Quality Assurance Toolkits

Introduction to Toolkits

An important part of maintaining an active, widely used POLST program is to conduct periodic evaluations of program use. The tools on this page are intended to help all programs, regardless of research expertise or funding, conduct quality assurance to ensure that their program is following the National POLST standards.

Please share your feedback (what worked, provide sample policies, questions, comments, new tool ideas, etc). These documents will be updated as feedback and additional questions are received.

Quality Indicator Toolkit

The Quality Indicator Toolkit is being created by the National POLST Research & Quality Assurance Committee. It provides three ways to complete each measure and is intended to help individuals or organizations interested in quality assurance activities (not research), particularly if they have limited funds or little/no research experience.

Do you have suggestions for others? Let us know.


The POLST Quality and Research Toolkit (PQRsT)

Download the full toolkit (PDF, 3.6 MB) or access each component individually below.

The POLST Quality and Research Toolkit (PQRsT) is designed to facilitate the study and improvement of POLST programs through data collection and analysis. The PQRsT consists of 30 instruments that have been created to study POLST for research or quality improvement projects, along with related research materials. POLST programs and researchers who have studied POLST programs have generously shared the instruments in the PQRsT in order to benefit POLST programs nationwide. Each instrument is paired with a summary, which provides more information on utilizing the instrument in data collection.

This project was generously funded by Judy (Citko) Thomas, JD and the California Coalition for Compassionate Care. The PQRsT version 1.0 2-22-2013 was compiled and annotated by Erik Fromme, MD, MCR, FAAHPM (Feedback, additions welcome: Erik_Fromme@DFCI.HARVARD.EDU)

Note on Terminology and Modifying Materials

POLST forms are known by different names in different states, including MOLST, MOST, POST, LaPOST, and TPOPP. For simplicity, the term POLST is used when referring to POLST forms or programs in general. When referring to specific programs or forms, the actual program name is used. Each instrument’s nomenclature has been retained to acknowledge the work that went into creating them and the creators’ generosity in sharing them.


The below files are available for download in Word document format.

General POLST Instruments

  1. POLST Quality Improvement Chart Review Form (Summary, Instrument)
  2. LaCrosse Advance Directive Study II Instrument (Summary, Instrument)
  3. NY MOLST Quality Chart Review (Summary, Instrument)
  4. NY MOLST Facility Questionnaire (Summary, Instrument)
  5. NC MOST Provider Survey (Summary, Instrument)
  6. NC MOST Provider Interview (Summary, Instrument)
  7. MI POLST Chart Review Form (Summary, Instrument)
  8. CA POLST Quality Chart Review (Summary, Instrument)

Instruments Used in Nursing Facilities

  1. OR Nursing Home and Hospice Telephone Survey (Summary, Instrument)
  2. CA POLST Nursing Home Survey I (Summary, Instrument)
  3. CA POLST Nursing Home Survey II (Summary, Instrument)
  4. OR Nursing Facility Chart Review Short Version (Summary, Instrument)
  5. Nursing Facility Chart Review Long Version (Summary, Instrument)
  6. CA Skilled Nursing Facility Interview Guide (Summary, Instrument)
  7. CA POLST assisted living survey (Summary, Instrument)
  8. MI POLST Program Partner Survey (Summary, Instrument)
  9. WA POLST Nursing Facility Project (Summary, Instrument)

Instruments Used with Emergency Services Personnel

  1. OR Emergency Medical Services Survey (Summary, Instrument)
  2. NY MOLST Emergency Medical Technician Survey (Summary, Instrument)
  3. NY MOLST Emergency Medical Services Quality Assurance Project (Summary, Instrument)

Instruments Used in Hospitals

  1. NY Hospital employee anonymous survey (Summary, Instrument)
  2. WI Hospital chart review form (Summary, Instrument)
  3. CA POLST Hospital Survey (Summary, Instrument)

Instruments Used in Hospice Programs

  1. Hospice telephone survey (Summary, Instrument)
  2. Hospice chart review form (Summary, Instrument)

Other Instruments

  1. CA POLST Knowledge Pre-Survey (Summary, Instrument)
  2. NC Advance Care Planning Survey (Summary, Instrument)
  3. KS TPOPP Coalition Survey (Summary, Instrument)
  4. KS TPOPP Implementation Plan Survey (Summary, Instrument)

Other Research Materials

  1. List of POLST Metrics by Jane Dinnen, RN (Instrument)
  2. MI Nursing Facility Telephone Survey Permission Script (Instrument)
  3. Sample MOLST Survey cover letter (Instrument)
  4. Sample MOLST Implementation plan (Instrument)
  5. Sample MOLST EMS Pilot Results Letter (Instrument)
  6. NC MOST Research Presentation Poster (Instrument)
  7. WA POLST Project Recruitment Letter (Instrument)
  8. WA POLST Verbal and Written Consent Forms (Instrument)
  9. WA POLST Nursing Home Evaluation Project Report (Instrument)
  10. Sample study IRB protocol (Instrument)
  11. California POLST Minimum Data Set Questions (Summary, Instrument)

Literature Review

Download the POLST Literature Review (.docx)