Saint Vincent Hospital Patient and Family Advisory Council 2015 Report. Total Responses. # Answer Bar Response % 1 Prior to % %

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1 Saint Vincent Hospital Patient and Family Advisory Council 015 Report Last Modified: 10/08/ Hospital Name Answer Total Responses Saint Vincent Hospital 1. Year PFAC Established 1 Prior to Staff PFAC Contact Name and Title Robert Ready, Senior Director of Patient Care Services and Professional Practice 4. Staff PFAC Contact and Phone Robert.Ready@stvincenthospital.com, Our PFAC has (click the best choice): 1 by-laws agreed-upon policies and procedures 3 neither 6. Our PFAC manages itself through (describe in 1500 characters or fewer) :

2 7. Our PFAC recruits new using the following approaches (click all that apply): 1 Word of mouth Promotional efforts within institution to patients 3 Promotional efforts within institution to providers or staff 4 Through existing 5 Facebook and Twitter 6 Recruitment brochures 7 Hospital publications 8 Hospital banners and posters 9 Through care coordinators 10 Through patient satisfaction surveys 11 Through community-based organizations 1 Through houses of worship 13 At community events 14 Other 15 None 8. Describe other recruitment method (in 1500 characters or fewer): 9. Our PFAC chair or co-chair is a patient or family member 1 Yes No 10. Our PFAC chair or co-chair is a hospital staff member 1 Yes No 11. Chair/Co-Chair hospital position title:

3 Senior Director of Patient Care Services and Professional Practice 1. This person is the official PFAC staff liason 1 Yes No 13. Total number of staff on the PFAC: Total number of current or former patients or family on the PFAC: The name of the hospital department supporting the PFAC is: Office of Patient Advocates 16. If not mentioned above, the hospital position of the PFAC staff liason is: Senior Director of Patient Care Services & Professional Practice 17. The hospital reimburses PFAC for the following costs associated with attending or participating in meetings (click all that apply): 1 Provide free parking Provide meals 3 Provide translator or interpreter services 4 Provide assistive services for those with disabilities 5 Provide meeting conference call or webinar options

4 6 Provide mileage or travel stipends 7 Provide financial support for child care or elder care 8 Provide stipends for participation 9 Provide on-site child or elder care Provide reimbursement for attendance at annual PFAC conference Provide reimbursement for attendance at other conferences or trainings 1 Provide gifts of appreciation to PFAC annually 13 Cover travel expenses to attend conferences 14 Provide other supports 15 None 18. Describe other supports provided (in 1500 characters or fewer): 19. Our catchment area is geographically defined as: Central Massachusetts 0. Race: American Indian or Alaska Native Asian Black or African American Native Hawaiian or Other Pacific Islander White 0.1% % % 0% 93% 1. Ethnicity: Hispanic or Latino Not Hispanic or Latino 4% 96%. Race: American Indian or Alaska Native Asian Black or African American Native Hawaiian or Other Pacific Islander White 0.04% 3% 4% 0.01% 81% 3. Ethnicity: Hispanic or Latino Not Hispanic or Latino 9% 91%

5 4. Race: American Indian or Alaska Native Asian Black or African American Native Hawaiian or Other Pacific Islander White 0% 0% 7% 0% 86% 5. Ethnicity: Hispanic or Latino Not Hispanic or Latino 7% 93% 6. Our PFAC is undertaking the following activities to ensure appropriate representation of our hip in comparison to our patient or catchment area (describe in 3000 characters or fewer): The PFAC increased diversity of new in order to re-reflect Saint Vincent Hospital s (SVH) diverse population. Within the last year, two new including a Latina and an African American have been recruited to our PFAC. SVH continues to seek opportunities to expand the diversity of our PFAC. 7. Our process for developing and distributing agendas for our PFAC meetings (click the best choice): The staff develops the agenda and sends it out prior to the meeting The staff develops the agenda and distributes it at the meeting PFAC develop the agenda and send it out prior to the meeting PFAC develop the agenda and distribute it at the meeting The PFAC has a collaborative process between staff and patients/family to develop and distribute the agenda 6 Other process 7 None 8. Describe the process (in 1500 characters or fewer): All provide input for future agendas. PFAC co-chairs work collaboratively weeks prior to meeting to develop an agenda.

6 9. Describe the process (in 1500 characters or fewer): 30. The PFAC goals set for FY 015 were (describe in 1500 characters or fewer): Saint Vincent Hospital will continue its work with the Oncology PFAC in developing new initiatives to support patients and families dealing with cancer diagnoses. We will continue to seek PFAC input and participation in patient experience initiatives, including participation in such activities as patient rounding and participation in hospital committees and work groups. Include PFAC in planning of potential building construction and/or expansion of service lines. Continued focus on adding PFAC hip diversity to reflect the population we serve 31. The FY 015 goals were (click the best choice): 1 Developed by staff and reviewed by PFAC Developed by PFAC and staff 3 Neither 3. Our PFAC has the following subcommittees (click all that apply): 1 Government Relations Emergency Department 3 Education and Communication 4 Family Support 5 Policies and Procedures 6 Palliative Care 7 Annual Report 8 Publications 9 Nominations 10 Marketing 11 Behavioral Health 1 Medication Safety 13 Hospital Safety 14 Other 15 None 33. Describe other subcommittee (in 1500 characters or fewer):

7 Oncology PFAC. Some also participate in hospital committees, such the Ethics Committee and Schwartz Rounds. 34. How does the PFAC interact with the Hospital Board of Directors? (click all that apply) 1 PFAC submits annual report to Board PFAC submits meeting minutes to Board 3 PFAC member(s) attends Board meetings 4 Board member(s) attends PFAC meetings 5 PFAC member(s) are on board-level committee(s) 7 Other 35. Describe other interaction (in 1500 characters or fewer): 36. URL/link to the PFAC section of the hospital website: Describe the PFAC's use of , listservs, or social media (in 3000 characters or fewer): We communicate through , phone, regular mail, and in-person. 38. Number of new PFAC this year: 39. The orientation was provided by: Number of Staff Members Number of PFAC Members The content included (click all that apply):

8 1 Meeting with hospital staff A general hospital orientation 3 Information on concepts of patient- and family-centered care (PFCC) 4 Information on patient engagement in research 5 PFAC policies, member roles and responsibilities 6 Information on health care quality and safety 7 History of the PFAC 8 A "buddy program" with old 9 How PFAC fits within the organization's structure 10 Other 41. Describe other content (in 3000 characters or fewer): 4. PFAC are considered hospital volunteers and therefore (click all that apply): 1 Attend hospital volunteer trainings Require immunizations or TB checks 3 Require CORI checks 4 Other 43. Describe other PFAC member requirement(s) (in 1500 characters or fewer): Only those working in projects that involve visiting patient care areas are required to register as volunteers. As a registered volunteer, they are required to go through volunteer orientation, maintain immunizations up-to-date, and go through CORI checks. 44. Our PFAC provides education to our on the topic of patientcentered outcomes research 1 Yes No 45. Accomplishment 1 (describe in 3000 characters or fewer):

9 Patient Rounding: In an ongoing effort to assess and improve the patient experience at SVH, the Hospital Chief Nursing Officer met with the PFAC s Co-chair and provided training on patient rounding. The PFAC Co-chair conducted initial rounds with positive results. Further training opportunities will be offered to other interested PFAC. 46. The idea for Accomplishment 1 came: 1 Directly from the PFAC From a department, committee, or unit that requested PFAC input 47. Accomplishment (describe in 3000 characters or fewer): Ebola: During the Ebola outbreak and concerns about its impact in the United States, the Chief Medical Officer of Saint Vincent Hospital reviewed the Hospital Ebola preparedness plan with the PFAC. The PFAC provided feedback regarding the hospital s Ebola plan and revisions to the plan were initiated. 48. The idea for Accomplishment came: 1 Directly from the PFAC From a department, committee, or unit that requested PFAC input 49. Accomplishment 3 (describe in 3000 characters or fewer): Accomplishment 3 Patient experience initiatives: An overview of the Hospital patient experience initiative was provided to PFAC for their input and feedback. The following initiatives were included in the review. Reinforcing Existing Caring Science Programs Job interview questions to screen for caring individuals. Team assessments to understand how connected teams are in different caring areas. The more connected the teams are, the better they work together, which triggers a better patient experience. No Pazz Zone (NPZ): Staff are expected to never pass by a chance to be responsive to needs of patients & visitors. All staff are expected to be responsive to patient call lights, to acknowledge and assist visitors, and pick up clutter/trash. Medication side-effects teach back cards: to make patients aware of the side effects associated with their medications. Ambassador Program: training secretaries to be ambassadors and connect positively with patients to provide a more welcoming environment. The Care Channel: Sets a soothing and welcoming tone. SHHH Campaign (Silent Hospital Help Heal): Quiet hour in units, reducing sound levels and deeming lights to help patients rest. Patient survey results. Ongoing patient experience tactics reviewed. 50. The idea for Accomplishment 3 came: 1 Directly from the PFAC

10 From a department, committee, or unit that requested PFAC input 51. Accomplishment 1 (describe in 3000 characters or fewer): Oncology Patient Handbook: The Oncology PFAC focused on creating a new patient handbook for patients with new cancer diagnosis. The handbook is currently in its final phase of development and printing. The patient handbook is intended to assist patients through their cancer treatment process, and to offer support and prepare them from the perspective of a fellow cancer patient. 5. The idea for Accomplishment 1 came: 1 Directly from the PFAC From a department, committee, or unit that requested PFAC input 53. Accomplishment (describe in 3000 characters or fewer): Schwartz Rounds: PFAC continue to attend Schwartz Rounds. In addition, a PFAC meeting was dedicated to reviewing a recent Schwartz Rounds on unnecessary patient suffering. PFAC encouraged the hospital to utilize the Schwartz Rounds video with hospital staff and medical doctor training. The hospital has taken this advice and is incorporating into staff education. 54. The idea for Accomplishment came: 1 Directly from the PFAC From a department, committee, or unit that requested PFAC input 55. Accomplishment 3 (describe in 3000 characters or fewer): Patient Satisfaction Questions: A special meeting was held with available PFAC to obtain their feedback on selected patient satisfaction questions. The following areas were considered very important by PFAC : The importance of the caregiver listening to the patient. Offering choices to patients and families in their healthcare. Making sure the patient feels like they have the knowledge and feel equipped to manage safely after discharge. That patients/families need to feel that staff care for/about them (the patient). 56. The idea for Accomplishment 3 came:

11 1 Directly from the PFAC From a department, committee, or unit that requested PFAC input 57. Challenge 1 (describe in 3000 characters or fewer): Recruiting to diversify the PFAC. However, the PFAC did increase diversity of new in order to re-reflect our hospital diverse population. Two new including a Latina and an African American have been recruited to our PFAC. 58. Challenge (describe in 3000 characters or fewer): Resignations from PFAC, and the untimely deaths of. 59. Challenge 3 (describe in 3000 characters or fewer): Involving PFAC proactively for their input prior to time sensitive hospital projects being initiated. 60. Our PFAC provided advice or recommendations to the hospital on the following areas mentioned in the law (click all that apply): 1 Quality improvement initiatives Patient education on safety and quality matters 3 Patient and provider relationships 4 Institutional Review Boards 5 Other 6 None 61. Describe other advice/recommendations (in 1500 characters or fewer): 6. PFAC participated in the following activities mentioned in the law (click all that apply):

12 1 Served as of task forces Served as of awards committees 3 Served as of advisory boards/groups or panels 4 Served on search committees and in the hiring of new staff 5 Served as co-trainers for clinical and nonclinical staff, inservice programs, and health professional trainees 6 Serve on selection of reward and recognition programs 7 Serve as of standing hospital committees that address quality 8 Other areas of service not listed above 9 None 63. More details about PFAC member activities: Number of serving on task forces Number of serving on awards committees Number of serving on advisory boards/groups or panels List names of above groups and number of serving on each Number of serving on search committees Number of serving as cotrainers Number of serving as of hospital quality committees List names of above groups and number of serving on each List names and number of participating in other areas of service The hospital shared the following public hospital performance information with the PFAC (click all that apply): 1 Serious Reportable Events Healthcare-Associated Infections 3 Department of Public Health (DPH) information on complaints and investigations 4 Staff influenza immunization rate 5 Patient experience/satisfaction scores 6 Patient complaints 7 Patient Care Link 8 Joint Commission surveys 9 Hospital Compare 10 Family satisfaction surveys 11 Quality of life data 1 Rapid response data 13 Other 14 None

13 65. List other public hospital performance information shared (in 1500 characters or fewer): 66. Describe the process by which public hospital performance information was shared (describe in 1500 characters or fewer): During PFAC meetings and presentations 67. Our PFAC activities related to the following state or national quality of care initiatives (click all that apply): 1 Healthcare-Associated Infections Rapid response teams 3 Hand-washing initiatives 4 Checklists 5 Disclosure of harm and apology 6 Fall prevention 7 Informed decision making/informed consent 8 Improving information for patients and families 9 Health care proxies/substituted decision making End-of-life planning (e.g. hospice, palliative, advanced directives) Care transitions (e.g. discharge planning, passports, care coordination, and follow-up between care settings) 1 Observation status for Medicare patients 13 Mental health care 14 Other program 15 None 68. Describe other program (in 1500 characters or fewer): SVH s Ebola preparedness plan 69. The hospital shares the PFAC annual reports with PFAC : 1 Yes No

14 70. Massachusetts law requires that the PFAC report be available to the public. We (click the best choice): 1 Post the report online Provide a phone number or to use for accessing the report 3 Other 71. Describe other method for making the report available to the public (in 1500 characters or fewer):