Organizational Challenges to Implementing Hospital-based Palliative Care

BACKGROUND Hospitals are increasingly adopting palliative care programs because seriously ill patients too often experience unnecessary pain and suffering and lack self-determination. This study explores the adoption of an innovative service technology, palliative care, in the complex organization of the hospital. The objective of this study is to understand organizational barriers and facilitators to implementing interdisciplinary palliative care in hospitals in three different healthcare systems.

METHODS Using a conceptual model that integrates Hasenfeld's human service organizations framework with innovation diffusion theory we qualitatively compare three palliative care programs in three different large integrated healthcare systems with hospital-based palliative care programs in the same major metropolitan area that varied by financing type (global budget versus fee-for-service) and mandate (mandated versus voluntary programs) to identify barriers and facilitators to implementation. In this multi-site case study design we conducted semi-structured in-person interviews with key informants (physicians, nurses, social workers, administrators, and executive, total n= 23) in each palliative care program (total cases n= 3). Qualitative analyses consisted of an iterative approach, coding for themes within and across cases, then comparing variations in programs and generalizing back to theorized relationships with the organizational environment (healthcare system), service technology (interdisciplinary palliative care), and implementation process factors.

RESULTS Because it has been stigmatized by its association with hospice and death and dying, hospital medical providers are resistant to providing palliative care, they see it as an anathema to their mission, equate it with "giving up" and treatment failure, and are not always clear about what palliative care is and how to provide it. Moreover, palliative care is delivered by an interdisciplinary team which does not conform to the traditional disciplinary hierarchies and power dynamics in the hospital environment, the palliative care team is sometimes seen as encroaching on the "turf" of other healthcare providers, it is typically not well institutionalized with a standardized service and reimbursement mechanisms parallel to other subspecialties or consultative services. However, strong leadership, executive support, financial incentives, user integration in the implemtation process, and opportunities for user observability, in addition to other factors, can facilitate the implementation of hospital-based palliative care programs.

CONCLUSIONS Organizations with capitated financing mechanisms (global budgets) have financial incentives to implement palliative care. In addition to executive support and innovation champions, including users in the implementation process and increasing opportunities for observability of outcomes are among the best ways to overcome resistance to palliative care. The conceptual model was useful in understanding the implementation of this health services innovation within multiple levels of context.