StandardS of Practice for HoSPice ProgramS

1 StandardS of Practice for HoSPice ProgramS PROFESSIONAL DEVELOPMENT AND RESOURCE SERIESS tandardS of Practice for HoSPice ProgramS PROFESSIONAL DEVELOPMENT AND RESOURCE SERIESiiStandardS of Practice for HoSPice ProgramS PROFESSIONAL DEVELOPMENT AND RESOURCE SERIES iiitable of contents1 / NHPCO s Quality Program and StandardS of Practice 12 / How to Use the StandardS 53 / Patient and Family/caregiver-Centered Care (PFC) 74 / Ethical Behavior and Consumer Rights (EBR) 275 / Clinical Excellence and Safety (CES) 376 / Inclusion and Access (IA) 637 / Organizational Excellence (OE) 698 / Workforce Excellence (WE) 759 / Compliance with Laws and Regulations (CLR) 9910 / Stewardship and Accountability (SA) 10711 / Performance Measurement (PM) 11712 / NHPCO Performance Measures 12713 / Appendix I: HoSPice Inpatient Facility (HIF) 13114 / Appendix II: Nursing Facility HoSPice Care (NF) 14515 / Appendix III.

2 HoSPice Residential Care Facility (HRCF) 15516 / StandardS of Practice Change Tables (2018) 17217 / Acknowledgements 198 StandardS of Practice for HoSPice ProgramS PROFESSIONAL DEVELOPMENT AND RESOURCE SERIES1 / NHPCO S StandardS of PracticePROFESSIONAL DEVELOPMENT AND RESOURCE SERIES11 / nHPco S StandardS of PracticeThe National HoSPice and Palliative Care Organization s (NHPCO) StandardS of Practice encompass key components of quality that offers HoSPice providers a clear framework for a 360-degree surveillance of their entire operation, focusing on both clinical and non-clinical areas.

3 The StandardS of Practice assist HoSPice providers in meeting requirements in the Medicare HoSPice Conditions of Participation which require Medicare-certified providers to implement and maintain a Quality Assessment Performance Improvement (QAPI) process for their organization. HoSPice providers who choose to adopt StandardS of Practice beyond compliance regulations will measurably demonstrate organizational excellence and improvement efforts across all areas of HoSPice operations. The significant value of this document lies in the effect it can have on the evolution and improvement of each organization s HoSPice services.

4 It is not intended to be filed away or sit on a shelf. Rather, it should be used as an active, viable tool for reference, self-evaluation, and improvement activities. We invite you to apply the principles and StandardS for evaluation and continuous improvement in your StandardS of Practice for HoSPice ProgramS (2018) are organized around the following core components, which provide a framework for developing and implementing QAPI, thus reflecting NHPCO s commitment to ensuring that members have the tools and resources that ultimately result in improving care of patients and their and Family/caregiver-Centered Care.

5 Providing care and services that are responsive to the needs and exceed the expectations of those we Behavior and Consumer Rights: Upholding high StandardS of ethical conduct and advocating for the rights of patients and their Excellence and Safety: Ensuring clinical excellence and promoting safety through StandardS of and Access: Promoting inclusiveness in our community by ensuring that all people regardless of race, ethnicity, color, religion, gender, disability, sexual orientation, age, disease or other characteristics have access to our ProgramS and Excellence: Building a culture of quality and accountability within our organization that values collaboration and communication and ensures ethical business Excellence.

6 Fostering a collaborative, interdisciplinary environment that promotes inclusion, individual accountability, and workforce excellence through professional development, training, and support to all staff and of Practice for HoSPice ProgramS2 Compliance with Laws and Regulations: Ensuring compliance with applicable laws, regulations, and professional StandardS of Practice , implementing systems and processes that prevent fraud and and Accountability: Developing a qualified and diverse governance structure and senior leadership who share the responsibilities of fiscal and managerial Measurement: Collecting, analyzing, and actively using performance measurement data to foster quality assessment and performance improvement in all areas of care and services.

7 PROFESSIONAL DEVELOPMENT AND RESOURCE SERIES3 StandardS of Practice for HoSPice ProgramS PROFESSIONAL DEVELOPMENT AND RESOURCE SERIES2 / How to Use the StandardsPROFESSIONAL DEVELOPMENT AND RESOURCE SERIES52 / How to Use the StandardS The National HoSPice and Palliative Care Organization s (NHPCO) StandardS of Practice for HoSPice ProgramS (2018) ( StandardS ) is organized into ten (10) chapters. None of the chapters are meant to stand alone. Each chapter begins with one or more principles of HoSPice care supporting that component of quality. Following the principle(s), the defined StandardS are divided into numerical group designations.

8 The primary standard is designated by a whole number ( , 1, 2, 3) and is followed by related StandardS designated by the same whole number, a decimal, and a second number ( , , , ). The numeric designations are solely for reference and are not intended to reflect priority or each group of StandardS is a set of Practice Examples. Practice Examples are meant to be examples of various ways to implement the StandardS . The Practice Examples are not intended to be requirements or descriptions of the best or only way to meet the StandardS . They are only intended as examples from Practice that can be imitated or used to spur ideas and the end of the StandardS text are appendices.

9 Since the principles and StandardS in all chapters apply to the provision of HoSPice care in all settings, the appendices contain only additional principles and StandardS relevant to a particular Practice area. StandardS Change Tables follow the appendices to facilitate easy identification of key changes in the 2018 note: The Pediatric StandardS are not included as an appendix in this document. They will be issued as a separate appendix in 2018, but will be included as an appendix in subsequent versions of NHPCO s StandardS of of Practice for HoSPice ProgramS PROFESSIONAL DEVELOPMENT AND RESOURCE SERIES3 / Patient and Family/caregiver-Centered Care (PFC)PROFESSIONAL DEVELOPMENT AND RESOURCE SERIES73 / Patient and family/ caregiver-centered care (Pfc)PrinciPleS Providing care and services that are focused on the dying person and the grieving family s unique experience.

10 The patient, family, caregiver, and other individuals identified by the patient are the unit of care. The HoSPice interdisciplinary team, in partnership with the patient, family, caregiver, and other individuals identified by the patient, develops, coordinates, and implements a care-directed, individualized, and safe plan of palliative care. Addressing grief and bereavement needs begins at the time of admission to HoSPice with the initial comprehensive assessment and continues through 13 months after the patient s death, and beyond if necessary. Anticipatory grief services are provided to help patients, families, caregivers, and other individuals identified by the patient cope with the losses that occur during the illness and eventual death.