ACHC Palliative Care Accreditation: Community Hospital Program Achieves National Recognition

IHS Approach

Phase 1: NCP Guideline Mapping and Gap Analysis (Month 1)

IHS conducted a domain-by-domain mapping of the program's existing policies, assessment tools, and documentation practices against the 8 NCP Clinical Practice Guideline domains: Structure and Processes of Care, Physical Aspects of Care, Psychological and Psychiatric Aspects, Social Aspects, Spiritual/Religious/Existential Aspects, Cultural Aspects, Care of the Patient Near the End of Life, and Ethical and Legal Aspects. The mapping confirmed that all 8 domains were addressed clinically but that documentation and policy infrastructure had significant gaps in Domains 3, 4, 5, and 8.

Phase 2: Goals-of-Care Documentation System (Months 2-4)

IHS designed a structured goals-of-care documentation framework for both the inpatient and outpatient settings. The framework included: a standardized goals-of-care conversation documentation template capturing the conversation participants, key patient values and preferences expressed, clinical prognosis communication documented, and specific goals established; a goals-of-care documentation requirement embedded in the initial palliative care consultation note template; and a care plan linkage protocol ensuring that documented goals drove care plan content. Clinical staff training was conducted on the documentation standard.

Phase 3: IDT Meeting Structure and Documentation (Months 2-3)

IHS designed a formal IDT meeting structure for the inpatient consultation service, including: a structured weekly IDT meeting agenda covering active consultation patients, required disciplines present, care plan review and update documentation, and action item tracking. A standardized IDT meeting documentation form was implemented. The outpatient clinic established a monthly IDT case conference with the same documentation standard.

Phase 4: NCP Domain Policy Infrastructure (Months 3-6)

IHS developed or revised policies and assessment tools to close the documentation gaps in Domains 3-5 and 8. This included: a psychological and psychiatric symptom assessment protocol with standardized screening tools (PHQ-9, GAD-7) integrated into the palliative care assessment workflow; a social needs assessment tool with documentation requirements; a spiritual care assessment protocol with chaplaincy referral criteria; and an ethical consultation referral policy with documentation requirements for ethics committee involvement.

Phase 5: QAPI Program Build (Months 2-12)

IHS designed a palliative care-specific QAPI program with seven indicators: goals-of-care documentation completeness rate, pain assessment documentation completeness, IDT meeting attendance documentation compliance, advance directive completion rate for inpatient consultations, patient/family satisfaction (program-specific survey), time to initial consultation from referral, and outpatient visit documentation completeness. Monthly data collection and quarterly QAPI meetings were established beginning month 2, with 10 months of trend data available at survey time.

Phase 6: Outpatient Documentation Standardization (Months 4-7)

IHS revised the outpatient clinic's documentation infrastructure to align with the inpatient service: standardized initial assessment tool covering all 8 NCP domains, structured visit note template, care plan documentation requirements, and goals-of-care documentation integration. Staff training was conducted across both settings.

Phase 7: Mock Survey (Month 11)

The mock survey reviewed 20 inpatient consultation records and 10 outpatient records, conducted staff interviews across all disciplines, and assessed the program's QAPI documentation. Two findings were identified: three outpatient records where the spiritual care assessment element was present but not linked to a documented clinical response, and one IDT meeting log missing the care plan update notation. Both were corrected within one week.