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In this report clinicians at nine hospitals describe how they and their colleagues established formal programs of palliative care. The report is one result of an ongoing collaboration between two foundations that have similar missions and complementary operating styles. The Robert Wood Johnson Foundation (RWJF) has as its mission improving the health and health care of all Americans through funding for demonstration projects, training, educational and communications activities, policy analysis, and research. These case studies are stories written by leaders, clinicians who became innovators when they saw the need for palliative care at their hospitals and devoted themselves to creating programs to meet that need. Whether they were senior or junior faculty members, all the leaders overcame significant barriers to the development of palliative care within their hospitals. The narratives exemplify the current debate that exists about the definition of "palliative care." Is it end-of-life care?
The authors' programs serve different groups of people and employ diverse clinical models appropriate for particular patient populations. As the charts of financial information show, there is considerable variation in the financing of hospital-based palliative care programs and in institutions' methods of collecting and reporting data. Palliative care programs should be constructed around an interdisciplinary team, including at least a doctor, nurse, social worker, pharmacist, and chaplain. Patients, families, and physicians should discuss goals and preferences and should plan the care together. Palliative care should reach patients throughout the hospital, should encourage collaboration across clinical and administrative boundaries, and should foster respect for patients' and families' wishes. Palliative care programs should provide bereavement services for families and staff members. The impetus for commissioning these case studies was the growing national concern about care at the end of life. Through study or advocacy, a number of projects are now seeking to make end-of-life care more widely available.
These pioneers have developed creative ways to surmount obstacles and effect change, and they provide practical advice for other practitioners. The Balm of Gilead is a comprehensive program for end-of-life care supported in large part through funding from the Initiative for Excellence in End-of-Life Care of the Robert Wood Johnson Foundation. To relieve the suffering of terminally ill patients and their families, the Balm of Gilead Center has created a team of staff, family members, and community volunteers dedicated to providing high quality end-of-life care. The Balm of Gilead Center provides inpatient palliative care for medically underserved people with terminal illnesses who do not have a place to live or do not have support services at home.
For those who need home hospice care, the Balm of Gilead Center provides teams of physicians, nurses, clergy, and volunteers who are dedicated to helping families care for their loved ones at the end of life. My desire to develop palliative care services within the public health system is rooted in my desire for overall high-quality care for the medically underserved. In 1994, I was recruited from my private practice for underserved persons in the mountains to a public-health practice for underserved persons in urban Birmingham with the Jefferson Health System and Cooper Green Hospital. I developed and administered a three-month survey of inpatients at Cooper Green Hospital, identifying 18 terminally ill medical-surgical patients who needed palliative care. The county's home hospice program had eliminated the financial barrier to palliative care by offering its services regardless of insurance status or ability to pay.
The institutions sealed their collaboration by sending a joint team to the Institute for Healthcare Improvement (IHI) series on palliative and end-of-life care to begin building a team and a cohesive program.
Patients admitted to the Palliative Care Unit receive a comprehensive evaluation of their needs by the Center's palliative care specialist and by its medical director.
The medical director provides clinical leadership through daily rounds, 24-hour consultation, and interdisciplinary meetings for review and planning. To meet social, emotional, and spiritual needs, a multidisciplinary team of physicians, nurses, patient care technicians, clergy, social workers, and volunteers coordinates comfort care.
The entire interdisciplinary team coordinates holistic comfort care, addressing the four major areas of suffering associated with the end of life in biweekly meetings where the team reviews the physical, social, emotional, and spiritual needs of each patient and family. The Balm of Gilead Center also reaches out and educates medical providers, patients, students, and the general public. The Balm of Gilead Center has provided information to other institutions interested in establishing their own palliative care programs.
For those who have adequate family support and choose to die at home, the Balm of Gilead Center provides physicians, nurses, clergy, and volunteer care teams who are dedicated to helping families care for loved ones at the end of life.
During the coordination of home care and care on the inpatient unit, the family or other caregivers receive training in hospice care, end-of-life issues, and bereavement.
From 1998 to 1999, the average daily census of patients in home-based hospice has increased from 22 to 28 patients (a 27 percent increase). Engaging the wider community is central to Gilead's mission to encourage high quality end-of-life care far beyond its own patients and their families. Volunteer care teams of six to ten persons offer practical, emotional, and spiritual support to patients and families in both the hospital and the hospice. Community Care Teams developed by church, civic, and neighborhood groups form Circles of Care to serve those in the hospice, as well as those who are pre-hospice, during terminal illness and bereavement. Volunteer professional partners offer specialized skills to patients and families, train clinical staff, and provide valuable aid to the Center's administrative staff.
Undergraduate and graduate students serve and learn at the Balm of Gilead, offering support for patients and families and for Gilead administrative and research projects while simultaneously meeting their own academic and career-preparation goals. This mission to engage the community is guided by Gilead's coordinator of Community Education and CareSharing, who has more than 25 years' experience in clinical psychology as a therapist specializing in the needs of professional and personal caregivers and five years' experience as lay chaplain in the collaborative health ministry of two congregations whose members were primarily elderly.
Eight community-based volunteer teams totaling 68 members contributed 835 hours to Gilead patients and families.
Five church teams from four denominations contributed 373 hours to four families served by the Gilead home-hospice program and to each successive family occupying a church-sponsored room on the Gilead Palliative Care Unit.
One neighborhood organization team contributed 289 hours to two pre-hospice families and to one hospice family. Two teams of first- and second-year medical students contributed 173 hours to patients and families served by the Gilead Palliative Care Unit. From November 1998 through September 1999, 20 professionals from fields such as mental health, academic research, pastoral care, music, photography, computer consultation, data management, massage therapy, cosmetology, and barbering volunteered a total of 559 hours during Gilead's first year—286 in direct patient service and 273 in staff consultation and program assistance. From November 1998 through September 1999, 18 undergraduates, who were preparing for careers in various pre-health disciplines at local colleges and universities, contributed 458 hours visiting Balm of Gilead patients and assisting with Gilead research projects and public presentations. From November 1998 through September 1999, two hospital volunteers choosing service on the Balm of Gilead Palliative Care Unit contributed 10 additional hours of visiting and sitting with patients. The integration of palliative care into the larger health care system is transformting palliative care in medical settings through consultation, education, and advocacy. Throughout Cooper Green Hospital, the Balm of Gilead Center provided the leadership and expertise to institute a routine procedure for addressing pain as a fifth vital sign (along with blood pressure, respiration, temperature, and heart rate). Referrals to the consult service provided by Gilead's medical director and its palliative care specialist have increased the frequency of the dissemination of palliative processes throughout Cooper Green.
Initial steps have been taken to introduce advance directives for health care (ADHC) into the hospital and its clinics. Effective practices in bereavement care flow from the Gilead Center into the surrounding community in several ways.
For this program, Cooper Green's Human Resources Department provided Gilead with the names of employees who had recently experienced the death of a family member. The Balm of Gilead is now developing a county-wide bereavement program for families served by the entire network of safety-net institutions and clinics. The Balm of Gilead staff participates in the palliative care training of medical students and physicians at the University of Alabama at Birmingham. Gilead also disseminates the best practices of end-of-life care to the broader health-care delivery network. The Balm of Gilead program responded to these reservations with friendly persistence, establishing mutually beneficial collaboration as much as possible, regardless of contractual arrangements. In response to other emerging, unanticipated realities, Gilead's Palliative Care Unit is trying to supplement its palliative care beds with hospice beds.
The Balm of Gilead Center has assumed a statewide leadership role in end-of-life issues by participating in the creation of Alabamians for Better Care at Life's End (ABCLE). The palliative care specialist, project administrator, and community care sharing coordinator are funded through grants.
The project administrator's position is funded through a grant from the Robert Wood Johnson Foundation.


Beth Israel Hospital and Deaconess Hospital, which merged in October 1996 to form Beth Israel Deaconess Medical Center (BIDMC), had each been strongly committed to improving the care of patients near the end of life.
At the time of the merger, many pieces of a comprehensive palliative care program already existed, including a 15-bed inpatient hospice unit established at Deaconess Hospital in early 1996, an affiliated outpatient hospice system, and the region's largest pain center. With crucial and timely support through the Faculty Scholars Program of the Project on Death in America, BIDMC and CareGroup leaders made a renewed two-year commitment in 1999 to support the development of a comprehensive palliative care program.
The Boston Jewish community founded Beth Israel Hospital in 1916 to meet the needs of a growing immigrant population. At the same time that Beth Israel and Deaconess merged to form Beth Israel Deaconess Medical Center, BIDMC joined with Mount Auburn Hospital, New England Baptist Hospital, and several suburban Boston hospitals to form CareGroup. The three years following the BIDMC merger and the simultaneous formation of CareGroup brought enormous organizational change, even turmoil. CareGroup has experienced analogous changes during the second and third years of its existence. Amid these organizational upheavals, it was difficult to develop any new clinical initiatives, like an enhanced palliative care program, that required the consistent support of leaders or the allocation of new financial resources. Both Beth Israel Hospital and Deaconess Hospital had been pioneers in palliative care before their 1996 merger.
Beth Israel Hospital (BIH) brought its own record of leadership to the merger as creator in 1972 of the first patient's bill of rights, as a pioneer in DNR policies and procedures during the mid-1970s (Rabkin et al., 1976), as the location for Frederick Wiseman's widely acclaimed six-hour 1990 documentary "Near Death," and as one of five national sites for the landmark SUPPORT study.
While Beth Israel's staff accepted the overall validity of the SUPPORT study, they did not believe that the failure of the intervention phase meant that hospital-based efforts to improve end-of-life care were doomed. In addition, the aggregate, institution-wide nature of the SUPPORT study's results did not indicate that specific individuals, clinical departments, or service units had particular responsibilities or opportunities for improving care.
Nonetheless, in the wake of the SUPPORT study, I had encouraging initial discussions with BIH leaders about developing and implementing an institution-wide effort to improve end-of-life care in late 1995 and early 1996. Building from focus groups of patients that identified core "dimensions" of "patient-centered care," Picker developed a standardized method for surveying patients after their discharge from U.S.
Although Beth Israel had begun using early Picker instruments to assess quality of hospital care by 1989, organization-wide attention to Picker "scores" was heightened dramatically in 1997.
The BIDMC–Picker results in early 1997 attracted immediate and intense attention throughout the organization. Perhaps more important, the Picker results seemed to have clear and direct implications for quality improvement activities, in striking contrast to the uncertain implications of the SUPPORT results.
While Beth Israel Hospital was grappling with the implications of the SUPPORT study in late 1995, nearby Deaconess Hospital was planning for improved end-of-life care of its own. The average number of deaths per year at Deaconess Hospital at this time was approximately 350.
Given the discrepancy between the January and February 1995 inpatient surveys, the Deaconess Hospital financial staff needed to anticipate the consequences of changing the care of current inpatients.
In April 1996 Deaconess Hospital and HealthCare Dimensions signed a contract establishing a 15-bed inpatient hospice in the hospital's Palmer Building. As a result of this contract, Deaconess Hospital now had an on-site hospice unit to which acute care inpatients who were too ill to go home could easily be transferred. Since 1996, more than 1,000 patients have received care on the unit, with a mean length of stay of just over 20 days but a median stay of only nine days. A relatively consistent average daily census of greater than nine patients (recently 11.5 patients) has resulted in an operating surplus for the unit.
One primary financial benefit of the PCC that BIDMC hoped for was the reduction in acute care inpatient stays, beyond DRG reimbursement, for terminally ill patients.
To provide prompt, interdisciplinary, and comprehensive palliative care consultation services that meet the needs of BIDMC patients and families who confront life-threatening or life-limiting illness, and that enhance the clinical excellence of physicians, nurses, and others who are responsible for their care. To provide educational programs that create and sustain palliative care knowledge and skills of the highest order throughout the BIDMC and CareGroup communities. To create systematic programs throughout CareGroup that will transform the quality of care that patients and families receive near the end of life, sharing ideas and achievements with the communities we serve and with others working in this field, locally, nationally, and internationally. To conduct research that strengthens and expands the knowledge needed to improve palliative care. Tangible results from BIDMC's involvement in the 1997-98 IHI Breakthrough Series Collaborative were disappointing. Initial steps to encourage nursing staff on one of the general medical units, with nearly 100 deaths annually, to record pain as a fifth vital sign by documenting the frequency of pain levels greater than five on a 10-point scale found fewer than 5 percent of patients with levels that high, a percentage so low that the staff did not consider a major unit-wide change in pain assessment to be worthwhile. Post-merger difficulties in integrating Beth Israel and Deaconess administrative and clinical activities continued to consume much of the time and energy of Palliative Care Working Group members who might otherwise have been available for additional program development. Shortly after the FY1999 budget lines were approved in principle, BIDMC's overall financial projections for the fiscal year were revised significantly. During the mid-1999 development of the FY2000 BIDMC budget, the challenge of reducing an anticipated FY1999 operating deficit by nearly $40 million led to the first layoffs that Beth Israel personnel had experienced in decades, including the reduction of Social Work Department staff on inpatient services by nearly 50 percent. Corporate training programs have a number of benefits when it comes to furthering your career prospects, and can provide you with the skills and training you need to embark on a successful role within a company. Depending on the program, you will receive a salary when training, as well as benefits and bonuses. You will be able to garner a new set of skills that will prove useful when applying for positions within the company, such as communication techniques, time management, and customer service skills. Other skills include how to organize your time properly so you get the most out of the working day, and how to assume leadership, the latter of which could prove useful if you are hoping to get an entry-level managerial position once you have completed the course. There are a plethora of other benefits to a training program, such as broadening your skill-set and learning how to think critically. Run on the Saba LMS platform, the American Red Cross Saba Learning Center is the online training and education portal for both Red Cross instructors and volunteers. It is no simple task to manage the training of 300,000+ people in different countries and different skill levels but with the aid of the University of Subway Doctor’s Associates is able to do just that. Having such a standing only means you need a quality team to help you manage and run your corporate learning management system (LMS).
Powered by Skillport technology, Dunkin University is the umbrella training facility for both Baskin Robbins and Dunkin Donuts. There are many ways to train and become a security guard but there is only one security company that stands out more than any other organization with their intensive and high standard online curriculum to not only maintain proper certifications withing the security industry, but to also teach them new skills and future learning material to better prepare them for any threat or scenarios they would have to deal with when on the job.
This electronics giant gets a lot of criticism for not having enough knowledge employees staffed at its big box stores. Just because you are not the largest fast food burger company in the world does not mean you do not have a world class training portal for your employees. When starting a training program, it is imperative that you understand exactly what it is you are training for, and what benefits the program will have on your career. You will need to consider the time and effort of the training program, and how this will benefit you in the long run.
There has been a trend in recent years for companies to introduce online corporate training programs, which have a number of benefits over the traditional model. To request this presentation at your school or organization, fill out the online request form and someone from the Sheriff's Office will contact you very soon. Clinicians and managers at each of these institutions negotiated innovative clinical and institutional arrangements and made effective use of the reimbursement policies of public and private payers.
Through the hospice program of Jefferson County's Department of Health, home-based services are extended to all people regardless of their ability to pay. In addition, I found that on any given day from four to seven patients who had been hospitalized for more than seven days could have been discharged if they had had palliative care.
Thus the county public health system had provided an end-of-life "safety net" for uninsured people whose ages disqualified them from the government insurance reserved for the very young and the very old through Medicaid and Medicare. Carole Samuelson, the health officer of the Jefferson County Department of Health, which sponsors the public home-hospice program, was equally receptive. Generous awards from national and local foundations provided vital financial backing and credibility within the institutions and the community. Representatives from a number of hospitals in Alabama as well as from Wishard Health Services of Indianapolis have visited the unit. Through the hospice program of the Jefferson County Department of Health, we extend home-based services to all people regardless of their ability to pay. Congregational care teams participating in the palliative unit's Adopt-A-Room Program add to the comfort of patients and families. Consultations focusing on alternatives to current and future treatment also provide a natural forum in which to educate medical and nursing colleagues about palliative care methods and about decision making concerning ethical issues.


Thomas Delbanco, chief of BIH's Division of General Medicine and Primary Care, founded the Picker Institute in 1987.
But the fact that the unit remains the only inpatient facility of its kind in Massachusetts has caused an unexpected, sometimes problematic, pattern of referrals.
Joanne Lynn's presentation at medical grand rounds in January 1997, as part of the BIDMC-JAMA "Clinical Crossroads" series, helped spark renewed efforts to address the inadequate care that had been documented by the SUPPORT study. David Eisenberg, which had documented in two recent studies that approximately 70 percent of BIDMC oncology patients and approximately the same number of HIV patients use alternative therapies for symptomatic or curative goals. You will be able to garner real-world experience in your chosen job field, and can even use the skills you have learned for future work opportunities. These schemes can last for several months up to a number of years, and once you have completed the course, you will be able to work in an entry-level position within the company. Not only will you be able to use these new skills within the company, but undertaking a training program will look great on your resume, and might impress employers when you are applying for other job vacancies in the future. The program will also outline the things you can do to reduce the overheads of the company, and how to make the business more successful.
You will also be able to make new friends, meet new people from a wide range of backgrounds, and study under the direction of tutors and teachers who are experts in their field. It is the main site for those who want to become ARC certified in a life saving skill, or simply take emergency response courses, for better preparedness in challenging situations.
Besides the usually corporate jobs they true life of the company are the pilots, maintenance crew, aircraft engineers, stewardess, and even custodial workers. One of the requirements of being an international brand is having uniformity among all of your locations, and this multi-nation corporation is no different. With the formation of their online learning academy, the Securitas LMS does this like no other corporate learning portal and is able to reach their many employed personal throughout the world with their own set of standards and requirements depending on the region and company their are employed to protect. However, in the past few years Best Buy as listened and made huge investment in their employee training, including revamping their e-learning offerings and providing their Best Buy employees with proper tools and resources to better educate and train themselves on not only the products and services the company carries, but also on how to better serve the customer and the community they serve.
But luckily for us, Oceaneering employees are made of tougher stuff than us, and they know it. Just one glance at the BK Gateway website and one can see that Burger King’s employee training portal is just as advanced technologically and thorough in its course offerings as their competitors. Find out what position in a company you will be able to apply for once you have completed your training, and whether the skills you will learn pertain to your chosen career field. If you want to work in a particular field, and the only way to gain an entry-level position is through a corporate education program, weigh up the pros and cons of studying on the program before you make your application.
Students can study in the comfort of their own home at a time that suits them, and can converse with course tutors via by email or an internal messaging system. DeMarco, in conjunction with the Sheriff's Alcohol and Substance Abuse Task Force, is pleased to be able to offer a special presentation designed to educate parents and community members about drug abuse and the heroin epidemic that has swept across Long Island.
Each of these programs of palliative care is a product of the organizational culture of the institution in which it operates. However, there were few palliative care services in Jefferson County for people with no home or family or for people whose families were too old, too ill, or too drained by life's other demands to provide consistent care. He was highly receptive to my proposal of an inpatient palliative care unit and of hospital-wide adoption of pain assessment and control measures. Under my leadership as its medical director, the county hospice had not only seen its daily census increase dramatically but also had become licensed and accredited. Samuelson saw that if the hospital and the health department collaborated on their clinical and administrative leadership and shared a medical director, their institutions would provide complementary care for the terminally ill. Each room is furnished and decorated in home-like fashion by a local church or community group. Home health aides help with activities of daily living, such as bathing, eating, or changing linen.
Here are some of the benefits and advantages of a corporate curriculum, with focus on the career opportunities they provide.
You will also learn how to work well on a team, and how to solve problems when under pressure – two skills that are essential in almost any workplace. With the help of Saba’s learning management software, the American Red Cross was able to achieve just that.
However, regardless of your position with the company, US Airways Wings employee website is the main education, training, and travel benefits center that is mandatory to use for proper US Airways related standards and policies, as well as air fare discounts and travel perks that can easily be obtained directly from this website. Whether its perfectly brewed coffee or deliciously glazed doughnuts, attention to quality and detail is one of the main curriculum taught to all employees, regardless if one is a baker or at the from serving to the customer.
This is all possible via the new Best Buy learning lounge website which includes the Best Buy Employee Toolkit (ETK) mentioned above as well. That’s why the Oceaneering LMS training website was setup such that employee access for the offshore crew would be easy and they would not need to dock back to continue their education or learn on new updates for their equipment.
Their program might not provide college credits, but completing the program sure does make one feel confident they can handle any position within the company. The modules taught in a corporate curriculum will depend on various factors but will often cover the structure and history of a company, as well as the policies of a company.
Ask yourself what you want to get out of the program, and what the advancement potential is. Some of the biggest companies in the country have either introduced online elements to their corporate programs, or only offer online training courses.
The purpose of the kit is to help you raise awareness, change attitudes, and improve driving, pedestrian, and bicycling behaviors in your community. Schwartz Department of Geriatrics and Adult Development at Mount Sinai School of Medicine, who helped to initiate and lead the process that produced this report, describes lessons from the short history of these programs in her introduction.
They could envisage a comprehensive program for suffering people within the public health system, a program that would provide compassionate and continuous care through all phases and all treatment settings. At the Red Cross, saving peoples lives is not taken lightly and having a network of instructors who keep track of their training classes (such as CPR, first-aid, etc…) and course schedule is crucial, so any technological advantage they can get, they will implement. For a corporation as large as they, and in an industry as complex as this, US Airways has done a great job setting up this one stop portal to be comprehensive and informative.
Additionally, Dunkin’s intense training program is setup for making employees who show potential into restaurant managers, so there is no wonder why Dunkin Brands online university is part of our top corporate training programs. With access to the latest ROV and other machinery courses, the crew can keep learning and refining their skills regardless of their location. Other subjects that may be covered include diversity training, health and safety, and employment law.
You will need to choose a training program that incorporates a type of study that best suits you, and a course you will be able to commit to.
Will you be able to apply for a managerial role within the company 6 months after you have completed your training?
The indispensable contribution of a nurse practitioner to the daily functioning of a palliative care unit had been confirmed for the medical director during his observations as a visiting scholar at Northwestern University. Dissemination throughout the hospital has begun with the development of a hospital-wide employee bereavement program. The initial displacement of numerous senior administrative and clinical leaders, when many positions were consolidated, was followed by a second period of major leadership turnover.
Powered by PeopleSoft’s technology, this LMS was implemented perfectly to handle large videos and technical material with an easy to navigate structure.
Take some time to look over what the program covers, and how many hours you will need to study for. Online programs are popular with workers who have other commitments during the working day, and allows them to study for the course in the evening or during the weekend. Speak to course tutors and read through the website of the training scheme to find out the answers to these questions. Forse and a hospice nurse, surveyed 263 patients, identified 19 of them as being appropriate for admission to a palliative care unit, identified another 60 as patients who would benefit from a palliative care consultation, and identified nine more as needing palliative care at home. Rabkin, CEO of CareGroup, pledged $225,000 in new institutional funds to supplement the requested $450,000 in RWJ support. Mitchell Rabkin as CEO of CareGroup, and many other senior leadership changes in both BIDMC and CareGroup followed.



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