UPMC, the Pittsburgh-based health system, has been working to foster shared decision-making across its 20-plus hospitals and its 5,100 licensed beds. The organization selected the ICU at UPMC St. Margaret, where communication was lacking between clinicians and patients and their families, as an opportunity to drive change.
Tami Minnier, RN, MSN
"Because no two patients are alike, shared decision-making becomes all about conversation, and not all clinicians are good at having a conversation," says Tami Minnier, RN, MSN, FACHE, chief quality officer for UPMC, which includes the 249-bed acute care and teaching hospital UPMC St. Margaret, about 8 miles east of the city's downtown.
UPMC tapped a palliative care expert to train the physicians and nurses in "how to open the door," using actors to role-play both clinicians and patients. One of the first things the clinicians learned is to identify the power of attorney. "You don't want to have this discussion with the wrong person and you can't just grab whoever is sitting in the waiting room," Minnier says.
Now clinicians meet with the patient (if possible) and the family members on day 3 or 4 of the patient's stay in the ICU—she says "that's when you typically know if care is going to be more complex"—to explain projections for care and the treatment options, Minnier says. "We lay out where we could go from here," and gather input.
UPMC's ICU program has been leadership-driven and supported, which Minnier says gives clinicians "the motivation and permission they need."
A helpful tool in these discussions has been the "goals of care" document, which Minnier hopes will be consistent in patients' electronic medical records in the near future. She says all patients should have a conversation with their doctors about their advanced directive and other wishes for care. At last count, thanks in part to National Healthcare Decisions Day each April 16, UPMC has provided goals of care forms through access on UPMC.com to more than 100,000 patients.