ANNUAL REPORT OF THE COOLEY DICKINSON PATIENT AND FAMILY ADVISORY COUNCIL

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1 ANNUAL REPORT OF THE COOLEY DICKINSON PATIENT AND FAMILY ADVISORY COUNCIL I. INTRODUCTION Cooley Dickinson Hospital is committed to patient-centered care based on active partnerships among patients, families, and health care providers. It also recognizes the importance of participation by patients and their families and loved ones in the delivery of care. The Patient and Family Advisory Council is an important contributor in achieving this goal by helping to recognize the uniqueness of each patient. II. COOLEY DICKINSON HOSPITAL A SNAPSHOT Cooley Dickinson Hospital is a 140-bed community hospital in the city of Northampton, in rural Western Massachusetts. The Hospital offers advanced diagnostic and therapeutic care in many specialty and subspecialty areas of medicine and surgery. In addition, the hospital provides care and services in multiple health centers located within neighboring communities, such as Easthampton, Worthington, and Amherst. In a typical year, Cooley Dickinson Hospital: serves nearly 80,000 community members cares for more than 7,200 inpatients records emergency room visits in excess of 36,000, and delivers more than 850 babies In addition, the Hospital offers teaching and internship opportunities to high-quality students. We are committed to training and mentoring the next generation of area leaders in science and medicine, providing a wealth of opportunities for nurses and other health professionals. These clinicians, in turn, provide fresh and innovative perspectives on care and treatment of patients. III. THE PATIENT AND FAMILY ADVISORY COUNCIL AT COOLEY DICKINSON HOSPITAL A. OVERVIEW The Patient and Family Advisory Council is grounded in a commitment to health care that is truly patient-centered, taking into consideration patients cultural traditions, their personal preferences and values, their family situations, and their lifestyles. Patientcentered care makes patients and their loved ones an integral part of the care team, collaborating with health care professionals in making clinical decisions. B. BACKGROUND Cooley Dickinson Hospital formed the Council in 2009, in anticipation of state regulations that required hospitals to establish Patient and Family Advisory Councils. The Council began formal operation in September There is considerable overlap in membership between the Council and other servicebased and hospital-wide committees, including the Hampshire County Continuing Care Consortium, established in 2008, and the Palliative Care Team, established in Cooley Dickinson Hospital Patient and Family Advisory Council Annual Report 1

2 C. STRUCTURE AND OPERATION OF THE COUNCIL The Council was supported through fiscal year 2014 by Dianne Cutillo, Senior Director, Public Affairs, and a member of the health system s Senior Leaders Team. She served as co-chair alongside an elected member representing the community. The Council met monthly except during July and August. The Council does its work through participation in three types of initiatives: Council committees. In the Council year, the Council committees were: Emergency Department, Palliative Care, Membership, Policies/Procedures, and Ad Hoc Publicity. As members of Cooley Dickinson quality improvement and project teams, such as Cancer Center Design and Patient Flow Improvement. As representatives of patients and families on four Cooley Dickinson Board of Trustees Committees: Development and Public Relations, Healthy Communities, Patient Care Excellence (PaCE), and Resource. Cooley Dickinson Hospital staff and leaders value the perspective of Council members when they serve in roles beyond the advisory council itself. For example, Emergency Department Director Jennifer Dekoschack values Council members assistance with projects and said they are able to give the perception of the community and feedback as to what the community would expect. David Davidson, Employee Engagement committee co-leader and Employee and Labor Relations Specialist, said that team s two PFAC representatives challenged and supported the team and gave a perspective that we often miss, that patients want us to succeed not only in giving them great patient care, but also for ourselves as members of the CDH community Former Trustees Patient Care Excellence Committee Chair James Donnelly, MD, said it s been invaluable to have the PFAC member give the patient s perspective at PaCE meetings. D. COMPOSITION The Council is comprised of representatives of the following: hospital staff, former patients and family members of patients, and health professionals outside of the hospital who work frequently with Cooley Dickinson patients. (See Appendix A.) New Council members undergo training and orientation to the Hospital and its policies upon becoming a member. The orientation ensures that each member understands the Council s purpose, goals, and policies, as well as relevant hospital policies. All members annually sign a hospital confidentiality statement. The Council s operations are guided by a document that outlines its mission, purpose, committee structure, terms, and membership and co-chair responsibilities. (See Appendix B.) Outside of the Council s meetings, members connect via electronic mail and face-to-face meetings that help ensure accurate, timely and, inclusive communication. Council members use these exchanges to engage in important dialogue, review draft materials, and access project-related communications. Cooley Dickinson Hospital Patient and Family Advisory Council Annual Report 2

3 IV. FISCAL YEAR 2014 ACCOMPLISHMENTS A. ADVISORY COUNCIL MEETINGS During , the Council held sessions with a number of people who shared Hospital initiatives and sought guidance about patient and family perspectives: John McCann, Patient Advocate and Engagement Manager presented information about new patient satisfaction initiatives, discharge calls and point-of-service rounding by hospital leaders. (October 2013) Marjorie Helly, Quality Manager, asked for input regarding a revised summary of care form that is provided to patients when they are discharged from the hospital. (December 2013) PFAC member Jeff Caplan brought a draft of a pain tool for patients to the Council for its input, on behalf of the Patient Satisfaction Team on which he serves. (December 2013) Cooley Dickinson Health Care Board of Trustees Chair Matthew Pitoniak visited to hear about Council members experiences and concerns. Jeff Harness, Director of Integrated Care and Population Health, reported on the upcoming health assessment and discussed the grant process. (February 2014) Shannon Dillard, Patient Safety and Regulatory Compliance Manager, and Michael Paquette, Director of the Pharmacy, discussed the organization s Culture of Safety Survey results and the steering committee that was being created to plan improvements based on the survey results. (February 2014) Jeanne Ryan, Executive Director of the VNA & Hospice, presented an overview of the services provided by the agency (March 2014) Joanne Marqusee, newly appointed President and Chief Executive Officer, met with PFAC to introduce herself, meet the Council members, and get to know the Council s contributions. (May 2014) Bradley Kempson and Sue Allen, Information Systems Department, presented plans for a new patient portal and asked for feedback on how to communicate about it to patients. (May 2014) Tammy Cole-Poklewski, Director of Quality and Patient Safety, asked for input on the Board of Trustees Quality Dashboard. (May 2014) Council members also participated in January 2014 in interviews of two finalists for the position of President and CEO for Cooley Dickinson Health Care. Council members earlier contributed to interviews by the consulting firm conducting the search for a new CEO about what leadership skills, attributes and experiences they believe the next CEO should possess. In addition, the council met in January 2014 with Deb Wachenheim, Health Quality Manager for Health Care for All. She presented the history of Health Care for All s involvement with patient and family advisory boards, heard from members about their experiences as PFAC members, and discussed plans for the 2014 statewide conference for patient and family advisors. Cooley Dickinson was well represented at the second annual Patient and Family Advisory Council Conference in May Attendees were community members Don Reutener, Jim Lomastro, David P. Stevens, and Barbara Williams and staff members Cooley Dickinson Hospital Patient and Family Advisory Council Annual Report 3

4 Dianne Cutillo, Jeff Harness, and Robin Kline. Williams served as a member of Health Care for All s planning committee for the conference. PFAC members and Cooley Dickinson staff served as panelists at several conference workshops: Reutener, Palliative Care Medical Director Jeffrey Zesiger, MD, and Hospice Manager Maureen Groden, RN, MD, CHPN, of Cooley Dickinson VNA & Hospice presented at Educating the Public on Care at the End of Life. Cutillo and Stevens presented at Advising Beyond PFAC Meetings. Jeff Harness, Director, Community Health and Government Relations, presented at Community Outreach and Partnering to Improve Health Care. Williams was a facilitator for discussion at the workshop Getting Engaged with the Massachusetts Health Confidence Campaign. B. COUNCIL COMMITTEES Emergency Department: Three current and two past members of PFAC serve on the Emergency Department Partnership Team along with multidisciplinary staff and physicians. The team seeks to enhance the experience of patients and their families in the Emergency Room as well as help to improve the functioning of the entire ED. Director Jennifer Dekoschak has been enthusiastic about the team and has made excellent suggestions about projects she would like it to undertake. Additionally, the hospital s new CEO, Joanne Marqusee, has initiated a performance improvement project in the department that will use the Lean methodology and made that a priority for the Leadership Team. These are a few of the projects in which PFAC members were active in the year: Keeping patients informed. One of the most important aspects of a patient/family experience is the need to be informed about the process in the ED. There is sometimes a long wait for the results of tests of other procedures and patients who understand where they are in that process are less anxious. This should make it easier for patients to contact someone by name to inquire about their status. Since the ED is the front door of the hospital, the team played a major role in the redesign of the entrance and waiting room. We spoke to an environmental expert and an architect about ways to improve the current space as well as expand it. These included improving the lighting to serve the various needs of those waiting, discussing ways to increase natural light, finding a space to accommodate the increased need for waiting space when the census gets high, and improving the appearance and signage outside the entrance. While some of these projects were completed, the planning of changes to the area adjacent to the ED has put others on hold. The Resource Manual to assist Emergency staff in referring student patients to services at the five colleges in the area was updated; PFAC members initially created it. We discussed the possibility of patient focus groups so we could better understand the ED from their point of view. Two of our members serve in local college wellness departments and they provided the unique view of students and college personnel. With the full support of our ED Director, we anticipate another productive year. Cooley Dickinson Hospital Patient and Family Advisory Council Annual Report 4

5 Palliative Care: The Palliative Care Committee met monthly with Cooley Dickinson directors of Palliative Care, VNA & Hospice, and clinical and administrative members of their staffs. The committee now also includes representatives from other hospital units who focus on a patient s physical, emotional, social, and spiritual needs and are interested in community outreach. The committee continues to conduct community outreach sessions. In addition to covering the basics of Palliative Care, Hospice Care, and the objective and personal uses of MOLST, the sessions now include family- and patient-oriented health communications that aim to improve understanding of clinical choices and the use of shared decision making in setting personal end-of-life goals. We are attempting, through VNA & Hospice, to organize, coordinate, and record community sessions in a comprehensive, readily available calendar so that all who wish to participate in community outreach may do so. We are discussing and implementing plans to improve outreach to younger members of the community, particularly those who, of necessity or devotion, participate in discussions with their elders about end-of-life issues. Health system members of the palliative care team, Groden and Zesiger, contributed articles and interviews re end-of-life issues to the Daily Hampshire Gazette. Each also received an Innovation Award from the Home Care Alliance of Massachusetts. Arranged a talk for all those interested at Cooley Dickinson Hospital by Fred Nenner, from the Department of Social Work, Lutheran Medical Center, Brooklyn, NY, on ethical issues relevant to end-of-life concerns. All on the Palliative Care Committee owe a debt of gratitude to Maureen Groden, whose knowledge of the issues we deal with and her good common sense have creatively informed our efforts for the past several years. Membership Committee: In , the membership committee has been actively recruiting new members to begin a two-year term in the fall. On the advice of other PFACs, the membership committee requested names from various hospital organizations and directors for referrals. Ten referrals were received and nine prospective members were interviewed. A PFAC community member and the Director of Volunteer Services, also a member of PFAC, conducted the interviews. At the September PFAC meeting, the Council unanimously approved the committee s recommendation to elect five new members to the Council. In order to address issues of diversity, a membership committee member attended several workshops regarding diversity and recruitment given at the annual PFAC conference in May The conference was rich with suggestions about recruitment. These ideas enabled the membership committee to broaden its ideas regarding diversity and to further consider issues of inclusion and the process of welcoming new members. Two additional PFAC members resigned this year. As of September 2014, prior to new members being added, the composition of the council is: 11 community members and four hospital staff. Policies/Procedures Committee (formerly Governance Committee): After lengthy discussion between the Board of Trustees Patient Care Excellence (PaCE) Committee and a subcommittee representing the Patient Family Advisory Council, the full Board of Cooley Dickinson Hospital approved the PFAC s Policies and Procedures" Cooley Dickinson Hospital Patient and Family Advisory Council Annual Report 5

6 in December This document details PFAC's structure, officers, terms of office, and operating policies. Ad Hoc Publicity Committee: The Patient and Family Advisory Council brochure that the Committee created is in print in English and Spanish versions. Starting in the fall of 2014, the brochure will be available in various Cooley Dickinson Hospital departments and in local communities through Senior Centers and Chambers of Commerce, etc., and on the various college campuses. The brochure may also be distributed at the offices of doctors affiliated with Cooley Dickinson Hospital. Microsystems and Other Hospital Teams Employee Engagement Team: The team first defined what it understood employee engagement to mean and agreed on: Employee Engagement is a measurable degree of an employee's positive or negative emotional attachment to his or her job, colleagues, and organization that profoundly influences his or her willingness to learn and perform at work. The Team then developed a comprehensive survey of questions to determine in what ways and to what extent Cooley Dickinson employees were or were not engaged. Blank surveys were widely distributed and publicized and the response rate (more than 50 percent) was impressive. The team spent considerable time analyzing the results of the survey to come up with a clear and precise description of which current practices in hospital operations and management promote employee engagement and which worked against it. The team then prepared a report for senior management, the CEO, and the Board of Trustees. The hope of the Team is that this report will be a useful tool with which management can fashion an effective strategy for building on operations and employee cultures that are currently successful and addressing those that are not. Patient Flow Improvement Team: The team met throughout the year to plan for the transition of the Emergency Department patients to an inpatient bed on a 24 hour/day, 7 day/week basis. Representatives from many services have joined discussions to identify ways that this process can be shortened and coordinated in a safe manner. A new tool has been developed to assist nurse-to-nurse transfer of patients; it includes preliminary and essential patient data. Patient Satisfaction Improvement Team: The Patient Satisfaction team developed a plan to improve pain management by improving communication about patients pain using an improved tool that was scheduled to be tested in inpatient units. However, the team was put on hiatus to allow staff to focus on other hospital priorities, including implementation of an improved electronic medical record. Cancer Center Design Team: The team has been meeting on a weekly basis to review the plans for the new Mass General Cancer Center at Cooley Dickinson Hospital that is due to open in Floor layouts were reviewed and discussed and recommendations made in regard to changes, including the PFAC member s suggestion that a nourishment area be added to the center. Nursing staff members of the committee have advised on equipment needed in patient infusion bays, exam rooms, and nursing stations. The final Cooley Dickinson Hospital Patient and Family Advisory Council Annual Report 6

7 selection of color schemes for flooring, walls, furniture, etc., is expected to be completed this fall. Board of Trustees Committees Development/Public Relations Committee: PFAC member Pip Stromgren felt warmly welcomed at her first Development/PR Committee meeting in May. This committee meets every other month. During the year, it has focused on implementation of Cooley Dickinson s affiliation with Mass General; the capital campaign to raise funds for the new cancer center and nurse development programs; and communications regarding adverse outcomes in the hospital s Childbirth Center. Resource Committee: The representative to the Resource Committee attended its monthly meeting beginning in December and, being new to the Committee, mainly participated through listening as he became comfortable with processes and procedures. The committee deliberated on matters related to Human Resources, such as labor negotiation, pension issues, and the employee engagement survey referenced in the Employee Engagement Team report above. A good portion of Resource Committee time was consumed with the budget as well as the investment plan. The committee also reviewed the financing and plans for the cancer center and deliberated on how to increase the number of primary care practitioners to the area. Patient Care Excellence Committee (PaCE): PaCE meets monthly to ensure that Cooley Dickinson maintains and improves the high level of excellent care provided to patients. The laser focus of the PaCE committee has been particularly meaningful through this past year of transition. Its ongoing and systematic review, across all hospital departments, coupled with strategic interventions calling for additional reports and new procedures as warranted, is leading to constant improvement. PFAC presents patient and family perspective as appropriate. Some of the more technical discussion is beyond our purview. The effort that senior staff expends to improve Cooley Dickinson Hospital is impressive. We are privileged to have a seat at the table. The PFAC representative to PaCE has shared this perspective with PFAC colleagues, who can then share the improvement efforts with the broader community. Healthy Communities Committee: We began the year with a clear sense of priorities and purpose because we had completed a community health assessment in the previous fiscal year. The priorities determined through the health assessment process are listed below in bold, with project highlights. Behavioral Health: We worked with community partners and a consultant to map the current system, map the preferred system, identify forces that are barriers to improving, and establish an action plan to better coordinate and communicate between the parts of the community system of behavioral health care. We also participated in regional opiate overdose prevention initiatives with the District Attorney s office and other community partners. We also supported our behavioral health program and the National Alliance for the Mentally Ill Western Cooley Dickinson Hospital Patient and Family Advisory Council Annual Report 7

8 Massachusetts to organize and host the First Annual Mental Health Awareness Fair, held at the hospital in May Youth Substance Abuse: We provided a small grant to support the Strategic Planning Initiative for Families and Youth to work with Hampshire County School to implement the Prevention Needs Assessment Survey. The survey will be conducted in winter/spring City of Easthampton: We provided several small grants to the City of Easthampton and community partners to implement policies and programming to encourage people to be more physically active and to eat healthy foods. Specific projects included assessing the condition of sidewalks for walkability and making a report to the City; hosting a night of walking and healthy eating in collaboration with local restaurants; supporting the Community Center to be better prepared and equipped to serve healthy meals; assessing school policy with respect to healthy eating and being physically active; and supporting a new school garden and a program to get parents, school staff, and community members more engaged in supporting school gardening. We also provided a grant to the City of Easthampton to train landlords how to become smoke free in their buildings; disrupt a youth smoking area through environmental changes; and train two people on tobacco treatment. Transportation to Access Health Care Services: We worked with the Pioneer Valley Planning Commission and the United Way of Hampshire County to further study transportation barriers to health care and identify best practices and possible solutions. The PVPC created a chart of travel times involved in taking a bus from various locations to Cooley Dickinson Hospital. The United Way of Hampshire County surveyed and conducted groups to better understand transportation barriers for fragile populations. Latino Health Access: We provided a grant to support Casa Latina to create a pilot patient navigator project, including a new focus on Easthampton, as well as support general operations and planning for this important agency. Chronic Disease Prevention: Continue to support and/or advocate for existing programs that support patients or clients who have a chronic illness. Programs include A Positive Place, Care Transitions Coaching, and the Center for Excellence in Diabetes Education. Health Access and Health Equity: Continue to support existing programs and project aimed at improving health access including operating Hampshire Health Connect and making the Medical Interpreters program available to community primary care practices. We also were actively involved in helping the Hilltown Community Health Centers and community partners continue to study and work towards establishing a satellite health center in Amherst. The Town of Amherst is supporting the initiative by providing low cost space in the Bangs Center. The proposed center would start in the spring of V. FUTURE PLANS The current Council committees will continue their work in the year. Council members have also agreed to continue to serve on Board Committees and other Hospital Cooley Dickinson Hospital Patient and Family Advisory Council Annual Report 8

9 teams to represent the voice of patients and family members in the management of quality and satisfaction improvement work of the hospital. VI. SUMMARY Moving forward, Cooley Dickinson Hospital will continue to cultivate the participation of patients and family members, incorporating their vision and voice into its work and various hospital initiatives. The Council will serve as the primary vehicle for doing so. Cooley Dickinson Hospital staff have long been committed to creating a patient and family-centered environment of care. This value comes to life every day through the actions of our broad and various staffs. But it is the perspective the voices and the vision of our patients and families that provides our moral and operational compass. The annual report of the Patient and Family Advisory Council is delivered to the hospital s Board of Trustees and its Patient Care Excellence Committee by the Senior Director of Public Affairs, along with a designated patient/family member. The Council s annual reports are available for download via the hospital s website ( Cooley Dickinson Hospital Patient and Family Advisory Council Annual Report 9

10 Appendix A: Council Members and Assignments Name Position Committee/Team(s) Comments David P. Stevens Community Co- Chair Policies and Procedures Committee; Healthy Communities Committee Reappointed February 2011; Elected as Co-Chair June 2012; Reelected Co-Chair, June 2013 Dianne Cutillo CDH Co-Chair Appointed September 2011 Sara Aierstuck Member Emergency Department Committee Appointed January 2012; Resigned January 2014 Jeff Caplan Member PaCE Committee; Patient Satisfaction Improvement Team David Cohen Member Emergency Department; Employee Engagement Team Ellie Fraser Member Patient Flow Improvement Team Robin Kline CDH Member Membership Committee Jim Lomastro Member Resource Committee; Health Care for All Statewide Conference Working Group Appointed November 2011; Elected Co-Chair, June 2014 Appointed May 2011 Reappointed February 2012 Appointed March 2012 Reappointed February 2012 Elvira Loncto Member Reappointed February 2012 John McCann CDH Member Appointed April 2013 Emily Nagoski Member Evidence-Based Practice, Standardization, and Hardwiring; Bullying Work Group; Emergency Department Donna O Meally Member Membership Committee Chair Don Reutener Member Palliative Care, Membership Committee Donald Robinson Member Emergency Department; Policies and Procedures Appointed January 2012 Appointed January 2012 Appointed January 2011 Reappointed January 2011; Nominating Committee Chair, Cooley Dickinson Hospital Patient and Family Advisory Council Annual Report 10

11 Committee Jeanne Ryan CDH Member Healthy Communities Pip Stromgren Member Cancer Care Design Team; Ad Hoc Publicity Committee; Membership Committee; Development/PR Committee Barbara Williams Member Emergency Department; Health Care For All Statewide Conference Advisory Committee 2014; Resigned June 2014 Appointed September 2011 Appointed November 2011 Reappointed February 2011 Cooley Dickinson Hospital Patient and Family Advisory Council Annual Report 11

12 Appendix B Patient and Family Advisory Council Cooley Dickinson Hospital 30 Locust Street Northampton, MA Administrative Policy #2.00 P a g e 12 of 19 Effective Date: December 2013 PURPOSE POLICY The Patient and Family Advisory Council was formed in 2009 to ensure that the voices of patients and families are represented in multidisciplinary efforts to improve the experience of care for patients and family members. Cooley Dickinson Hospital will promote and support patient- and familycentered care by collaborating with the Patient and Family Advisory Council. The Patient Care Excellence Committee (PaCE) of the Board of Trustees oversees the Council because of its responsibility to provide oversight of and monitor the quality of care, including standards, credentials, outcomes, evaluation, and patient satisfaction. The goals of the Council are to: Advise the hospital on matters including, but not limited to, patient and provider relationships; quality improvement initiatives; and community education. Provide the input of families and patients to the PaCE Committee to influence the quality and safety of care and the patient experience. Support patient- and family-centered communications and behaviors that enhance ongoing care and services in alignment with hospital values (defined in the Code of Conduct, Administrative Policy 3.09). Participate in hospital improvement teams and, as appropriate, in the process of hiring hospital leadership and in developing programs, services, and policies. Support hospital goals for cultural competencies and encourage positive interactions with diverse populations. Partner with hospital staff, as through participation on hospital teams, to promote consumer-friendly communications and provide outreach around specific hospital initiatives. SCOPE DEFINITIONS This policy applies to Cooley Dickinson Health Care staff and Community Council Members. Community Council Member A current or former hospital patient or family member, preferably with experience within a year of election, or community Cooley Dickinson Hospital Patient and Family Advisory Council Annual Report 12

13 care provider of patients/clients with frequent interaction with the hospital who is elected to the Patient and Family Advisory Council. Community Co-Chair A Community Council Member elected by a majority vote of Council members. Hospital Co-Chair The hospital staff member appointed by hospital administration to co-lead the Council. PROCEDURE A. Council Meetings 1. The Council meets as a whole 10 times per year on the second Tuesday of September through June. The meeting time may be adjusted by the Council Co- Chairs, in consultation with Council members. 2. Special meetings may be called by the Council Co-Chairs with at least 24 hours notice to Council members of the meeting schedule and agenda. 3. To conduct business, a quorum of 50 percent plus one must be present. B. The Work of the Council 1. The Council does its work through: a. Participation on Microsystems teams, which focus on process and quality improvement in departments throughout the hospital, and other hospital and health system teams. The role of Council members on these teams is to represent the patient-family voice in deliberations. b. Representing patients and families on Committees of the Cooley Dickinson Board of Trustees. c. Full Council meetings. 2. The Council will have a standing Membership Committee that shall include at least one hospital staff member. C. Hospital and Member Responsibilities 1. The hospital shall: a. Assign appropriate staff as needed to membership on the Council. Other hospital staff members may participate on Council committees according to their expertise and interest. b. Work collaboratively with the Council to promote the best possible patientand family-centered practices. c. Assign the hospital co-chair to respond to recommendations of the Council in a timely manner. d. Provide meeting space. Cooley Dickinson Hospital Patient and Family Advisory Council Annual Report 13

14 e. Orient members to the hospital and Council. f. Provide staff support to take and record meeting minutes; notify members of upcoming meetings with agendas; distribute meeting minutes to the Council and Board of Trustees; keep the Council membership list and attendance record up to date; track compliance with confidentiality agreements; retain Council minutes for a minimum of five years; transmit annual accomplishments to the hospital s Board of Trustees and administration; and post the Council s Annual Report on the hospital s website. 2. The hospital may: a. Through the PaCE Committee or its designees, request that the Council participate in specific performance improvement work. 3. Members shall: a. Complete the criminal records check and immunizations required of official CDH volunteers (as defined in the Infection Prevention Policy #2.04). The hospital will pay for any expenses incurred to meet immunization requirements. b. Complete an orientation to the Council. c. Annually sign a hospital confidentiality agreement and refer input regarding a particular patient or incident to the hospital s Concerns and Compliments Process. d. Attend 70 percent of meetings during a given year. A member who misses more than three meetings shall be considered inactive and his/her status will be reviewed by the Membership Committee. e. Serve on at least one committee, such as Microsystems, departmental team, or trustee committee. f. Represent Cooley Dickinson to multiple constituencies, so that non-council members may better understand the role and responsibilities of the council. However, Council members should defer to the Hospital-designated spokesman as the official spokesperson of Cooley Dickinson. Council members shall maintain an appropriate degree of confidentiality concerning hospital and other council processes. (As per Administrative Policy #68 and Cooley Dickinson Health Care, Cooley Dickinson Hospital, VNA & Hospice of Cooley Dickinson Board of Trustees Statement of Trustee Roles and Responsibilities.) D. Membership 1. The Council consists of no more than 21 members, drawn from patients and family members, preferably with experience of Cooley Dickinson within a year of election, or community caregivers of patients/clients with frequent interaction Cooley Dickinson Hospital Patient and Family Advisory Council Annual Report 14

15 with the hospital. The hospital may name additional members from employees or Trustees of the hospital. 2. The Council will consist of a majority of patient and family community members. 3. Application to become a member is always open to the community; the Membership Committee will also recruit members when necessary. Information about the Council and applications for membership are available from the hospital s Office of Public Affairs and at 4. Special attention will be given to the recruitment of representatives of the diverse population served by Cooley Dickinson Hospital, with consideration of geography, age, race, color, national origin, language, culture, citizenship, creed, religion, gender identity/expression, sexual orientation, marital status, physical or mental disability, educational background, economic status, and family status. 5. Members: a. Show an ability and willingness to improve the patient/family experience on behalf of other patients and family members and support the mission of the Council. b. Demonstrate strong communication skills and a commitment to high standards of comprehensive and compassionate care for patients and families. c. Show an interest in interdisciplinary, collaborative efforts and respect for persons of all backgrounds. d. Practice Cooley Dickinson s BECOME values. e. Commit to attending Council meetings and an additional committee/team. 6. Election of Members. The Membership Committee will review applications and interview applicants in person; a hospital staff member must participate in interviews of prospective members. a. The Membership Committee will take into consideration the characteristics for members described in D1, D4, and D5 of this policy, as well as an area of expertise the Council needs and the prospective member s ability to represent an outlook not on the Council at the time. The Membership Committee may also request further information before making a recommendation. b. After screening, the Membership Committee will make a recommendation about the candidate to the full Council; the hospital staff person involved in the screening and interview of a candidate must support the recommendation for election. A majority vote of those present and voting is required for election. Cooley Dickinson Hospital Patient and Family Advisory Council Annual Report 15

16 c. The Membership Committee will communicate the result to candidates immediately following the meeting at which their election was voted on. d. Council member terms are two years and normally begin October 1. A member s term may be renewed for two additional two-year terms, for a maximum of six consecutive years. e. A former Council member may apply to rejoin the Council after a two-year period off the Council if he or she has patient or family member experience with the hospital within one year of reapplication. f. The Membership Committee will fill vacancies on the Council on an as-needed basis. g. Upon a member s resignation from the Council, the co-chairs shall appoint a current Council member to succeed the resigning member for Councildesignated seats. h. When members resign, they are no longer considered Council representatives to teams or committees. If they wish to remain on a team or committee, they must consult with Volunteer Services. F. Leadership 1. There shall be two co-chairs of the Council, a hospital staff member appointed by the hospital and a community Council member elected by the Council. 2. Co-chairs: a. Schedule or cancel meetings, set the agenda for meetings, preside over meetings, and coordinate between Council members and hospital staff when necessary. b. Make appointments, in consultation with Council members, to Microsystems or other teams and Trustee committees. Co-chairs may appoint non-council community and hospital members to serve on Council committees with preference given to current, active Council members. c. Form committees as needed, including ad hoc committees to work with hospital staff to address specific areas of concern. The community co-chair serves a one-year term and may serve up to three oneyear terms. a. Election of the community co-chair is annually in June. b. In May, the current community co-chair shall appoint a nominating committee to receive all names for nomination. Individuals interested in running for the leadership position of Community Co-Chair shall inform the nominating committee of their interest prior to the June meeting. Cooley Dickinson Hospital Patient and Family Advisory Council Annual Report 16

17 c. Robert s Rules govern the election process. i. The Nominating Committee will place in nomination all names that were received. Nominations from the floor will be accepted if they receive a second. A formal motion to close the nomination process must be approved. ii. The election will be held by paper ballot. iii. All Council members are eligible to vote. The winner is decided by a simple majority of those present. iv. All results will be publicly announced at the June meeting. v. The newly elected community co-chair will assume all duties at the adjournment of the June meeting. SEARCH WORDS REGULATIONS POLICY OWNER STAKEHOLDER REVIEW Patient and Family Advisory Council, patient-centered care, PFAC, patient experience 105 CMR : Patient and Family Advisory Council; : Policies and Procedures for Patient and Family Advisory Council Cooley Dickinson President and CEO Cooley Dickinson Senior Leadership Team Patient and Family Advisory Council Patient Care Excellence Committee of the Board of Trustees FINAL APPROVAL BY* Cooley Dickinson Health Care Board of Trustees MOST RECENT REVIEW/REVISION DATE Signatures PaCE Chair (Date) Policy Owner (Date) Cooley Dickinson Hospital Patient and Family Advisory Council Annual Report 17

18 Addendum to the ANNUAL REPORT OF THE COOLEY DICKINSON PATIENT AND FAMILY ADVISORY COUNCIL Responses to Health Care for All Questions Suggested for Patient and Family Advisory Council Annual Report PFAC Organization 1. Does your PFAC have by-laws and/or policies and procedures? If so, please attach them with your report or send a link to access them on-line. See Appendix B of Cooley Dickinson Annual Report 2. How do you recruit PFAC members? See Membership Committee, Section IVB in Cooley Dickinson Annual Report 3. Is the PFAC chair or co-chair a patient or family member? Yes 4. If there is a hospital staff chair or co-chair, what hospital position does that person hold? See Section IIIC of the Cooley Dickinson Annual Report 5. Are at least 50% of PFAC members current or former patients or family members? Yes. 6. What hospital department supports the PFAC? What is the hospital position of the PFAC staff liaison? Duplicate of Question 4 7. Does the hospital reimburse PFAC members for any costs associated with attending meetings and/or provide any other assistance (eg. free parking, child or elder care, translation or interpretation services, conference calls, meals, mileage reimbursement or other travel stipends, etc.)? The Hospital paid for registration fees for PFAC members who attended the statewide conference and provides refreshments at Council meetings. 8. The PFAC regulations require every PFAC to represent the community served by the hospital. What is your PFAC/hospital doing to comply with this requirement? See Membership Committee, Section IVB in Cooley Dickinson Annual Report 9. Who sets agendas for PFAC meetings? The Council Co-Chairs Cooley Dickinson Hospital Patient and Family Advisory Council Annual Report 18

19 10. Does the PFAC have subcommittees? If yes, please list and describe them. See Section IVB in Cooley Dickinson Annual Report 11. How does the PFAC interact with the Board of Directors (Check or circle all that apply) a. PFAC submits annual report to Board Yes b. PFAC submits meeting minutes to Board Yes c. PFAC member(s) attends Board meetings No d. Board member(s) attends PFAC meetings On occasion e. PFAC member(s) are on board-level committee(s) Yes 12. Is there a PFAC section on the hospital website? Does your PFAC use social media and if so, how? No Orientation and Continuing Education 14. Describe the PFAC orientation for new members. Include in description how often it is given, by whom, and the content covered. Please include any requirements for PFAC members as hospital volunteers (eg. hospital volunteer trainings, immunizations, CORI checks, TB checks, etc.). For orientation, see Section IIID of the Cooley Dickinson Annual Report For requirements, See Appendix B, Patient and Family Advisory Council Administrative Policy Policy and Procedures PFAC Impact and Accomplishments 15. See Section IV of Cooley Dickinson Annual Report. Cooley Dickinson Hospital Patient and Family Advisory Council Annual Report 19