Serious illness care quality during COVID-19: Identifying improvement opportunities in narrative reports from a National Bereaved Family Survey.

BACKGROUND: COVID-19 significantly impacted care delivery to seriously ill patients, especially around including family and caregivers in patient care. AIM: Based on routinely collected bereaved family reports, actionable practices were identified to maintain and improve care in the last month of life, with potential application to all seriously ill patients. DESIGN: The Veterans Health Administration's Bereaved Family Survey is used nationally to gather routine feedback from families and caregivers of recent in-patient decedents; the survey includes multiple structured items as well as space for open narrative responses. The responses were analyzed using qualitative content analysis with dual review. SETTING/PARTICIPANTS: Between February 2020 and March 2021, there were 5372 responses to the free response questions of which 1000 (18.6%) responses were randomly selected. The 445 (44.5%) responses from 377 unique individuals included actionable practices. RESULTS: Bereaved family members and caregivers identified four opportunities with a total of 32 actionable practices. Opportunity 1: Facilitate the use of video communication, included four actionable practices. Opportunity 2: Provide timely and accurate responses to family concerns, included 17 actionable practices. Opportunity 3: Accommodate family/caregiver visitation, included eight actionable practices. Opportunity 4: Offer physical presence to the patient when family/caregivers are unable to visit, included three actionable practices. CONCLUSION: The findings from this quality improvement project are applicable during a pandemic, but also translate to improving the care of seriously ill patients in other circumstances, such as when family members or caregivers are geographically distant from a loved one during the last weeks of life.

Identifying Opportunities to Improve End-of-Life Care During the COVID-19 Pandemic Using Family Narrative Reports (FR214C)

Outcomes 1. Apply bereaved family suggestions for improving end-of-life care quality in the context of COVID-19 2. Describe opportunities to improve end-of-life care quality using qualitative methods on family and caregiver narrative reports Introduction The COVID-19 pandemic led to changes, such as visitation restrictions, that impacted the nature of care delivered to seriously ill patients, especially around including family and caregivers at the end of life. The VA Quality Improvement Resource Center (QuIRC) for palliative care aimed to identify actionable practices to improve end-of-life care quality during the global pandemic. Methods The VA's Bereaved Family Survey (BFS) is used nationally to gather routine feedback from families and caregivers of recent in-patient decedents. QuIRC leveraged the qualitative comments from the BFS. Between February 2020 and March 2021, there were 5,372 responses to two open-ended questions and one open share space in the VA's BFS, of which 1,000 (18.6%) responses were randomly selected. 445 (44.5%) of the responses were related to COVID-19. These were analyzed using standard qualitative content analysis with dual review. Results Four opportunities with a total of 32 actionable practices were suggested by bereaved family members. Opportunity 1: Facilitate the use of video communication (included four actionable practices). Opportunity 2: Provide timely and accurate responses to family concerns (included 17 actionable practices). Opportunity 3: Accommodate family/caregiver visitation at the end of life (included eight actionable practices). Supporting quote: "We were able to be with him as he took his last breath. We were so very thankful we were able to be with him.” Opportunity 4: Offer physical presence to the patient when family/caregivers are unable to visit (included three actionable practices). Supporting quote: "It was so comforting to know, sitting here in [remote location], that [patient name] was not dying all alone.” Conclusion The findings from this quality improvement project are applicable during a global pandemic, but also translate to improving end-of-life care in all circumstances, such as when family members or caregivers are geographically distant.

Protecting the healthcare workforce during COVID-19: a qualitative needs assessment of employee occupational health in the US national Veterans Health Administration.

OBJECTIVE: Early in the COVID-19 pandemic, US Veterans Health Administration (VHA) employee occupational health (EOH) providers were tasked with assuming a central role in coordinating employee COVID-19 screening and clearance for duty, representing entirely novel EOH responsibilities. In a rapid qualitative needs assessment, we aimed to identify learnings from the field to support the vastly expanding role of EOH providers in a national healthcare system. METHODS: We employed rapid qualitative analysis of key informant interviews in a maximal variation sample on the parameters of job type, rural versus urban and provider gender. We interviewed 21 VHA EOH providers between July and December 2020. This sample represents 15 facilities from diverse regions of the USA (large, medium and small facilities in the Mid-Atlantic; medium sites in the South; large facilities in the West and Pacific Northwest). RESULTS: Five interdependent needs included: (1) infrastructure to support employee population management, including tools that facilitate infection control measures such as contact tracing (eg, employee-facing electronic health records and coordinated databases); (2) mechanisms for information sharing across settings (eg, VHA listserv), especially for changing policy and protocols; (3) sufficiently resourced staffing using detailing to align EOH needs with human resource capital; (4) connected and resourced local and national leaders; and (5) strategies to support healthcare worker mental health.Our identified facilitators for EOH assuming new challenging and dynamically changing roles during COVID-19 included: (A) training or access to expertise; (B) existing mechanisms for information sharing; (C) flexible and responsive staffing; and (D) leveraging other institutional expertise not previously affiliated with EOH (eg, chaplains to support bereavement). CONCLUSIONS: Our needs assessment highlights local and system level barriers and facilitators of EOH assuming expanded roles during COVID-19. Integrating changes both within and across systems and with alignment of human capital will enable EOH preparedness for future challenges.

Opportunities for improving opioid disposal practices in the Veterans Health Administration.

PURPOSE: The potentially vast supply of unused opioids in Americans' homes has long been a public health concern. We conducted a needs assessment of how Veterans Affairs (VA) facilities address and manage disposal of unused opioid medications to identify opportunities for improvement. METHODS: We used rapid qualitative content analysis methods with team consensus to synthesize findings. Data were collected in 2 waves: (1) semistructured interviews with 19 providers in October 2019 and (2) structured questions to 21 providers in March to April of 2020 addressing how coronavirus disease 2019 (COVID-19) changed disposal priorities. RESULTS: While many diverse strategies have been tried in the VA, we found limited standardization of advice on opioid disposal and practices nationally. Providers offered the following recommendations: target specific patient scenarios for enhanced disposal efforts, emphasize mail-back envelopes, keep recommendations to providers and patients consistent and reinforce existing guidance, explore virtual modalities to monitor disposal activity, prioritize access to viable disposal strategies, and transition from pull to push communication. These themes were identified in the fall of 2019 and remained salient in the context of the COVID-19 pandemic. CONCLUSION: A centralized VA national approach could include proactive communication with patients and providers, interventions tailored to specific settings and populations, and facilitated access to disposal options. All of the above strategies are feasible in the context of an extended period of social distancing.