PatientsOn

Board Engaging Patients and Families as Partners in Care and Organizational Improvement

Executive Summary Guided by Hospital Quality Institute (HQI) and Patient & Family Centered Care partners (PFCCpartners), 11 California hospitals and hospital systems joined forces in a fast-paced collaborative to engage patients and their families as partners in organizational operations and improvement.

Background The Hospital Quality Institute (HQI) partners with California hospitals and hospital systems to accelerate safety and quality improvement and advance California as a national leader in quality performance. Responding to requests by hospitals/hospital systems for practical assistance to strengthen patient and family engagement, HQI designed and led a five-month hospital collaborative to catalyze engagement.

Patient and family engagement (PFE) is an important attribute of health care quality, safety and reliability. It involves integration of patient and family voices into decisions about patient care, as well as health care organizational design, operations, improvement and governance. Recent empirical studies have linked PFE with:

• Greater quality, safety and outcomes of care1,2

• Care delivery that conforms to patient’s preferences and values 3,4

• Fewer diagnostic tests3,5

• Decreased use and cost of health care services3,5,6,7,8

• Increased patient buy-in to prescribed treatment7,8

• Improved patient experience9

• Greater satisfaction and retention of health care professionals10,11

Proven organizational strategies exist to accelerate PFE. However, a recent national survey12 by the American Hospital Association uncovered that their implementation is not yet widespread. For example, only 41% of U.S. hospitals have a functioning Patient and Family Advisory Council (PFAC). California’s adoption rate is 47%13, better than the national average, but still leaving more than half of the hospitals in our state absent a key organizational strategy for achieving PFE.

1 Weingart SN, Zhu J, Chiapetta L, et al. Hospitalized patients’ participation and its impact on quality of care and patient safety. International Journal for Quality in Health Care. 2011; 23(3):269-77.2 Fumagalli S, Boncinelli L, Nostro A, et al. Reduced cardiocirculatory complications with unrestrictive visiting policy in an intensive care unit. Circulation. 2006;113:946–952.3 Stacey D, Légaré F, Col NF, Bennett CL, Barry MJ, Eden KB, Holmes-Rovner M, Llewellyn-Thomas H, Lyddiatt A, Thomson R, Trevena L, Wu JH. Decision aids for people facing health treatment or screening decisions. Cochrane Database Syst Rev. 2014 Jan 28;1:CD001431. 4 Barry MJ, Edgman-Levitan S. Shared decision making--pinnacle of patient-centered care. N Engl J Med. 2012 Mar 1;366(9):780-1.5 Bertakis KD, Azari R. Patient-centered care is associated with decreased health care utilization. JABFM. 2011;24(3):229-239. 6 Veroff D, Marr A, Wennberg DE. Enhanced support for shared decision making reduced costs of care for patients with preference-sensitive conditions. Health Aff (Millwood). 2013 Feb;32(2):285-93.7 Greenfield S, Kaplan S, Ware JE Jr. Expanding patient involvement in care. Effects on patient outcomes. Ann Intern Med. 1985 Apr;102(4):520-8.8 Greenfield S, Kaplan SH, Ware JE Jr, Yano EM, Frank HJ. Patients’ participation in medical care: effects on blood sugar control and quality of life in diabetes. J Gen Intern Med. 1988 Sep-Oct;3(5):448-57.9 Hibbard JH, Greene J. What the evidence shows about patient activation: better health outcomes and care experiences; fewer data on costs. Health Aff (Millwood). 2013 Feb;32(2):207-14.10 McCarthy D. Case study: achieving a culture of patient- and family-centered care at Bronson Methodist Hospital. Quality Matters. 2007.11 Chaboyer W, McMurray A, Johnson J, Hardy L, Wallis M, Sylvia Chu FY. Bedside handover: quality improvement strategy to “transform care at the bedside”. J Nurs Care Qual. 2009;24(2):136-4212 2014 Survey by the American Hospital Association (AHA) and Health Research and Educational Trust (HRET): “The Current State of Patient and Family Engagement Strategies in American Hospitals.”13 2015 HRET HEN 2.0 Baseline Needs Assessment Survey

Collaborative DesignHQI designed and delivered Patients On Board in partnership with PFCCpartners, a California-based patient-and-family run organization dedicated to improving health care. The partnership provided the hospitals with a unique program of shared learning and individualized support to meet the goals of the initiative. The program took place between August and December 2014.

The work in each organization was driven by a dedicated core implementation team, including:

• Executive Sponsor, whose role was to champion the cause and inspire organizational commitment; provide resources and support for the work; and remove obstacles.

• Patient Engagement Coordinator, who managed the work during the collaborative period and beyond, and acted as the point person for patients, families, staff and leadership.

• At least two other influential leaders/champions that could actively support and advance implementation.

Each learning session delivered new content while also providing a structured opportunity for community exchange and group coaching.

Goal and ObjectivesThe goal of Patients on Board was to equip the hospitals/systems with practical, evidence-based strategies to guide transformative engagement. In the process, the participating hospitals were expected to achieve three of the following five objectives:

• Articulate a plan for engaging/integrating Patient/Family Advisors (PFAs).

• Identify an executive with accountability for PFE and experience.

• Complete at least one meeting of a newly established Patient and Family Advisory Council (PFAC).

• Appoint at least one PFA as a member of at least one organizational improvement team or committee.

• Involve at least one PFA as a member of the organization’s team implamenting the Patients on Board collaborative.

Participating Organizations and TeamsChino Valley Medical CenterDesert Regional Medical CenterDesert Valley HospitalHemet Valley Medical CenterJohn Muir HealthKaiser Permanente South SacramentoKindred Hospital La MiradaMenifee Valley Medical CenterMethodist Hospital of Southern CaliforniaSan Gabriel Valley Medical CenterTahoe Forest Hospital

“Patient and family engagement is the cornerstone of health care safety and quality improvement.”

Julie Morath, RN, MSPresident and CEO

Hospital Quality Institute

CurriculumThe program followed a proven roadmap – the PFCCpartners’ “5 Gateways” curriculum. PFCCpartners and HQI collaborated on a sequential curriculum rollout through a series of in-person and virtual learning sessions and provided practical guidance to the hospitals as they worked to achieve successful patient and family engagement. The start of new Gateways was built upon the accomplishment of the key milestones from the previous ones. Participants were given assignments to be completed prior to the next session.

The 5 Gateways were as follows:1. Month 1: Setting the Table in the

Organization (develop and communicate vision, scope and charter; link to organizational strategy; define and commit resources; form a steering team and identify a coordinator)

2. Month 2: Recruiting PFAs (establish referral, application and interview processes; publicize PFE opportunities widely; recruit and select PFAs)

3. Month 3: Training and Orienting PFAs (establish and orient PFAs to their role expectations and core competencies)

4. Month 4: First Meetings (prepare and hold a formal meeting; set ground rules and expectations; establish a strong connection to the organization; provide participants the time to share their story; prepare leaders and staff to work with PFAs)

5. Month 5: Sustainability Practices (establish continuous recruitment and grow PFA numbers and involvement; increase and deepen the PFA engagement opportunities; grow the impact of PFAs)

Outcomes and Lessons LearnedBy the end of the program, all hospitals/systems have articulated a formal organizational plan for engaging and integrating PFAs; all have appointed executives with accountability for patient/family engagement and experience; the majority have successfully held the first meeting of a newly formed PFAC; and several have added PFAs to ongoing committees. For most participating organizations, Patients On Board was the first step on a much longer journey and the collaborative helped establish a foundation for their continued progress in this area.

Integration with Other InitiativesPatients On Board coincided with the ending period of the original phase of CMS’ Hospital Engagement Network (HEN 1.0), aimed at comprehensive improvements in patient safety. All POB participating hospitals/systems were members of California’s HEN (CalHEN), operated by HQI. CalHEN’s Clinical Improvement Advisors provided hands-on hospital support to help coach the field implementation of the program. This integration helped avoid programmatic silos and created a more powerful impact of the work.

Balance Virtual with In-Person MeetingsTwo in-person events were held as “bookends” at the beginning and the end of the program, while a series of webinars and coaching calls took place between them. The Kickoff in-person event set the stage for upcoming Gateway rollouts and was particularly helpful in establishing a sense of community among the collaborative participants. The Capstone event showcased and celebrated the achievements of the participating hospital teams and solidified plans for spread and sustainability. Both events were hosted by a participating hospital, Methodist Hospital of Southern California, which added to the authenticity of the work.

Do Not Underestimate Organizational Change and Support RequiredMeaningful integration of patients and families as organizational advisors is best achieved within a larger context of a patient-and-family-centered organizational culture. For most POB teams, the work in the collaborative required driving a major change in their organizations. It required a strong core team; an expense of time and resources; a clear vision that is widely known and easy to endorse; effective continuous communication at all levels; tactical plans, processes and assignments for implementing the work, solving problems, removing obstacles, enforcing accountability and celebrating the wins; and above all – executive support. In fact, the support and engagement of senior leaders was a critical determining factor for success of the hospitals/systems in the program.

Other Lessons Learned • Hospitals benefit from reassurance that it is important to simply begin implementing this work. Even if small, successful first steps help secure continuous commitment, attention and gradual movement forward in the organization.

• It is essential to develop a PFE vision and formally integrate it with the organizational strategy. It is also critically important to communicate widely and persistently at all levels, linking vision and strategy.

• Successful recruitment of the first Patient Family Advisor (PFA) tends to be a monumental milestone and provides a boost of energy for the team and the organization to charge forward.

• Hearing directly from patients and families via formal opportunities for patient/family testimonials is powerful and serves to energize and catalyze further action.

• PFA recruitment is best done by casting a wide net inside and outside of the organization to solicit PFA referrals and applications. Clear communication through multiple channels should highlight the referral process and reinforce the organization’s vision, goals and plans.

• Provide a consistent staff person who is the main point of contact for the potential and recruited PFAs. This person needs to be easy to reach and responsive.

• The roles for new PFAs need to be thoughtfully defined. PFAs need to be oriented and supported to function within these roles and the hospital workforce needs to be informed, oriented, and prepared to work effectively with the new PFAs.

leaders and requests followed from several departments and divisions for the PFA to present to their staff. A snowball effect ensued, with ever-growing demand for the PFA’s engagement and time, which prompted rapid recruitment and onboarding of several new advisors.

JMH currently has five busy PFAs who regularly attend monthly PFAC meetings, while also taking part in numerous other advising activities. For example, all five PFAs attended a retreat for medical executive leaders, cementing the physicians’ already strong support of PFA engagement; PFAs have been appointed as members of the hospital Safety and Performance Improvement Committee as well as the Quality Improvement Committee of the Physician Network on the ambulatory side; and a PFA has become involved with the team redesigning the system’s website and developing a patient portal.

“I love and enjoy my work of being a Patient Advisor. I have been surprised by the genuine interest, commitment and support that so many people at John Muir have had in listening and responding to patients’ needs.” Jim Corr, Patient and Family Advisor

While JMH’s PFAC is currently a system-wide committee spanning both hospital campuses, JMH’s future plans include forming a local PFAC in each hospital while maintaining the system-level PFAC in a steering capacity. Plans are grounded in careful consideration of factors that will ensure sustainability of PFA engagement, such as ongoing advisor recruitment, and support and capacity building once PFAs have entered their role.

“Our organization is changing as a result of patient involvement. We are committed to weaving patients and families into the fabric of the institution. This gives the patient/family perspective a seat at the table as we move forward as a health system.”

Nick Mickas, MD, Chief of Staff,John Muir Medical Center

Walnut Creek Campus

John Muir Health (JMH) is a nonprofit hospital system with two hospital locations in the East Bay area of Northern California. In recent years, JMH has added attention to patient experience to its operational strategy. This involved formation of an executive-level steering committee for patient experience, appointment of accountable leaders and personnel, and commitment of resources. The timing of Patients On Board collaborative was right, as it coincided with JMH’s desire to bring its patient experience effort to the next level by forming a PFAC and begin formally engaging patients and families as organizational advisors.

From the beginning of Patients On Board, a robust contingent of JMH organizational leaders became engaged in all aspects of the collaborative. This included the Chief Medical Officer as the Executive Sponsor, the Chief of Staff, two physician champions, two nursing administrators, a leader for patient experience, and a variety of other leaders. A Director of Patient Relations and Accreditation was appointed to manage the patient/family engagement portfolio.

Upon drafting their vision and charter for patient/family engagement, the team had secured full executive support and, early on, oriented the JMH Board of Directors as to the PFA plans and rollout activities. The board was immediately supportive, with one board member also volunteering to become a member of the newly forming PFAC.

The first recruited patient/family advisor was invited to attend a JMH leadership retreat and asked to provide a closing story. This was exceedingly well received by the organization’s

Representative Examples

JMH Recruitment Flyer

Tahoe Forest Health System (TFHS) operates a 25-bed critical access hospital serving six rural counties in Northern California and Nevada. The organization places high value on patient experience and engagement. The work is coordinated by an energetic Patient and Family Centered Care (PFCC) Committee staffed by interdisciplinary clinical and operational leaders.

Early on, the champions engaged in walk-throughs to document care processes and surroundings “from the eyes of the patient.” The process revealed various improvement opportunities in order to align the care environment with the espoused principles of patient and family-centered care.

The learnings bolstered the leaders’ resolve to improve and to establish mechanisms for direct communication and patient feedback in order to reliably consider the patient perspective in hospital operations.

Walk-through findings at TFHS informed improvement action toward more patient and family centered care environments

In short order the team of champions - actively supported by the Leadership Team and the Board - developed a plan to form a Patient Advisory Council and undertook an information blitz within the organization and the surrounding community. A staff person (Patient Advocate) took on the role of managing the process.

Within several months, TFHS recruited and onboarded six PFAs and began holding regular meetings of their PAC. Department directors attend the meetings to bring areas for discussion of the process improvement. The PFAs are now an invaluable part of the fabric of the hospital. Their contributions have included co-design of the white boards in patient rooms, improvements in the processes of patients’ transitions out of the hospital, preoperative processes in the Surgery Department, and noise level reduction in the Emergency Department.

Flyer disseminated as part of TFHS’ information blitz

TFHS’s new Patient Advisory Council

A collaboration of California Hospital Association, Hospital Council of Northern and Central California, Hospital Association of Southern California and Hospital Association of San Diego and Imperial Counties

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