Partnering With Patients and Families to Ensure Safety and Quality Care Highlights of the 2007 Patient–and Family–Cente

1. Partnering With Patients and Families to Ensure Safety and Quality CareHighlights of the 2007 Patient–and Family–Centered Care Benchmarking Project Kathy Vermoch May 4 and 7, 2007

2. Goals of This Presentation • Participants will: • Understand the findings and conclusions of the UHC Patient–and Family–Centered Care (PFCC) Benchmarking Project • Learn about effective methods for implementing the core concepts of PFCC across the organization • Dignity and respect • Information sharing • Participation • Collaboration

3. What Is PFCC? The Institute for Family–Centered Care (IFCC) defines* patient–and family–centered care (PFCC) as: “An innovative approach to the planning, delivery, and evaluation of health care that is grounded in mutually beneficial partnerships among health care patients, families, and providers.” Successfully implementing PFCC concepts requires a major paradigm shift: PFCC means developing collaborative partnerships with patients and families to improve care and operational efficiency and recognizing patients and families as equal, important members of the care team. Source: *http://www.familycenteredcare.org/faq.html

4. The IOM Supports Patient–Centeredness • Health care should be based on continuous healing relationships. • Care should be individualized. • It is important for patients to be involved in their own care decisions. • Patients and families should have better access to information. • Health care should become more transparent. • IOM’s “Six Aims for Healthcare Improvement” are safety, patient–centeredness, efficiency, effectiveness, timeliness, and equity. Many health care professional, regulatory, and quality improvement organizations also support or require PFCC concepts, e.g., AHA, Joint Commission, and ACGME Source: Institute of Medicine — Crossing the Quality Chasm: A New Health System for the 21st Century

5. PFCC Is a Business Decision • 3 years ago MCG Health, Inc. began implementing PFCC in neurosciences: • The unit’s Press Ganey satisfaction was at the 10th percentile (the lowest across the medical center.) Staff morale was poor and there were 7.5 FTE open positions. • MCG had poor market share in neuroscience. • Patient/family advisors worked with caregivers on fixing problems, facility design, and interviewing staff, including medical staff; every staff member signed a commitment to PFCC concepts. • Dramatic improvements were seen almost immediately…

6. …PFCC Is a Business Decision • After implementing PFCC concepts in MCG’s Neurosciences unit: • Unit Press Ganey satisfaction = 95th percentile. • The unit has low turnover with a waiting list of quality candidates. • The unit has experienced a significant decrease in medication errors. • MCG’s neurosciences market share has increased 12% in 3 years.

7. PFCC–Not Just a Nice Thing to Do! • Communication problems may lead to legal action for malpractice:* • Failing to understand patients’ or families’ perspectives • Delivering information poorly • Devaluing patient and/or family views • Desertion MCG’s leaders feel that the organization’s commitment to PFCC is a significant factor in the dramatic decrease in malpractice suits they’ve experienced in recent years (see next slide). Source: *Beckman et al., Archives of Internal Medicine, 1994

8. Litigation Claims Files MCG: Favorable Trend in Variances, Claims, and Litigation Files, Claims, and Litigation 90 80 Most UHC members report regular, annual increase in malpractice pay-outs 70 60 50 Number of Recorded Incidents 40 30 20 10 0 2001 2002 2003 2004 2005 2006 (YTD) Years Source: MCG Health, Inc.

9. Project Findings

10. Goals of the PFCC Project • The project’s steering committee focused the study on the following key objectives: • To assist UHC members in determining their PFCC strengths and improvement opportunities • To identify useful metrics for monitoring progress in achieving PFCC goals • To develop an aggregate database of PFCC practices in academic health centers • To discover how organizations are successfully implementing PFCC’s core concepts to address the principles of quality care as outlined by the Institute of Medicine

11. Project Participation and Data Collection • 26 organizations completed a PFCC survey/assessment.* • Part 1, Self-assessment–a rating of the organization’s current PFCC status across the entire enterprise (excluding behavioral health and prisoner care) • Part 2, Drill-down on current practices–respondents had the option to respond for the entire organization or to select the unit or facility most successful in implementing PFCC • Organizations recommended by the steering committee were interviewed about their PFCC initiatives and practices (MCG, Vanderbilt, Washington, Colorado, Methodist, and Denver). • 77 innovative strategy reports describing PFCC-related initiatives were submitted. • The PFCC health care literature was researched. *Many survey questions were adapted from “Strategies for PFCC: A Hospital Self-Assessment Inventory.” IFCC

12. Though Status VariesAll Respondents Are EngagedIn PFCC Implementation • Overall organizational PFCC status: • Have not yet begun to implement PFCC = 0% • Early stages of PFCC implementation = 32% • Partial PFCC implementation in selected locations = 68% Source: Survey Q 1 (one outlier response was trimmed)

13. Disconnects Exist Between PFCC Goals and the Efforts Made to Achieve Those Goals • 65% indicated that PFCC is part of the organization’s mission and values and 68% include PFCC goals in strategic planning, but… • 68% responded “none” or “unknown” for the annual budget devoted to supporting PFCC initiatives. • 42% agreed that PFCC is part of the philosophy of care (POC), but none included patients/families in POC development. • 36% reported that PFCC is included in job descriptions and performance evaluations. • 20% have created a paid patient and family leader position. Source: Survey Qs 2, 3, 5, 12, 71, 73

14. PFCC Leadership Strategies Collaborate with patients and family advisors to: • Incorporate PFCC concepts into mission, vision, values, plans, safety initiatives, philosophy, and scope of care for each area • Create and describe a paid patient and family leader position (supported by appropriate budget and resources) and with primary responsibility for overseeing, coordinating, and implementing PFCC initiatives across the enterprise • Select leaders and providers who practice PFCC concepts, e.g., outsourced service/equipment vendors, administrative leaders, and caregivers–including medical staff • Leaders must believe in and practice PFCC concepts and act as role models for the organization • Hold staff and vendors accountable by including PFCC goals in job descriptions, evaluations, credentialing procedures, and contracts Source: UHC PFCC project

15. Dignity and Respect PFCC Core Concept: Dignity and Respect • Dignity and Respect: • Health care practitioners listen to and honor patient and family perspectives and choices • Patient and family knowledge, values, beliefs, and cultural backgrounds are incorporated into the planning and delivery of care* Methodist’s International Department includes speakers of 12 languages and represents 14 ethnicities to improve communication and assist in understanding cultural concerns and enhancing the care experience for patients and families. Source: *The Institute for Family–Centered Care

16. Dignity and Respect: Improvement Opportunities • 64% agreed that effective processes are in place to ensure patients/families are greeted in a friendly manner. • 52% agreed that the ethnic/cultural diversity of staff is consistent with the patient populations served. • 40% agreed that the facility offers a healing, supportive décor. • 40% agreed that conversations about patients are conducted away from public areas. • 52% agreed that confidential registration discussions are held in private locations. • 32% agreed that care settings provide privacy. Source: Survey Qs 22, 24, 30, 31, 36, 46

17. PFCC Dignity and Respect Strategies Partner with patients and family advisors to: • Put effective processes in place to ensure all staff and employees always introduce themselves to the patient and family and explain their roles in his/her care • Implement friendly policies and procedures that respect the cultural and lifestyle needs of patients and families • Implement practices to encourage family participation in the care team and endure that other team members listen to and respect their opinions • Put organization-wide practices in place that are designed to provide patient/family privacy and respect confidentiality Fairview Children’s Hospital has open visitation and digital camera technology is used to create picture ID badges for parents, who are viewed as equal members of the care team.

18. Information Sharing PFCC Core Concept: InformationSharing • Information Sharing: • Health care practitioners communicate and share complete and unbiased information with patients and families in ways that are affirming and useful • Patients and families receive timely, complete, and accurate information to allow them to effectively participate in care and decision making Source: The Institute for Family Centered Care

19. Paper Records Are Common and May Hinder Patient, Family, and Provider Communications 31% of survey respondents offer few or no electronic systems for patients and families but Duke, UAMS, MCG, Oregon, OSU, Vanderbilt, Colorado, and others have invested in electronic systems that offer patients and families many communication options and resources, e.g., personal health information, test results, education, scheduling and registration, billing, e-mail providers. Source: Survey Qs 93, 94, 95, 96

20. Not All Are Compliant With Joint Commission Safety Requirements for Error Communication and Reporting • 88% have a standard procedure in place to communicate errors, near misses, and adverse events to patients/families. • 84% have a process in place for patients and families to report safety concerns consistent with National Patient Safety Goal 13 (Patient Involvement) • Vanderbilt’s patient safety initiatives are strongly aligned with PFCC goals; separate communications and educational programs were designed (with advisor input) for both staff and patients/families e.g., patient identification • Denver Health discovered that 80% of errors were due to miscommunication; they’ve incorporated PFCC goals into improvement initiatives to increase safety Source: Survey Qs 98, 99

21. Confidentiality Is Not New! • HIPAA regulations do not prevent sharing personal health information with patients and families (in accordance with patient preferences). • Organizations that have made a strong commitment to PFCC are also bound by HIPAA regulations and have learned how to respect confidentiality and promote information sharing. • Put processes in place to provide privacy and protect confidentiality and train staff and patient/family advisors to respect these concepts–then monitor compliance and hold them accountable.

22. PFCC Information Sharing Strategies Partner with patients and family advisors to: • Encourage patients and families to dialogue, share information, and embrace their roles as members of the care team, including participation in rounds, goal-setting, safety, and care decisions. Provide patients and families with easy access to educational and personal health information and the medical record. • Implement electronic systems to facilitate communication, information sharing, and education. • Routinely follow-up with patients/families to ensure that care instructions were understood and if additional support is needed. • Colorado’s “Diabetes Star” Web system offers access to personal health information and guides patients in goal setting. • At OSU’s Ross Hospital, patient relations staff and nurse managers conduct proactive rounds to meet patients and families, encourage communication and participation, and identify and address concerns and complaints quickly. Source: UHC PFCC project

23. PFCC Core Concept: Participation Participation • Participation: • Patients and families are encouraged and supported in participating in care and decision-making at the level they choose • The caveat “at the level they choose” above indicates that flexible care systems must be in place that can be adjusted as needed according to patient and family preferences (e.g., family preference for remaining with the patient during a code). • Only 35% of survey respondents agreed that flexible care delivery systems are in place to accommodate patient and family preferences. Sources: The Institute for Family Centered Care and Survey Q 6

24. Patients and Families Have Limited Opportunities for Presence or Participation in Rounds 58% of respondents have no process in place to accommodate family schedules but at UH Case’s Rainbow Babies and Children’s Hospital, if families cannot be present during rounds then the attending, fellow, bedside nurse, and charge nurse round with families when they arrive. Source: Survey Qs 83, 83a, 84, 85, 85a

25. Total staffed inpatient acute care rooms that are private rooms: Median = 50% Mean = 52% Minimum = 5% Maximum = 100% Inpatient rooms with family sleep space: Median = 10% Mean = 35% Minimum = 0% Maximum = 100% 31% don’t provide family sleep space in critical care units Room Design and Visitation Policies Often Don’t Provide Privacy, Family Sleep Space, or Access to Inpatients Only 12% of respondents strongly agreed that families have 24/7 access to inpatients Source: Survey Qs 14, 107, 109, 110

26. PFCC Participation Strategies Partner with patients and family advisors to: • Implement effective procedures for the competent, mature patient to define his/her family and to declare preferences for involvement (The IFCC defines family as “two or more persons who are related in any way—biologically, legally, or emotionally”) • Provide 24/7 family access to inpatients • Build flexibility into standardized procedures that can be adapted to meet patient and family preferences (including preferences for family presence during painful, invasive, and emergency procedures) • Encourage family presence and participation because families are the patients’ support system and are knowledgeable about his/her care and condition; their input is necessary for quality, safety, information sharing, and satisfaction Source: UHC PFCC project

27. PFCC Core Concept: Collaboration Collaboration • Collaboration: • Patients, families, health care practitioners and hospital leaders collaborate in: • Policy and program development • Implementation and evaluation • Health care facility design • Professional education • The delivery of care Source: The Institute for Family–Centered Care

28. Only Half of Respondents Have Patient/Family Advisory Councils • It is essential for caregivers to collaborate with patients and families at all levels of the organization. Each group contributes unique perspectives and experiences important to shaping organizational policies, programs, practices, and facility design. • 52% of survey respondents have functional patient/family advisory councils in place. • Of these, 77% include the regular participation of senior leaders. But… Source: Survey Qs 74, 75

29. …Some Organizations Have Developed Collaborative Partnerships with Patients and Families • At Duke, patient/family advisors participate on more than 15 organizational committees and other initiatives. • At Vanderbilt patient/family advisors accompany senior executives on rounds and they also act as “secret shoppers” reporting on their service experiences. • MCG won’t “bid out” construction jobs until patient/family advisors have signed off on the blueprints. • At Washington patient and family advisors on the aesthetics committee regularly provide feedback on facility environment and design. Source: UHC PFCC project and survey Q 101 36% of respondents agreed that patient and family advisors participate in facility design.

30. Effective Patient/Family Advisors • Ask doctors, nurses, and other staff for recommendations and put notices hospital and newspapers to find potential advisors. • Look for individuals who have a genuine interest in improving care but without a strong personal agenda or “an axe to grind.” • Candidates must be carefully interviewed and trained as volunteers (including safety, HIPAA, and confidentiality training). • Most project participants don’t pay advisors but they may offer a teaching stipend and other perks, e.g., free parking, meals, or tickets to university sporting events. • Some organizations set a time limit/term for advisor participation while others find that there is a natural attrition process. • It is essential to also train staff to successfully work with advisors to achieve mutual improvement goals. Washington pairs advisors with committee members for follow-up, advice, and to answer questions.

31. PFCC principles are included in curriculum: Nursing = 50% School of medicine = 27% Allied health = 23% Dental = 8% Patients/families participate as faculty in orientation/education: 15% of employees 12% of volunteers 8% of temporary staff and students/trainees 8% of medical staff 4% of trustees PFCC Is Not Often Included in Health Care Education and Patients/ Families Rarely Serve as PFCC Teachers Only 19% of survey respondents agreed that patient and family advisors helped to develop patient, family, and staff PFCC educational materials Source: Survey Qs 9, 78, 79

32. Patients and Families Rarely Collaborate in Provider Selection Practices • 8% invite patient/family advisors to interview clinical and administrative leaders. • 4% ask patient/family advisors to help in the selection of residents. • 4% include patient/family advisors in selecting outsourced service and equipment vendors. • 16% indicated that processes are in place to ensure that outsourced service and equipment vendors practice PFCC principles. Source: Survey Qs 7, 80, 81, 82

33. PFCC Collaboration Strategies Partner with patients and family advisors to: • Develop a functional patient/family advisory council(s) that meets at least quarterly, includes senior leaders, and makes recommendations to the leadership • Design a healing, supportive environment that encourages family presence/involvement-including family resource centers, sleeping spaces, training labs, and easily understood signage • Develop understandable educational materials and include patients and families in training programs designed for patients, families, and staff • Select leaders and providers who practice PFCC concepts, e.g., outsourced service/equipment vendors, administrative leaders, and caregivers–including medical staff Source: UHC PFCC project

34. PFCC in Ambulatory Care and Business Office Practices

35. PFCC and Ambulatory Care • Most PFCC-initiatives are focused on inpatient care units • Primarily in maternal and child care and end-of-life care • In ambulatory care, PFCC care concepts are most likely to be implemented in selected settings such as pediatric or oncology clinics • A study* evaluating the affects of PFCC on outpatient visits concluded that when patients and doctors find common ground: • Physical health status improved • Emotional health improved • Fewer referrals and diagnostic tests were needed two months after the visit * Source: Stewart, et al. The Impact of Patient-Centered Care on Outcomes, Journal of Family Medicine, 2000

36. PFCC and the Business Office • Self-assessment and survey data revealed many opportunities to implement PFCC concepts in non-clinical areas: • Registration, scheduling, and access to services, e.g., the need for simple, consistent, and confidential registration and scheduling procedures; convenient access to services; coordinated support during scheduling and care transition, etc. • Finance, charge, billing, and payment procedures, e.g., the need for consistent, easy and convenient practices (simple language, combined copay, flexible, online payment options, etc.) • See appendix for survey data

37. PFCC Performance Measures: Self-Assessment Scores, Satisfaction Surveys, and Other Outcomes Measures

38. Much PFCC Improvement Is Needed in Every Area Evaluated • Many felt that the self-assessment process was beneficial; getting key stakeholders to discuss the issues is eye-opening. • None of the respondents achieved the maximum score in any PFCC topic. Average PFCC Self-Assessment Scores (Maximum Possible Score = 1.0*) • *Scoring: • Strongly agree = 1.0 • Agree = 0.5 • Neutral = 0.0 • Disagree = -0.5 • Strongly disagree = -1.0 • Average score: sum of scores divided by the number of responses Source: Survey Qs 2 through 67

39. Vendor surveys (national benchmarks): 92% Inpatient 58% Outpatient Internal surveys (internal benchmarks) : 54% Inpatient 38% Outpatient 4% Patient satisfaction not measured Complaint Process: 73% Inpatient 65% Emergency department 54% Outpatient Other outcomes measures: 65% Employee turnover 65% Length of stay 62% Fall rates 54% Errors 42% Financial measures Measures Most Commonly Used by Respondents to Monitor PFCC Performance Source: Survey Q 113

40. PFCC Satisfaction Scores Show Improvement Opportunities • 18 organizations that participate in Press Ganey Adult Inpatient Satisfaction Surveys submitted their most recent scores for key PFCC questions: • Explanation of tests and treatments • Information given to family about condition and treatment • Instructions given for care at home • Inclusion in treatment decisions • Nurses kept you informed • Physician’s concern for questions and worries • Average PFCC scores were calculated: • 4 organizations (22%): > 85.0 (range 85.2 to 88.5) • 10 organizations (56%): > 80.0 and < 85.0 (range 81.0 to 84.6) • 4 organizations (22%): < 80.0 (range 76.5 to 79.4) Source: Survey Q 115

41. New Press Ganey PFCC Measures UHC members using PG surveys are encouraged to use these new questions to evaluate and benchmark PFCC practices • Effective March 2006 Press Ganey added PFCC custom questions to all 13 PG survey instruments: • How well staff explained their roles in your care • Degree to which the staff supported your family throughout your health care experience • Degree to which your choices were respected to have family members/friends with you during your care • Degree to which you and your family were able to participate in decisions about your care • Degree to which staff respected your family's cultural and spiritual needs Source: Press Ganey PFCC Metrics Task Force (including a Univ. of Washington representative)

42. HCAHPS Measures • HCAHPS measures that may be used as indicators of patient-centeredness for UHC’s key organizational reports: • How often did nurses treat you with courtesy and respect? • How often did nurses listen carefully to you? • How often did nurses explain things in a way you could understand? • How often did doctors treat you with courtesy and respect? • How often did doctors listen carefully to you? • How often did doctors explain things in a way you could understand? • Using any number from 0 to 10, where 0 is the worst hospital possible and 10 is the best hospital possible, what number would you use to rate this hospital?

43. PFCC Measurement Strategies • Establish, evaluate, and routinely monitor PFCC performance measures • Regularly collect complaint and customer satisfaction information in all care settings, including comparative external satisfaction benchmarks versus other providers • Work with patients and families to review data, identify opportunities, and design, implement, and monitor performance improvements • It may be difficult to discuss satisfaction data with patients and families but this is essential to better understand the information and create solutions that will successfully address patient and family needs • The Institute of Medicine endorses transparency in health care organizations to improve quality and safety

44. Next Steps Implementation

45. Project Conclusions • Many PFCC improvement opportunities exist in the areas of: • Leadership • Patient and family involvement in strategic planning, operations, and care delivery • Communications and information sharing • Facility design • Support and resources for patients and families • Education of patients/families and staff • Scheduling, registration, access, care transitions, and charge, billing, and payment practices • Many other aspects of service and care delivery • All project participants have improvement opportunities

46. The Most Important Take-Aways From This Study • Patients and families are important, equal members of the care team and have the right to participate in decisions affecting the planning, delivery, and evaluation of care. • Don’t assume that you understand and can effectively address patient and family needs and concerns without sharing the data, asking their opinions, and involving them in designing solutions to create a friendlier, more effective, efficient, and safer health care organization. “The doctors and nurses focus on my physical health and on treating my condition and that’s very important, but quality of life is also very important to me and they don’t always think about that.” Terry H, MCG’s Neurosciences Patient/Family Advisory Council

47. PFCC–Not Just a Nice Thing to Do! • Blue Shield of California conducted an 18-month study of 756 HMO members (all with late-stage illness and access to the same benefits and provider network). Half were blindly assigned to receive usual case management (UCM) and half received patient centered management (PCM) including working with a care manager to develop goals based on disease state, treatment options, pain management, and end-of-life decisions. Survival rates were the same for both groups; the study concluded that PCM effectively reduced overall costs by 26%: • $18,000 cost reduction per patient • Hospital admissions reduced by 38% • Hospital days reduced by 36% • Emergency room visits reduced by 30% • Home care use increased by 22% • Hospice use increased by 62% • Higher satisfaction rates for 92% of the PCM members Source: LSweeney, et al, The American Journal of Managed Care, Feb 2007

48. Implement PFCC Concepts Through Partnerships With Patients and Families • Dignity and Respect: Health care practitioners listen to and honor patient and family perspectives and choices. Patient and family knowledge, values, beliefs, and cultural backgrounds are incorporated into the planning and delivery of care. • Information Sharing: Health care practitioners communicate and share complete and unbiased information with patients and families in ways that are affirming and useful. Patients and families receive timely, complete, and accurate information to allow them to effectively participate in care and decision making. • Participation: Patients and families are encouraged and supported in participating in care and decision making at the level they choose. • Collaboration: Patients, families, health care practitioners, and hospital leaders collaborate in policy and program development, implementation and evaluation; health care facility design; professional education; as well and in the delivery of care. Source: The Institute for Family Centered Care

49. Where To Start? • Begin partnering with patients/families to implement PFCC concepts in locations that make sense for your organization: • Maternal/child services because family participation is expected and natural • Units with the greatest opportunity to improve customer satisfaction • Locations with the greatest opportunity to improve safety • Units with a PFCC champion who is receptive to change • Construction projects that bring key stakeholders together • Share PFCC success stories and work with others to foster and implement a PFCC culture across the organization • PFCC applies to every facet of health care–inpatient, outpatient, ED, ancillary, home care, hospice, behavioral, subacute/long-term care, scheduling, registration, billing, support services, outsourced vendors, etc.

50. PFCC Advice for Beginners • Stories change culture; ask patients, families, and staff to share their (positive and negative) health care experiences. • Senior leadership buy-in is essential to provide role models and resources, and to hold staff accountable for practicing PFCC concepts. • Select PFCC performance measures (including safety measures), collect baseline data, monitor performance, and then share the results. • Look for early adopters and work with them to successfully implement PFCC concepts and help others to learn from their example. Continued...