Using Structured Documentation to Improve Advanced Care Planning: A Quality Improvement Project

Introduction:

Advance Care Planning (ACP) is a core component of high quality geriatric care, with the British Geriatrics Society (BGS) advocating a proactive, sensitive and patient centred approach, with recent guidance highlighting the importance of clear communication and documentation. Despite national guidance, ACP uptake and documentation at Doncaster Royal Infirmary remains variable and many patients do not die at their preferred place of death, despite the existence of a local ACP checklist. This quality improvement project aimed to improve clinician compliance and documentation with the ACP checklist and communication of advance care plans across the multidisciplinary team (MDT).

Method:

A two cycle quality improvement project utilising PDSA cycle methodology was undertaken for patients identified through our alert system. A retrospective review of electronic medical records, ReSPECT forms and discharge summaries was performed. Baseline data was collected from patients added between January–March 2025, followed by intervention delivery and repeat data collection from patients added between April–June 2026. Data collected included ACP checklist completion, documentation of CPR decisions and ACP on ReSPECT forms and discharge summaries, medication rationalisation, pre-emptive medication prescribing, future treatment and readmission plans. Interventions included a teaching session for the MDT and posters promoting ACP checklist use.

Results:

38 patients were included in cycle 1 and 30 in cycle 2. Overall, ACP checklist compliance improved from 37% to 90%. ACP documentation increased from 53% to 94% on the ReSPECT form, and from 76% to 93% on discharge summaries. Documentation on plans for readmission increased from 74% to 93%, with further improvements in plans for future treatment (58% to 83%) and investigations (47% to 70%), and discussions with patients/next of kin (74% to 83%). CPR status documentation remained high (74% to 77%). GP review in the community remained an area for improvement (40%).

Conclusion:

This quality improvement project demonstrated that targeted multidisciplinary interventions can improve ACP documentation and checklist compliance. Improved adherence supported clearer documentation of escalation decisions, treatment preferences and communication of care plans across the MDT. Sustainability measures include incorporation of ACP education into induction programmes and development of ACP resource folders to support clinicians in routine practice. Future cycles will focus on palliative care register referral and ensuring consistent transfer of CPR decisions to discharge documentation.