HCFA Suggested 2014 Patient and Family Advisory Council Annual Report Template

Transcription

1 HCFA Suggested 2014 Patient and Family Advisory Council Annual Report Template Hospital Name: Beth Israel Deaconess Hospital -Needham Date of Report: 10/13/14 Year Covered by Report: October October 2014 Year PFAC Established: Staff PFAC Contact (name and title): Beth Israel Deaconess Hospital-Needham staff members Elaine Rousseau RN, Director of Case Management, C0-Chair Kathleen Davidson, Chief Nursing Officer, Chief Operating Officer Albert Santos, Director of Inpatient Services Community Members Suzanne Nissen, Co-Chair Barbara McDonald Jean Klugman Susan Sheridan Staff PFAC Contact and Phone: Elaine Rousseau RN, Kathleen Davidson, Albert Santos, Suzanne Nissen, Barbara McDonald, Jean Klugman, Susan Sheridan, PFAC Organization 1. Does your PFAC have by-laws and/or policies and procedures? Yes if so, please attach them with your report or send a link to access them on-line. 2. How do you recruit PFAC members? Members are solicited through regular communications to patients, families and the community. Potential members complete a one page application. Members are screened, interviewed and selected by the hospital s PFAC Co-Chairs. The goal of the PFAC is to have at least 50% of the PFAC members from current or former patients or family members. 3. Is the PFAC chair or co-chair a patient or family member? The Community Co-Chair is a LICSW, who is not employed by the hospital. 4. If there is a hospital staff chair or co-chair, what hospital position does that person hold? The Hospital Co-Chair is the Director of Case Management 5. Are at least 50% of PFAC members current or former patients or family members? Yes 6. What hospital department supports the PFAC? Case Management and Nursing What is the hospital position of the PFAC staff liaison? Director of Case Management 7. Does the hospital reimburse PFAC members for any costs associated with attending meetings and/or provide any other assistance (e.g. free parking, child or elder care, translation or interpretation services, conference calls, meals, mileage reimbursement or other travel stipends,

2 etc.)? PFAC members are provided a meal at each meeting, free parking, and assistance with clerical tasks such as mailing letters. 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? The hospital recruits members that live in the community and use the hospital services themselves or for their family members. 9. Who sets agendas for PFAC meetings? The two Co-Chairs develop the meeting agendas 10. Does the PFAC have subcommittees? NA If yes, please list and describe them. 11. How does the PFAC interact with the Board of Directors (Check or circle all that apply) a. PFAC submits annual report to Board X b. PFAC submits meeting minutes to Board c. PFAC member(s) attends Board meetings d. Board member(s) attends PFAC meetings e. PFAC member(s) are on board-level committee(s) f. None of the above g. Other 12. Is there a PFAC section on the hospital website? Yes 13. Does your PFAC use social media and if so, how? NA 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 (e.g. hospital volunteer trainings, immunizations, CORI checks, TB checks, etc.). New members are oriented by two Co-Chairs through discussion and observation at a PFAC meeting. PFAC Impact and Accomplishments 15. The law allows a hospital to engage its PFAC in a broad consulting role. Did the PFAC provide advice or recommendations to the hospital on any of the following areas specifically mentioned in the law (Check or circle all that apply)? a. Patient and provider relationships X b. Institutional review boards c. Quality improvement initiatives X d. Patient education on safety and quality matters 16. Did PFAC members engage in any of the following activities mentioned in the law? (Check/circle all that apply):

3 a. Members of task forces X b. Members of standing hospital committees that address quality (list committees and how many PFAC members serve on each) c. Members of awards committees d. Members of advisory boards e. Participants on search committees and in the hiring of new staff f. Co-trainers for clinical and nonclinical staff, in-service programs, and health professional trainees g. Participants in reward and recognition programs 17. Was any of the following public hospital performance information shared with the PFAC? (Check/circle all that apply.) a. Serious Reportable Events X b. Healthcare-Associated Infections c. Department of Public Health (DPH) information on complaints and investigations d. Staff influenza immunization rate e. Other hospital performance information shared: please describe Press Ganey patient survey scores were shared with the members 18. Did PFAC quality of care initiatives relate to any of the following state or national quality of care initiatives: (Check/circle all that apply.) a. Healthcare-associated infections b. Rapid response teams X c. Hand-washing initiatives d. Checklists e. Disclosure of harm and apology f. Fall prevention g. Informed decision making/informed consent h. Improving information for patients and families X i. Health care proxies/substituted decision making j. End of life planning (e.g., hospice, palliative, advanced directives) k. Care transitions (e.g., discharge planning, passports, care coordination & follow up between care settings) l. Observation status for Medicare patients X

4 m. Mental health care n. Other-please describe 19. Describe the PFAC s specific accomplishments in relation to quality of care initiatives during the past year. Please note for each initiative undertaken, a. did the idea arise directly from the PFAC Or b. did a department, committee or unit request PFAC input on the initiatives? 1. Family Rapid Response Policy, initiated by hospital s Director of Quality, the policy was reviewed by the committee who offered edits to address the family s perspective. 2. Communication of Observation Visits Status, initiated by Director of Case Management. The Case Management department organized a process improvement team for the hospital that developed a letter to be used to communicate Observation Status to patients. As a whole the PFAC membership provided edits before the final version that were helpful in producing the final version. 3. Improving Communication with nursing staff, initialed by Director of Inpatient Services. Member, Jean Klugman, spent the day observing the nurses work on the inpatient unit and offered suggestions for improvement including changes in the use of portable computers, COWS, on the units, organization of medication room supplies, availability of BP cuffs, and organization of clean utility room discussed PFAC Annual Report 20. Does the hospital share the PFAC annual reports with PFAC members? Yes the report is shared with members 21. How do you make the PFAC report accessible to the public? The report is submitted to the Health Care For All website Goals 22. Does your PFAC set goals? If yes, what are they? (Please list.) Goals are set for each year. Goals for October 2014 through October 2015: 1. Establish Patient Focus Groups chaired by Co-Chair Susan Nissen to have discussions with patients to better understand the patient s perspective of the services they received both inpatient and outpatient from Beth Israel Deaconess Needham Hospital, information obtained during these discussions will be used to improve patient satisfaction and service delivery. 2. Involve PFAC members in appropriate hospital committees, such as the Patient Care Services Committee, where their involvement may enhance the patient experience. This is a Board level quality and safety committee comprising of Board members, CEO, physician leadership, nursing senior leadership and IT leadership.

5 3. Recruit new PFAC membership, through advertisement, personal invitation and by adding information about the PFAC to the hospital s patient portal webpage. (Note: As your PFAC sets goals, you should keep in mind the requirements and recommendations in the Massachusetts PFAC law and regulations.)