Harrington Memorial Hospital Patient and Family Advisory Council 2015 Report. Total Responses. Harrington Memorial Hospital 1.

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1 Harrington Memorial Hospital Patient and Family Advisory Council 015 Report Last Modified: 10/08/ Hospital Name Answer Total Responses Harrington Memorial Hospital 1. Year PFAC Established 1 Prior to % Staff PFAC Contact Name and Title Ann Beaudry, BSN RN, Director of maternal and Children's Services 4. Staff PFAC Contact and Phone abeaudry@harringtonhospital.org Our PFAC has (click the best choice): 1 by-laws 1 100% agreed-upon policies and procedures 3 neither 6. Our PFAC manages itself through (describe in 1500 characters or fewer) :

2 This question was not displayed to the respondent. 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 1 100% 5 Facebook and Twitter 6 Recruitment brochures 1 100% 7 Hospital publications 8 Hospital banners and posters 9 Through care coordinators 10 Through patient satisfaction surveys 1 100% 11 Through community-based organizations 1 Through houses of worship 13 At community events 1 100% 14 Other 1 100% 15 None 8. Describe other recruitment method (in 1500 characters or fewer): In order to reach and retain more community our council reached out to local companies through a letter. We asked that they seek a volunteer, that lives in the community, with an interest in the Hospital, and allow them the time to attend our quarterly meeting of the full group. This effort has given us two new, to date. Both have lived in the community most of their lives and they are delighted to be involved. We continue to look for volunteers through all of the previously stated means. 9. Our PFAC chair or co-chair is a patient or family member 1 Yes No 1 100% 10. Our PFAC chair or co-chair is a hospital staff member 1 Yes 1 100% No

3 11. Chair/Co-Chair hospital position title: Ann Beaudry, BSN, RN 1. This person is the official PFAC staff liason 1 Yes No 1 100% 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: Quality and patient Safety 16. If not mentioned above, the hospital position of the PFAC staff liason is: Kathleen Davis, VP of Quality and Patient Safety 17. The hospital reimburses PFAC for the following costs associated with attending or participating in meetings (click all that apply): 1 Provide free parking 1 100%

4 Provide meals 1 100% 3 Provide translator or interpreter services 4 Provide assistive services for those with disabilities 5 Provide meeting conference call or webinar options 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 1 100% 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): This question was not displayed to the respondent. 19. Our catchment area is geographically defined as: South Central Massachusetts and Northern Connecticut 0. Race: American Indian or Alaska Native Asian Black or African American Native Hawaiian or Other Pacific Islander White 0% 0.9% 1.% 0% 85.3% 1. Ethnicity: Hispanic or Latino Not Hispanic or Latino 9.8% 90.%. Race: American Indian or Alaska Native Asian Black or African American Native Hawaiian or Other Pacific Islander White 0.05% 0.35% 0.35% 0.01% 89.13%

5 3. Ethnicity: Hispanic or Latino Not Hispanic or Latino 9.% 90.8% 4. Race: American Indian or Alaska Native Asian Black or African American Native Hawaiian or Other Pacific Islander White 0% 0% 0% 0% 100 % 5. Ethnicity: Hispanic or Latino Not Hispanic or Latino 10.5% 89.5% 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): Our main PFAC has two Hispanic. We have formed a subgroup to look at the needs of the Spanish community that we serve. That subgroup is all Hispanic of the staff, including the co- chair. There are six participating in this group. We have met three times sinse May. 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 1 100% 6 Other process 7 None 8. Describe the process (in 1500 characters or fewer):

6 This question was not displayed to the respondent. 9. Describe the process (in 1500 characters or fewer): This question was not displayed to the respondent. 30. The PFAC goals set for FY 015 were (describe in 1500 characters or fewer): *recruitment and retention of new community. *establish a Spanish subgroup of frontline employees to discuss identified issues in that demographic. establish a patient visiting group to identify opportunities, in real time, for improvment. 31. The FY 015 goals were (click the best choice): 1 Developed by staff and reviewed by PFAC Developed by PFAC and staff 1 100% 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 1 100% 15 None 33. Describe other subcommittee (in 1500 characters or fewer):

7 There is currently two subcommittees. One is the spanish speaking subcommittee, that is looking for betters ways to serve that population. The second is a patient visiting group, which includes who speak Spanish and English. The goal is to visit patients and families in the evening. We will have a hospital employee along with a community member making rounds on several inpatient units. We will introduce ouselves as PFAC and ask for input about their experience in our hospital. All of the feed back will go back to the committee and to the Hospital directors, for action and trending. 34. How does the PFAC interact with the Hospital Board of Directors? (click all that apply) 1 PFAC submits annual report to Board 1 100% PFAC submits meeting minutes to Board 3 PFAC member(s) attends Board meetings 1 100% 4 Board member(s) attends PFAC meetings 5 PFAC member(s) are on board-level committee(s) 1 100% 7 Other 35. Describe other interaction (in 1500 characters or fewer): This question was not displayed to the respondent. 36. URL/link to the PFAC section of the hospital website: none 37. Describe the PFAC's use of , listservs, or social media (in 3000 characters or fewer): The Chair uses to communicate with for minutes, meeting times and agenda. The PFAC is reviewed on all Hospital phone lines with the Chair person's name and contact information. 38. Number of new PFAC this year: The orientation was provided by: Number of Staff Members Number of PFAC Members

8 The content included (click all that apply): 1 Meeting with hospital staff 1 100% A general hospital orientation 3 Information on concepts of patient- and family-centered care (PFCC) 1 100% 4 Information on patient engagement in research 5 PFAC policies, member roles and responsibilities 1 100% 6 Information on health care quality and safety 1 100% 7 History of the PFAC 1 100% 8 A "buddy program" with old 9 How PFAC fits within the organization's structure 1 100% 10 Other 41. Describe other content (in 3000 characters or fewer): This question was not displayed to the respondent. 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 1 100% 43. Describe other PFAC member requirement(s) (in 1500 characters or fewer): We have not required our PFAC to attend Hospital orientation, have a Cori or get vaccinated. All who will be participating in the Patient visiting program will do all of those things. 44. Our PFAC provides education to our on the topic of patientcentered outcomes research 1 Yes No 1 100%

9 45. Accomplishment 1 (describe in 3000 characters or fewer): Our first accomplishment was increasing the hip of our council and getting people engaged and participating. We interviewed the group to find a time that was best for them and we have continued to hold to that schedule. We had seven attend the Health care for All conference this year, with half of those attending being community. They were excited to be able to see what everyone is doing and came back with lots of ideas to talk about at our hospital. 46. The idea for Accomplishment 1 came: 1 Directly from the PFAC 1 100% From a department, committee, or unit that requested PFAC input 47. Accomplishment (describe in 3000 characters or fewer): We have established a Spanish Subgroup and have met several times so far, this year. The group is very dynamic and interested in helping the community to get the services they need. There are plans to do a fair in the spring. This will be an opportunity to educate the community about health care, insurance opportunities, and provide information about primary care physicians. This will be done with several of the subgroup providing interpreting as needed. 48. The idea for Accomplishment came: 1 Directly from the PFAC 1 100% From a department, committee, or unit that requested PFAC input 49. Accomplishment 3 (describe in 3000 characters or fewer): We have established a patient visiting subgroup. We are currently working out the details of the visits. Who will do them, when and how the information gathered will be handled. The goal is to improve the patient experience for all of those that we serve. This is being presented to our leadership team in October and will begin as a pilot at the end of that Month. This idea came from two Diagnostic Imaging employees who attended a Press Ganey conference where they heard a presentation from a Hospital PFAC who had established a patient visiting team. They were so impressed with what they heard that they brought it back to Harrington and asked to join PFAC. They presented at a meeting and the group decided to persue this. 50. The idea for Accomplishment 3 came:

10 1 Directly from the PFAC From a department, committee, or unit that requested PFAC input 1 100% 51. Accomplishment 1 (describe in 3000 characters or fewer): as above 5. The idea for Accomplishment 1 came: 1 Directly from the PFAC From a department, committee, or unit that requested PFAC input Total Accomplishment (describe in 3000 characters or fewer): This question was not answered by the respondent. 54. The idea for Accomplishment came: 1 Directly from the PFAC From a department, committee, or unit that requested PFAC input Total Accomplishment 3 (describe in 3000 characters or fewer): This question was not answered by the respondent. 56. The idea for Accomplishment 3 came: 1 Directly from the PFAC From a department, committee, or unit that requested PFAC input

11 Total Challenge 1 (describe in 3000 characters or fewer): The # one challenge is recruitment and retention. While we have made some great strides in this, we are continuing to get more community involved. 58. Challenge (describe in 3000 characters or fewer): To gain acceptance of PFAC, community on hospital committees. 59. Challenge 3 (describe in 3000 characters or fewer): Insuring hospital employees the ability to leave their department to attend meeting on a regular basis. The time for the meetings was changed to early morning to accomodate the community. The time can be difficult for people who are working. Sometimes they cannot leave their department because of acuity. It has not been a huge problem, but has impacted us at times. Members who have missed meetings are doing a great job keeping informed and engaged. 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 1 100% Patient education on safety and quality matters 3 Patient and provider relationships 1 100% 4 Institutional Review Boards 5 Other 1 100% 6 None 61. Describe other advice/recommendations (in 1500 characters or fewer): This question was not answered by the respondent. 6. PFAC participated in the following activities mentioned in the law (click all that apply): 1 Served as of task forces Served as of awards committees 3 Served as of advisory boards/groups or panels

12 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 1 100% 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 64. 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 1 100% 5 Patient experience/satisfaction scores 1 100% 6 Patient complaints 7 Patient Care Link 8 Joint Commission surveys 1 100% 9 Hospital Compare 10 Family satisfaction surveys 11 Quality of life data 1 Rapid response data 13 Other 14 None 65. List other public hospital performance information shared (in 1500 characters or fewer): This question was not displayed to the respondent.

13 66. Describe the process by which public hospital performance information was shared (describe in 1500 characters or fewer): reported at PFAC meeting. 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 1 100% 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): This question was not displayed to the respondent. 69. The hospital shares the PFAC annual reports with PFAC : 1 Yes 1 100% No 70. Massachusetts law requires that the PFAC report be available to the public. We (click the best choice):

14 1 Post the report online Provide a phone number or to use for accessing the report 3 Other 1 100% 71. Describe other method for making the report available to the public (in 1500 characters or fewer): The report will be shared upon request. Will work with the Marketing Department to upload to the Hospital website.