Palliative Care Quality Improvement Project: Integrating Palliative Care into Oncology

INTRODUCTION

Palliative care has evolved from a focus primarily on the care of dying patients into a comprehensive, evidence-based specialty for all patients with advanced illness. Modern palliative care encompasses symptom management, psychosocial and spiritual support, caregiver assistance, patient-clinician communication, complex decision making and end-of-life care. A growing body of evidence has established the value of integrating palliative care into oncology.^[1] This has also led to strong endorsements from leading oncology associations such as the American Society of Clinical Oncology (ASCO)^[1] and the European Society for Medical Oncology (ESMO)^[2] as well as global health authorities like the World Health Organization (WHO).^[3] It is no longer a question of whether palliative care improves the quality of life for patients and caregivers navigating a cancer diagnosis, but how it can be effectively integrated into oncology practice – especially in institutions where palliative care services are still developing. Customarily, oncologists have been responsible for managing all critical aspects of the care of patients with serious illness, such as breaking bad news, addressing complex symptoms, managing treatment-related side effects, discussing prognosis and initiating end-of-life care discussions. With oncology clinics becoming increasingly specialised and busy and oncologists focusing on diagnosing cancer and planning complex and evolving disease-directed therapies, there is a growing recognition of the need for specialist palliative care. This specialty of medicine has emerged as a crucial complement to comprehensive oncologic care.

The introduction of specialist palliative care services into oncology services represents a significant change in practice for senior oncologists, many of whom were trained in institutions where specialist palliative care services had not yet been developed or were not readily available. Despite the clear benefits and recommendations, adoption and implementation of integrating palliative care into oncology have some way to go and referral practices vary widely among oncologists, even in comprehensive cancer care centres.^[4,5] This inconsistency results in delayed referrals, avoidable patient suffering and increased healthcare costs.^[6] Addressing this gap requires structured, system-level interventions to promote timely and appropriate integration of palliative care into routine oncology services.

We initiated a palliative care quality improvement project (PCQIP) under the National Cancer Grid (NCG) Enable Quality Improvement in the Patient Care (EQUiP) India programme to enhance integrated and comprehensive patient care.

MATERIALS AND METHODS

Application of QI

After thorough discussion with the stakeholders, the problem statement was defined as ‘Inadequate referrals from oncology to palliative care’, which was seen as a priority for the institution and we decided to work systematically to solve this pressing issue. A baseline analysis showed that only 7.5% of the patients with Stage IV cancer registered in the hospital- based cancer registry (HBCR) (averaged for November– December 2020) were referred to palliative care. The team set a SMART goal ‘to increase referrals of patients with Stage IV cancer to the specialist palliative care team from 7.5% to 25% in the next 6 months’. The referral percentage (% of patients with Stage IV cancer referred to the specialist palliative care team) was the outcome measure tracked monthly using a run chart. Data filtered for patients with Stage IV cancer from HBCR were cross-checked for referrals using electronic medical record (EMR) records, ensuring an unbiased collection of data. To achieve the SMART goal, a process goal was established ‘implementing consensus-based referral criteria’, developed collaboratively with oncologists as part of a separate hospital project. This ensured a structured and stakeholder-driven approach to improving the referrals. The next step was process mapping using the GEMBA walk, which takes an external view of the problem and tracks the journey of the patient. In our case, it was when the patient with Stage IV cancer visited the healthcare facility in the outpatient department or emergency and then took treatment in the facility as per the standard operating protocol of the department.

We identified the root causes of the problem by performing fishbone analysis together as a team [Figure 1].

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Figure 1: Fishbone diagram for root cause assessment. OPD: Outpatient department, PIL: Patient information literature

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The main causes of the non-referrals of patients to palliative care and key drivers were identified. A list of interventions was categorised into an impact-effort matrix with team discussions [Figure 2].

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Figure 2: Impact/effort matrix. OPD: Outpatient department.

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The formalised key drivers were

• Clear referral criteria

• Implementation of referral criteria

• Engagement with Oncologists/Support staff

• Visibility of palliative care services.

RESULTS

During the study period, 537 patients with Stage IV cancer (range 35–72/month) were registered; 66 patients were referred to specialist palliative care (range 4–13/month). In the months of November and December 2020, the baseline referral proportion averaged 7.5%. After sequential implementation of the intervention bundle, referrals rose steadily, and an absolute increase of 10.8% was noted, reaching 18.3% in July 2021 [Figure 3]. The first intervention focused on the implementation of consensus-based referral criteria, which were established as the process goal for this QI project. These referral criteria had been developed as part of a separate institutional initiative by the palliative care team, drawing upon consensus from practicing oncologists across an associated corporate network of hospitals in North India.^[7] To operationalise these criteria, several strategies were introduced, including the placement of printed placards in clinical areas [Appendix 1], distribution of informational emails, formal notifications to tumour board coordinators and updating the tumour board discussion sheets to prompt consideration of palliative care referrals. This ensured a prompt during case discussions and strengthened accountability by making referral consideration a routine part of the multidisciplinary workflow. Formal communication strategies included prominently displaying the referral criteria in oncology outpatient departments and distributing this information via email between May and June 2021. These structured approaches facilitated better understanding of referral triggers and strengthened collaboration during tumour board meetings, leading to more consistent case discussions and feedback exchange between teams. In parallel, an unintended but valuable development was the increase in informal dialogue between oncologists and the palliative care team outside of tumour board settings. These feedback exchanges typically focused on complex situations such as persistent symptoms despite on-going cancer- directed treatment, uncertainty around transitions in goals of care, difficult psychosocial or caregiver situations and cases where patients had multiple unplanned hospital visits or functional decline. Case-based conversations further enhanced interdisciplinary interactions and contributed to more frequent and timely palliative care referrals. Collectively, these measures corresponded with a marked upward trend in the run chart [Figure 4]. While consistent representation was maintained at the central multidisciplinary tumour board, attendance at all disease-specific boards varied because of existing workforce limitations. By July 2021, we added a section on referral status (to palliative medicine) to the tumour board discussion report and updated e-prescriptions to mandate writing of treatment intent. Although these changes were gradual, they were sustainable, long-term interventions. Challenges in compliance with tumour board referral documentation led to bi-monthly audits to ensure that palliative care referrals were indicated when necessary. Some planned interventions, such as placing standees and translating patient information leaflets into Hindi, were delayed or aborted due to unforeseen challenges, teaching the team the importance of adapting to dynamic system-wide obstacles [Figure 3].

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Figure 3: Key drivers and linked interventions. OPD: Outpatient department, PDCA: Plan-Do- Check-Act, PIL: Patient information literature.

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Figure 4: Run-chart depicting monthly referrals to palliative care in patients with Stage IV cancer.

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Referral percentages (our outcome measure) were tracked monthly and depicted the journey of the project from Nov- Dec 2020 to July 2021. With all these interventions, the patients with Stage IV cancer referred from oncology to specialist palliative care increased over the study period from 7.5 % to 18% [Figure 4].

A sustainability plan was established following the taught methodology, ensuring that the introduced changes became integrated into the system. This approach focused on creating self-sustaining processes rather than relying on individuals, which are inherently less consistent and reliable [Table 1].

DISCUSSION

PCQIP represents a significant step toward strengthening the integration of palliative care into routine oncology practice at our institution. As a tertiary cancer centre in a low- and middle-income country (LMIC), we face substantial challenges, including high patient volumes, limited resources and variable acceptance of palliative care principles among clinicians.^[9] Despite the availability of specialist palliative care services since 2017, referrals remained suboptimal, prompting this structured QI intervention.

Using the A3-based PDSA cycle, informed by the EQUIP India programme and modelled on Stanford’s PC-PAICE framework, we systematically identified barriers, implemented context-specific interventions and evaluated their outcomes.

Although we did not reach our SMART goal of a 25% referral rate, we achieved a meaningful increase to 18% during the intervention period, despite the operational challenges posed by the COVID-19 pandemic. The increased visibility of referral criteria through emailed communication and display in oncology outpatient areas appeared to have the greatest influence on referral behaviour, reflected in the steep upward shift observed in the run chart. This demonstrates that even modest, workflow-integrated changes can initiate system-level impact in resource-constrained environments. Our experience also reinforced the need for realistic timelines to evaluate institutional transformation – an observation consistent with Dudgeon et al., who reported that external disruptions like the SARS outbreak influenced referral improvement initiatives despite evidence of overall progress.^[6] Our findings are aligned with those of Venketeswaran et al.,^[10] who demonstrated improved referrals through structured interventions and active stakeholder engagement in two Indian cancer centres. Both initiatives originated from recognition of inadequate early palliative care integration and employed similar strategies including referral criteria, pathways and team education. While symptom screening was integral in their model, it ranked lower on our impact-effort matrix due to feasibility and sustainability concerns in our setting. This highlights the importance of tailoring QI interventions to local resources and operational realities in LMIC oncology settings, a principle emphasised throughout our mentorship process. The institutional importance of this work is underscored by a robust global evidence base demonstrating that early palliative care improves symptom control, quality of life, caregiver satisfaction and sometimes survival, while also reducing unnecessary hospitalisations and costs in diverse settings, including LMICs.^[11-13] International guidelines (ASCO and ESMO) recommend early integration of palliative care into standard oncology practice,^[2,13] but translation into LMIC practice requires intentional, context-specific strategies.

In our institution, embedding referral prompts into tumour board documentation and EMRs, alongside early engagement of oncologist champions, proved vital. Interventions aligned with existing workflows, e.g. mandatory documentation of treatment intent and referral status, were more sustainable. In contrast, seemingly simpler activities such as placing standees or developing Hindi patient information materials faced logistical delays, reinforcing the value of impact-effort prioritisation. Workforce limitations initially hindered consistent palliative care participation across all DMG-specific tumour boards. Task-sharing with pro-palliative oncologists and prioritising the central tumour board improved continuity. Modifications to tumour board summary sheets ensured referral considerations were routinely evaluated, even in the absence of palliative care representation.

Importantly, PCQIP fostered a positive cultural shift by strengthening collaboration between oncology and palliative care teams. Establishing a psychologically safe and collegial environment was instrumental in breaking traditional silos of cancer care delivery. This cultural transformation is as critical as structural change, especially in LMICs where palliative care continues to grow as a specialty. Our experience adds to the emerging body of literature on pragmatic models of integration and offers a scalable framework for institutions striving to improve the quality of care for patients with serious cancer-related health needs.^[14,15]

CONCLUSION

This QI initiative demonstrated that structured, team-based methodologies, such as the PDSA cycle, can effectively enhance the integration of palliative care within oncology services, even in resource-limited settings. By fostering collaboration between oncology and palliative care teams, the project laid a sustainable foundation for an embedded model of palliative care into routine cancer care as has been described in the literature. Such interventions are particularly vital in LMICs, where palliative care remains underutilised despite endorsement by global authorities including WHO, ASCO and ESMO. Bridging the gap between policy and practice requires adaptable, data-driven strategies that address institutional barriers and promote clinician engagement.

Our findings highlight the replicability of this model across similar healthcare settings. Continued investment in QI processes is essential to ensure that palliative care is recognised and implemented as a core component of comprehensive cancer care, ultimately leading to better patient outcomes and system-level efficiency.