Define the Opportunity

Quality Improvement Project, Advance Care Planning / Goals of Care

Measure the Current State

An important starting point for any quality improvement project is to understand your current state as well as current work flow processes related to Advance Care Planning / Goals of Care Designations (ACP/GCD).

Select 1-3 measurable indicators to begin understanding your current state with respect to ACP/GCD practices in your setting. Types of indicators to consider may focus on workplace processes, healthcare provider experiences or patient experiences. Below are some examples of these types of indicators:

  • Workplace Process Measure: e.g. number of patients with a completed ACP/ GCD Tracking Record in the Green Sleeve or patient chart?
  • Healthcare Provider Experience Measure: Staff can be confused or unaware of their role and expectations about Green Sleeves, ACP documents and what to do with them on admission, hospital stay and discharge. It may be helpful to ask healthcare providers in your area “how clear are healthcare provider roles and responsibilities related to ACP/GCD?” (on a scale of 1-7)
    • Healthcare Provider Survey template if-acp-qi-hcp-survey-tool.pdf
  • Patient Experience Measure: Patients may also lack knowledge of ACP /GCD. By conducting a short survey of all patients in one day / one week, “Do you know if you have a Goals of Care Designation?” you will gain a better understanding of their experience.

It is best to keep your measures simple and tailored to your care setting. Think about what will motivate and make a difference to your team. When choosing indicators, use ACP/GCD measures/data currently available to you. Simple is best.

AHS’s Tableau has zone and some site specific data related to ACP/GCD measures such as ACP Tracking Record usage.

How to Access ACP GCD Data

Zone Data or Site Data (Calgary and Edmonton Zones only)

AHS Employees

Visit and search GCD

Non-AHS Employees

The AHS Tableau Server is available using the Health Analytics Portal (HAP). Visit  to find out more on how external users can register and get access.

Define the Opportunity

From your measures, you can narrow down opportunities for improvement and define a specific goal. State your opportunity as specifically as possible. For example:

 “In the last 2 weeks, 30 per cent of all healthcare professionals on our unit reported role confusion as a barrier to performing ACP GCD activities.”

Convert this to a stated goal that includes intended measurable results and intended dates. For example:

“By the end of _____   less than 10 per cent of all healthcare professionals on our unit will report role confusion as a barrier to performing ACP GCD activities.”