A pilot playbook in 15 seconds
- Start with purpose. Who is helped? Not billing capture. Not staffing cover.
- Pick the rail. Volunteer, employed, contracted, or a family's own doula under a policy.
- Review before the first visit. Compliance, privacy, background checks, insurance, referral rules.
- One small pilot. Honest measures. Stop rules agreed in advance.
- A pilot playbook. Small, reviewed, honest. qualitydeath.com/health-system/playbook-for-a-health-system
How to read this page
- Proposed Everything about program design here is a proposal: reasoned, not tested at your organization. Adapt it; do not adopt it whole.
- Documented Regulatory and safety facts carry a source that was opened and checked on 2026-09-29.
- This is not legal advice. Your compliance officer and counsel decide what your organization may do. For how doula work is and is not paid, read Health plans and payment first.
Scope check for the role you are designing
A doula in your program may
- Offer presence, companionship and vigil, especially when family cannot be there.
- Support values and legacy conversations and help families prepare questions for the team.
- Offer practical and emotional support to caregivers, within the role description.
- Notice changes and concerns and report them promptly to the named clinical contact.
- Record non-clinical visit notes where and how your policy says.
Hand to the care team
- Any symptom, medication, assessment or clinical question.
- Pronouncement of death and all post-death clinical and legal steps.
- Advance directive completion requiring legal or clinical judgment, and all billing (ACP codes 99497/99498 are the billing clinician's own time and cannot be delegated).
- Safety concerns: suspected abuse, exploitation, suicide risk (988 in the US) or danger in the home.
- Requests about medical aid in dying or stopping eating and drinking: to the clinician.
1. Decide the purpose and the population
Proposed Write one sentence: "We are adding this role so that [who] gets [what] that they do not get now." Candidate populations:
- Patients likely to die without a companion: no family, family far away, or family exhausted.
- Families under high caregiver strain who need time, presence and a steady non-clinical helper.
- Patients whose main unmet needs are non-clinical: meaning, legacy, ritual, company.
Documented This is not a new idea in hospitals: "No One Dies Alone" programs have used trained volunteers to sit with dying patients for over 20 years. A 2025 study of the program at Harborview Medical Center found 22 percent of referred patients had no volunteer visit, most often because the patient died before a volunteer arrived, which the authors read as a case for earlier referral.
Refuse two purposes outright. The role is not a billing strategy (doula work is not billable; see payment), and it is not clinical substitution. Documented A Medicare hospice must routinely provide substantially all core services (nursing, medical social services, counseling) directly by its own employees (42 CFR 418.64). A doula adds to that team; it does not stand in for any member of it.
2. Choose the rail
Proposed Four ways an organization can bring doulas in. Pick one for the pilot.
| Rail | Strengths | Trade-offs | Documented example |
|---|---|---|---|
| Volunteer | Fits existing hospice volunteer rules; low cost; clear supervision | Unpaid; availability varies; must not displace paid staff | Holy Name Medical Center; Partners In Care |
| Employed non-clinical staff | Reliable schedule; your policies, training and supervision apply fully | Budget line; job description must stay non-clinical | None named in a source we opened |
| Contracted community partner | Partner recruits and trains; flexible volume | Contract must require background checks, privacy terms and fair-market pay not tied to referrals | Goodwin Hospice with Present for You LLC, donor-funded |
| Family-engaged private doula, welcomed under a policy | No cost to you; honors the family's choice | You do not supervise them; need a visitor or partner policy and clear limits | None found; a policy question |
Documented Hospice volunteers must be used in defined roles, supervised by a designated employee, trained to industry standards, and provide at least 5 percent of paid staff patient care hours (42 CFR 418.78). The U.S. Department of Labor describes non-profit volunteers as serving "without contemplation or receipt of compensation" and not displacing regular employees. If a volunteer rail is chosen, keep it genuinely voluntary.
3. Define the role on one page
Proposed Start from your existing volunteer or companion job description and add, do not rewrite. The one page should answer:
- Purpose: the sentence from step 1.
- Does: the "may" column of the scope box above, in your words.
- Does not: hands-on personal care unless separately trained and permitted; anything clinical; transport; handling money or medications; witnessing legal documents unless your policy allows it; accepting gifts.
- Reports to: one named supervisor (volunteer coordinator, social work lead or spiritual care lead) and one clinical contact for each patient.
- Hand-off: what to report, to whom, how fast, and what counts as urgent.
- Hours and boundaries: when contact is allowed, and that personal phone numbers and social media are not used.
4. Governance and compliance review
Proposed Before anyone meets a patient, route the design through these reviews. The documented rules are the reason each one exists.
| Review | Question to answer | Source of the rule |
|---|---|---|
| Compliance officer and counsel | Is any payment tied to referrals or to federal program business? Is pay fair market value for services actually provided? | Documented Anti-Kickback Statute, 42 U.S.C. 1320a-7b(b); OIG General Compliance Program Guidance |
| Beneficiary inducement | Could offering the service at no charge influence which provider a Medicare or Medicaid patient chooses? How is it described in marketing? | Documented Social Security Act 1128A(a)(5); OIG policy statement |
| State law | Does any state licensing, funeral, fee-splitting or scope law touch the role? | Varies by state; ask counsel |
| Hospice Conditions of Participation | Is the role a volunteer role meeting 418.78, or staff or contract under the IDT's direction? | Documented 42 CFR 418.56, 418.64, 418.78 |
| Privacy | Is the doula workforce (employee or volunteer) or a business associate? What training is required? | Documented HIPAA "workforce" includes volunteers under the organization's direct control, paid or not (45 CFR 160.103); workforce must be trained (45 CFR 164.530(b)) |
| Background checks | Are checks done for everyone with patient contact or record access, including contracted staff? | Documented Hospices must obtain criminal background checks on employees with direct patient contact or record access, and require contractors to do the same (42 CFR 418.114(d)) |
| Infection control and immunizations | What training and immunization evidence is required? | Documented Hospice infection control program and education (42 CFR 418.60); CDC counts unpaid people and volunteers in healthcare settings as healthcare personnel for immunization |
| Liability and incidents | Who insures the doula? How are incidents reported and reviewed? | Proposed Risk management and your insurer |
| Ethics | Is there a route to ethics consultation for conflicts about goals, capacity or family disagreement? | Proposed Your ethics committee |
5. Selection, training and competency
Proposed Your organization decides what training is required. Private doula training is not a credential and varies widely; a 2022 scoping review found the role "mostly unregulated." Treat outside training as background, then train to your own policies. As one example, the 15 modules at /training (education, not a credential) map to the domains below.
| Domain | Example modules at /training |
|---|---|
| Role and scope | 1 What an end-of-life doula is, 11 Ethics, boundaries and hard topics |
| Dying and the system | 2 How people die, 3 Palliative care and hospice |
| Communication and culture | 4 Communication and presence, 8 Culture, faith and meaning |
| Core practice | 5 Values conversations, 6 Vigil, 7 Family support, 9 Legacy work, 10 After the death |
| Safety, privacy, teamwork | 13 Privacy, records and safety, 14 Working with the care team |
| Sustainability | 12 Self-care and moral distress, 15 Capstone |
Then add your own: orientation to your organization's policies, privacy training, infection control, documentation, escalation drills, and supervised shadowing (for example, three to five visits alongside an experienced volunteer or staff member). Set a probation period with a check-in at the end, monthly supervision, and a debrief after every death the doula attends. Revisit boundaries at each supervision.
6. Referral criteria and pathways
Proposed
- Who may refer: any member of the care team, and the patient or family themselves.
- Criteria: the population from step 1, written down, applied the same way to everyone.
- Consent: the patient (or their representative) agrees before a doula is introduced, and can stop at any time without it affecting their care.
- Introduction: a team member the family already knows introduces the doula by role, says what the doula does and does not do, and says the service is optional.
- Declines: recorded without comment, never re-pitched, and without any effect on other services.
- No pressure: no targets for acceptance rates.
- Conflicts of interest: program doulas do not market private services, funeral providers, attorneys or products to program families, and receive nothing for any referral.
Refer early. The Harborview study above found late referral was the most common reason a patient never received a visit.
7. Communication and documentation
Proposed Decide in writing: what the doula records (date, time, who was present, non-clinical activity, observations to report, hand-offs made); where (your volunteer or program record, or a limited section of the chart if policy says so); who reads it; and how concerns reach the IDT (a phone call for anything urgent, the team meeting for the rest). Keep doula notes out of the medical record unless your policy puts them there, and never on personal devices or apps. Notes describe what was seen and said, not diagnoses. Documented In hospice, the IDT must maintain a system for sharing information among all disciplines providing care, whether directly or under arrangement (42 CFR 418.56(e)).
8. Metrics that are honest and privacy-preserving
The evidence base is thin. Documented Reviews in 2019, 2022 and 2024 describe an evolving, poorly defined role with little evidence about impact. Do not claim improved outcomes or cost savings without your own data, and even then describe them as what happened in your pilot.
| Type | Measure | Note |
|---|---|---|
| Process | Referrals, acceptance, declines, time from referral to first visit, hours of presence, deaths attended | Counts only; no names in reports |
| Family experience | Short feedback questions; a validated instrument such as the FAMCARE scale | Documented FAMCARE was developed to measure family satisfaction with advanced cancer care (Kristjanson, 1993); check its fit and permissions for your setting |
| Hospice survey context | Track CAHPS Hospice Survey results over time | Documented The survey asks bereaved family caregivers about communication, timely help, respect, emotional and spiritual support, pain and symptoms, care preferences, training, and overall rating. Small pilots cannot show a change in it. |
| Staff experience | Short staff survey: time saved or added, clarity of the role | Include nurses, social workers and chaplains |
| Safety | Incidents, boundary concerns, privacy events, complaints | Every one reviewed |
9. Pilot design
Proposed Start with one team and a small number of doulas for three to six months. Before starting, agree in writing: the purpose, the measures above, a named evaluation lead, and stop rules (for example: any serious boundary or privacy breach pauses the program pending review; staff report more work than help at mid-point; families decline at a high rate). Hold a review meeting at the end with the team, the doulas, compliance and, if possible, a family representative. Write it up plainly: what you set out to do, what happened, what went wrong, what you changed, and what you cannot conclude from a small pilot.
10. Failure modes, and how to prevent each
Proposed
- Role creep into clinical care: a one-page role description, supervision that asks "did you do anything outside it?", and staff told not to delegate clinical tasks.
- Boundary violations (gifts, private contact, dual roles): written rules, supervision, and a named person to report to.
- Family conflict: the doula stays neutral and hands disagreements about care to the team; ethics consultation is available.
- Staff resentment: involve nurses, social workers and chaplains in design; show them the role adds, not replaces.
- "Doula washing" (using doulas to cut costs or staffing): a board-level commitment that no clinical or core position is reduced because of the program.
- Privacy breaches: training before first visit, no personal devices for notes, prompt reporting.
- Inequity of access: referral criteria applied equally; track who is offered the service; recruit doulas who reflect the community and its languages.
- Overpromising in marketing: describe the service, not outcomes; compliance reviews all public copy.
11. Risk register
Proposed A starting register. Likelihood and impact are placeholders for your team to score.
| Risk | Likelihood | Impact | Control | Owner |
|---|---|---|---|---|
| Payment linked to referrals or enrollments | Low | Severe | Counsel review; set pay for time; no volume terms | Compliance officer |
| Doula performs clinical tasks | Medium | High | Role description; supervision; staff education | Clinical manager |
| Privacy breach | Medium | High | Workforce training; device rules; incident process | Privacy officer |
| Program used to replace staff | Low to medium | High | Board commitment; staffing review | Executive sponsor |
| Boundary violation or exploitation | Low | Severe | Gift rules; background checks; supervision | Program lead |
| Inequitable access | Medium | Medium | Equal criteria; track offers by group | Program lead |
| Marketing overclaims | Medium | Medium | Compliance review of copy | Communications |
| Doula burnout | Medium | Medium | Debriefs; caseload limits; supervision | Program lead |
12. One-page checklist and agreement outline
Proposed Tick as you go. Ticks are kept only in this browser on this device.
Sample agreement (MOU) outline: headings only
Counsel must draft the actual agreement. These are headings to discuss, not legal text:
- Parties and purpose
- Scope of services and exclusions
- Supervision and reporting lines
- Qualifications, background checks, immunizations and training
- Compensation: basis and method (fair market value, not tied to referrals or program business)
- Conflicts of interest and non-solicitation of patients
- Privacy and confidentiality (including business associate terms if applicable)
- Documentation and records
- Incident reporting
- Insurance and indemnification
- Compliance with laws and program rules; exclusion screening
- Term, termination and review
13. What to ask the doula
Proposed Interview questions that surface judgment, not polish:
- Tell us what you do, and what you would never do, as a doula.
- A family member asks you whether to give an extra dose of pain medicine. What do you say and do?
- Tell us about a time you disagreed with a family's choice. What did you do with that?
- How do you work alongside nurses, social workers and chaplains?
- What would you write in a visit note, and what would you leave out?
- A patient offers you a gift or asks you to be their executor. How do you respond?
- Have you ever been offered anything for referring a family somewhere? What did you do?
- How do you look after yourself after a death?
- What training have you done, and what did it not prepare you for?
- Is there anything about your private practice that could conflict with this role?