health care system and our institutions, aren’t ready to have those conversations. So, while The Conversation Project helps create the social movement to have conversations, the Conversation Ready initiative really focuses on providers and institutions and helps them ensure that when patients want to talk about end-of-life wishes, we are ready to have that conversation.
Q: How has your organization implemented Conversation Ready?
First, we focused on the process that we want to evoke when a patient comes to us to talk about their wishes for care at the end of life. We describe this through the four Rs: reach, record, retrieve, and respect. We want to reach out to patients and families to ask what is important to them about their end-of-life care. We want to record those wishes in our medical record so that they are available at future points of care. At those future points of care, we want to then be able to retrieve that information and, thereby, do a better job of respecting their wishes, whatever those wishes may be. By reliably doing each of those steps — reach, record, retrieve, and respect — we think that will make us “Conversation Ready.”
To actual implement these concepts, we are organizing our work using Kotter’s change management framework. John Kotter studied change in institutions and organizations and asked, “How do we change places? How does the culture change?” He describes the answer in 8 steps: create a sense of urgency or a reason for action, build a guiding coalition or team, craft a vision, communicate it, remove obstacles, celebrate small wins, build on the change and make it part of the culture.
To craft our vision, we found ourselves contemplating the allergy analogy. We consider allergy information to be an essential part of care. We can’t care for patients appropriately unless we ask that question. We want to get to the point where knowing who the patient’s health care proxy is and having some sense of what is important to the patient regarding their end-of-life wishes are actually considered essential components of care, just like allergies. We want patients who come to BIDMC to know they’ll be cared for the way they would want. And we are doing that using Kotter’s framework to motivate people to want to change, help them figure out how to do it, and then support them through that process.
Q: What have been the keys to the success you've had so far?
One of the most important things was to form a good team. Our Chief Quality Officer, Ken Sands, decided to make Conversation Ready a priority. It became an annual operating plan goal and he has given it the executive-level support that I think something like this needs. We formed a team that includes representation from all over the hospital — not only clinical areas, but also regulatory affairs, IT systems, palliative care and social work. We also have two patient advisors on our team. It’s important to have broad representation on the team because to become Conversation Ready, you really need a lot of people and we need to include them in the process to figure out how to do this work.
Besides having executive buy-in and forming a good team, we have strived to work collaboratively by identifying who in our institution is already trying to do this better, and we asked ourselves “how can we learn from and work with them to help both them and the institution do better”? We want to enhance the work already underway and make it even better. This approach and message have really worked for us.
Q: The current health care environment is so challenging, especially with so many requirements, changes in reimbursement, constraints on time and resources, etc. With so many things that health care organizations have to do, how would you make the case for why improving end-of-life care is so important, especially when no one is mandating it?
That’s a great question. I think there are a couple different ways to answer it. One is that at some level, I think this is just the right thing to do. While that’s a hard argument to make to someone who is concerned about the financial stability of the hospital and of the health system’s financial success, I think it is important not to forget. The reason BIDMC is implementing Conversation Ready is because we want to provide excellent care to our patients. It is hard to do that if we do not know what is important to them and what they want for end-of-life care. I think that is the larger frame for this work.
The other argument for why this is valuable comes from the fact that there is increasing focus on end-of-life care and the associated costs. The statistics show that much of Medicare expenditures occur in the last year of life, if not the last few months, and many people are asking, “Why are we spending so much on patients who are so close to death? Is that the right thing to do or not?” These can be difficult questions to ask and we risk trending into discussions around “death panels,” so I prefer to focus on doing the right thing for our individual patients. Asking patients, “If you knew that your time were limited, what would be most important to you, how would you like to be treated if you’re near the end of your life?” helps us provide care that is more congruent with what is important to them. We know that many patients, if aware they are near the end of life, are likely to choose to forgo life sustaining treatments, instead opting for a natural death, often at home. So, if we focus on doing the right thing for our individual patients, we are likely to see benefits on a population level because we would be providing just the right amount of care — not too much and also not too little — at a time when it is most important to patients.
Q: What difference do you think it's made to be part of the Conversation Ready Community, as opposed to trying to make these changes on your own?
As an organization, we have learned a huge amount by being able to speak to the other institutions that were a part of the “pioneer” group of Conversation Ready organizations. I have reached out to several of them over the course of the year to learn more about how they are doing things at their institutions to inform our work at BIDMC. That has been a particularly valuable collaboration.
As an individual, I have also learned a lot by just seeing how they work within their institutions. What changes are they making to become Conversation Ready? What are the techniques that have worked for them? We have taken some of those ideas and are working to develop them at BIDMC.
Q: What tips do you have for organizations contemplating taking part in the Conversation Ready Community?
I would ask, “How can you ensure that you will get the most out of being a part of the Conversation Ready initiative? What are the things that you need in place to get the most value from it?” For us, making sure we had someone on our team that could participate in the conference calls and the other times that the group got together to learn was important. I would also ask, “Do you have the ability to have a regular meeting with an interdisciplinary group of people who can take what you learn from the Community and put it into practice?”
Q: How would you compare your progress in this area before and after you joined Conversation Ready?
At Beth Israel Deaconess Medical Center in Boston, there are many people around the institution who have been working on different aspects of becoming Conversation Ready for some years now. The challenge they kept having, however, was that they were bumping up against institutional obstacles that they couldn’t overcome and so their work was only able to go so far. It really wasn’t supported at a larger level within the organization. They also didn’t have a centralized resource to go to and ask questions. They didn’t know who else was working on these issues. They couldn’t pool their ideas and avoid reinventing the wheel. There just wasn’t a larger focus on it. We’re now creating that focus. The Conversation Ready group has become a resource to folks around the institution trying to get better at this, which is very exciting. It is a facilitating mechanism.
This is also similar to how we’ve related to the other Conversation Ready organizations. Personally, I have learned a lot just by looking at what others in the community are doing and thought to myself, “That’s a really cool idea” or “I like the way that they put that together.”
Sometimes the fact that another organization can do something makes me wonder if we can do it too. One of the most important things is to have some sense of what is out there and what’s possible and to “think outside the box.” Reaching out to other institutions, local environments, or departments is something we could do more, especially in academic medicine. Being able to do that on a regular basis, in a structured forum like the Conversation Ready Community, has been very valuable. It has helped us get a sense of where we are and how to get better.
It has also been exciting for us to be engaged with a lot of other organizations in the Community that agree this is important work. It can be really tough to get people to talk more about the end of life and death. It is not the easiest thing to motivate people around. So, it has been inspiring for us to be able to regularly touch base with a community in which everyone realizes the value and importance, and says, “This is difficult, but it is important and we should do it.” It has really motivated us.
For more information on the Conversation Ready Health Care Community please click here