Organization and evaluation of generalist palliative care in a Danish hospital

BMC Palliative Care

Table 3 Discrepancies in the departments/sections evaluations of Standard 2.19.1 were identified in 35 cases

Sections	Hospital’s self-evaluation		PAVI -survey		IKAS-data	Discrepancies
N = 35	Departments’ self evaluationStandard met?	Internal audit*	Providing palliative care	Instructions/guidelines for palliative care**	Accreditation of standard 2.19.1	1-5
Unit 1 Medical	Fully	NC	Yes	No		1
Unit 1 Medical	Fully	NA	Yes	No		1
Unit 1 Medical	Fully	NA	Yes	No		1
Unit 1 Medical	Fully	NA	Yes	No		1
Unit 1 Medical	Fully	NA	Yes	No		1
Unit 1 Medical	Fully	NA	Yes	No		1
Unit 1 Medical	Partially	RA	Yes	No		1 + 5
Unit 1 Medical	Partially	NA	Yes	Yes		5
Unit 2 Medical	Partially	NA	Yes	Yes		5
Unit 2 Medical	Not met	NC	Yes	Yes		5
Unit 2 Medical	Partially		Yes	Yes		5
Unit 2 Medical	Partially		Yes	Yes		5
Unit 3 Medical	Partially	RA + P	Yes	Yes		5
Unit 1 Oncology	Fully	RA	Yes	Yes	Indicator 1 and Indicator 2 were both met in full by all the departments	4
Unit 1 Haematol	Fully	RA	Yes	No		1 + 4
Unit 2 Surgical	Fully	NA	No	NQ		3
Unit 2 Surgical	Fully	NA	No	NQ		3
Unit 2 Surgical	Fully	NA	No	NQ		3
Unit 2 Surgical	Fully	NA	No	NQ		3
Unit 2 Surgical	Partially	P	Yes	Yes		5
Unit 2 Surgical	Partially	NA	Yes	Yes		5
Unit 1 Surgical	Fully	NA	Yes	No		1
Unit 3 Surgical	Partially	RA	Yes	No		1 + 5
Unit 3 Surgical	Partially	P	Yes	No		1 + 5
Unit 3 Surgical#	Fully	NA	No pall ptts #	NQ		3
Unit 3 Gyn/obs	Fully	RA + P	Yes	Yes		4
Unit 1 Gyn/obs	Not Relevant	NA	Yes	Yes		2
Unit 2 Anesth	Partially	NA	Yes	No		1 + 5
Unit 2 Anesth	Fully	RA	Yes	No		1 + 4
Unit 1 Miscellaneous	Not relevant	NC	Yes	No		2
Unit 1 Paediatric	Fully	NA	No	NQ		3
Unit 1 Paediatric	Fully	NA	No	NQ		3
Unit 1 Paediatric	Fully	NA	No	NQ		3
Unit 3 Paediatric	Fully	NA	Yes	No		1
Unit 3 Paediatric	Fully	NA	Yes	No		1

*Audit’s comments: P - positive - confirm indicator targets were met. RA - requires attention - discrepancy in fulfilling the indicators. NC - no comments. NA - no audit. ** NQ - not questioned survey# according to the PAVI-survey, this department did not treat palliative patients.
¤Types of discrepancies identified in the triangulation of the 3 dataset: Discrepancy 1: Departments stating in the PAVI-survey ‘not to have a palliative guideline/instruction’, while Standard 2.19.1 was fully or partially fulfilled according to the self evaluation.Discrepancy 2: Departments stating in the self-evaluation that use of the standard was “not relevant”, while responding in the PAVI-survey that their department ‘did provide palliative care’. Discrepancy 3: Departments stating in the PAVI-survey ‘not to provide palliative care’, while they fulfilled the standard according to the selfevaluation.Discrepancy 4: Departments that stated to ‘meet the standard in full’ in the self-evaluation, but received a comment in the audit that they ‘required attention’ Discrepancy 5: Departments that stated to fulfil Standard 2.19.1 only “partially” or “not met” in the self-evaluation, but were assessed by IKAS to “meet the Standard in full”, at the level of Indicator 2.

ISSN: 1472-684X