Standard 10: Hospice and Palliative Care

Why this criterion matters. Pain and other symptoms such as breathlessness, nausea and agitation drive most of the suffering in serious illness. Assessing them on a schedule, and acting on the scores, is what keeps patients comfortable.

Sample. Review the symptom assessment charts and plans for 20 patients on the service in the last 3 months, including any with uncontrolled symptoms.

1. Pain and symptoms are assessed on schedule with a validated tool.

Method. Check each sampled chart for scores at each scheduled assessment.

Evidence to show. Symptom assessment chart (HSP-FRM-001).

Pass when. At least 90% of scheduled assessments are recorded with a validated score.

2. Each patient has a written symptom plan with a review date.

Method. Check each sampled patient for a current plan and review date.

Evidence to show. Symptom plan within the individual care plan (CLN-FRM-003).

Pass when. Every sampled patient has a current plan with a review date.

3. An uncontrolled symptom is reviewed the same day.

Method. Check each uncontrolled symptom for the same-day review.

Evidence to show. Symptom assessment chart and plan change record.

Pass when. Every uncontrolled symptom has a same-day review.

Immediate fail (any one means the criterion is not met)

• A patient has uncontrolled pain or breathlessness with no review and no change to the plan.

Why this criterion matters. Opioids and other controlled medicines can cause harm through overdose, diversion or poor storage. Each dose reviewed, and each count recorded, keeps them safe for the patient and the staff.

Sample. Review the controlled drugs register and opioid review records for 20 patients on opioids in the last 3 months.

1. Each controlled medicine is counted and stored as the controlled medicines rules require.

Method. Count a sample of stock and check it against the register.

Evidence to show. Controlled drugs register (HOS-REG-001).

Pass when. Every counted balance matches the register.

2. Each opioid dose is reviewed when the condition changes.

Method. Check each opioid patient for a review after a change in condition.

Evidence to show. Opioid prescribing review record (MNP-FRM-001).

Pass when. At least 90% of changes in condition have an opioid review recorded.

3. Diversion and overdose are monitored.

Method. Check the monitoring record for each opioid patient.

Evidence to show. Opioid stewardship procedure (MNP-SOP-001).

Pass when. Every opioid patient has a monitoring entry in the last month.

Immediate fail (any one means the criterion is not met)

• A controlled medicine balance does not match the register and is not investigated.

Why this criterion matters. Patients with serious illness have goals and wishes that shape their care. If they are not asked and written down, care is given according to what the team assumes they want.

Sample. Review the goals and wishes records for 20 patients on the service, including any with an advance directive.

1. Each patient's goals, values and wishes are discussed and recorded.

Method. Check each sampled record for a goals and wishes entry.

Evidence to show. Goals, values and wishes record (HSP-FRM-002).

Pass when. At least 90% of sampled patients have a recorded entry.

2. Advance directives are recorded and held where they can be found.

Method. Check each advance directive for its location in the record.

Evidence to show. Consent and advance decision record (CON-FRM-001).

Pass when. Every advance directive is recorded with its location.

3. Goals are reviewed as the illness progresses.

Method. Check each record for a review after a change in condition.

Evidence to show. Goals, values and wishes record.

Pass when. At least 90% of changes in condition have a review recorded.

Immediate fail (any one means the criterion is not met)

• A patient with an advance directive is treated against it with no review recorded.

Why this criterion matters. Family and carers carry much of the burden of palliative care. Telling them what to expect, and supporting them, keeps the plan working at home and in the last days.

Sample. Review the family information and support records for 15 families, including 5 whose patient died in the last 6 months.

1. Families are told about the illness, the plan and what to expect.

Method. Check each sampled family record for the information given.

Evidence to show. Family support and bereavement follow-up record (HSP-FRM-003).

Pass when. At least 90% of families have the information recorded.

2. Each family has a named contact and the out-of-hours number.

Method. Check each sampled record for the named contact and the number given.

Evidence to show. Family support record.

Pass when. Every sampled family has a named contact and number recorded.

3. Carer support is offered and recorded.

Method. Check each record for the carer support offer and the answer.

Evidence to show. Family support record.

Pass when. Every family has an offer recorded.

Immediate fail (any one means the criterion is not met)

• A family of a dying patient is given no named contact or plan.

Why this criterion matters. Patients at the end of life have spiritual, cultural and emotional needs that can be as important as the physical ones. Asking about them, and acting on the answer, respects the whole person.

Sample. Review the needs records for 20 patients, and the chaplaincy and cultural practice records for the same period.

1. Spiritual, cultural and psychological needs are asked about at admission and at review.

Method. Check each sampled record for the question at both points.

Evidence to show. Spiritual, cultural and psychological needs record (HSP-FRM-004).

Pass when. At least 90% have the question recorded at admission and review.

2. The patient is connected to the chaplain or religious leader they choose.

Method. Check each request for the connection and its date.

Evidence to show. Needs record.

Pass when. Every request is connected the same day, or the reason is recorded.

3. Cultural practices are recorded and respected.

Method. Check each recorded practice against the care given.

Evidence to show. Needs record.

Pass when. Every recorded practice is reflected in the care plan.

Immediate fail (any one means the criterion is not met)

• A patient asks for a chaplain or religious leader and is not connected.

Why this criterion matters. The last days of life need a clear plan, comfort measures and a dignified environment. Without a plan, care becomes improvised and the patient suffers.

Sample. Review the dying care plan records for 15 patients who died in the last 6 months, and the comfort and pain records for the last 48 hours of each.

1. A written dying care plan is in place.

Method. Check each sampled death for a plan dated when the patient was recognised as dying.

Evidence to show. Dying care plan record (HSP-FRM-005).

Pass when. Every sampled death has a plan.

2. Comfort measures and pain control are given as the plan sets.

Method. Check each sampled plan against the doses recorded.

Evidence to show. Dying care plan record and medicines administration record.

Pass when. At least 90% of planned measures are recorded as given.

3. The plan is reviewed at each change in condition, and the family present is supported.

Method. Check each record for a review after a change and the family support recorded.

Evidence to show. Dying care plan record.

Pass when. Every change in condition has a review recorded.

Immediate fail (any one means the criterion is not met)

• A dying patient has no written plan, or pain is not reviewed when the condition changes.

Why this criterion matters. Palliative care needs skills that many clinicians do not learn in general training. Staff trained in palliative care and in talking about serious illness make the service safe and humane.

Sample. Review the training register for all staff in post, and the training matrix for the last 12 months.

1. Each staff member is trained in palliative care.

Method. Check the register for each person in post.

Evidence to show. Palliative care training register (HSP-REG-001).

Pass when. Every person in post has palliative care training recorded.

2. Training covers communication about serious illness and end-of-life care.

Method. Check each person's record for both courses.

Evidence to show. Palliative care training register.

Pass when. Every person has both recorded.

3. Training is recorded and refreshed.

Method. Check the refresher due dates against the register.

Evidence to show. Training matrix register (WRK-REG-001).

Pass when. No refresher is overdue.

Immediate fail (any one means the criterion is not met)

• A clinician with no palliative care training leads end-of-life care alone.

Why this criterion matters. Bereavement is a hard time for families, and some need help to cope. Offering follow-up after a death, and recording the offer, is a small act with a large effect.

Sample. Review the bereavement follow-up records for every death in the last 12 months.

1. Families are offered follow-up after each death.

Method. Check each death for a recorded offer.

Evidence to show. Bereavement follow-up procedure (HSP-SOP-005).

Pass when. At least 95% of deaths have an offer recorded.

2. The offer and the answer are recorded.

Method. Check each offer for the answer.

Evidence to show. Family support and bereavement follow-up record (HSP-FRM-003).

Pass when. Every offer has the answer recorded.

3. Families who accept are referred.

Method. Check each accepted offer for the referral date.

Evidence to show. Family support and bereavement follow-up record.

Pass when. Every accepted offer has a referral date.

Immediate fail (any one means the criterion is not met)

Why this criterion matters. A palliative service improves only if it looks at its own quality. Reviewing clinical quality, and asking patients and families what they think, shows what to change.

Sample. Review the quality review register for the last 12 months, the patient and family feedback summary, and every serious incident in the period.

1. Clinical quality is reviewed to improve the service.

Method. Check the register for a clinical review in each quarter.

Evidence to show. Palliative care quality review register (HSP-REG-002).

Pass when. Every quarter has a review recorded.

2. Patient and family feedback is requested and reviewed.

Method. Check the feedback summary for the period and the action taken.

Evidence to show. Patient feedback summary (QUA-REG-002).

Pass when. Feedback is summarised each quarter with an action.

3. Serious incidents are investigated.

Method. Check each serious incident for a root cause analysis.

Evidence to show. Root cause analysis (INC-SOP-001).

Pass when. Every serious incident has a root cause analysis.

Immediate fail (any one means the criterion is not met)

Why this criterion matters. Symptoms at night can be frightening and dangerous. A named clinician, reachable at any hour and with the patient's plan, gives the family a safe answer instead of a crisis.

Sample. Review the out-of-hours contact log for the last 3 months, and the on-call rota for the same period.

1. A named clinician with access to the plan is reachable at all hours.

Method. Check the rota for every hour in the period.

Evidence to show. On-call rota.

Pass when. The rota covers every hour.

2. Each out-of-hours contact is recorded with the time and the advice given.

Method. Check each entry in the log for the time and the advice.

Evidence to show. Out-of-hours contact log (HSP-REG-003).

Pass when. Every contact has the time and the advice recorded.

3. A crisis is escalated at once.

Method. Check each escalated contact for the time of escalation.

Evidence to show. Out-of-hours contact log.

Pass when. Every escalated crisis is escalated at once.

Immediate fail (any one means the criterion is not met)

• A family calls out of hours and no clinician with the plan is reachable.

Why this criterion matters. A decision not to resuscitate, or not to transfer to hospital, must be known to every clinician at the moment it matters. Recorded, dated and visible at the bedside, it is respected.

Sample. Review treatment limit records for 20 patients with a limit in the last 6 months, and check each one is visible at the point of care.

1. Each limit is recorded, dated and reviewed.

Method. Check each limit for the decision, date and review.

Evidence to show. Treatment limits record (HSP-FRM-006).

Pass when. Every limit is recorded, dated and reviewed.

2. The limit is visible to every clinician who may be called.

Method. Check the point-of-care display and the record for each limit.

Evidence to show. Treatment limits record (display).

Pass when. Every sampled limit is visible at the point of care.

3. The limit is known at the moment of crisis.

Method. Check the out-of-hours log for any crisis with a limit in place.

Evidence to show. Out-of-hours contact log.

Pass when. No crisis response goes against a recorded limit.

Immediate fail (any one means the criterion is not met)

• A decision not to resuscitate is not known to the clinician who is called.