Hospice and Palliative Medicine
I’m at the Intensive Board Review course in Boston and in the middle of a whirlwind of learning. Dr. Joseph Shega’s lecture on Dementia and feeding tubes provided excellent clinical evidence to support my article in yesterday’s New York Times Well Blog post, Food and the Dying Patient
By Jessica Nutik Zitter, MD
The Joint Commission has proposed “enhancements” to the advanced certification requirements for palliative care programs and has requested comments by August 21, 2014 via online survey. A healthy debate about some of the new requirements is taking place on AAHPM listservs and social media platforms. I love seeing the passionate concerns about how best to define high quality palliative care programs. Some of the themes that have emerged remind me of debates at other points in our young history as field. I thought it might be useful to reflect on a few of the past points when the field had to draw a line in the sand and say “this is what good palliative care looks like.”
In the mid ‘80’s the initial hospice Conditions of Participation (COP) laid out in fine detail what was required to be a hospice that could get Medicare reimbursement. Some hospices passionately resisted Medicare certification, feeling that the rigidity in the COPs would negate the “hospice spirit.” But it is worth noting that those initial Conditions of Participation enshrined certain aspects of the “hospice spirit” that were revolutionary for health care at the time, notably the emphasis on interdisciplinary care planning, the requirement for meaningful volunteer participation, and the requirement for bereavement follow up for families.
In the early and mid 2000’s, we had a series of debates about standards for certification of physicians (lots of concern about whether requiring two years of experience was too high a bar for entrance for the old ABHPM exam – or not high enough), accreditation of fellowship programs (with actual raised voices – if I remember correctly – around the issues of how much time in a hospice rotation and how many home visits should be required for trainees), and articulation of the competencies for hospice and palliative medicine specialists.
All of these processes for setting standards shared a common challenge:
finding a balance between two competing goals. On the one hand is the goal for clearly stipulating each structure, process and outcome that effectively enhances the quality of patient care. On the other hand is the need to be parsimonious so that the requirements, including the reporting burden, are achievable and reasonable.
People arguing for a tougher standard usually claim its necessity for ensuring the quality of care, while people arguing for a lower standard usually point out how difficult (or impossible) the standard will be to meet for the “average” program. I remember during the debate about fellowship accreditation standards that one of our very wise leaders pointed out that a higher standard was actually a very useful tool that program leaders could use in the fight to get resources for a program. This fellowship director – whose program at the time did NOT have a hospice rotation – said that he had been fighting to get a hospice rotation but couldn’t get approval from various GME office higher ups. There were too many objections about sending trainees out of the institution, vetting the hospice faculty, etc. But if the accreditation requirements specified a hospice rotation – whether of one month or 6 months (the amount under debate at the time) – he would easily get his GME office on board. “If it’s required, they’ll do it.”
I think it would be useful to keep this in mind when thinking about some of the proposals for TJC standards that may be very difficult for current programs to meet. For instance, some argue that palliative care programs should be able to provide consults 24/7, not just during business hours. This is consistent with the National Consensus Project standards, but is not the current norm for most hospital-based palliative care programs. And it would be a VERY difficult standard for small programs to meet. N of 1 programs would find it virtually impossible, unless they got very creative and worked out call sharing arrangements with other services. Or argued with the hospital C-suite – backed up by stiff TJC requirements – that they HAVE to expand and hire more palliative care service staff.
The realities are that workforce shortages and financial limitations may make it very difficult for many programs to achieve a standards bar set at a high level. But the very fact of setting the bar so that it is a challenging goal to shoot for, and not just an easy ratification of existing practices, may help raise the level of the entire field. In the push-pull between the highest standards and easy achievability, there is some just right place in between. I think we would do well as a field to continue our history of setting the bar high enough for a challenge – and then working to make sure all programs can get there. The guiding question – would I want to be cared for in a program like this? – won’t steer us wrong.
I invite others to comment and share their perspective, including on the TJC’s proposed revisions.
Consultant, Quality Initiatives
American Academy of Hospice and Palliative Medicine
On July 15, we had the opportunity to participate in a Summit convened by the American Board of Internal Medicine (ABIM) and attended by ABIM leaders and 26 societies representing both primary internal medicine and medicine subspecialties. The Summit was scheduled in response to the dissatisfaction with the ABIM Maintenance of Certification (MOC) program expressed by the greater internal medicine community. Stakeholders were provided the opportunity to share feedback from their constituents and discuss the MOC program. We presented the somewhat unique concerns of hospice and palliative medicine specialists:
- Hospice and palliative medicine has 10 co-sponsoring boards with varying expectations for MOC making the creation and approval of MOC activities that are relevant to HPM practitioners a challenge.
- At present, there is a lack of reciprocity between Boards for MOC activities.
- There is additional strain created on our already limited workforce by the requirement to maintain primary board certification. This is particularly onerous for those who practice HPM full time, as the vast material tested on the primary exam may be irrelevant to their practice.
A brief word of context: Since Hospice and Palliative Medicine received formal recognition as a medical subspecialty by the American Board of Medical Specialties (ABMS) in 2006 and the American Osteopathic Association (AOA) in 2007, AAHPM has been meeting with and advocating for the needs of the Hospice and Palliative Medicine (HPM) community related to certification, maintenance of certification (MOC) osteopathic continuous certification (OCC), and fellowship programs.
The American Board of Internal Medicine (ABIM) has been evolving its MOC program and there has been a great deal of communication between the ABIM, ABIM specialties and subspecialties, and ABIM physicians in the last few months. On July 10, ABIM announced several changes to the MOC. ABIM stated that it will:
- Increase flexibility on deadlines. ABIM’s Board agreed to create a year “grace period” for those who have attempted but failed to pass the MOC exam.
- Ensure transparency of information. In response to questions raised about ABIM’s governance and finances, they have added information to their website and ABIM’s 990s are publicly available on Guidestar.
- Ensure a broader range of CME options for medical knowledge/skills self-assessment (Part 2). To reduce redundancy and give physicians credit for relevant assessment activities in which they are already engaged, ABIM will align its knowledge assessment requirements and standards with already existing standards for certain types of CME products and providers.
- Provide more feedback regarding test scores. The ABIM agreed to provide more in-depth, actionable feedback on individual performance on all exam score reports by 2015.
- Evolve the “Patient Survey” requirement to a “Patient Voice” requirement. This requirement focuses on a variety of structured mechanisms to hear from patients. In addition to patient surveys, educational and training programs in patient communication, participation in patient/family advisory panels, and use of shared decision-making tools, activities which many of our members may already be doing, may also meet the patient voice requirement.
- Reduce the data collection burden for the practice assessment requirement. ABIM is re-designing the process to provide additional pathways to meet the requirement and focus more on measurement and improvement activities.
In a letter dated July 28, 2014, ABIM summarized the major issues presented at the Summit and reiterated that the purpose of the ABIM is to “issue a publicly recognized credential that indicates an individual has met professionally-determined standards in a defined discipline”. Specifically, they agreed that the secure exam “must evolve” and they announced plans to form a committee to explore how to move forward. Formal mechanisms for society input will be developed. Addressing extremely negative feedback related to Part 4 (self-evaluation of practice assessment), the ABIM promised dramatic changes over the next 12-24 months.
We are encouraged to learn of ABIM’s proposed changes to its MOC program and will continue to work closely with the ABIM to improve the MOC program. We welcome your comments and concerns . Your feedback enables us to accurately represent the concerns of our members. Please share your thoughts with us via the AAHPM blog.
Tara Friedman, MD, FAAHPM, AAHPM Board Member
Holly Yang, MD, FACP, FAAHPM, AAHPM Board Member
The HealthCare Chaplaincy Network held its first major conference on spiritual care in health care this past spring. The attendees were very pleased with the results and encouraged us to hold the event yearly.
We are now in the planning stages of our 2015 Conference titled “Caring for the Human Spirit: Integrating Spiritual Care in Healthcare”. Our aim is bring together a multidisciplinary international group of presenters and attendees to explore and discuss the latest research, clinical practice, education and advocacy issues in the integration of spiritual care in healthcare.
The conference will be on April 20-22 in Orlando, FL. Plenary speakers include Christina Puchalski, Betty Ferrell, George Handzo, John Swinton, Lucy Selman, and Lilliana Delima.
In addition to the plenaries, we have added sixteen 90 minute workshop slots to allow for small group interaction and networking and a broader range of topics. We are currently seeking proposals for these workshops.
Workshop proposals should include:
- Title of workshop
- Name(s) and credentials of the presenter(s)
- Three learning objectives
- An abstract of no more than 300 words describing:
- The issue the workshop will address.
- The relevance of this issue to the focus of the conference.
- The content to be presented to address that issue.
- The experience of the presenter(s) with this issue.
- The learning modalities to be employed.
All workshops should be aimed at the advanced practitioner/researcher and should maximize dialogue with participants. Preference will be given to multidisciplinary teams.
Proposals should be e-mailed to Sandra Jamison (firstname.lastname@example.org) by August 15, 2014. Questions should also be addressed to Ms. Jamison.
“All leaders are born, but exemplary leaders are made” (The Leadership Challenge®, A Wiley Brand)
Leadership is an observable set of skills and abilities that can be measured and learned. In fact, leadership development is really self-development.
AAHPM Leadership Forum: Ascend is an intensive two-day opportunity to explore leadership as it relates to relationship building, change management and coaching and mentoring. The model is highly interactive, because let’s face it – the complexity of the hospice and palliative care environment requires not only clinical expertise but also skilled communications in order to develop the care team in a way that ensures optimum patient experience. AAHPM Ascend is presented in partnership with the American College of Physician Executives (ACPE) and designed to equip emerging hospice and palliative physicians with effective leadership skills in their practice settings.
AAHPM Ascend brings nationally recognized ACPE faculty members Marty Martin and Kevin O’Connor, in addition to AAHPM Facilitators, who are hospice and palliative physicians. The facilitators will explore small group discussions around scenarios and topics that directly impact your work and role. In addition, a guided tour of the Leadership Practices Inventory® (LPI®) 360-degree Assessment will be provided by a certified LPI® coach to deepen the experience for attendees.
The Leadership Practices Inventory (LPI® 360) assesses five leadership domains, including:
- Model the Way
- Inspire a Shared Vision
- Challenge the Process
- Enable Others to Act
- Encourage the Heart
Over 30 years ago, Santa Clara University Business School Professors Jim Kouzes and Barry Posner set out to discover exactly how ordinary people accomplish great things. In fact, they wrote the book that has stood the test of time to become the modern classic on leadership. More than 2 million people worldwide have read their BusinessWeek bestseller, The Leadership Challenge®
Effective leaders develop higher performing teams and foster renewed loyalty and commitment, as well as higher levels of engagement and focus to meet patient’s needs; provide opportunities for engagement, clinical expertise and a self-reflective approach to leadership; and inspire teams to exceed expectations through a self-reflective, self-renewing model.
So what is the LPI® 360 and how can it be an effective development tool? The Leadership Practices Inventory®, (LPI®) 360 is an evidence-based assessment tool. Assessing frequency of 30 leadership behaviors serve as a basis for a development plan. It’s a journey, and this assessment measures one point in time, based on 30 observable behaviors. The insights discovered through the LPI® 360 process and report fosters a proactive, development approach to increasing frequency of leadership skills in practice, in order to become more self-aware and more effective as a leader.
Registration is limited to 70 participants, so early register today – space is filling up fast!
Cory Ingram, MD, MS, FAAHPM
I had the good fortune of participating in Dr. Stephen Beeson’s Ignite workshop at this years annual assembly meeting. The first of a series of leadership workshops offered in sequence from AAHPM. Dr. Beeson shared that the foundation to leadership is an ability to create a common ground. A well understood common ground. This is achieved through leadership skill that include listening, conflict resolution, relationship building, effective communication, giving and receiving or better yet inviting feedback. Lastly, it is about having the right mindset.
The right mindset is one of two cognitive stances. Either a fixed mindset or a growth mindset. The fixed mindset responds to a challenge with and inability to see a solution. The person with a growth mindset sees opportunity in a challenge. In creating and achieving common ground it is important to foster a growth mindset and a commitment to the common ground and not necessarily anyone person, but rather the team and the common ground. The common ground is best conveyed through story. A patient story that allows the common ground to be felt. Common ground building flows from a common vision of what is hoped to be achieved. In building a common ground culture change will happen slowly 4-6 people at a time.
Dr. Beeson suggested the use of huddles, debriefs, and rules of engagement to foster effective communication and overcome challenges. The huddles and debriefs must include the common ground. Ascribing to the motto: “All of us is better than one of us” allows for talent to be tapped from all the team members. Fostering curiosity from the team members allows for group reflection to ensure nothing is being missed and that the group is on the right track. Trust among team members is paramount. Keep in mind it takes two to create trust and one to break that trust. Elite teams have a clear mission and identity and mission trumps identity. Their roles are clear and communication effective. Coaching and training are both available on the team and members receive recognition of great work.
How do you recognize success? Contagion is likely the sign of success and is defined at the lateral movement of the common ground. It will spread on it’s own.
I wish I could attend the next leadership forum this fall and would encourage attendance of this leadership workshop series from AAHPM. Thanks AAHPM for offering such a valuable resource for professional development.
AAHPM Leadership Forum: Ascend
AAHPM Ascend is a new intensive two-day program included in AAHPM’s comprehensive new Leadership Forum
premiering September 14–16, 2014, in Oak Brook, IL. This program has limited capacity and will be offered in
The AAHPM annual meeting has been known to be one of “the best support groups from all around the world.” It provides an opportunity to meet with dedicated, visionary, like-minded colleagues and reignite our shared passion. Sometimes though, we need a little bit more focused attention on our own career development.
This is where my AAHPM mentorship story starts. Career development as a junior faculty member committed to palliative medicine can be very challenging. It’s even harder when you try to combine another field, like I did in geriatric medicine. I wanted a mentor who understood key issues in both geriatrics and palliative medicine. I also wanted several qualities in a mentor: someone who excelled at scientific endeavors and at caring for patients, a good sense of humor, enthusiasm, and the ability to think critically yet speak kindly was a must-have. This is where Eric Widera came in, well, almost.
My personal needs assessment was done. I knew I needed mentorship, identified the qualities that I wanted in a mentor, the only problem was “the ask.” Approaching someone to be your mentor can be very awkward. Wondering around the annual assembly asking people who inspire you to be your mentor doesn’t work (I know — I tried). Fortunately I was redirected by Arif Kamal and Thomas LeBlanc who shared information about their successful experiences with the AAHPM year-long mentorship program with me. In addition to identifying mentors who had the qualities they wanted, Arif and Thomas had created an action plan for collaboration that demonstrated mutual interest and investment from both mentor and mentee.
I revisited my mentorship needs assessment and added an action plan with objectives that I wanted to accomplish at the end of the year. Then I thought: “who would be excited to do this as well?” and this is actually where Eric came in.
Since I already knew Eric, I did not need someone to help with introductions. What I needed was an “ask” that would get his buy-in. Eric is a social media guru who knows almost every pop culture reference, so my mentorship collaboration proposal was a Top-Ten List in PowerPoint format. As you likely deduced, it worked.
Over the course of the year-long AAHPM mentorship program, I was able to do the following:
• Visit UCSF where I received advice from the faculty on several projects that I was working on and on my own career development plan
• Organize an amazing group of faculty to present at the Reynolds, AGS, and AAHPM annual meetings
• Publish curricula on conducting code status discussions on the MedEd Portal
• Co-author a “Curbside Consultation” article published in the American Family Physician about how to discuss hospice care with patients (and was invited to write another one on Advance Directives)
• Work with a task force to successfully disseminate the AGS Geriatrics Evaluation and Management Tools to VA health care providers
The AAHPM mentorship year has been an enormously positive experience. I still can’t believe that AAHPM essentially paid me $1500 and provided free conference registration for me to receive career advice, networking connections, editorial expertise, and life coaching. I also hope they don’t start charging for this now that I pointed it out (oops-sorry future applicants). I am truly grateful and indebted to AAHPM and Eric for this wonderful mentorship opportunity. My mentorship advice to everyone who is thinking of applying: do it while it is still free!
Written by Shaida Talebreza (with mentorship from Eric Widera)
Palliative Care Network’s unique conference strives to achieve its mission of “Palliative Care for Everyone, Everywhere.” This is achieved by ensuring the free flow of information and narrowing the knowledge gap. Submission, participation, and access to conference materials is FREE. The online conference allows palliative care professionals from various disciplines around the world to share and improve the understanding of palliative care. This ultimately results in alleviating suffering of patients worldwide. The conference is an academic exercise held in collaboration with leading Palliative Care organizations. Join for FREE and take part in the conference.
Last October, I was fortunate enough to attend the National Palliative Care Research Center’s “Kathleen M. Foley Research Retreat” as one of AAHPM’s Research Scholars. The annual Foley Retreat brings together the country’s leading experts in palliative and hospice care research to discuss the state of the science, set priorities for future research, and allow for the creation of new friendships and collaborations among colleagues. It is a remarkable experience.
As a non-clinician health services researcher whose work is clinically-focused, it can sometimes be a little bit daunting to find where you belong. Does a non-clinician fit in at a clinical society meeting (like AAHPM’s Annual Assembly)? Sure. But often, the annual meetings of clinical societies predominately cater their offerings towards practitioners – and rightly so. Well, what about more methods-focused organizations? Sure, those are phenomenal meetings, too, but let’s be honest – sometimes those meetings tend to “geek out” over the minutiae of research methods at the expense of real-life applicability. The sweet spot for someone like me can be hard to find.
But enough with my Goldilocks-meets-Little Orphan Annie soliloquy. I can confidently say that after last fall’s NPCRC Foley Retreat, I have found a community where I believe that I belong. The Foley Retreat is one of the most inspiring meetings I’ve attended, and the passion of its attendees is readily apparent. These individuals are the true leaders and innovators in palliative care research. They are the ones actively working to build the evidence base for the care of those with serious illness, the ones who have paved the way for junior palliative care researchers, and the ones who we ultimately aspire to emulate in our careers. Aside from seeing exciting research presented by both junior and senior colleagues funded by NPCRC and ACS, there is another aspect of this retreat worth highlighting. The relaxed atmosphere of the retreat allows for friendly and supportive interactions amongst attendees. Indeed, I have never felt so welcomed during another professional meeting – mid-level and senior researchers were genuinely interested in my work, freely providing their suggestions, perspectives, and general career mentorship. The Foley Retreat makes the nurturing of junior attendees a priority – something that as an early stage investigator myself, I truly appreciate.
I can’t adequately thank AAHPM for its ongoing commitment to my career development. The Research Scholars Program is but one example of how AAHPM is dedicated to supporting and advancing the careers of junior palliative care researchers. Thank you for affording me the opportunity to participate in such a phenomenal experience. I’m already excitedly looking forward to next year’s retreat!
Dio Kavalieratos, PhD
Postdoctoral Fellow, University of Pittsburgh School of Medicine
Adjunct Assistant Professor of Health Policy and Management, University of North Carolina at Chapel Hill
So how is the leadership thing working out? Palliative care, hospice care and healthcare in general has evolved into the most complex team sport of all time. And getting people to move cohesively around a simple common ground effort should not be that hard…but it is. Some try the bull-horn approach (I did that for a while…and it worked as well as me telling my patients to lose weight), other leaders try the expert approach (I am so smart…that I will just do it myself…)- that didn’t work either (and it was really tiring). Leadership is about building influence and the capacity to change anything with your teammates…not to them.
How do we do this? How do we create common ground that everyone knows, supports and contributes to? How do we tap the intelligence of the team (all of us is always smarter than one of us)? How do we effectively communicate with each other. All of this sounds so simple, but so infrequently done. I look forward to spending a day of discovery, skill building and practice to lead your team. See you soon-
Stephen Beeson MD
ACPE faculty Stephen C. Beeson, MD, will lead the 2014 AAHPM Leadership Forum Ignite Program – Physician Engagement & Influence in Organizational Management. Ignite premieres during the 2014 Annual Assembly and will be offered as a full-day learning experience in subsequent years.