Table 1.

Palliative Care Champions Committee Initiatives to Improve Advance Directive Completion

Timeline	Initiative
2006–2007	• Revise advance directive (AD) worksheet
2007–2009	• Ongoing in-service education of staff nurses about AD completion process
2010	• Biannual chart audit of all inpatient units on use of AD worksheet completion and AD scanning into the medical   record
2011	• Streamline the AD worksheet into a user-friendly electronic document that is available to all staff through the   electronic health record (EHR) • AD chart audits on all inpatient units
2012	• Develop an electronic AD education module with mandatory assignment to all RNs. Module objectives were to 1)   accurately complete an AD section in the EHR, 2) recognize the Health Information Management process for scanning a   patient’s legal AD into the EHR, and 3) locate a patient’s AD in the EHR • Health Information Management scanning initiative including specific bins/folders on each unit with daily   collection of ADs • One-on-one RN staff education with palliative care champion, focusing on review of different AD documents and   review of how to complete the AD section in the EHR • Continue chart audits on inpatient units
2013	• Quality improvement survey of RN staff about AD completion (July 2013) • Update AD documentation sections in the EHR • Generate automatic messages to inpatient RN staff if patient AD section incomplete • PCCC Graduate RN student chart audit of entire hospital • Prepare for and participate in the Joint Commission Advanced Certification for Palliative Care process
2014	• Develop education on EHR AD section • Develop algorithm and EHR reminders to assist nurses in identifying process for AD completion • Disseminate scripted phrases for AD conversations • Review and reeducate about state Healthcare Directive Statutes and various types of surrogate decision makers • Develop information sheet “Top 10 questions about AD that you are afraid to ask…” • Work with unit clerks to order materials and reorganize AD drawers • Palliative Medicine fellow conducts AD audits and shares results with champions on individual units
2015	• Conduct AD education focusing on RN “comfort of completion” • Update palliative care intranet site to include AD information and educational materials • Review of Health Information Management scanning initiative • Update computerized training module • Prepare for and participate in the Joint Commission Advanced Certification for Palliative Care process
2016	• Quarterly EHR-based, individualized inpatient unit audit and feedback reports on AD completion • Ongoing PCCC education of staff (in-services, posters) • Discuss with palliative care administration about having a dedicated team to have AD conversations with patients • Update Health Information Management scanning on each individual unit initiative: Direct scan to EHR on daily basis   and auditing of scanned documents
2017	• Conduct “unit competitions” with incentives awarded to winning unit for most ADs completed • Individual unit AD completion projects • Videos, posters, staff meeting agendas, individual 1:1 education sessions • Monthly EHR-based reports on AD completion • Quality improvement survey of RN, care coordinator, social worker, and medical assistant staff (August 2017) • Prepare for and participate in the Joint Commission Advanced Certification for Palliative Care process

^*AD section refers to the “Healthcare Directive Screening” section of the EHR.