Date of Paper/Work


Type of Paper/Work

Doctor of Nursing Practice Project

Degree Name

Doctor of Nursing Practice



First Advisor

Dr Emily W. Nowak, Ph.D., RN


Doctor of Nursing Practice


Planning for health care needs is a responsibility that requires informed decision making, time, and individualized attention. Advance care planning (ACP) is an organized process of communication that is intended to assist, engage, and support health care consumers, their families, and the involved health care professionals in understanding, reflecting upon, and discussing the individual’s goals, values, and preferences for their present and future health care needs (Respecting Choices, 2007). ACP an appropriate intervention for all adult health care consumers particularly those with chronic disease or advanced illness.

Fairview Red Wing Health Services (FRWHS) is among many health care organizations worldwide that have failed to incorporate ACP as a routine standard of care. This descriptive systems change project (SCP) was developed to address the inadequate utilization of ACP for individuals and families referred to the FRWHS Palliative Care program. The purpose of this SCP was to identify if the implementation of a formal ACP model would foster the initiation, utilization, and standardization of ACP processes by FRWHS health care professionals for patients referred to Palliative Care. In collaboration with the Honoring Choices Minnesota ACP collaborative, FRWHS initiated and implemented a formal ACP model. This SCP included electronic medical record (EMR) audits and educational interventions. EMR audits were conducted to evaluate ACP documentation practices of health care professionals who referred patients with chronic disease or advanced illness to the FRWHS Palliative Care program prior to the intervention (referred to as no intervention EMR audits). Educational interventions were implemented to enhance ACP awareness and knowledge for FRWHS staff. Following the implementation of interventions, EMR audits were conducted to evaluate if the interventions elicited change (referred to as with intervention EMR audits). It was intended that initiation and 5 Standardization of a Formal Advance Care Planning Model implementation of a formal ACP model would facilitate the utilization and standardization of ACP processes, ensure compliance with ethical and legal requirements, and ultimately provide higher quality patient care throughout FRWHS. Although this SCP was not statistically significant in its entirety, the implementation of the formal ACP model and educational interventions did elicit change for the FRWHS Palliative Care program. Implications for present and future practice and research have been identified as a result of this SCP.