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.

Dale Lupu
Consultant, Quality Initiatives
American Academy of Hospice and Palliative Medicine