Photo Credit: Dr. Stephani Nonas from the Department of Pulmonology and Critical Care Medicine
The advance care planning improvement initiative is a hospital-wide (adult non-observation patients to start) effort done in partnership with the Caring Wisely team at OHSU to create a system that enables provider involvement in Advance Care Planning at every hospitalization, hoping that it will reduce the number of patients/families that arrive at critical care junctures underprepared for the complex care decisions they often face.
This is the third year of the project - the first 2 years focused on educational outreach to make providers aware of the Advance Care Planning navigator in Epic and to increase documentation of surrogate decision maker (SDM) as the initial step in the continuum of Advance Care Planning. We successfully increased rates from <10% to as high as 50% before returning to a new baseline of 30%.
This year, we are spreading a bundle of workflow system changes that different services had used to maintain high rates of SDM documentation to the Internal Medicine Medical Teaching Service & Medical ICU. Our hope is to continue to engage in a multi-professional workflow that is being defined with the help of the Caring Wisely group through ongoing multi-professional pilots. We hope to drive documentation hospital-wide to 70% by the end of the year.
We need your help! Click the 'Get Involved' button below if you would like to get involved with the project!


  • Pilots in the Internal Medicine Medical Teaching Service & MICU are ongoing
    • Recent Trials = observing process without any new outreach, BPA still active
    • How it's going:


Sub-Committee Members:

  • Briana Ketterer, MD - Chief Resident, Internal Medicine
  • Kaleb Keyserling, MD - Internal Medicine
  • Alina Plavsky, MD - Internal Medicine
  • Garrett Waagmeester, MD - Chief Resident in Quality & Safety, Portland VAMC
  • Brady Wright, MD - Clinical Informatics