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Closing the health gap: Quick Retrieval of Advance Directives

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Closing the health gap: Quick Retrieval of Advance Directives

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Content Running head: QUICK RETRIEVAL OF ADVANCE DIRECTIVES 1

Closing the Health Gap
Quick Retrieval of Advance Directives

Lindsey E. Stangland
Dworak-Peck School of Social Work, University of Southern California
SOWK 722: Implementing Your Capstone and Re-envisioning Your Career
Dr. Araque
July 7, 2020

QUICK RETRIEVAL OF ADVANCE DIRECTIVES 2
Table of Contents
Executive Summary ........................................................................................................................ 4
Problem Statement ..........................................................................................................................7
Definitions ...................................................................................................................................... 9
Social Significance .......................................................................................................................... 9
Current Environmental Context ....................................................................................................10
Self Determination Act .............................................................................................................. 11
Medicare .................................................................................................................................... 11
Current Advance Directive Interventions ...................................................................................... 12
Respecting Choices .................................................................................................................... 12
Multimedia ................................................................................................................................. 13
Storage ....................................................................................................................................... 13
Impact of No Advance Directives .................................................................................................. 14
Theory of Change ........................................................................................................................... 15
Systems Theory .......................................................................................................................... 15
Ecological Theory ....................................................................................................................... 15
Problems of Practice and Innovative Solutions ............................................................................. 16
Proposed Innovation ................................................................................................................. 16
Stakeholder Perspectives ........................................................................................................... 18
Recap of Evidence and Current Context .................................................................................... 19
Comparative Assessment with Other Opportunities for Innovation ........................................ 20
Logic Model and Sustainability .................................................................................................... 22
Resources .................................................................................................................................. 22
Short-term Outcomes ............................................................................................................... 22
Intermediate Outcomes ............................................................................................................ 23
Long-term Outcomes ................................................................................................................ 23
Likelihood of Success ................................................................................................................ 23
Project Structure and Methodology .............................................................................................. 24
QUICK RETRIEVAL OF ADVANCE DIRECTIVES 3
Description of Capstone Deliverable/Artifact .......................................................................... 24
Project Implementation Methods ............................................................................................. 26
Financial Plan and Staging ....................................................................................................... 27
Budget ................................................................................................................................... 28
Staging .................................................................................................................................. 28
Project Impact Assessment Methods ........................................................................................ 28
Stakeholder Engagement Plan ................................................................................................... 31
Internal Stakeholders ............................................................................................................ 31
External Stakeholders ........................................................................................................... 32
Communication Strategies and Products ................................................................................. 32
Ethical Considerations .............................................................................................................. 33
Conclusions, Actions, and Implications ....................................................................................... 34
Summary of Project Plans......................................................................................................... 34
Current Practice Context for Project Conclusions .................................................................... 35
Project Implications for Practice and Further Action .............................................................. 35
Project Limitations ................................................................................................................... 36
Conclusion ................................................................................................................................ 37
References ..................................................................................................................................... 38
Appendix A .................................................................................................................................... 42
Appendix B .................................................................................................................................... 43
Appendix C .................................................................................................................................... 44
Appendix D ................................................................................................................................... 53
Appendix E .................................................................................................................................... 54
Appendix F .................................................................................................................................... 55
Appendix G ................................................................................................................................... 56
Appendix H .................................................................................................................................... 57
Appendix I ..................................................................................................................................... 58
QUICK RETRIEVAL OF ADVANCE DIRECTIVES 4

Quick Retrieval of Advance Directives
"I have a healthcare directive, not because I have a serious illness, but because I have a family."
-Dr. Ira Byock
Executive Summary
A pronounced health gap is clearly evident across the entire United States. Despite
multiple attempts to close the health gap, to date they have not been successful (Gabow, 2016).
Closing the health gap is a complicated challenge because multiple factors have created it. These
inter-related factors that have influenced and created the health gap include neighborhood
context, healthcare systems, increased risk for disease, racial and other forms of discrimination,
gender inequality, and lack of support systems (Gabow, 2016).
Within the Grand Challenge of Closing the Health Gap, advance care planning has an
important place. Research indicates that the preference for having an advance directive can be
influenced by individual attitudes, cultural beliefs, health conditions, and trust in health care
professionals (Jones, Moss and Harris-Kojetin., 2011). Completion of advance directives has
significantly improved multiple outcomes within Closing the Health Gap, including
the likelihood that clinicians and families understand and comply with the patient’s wishes,
reduction in hospitalization at the end of a patient's life, fewer and less invasive treatments at
the end of an individual's life, increased utilization of hospice services, and increased likelihood
that a patient will die in their preferred place (Detering and Silver, 2018). As a society, there is a
social norm of avoiding any discussion of the potential of death, and then only doing so when
preparing for our own death or the death of a loved one upon advancing age or when a
QUICK RETRIEVAL OF ADVANCE DIRECTIVES 5
serious/terminal illness occurs. Communication between patients, their physicians and their
families about the preferences and values of care are essential; however, due to the nature of
these decisions, a conspiracy of silence often delays or prohibits these sensitive but extremely
important discussions (Karnik and Kanekar, 2016). These essential conversations are a
precursor to completing an advance directive.
There is significant room for improvement in the completion, retrieval, and distribution
of advance directives. Most would agree that advanced directive documents should be
thoroughly completed, securely stored and transmissible, and easily and confidentially
accessible. Quick Retrieval of Advance Directives (QRAD) is a nonprofit organization that will be
established to tackle these issues with three primary organizational purposes. The first purpose
will be to educate physicians/medical providers and the public about the importance of
completing advance directives. The second purpose of the organization will be to meet with
individuals and their families about the completion and updating of their advance directives to
ensure that individuals get their end-of-life wishes properly documented. The third purpose of
QRAD will be to create a computer software program that communicates directly with medical
insurance companies so that when an individual's medical insurance information is retrieved at
the hospital or medical provider's location, the completed advance directive can be retrieved at
the same time. QRAD also ensures that the documents will be able to be located across all levels
of care, and even when a person is located out of state.
There are several groups from both a healthcare and community perspective that likely
feel very connected to this problem who could benefit from the implementation of QRAD’s
transformational system. Physicians and medical providers are an essential stakeholder group in
this innovation. They have a vested interest in ensuring that individuals have medical decision-
makers and also have a need to know the individuals' desired medical preferences. The
innovation that is proposed to solve this problem will draw on the foundations of systems and
ecological theory. The startup period for QRAD will be geared toward project planning,
QUICK RETRIEVAL OF ADVANCE DIRECTIVES 6
including organizational partnerships, logo and website design and refinement, marketing plan
completion, and networking with medical insurance companies and hospital organizations.
QRAD has three components to the organization that are all essential to be measured.
The first component is the education of individuals about advance directives, as well as advance
directive completion. Demographic information, as well as reason for the contact, will be
collected when an individual completes the Contact Us section of QRAD’s website. QRAD has a
goal of completing 10 advance directives per month in the startup phase and 40 advance
directives per month in the implementation phase by connecting with individuals through
QRAD's website and having a conversation with a QRAD staff member, either in person or
virtually. Advance directive completion will be confidentially documented within QRAD’s
system.
The second component is the education of physicians/medical professionals. This will be
evaluated by the QRAD physician/medical provider education pre-test and post-test
administered to the physicians/medical professionals asking about their comfort level with
addressing advance directives with their patients. The goal is for 75% of physicians/medical
professionals to report that they have a higher comfort level in addressing advance directives.
An increase in the completion of advance directives will be evaluated in the physician/medical
professional's medical practice by chart review, with a goal of a 40% higher completion rate of
advance directives within their medical practice.
In the startup phase of QRAD, the goal is to connect with one medical insurance
company and one healthcare organization. Once this connection has occurred and the software
has been developed, the goal is that 30% of all advance directives possessed via the medical
insurance company be filed and accessible through the QRAD software program that will be
designed to securely and confidentially connect directly with the healthcare medical record.
The long-term outcome for QRAD is for the program to be entirely successful, and the
negative stigma surrounding talking about end-of-life wishes will be diminished. Due to
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education surrounding the importance of end-of-life planning, the social norm would change,
and end-of-life planning would be talked about openly. Not only would advance directives be
completed, but they would be able to be more easily located so that family and physicians can
honor those end-of-life wishes. Physicians, patients, and their families would all be educated
about advance care planning, and once the documents are completed, patient wishes can be
located with ease of access when needed.
QRAD is supported by a financial plan that requires approximately $499,084 annually
for the startup period and $452,073 annually on an ongoing basis. Much of the expenses in the
startup period are related to a medical director, personnel and contractors. The projected
annual expenses include continued contractor needs, as well as educational materials and
additional operational needs to sustain the program. Details of these expense plans are
contained in the budgets (Appendix F & G). QRAD is dependent on foundations, Medicare
reimbursement, grants, revenue, and a significant fundraiser for its funding. Once the startup
period is completed and plans for expansion are explored, alternate funding sources will be
considered.
The next step in implementation is creating the curriculum to educate physicians and
medical professionals and to connect with a software development organization to develop the
software that connects with medical insurance companies and healthcare systems. QRAD has
already been in communication with one medical insurance company and one healthcare
organization regarding this innovation, and each have expressed interest. Growth for QRAD will
include additional healthcare organizations and medical insurance companies once the software
is developed.
Problem Statement
The American Academy of Social Work and Social Welfare has chosen Close the Health
Gap as one of the 12 Grand Challenges to tackle our nation's toughest social problems. As a
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society, inadequate access to primary health care persists, coupled with the effects of
discrimination, poverty, and dangerous environments (“Close the Health Gap,”2019). To achieve
health equality, the field of social work must create community-based interventions to facilitate
health care access. One initiative within the health gap is the completion of advance directives to
ensure that patient end-of-life wishes are documented, updated regularly, appropriately stored,
and honored.
A profound paradox exists in modern medicine at the end of life in the U.S. It is not
uncommon for individuals to receive unwanted medical care at the end of life due to the absence
of a completed advance directive that documents the patient’s health care preferences. For
example, 70% of people say they prefer to die at home, and yet 75% of people die in an
institution (Teno et al., 2004), and one-fifth of hospital deaths occur in an even more costly
intensive care unit (Gruneir, Mor, Weitzen, Truchil, Teno and Roy., 2007). In the event end-of-
life decisions are necessary, 50% of patients are unable to make them; and despite the many
benefits, only one-third of U.S. adults have completed advance care planning (Weil., 2017).
Ninety percent of people say that talking with loved ones about future healthcare
decisions is essential; however, only 27% have had the discussion (The Conversation Project,
2018). Similarly, 80% of people say they would like to talk to their doctor about planning for
future healthcare, and 60% of physicians/medical providers believe it is essential to have these
conversations. However, only seven percent of patients have had this conversation with their
physician (The Conversation Project 2018). Forty-six percent of physicians/medical providers
report that they do not know how to have this conversation with patients, and only 29% said
their medical practice or healthcare system had a formal system to document the end-of-life
wishes (Birenbaum, 2016). Lack of advance directive completion is often due to individuals
thinking that they are healthy, too busy, do not have enough information about their medical
condition, and/or want to leave their health in God's hands (Schickedanz, Schillinger,
Landefeld, Knight, Williams and Sudore., 2009). Due to these barriers, advance care planning
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conversations often do not occur until an individual is in the final stages of life. Furthermore,
even if documents have been completed, often they cannot be located and have not been
discussed with the individual's family or physician/medical providers.
Medicare is the health care pay source for 80% of all United States decedents at an
average per capita cost of $80,000 during the last 12 months of life (French et al., 2017). An
estimated two-thirds of Medicare beneficiaries are hospitalized at least once in the last six
months of life, and 25% of those have multiple hospitalizations. Nationally, about 25% die in the
hospital (Institute of Medicine, & Committee on Approaching Death: Addressing Key End of Life
Issues. 2014). Adequate advance care planning can significantly reduce Medicare spending,
decrease the likelihood of in-hospital deaths, and increase the use of hospice care. With an aging
population that is increasingly vulnerable to illness and unwanted medical care, particularly
during this phase of the global pandemic, individuals need to have an advance directive.
Definitions
A wide range of terms are used in advance care planning. Although many are often used
interchangeably, there are important distinctions between each term necessitating clarification.
Appendix A provides definitions of key terms referenced in advance care planning.
Social Significance
As a society, social norms against discussing the potential of death are pervasive.
Generally, only when faced with our own or a loved one’s imminent death do these
conversations occur, if at all. Communication between patients, their physicians/medical
providers, and their families about their preferences and values of care is essential. However,
due to the nature of these decisions, a conspiracy of silence often delays or prohibits these
discussions (Karnik and Kanekar, 2016).
Despite recognizing the many benefits of having an end-of-life conversation, a variety of
barriers including discomfort with the topic, lack of time and reimbursement, physician/medical
QUICK RETRIEVAL OF ADVANCE DIRECTIVES 10
providers’ ideology, delaying discussions, patient family dynamics, lack of patient education,
inconsistencies in accessibility to advance directive documents, and lack of training impede
physicians/medical providers from having these crucial conversations with their patients and
families. Generally, these conversations are occurring when the patient is at a medical
appointment, but more often occurring when a patient has been admitted to the hospital at a
time of crisis. If documents have been completed before the hospitalization, often they cannot be
located and have not been discussed with the individual's family or physician/medical provider.
A second challenge is locating the completed documents. The inability to locate the
advance directive documents has been proven to be just as harmful as not having them. It is
common for individuals to place their advance directive in their safety deposit box or personal
safe or in files with other important papers at home. In these instances, family members and
physicians/medical providers have limited, to no access, to the documents when needed.
Current recommendations for storing an advance directive is to keep a copy on the fridge, in the
car glove compartment, in a wallet and/or purse, in an email on a smartphone, or to enroll in a
registry if the state of residence has one. All of these options do not solve the problem of family
and physicians/medical providers not knowing whether an individual has a completed advance
directive, and if so, quickly locating and accessing it, especially if the individual has traveled out
of the state or to another country.
Current Environmental Context
In an attempt to address the social norm of avoiding conversations regarding death and
dying, the field of social work prepares medical social workers to encourage and facilitate
communication among patients and their families to discuss their preferences and values of
care, to promote advance care planning, to advocate for the patient's wishes to be honored, and
to provide education surrounding advance directives (Stein & Fineberg, 2013). The majority of
organizations that engage in advance care planning are focused on the awareness piece of the
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conversation. This means that they are aware of the issues surrounding advance care planning
and want others in the community to be aware as well.
Self Determination Act
The Patient Self-Determination Act was passed in 1991 (Kelley, 1995). The purpose of
this Act is to ensure that a patient's right to self-determination in health care decisions is
communicated and protected. The Act identifies the patient, family members and loved ones,
and the medical professionals as beneficiaries of the Act’s protections. The Act also seeks to
address the soaring costs of end-of-life care. When individuals do not wish to be revived but are
unable to voice their wishes, medical facilities typically default to life-sustaining care which
results in soaring medical costs (Cedeno, Dang, Hartman & Et al. 2018). The Act also attempts
to eliminate racism, classism, sexism, and homophobia as all patients would be informed of
their rights and be allowed to complete an advance directive to communicate their medical
treatment wishes. (Cedeno, Dang, Hartman, Johnson, and Villareal., 2018).
Medicare
Effective January 1, 2016, the Centers for Medicare and Medicaid Services pays for
voluntary advance care planning conversations. The Medicare Physician Fee Schedule currently
provides for payment of advance care planning and consultation in a physician's/medical
provider’s office and the hospital. Medicare reimbursement also allows other providers such as
social workers, nurses, nurse practitioners, and physician assistants to facilitate conversations
and bill under the physician. Though Medicare reimburses for advance care planning
conversations, there are still barriers to those conversations occurring, such as
physician’s/medical provider’s lack of knowledge of the Medicare reimbursement change, the
physician's/medical provider’s comfort level with the conversation, a physician's/medical
provider’s belief that someone else is responsible for having the conversation, and the inability
to accurately document and retrieve the documents once they are completed.
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Current Advance Directive Interventions
The Patient Self-Determination Act and Medicare have made an impact in encouraging
advance care planning conversations, as well as educational programs such as The Conversation
Project, Respecting Choices, and Netflix. These programs have made headway in educating the
public; however, storage and access to these completed documents continues to be problematic.
The Conversation Project
The Conversation Project is a public engagement campaign to have every person's wishes
for end-of-life care expressed and respected. It is focused on changing the fact that too many
people die in a manner they would not choose, and too many of their loved ones are left feeling
guilty, depressed, and uncertain about whether they did the right thing and made the right
decisions. The Conversation Project began when Ellen Goodman and a group of concerned
media, clergy, and medical professionals gathered to share stories of individuals who had a
"good death" and those with "hard deaths" within their circle of loved ones ("The Conversation
Project," 2018). Through this sharing, they realized that the difference between the two
experiences often hinged on whether or not they had the conversation related to how their loved
ones would like their end-of-life experiences to be. The Conversation Project has developed a
three-pronged strategy to change our national, cultural norm ("The Conversation Project,"
2018).
Respecting Choices
Respecting Choices is an evidence-based model of advance care planning that creates a
healthcare culture of person-centered care. Respecting Choices helps healthcare organizations
and communities develop a culture of person-centered care by implementing care planning
systems and shared decision making into the routine of care ("Person-Centered Care," 2018).
Research was conducted on all 540 individual adult La Crosse, Wisconsin residents who died
under the care of any health organization in La Crosse County. The findings showed that 85% of
these individuals who passed away had some written advance directive and that 96% of these
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documents were found in the medical record of the treating health organization. The
preferences to forego treatment in these documents were consistent with treatment decisions
98% of the time ("Person-Centered Care," 2018).
Multimedia
It is hard to imagine the questions and issues with which you will be presented at the end
of your life or the end of a loved one's life until you are in the situation. Netflix has created two
documentaries to show how hard it is to make end-of-life decisions and how important it is to
plan and have conversations with our loved ones in advance. “End Game” is a Netflix Original
documentary produced in 2018 featuring patients facing the inevitable outcome. The
documentary focuses on terminally ill patients who meet extraordinary medical practitioners
seeking to change our approach to life and death. “Extremis” is a second Netflix documentary
produced in 2016 featuring a cherished life slipping away. It focuses on the family's time of grief
and how their love becomes both their anchor and their guide for the decisions they need to
make for a loved one. ZDogg MD also produced a rap song titled, "Ain't the Way to Die" that
shows the first-hand experience from a physician's/medical provider’s point of view about what
it is like to take care of patients at their end of life. Often, it is hard to imagine our end of life or
that of a loved one until we are in the situation and are faced with having to make highly
emotional, and sometimes rushed, decisions. These documentaries showcase firsthand some of
the scenarios and situations that we may be faced with so that we can anticipate and feel better
prepared for when the time comes.
Storage
Storage of an advance directive is just as important as the completion of the advance
directive. The Electronic Medical Record (EMR) has the potential to coordinate care across
providers and care settings, as well as to remind clinicians to enter advance care planning
information (Dillon, et al., 2017). However, recorded advance care planning information may be
inaccurate or not actionable (Dillon, et al., 2017). In a study done by Wilson, et al, it was
QUICK RETRIEVAL OF ADVANCE DIRECTIVES 14
reported that 51% of patients who were age 65 years and older had advance care planning
documentation. However, only 33.5% of these records included a scanned document, which
included the signature required to be legally valid (Dillon, et al., 2017). In a second study done
by Evan Walker, MD, he emphasized the need for standardized and frequent advance care
planning documentation in the electronic medical record. However, how often these discussions
are documented in the electronic medical record is unknown (Walker, Mcmahan, Barnes, Katen,
Lamas & Sudore., 2018). Researchers analyzed electronic medical record documentation of 414
patients from primary care clinics of the San Francisco VA Medical Center, all at least age 60
years, with multiple medical conditions. Fifty-one percent had engaged in some form of advance
care planning in the past; however, only 55% of the discussions were recorded accurately.
Instead, most of them were buried as free text in physician or hospital notes, often years old,
making these documented wishes challenging to find when needed (Walker, et al., 2018).
Barriers to documenting advance care planning include electronic medical record design
challenges, the need to scan the documents into the electronic medical record, and the time
needed to appropriately document the conversation (Dillon, et al., 2017).
Impact of No Advance Directives
Advance care planning often occurs late or fails to occur for patients who would most
benefit from it. Technological advances are prolonging life at advanced stages of a terminal
illness, and end of life is often lower quality and costlier to patients, their families, health
systems, and society as a whole due to these circumstances. When an individual does not have
an advance directive, the cost of dying skyrockets. According to the Agency for Healthcare
Research and Quality, one-quarter of all Medicare spending annually, $139 billion, goes toward
care for just 5 percent of beneficiaries who die each year (Ensocare, 2017). Research suggests
that $1.7 billion in annual health-care expenses could be avoided if all adults had an advance
directive (Ensocare, 2017).
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Theory of Change
Systems Theory
Systems theory states that behavior is influenced by a variety of factors that work
together as a system. An individual's family, friends, economic class, home environment, and
other factors all influence how a person thinks and acts (Swhelper, 2019). Missing or ineffective
parts of the system can have a negative impact on behavior. Similarly, resolving the missing or
ineffective parts of the system can have a positive impact on behavior. In systems theory, it is
essential to observe and analyze all of the systems that contribute to an individual's behavior
and welfare. In advance care planning, there are multiple systems in place that affect whether
individuals are open to talking about their end-of-life wishes. They must have a good
relationship with an individual who can make medical decisions for them. The relationship with
their physicians/medical providers is also essential. They must feel that their physicians are
open to the conversation surrounding the topic and have confidence that their physicians will
provide accurate information regarding their medical condition. The environment and culture
surrounding advance directives needs to change in order for individuals to be more open to
documenting their advance directives.
Ecological Theory
The ecological theory is fundamentally concerned with the interaction and
interdependence of people in their environment. Individuals do not operate in isolation but are
influenced by the physical and social environments in which they live and interact. The
environment around advance directive completion may encourage or dismay an individual to
complete an advance directive and have conversations surrounding their end-of-life wishes. As
an individual's environment may change, their willingness to complete an advance directive may
change. Individuals who work in a hospital setting may be more willing to complete an advance
directive and may be more open to conversation as they see the importance of having them and
the consequences if an individual does not have one. Similarly, an individual who has had a
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negative experience may be more open to discussing advance directives and completing them, as
opposed to someone who has not had any experience.
Problems of Practice and Innovative Solutions
Proposed Innovation
There is significant room for improvement in the completion, storage and distribution of
advance directives; and it can be argued that they should be routine, transmissible and
accessible. The proposed innovation QRAD is a nonprofit organization that will have three
primary purposes. The first purpose will be to educate physicians/medical providers and the
public about the importance of completing advance directives. The second purpose of the
organization will be to meet with individuals and their families about the completion and
updating of their advance directives to ensure that individuals get their end of life wishes
documented on the proper forms. The third purpose of the organization will be to create a
computer software program that communicates directly with medical insurance companies so
that when an individual's medical insurance is retrieved at the hospital or medical provider's
location, the completed advance directive can be retrieved at the same time.
Advance care planning conversations rarely occur between medical providers and their
patients due to a number of reasons, including the physician's/medical provider’s lack of
comfort with the conversation, the medical provider waiting for the patient to initiate the
conversation, lack of time to adequately have this sensitive discussion, and trouble with
reimbursement (Spoelhof & Elliott, 2012). With the implementation of QRAD, medical
providers will be educated about the importance of having an advance directive, as well as how
to talk with patients and families about an advance directive. QRAD, in partnership with The
Conversation Project, will provide scripts and educational materials to start the conversation.
Medical providers will be able to access the documents with ease and review them with their
patients at the time of the appointment or hospitalization. It will take away the barrier of lack of
QUICK RETRIEVAL OF ADVANCE DIRECTIVES 17
time regarding having the lengthy initial conversation as QRAD will provide facilitators to assist
with the initial discussions in the physician's/medical provider’s office, patient's home, or
virtually. It is expected that the medical provider will start the conversation, connect the
individual to QRAD to continue this deeply personal conversation, and then QRAD will assist
the individual in completing their advance directive, regularly review the patient’s wishes, and
update the advance directive as desired.
By implementing QRAD, the physician/medical provider will have access to the
documents when a patient comes in for routine visits and/or when they are ill. A
physician/medical provider will be more easily able to access and review their patient's wishes
and initiate conversations over time to either confirm their patient's wishes or make changes as
a patient's condition declines. It will be necessary for the medical staff to ensure that the
documents are uploaded in the appropriate area for the physician/medical provider to routinely
review them. In most medical offices, it is practice to review medical insurance at every
appointment, so it will not require any burdensome, additional steps at the beginning of an
appointment.
Not only will the communication and ease of access to the documents influence medical
providers and office visits, but it will also affect the role that the patient's family plays in advance
care planning. QRAD will eliminate the problem of not being able to locate the documents at the
time of need. There will be no question as to whether an individual has completed advance
directive documents, and if they do, where they are located. Historically, a patient's family has
not known if their family member has an advance directive, and they made decisions regarding
what they believed the individual wanted. Often after decisions are made, an advance directive
has been found, which either confirmed the patient's wishes or identified that the patient had
expressed a desire for something different. In the event aggressive care has been decided upon, a
family is often faced with the decision to remove life-saving interventions once an advance
directive is found. It will also encourage conversations among family members when it is time to
QUICK RETRIEVAL OF ADVANCE DIRECTIVES 18
renew health insurance, because spouses frequently discuss health insurance options and
coverages to ensure that the insurance plan in which they are enrolled is still the desired plan.
Stakeholder Perspectives
There are several groups from both a healthcare and community perspective that likely
feel very connected to this problem and could benefit from the implementation of QRAD. One
major stakeholder is Medicare. Medicare is an insurance program for individuals 65 years and
older, as well as those younger than 65 with specific disabilities. Medicare is offered by the
federal government (Medicare, 2017). Medicare has already recognized the importance of
advance directive completion, as they are reimbursing for advance directive conversations. It is
vital to Medicare that individuals have their advance directive completed so that individuals are
not receiving, and Medicare is not paying for, medical treatments that an individual does not
desire. Like other organizations, Medicare recognizes the importance of the conversation but
has not created a way to universally document and store the advance directive documents once
they are complete.
Physicians and medical providers are an essential stakeholder group in this innovation.
They have a vested interest in ensuring that individuals have medical decision-makers and a
need to know the individual’s desired medical preferences. Within the hospital organization
bedside, nurses are also stakeholders. They are doing direct patient care and are often
interacting with the patient and family most when a difficult decision needed. A physician or
nurse may be made to provide care to an individual that the individual may not want due to that
individual not having an advance directive in place.
Individuals and their families who lack information and an understanding of the
importance of completing advance directives and need assistance once they are ready to do so is
another stakeholder group. This essential group is the one most impacted by the work that
QRAD does. Individuals who are not educated on the importance of an advance directive likely
do not have one. This is problematic for the individual as well as their family. A patient's family
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may be forced to make medical decisions regarding an individual's care when they do not know
what the individual may want. Advance directives are essential for individuals over the age of 18.
Internal stakeholders for QRAD include QRAD's board of directors, employees, and managers.
They have an essential role in QRAD as they will assist in ensuring that the program is
successful. These individuals will be the ones who assist in ensuring that the culture of QRAD is
positive both inside and outside of the organization. They will have an essential role in
marketing QRAD and ensuring that QRAD has a good reputation, one that is known for quality
work and that individuals respect.
Recap of Evidence and Current Context
The Patient Self-Determination Act that was passed in 1991 recognizes the importance of
ensuring that a patient's right to self-determination in health care decisions be communicated
and protected (Kelley, 1995). While the impact of this Act has been felt in the context of
admitting individuals to nursing homes and hospitals, it has not been successful in influencing
the general public on the completion of advance directives. Advance directives are often
discussed with an individual when they are just being admitted to a nursing home or hospital
and are filled out due to necessity. The documents may not reflect an individual's true wishes as
they may feel pressure to declare their wishes during a period of intense stress and crisis. These
are less than optimal times to complete an advance directive. It is crucial for advance directives
to be completed when a person is not in a crisis state. By completing an advance directive when
enrolling in medical insurance or at a routine medical appointment, it will allow for the advance
directive to be completed in a non-emergent state when an individual may be able to think more
clearly, may have more rational conversations with trusted loved ones, and their wishes may be
more accurately reflected. The family will also not be struggling to find the advance directive in
the emergent time.
The benefit to the insurance companies of having enrollees’ complete advance directives
is a reduction in the medical costs associated with end-of-life treatments and hospitalizations.
QUICK RETRIEVAL OF ADVANCE DIRECTIVES 20
Medicare has already invested in the importance of completing advance directives by paying
providers to have advance care planning conversations. It would also benefit individuals who are
enrolled in Medicaid as that population generally does not have a completed advance directive
due to the believed expense of completing one. By having individuals who are enrolled in
Medicaid also complete an advance directive, it will reduce the end-of-life medical spending on
that population. If an individual does not have a robust support system or is estranged from
family, it will encourage designating one person as a decision-maker so that physicians/medical
providers know to whom they should discuss end-of-life decisions.
Despite good intentions, most advance care planning programs do not address the entire
problem of knowing an individual's end-of-life care wishes, as well as being able to locate the
documents that describe those wishes. Often, these programs educate about the importance of
completing an advance directive, but they fail to provide a universal way for advance directives
to be accessed across multiple care settings. Advance care planning programs are seen as a
solution to addressing the problem of individuals not having completed advance directives.
However, it continues to be the norm in our society that most individuals do not have an
advance directive in place. It also continues to be the norm that if an advance directive is in
place, it has not been discussed with family or with an individual's physician/medical provider.
Even if it has been discussed, a completed advance directive frequently cannot be located. QRAD
will fulfill the need to encourage more people to complete an advance directive as it will be
connected with medical insurance applications and require that the document be reviewed on at
least an annual basis when individuals re-enroll in their medical insurance.
Comparative Assessment with Other Opportunities for Innovation
Programs focused on advance directives have existed for many years to help ensure that
patient wishes are understood and that they are honored. Most advance directive programs have
focused on educating the public by using signs, billboards, distributing educational materials in
physicians/medical providers offices, and at hospitals and nursing homes. They are meant to
QUICK RETRIEVAL OF ADVANCE DIRECTIVES 21
increase the awareness of the importance of advance directives and the likelihood that an
individual knows what an advance directive is. Unfortunately, only a few of the advance care
planning programs provide for a personal one-on-one or virtual discussion with the patient and
family members to ensure that the patient understands what decisions are being made and that
the healthcare representative has a clear understanding of the patient's wishes.
While some advance care planning programs include educational material, a tool to have
a conversation, and recommendations on how to communicate wishes to the physician/medical
provider, the programs rarely include a way for the documents to be universally stored and
accessed once completed. Respecting Choices and Five Wishes are two nonprofit organizations
whose work closely resembles the proposed model of QRAD. However, they both focus on the
importance of the conversation and do not provide a way for the documents to be universally
located once completed. QRAD is focused on creating systemic change by connecting the already
completed advance directives with the health insurance company for universal access and to
ensure that advance directives are updated regularly. Although Respecting Choices and Fives
Wishes both highlight the importance of having an advance directive conversation, the model of
QRAD is a transformative process looking specifically at how to not only have the documents
completed, but to also have them reviewed on a regular basis, and universally stored, with ease
of access when needed.
There is limited academic literature that speaks about the storage of advance directives.
However, the available data has shown that storage of advance directives once completed is
equally as crucial as completing them to ensure that they can be located when needed. This data
is crucial, because it shows the relevance of a program model such as QRAD, which builds in
support structures such as communication and completion.
In the future, it would be worthwhile to gather information about how socioeconomic
status, race, and religious beliefs affect whether an individual has completed an advance
directive. It would be essential to interview individuals within those cultures and tailor
QUICK RETRIEVAL OF ADVANCE DIRECTIVES 22
educational material specifically to those populations. QRAD will not be an intervention able to
reach everyone, as the U.S. does not have universal health care systems, and not everyone has
medical insurance. Furthermore, research on successful programs and the elements that have
contributed to their success will be instrumental for building and sustaining continued positive
momentum on completing advance directives and finding a universal way to update and store
them regularly.
Logic Model and Sustainability
Resources
The resources crucial for QRAD to be successful to operate and be sustained are staffing,
contractors, time, funding, research findings, office materials, advance directive documents, and
software development and updates. These resources are necessary to educate the
physicians/medical providers, educate patients and families, and assist in completing the
advance directives. They are also needed to create software to connect with medical insurance
companies and healthcare organizations. QRAD hopes to reach patients, their families,
physicians/medical providers, health care organizations, and medical insurance companies.
Short-term Outcomes
QRAD has short, intermediate, and long-term outcomes, as can be seen in Appendix B.
All of these outcomes are equally as important in ensuring the success of QRAD. The short-term
outcomes focus on physician/medical provider education, knowledge, awareness,
opinions/attitudes, and motivation. QRAD also focuses on patient education and awareness,
knowledge, attitudes, and motivation. Networking with both the medical insurance company
and the health care organization is essential during this phase. It is crucial to have buy-in from
both organizations during the short-term outcomes to ensure QRAD’s success. QRAD will also
collaborate with other organizations such as The Conversation Project that has already initiated
programs similar to QRAD to utilize their professional educational materials and to encourage
QUICK RETRIEVAL OF ADVANCE DIRECTIVES 23
them to use the software development that QRAD has created for universal storage and
retrieval.
Intermediate Outcomes
Intermediate outcomes include training of QRAD staff as well as the staff at the medical
insurance companies and health care organizations. It will be crucial to have staff investment in
the program and this will be encouraged through an excellent staff training program. New
procedures for storing and retrieving the documents will be required, and the staff will, in part,
be who make the new system successful. The staff will be scanning documents into the new
system, and it will be essential to have high quality assurance practices, documented policies
and procedures, and flawless execution. Software development and regular updating are also
critically important.
Long-term Outcomes
The long-term outcomes for QRAD include reducing the negative stigma surrounding
advance directives, and that advance directive completion will become the norm in our society.
It also includes increasing the comfort level of physicians/medical providers with having
discussions surrounding advance directives, and ultimately having patients’ end-of-life wishes
honored. Completed advance directives will be filed and timely retrieved in accordance with
QRAD's safe and secure retrieval system.
Likelihood of Success
The implementation of QRAD has already begun. Communication has occurred with a
medical system regarding the innovation, and they are highly interested in implementation.
QRAD has partnered with The Conversation Project to use its educational materials when
working with individuals and families. Communication has also occurred with a private medical
insurance company regarding the innovation of QRAD. The leaders of the insurance company
are in discussion as to whether the innovation will be something that they can do. If the
QUICK RETRIEVAL OF ADVANCE DIRECTIVES 24
insurance company that is currently contemplating the innovation is unable to commit, another
medical insurance company will be contacted.
While it is crucial to think big, it is also essential to start small and grow to scale in
accordance with resources and demand to ensure success. Identifying implementation steps and
moving diligently forward to operationalize in a manageable way is vital. This is such important
work--it deserves to be done well to ensure that it is successful. It will be necessary to select a
small group of individuals to pilot the program. The problem of not having an advance directive
or being unable to locate one that has been previously completed is so significant that in order
for the program to be successful, it will be essential to narrow it down to a small pilot group of
individuals. This pilot group can be determined by the health care system in collaboration with
the insurance company. Evaluating the success of the program would include tracking the
increased percentage of advance directives that are completed and stored, and on a longer-term
basis, studying whether the cost of health care declined based upon having an advanced
directive in place and honored. If the pilot program is successful, to truly make this a national
program, conversations with organizations such as Medicare and Medicaid about potential
partnerships and collaboration regarding connecting advance directives with medical insurance
will need to occur.
Project Structure and Methodology
Description of Capstone Deliverable/Artifact
The prototype for QRAD consists of two parts, the first of which is a website, and the
second part of the prototype is a marketing plan. The QRAD website has been developed, and
the web address is http://qradvancedirectives.com/. The website includes a home page, about
us page, services page, and resources page. It also includes a dedicated QRAD phone number,
email address, and a section with details on how to contact QRAD. Information about QRAD's
mission, stakeholders, opportunities and services are also showcased on the website. The second
QUICK RETRIEVAL OF ADVANCE DIRECTIVES 25
part of the prototype consists of a marketing plan (Appendix C). The marketing plan outlines
QRAD's overall marketing effort and includes an executive summary, situational analysis,
SWOT analysis, objectives, marketing strategy, action program, financial forecast, and controls.
The website is operational so that QRAD's overall marketing efforts can be realized.
Comparative Market Analysis
QRAD has been created to inform individuals of the importance of advance directives, to
educate physicians/medical providers about advance directives, and to develop a system to store
these personal documents in a secure, universal, electronic storage system. QRAD has many
competitors, such as Respecting Choices, The Conversation Project, and Five Wishes (Appendix
D). These competitors are similar to QRAD because of their commitment to educating the public
about the importance of advance directives. These are highly respected organizations; however,
many of their programs focus primarily on the importance of completing advance directives but
do not address the need for secure universal storage and retrieval systems and methods. They
also focus primarily on educating individuals and families and not on informing
physicians/medical providers, which leaves a void as it relates to identifying strategies for
enhancing physician’s/medical provider’s comfort with these sensitive conversations. Providers
have often reported that one of the reasons they do not address advanced directives with their
patients is due to their lack of education about advanced directors, as well as a general lack of
comfort with having the conversation (Kwon, 2016).
Physician/medical professionals’ comfort with the conversations, as well as a better
understanding of advance care planning documentation practices, will lead to quality
improvement opportunities to enhance patient safety and increase the likelihood that the
patient’s wishes are honored (Walker, 2018). One key advantage that these competitors have is
name recognition within the medical systems. QRAD is an innovation that is still in the
implementation phase as evidenced by its organizational value and resource requirements.
Nonetheless, once QRAD is officially launched, it will be intersectional and have a different,
QUICK RETRIEVAL OF ADVANCE DIRECTIVES 26
unique approach to help individuals as well as physicians/medical providers fully engage in the
services and opportunities QRAD provides.
Project Implementation Methods
An implementation plan for QRAD is essential as it provides structure, organization,
established priorities, and focus consistent with QRAD’s mission and vision (Appendix E). With
the implementation of QRAD, many things needed to be initiated and started ahead of time.
These included creating a QRAD logo, designing and establishing the website, developing a
marketing plan, and partnering with The Conversation Project to use their advance directive
conversation guides. In addition, fruitful discussions with the health care organization and the
medical insurance company also occurred.
QRAD will measure various collected data every month to assess the progress of advance
directive completion and universal storage. For those who participate, the QRAD
physician/medical provider education pre-test and post-test will evaluate physicians’ comfort
levels with these sensitive conversations. Medical chart reviews will be completed, and tracking
will be done regarding the number of advance directives that are newly completed and/or
updated. A tracking system for universal storage/retrieval will be developed as part of the
software development process. All information collected regarding advance directive completion
and storage will be kept in a confidential and secure individualized file. The Program Director
will generate periodic reports of the outcomes of QRAD based on the information tracked. The
measurable outcomes will be reviewed, and overall quality assurance will be completed to
ensure that the program meets the targeted outcomes as stipulated in funding this program.
An individual will get connected with QRAD in one of two ways. The first way is through
QRAD’s website and clicking on the Contact Us button. Once an individual clicks the Contact Us
button, they will be contacted by a QRAD representative within 24 hours during the business
week. They will have the option of setting up a virtual meeting with a QRAD representative or an
in-person meeting. The second way an individual is connected to QRAD is through information
QUICK RETRIEVAL OF ADVANCE DIRECTIVES 27
from their physician’s office directing them to QRAD’s website. Once on the website, the
individual will see QRAD’s mission and vision as well as how QRAD can work with them. QRAD
works with individuals on educating them, physicians, and other medical providers about the
importance of having advance directives and how to complete them. QRAD also provides caring
and compassionate assistance to individuals in determining their end-of-life wishes and
correctly documenting their preferences in advance directives. As they navigate to the About Us
page, the individual will find QRAD’s core values as well as why QRAD was created. The services
that QRAD provides to individuals, physicians/medical providers, and the medical community
are explained on the Services page. On the final page, Resources are provided, including advance
directive documents, other organizations that address advance directives, and links to additional
resources.
Financial Plan and Staging
Quick Retrieval of Advance Directives is supported by a financial plan that requires
approximately $885,000 in funding to support its startup phase and its implementation phase.
As a nonprofit organization, QRAD is dependent on foundations, grants, revenue, and a
significant fundraiser for its funding. At startup, QRAD will have three employees and will target
one medical insurance company and one healthcare organization. The startup phase will be
relatively slow due to the time it will take to build awareness, goodwill, and a client base. It is
essential to have multiple funding sources in the event any of the sources reduces or stops
providing either short or long-term funding. The budget cycle for QRAD will run during the
fiscal year starting each year on October 1. At the end of the fiscal year, an accountant/auditor
will evaluate the validity of the project's financial statement to account for the money that was
used to support the program. Continual exploration of different funding opportunities,
including but not limited to charging licensing/administrative fees for access to the QRAD
software, will be essential to the long-term success of QRAD.
QUICK RETRIEVAL OF ADVANCE DIRECTIVES 28
Budget
QRAD Annual Start Up Phase Budget is shown in Appendix F.
QRAD Annual Budget is shown in Appendix G.
Staging
QRAD has two primary phases. One is the startup phase with a focus on developing a
website, connecting with agencies for curriculum on the education of individuals about the
importance of advance directives as well developing a curriculum for physicians/medical
providers. It also includes connecting with a software development company to develop the
software that works in coordination with medical insurance companies and the hospital's
software. QRAD is still working out the details of this phase and has started to discuss pricing,
as well as additional details of creating the software. Once the software is developed, it will be
tested in conjunction with the hospital system and medical insurance company's software
system. Connecting with a medical insurance company and the health care system will also
occur during this phase. The second phase is the implementation phase with a focus of
implementing the training of the physicians/medical providers, training the staff needed to
implement the program, doing a pilot and eventually doing full implementation of the program.
Project Impact Assessment Methods
QRAD has three components to the organization that are all necessary to be measured.
These include advance directive completion with QRAD, physician/medical professional
education and comfort level, along with advance directives being filed with a medical insurance
company. QRAD also has a goal of completing ten advance directives per month in the startup
phase as well as 40 conversations per month in the implementation phase by connecting with
individuals through QRAD's website and having a conversation with a QRAD staff member
either in person or virtually.
The first component is the education of individuals about advance directives as well as
advance directive completion. Demographic information as well as reason for the contact will be
QUICK RETRIEVAL OF ADVANCE DIRECTIVES 29
collected when an individual completes the Contact Us section of QRAD’s website. After meeting
with an individual/family about advance directive education and/or completion a QRAD follow
up survey will be sent to them either electronically or by mail within 10 days of the meeting
(Appendix H). This will be the expectation whether advance directives were completed at the
meeting or not. QRAD has a goal of completing 10 advance directives per month in the startup
phase and 40 conversations per month in the implementation phase by connecting with
individuals through QRAD's website and having a conversation with a QRAD staff member
either in person or virtually.
The second component is the education of physicians/medical professionals. This will be
evaluated by the QRAD physician/medical professional education pre-test and post-test
(Appendix I) that will be administered to the physicians/medical professionals about their
comfort level and completion of addressing advance directives. This is a tool that was created
from the Primary Physician Questionnaire and Advance Care Planning Engagement Survey
(Sudore, 2013; Chan, 2016). Items on the QRAD physician/medical professional education pre-
test and post-test consider the knowledge, attitude, and experience with advance directives.
Demographic information is also collected, such as gender, ethnicity, age, credentials, and
length of time practicing medicine. The questions are scored on a five-point rating scale, as well
as items having a dichotomous Yes/No format and others being open-ended if the individual
feels that they needed to expand on their answer.
The QRAD physician/medical professional pre-test and post-test will be entered
electronically into an online survey tool (SurveyMonkey). Links to the surveys will be sent out
via email to the physicians/medical providers three months apart. The first delivery of the
QRAD physician/medical professional pre-test of the inventory will occur two weeks before the
start of the training. If the QRAD physician/medical professional education pre-test has not
been completed within two days of the start of the educational training, a reminder email will
be sent requesting completion. A physician/medical provider will not be able to participate in
QUICK RETRIEVAL OF ADVANCE DIRECTIVES 30
the educational training unless the QRAD physician/medical professional education pre-test has
been completed. The first delivery of the QRAD physician/medical professional education post-
test of the inventory will occur three months after the completion of the training. This will give
adequate time to finish that training before taking the QRAD physician/medical professional
education post-test and to see improvement in the comfort level and conversations completed
by the physician/medical professional. If the QRAD physician/medical provider education post-
test has not been completed within a week of the survey being sent, a reminder email will be
sent out requesting completion.
The goal is for 75% of physicians/medical professionals to report that they have a higher
comfort level in addressing advance directives. The completion of advance directives will be
evaluated in the physician’s/medical professional's medical practice by chart review and have a
goal of a 40% higher completion rate of advance directives within their medical practice.
In the startup phase of QRAD, the goal is to connect with one medical insurance
company and one healthcare organization. Once this connection has occurred, and the software
development has occurred, the goal is to have 30% of all advance directives in the pilot group
that the insurance company has completed filed through the new program that connects directly
with the healthcare medical record.
The long-term outcome for QRAD would be for the program to be entirely successful,
and the negative stigma surrounding talking about personal end-of-life wishes be significantly
diminished. Due to education surrounding the importance of end-of-life planning, the social
norm would change, and end-of-life planning would be talked about openly. Not only would
advance directives be completed, but they would be able to be more easily located so that family
and physicians can honor those end-of-life wishes. Physicians, patients, and their families would
all be educated about advance care planning and that once the documents are completed,
patient wishes can be located with ease of access when they are needed.
QUICK RETRIEVAL OF ADVANCE DIRECTIVES 31
Expected long term outcomes for QRAD include an increase in the percentage of written
advance directives prior to the time of death. The goal is for 75% of decedents to have a written
advance directive prior to the time of death. Ninety percent of the time, the advance directive
will be in connection with QRAD and have been available in the medical record of the healthcare
organization caring for the decedent at the time of death. There will be an increase in
individuals' preferences as found in the advance directive transferred to appropriate medical
orders. Ninety percent of the time, an individual patient’s wishes are documented by the treating
provider and reflected in the provider's orders in the organization. Patients and families will feel
more comfortable talking about advance directives due to the educational material they have
been able to review and will have greater confidence in being able to access the information at
the time of need. Individuals who participate in QRAD will rate their satisfaction as 4 or 5 on a
5-point scale on a patient satisfaction survey.
Stakeholder Engagement Plan
Internal Stakeholders
Internal stakeholders are the entities within a business. These include QRAD's board of
directors, employees, managers, and employees. These internal stakeholders have a
considerable influence on QRAD's budget and planning. Board of Directors and Executives are
the primary internal stakeholders who hold power to shift the culture of an organization as they
are the decision-makers. This is essential to QRAD because QRAD requires a culture shift within
the hospital system as well as within a medical insurance company. Other internal stakeholders
are people who aspire to leadership and those who already hold leadership roles. Individuals
who value the importance of advance directives have the power to assist with this needed culture
change. Physicians/medical providers are also key internal stakeholders as they are directly
affected by whether an individual has an advance directive or not. In order for QRAD to be
successful, it will be essential to have the buy-in and support of its internal stakeholders.
QUICK RETRIEVAL OF ADVANCE DIRECTIVES 32
External Stakeholders
External stakeholders include entities not within a business itself. While they are not
within the business, they do care about or are affected by its performance. Medicare is one
external stakeholder as they have shown that they already care about advance directive
completion by providing reimbursement. Additional entities would include other similar
advance care planning organizations. QRAD will not be able to reach every individual, so it will
be necessary to partner with other similar organizations that are able to reach individuals QRAD
cannot and can provide those individuals with training, presentations, and resources. Hospital
organizations are another key external stakeholder. When a hospital partners with QRAD, the
hospital will be able to increase the number of correctly completed advance directives,
physicians should report that they are more comfortable with advance directive conversations,
and a significant reduction in unwanted costly medical care is possible due to the advance
directives being clear about the individual’s end-of-life preferences upon entering the medical
system. Likewise, medical insurance companies are also external stakeholders as they benefit
from individuals having completed advance directives by reducing the cost of medical claims
they must cover.
By QRAD providing training and awareness around advance directive completion, this
can promote and strengthen community ties and participation, working toward decreasing the
stigma surrounding advance directive conversations. By doing this, it has the potential to
increase donations, grants, and private investors willing to support this program, impacting the
budget planning and allowing for more opportunities for QRAD to expand its community
outreach.
Communication Strategies and Products
The initial phase of QRAD will be to focus on the promotion of the program. Multiple
media approaches such as print and online tools, e.g., QRAD's website, email, videos, and social
media will be used to provide a greater awareness of the importance of advance directive
QUICK RETRIEVAL OF ADVANCE DIRECTIVES 33
completion and to promote QRAD. During the startup phase, marketing tools were developed,
including a QRAD logo, a website, an email address, an infographic, and a short-form video to
promote QRAD. Information about QRAD and its services and resources are documented on the
website, as well as multiple ways to contact QRAD. QRAD offers personal connections with
individuals to answer questions about advance directives, why they need one, and to ensure that
their end-of-life wishes are documented and communicated to their family and medical
providers. QRAD works with physicians and medical professionals by training them on what an
advance directive is and enhancing their comfort with having conversations regarding end-of-
life decisions and advance directives. Hospitals and medical insurance companies work with
QRAD by assisting them in determining an effective and hassle-free way to universally store and
retrieve advance directive documents for their patients. Additional resources and form
documents can also be accessed on QRAD's website.
QRAD has also partnered with The Conversation Project to utilize their tools for
facilitating conversations regarding advance directives, including how to choose a healthcare
representative and how to communicate with an individual's physician. Speaking and publishing
opportunities will also be pursued. The next phase of the program includes having the software
developed in partnership with a medical insurance company and a healthcare system that are
both committed to supporting a trial of the program.
Ethical Considerations
The primary ethical concerns for QRAD are informed consent and confidentiality. The
program aims to create a safe space for individuals to discuss their personal end-of-life wishes.
Therefore, conversations and information shared by the individual completing an advance
directive should not be shared without explicit consent from the individual completing those
documents. Assuring confidentiality would also help prevent any potential backlash from family
or loved ones who may have differing viewpoints.
QUICK RETRIEVAL OF ADVANCE DIRECTIVES 34
An individual’s willingness or resistance to completing an advance directive is also
important to consider. One barrier may be that they are not open to discussing their end-of-life
wishes. This may be influenced by cultural beliefs around end-of-life conversations and the
stigma surrounding them. In addition, if an individual does not feel connected with the person
they are having the conversation with, then they likely will not be open and honest regarding
their end-of-life wishes. This could result in not completing an advance directive or having their
wishes inaccurately documented. Who is present during these sensitive conversations can also
influence the choices an individual makes and can result in the advance directive not accurately
reflecting how they really feel. All of these things are important to take into consideration when
discussing such a sensitive topic of who should be making end-of-life decisions and what end-of-
life decisions should be made.
Conclusions, Actions, and Implications
Summary of Project Plans
QRAD aims to inform individuals, as well as the medical community, about the
importance of completing advance directives and having secure storage and retrieval systems for
quick and secure access during a time of need. QRAD started this initiative by creating a
website, developing a marketing plan, and coordinating with The Conversation Project for tools
to facilitate conversations surrounding advance directives. QRAD is also working on the
curriculum to train physicians and is partnering with additional medical insurance companies
and healthcare systems to expand its outreach.
It is imperative for QRAD to work with individuals, physicians, and within the medical
community to promote a coordinated approach to achieving its goals. QRAD’s efforts will
decrease the stigma associated with advance directive completion and will allow individuals to
have their end-of-life decisions made by an individual of their choosing. The success of QRAD
will help individuals preserve their dignity at time of death and increase the likelihood that their
QUICK RETRIEVAL OF ADVANCE DIRECTIVES 35
end-of-life wishes will be honored. In order to continue to expand, QRAD will network and
connect with other organizations similar to QRAD and continue to influence other hospital
systems and medical insurance companies to promote a uniform approach to managing advance
directives.
Current Practice Context for Project Conclusions
Most people do not have a completed advance directive, and of those who do, many
cannot locate their advance directives and have not discussed their end-of-life wishes with their
family members or medical providers. The culture around advance directives includes a negative
stigma associated with talking about our end-of-life wishes for fear that something terrible may
happen. The greatest likelihood that an individual’s wishes will be honored requires that an
advance directive be completed and subsequently located, and that the individual’s wishes are
discussed with both their family members and physicians/medical providers. QRAD believes
that in order for advance care planning to be more openly talked about and to reduce the
cultural norm against discussing death and dying, it is essential that significant outreach occur.
Education, training, compassionate dialogue and systems support are all essential to effectively
making an impact on advance care planning, including advance directive completion, storage
and easy and timely retrieval.
Project Implications for Practice and Further Action
By implementing QRAD, individuals will be educated about the importance of advance
directive completion, as well as be encouraged to complete the documents. Physicians/medical
professionals will feel more comfortable having the sensitive conversations regarding advance
directives with their patients, and they will be able to refer their patients to QRAD for assistance
with advance directive completion. Physicians/medical professionals can also be assured that
the completed advanced directives meet all of the requirements to be a legal document.
Individuals who have completed an advance directive will be assured that the documents will be
able to be located when entering the physician/medical provider's office and when entering the
QUICK RETRIEVAL OF ADVANCE DIRECTIVES 36
hospital. This will ensure that an individual's family will know the individual's wishes and that
their wishes are more likely to be honored. QRAD will change the norm that advance directive
completion will only be done when a person is aging or ill and that the document is readily
available when needed.
Project Limitations
As with any new start-up initiative, some barriers can be anticipated. Identified barriers
specific to QRAD include actual development of the program, any relevant state and federal
legislation/regulations, and health care system and medical insurance company buy-in. One of
the limitations applicable to QRAD includes federal legislation. In the United States, the federal
government has often left it up to the state legislatures to determine laws and policies regarding
advance directives. This has made it difficult for a universal storage and retrieval program to be
developed. Concerning advance directive laws and policy, experts have agreed on a need for a
standard system for the application of advance directives. The standard system would enable
physicians/medical providers to implement advance directives in an efficient and effective
formal pathway (Kim, Kim, and Hong, 2013). While it is agreed that a standard system is
needed, no standard system is currently in place. Lack of federal legislation also leads to another
barrier of funding, which is hard to secure when creating a non-profit agency such as QRAD.
QRAD faces financial risks when its primary, ongoing funding sources are grants and donations.
While these barriers are significant to the success of QRAD, it is anticipated that the
greatest initial challenge in launching QRAD is buy-in from healthcare systems and medical
insurance companies. Healthcare systems and medical insurance companies do not always value
the importance of advance directive completion, or they do not have a budget and resources for
advance directives. Resistance to change from the hospital system or medical insurance
company or implications of the cost could potentially derail innovation efforts of QRAD.
The tracking and reporting of potential reductions in medical costs will be especially
important to meeting the goals of QRAD. Potential medical cost savings from having accessible
QUICK RETRIEVAL OF ADVANCE DIRECTIVES 37
advance directives when needed is projected to far exceed the cost of QRAD operating expenses.
By building and maintaining professional relationships and networks with healthcare systems
and medical insurance companies, QRAD anticipates that funding will remain strong and
continue to grow over time. Any ongoing reservations or challenges that arise about QRAD will
be swiftly addressed and resolved. QRAD will continue to grow and evolve through conducting
education and training sessions, public speaking events, and marketing opportunities. QRAD is
at the forefront of a huge transformation with original solutions and aims to change the culture
around discussing death and dying, expressing end-of-life wishes, and advance directive
completion, storage and retrieval.
Conclusion
Advance directives are necessary so that an individual's family knows his/her end-of-life
wishes. Unfortunately, this is not something that is openly talked about in our American society.
Many barriers prohibit an individual from completing an advance directive, such as age, race,
socioeconomic status, religiosity, willingness to be open regarding end-of-life wishes, and
relationships with physicians/medical providers. Organizations such as The Conversation
Project and Respecting Choices have begun to address the problem by educating the public
about the importance of advance directives and providing a script for providers to use when
having these deeply personal and sensitive conversations. Electronic medical records have
attempted to record completed documents; however, there is significant room for improvement
as they are often out of date. Even if the completed documents can be located, there is no
integrated, uniform system to transmit this information from one setting to another. QRAD’s
innovative programs and systems will effectively and efficiently mitigate these issues and work
to remove the negative stigma around advanced directives, increase education about advanced
directives and the medical decisions that can be made, and provide professional caring and
compassionate assistance in correctly completing an advance directive.
QUICK RETRIEVAL OF ADVANCE DIRECTIVES 38
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QUICK RETRIEVAL OF ADVANCE DIRECTIVES 42
Appendix A
Glossary
Advance Directive: An advance directive is a written document that indicates an individual's
choices about medical treatment. It allows an individual to appoint someone to make
healthcare decisions on their behalf when they are no longer able to and to administer or
withhold treatment and procedures based on previously stated wishes (Nabili, 2018).
Medical Power of Attorney/Health care Representative: The medical power of
attorney document allows individuals to select any adult to make medical decisions on their
behalf upon temporary or permanent inability to make those decisions on their own (Nabili,
2018).
Living Will: A living will is a written statement that documents the type of life-prolonging
treatments or procedures to perform if someone has a terminal condition or is in a persistent
vegetative state (Nabili, 2018). It presents the most significant opportunity for medical
personnel to misinterpret a patient's exact wishes. Terms such as "terminal condition,"
"incurable illness," or "seriously incapacitating," are left to the physicians' interpretation
(Mirarchi, 2009). One physician may view a patient's medical condition as needing aggressive
treatment while another physician may state that comfort measures should be enacted
(Mirarchi, 2009).
Power of Attorney: A power of attorney is a document that allows an individual to appoint a
person or organization to manage their property, financial or medical affairs if the individual
becomes unable to do so (Rice, 2020).
Out-of-Hospital Do Not Resuscitate Declaration and Order (DNR): An out-of-
hospital DNR is for people who do not want to be resuscitated if their heart stops or if they stop
breathing while at home or anywhere outside of a medical facility. An out-of-hospital DNR is a
document signed by a physician and is usually only written for terminally ill, elderly or frail
individuals ("Do Not Resuscitate (DNR) and POLST", 2018).
Running head: QUICK RETRIEVAL OF ADVANCE DIRECTIVES 43
Appendix B
Quick Retrieval of Advance Directives Logic Model

Running head: QUICK RETRIEVAL OF ADVANCE DIRECTIVES 44

Appendix C
Quick Retrieval of Advance Directives Marketing Plan
Company: Quick Retrieval of Advance Directives
Date: July 7, 2020
Executive Summary
There is significant room for improvement in the completion, retrieval and distribution
of advance directives. Most would agree that advanced directive documents should be
thoroughly completed, securely stored and transmissible, and easily and confidentially
accessible. Quick Retrieval of Advance Directives (QRAD) is a non-profit organization that will
be established to tackle these issues with three primary organizational purposes. The first
purpose will be to educate physicians/medical providers and the public about the importance of
completing advance directives. The second purpose of the organization will be to meet with
individuals and their families about the completion and updating of their advance directives to
ensure that individuals get their end-of-life wishes properly documented. The third purpose of
QRAD will be to create a computer software program that communicates directly with medical
insurance companies so that when an individual's medical insurance information is retrieved at
the hospital or medical provider's location, the completed advance directive can be retrieved at
the same time. QRAD also ensures that the documents will be able to be located across all levels
of care, and even when a person is located out of state.
Mission Statement
QRAD’s mission is to help individuals ensure that their personal and end-of-life wishes
are known and honored by providing education about the importance of advance directive
completion. In addition, QRAD supports individuals in completing the documents and provides
a way to universally store and retrieve their advance directives.
Situation Analysis
QUICK RETRIEVAL OF ADVANCE DIRECTIVES 45
Product/Service QRAD offers expertise and service for the completion
of advance directives to individuals, and professional
consultation to other organizations.
Unique Proposition The model of QRAD is a transformative change
process that looks specifically at how to not only have
advance directive documents completed and reviewed
on a regular basis, but also have them universally
stored and subsequently accessed when needed.
Best Practices QRAD’s core values include:
• Integrity
• Accountability
• Diligence
• Ethical
Marketing Objectives and
Performance
QRAD’s marketing objective is to increase brand
awareness among individuals as well as the medical
community.
Challenges Current challenges for QRAD include:
• Stigma surrounding advance directive/end of
life conversations
• Funding
• Buy-in from the hospital system & medical
insurance company
• Confusion regarding end-of-life documents
• COVID-19
Competitor Analysis Respecting Choices and The Conversation Project are
two non-profit organizations whose work closely
resembles the proposed model of QRAD; however,
they both focus on the importance of the conversation
and do not provide a way for the documents to be
universally located once completed.
SWOT Analysis
Strengths Weaknesses
• Quick Retrieval of Advance
Directives is innovative & creative
• Design addresses the need to
educate physicians/medical
professionals about the importance
of advance directives and
completion of them
• Buy-in from individuals
• Individuals being uncertain or confused about
completing the advance directive documents
• Individuals being unwilling to have open and
honest conversations with their loved ones
about their end-of-life wishes
• Concern regarding HIPPA
• Financing
QUICK RETRIEVAL OF ADVANCE DIRECTIVES 46
• Design addresses barriers to
communication of advance
directives once they are completed
• Design addresses essential need to
have advance directives completed
and sensitive conversations held
• Design addresses storage, updating,
transmission and retrieval upon
completion of the documents
• Design tackles the norm of only
addressing end-of-life/medical
wishes when an individual is at the
end of their life or in a medical crisis
• Small team to manage high workload
demands
• Cooperation between hospital and medical
insurance information technology leaders
Opportunities Threats
• Opportunities for individuals to have
their end-of-life wishes honored and
for family and physician's/medical
providers to know an individual’s
end-of-life wishes
• Opportunities to reduce family
stress, guilt and disagreements over
medical care decisions of a loved
one.
• Individuals willingness to complete the
documents/have conversations
• Hospital/medical insurance companies may
not be in support or have buy-in to the process
• COVID-19
• Lawyers/individuals who prepare documents
for pay
• Other Advance Directive organizations

Target Market
QRAD has three target markets:
1. Individuals: Individuals come to QRAD because they have questions about what an
advance directive is, why they need one, and to ensure their end-of-life wishes are
documented and communicated to their family and medical providers.
2. Physicians: Physicians and medical professionals come to QRAD for training on
advance directives and to enhance their comfort with having conversations regarding
their patients’ end-of-life decisions and advance directives.
3. Medical Communities: Hospitals and medical insurance companies come to QRAD
for assistance in determining an effective and hassle-free way to universally store and
retrieve advance directive documents for their patients.
QUICK RETRIEVAL OF ADVANCE DIRECTIVES 47
Marketing Objectives
• Increase Brand Awareness
o Increase social media impressions among new target audience by 30% by the
end of Phase 2.
• Improve Brand Reputation
o Gain and retain a 90% positive share of voice during Phases 2 and 3 so that
prospective customers, know, like, and trust QRAD.
• Increase Brand Presence
o Create and publish a blog every month on external sources so QRAD’s target
audience follows to increase brand presence.
• Increase Traffic
o Test three new traffic generation methods every month to increase traffic month
over month by 3%.
• Increase Customer Advocacy
o Implement a client ambassador program during Phase 1 so that current clients
can introduce our program to new prospective clients.
• Retain Existing Clients
o Reduce bugs to zero for every feature so that user churn decreases.
• Launce Universal Storage Product
o Meet with and finalize the software portion of QRAD by the end of Phase 1.
• Introduce QRAD to New Local Market
o Conduct market research during the first half of Phase 1 and develop
appropriate messaging strategy by the end of Phase 1.
• Attract New Customers
o Establish partnership with two new healthcare organizations and medical
insurance companies by the end of Phase 3.
QUICK RETRIEVAL OF ADVANCE DIRECTIVES 48
Distribution Strategy
Hybrid Distribution Channels:
• Direct Channel (Zero Level): A direct relationship is facilitated between QRAD and the
client.
o QRAD will be able to provide clients with the logic of using QRAD and finding a
solution to their needs.
o QRAD will establish a personal connection with individuals who want to discuss
advance directives as well as the healthcare systems and medical insurance
companies that can benefit from universal retrieval.
• Indirect Channel (One Level Channel): The channel of distribution involves one
intermediary to transfer goods to the client. QRAD relies on the cooperation of
physicians/medical professionals to assist with having advance directive conversations
with the client.
o QRAD will be able to reach more individuals by using the channel of
physicians/medical professionals.
Promotion Strategy
• Social Media Promotion
o Social network shows an organization that is in touch with people on a more
personal level. This can help lessen the divide between QRAD and the individual,
which in turn presents a more appealing and familiar image. This will assist in
encouraging and normalizing advance directive completion.
• Branded Promotional Gifts
o A functional branded gift is more effective than handing out simple business
cards. QRAD will use branded gifts such as an ink pen when working with
someone to complete an advance directive and a magnet that can be placed on
the refrigerator documenting that a person has an advance directive completed.
QUICK RETRIEVAL OF ADVANCE DIRECTIVES 49
Other promotional gifts will be explored as QRAD expands its outreach and
funding.
• QRAD Follow Up Survey
o Contacting individuals through the mail is a promotional strategy that puts
client satisfaction first. These follow-up surveys will be used for marketing by
asking questions relating to how clients feel about their QRAD experience. This
will serve the dual purpose of promoting QRAD as an organization that cares
about its clients’ opinions, and one that is always striving to provide high
quality, compassionate, caring, confidential and responsive service.
• Mail Order Marketing
o When an individual connects with QRAD, their contact information will be
collected. Separate reminders to complete and update their advance directive
documents will be mailed. Once the universal storage system of QRAD is
developed, a mailing will go out to instruct individuals on how to enter and save
their documents for secure universal storage.
• Contests as a Promotional Strategy
o Contests are a frequently used promotional strategy. QRAD will promote
advance directive conversations by incentivizing individuals to enter a drawing
to win a gift card. Advance directive completion is not required to be entered
into the drawing. This will enable QRAD to get their name and logo in front of
the public.
Action Plan
QRAD is comprised of a small team of three passionate individuals who are fully committed to
QRAD’s mission. Initially the marketing action items will be shared among team members to
distribute the responsibility of QRAD marketing. As QRAD grows, at least one team member
will be hired to focus strictly on marketing.
QUICK RETRIEVAL OF ADVANCE DIRECTIVES 50
QRAD Marketing Action Plan
Action Item Who?
What other
resources are
needed?
When?
High/Medium/Low
Priority
Develop website for QRAD QRAD
Founder
• Time
• Website
Design
Professional
Completed High
Maintain website for QRAD QRAD
Founder
• Time
• Crazy Egg

Ongoing High
Website visitor tracker QRAD
Team
Member
• Google
Analytics
Ongoing Medium
Post videos/
infographics/
articles on LinkedIn
QRAD
Founder
• Time Ongoing/
1 new post
monthly
High
Work with social media
such as
Facebook/LinkedIn/Twitter
to create social media ads
QRAD
Team
Member
• Time
• Graphic
Design
• Marketing
6-12 months High
Social media posts QRAD
Team
Member
• Time
• Hootsuite
Ongoing High
Social media marketing
evaluation
QRAD
Team
Member
• Time
• Followerwonk
Ongoing Medium
Create and manage a blog QRAD
Team
Member
• Time
• Research
• Hubspot
Ongoing/
New blog post
weekly
High
Create and send out
monthly newsletter
QRAD
Team
Member
• Time
• Research
• Publishing
Ongoing/
New
newsletter
monthly
Medium
Develop email pieces to
send to potential new
customers
QRAD
Founder
• Time
• Graphic
Design
Immediately High
Create & disseminate
printed educational
materials
QRAD
Founder
• Time
• Graphic
Design
Immediately/
Dissemination-
Ongoing
High
Mail out customer
satisfaction surveys
QRAD
Team
Member
• Time
• Survey
tracking

Ongoing/
As needed
High
Follow up Phone Calls QRAD
Team
Member
• Time
• Phone call
tracking
Ongoing/
As needed
High
QUICK RETRIEVAL OF ADVANCE DIRECTIVES 51
Send Thank You Notes QRAD
Team
Member
• Time
• Marketing
materials
Ongoing/
As needed
Low
Medical community mailers QRAD
Team
Member
• Time
• Marketing
materials
Ongoing/
As needed
Low
Billboards QRAD
Team
Member
• Billboard
production
company
• Financing
6 months Medium
Attend medical insurance
company and hospital
system conventions
QRAD
Team
Member
• Time
• Marketing
Materials
• Promotional
Gifts
Ongoing Medium
Networking QRAD
Team
Member
• Time Ongoing High
Community Outreach Party QRAD
Team
Member
• Time
• Financing
6-12 months Low
Research Competitors/
Target Market
Prospecting-phone calls to
qualified leads
QRAD
Team
Member
• Time
• BuzzSumo
Ongoing Medium
Evaluation of advertising
effectiveness
QRAD
Founder
• Time
• KISSmetrics
Ongoing High
Email list management QRAD
Team
Member
• Time
• Mailchimp
Ongoing Low

Financial Budget
The budget set aside for marketing in the startup phase is $3,600 and in the implementation
phase of operation is also $3,600. This can be broken down as follows:
Marketing Avenue Allocation
Medical Community Mailers $900.00
Billboards $750.00
Social Media Sponsored Ads $1,000.00
Printed Materials $950.00
Total $3,600.00

Control Chart
QUICK RETRIEVAL OF ADVANCE DIRECTIVES 52
The following controls have been put into place to monitor and measure the results of QRAD to
ensure the desired objectives are achieved.
Activity Performed By Date/Frequency
Complete performance
evaluation of all QRAD staff
Top Management Annually
Review salaries and other
incentives of all QRAD staff
Top Management Annually
Measure financial results
against projections
Top Management Monthly/Quarterly/Annually
Carry out survey to determine
clients’ satisfaction with QRAD
and the service quality
Internal Audit Annually/As needed after advance
directive conversations
Diagnose any gap/shortfall of
QRAD to identify the causes
and recommend corrective
measures
Internal Audit As necessary
Take corrective action Top Management As necessary

QUICK RETRIEVAL OF ADVANCE DIRECTIVES 53
Appendix D
Comparative Analysis of Current Market

Running head: QUICK RETRIEVAL OF ADVANCE DIRECTIVES 54
Appendix E
QRAD Procedure & Timeline for Implementation
Running head: QUICK RETRIEVAL OF ADVANCE DIRECTIVES 55

Appendix F
QRAD Annual Startup Phase Budget

QUICK RETRIEVAL OF ADVANCE DIRECTIVES 56
Appendix G
QRAD Annual Budget

QUICK RETRIEVAL OF ADVANCE DIRECTIVES 57
Appendix H
QRAD Follow Up Survey
1. Your age:
a. 18-30 years old
b. 30-40 years old
c. 40-50 years old
d. 50-60 years old
e. 60-70 years old
f. 70+ years old

2. Your gender:
a. Male
b. Female

3. What is your race:
a. African American
b. Hispanic
c. Asian American
d. Caucasian/White
e. Other: ___________________________________________________

4. Do you have a completed advance directive?
a. Yes
b. No

Please include your level of satisfaction with the advance care planning discussion you just had:
1. I feel that this discussion was helpful to me.
1-not at all 2 3 4 5-very much
2. I feel better prepared to make decisions about my future healthcare.
1-not at all 2 3 4 5-very much
3. I feel the Facilitator helped me with my needs for advance care planning.
1-not at all 2 3 4 5-very much
4. I feel that the educational materials given to me enhanced my understanding of
advance care planning.
1-not at all 2 3 4 5-very much
5. Comments/Suggestions: ______________________________________
QUICK RETRIEVAL OF ADVANCE DIRECTIVES 58
Appendix I
QRAD Physician/Medical Provider Education Pre-test & Post-test
5. Your Degree:
a. MD
b. NP
c. PA

6. How long have you been practicing medicine?
a. 0-5 years
b. 6-10 years
c. 11-15 years
d. 16-20 years
e. >20 years

7. Do you have a particular sub-specialization?
a. Yes
If yes, subspecialty: __________________________________________
b. No

8. Your age:
a. 20-30 years old
b. 30-40 years old
c. 40-50 years old
d. 50-60 years old
e. 60-70 years old
f. 70+ years old

9. Your gender:
a. Male
b. Female

10. What is your race:
a. African American
b. Hispanic
c. Asian American
d. Caucasian/White
e. Other: ___________________________________________________

11. Do you have a completed advance directive?
a. Yes
b. No

12. Where do advance care planning discussions typically take place?
a. Outpatient clinical setting
b. Hospital
c. Other (Please specify): ________________________________________

13. I am comfortable having advance care planning discussions in general with my patients.
a. Not at all
QUICK RETRIEVAL OF ADVANCE DIRECTIVES 59
b. A little
c. Somewhat
d. Fairly
e. Extremely

14. I have received adequate training in facilitating advance care planning conversations.
a. Strongly Agree
b. Agree
c. Neutral
d. Disagree
e. Strongly Disagree

15. It takes too much of my time to discuss advance care planning with a patient.
a. Strongly Agree
b. Agree
c. Neutral
d. Disagree
e. Strongly Disagree

16. I feel comfortable communicating a prognosis to my patients.
a. Strongly Agree
b. Agree
c. Neutral
d. Disagree
e. Strongly Disagree

17. Advance care planning is too upsetting for patients and their families.
a. Strongly Agree
b. Agree
c. Neutral
d. Disagree
e. Strongly Disagree

18. I believe it is the patient who should initiate discussions about advance care planning.
a. Strongly Agree
b. Agree
c. Neutral
d. Disagree
e. Strongly Disagree

19. In reality, advance care planning wishes are rarely honored.
a. Strongly Agree
b. Agree
c. Neutral
d. Disagree
e. Strongly Disagree

20. Barriers to completing advance care planning conversations include (check all that
apply):
a. Not my responsibility; one of the other physicians should have the conversation.
b. It upsets the patient and family too much
QUICK RETRIEVAL OF ADVANCE DIRECTIVES 60
c. Time
d. Lack of training regarding advance directives
e. Lack of comfort level with having conversations about advance care planning
with patients.
f. Other: ___________________________________________________

21. About what percentage of the patients in your practice have a progressive, chronic life-
limiting disease?
a. 0%-25%
b. 25%-50%
c. 50%-75%
d. 75%-100%
e. Other: ___________________________________________________

22. Of these patients, about what percentage have you talked about advance care planning?
a. 0%-25%
b. 25%-50%
c. 50%-75%
d. 75%-100%
e. Other: ___________________________________________________

23. About what percentage of the patients in your practice would you consider terminally ill?
a. 0%-25%
b. 25%-50%
c. 50%-75%
d. 75%-100%
e. Other: ___________________________________________________

24. Of these patients, what percentage have you talked about advance care planning?
a. 0%-25%
b. 25%-50%
c. 50%-75%
d. 75%-100%
e. Other: ___________________________________________________
Running head: QUICK RETRIEVAL OF ADVANCE DIRECTIVES PROTOTYPE 1
Closing the Health Gap
Quick Retrieval of Advance Directives Prototype
Lindsey E. Stangland

Doctor of Social Work
Dworak-Peck School of Social Work
University of Southern California
SOWK 722: Implementing Your Capstone and Re-envisioning Your Career
Dr. Araque
August 2020
QUICK RETRIEVAL OF ADVANCE DIRECTIVES PROTOTYPE 2

Quick Retrieval of Advance Directives (QRAD)
Website
The website for Quick Retrieval of Advance Directives (QRAD) can be found at:
www.qradvancedirectives.com
Quick Retrieval of Advance Directives (QRAD)
Marketing Plan
Company: Quick Retrieval of Advance Directives
Date: July 7, 2020
Executive Summary
There is significant room for improvement in the completion, retrieval and
distribution of advance directives. Most would agree that advanced directive documents
should be thoroughly completed, securely stored and transmissible, and easily and
confidentially accessible. Quick Retrieval of Advance Directives (QRAD) is a non-profit
organization that will be established to tackle these issues with three primary organizational
purposes. The first purpose will be to educate physicians/medical providers and the public
about the importance of completing advance directives. The second purpose of the
organization will be to meet with individuals and their families about the completion and
updating of their advance directives to ensure that individuals get their end-of-life wishes
properly documented. The third purpose of QRAD will be to create a computer software
program that communicates directly with medical insurance companies so that when an
individual's medical insurance information is retrieved at the hospital or medical provider's
QUICK RETRIEVAL OF ADVANCE DIRECTIVES PROTOTYPE 3

location, the completed advance directive can be retrieved at the same time. QRAD also
ensures that the documents will be able to be located across all levels of care, and even when
a person is located out of state.
Mission Statement
QRAD’s mission is to help individuals ensure that their personal and end-of-life
wishes are known and honored by providing education about the importance of advance
directive completion. In addition, QRAD supports individuals in completing the documents
and provides a way to universally store and retrieve their advance directives.
Situation Analysis
Product/Service QRAD offers expertise and service for the completion
of advance directives to individuals, and professional
consultation to other organizations.
Unique Proposition The model of QRAD is a transformative change
process that looks specifically at how to not only have
advance directive documents completed and reviewed
on a regular basis, but also have them universally
stored and subsequently accessed when needed.
Best Practices QRAD’s core values include:
• Integrity
• Accountability
• Diligence
• Ethical
Marketing Objectives and
Performance
QRAD’s marketing objective is to increase brand
awareness among individuals as well as the medical
community.
Challenges Current challenges for QRAD include:
• Stigma surrounding advance directive/end-
of-life conversations
• Funding
• Buy-in from the hospital system & medical
insurance company
• Confusion regarding end-of-life documents
• COVID-19
QUICK RETRIEVAL OF ADVANCE DIRECTIVES PROTOTYPE 4

Competitor Analysis Respecting Choices and The Conversation Project are
two non-profit organizations whose work closely
resembles the proposed model of QRAD; however,
they both focus on the importance of the conversation
and do not provide a way for the documents to be
universally located once completed.
SWOT Analysis
Strengths Weaknesses
• Quick Retrieval of Advance
Directives is innovative & creative
• Design addresses the need to
educate physicians/medical
professionals about the importance
of advance directives and
completion of them
• Design addresses barriers to
communication of advance
directives once they are completed
• Design addresses essential need to
have advance directives completed
and sensitive conversations held
• Design addresses storage, updating,
transmission and retrieval upon
completion of the documents
• Design tackles the norm of only
addressing end-of-life/medical
wishes when an individual is at the
end of their life or in a medical crisis
• Buy-in from individuals
• Individuals being uncertain or confused about
completing the advance directive documents
• Individuals being unwilling to have open and
honest conversations with their loved ones
about their end-of-life wishes
• Concern regarding HIPPA
• Financing
• Small team to manage high workload
demands
• Cooperation between hospital and medical
insurance information technology leaders
Opportunities Threats
• Opportunities for individuals to have
their end-of-life wishes honored and
for family and physician's/medical
providers to know an individual’s
end-of-life wishes
• Opportunities to reduce family
stress, guilt and disagreements over
medical care decisions of a loved
one.
• Individuals willingness to complete the
documents/have conversations
• Hospital/medical insurance companies may
not be in support or have buy-in to the process
• COVID-19
• Lawyers/individuals who prepare documents
for pay
• Other Advance Directive organizations
Target Market
QRAD has three target markets:
QUICK RETRIEVAL OF ADVANCE DIRECTIVES PROTOTYPE 5

1. Individuals: Individuals come to QRAD because they have questions about what an
advance directive is, why they need one, and to ensure their end-of-life wishes are
documented and communicated to their family and medical providers.
2. Physicians: Physicians and medical professionals come to QRAD for training on
advance directives and to enhance their comfort with having conversations regarding
their patients’ end-of-life decisions and advance directives.
3. Medical Communities: Hospitals and medical insurance companies come to
QRAD for assistance in determining an effective and hassle-free way to universally
store and retrieve advance directive documents for their patients.
Marketing Objectives
• Increase Brand Awareness
o Increase social media impressions among new target audience by 30% by
the end of Phase 2.
• Improve Brand Reputation
o Gain and retain a 90% positive share of voice during Phases 2 and 3 so that
prospective customers, know, like, and trust QRAD.
• Increase Brand Presence
o Create and publish a blog every month on external sources so QRAD’s target
audience follows to increase brand presence.
• Increase Traffic
o Test three new traffic generation methods every month to increase traffic
month over month by 3%.
• Increase Customer Advocacy
o Implement a client ambassador program during Phase 1 so that current
clients can introduce our program to new prospective clients.
• Retain Existing Clients
o Reduce bugs to zero for every feature so that user churn decreases.
QUICK RETRIEVAL OF ADVANCE DIRECTIVES PROTOTYPE 6

• Launce Universal Storage Product
o Meet with and finalize the software portion of QRAD by the end of Phase 1.
• Introduce QRAD to New Local Market
o Conduct market research during the first half of Phase 1 and develop
appropriate messaging strategy by the end of Phase 1.
• Attract New Customers
o Establish partnership with two new healthcare organizations and medical
insurance companies by the end of Phase 3.
Distribution Strategy
Hybrid Distribution Channels:
• Direct Channel (Zero Level): A direct relationship is facilitated between QRAD and
the client.
o QRAD will be able to provide clients with the logic of using QRAD and
finding a solution to their needs.
o QRAD will establish a personal connection with individuals that want to
discuss advance directives as well as the healthcare systems and medical
insurance companies that can benefit from universal retrieval.
• Indirect Channel (One Level Channel): The channel of distribution involves one
intermediary to transfer goods to the client. QRAD relies on the cooperation of
physicians/medical professionals to assist with having advance directive
conversations with the client.
o QRAD will be able to reach more individuals by using the channel of
physicians/medical professionals.
Promotion Strategy
• Social Media Promotion
QUICK RETRIEVAL OF ADVANCE DIRECTIVES PROTOTYPE 7

o Social network shows an organization that is in touch with people on a more
personal level. This can help lessen the divide between QRAD and the
individual, which in turn presents a more appealing and familiar image.
This will assist in encouraging and normalizing advance directive
completion.
• Branded Promotional Gifts
o A functional branded gift is more effective than handing out simple business
cards. QRAD will use branded gifts such as an ink pen when working with
someone to complete an advance directive and a magnet that can be placed
on the refrigerator documenting that a person has an advance directive
completed. Other promotional gifts will be explored as QRAD expands its
outreach and funding.
• QRAD Follow Up Survey
o Contacting individuals through the mail is a promotional strategy that puts
client satisfaction first. These follow-up surveys will be used for marketing
by asking questions relating to how clients feel about their QRAD experience.
This will serve the dual purpose of promoting QRAD as an organization that
cares about its clients’ opinions, and one that is always striving to provide
high quality, compassionate, caring, confidential and responsive service.
• Mail Order Marketing
o When an individual connects with QRAD, their contact information will be
collected. Separate reminders to complete and update their advance
directive documents will be mailed. Once the universal storage system of
QRAD is developed, a mailing will go out to instruct individuals on how to
enter and save their documents for secure universal storage.
• Contests as a Promotional Strategy
o Contests are a frequently used promotional strategy. QRAD will promote
advance directive conversations by incentivizing individuals to enter a
QUICK RETRIEVAL OF ADVANCE DIRECTIVES PROTOTYPE 8

drawing to win a gift card. Advance directive completion is not required to
be entered into the drawing. This will enable QRAD to get their name and
logo in front of the public.
Action Plan
QRAD is comprised of a small team of three passionate individuals who are fully committed
to QRAD’s mission. Initially the marketing action items will be shared among team members
to distribute the responsibility of QRAD marketing. As QRAD grows, at least one team
member will be hired to focus strictly on marketing.
QRAD Marketing Action Plan
Action Item Who?
What other
resources are
needed?
When?
High/Medium/Low
Priority
Develop website for QRAD QRAD
Founder
• Time
• Website
Design
Professional
Completed High
Maintain website for QRAD QRAD
Founder
• Time
• Crazy Egg

Ongoing High
Website visitor tracker QRAD
Team
Member
• Google
Analytics
Ongoing Medium
Post videos/
infographics/
articles on LinkedIn
QRAD
Founder
• Time Ongoing/
1 new post
monthly
High
Work with social media
such as
Facebook/LinkedIn/Twitter
to create social media ads
QRAD
Team
Member
• Time
• Graphic
Design
• Marketing
6-12 months High
Social media posts QRAD
Team
Member
• Time
• Hootsuite
Ongoing High
Social media marketing
evaluation
QRAD
Team
Member
• Time
• Followerwonk
Ongoing Medium
Create and manage a blog QRAD
Team
Member
• Time
• Research
• Hubspot
Ongoing/
New blog post
weekly
High
Create and send out
monthly newsletter
QRAD
Team
Member
• Time
• Research
• Publishing
Ongoing/
New
newsletter
monthly
Medium
QUICK RETRIEVAL OF ADVANCE DIRECTIVES PROTOTYPE 9

Develop email pieces to
send to potential new
customers
QRAD
Founder
• Time
• Graphic
Design
Immediately High
Create & disseminate
printed educational
materials
QRAD
Founder
• Time
• Graphic
Design
Immediately/
Dissemination-
Ongoing
High
Mail out customer
satisfaction surveys
QRAD
Team
Member
• Time
• Survey
tracking

Ongoing/
As needed
High
Follow up Phone Calls QRAD
Team
Member
• Time
• Phone call
tracking
Ongoing/
As needed
High
Send Thank You Notes QRAD
Team
Member
• Time
• Marketing
materials
Ongoing/
As needed
Low
Medical community mailers QRAD
Team
Member
• Time
• Marketing
materials
Ongoing/
As needed
Low
Billboards QRAD
Team
Member
• Billboard
production
company
• Financing
6 months Medium
Attend medical insurance
company and hospital
system conventions
QRAD
Team
Member
• Time
• Marketing
Materials
• Promotional
Gifts
Ongoing Medium
Networking QRAD
Team
Member
• Time Ongoing High
Community Outreach Party QRAD
Team
Member
• Time
• Financing
6-12 months Low
Research Competitors/
Target Market
Prospecting-phone calls to
qualified leads
QRAD
Team
Member
• Time
• BuzzSumo
Ongoing Medium
Evaluation of advertising
effectiveness
QRAD
Founder
• Time
• KISSmetrics
Ongoing High
Email list management QRAD
Team
Member
• Time
• Mailchimp
Ongoing Low
Financial Budget
The budget set aside for marketing in the start up year is $3,600 and in the first full year of
operation is also $3,600. This can be broken down as follows:
Marketing Avenue Allocation
Medical Community Mailers $900.00
QUICK RETRIEVAL OF ADVANCE DIRECTIVES PROTOTYPE 10

Billboards $750.00
Social Media Sponsored Ads $1,000.00
Printed Materials $950.00
Total $3,600.00
Control Chart
The following controls have been put into place to monitor and measure the results of QRAD
to ensure the desired objectives are achieved.
Activity Performed By Date/Frequency
Complete performance
evaluation of all QRAD staff
Top Management Annually
Review salaries and other
incentives of all QRAD staff
Top Management Annually
Measure financial results
against projections
Top Management Monthly/Quarterly/Annually
Carry out survey to determine
clients’ satisfaction with QRAD
and the service quality
Internal Audit Annually/As needed after advance
directive conversations
Diagnose any gap/shortfall of
QRAD to identify the causes
and recommend corrective
measures
Internal Audit As necessary
Take corrective action Top Management As necessary

QUICK RETRIEVAL OF ADVANCE DIRECTIVES PROTOTYPE 11

References
Hose, C. (2019, February 4). Top Ten Promotional Strategies. Smallbusiness.Chron.Com.
https://smallbusiness.chron.com/top-ten-promotional-strategies-10193.html
Jenkins, L. (2019, July 19). Distribution Strategy | Cutting Edge Distribution Strategies
2020. Select Hub. https://www.selecthub.com/enterprise-resource-
planning/cutting-edge-distribution-strategies/
Kosaka, K. (2018, February). How to Define and Measure Marketing Objectives: A Start-to-
Finish Guide. Alexa Blog; Alexa Blog. https://blog.alexa.com/marketing-objectives/

Abstract (if available)

Abstract There is significant room for improvement in the completion, retrieval and distribution of advance directives. Most would agree that advanced directive documents should be thoroughly completed, securely stored and transmissible, and easily and confidentially accessible. Quick Retrieval of Advance Directives (QRAD) is a non-profit organization that will be established to tackle these issues with three primary organizational purposes. The first purpose will be to educate physicians/medical providers and the public about the importance of completing advance directives. The second purpose of the organization will be to meet with individuals and their families about the completion and updating of their advance directives to ensure that individuals get their end-of-life wishes properly documented. The third purpose of QRAD will be to create a computer software program that communicates directly with medical insurance companies so that when an individual's medical insurance information is retrieved at the hospital or medical provider's location, the completed advance directive can be retrieved at the same time. QRAD also ensures that the documents will be able to be located across all levels of care, and even when a person is located out of state.

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Asset Metadata

Creator Stangland, Lindsey E. (author)

Core Title Closing the health gap: Quick Retrieval of Advance Directives

School Suzanne Dworak-Peck School of Social Work

Degree Doctor of Social Work

Degree Program Social Work

Publication Date 08/24/2020

Defense Date 07/31/2020

Publisher University of Southern California (original), University of Southern California. Libraries (digital)

Tag advance care planning,advance directives,healthcare power of attorney,living will,OAI-PMH Harvest

Language English

Contributor Electronically uploaded by the author (provenance)

Advisor Araque, Juan Carlos (committee chair)

Creator Email lebstangland@gmail.com,lstangla@usc.edu

Permanent Link (DOI) https://doi.org/10.25549/usctheses-c89-366542

Unique identifier UC11666609

Identifier etd-StanglandL-8932.pdf (filename),usctheses-c89-366542 (legacy record id)

Legacy Identifier etd-StanglandL-8932.pdf

Dmrecord 366542

Document Type Capstone project

Rights Stangland, Lindsey E.

Type texts

Source University of Southern California (contributing entity), University of Southern California Dissertations and Theses (collection)

Access Conditions The author retains rights to his/her dissertation, thesis or other graduate work according to U.S. copyright law. Electronic access is being provided by the USC Libraries in agreement with the a...

Repository Name University of Southern California Digital Library

Repository Location USC Digital Library, University of Southern California, University Park Campus MC 2810, 3434 South Grand Avenue, 2nd Floor, Los Angeles, California 90089-2810, USA