Patient and Family Advisory Council 2014 Annual Report Hospital Name: WinchesterHospital Date of Report: Oct. 1, 2014 Year Covered by Report: Oct.1, 2013 Sept. 30, 2014 Year PFAC Established: 2010 Staff PFAC Contact (name and title): Kathy Schuler, RN, vice president of patient care and chief nursing officer Staff PFAC Contact E-mail and Phone: kschuler@winhosp.org 781-756-2127 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. Attached 2. How do you recruit PFAC members? Potential members are nominated by the hospital staff, the medical staff and the board of directors. Patients and family members can also express interest in becoming a member of PFAC through the hospital website. 3. Is the PFAC chair or co-chair a patient or family member? Yes 4. If there is a hospitalstaff chair or co-chair, what hospital position does that person hold? The co-chair also holds the hospital position of vice president of patient care and CNO. 5. Are at least 50% of PFAC members current or former patients or family members? Yes, nine of the current 16 members of PFAC are former patients or family members. 6. What hospital department supports the PFAC? What is the hospital position of the PFAC staff liaison? The Patient Care Division supports PFAC. PFAC staff support liaison is the executive assistant to the vice president of patient care and CNO. 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.)? PFAC members have access to free on-site parking, and dinner is provided at each meeting. In addition, PFAC members were encouraged to attend the annual PFAC conference on May 14, 2014 sponsored by Health Care for All. The hospital paid the registration fee for any PFAC member who attended.
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? PFAC members are selected to represent a variety of the communities and services of the hospital. The council welcomes a broad demographic mix, representing patients, family members and providers. Additionally, the Maternal Child Health PFAC exists to serve the unique needs of that patient population. 9. Who sets agendas for PFAC meetings? At each meeting, PFAC is asked to suggest agenda topics for the next meeting. In addition, hospital leaders periodically request to present various issues to the PFAC. The co-chairs then formalize the agenda including topics from all these sources. 10. Does the PFAC have subcommittees? If yes, please list and describe them. No, currently PFAC does not have sub-committees. However, as reported above, there is a separate PFAC for Maternal Child Health. This specialized PFAC is comprised of parents of current or former patients of our Special Care Nursery as well as hospital staff. The MCH PFAC focuses on the unique needs of this patient population and their families. 11. How does the PFAC interact with the Board of Directors (Check or circle all that apply) a. PFAC submits annual report to Board b. PFAC submits meeting minutes to Board c. PFAC member(s) attends Board meetings annually, to present the annual report 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? 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.).
All members of PFAC who are not currently employed by or on the medical staff of the hospital attend an orientation. The orientation is provided by the director of volunteers and mirrors the same orientation given to volunteers, including information on patient privacy and HIPAA. Orientation is available on an annual basis as new members join the council. If a council member s term should need to be filled during a year, the new member would attend a volunteer orientation. 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 Yes b. Institutional review boards Yes c. Quality improvement initiatives Yes d. Patient education on safety and quality matters Yes 16. Did PFAC members engage in any of the following activities mentioned in the law? (Check/circle all that apply): a. Members of task forces Yes b. Members of standing hospital committees that address quality (list committees and how many PFAC members serve on each) A member of PFAC is a sitting member of the Patient Safety Committee, Service Excellence Response team and the Medical Orders for Life-Sustaining Treatment Initiative team. 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 Yes b. Healthcare-Associated Infections c. Department of Public Health (DPH) information on complaints and investigations d. Staff influenza immunization rate Yes e. Other hospital performance information shared: please describe
8. 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 c. Hand-washing initiatives d. Checklists e. Disclosure of harm and apology f. Fall prevention Yes g. Informed decision making/informed consent h. Improving information for patients and families Yes i. Health care proxies/substituted decision making Yes j. End of life planning (e.g., hospice, palliative, advanced directives) Yes k. Care transitions (e.g., discharge planning, passports, care coordination & follow up between care settings) Yes l. Observation status for Medicare patients 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? In its fourth year, PFAC provided the hospital with insight on a number of different topics and had an impact on the quality of care at the hospital. At each meeting of PFAC, the group was informed of the hospital s evaluation and selection of an affiliate partner. This was done by a member of the senior management team at each meeting. PFAC spoke freely and provided their thoughts on any potential affiliation, recognizing the joint advantages of a new organizational structure and of retaining Winchester Hospital s culture. In 2012,PFAC provided the hospital with feedback related to hospital employees and flu vaccines, advocating strongly that all hospital employees should be vaccinated. In
2013, taking this advice from PFAC seriously, the hospital mandated all employees, volunteers and the medical staff to receive the flu vaccine. As a result of that decision, Winchester Hospital was one of only three hospitals in the state to reach a 99 percent vaccination rate. In addition to the hospital-wide PFAC, our Maternal Child Health (MCH) Division has a PFAC to meet the unique needs of these patients and their family members. This year the MCH PFAC worked on increasing the support and education from our lactation consultants to the parents of the Special Care Nursery. Their discussions ultimately resulted in the creation of crib cards that communicate parent preferences related to contact for the first feeding, bathing, testing etc. PFAC also implemented a plan to increase the information/education about safe sleep habits for infants. Their efforts led to both printed information and a video, which are now available to parents and caregivers of infants. The hospital requested feedback from PFAC on a number of quality initiatives and made more informed decisions as a result of the feedback. The chart below relates initiatives discussed, PFAC feedback given and hospital actions taken. Topic PFAC Advice Hospital Action Plain Language Codes Hospital should move towards plain language codes Hospital intends to move to plain language codes during 2015 Flu Vaccine Mandate all employees Flu vaccine mandated in 2013 MOLST Hypoglycemia Protocol Patient Portal Patient Discharge Summary PFAC felt the hospital needed to produce educational material for patients explaining the protocol utilized during hospitalization PFAC provided great insight on why and when a patient would use a patient portal PFAC provided the team working on the MOLST initiative with insight on how to engage the community Draft of new patient discharge summary presented to the PFAC for review and revision Brochure developed and now provided to all patients on the hypoglycemia protocol Development of the hospital patient portal and development of strategies to engage patients was assisted by feedback from patients. MOLST team informed by discussion Several revisions made to the form based on the feedback from the group.
PFAC Annual Report 20. Does the hospital share the PFAC annual reports with PFAC members? Yes 21. How do you make the PFAC report accessible to the public? Link on website Goals 22. Does your PFAC set goals? If yes, what are they? (Please list.) (Note: As your PFAC sets goals, you should keep in mind the requirements and recommendations in the Massachusetts PFAC law and regulations.) In September 2013, the Winchester Hospital Fiscal Year 2014 Patient Experience and Patient Safety Goals were reviewed with PFAC to frame the discussion of PFAC goals for the year ahead. As a result, PFAC requested to become more involved with the Palliative Care Initiative. Members also requested to have a joint meeting with the Lahey PFAC when appropriate. Additionally, members expressed an interest in the hospital s readmission initiatives, specifically the time taken to see a primary care physician after discharge.