Evidence-based Quality Improvement Research Articles

Improving Hospice and Palliative Care Through Nurse Practitioner Engagement in a Community Paramedicine Program

More than 80% of Americans would prefer to die at home, but only 20% do. Paramedics have a role in caring for terminally ill patients, especially when involved in a community setting. A knowledge gap was noted with community paramedics (CPs) regarding end-of-life questions and palliative care for paramedics. This evidence-based quality improvement project aimed to provide structured, evidence-based palliative and hospice education to CPs. Nurse practitioners can provide education and training on palliative and hospice care to CPs and help patients remain at home.

Preparing for the spread of patient-reported outcome (PRO) data collection from primary care to community pharmacy: a mixed-methods study

BackgroundMedication non-adherence is a significant public health problem. Patient-reported outcomes (PROs) offer a rich data source to facilitate resolution of medication non-adherence. PatientToc™ is an electronic PRO data collection software originally implemented at primary care practices in California, United States (US). Currently, the use of standardized PRO data collection systems in US community pharmacies is limited. Thus, we are conducting a two-phase evaluation of the spread and scale of PatientToc™ to US Midwestern community pharmacies. This report focuses on the first phase of the evaluation. The objective of this phase was to prepare for implementation of PatientToc™ in community pharmacies by conducting a pre-implementation developmental formative evaluation to (1) identify potential barriers, facilitators, and actionable recommendations to PatientToc™ implementation and (2) create a draft implementation toolkit.MethodsData collection consisted of demographics, observations, audio-recorded contextual inquiries, and semi-structured interviews with staff (e.g., primary care providers, pharmacists, pharmacy technicians) and patients during 1-day site visits to a purposive sample of (1) primary care practices currently using PatientToc™ and (2) community pharmacies in Indiana, Wisconsin, and Minnesota interested in the future use of PatientToc™. Post-visit site observation debriefs were also audio-recorded. Verbatim transcripts of all recordings were coded using deductive/inductive approaches and intra-/inter-site summaries were produced identifying potential barriers, facilitators, and actionable recommendations mapped to the Consolidated Framework for Implementation Research constructs. A stakeholder advisory panel engaged in an Evidence-Based Quality Improvement (EBQI) implementation process. This included “member checking” and prioritizing findings, and feedback on the adapted PatientToc™ application, implementation strategies, and accompanying toolkit for community pharmacy implementation.ResultsTwo primary care practices, nine pharmacies, and 89 individuals participated. Eight major themes (four barriers and four facilitators) and 14 recommendations were identified. Throughout the four EBQI sessions, the panel (1) confirmed findings; (2) designated high priority recommendations: (a) explain PatientToc™ and its benefits clearly and simply to patients, (b) ensure patients can complete questionnaires within 10 min, and (c) provide hands-on training/resources for pharmacy teams; and (3) provided feedback on the adapted PatientToc™ application and finalized toolkit items for initial community pharmacy implementation.ConclusionsAdoption of electronically captured PROs in community pharmacies is warranted. The implementation strategies systematically developed in this study can serve as a model for implementation of technology-driven health information patient care services, in the understudied context of community pharmacies.

Capitalizing Upon Graduate Student Projects to Sustain Clinical Outcomes.

As part of a clinical-academic partnership, graduate nursing students initiated evidence-based quality improvement projects in a large, metropolitan, 5-time Magnet®-designated pediatric hospital to encourage continuous innovation and evidence-based practice. This article describes the evolution and strategies used by leadership and staff to sustain the projects over time. Data collected by the organization report trended outcomes, highlight themes for success from graduate nursing students from 2017 through 2020, and report the implications for nurse executives.

Evidence-basing for quality improvement; bringing clinical practice guidelines closer to their promise of improving care practices.

Clinical practice guidelines (CPGs) have become central to efforts to change clinical practice and improve the quality of health care. Despite growing attention forrigorous development methodologies, it remains unclear whatcontribution CPGs make to quality improvement. This mixed methods study examines guideline quality in relation to the availability of certain types of evidence and reflects on the implications of CPGs' promise to improve the quality of care practices. The quality of 62 CPGs was assessed with the Appraisal of Guidelines, Research, and Evaluation (AGREE) instrument. Findings were discussed in 19 follow-up interviews to examine how different quality aspects were considered during development. The AGREE assessment showed that while some quality criteria were met, CPGs have limited coverage of domains such as stakeholder involvement and applicability, which generally lack a 'strong' evidence base (e.g., randomized controlled trials [RCT]). Qualitative findings uncovered barriers that impede the consolidation of evidence-based guideline development and quality improvement including guideline scoping based on the patient-intervention-comparison-outcome (PICO) question format and a lack of clinical experts involved in evidence appraisal. Developers used workarounds to include quality considerations that lack a strong base of RCT evidence, which often ended up in separate documents or appendices. Findings suggest that CPGs mostly fail to integrate different epistemologies needed to inform the quality improvement of clinical practice. To bring CPGs closer to their promise, guideline scoping should maintain a focus on the most pertinent quality issues that point developers toward the most fitting knowledge for the question at hand, stretching beyond the PICO format. To address questions that lack a strong evidence base, developers actually need to appeal to other sources of knowledge, such as quality improvement, expert opinion, and best practices. Further research is needed to develop methods for the robust inclusion of other types of knowledge.

Effects of Clinical Nurse Educator Professional Role Development: An Evidence-Based Quality Improvement Project.

Centralization of clinical nurse educators (CNEs) from medical-surgical and critical care in a rural Midwestern hospital created role confusion and poor role outcomes. An evidence-based quality improvement project was developed to integrate the Association of Nursing Professional Development's transition to practice fellowship and practice model. Outcomes were focused on CNE self-assessed competency and three nurse-sensitive quality outcomes. Results were mixed but support that CNEs influenced patient quality outcomes and improved their self-assessed competency.

From evidence to quality improvement to provide high value and patient centered care

Evidence-based practice and quality improvement should be at the heart of healthcare and public health. However, their implementation remains insufficient which is reflected in Switzerland in the high frequency of low-value care, in the wide regional variation in care practices, and in the absence of quality monitoring for the majority of healthcare processes. It is necessary to strengthen the monitoring of quality, particularly that perceived by patients, to help strengthening high-value and patient centered care. Because data do not speak for themselves, it is critical to organize how to use indicators for decision.

The end-of-life care in the emergency department setting with respect to the Middle East countries and comparison with the Western countries.

Patients who are affected with severe chronic illness or in need for end-of-life care ((EOLC), they are mainly treated in the emergency departments (EDs) to provide the utmost amount of care for their condition. The major aspects which impact the accessibility of care in the ED include the clinical, social, and economic factors in different regions of countries. In recent years as the EOLC has been provided, it has been observed that patients experiencing EOL and dealing with a dying process do not always achieve the experience what resonates with a good death. The main cause of concern for these patients is the problem that in the ED they do not have access to palliative care options, mainly the ones who are suffering from noncancer ailments. These patients are provided palliative care at a very later stage in the ED when they could have been provided with palliative management at home in an earlier manner. EOLC plays a very critical role in ensuring that terminally ill patients are given a proper and adequate amount of care. The present article aims to highlight the EOLC in the ED in the Middle-Eastern regions. We aim to present a broader view that has impacted the current situation of EOLC in the Middle East regions and demonstrate a description of the EOLC in an ED setting between the Middle Eastern regions and western culture focusing on the following five important factors: Situation acceptance in the ED, cultural compatibility of bioethics, treatment perspective, skills among clinical providers and physician's attitude. In this literature review, we present the evidence associated with the EOLC in the ED setting with respect to the Middle East countries and bring out their differences in the religious, clinical, social, ethical, and economic aspects in comparison with the Western countries. We also tried to determine the differences between the two regions in terms of the principle of explaining the fatal diagnosis or poor prognosis, family relations, and do-not-resuscitate decision. This comparative analysis will help to bring out the gaps in the quality of care in the ED in the Middle East countries and promote the development of well-assessed policies and strategies to improve EOLC. The findings of this study and the future interventions that can be implemented to improve the structure and design of the EOLC that will act as a guiding force to execute evidence-based quality improvement program.

The effectiveness of a parent participation in postoperative pain management programs for children in a urology ward: A randomized controlled trial.

Postoperative pain has adverse effects on children after urology treatment, including sleep disturbance, incision dehiscence, bleeding, and delayed recovery. Parents, as the most direct caregivers of children, can make accurate assessments of children´s personal behaviors and responses, which is very important for the management of postoperative pain in children. The purpose of the current study was to develop a Parent Participation in Postoperative Pain Management Program for children in a urology ward and to evaluate its effects on children's postoperative pain scores and other outcome indicators. This research comprised two phases. The first phase was the development of a Parent Participation in Postoperative Pain Management Program. The second phase was a randomized controlled trial between two groups, and was carried out in a 45-bed inpatient urology ward of a tertiary children's hospital in China. In the trial, 211 children and their parents were randomly selected as a control group between July 1 and August 15, 2019, and 202 children and their parents were randomly selected as an intervention group between August 16 and September 15, 2019. Following the framework and methods of the Evidence-based Continuous Quality Improvement Model developed at Fudan University Evidence-Based Nursing Center, we systematically gathered evidence regarding parental involvement in postoperative pain management in children to construct the program. To evaluate the program's effectiveness, the control group performed routine postoperative pain management, while the intervention group underwent the Parent Participation in Postoperative Pain Management Program. The management period was during hospitalization, and generally ranged 3-7days. The Statistical Table of Pain Assessment for Children after Urology was employed by researchers. The results revealed no significant differences in demographic characteristics between the two groups of children and their parents. Children's pain scores during dressing removal (Z=-3.108, p=0.002), at discharge (Z=-2.185, p=0.029) and during catheter removal (Z=-6.553, p=0.000) were significantly lower in the intervention group compared with the control group. The Parent Participation in Postoperative Pain Management Program was found to be effective for alleviating postoperative pain scores among children, and provided useful information regarding postoperative pain management in children involving four aspects of parental involvement: cognition, guidance, documentation and support.

Undertaking general practice quality improvement to improve cancer screening - a thematic analysis of provider experiences

BackgroundCancer is a major cause of illness and death, and its incidence and mortality can be reduced through effective screening. In order to improve below target screening rates in one region of Australia, the local Primary Health Network supported local general practices to implement a range of quality improvement initiatives.MethodsWe used a qualitative approach and interviewed 18 general practice staff and five Primary Health Network staff and contractors to understand their experiences with these quality improvement initiatives.ResultsIn a thematic analysis, we identified four key themes related to program set-up and implementation; patient and community education and promotion; engaging patients and communities in screening; and general practice enhancement. Program roles were clear and understood, and the program received strong oversight and support. Practice staff felt supported and motivated. Information Technology was a challenge for many practices often requiring tailored assistance. Education provided by practices facilitated patient empowerment but practice staff noted difficulties engaging patients in screening. Practices were enhanced though strong leadership and teamwork and practice learning activities.ConclusionsThe tailored evidence-based quality improvement initiatives were considered effective in supporting general practices to increase their cancer screening. Key facilitators reported by participants included use of Plan-Do-Study-Act cycles, enhanced data entry and audit capacity, effective recall and reminder systems and maintaining staff motivation.

Standardized Process Measures in Radiographic Hip Surveillance for Children with Cerebral Palsy.

Introduction:Detection of hip migration in children with cerebral palsy (CP) through radiographic surveillance can prevent dislocations. Migration Percentage (MP) is the accepted method for quantifying hip subluxation in CP on pelvis x-ray but was not being reported at our institution. Our objective was to improve care for children with CP by standardizing radiographic techniques and reporting radiographs obtained as part of a hip surveillance program.Methods:A baseline retrospective review of CP surveillance pelvis x-ray reports was performed. We then educated radiologists and technologists, standardized imaging techniques, and required structured radiology reporting to include MP measurement and dislocation risk categories. We tracked compliance with the reporting template for 10 months. Images and reports were also assessed for quality and accuracy by an orthopedic surgeon.Results:Baseline period reports showed no consistency. In total, 449 children with CP (mean age: 7.3 years ± 4.2) had a surveillance pelvis radiograph during the postintervention study period (May 2019–February 2020). An estimated 90% reporting compliance was achieved and sustained by 5 months. Eight (89%) of the children with high-risk hips were newly diagnosed during our study period; all had a progressive increase in MP from prior examinations. All clinicians surveyed agreed that the standardized reports, including MP, were helpful to their practice.Conclusions:Using evidence-based process measures and quality improvement methodology, we standardized hip surveillance for children with CP. Radiology reports that include MP and risk category for hip dislocation enable clear communication for referrals across specialties and early detection and treatment for better outcomes.

Incorrect Surgical Counts: A Potential for Retained Surgical Items.

In the main operating rooms of a large academic hospital there was a report of 408 count discrepancies in 2015-2016 and 13 incidences of retained surgical items (RSIs). There was a lack of a consistent and standardized surgical count process among nurses. To reduce count discrepancies by 25%, prevent RSIs, and improve the compliance of the perioperative nursing team regarding the surgical count process. An evidence-based quality improvement project with a sample of 455 surgical procedures and 118 nurses. Data collection occurred over an eight-week period in 2018 using a Plan-Do-Study-Act (PDSA) methodology to study the effectiveness of the utilization of the Association of periOperative Registered Nurses (AORN) practice guidelines for the prevention of RSIs. The inclusion of risk reduction strategies such as the utilization of an AORN guideline whiteboard to record surgical items and the identification of high-risk items for retained device fragments or high-risk surgical items for RSIs resulted in the reduction of incorrect surgical counts by 71.43%, with no incidence of RSIs. Further, nurse compliance on surgical count practices improved significantly, F (5, 46) = 2.47, p = .046, PES = .21. The implementation of the AORN guidelines for perioperative surgical count practices by the perioperative nursing team provided an improved surgical count process. A system approach to performance improvement is needed to prevent RSIs.

The quality of social determinants data in the electronic health record: a systematic review.

ObjectiveThe aim of this study was to collect and synthesize evidence regarding data quality problems encountered when working with variables related to social determinants of health (SDoH).Materials and MethodsWe conducted a systematic review of the literature on social determinants research and data quality and then iteratively identified themes in the literature using a content analysis process.ResultsThe most commonly represented quality issue associated with SDoH data is plausibility (n = 31, 41%). Factors related to race and ethnicity have the largest body of literature (n = 40, 53%). The first theme, noted in 62% (n = 47) of articles, is that bias or validity issues often result from data quality problems. The most frequently identified validity issue is misclassification bias (n = 23, 30%). The second theme is that many of the articles suggest methods for mitigating the issues resulting from poor social determinants data quality. We grouped these into 5 suggestions: avoid complete case analysis, impute data, rely on multiple sources, use validated software tools, and select addresses thoughtfully.DiscussionThe type of data quality problem varies depending on the variable, and each problem is associated with particular forms of analytical error. Problems encountered with the quality of SDoH data are rarely distributed randomly. Data from Hispanic patients are more prone to issues with plausibility and misclassification than data from other racial/ethnic groups.ConclusionConsideration of data quality and evidence-based quality improvement methods may help prevent bias and improve the validity of research conducted with SDoH data.

Burnout and Well-Being: Evaluating Perceptions in Bone Marrow Transplantation Nurses Using a Mindfulness Application.

Oncology nurses are at increased risk for developing burnout. Although various interventions have been researched, mindfulness has been proven to be beneficial in mitigating burnout while improving well-being. The aim was to evaluate whether the use of a mindfulness mobile application (app), Headspace®, increases perceptions of well-being and decreases perceptions of burnout among inpatient bone marrow transplantation (BMT) staff nurses and nurse practitioners (NPs). This evidence-based practice quality improvement initiative introduced the Headspace app to BMT nurses and evaluated its impact on burnout and well-being at baseline and every 30 days for 90 days. There were significant improvements in burnout and well-being in staff nurses and NPs from baseline to each time point. Sleep hygiene meditations were the most widely used programs within the Headspace app for both nursing groups.

The evolution of a clinical scholars program through a pediatric nursing academic-practice partnership.

Academic-practice partnerships have the potential to improve clinical outcomes through joint initiatives focusing on nursing. Nurses at the bedside are able to greatly impact care, but often they lack the resources (time, knowledge, and expertise) to enact and facilitate quality improvement initiatives. Through an academic-practice partnership, academic and practice partners can work collaboratively to develop innovative evidence-based practice, quality improvement, and research projects. The benefits of these partnerships are far reaching as they involve faculty, students, and clinicians within the practice. In this article, we describe the development and evolution of a pediatric clinical scholars program that increases nursing engagement for leadership in evidence-based practice, quality improvement, and research projects to improve health outcomes.

Allergen immunotherapy: The growing role of observational and randomized trial "Real-World Evidence".

Although there is a considerable body of knowledge about allergen immunotherapy (AIT), there is a lack of data on the reliability of real-world evidence (RWE) in AIT, and consequently, a lack of information on how AIT effectively works in real life. To address the current unmet need for an appraisal of the quality of RWE in AIT, the European Academy of Allergy and Clinical Immunology Methodology Committee recently initiated a systematic review of observational studies of AIT, which will use the RELEVANT tool and the Grading of Recommendations Assessment, Development and Evaluation approach (GRADE) to rate the quality of the evidence base as a whole. The next step will be to develop a broadly applicable, pragmatic "real-world" database using systematic data collection. Based on the current RWE base, and perspectives and recommendations of authorities and scientific societies, a hierarchy of RWE in AIT is proposed, which places pragmatic trials and registry data at the positions of highest level of evidence. There is a need to establish more AIT registries that collect data in a cohesive way, using standardized protocols. This will provide an essential source of real-world data that can be easily shared, promoting evidence-based research and quality improvement in study design and clinical decision-making.

C4Tech: Virtual connections between the classrooms, clinicians, and community clinics to bridge the gap between research and practice

Aim E-learning technologies are becoming vital components of medical and health professions education, as highlighted during the current coronavirus disease (COVID-19) pandemic. The National Academy of Medicine (NAM) considers education technologies essential to forming connections between education and healthcare delivery systems, which promote evidence-based practice and continuous learning and quality improvement in healthcare. There is a lack of evidence-based models to guide the integration of technology in medical and health profession education, in particular models that form synergistic linkages between healthcare education and delivery systems. This paper presents the evaluation of an innovative blended learning model, which leverages virtual technology to connect students in the classroom with clinicians in community clinics (C4Tech) for authentic learning related to quality improvement (QI) and social determinants of health (SDH). Method This study applied a case study approach to evaluate the efficacy of the C4Tech model in supporting learning outcomes and assessed how virtual collaboration influenced the process of learning. Results This study contributes to a more comprehensive understanding of how to design effective blended courses that connect the healthcare education and delivery systems through virtual technology. It also demonstrates how to connect students and practicing clinicians virtually to design evidence-based quality improvement projects.

Increasing patient participation in hand hygiene practices in adult surgical wards in a tertiary institution: a best practice implementation project

The WHO states that hospital-acquired infections may be transmitted through contaminated hands. Practicing hand hygiene using alcohol-based handrub or soap and water reduces harmful organisms. The Joanna Briggs Institute (JBI) best practice recommends empowering patients with hand hygiene knowledge and engaging their involvement to strengthen hand hygiene practices. The aim of this project was to improve hand hygiene among surgical inpatients. This evidence-based quality improvement project was conducted in three phases: the baseline audit, implementing best practice, and the postimplementation audit. Participants were patients hospitalized in three surgical wards of a 1200-bed acute care tertiary hospital. This project utilized the online JBI Practical Application of Clinical Evidence System and The Getting Research into Practice program to identify barriers and strategies. Nurses provided patients with an education pamphlet and regularly reminded them to improve their hand hygiene practices. Ninety-four patients were audited between April and June 2018. Patients' hand hygiene practices improved from 19.1% at baseline audit to 61.7% (P < 0.01) at first follow-up audit. Patients' hand hygiene improved from 48.9 to 72.3% (P = 0.03) before meals, and from 92.6 to 98.9% (P = 0.65) after toileting. The proportion of patients who received a hand hygiene information leaflet in an appropriate language increased from 64.9 to 89.4% (P < 0.01). Patients' involvement in the hand hygiene program has significantly improved their hand hygiene practices. Patient education and patient information leaflet continue to be an effective strategy to improve knowledge and practices.

Importance of addressing malnutrition in cancer and implementation of a quality improvement project in a gastrointestinal cancer clinic.

Malnutrition is exceedingly common in cancer patients, with some of the highest rates seen in gastrointestinal (GI) malignancies. Malnutrition and cachexia in cancer patients is associated with worse quality of life, poor treatment tolerance, and increased morbidity and mortality. The importance of early recognition of malnutrition in cancer patients is key, and numerous screening tools have been validated to aid practitioners in this diagnosis. In this paper, we summarize the importance of identifying and managing malnutrition in GI cancer patients as well as its impact on clinical outcomes. We then focus on presenting our own novel quality improvement project that aims to expand access to dietitian services in a GI cancer clinic at a large safety-net hospital system. Utilizing evidence-based quality improvement methodologies including the Model for Improvement and Plan-Do-Study-Act cycles, we increased the proportion of GI oncology patients seen by a dietitian from 5% to 20% from October 2018 to July 2019. In particular, we outline the challenges faced in the implementation process of a malnutrition screening tool built into the electronic medical record in an outpatient oncology clinic. We focus on the tool's ability to capture a greater number of patients with malnutrition and its clinical impact.

Alberta Health Services Emergency Strategic Clinical Network Quality Improvement and Innovation forum 2021

The Alberta Health Services Emergency Strategic Clinical Network Quality Improvement and Innovation forum 2021. &#x0D; Patrick McLane and Eddy Lang on behalf of the Emergency Strategic Clinical Network&#x0D; Evidence-based research and quality improvement work are pivotal to health systems meeting their goals. Translating findings and disseminating innovative practices to new settings occurs in part through knowledge translation events, such as conferences and workshops.&#x0D; The Emergency Strategic Clinical NetworkTM (ESCN) Quality Improvement and Innovation forum fills a gap between local and national events. It is devoted to sharing methods and results of emergency department projects in Alberta among those working in emergency care. 2021 was the third consecutive year the ESCN has held this event.&#x0D; The event provides an opportunity for those working on quality improvement in emergency medicine to network with one another, share innovative projects, share know how and translate promising works to new settings. In addition, the event provides an opportunity to identify projects for potential development through local, provincial, or national funding opportunities.&#x0D; In light of the ongoing pandemic, this year’s forum was held virtually with the support of the University of Calgary Continuing Medical Education group. Funding was kindly provided by the College of Physicians and Surgeons of Alberta. Nineteen teams presented their projects orally. Invited nurse and clinician scientists ranked all submissions to the forum, and the top ranked submissions were recognized in the following categories:Submissions by ESCN staff and the event sponsor were not eligible for recognition.&#x0D; A new feature this year was a presentation by ESCN patient advisors on their perspectives on quality improvement, which was well received by all.&#x0D; Strong attendance shows the value practitioners see in the forum. In 2021, the forum was attended by approximately 140 educators, managers, nurses, physicians and researchers from across Alberta. This is a marked increase over previous years. Post-event evaluation survey feedback suggests that the online format was greatly appreciated and made the event more accessible. Requests for more rural oriented content in event feedback may also indicate that the event drew more rural attendees this year.&#x0D; We are pleased to partner with the Canadian Journal of Emergency Nursing to make abstracts from the event widely available. Individual presenters have had the option of submitting their abstracts for publication in CJEN. In some instances, abstracts have already been published through other conferences and so could not be submitted to CJEN.&#x0D; The findings presented in the abstracts are solely the work of the submitting authors. The ESCN does not guarantee the accuracy of any reported information. The views expressed in the abstracts are solely the views of the authors and do not represent the ESCN or Alberta Health Services.&#x0D; Correspondence to: emergencyscn@ahs.ca

Structure and process of palliative care provision: a nationwide study of public hospitals in Thailand

BackgroundThe demand for palliative care in hospitals in Thailand has rapidly increased in recent years. Subsequently, the way in which palliative care systems should be arranged to facilitate the care process and patient preparation for their end stage of life is still an ongoing debate among policy makers and researchers. Although palliative care is provided in most facilities, there is no clear protocol for palliative care due to a lack of empirical evidence. Thus, this study attempts to analyse the situation and quality of palliative care provision in Thai public hospitals.MethodsA cross-sectional study was conducted in 2018. A questionnaire with measures concerning hospital characteristics, the structure of palliative care provision, and processes related to achieving a good death was developed. The questionnaire was sent to all 862 public hospitals across 76 provinces, and the response rate was 62.88%. A structural equation model was specified to operationalize Donabedian’s framework. To our knowledge, this is the first nationwide study to investigate facility-level palliative care provision in Thailand.ResultsThe study results confirmed the relationships between the structure and process of palliative care provision in hospitals. The sufficiency and competency of doctors and nurses and the variety of relaxation equipment were either directly or indirectly associated with the process components relevant to the response to the patient’s needs, effective communication, and respect for the patient’s dignity. In addition, the performance of palliative care research in hospitals was associated with the response to the patient’s needs and effective communication, while the allocation of physical areas was associated with effective communication.ConclusionThis model can be used to evaluate the overall situation of palliative care provision at the national level. It could also contribute to the development of standard measurements for evidence-based palliative care quality improvement in hospitals.