C O L L A B O R A T I V E C A S E M A N A G E M E N T

Dying Well: Case Management Leads a Process Redesign Project

By May Mamiya, LCSW, CCM

The complexity of the American health care system today has resulted in frequent compartmentalization: body parts, treatment roles, support
activities are separated into categories and specialties. Often improved outcomes are achieved. However, at times, patients and families
complain about fragmentation and poor communication. Practitioners seeking to provide “holistic care” face many systems barriers.

Related to care at end-of-life, efforts to establish hospice or
palliative care programs have paradoxically contributed to the
dilemma. While excellent services become available to
patients accepted into such programs, those dying other
places in the hospital may not receive the same attention.
The process redesign effort described in this article was
not part of a hospice or palliative care initiative (although
practitioners from those programs were valued members of
the planning group). It actually started when the medical
center’s Morgue Committee
completed its charge: to streamline
the procedures by which staff –
literally – moved dead bodies from
nursing units to the hospital’s morgue
“Life changes
and from there to designated
mortuaries. Some participants felt
in the instant.
there was still work to do – focusing on
a different aspect of the dying process: The ordinary
the care of patients and families
before death occurs. Since the instant…”
discussion at the first committee
focused on all patients who died in Joan Didion
The Year of Magical Thinking
the facility, there was no
predisposition to separate out special
categories for those receiving hospice
or palliative care services.
The new Dying Well Task Force set for itself a straightforward
goal: to improve and make more consistent the supports
available to any dying patient (and his/her family and friends)
at Vassar Brothers Medical Center. Members knew some units
already provided remarkable care. But, they also recognized
there was considerable variation in responsiveness. In areas
where deaths were infrequent there was less awareness of
existing procedures (i.e., the ability to get a food tray for family
from the Dietary Department or a cot for an overnight stay)
and supports (pastoral care and social work staff, trained
volunteers, etc.). They also knew that some providers were
more comfortable than others in working with the terminally
ill. What seemed needed were easier access to available
resources and “coaching” about ways to offer support.
TASK FORCE ACTIVITIES
After six meetings over two and a half months, one tangible
result of the task force’s work was a resource binder – some 30
pages of information. Section One had a simple check-list to
remind staff of certain procedures (for example: advanced
directives completed, consult to palliative care or hospice
considered) and resources. It also included a form to use to request
food trays for families from the Dietary Department. Section Two
had more extensive resource listings – of both hospital and
community services, with specific referral instructions.
Relevant administrative and nursing policies comprised
Section Three and a concise guide to cultural and spiritual
traditions followed. The last section
included readings from Hospice
sources and professional journals.
Several laminated “Quiet Please”
signs (with an ocean picture) were
included to use as alerts outside
the dying patient’s room so all staff
would be alerted. Bereavement
materials, not new to the
organization but frequently
overlooked, were also added.
A newly crafted policy on “Care of
the Dying Patient,” written by the Task
Force, was included in Section Three.
It started with a clear statement of
commitment to “providing the highest
quality end-of-life care to patients and compassionate support
for their loved ones. Staff members recognize their legal, moral
and professional responsibility to meet patients’ medical needs
throughout the course of an illness and to respect treatment
choices. End-of-life care requires special attention to the
physical and emotional comfort of patients and their loved
ones. ” The fifteen procedural steps that followed elaborated on
the topics included in the manual’s check-list.
The focus was on the small details and the primary effort
was to tie together the existing services, policies, supports and
to make improvements where possible. When one nurse, for
example, shared how uncomfortable she had recently felt
packing up a deceased patient’s belongings in the clear plastic
bags available, there was a decision made to purchase opaque,
drawstring bags imprinted with a small hospital logo. Finding
ways to demonstrate caring and respect were paramount.
Plans were then made to deliver the manuals to 11 in-patient
units, with a small team prepared to offer informal education
and assess additional needs.

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EXHIBIT A

Front-line colleagues applauded the accessibility of the “how-to”

information and the delineation of concrete ways to offer assistance. They
really liked the check list (see exhibit A) and the resource listings for families
(which gave directions to hospital sites such as the cafeteria, ATM machine,
CARE OF
chapel, and community resources such as near-by restaurants, reliable taxi THE DYING
companies, etc.).
Most staff seemed to understand clearly the importance of the effort,
PATIENT
accepting without question the assertion of a physician member of the task CHECKLIST
force: providing care to the dying patient is an extraordinary opportunity
for marketing (equaled only at the time of birth) and for developing a loyal ■ DNR in place – or discussed
customer base that chooses to return to the health care system because of with patient/family
the quality of care provided and attention to physical, emotional and
spiritual needs. ■ Consult with Palliative
Care or Hospice considered
CASE MANAGEMENT ROLE
Interestingly, the positive response reflected a similar kind of positive
■ Patient placed in private
energy that had infused task force meetings. While the subject matter was
serious and included topics many try to avoid, the effort generated room (if available)
enthusiasm. The case management role involved taking leadership of a
process which encouraged sharing of “front line” experiences. Good ideas ■ “Quiet please” sign on door
and positive energy were generated from the interdisciplinary exchange.
Members volunteered (or were recruited) from many areas: nursing, ■ Special information
palliative care, environmental and food services, guest services, pastoral packet given (including
care. The group had no budget or official sanction but was quickly “adopted” info. on VBMC and
as a project of the Ethics Committee. area resources)
Case managers, working singly or as a department, could not and would
not have achieved the same outcomes. The buy-in and ownership of all ■ Cot with linens requested
involved were critical. However, their leadership seemed natural: case
from Environmental
managers were good communicators and organizers and the project’s goals
Services (for family during
were perfectly aligned with their mission to create a “seamless continuity of
care.” They helped gather data and organize information, build consensus,
very last days)
write a policy and perhaps most importantly, develop a “sales campaign”
for the “product.” ■ Request for special food
Case managers’ familiarity with “measurements” also made tray made to Food Service
coordination of another phase of the project easy. Early in their discussions,
task force members had recognized that the hospital’s current patient ■ PSG volunteers requested
satisfaction survey process (through the Press Ganey organization) did not for support (ext. ###)
attempt to get feedback from families whose relatives had died here. There
were no objective outcome measures. Collaboration with the Pastoral Care ■ Referral made to
Director, who had recently initiated bereavement mailings, resulted in the Pastoral Care (ext. ###)
inclusion of a brief (optional) survey with the 179 letters sent out in late
winter 2006. The 13 questions posed (see exhibit B on page 8) asked for ■ Referral made to
feedback on pain management, spiritual and emotional support,
Social Work (ext. ###)
explanations about condition and treatment, and inclusion in decision-
making for both the deceased patient and family.
At time of death,
The initial response was impressive: 40 surveys returned within 10 days of
the mailing. And the results were also heart-warming: the majority gave high
refer to Morgue policy
ratings. One respondent wrote: “The staff was wonderful. They moved Mr. F. to
a private room so his family could say their goodbyes. They also provided

(continued on page 8)
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Dying Well: Case Management Leads a Process Redesign Project (continued from page 7)

drinks and snacks for everyone.

When I decided to stay the night,
they provided me with a lounging
chair for comfort. All through the
night they checked on him to make
sure he was comfortable. I was
extremely pleased with the entire
staff.” The comments provided
concrete feedback regarding
some of the task force’s major
initiatives: clear reinforcement
for continuing efforts.
Monthly mailings have now
provided feedback from almost
100 families. Many have
specifically identified staff who
were helpful and these individuals
have been cited through existing
employee recognition programs.
When there have been critical
comments and if a name and
telephone number were given,
case managers on the task force
have made follow-up calls and
referred problems to the
appropriate unit manager or
department head. Most concerns
to date have focused on issues of
physician communication, staff
insensitivity, or lack of notification
of impending death. Summaries of
the survey results and any follow-
up activities have been reported to
the Ethics Committee and from
there to the hospital’s Clinical
Improvement Council and Board.

SUMMARY
The Dying Well Task Force at a recently called “wrap up”
meeting determined this process redesign project was
successful because it was:
1) Low cost (largely the cost of 11 binders, opaque plastic
bags and copying);
2) easily replicable (for a similar goal – or others);
3) identifiable, with a tangible outcome (the binder) which
users immediately embraced as a useful tool;;
4) easily understood, with a goal that had universal application
(i.e., everyone is a potential beneficiary);
5) a launching pad for additional efforts to measure the
impact and assess on-going needs.
5 EXHIBIT B • Example of Vassar Brothers Medical Center After-Care Family Survey
Case management members also assert that leadership
of the project gave them the opportunity to demonstrate a
critical role: encouraging collaboration to make it easier for
everyone in the medical center to do the “right thing” for
patients and their families.
May Mamiya, LCSW, CCM has been Director of Case
Management at Vassar Brothers Medical Center since 1995.
A graduate of Columbia University School of Social Work, she
has over 35 years experience in health care and helped establish
Hospice and palliative care programs in her community.