Initial Report Last Modified: 09/28/2016

Initial Report Last Modified: 09/28/2016

1. Hospital Name 123 Other 0 0% 243 AdCare Hospital 0 0% 244 Addison Gilbert Hospital 0 0% 245 Anna Jaques Hospital 0 0% 246 Arbour Fuller Hospital 0 0% 247 Arbour Hospital 0 0% 248 Arbour HRI 0 0% 249 Athol Memorial Hospital 0 0% 250 Austen Riggs Center 0 0% 251 BayRidge Hospital 0 0% 252 Baystate Franklin Medical Center 0 0% 253 Baystate Mary Lane Hospital 0 0% 254 Baystate Medical Center 0 0% 255 Baystate Noble Hospital 0 0% 256 Baystate Wing Hospital 0 0% 257 Berkshire Health Systems, North Adams Campus of BMC 0 0% 258 Berkshire Medical Center Inc., Berkshire Campus 0 0% 259 Beth Israel Deaconess Hospital - Milton 0 0% 260 Beth Israel Deaconess Hospital - Needham 0 0% 261 Beth Israel Deaconess Hospital - Plymouth 0 0% 262 Beth Israel Deaconess Medical Center 0 0% 263 Beverly Hospital 0 0% 264 Boston Children's Hospital Family and Teen Council 0 0% 265 Boston Medical Center Corporation 0 0% 266 Bournewood Hospital 0 0% 267 Braintree Rehabilitation Hospital 0 0% 268 Bridgewater State Hospital 0 0% 269 Brigham & Women's Faulkner Hospital 0 0% 270 Brigham & Women's Hospital 0 0% 271 Cambridge Health Alliance 0 0% 272 Cape Cod & Island Community Health Center 0 0% 273 Cape Cod Hospital 0 0% 274 Carney Hospital 0 0% 275 Charlton Memorial Hospital 0 0% 276 Clinton Hospital 0 0% 277 Cooley Dickinson Hospital, Inc. 0 0% 278 Dana Farber Cancer Institute 0 0% 279 Dr. Solomon Carter Fuller Mental Health Center 0 0% 280 Edith Nourse Rodgers Memorial Veterans Hospital 0 0% 281 Emerson Hospital 0 0% 282 Fairlawn Rehabilitation Hospital 0 0% 283 Fairview Hospital 0 0% 284 Falmouth Hospital 0 0% 285 Framingham Union Hospital 0 0% 286 Franciscan Hospital for Children 0 0% 287 Good Samaritan Medical Center 0 0% 288 Hallmark Health System 0 0% 289 Harrington Memorial Hospital 0 0% 290 HealthAlliance Hospital, Leominster Campus 0 0% 291 HealthSouth Rehabilitation Hospital of Western Mass 0 0% 292 Hebrew Rehabilitation Center - Boston and Dedham 0 0% 293 Heywood Hospital 0 0% 294 High Point Treatment Center Inc 0 0% 295 Holy Family Hospital & Medical Center 0 0% 296 Holyoke Medical Center 0 0% 297 Kindred Hospital Boston 0 0% 298 Kindred Hospital North Shore 0 0% 299 Kindred Hospital Northeast 0 0% 300 Lahey Hospital and Medical Center 0 0% 301 Lawrence General Hospital 0 0% 302 Lemuel Shattuck Hospital 0 0% 303 Leonard Morse Hospital 0 0% 304 Lowell General Hospital 0 0% 305 Marlborough Hospital 0 0% 306 Martha's Vineyard Hospital 0 0% 307 Massachusetts Ear and Eye Infirmary 0 0% 308 Massachusetts General Hospital 0 0% 309 Massachusetts Hospital Association 0 0% 310 McLean Hospital 0 0% 311 Melrose-Wakefield Hospital 0 0% 312 Mercy Medical Center Campus 0 0% 313 MetroWest Medical Center 0 0% 314 Milford Regional Medical Center 0 0% 315 Morton Hospital & Medical Center, Inc. 0 0% 316 Mount Auburn Hospital 0 0% 317 Nantucket Cottage Hospital 0 0% 318 Nashoba Valley Medical Center 0 0% 319 New England Baptist Hospital 0 0% 320 New England Rehab Hospital at Beverley 0 0% 321 New England Rehab Hospital at Lowell 0 0% 322 New England Rehabilitation Hospital 0 0% 323 New England Sinai Hospital 0 0% 324 Newton-Wellesley Hospital 0 0% 325 North Shore Medical Center 0 0% 326 Norwood Hospital 0 0% 327 NSMC Salem Hospital 0 0% 328 NSMC Union Hospital 0 0% 329 Pembroke Hospital 0 0% 330 Providence Behavioral Health Hospital 0 0% 331 Saint Anne's Hospital 0 0% 332 Saint Vincent Hospital 0 0% 333 Shriners Hospitals for Children Boston 0 0% 334 Shriners Hospitals for Children Springfield 0 0% 335 Signature Healthcare Brockton Hospital 0 0% 336 South Shore Hospital 0 0% 337 Southcoast Hospitals Group Inc., Charlton 0 0% 338 Southcoast Hospitals Group Inc., St. Luke's 0 0% 339 Spaulding Hospital Cambridge 0 0% 340 Spaulding Hospital Rehabilitation Hospital Boston 0 0% 341 Spaulding Rehabilitation Hospital Cape Cod 0 0% 342 St. Elizabeth's Medical Center 0 0% 343 Sturdy Memorial Hospital 0 0% 344 Tewksbury Hospital 0 0% 345 The Meadows of Central Massachusetts 0 0% 346 Tobey Hospital 0 0% 347 Tufts Medical Center 0 0% 348 UMass Memorial Medical Center 1 100% 349 VA Boston Healthcare - Brockton 0 0% 350 VA Boston Healthcare - West Roxbury 0 0% 351 Vibra Hospital of Southeastern Massachusetts 0 0% 352 Vibra Hospital of Western Massachusetts 0 0% 353 Vibra Hospital of Western Massachusetts - Central Campus 0 0% 354 Walden Behavioral Care, LLC 0 0% 355 Western Massachusetts Hospital 0 0% 356 Westwood Lodge Hospital 0 0% 357 Whidden Hospital 0 0% 358 Whittier Rehabilitation Hospital - Bradford 0 0% 359 Whittier Rehabilitation Hospital - Westborough 0 0% 360 Winchester Hospital 0 0% 361 Worcester Recovery Center and Hospital 0 0%

2. If you selected "Other", please list hospital name: 3. Which best describes your PFAC? 1 We are the only PFAC at a single hospital 0 0% 2 We are a PFAC for a system with several hospitals 0 0% 3 We are one of multiple PFACs at a single hospital 0 0% 4 We are one of several PFACs for a system with several hospitals 1 100% 5 Other (please describe): 0 0% Other (please describe): 4. Will another PFAC at your hospital also submit a report? 1 Yes 0 0% 2 No 0 0% Total 0 5. Will another hospital within your system also submit a report? 1 Yes 0 0% 2 No 0 0% Total 0

6. Staff PFAC Co-Chair Contact: Name and Title: Email: Phone: Ana Mechlin, Patient Experience Project Coordinator ana.mechlin@umassmemorial.org 774-441-6742 7. Is the Staff PFAC Co-Chair also the Staff PFAC Liaison/Coordinator? 1 Yes 1 100% 2 No 0 0% 8. Patient/Family PFAC Co-Chair Contact: Name and Title: Email: Phone: Daniel Wolpert dwolpert@fleet-safety.com 508-868-3752 9. Staff PFAC Liaison/Coordinator Contact (if applicable): Name and Title: Email: Phone:

10. This year, the PFAC recruited new members through the following approaches (check all that apply): 1 Word of mouth / through existing members 1 100% 2 Promotional efforts within institution to patients or families 0 0% 3 Promotional efforts within institution to providers or staff 1 100% 5 Facebook and Twitter 1 100% 6 Recruitment brochures 1 100% 7 Hospital publications 0 0% 8 Hospital banners and posters 0 0% 9 Case managers / care coordinators 0 0% 10 Patient satisfaction surveys 0 0% 11 Community-based organizations 0 0% 12 Houses of worship 0 0% 13 Community events 1 100% 14 Other 0 0% 15 N/A - we did not recruit new members in FY 2016 0 0% 11. Please describe other recruitment approach: 12. Total number of staff members on the PFAC: 7

13. Total number of patient or family member advisors on the PFAC: 22 14. The name of the hospital department supporting the PFAC is: Patient Experience 15. The hospital position of the PFAC Staff Liaison/ Coordinator is: Project Coordinator 16. The hospital provides the following for PFAC members to encourage their participation in meetings (click all that apply): 11 Parking, mileage, or meals 1 100% 19 Translator or interpreter services 0 0% 20 Assistive services for those with disabilities 0 0% 21 Provision / reimbursement for child care or elder care 0 0% 22 Stipends 0 0% 23 Payment for attendance at annual PFAC conference 1 100% 24 Payment for attendance at other conferences or trainings 0 0% 25 Annual gifts of appreciation 0 0% 26 Conference call phone numbers or "virtual meeting" options 1 100% 27 Meetings outside 9am-5pm office hours 1 100% 28 Other 0 0% 29 N/A - the hospital does not reimburse PFAC members 0 0%

17. Please describe other provision by the hospital for PFAC members: 18. Our catchment area is geographically defined as (if you are unsure select "don't know"): Worcester County, MA 19. 20. Our defined catchment area is made up of the following racial groups (please provide percentages; if you are unsure of percentages please select "don't know"): American Indian or Alaska Native Asian Black or African American Native Hawaiian or other Pacific Islander White 0.2% 4% 3.6%.2% 80.7% 21. 22. What percentage of people in the defined catchment area are of Hispanic, Latino, or Spanish origin? 9.4% 23.

24. In FY 2016, the hospital provided care to patients from the following racial groups (please provide percentages): American Indian or Alaska Native Asian Black or African American Native Hawaiian or other Pacific Islander White Other 0.18% 3.29% 5.51% 0.05% 74.26% 16.71% 25. 26. What percentage of patients that the hospital provided care to in FY 2016 are of Hispanic, Latino, or Spanish origin? 10.11% 27. 28. In FY 2016, the PFAC patient and family advisors came from the following racial groups (please provide percentages): American Indian or Alaska Native Asian Black or African American Native Hawaiian or other Pacific Islander White Other 10% 80% 10% 29.

30. What percentage of PFAC patient and family advisors in FY 2016 were of Hispanic, Latino, or Spanish origin? 10% 31. 32. What percentage of patients that the hospital provided care to in FY 2016 have limited English proficiency (LEP)? 8.23% 33. 34. What percentage of patients that the hospital provided care to in FY 2016 spoke the following as their primary language? Spanish Portuguese Chinese Haitian Creole Vietnamese Russian French Mon-Khmer/Cambodian Italian Arabic Albanian Cape Verdean 4.57% 1.22% 0.2% 0.03% 0.43% 0.07% 0.03% 0.02% 0.01% 0.52% 0.31% 35.

36. What percentage of PFAC patient and family advisors in FY 2016 have limited English proficiency (LEP)? 37. 38. In FY 2016, what percentage of PFAC patient and family advisors spoke the following as their primary language? Spanish Portuguese Chinese Haitian Creole Vietnamese Russian French Mon-Khmer/Cambodian Italian Arabic Albanian Cape Verdean 7% 39. 40. The PFAC is undertaking the following activities to ensure appropriate representation of our membership in comparison to our patient or catchment area: PFAC has been attending and participating in many community events in order to recruit members that represent our community. A representative sits on the Special Population Recource Center Community Advisory Board and we hope to see many new community members from this partnership. 41. Our process for developing and distributing agendas for thepfac meetings (click the best choice): 1 Staff develops the agenda and sends it out prior to the meeting 0 0% 2 Staff develops the agenda and distributes it at the meeting 0 0% 3 PFAC members develop the agenda and send it out prior to the meeting 0 0% 4 PFAC members develop the agenda and distribute it at the meeting 0 0% 5 PFAC members and staff develop agenda together and send it out prior to the meeting 1 100% 6 PFAC members and staff develop agenda together and distribute it at the meeting 0 0% 7 Other 0 0% 8 N/A the PFAC does not use agendas 0 0% 42. If staff and PFAC members develop the agenda together, please describe the process: Monthly planning meetings are held to communicate thoughts and ideas. Staff and PFAC members are sometimes given tasks to recruit presenters to the meetings. Presentations from various departments help to keep the group upated on what is happening in the Medical Center. There are also many re-occuring agenda items such as; standing committee updates, manager's meeting updates, review of the minutes, etc. The agenda is then sent in a reminder emal to members of the council a week or two in advance to the meeting. 43. If other process, please describe: 44. The PFAC goals and objectives for 2016 were: (select the best choice): 1 Developed by staff and reviewed by PFAC members 0 0% 2 Developed by PFAC members and staff 1 100% 3 N/A we did not have goals and objectives for FY 2016 0 0% 4 Developed by staff alone 0 0%

45. The PFAC had the following goals and objectives for 2016: PFAC Representation on Patient Care Committees, Marketing PFAC to Department Heads, Improving the Patient Experience, Recruitment of New Members 46. Please list any subcommittees that your PFAC has established: 47. How does the PFAC interact with the hospital Board of Directors (click all that apply): 1 PFAC submits annual report to Board 0 0% 2 PFAC submits meeting minutes to Board 0 0% 3 PFAC member(s) attend(s) Board meetings 0 0% 4 Board member(s) attend(s) PFAC meetings 1 100% 5 PFAC member(s) are on board-level committee(s) 0 0% 7 Other 0 0% 8 Action items or concerns are part of an ongoing Feedback Loop to the Board 0 0% 48. Please describe other interactions with the hospital Board of Directors. 49. Describe the PFAC's use of email, listservs, or social media for communication: PFAC uses email on a regular basis to provide feedback, suggestions or submit content for the meeting. PFAC also has a facebook page used for recruitment and to update the public on things they are working on.

50. Number of new PFAC members this year: 7 51. Orientation content included (click all that apply): 1 Meeting with hospital staff 1 100% 2 General hospital orientation 1 100% 3 Hospital performance information 0 0% 4 Patient engagement in research 0 0% 5 PFAC policies, member roles and responsibilities 0 0% 6 Health care quality and safety 1 100% 7 History of the PFAC 0 0% 8 "Buddy program" with experienced members 0 0% 9 Information on how PFAC fits within the organization's structure 0 0% 10 Other 0 0% 11 In-person training 1 100% 12 Massachusetts law and PFACs 1 100% 14 Concepts of patient- and family-centered care (PFCC) 0 0% 15 Skills training on communication, technology, and meeting preparation 0 0% 16 Immediate assignments to participate in PFAC work 0 0% 17 Check-in or follow-up after the orientation 1 100% 18 N/A the PFAC members do not go through a formal orientation process 0 0% 52. Please describe other orientation content:

53. The PFAC received training on the following topics (click all that apply): 1 Concepts of patient- and family-centered care (PFCC) 0 0% 2 Patient engagement in research 0 0% 3 Types of research conducted in the hospital 0 0% 4 Hospital performance information 1 100% 6 Health care quality and safety measurement 1 100% 7 A high-profile quality issue in the news in relation to the hospital (e.g. simultaneous surgeries, treatment of VIP patients, mental patient discharge, etc) 0 0% 8 Other 1 100% 10 Health literacy 0 0% 54. Please describe other topics: PFAC Members were given LEAN training and idea board training 55. Accomplishment 1: PFAC members participated in a LEAN Green Belt A3 project in which they worked with a clinic to minimize wait times for their patients 56. The idea for Accomplishment 1 came from: 1 Patient/family advisors of the PFAC 0 0% 2 Department, committee, or unit that requested PFAC input 1 100%

57. Accomplishment 2: PFAC implemented an idea board identical to the idea boards used by each department within the medical center. This helps to keep the PFAC's ideas organized and in line with system goals 58. The idea for Accomplishment 2 came from: 1 Patient/family advisors of the PFAC 0 0% 2 Department, committee, or unit that requested PFAC input 1 100% 59. Accomplishment 3: PFAC members joined many standing committees within the organization including, Patient Safety Committee, Infection Control Committee, Cancer Committee, and Patient Flow Committee 60. The idea for Accomplishment 3 came from: 1 Patient/family advisors of the PFAC 1 100% 2 Department, committee, or unit that requested PFAC input 0 0% 61. Accomplishment 4: UMass included their Marlboro member hospital in this year's end of year gathering where we celebrate PFAC's many accomplishments

62. The idea for Accomplishment 4 came from: 1 Patient/family advisors of the PFAC 1 100% 2 Department, committee, or unit that requested PFAC input 0 0% 63. Accomplishment 5: 64. The idea for Accomplishment 5 came from: 1 Patient/family advisors of the PFAC 0 0% 2 Department, committee, or unit that requested PFAC input 0 0% Total 0 65. Click to write the question text 1 N/A we did not encounter any challenges in FY 2016 0 0% 66. Challenge 1: Recruitment of new members representing our community

67. Challenge 2: Initiation and sustaining community outreach projects 68. Challenge 3: Attendance at the monthly meetings 69. Challenge 4: On-boarding of new members 70. Challenge 5:

71. The PFAC members serve on the following hospital-wide committees, projects, task forces, work groups, or Board committees (click all that apply): 1 Behavioral Health/substance use 0 0% 2 Bereavement 0 0% 4 Care Transitions 0 0% 5 Code of Conduct 0 0% 6 Community Benefits 0 0% 7 Critical Care 0 0% 8 Other 1 100% 9 N/A the PFAC members do not serve on these 0 0% 10 Board of Directors 0 0% 11 Discharge Delays 0 0% 12 Lesbian, gay, bisexual, and transgender (LGBT) sensitive care 0 0% 13 Drug Shortage 0 0% 14 Eliminating Preventable Harm 0 0% 15 Emergency Department Patient/Family Experience Improvement 1 100% 16 Ethics 0 0% 17 Institutional Review Board (IRB) 0 0% 18 Patient Care Assessment 0 0% 19 Patient Education 0 0% 20 Patient and Family Experience Improvement 0 0% 21 Pharmacy Discharge Script Program 0 0% 22 Quality and Safety 1 100% 23 Quality/Performance Improvement 1 100% 24 Surgical Home 0 0% 27 Culturally competent care 0 0% 72. Please describe other committees, projects, task forces, work groups, or Board committees: Cancer Committee, Infection Control Committee, MyChart implementation work group 73. How do members on these hospital-wide committees or projects report back to the PFAC about their work? We leave time on the agenda each month for committee members to report out on their committee work.

74. The PFAC provided advice or recommendations to the hospital on the following areas mentioned in the Massachusetts law (click all that apply): 1 Quality improvement initiatives 1 100% 2 Patient education on safety and quality matters 1 100% 3 Patient and provider relationships 1 100% 4 Institutional Review Boards 0 0% 6 N/A the PFAC did not provide advice or recommendations to the hospital on these areas in FY 2016 0 0% 75. PFAC members participated in the following activities mentioned in the Massachusetts law (click all that apply): 1 Task forces 1 100% 2 Award committees 0 0% 3 Advisory boards/groups or panels 0 0% 4 Search committees and in the hiring of new staff 1 100% 6 N/A the PFAC members did not participate in any of these activities 0 0% 7 Co-trainers for clinical and nonclinical staff, in-service programs, and health professional trainees 0 0% 8 Selection of reward and recognition programs 0 0% 9 Standing hospital committees that address quality 1 100% 76. Complaints and serious events 1 Complaints and investigations reported to Department of Public Health (DPH) 0 0% 2 Serious Reportable Events reported to Department of Public Health (DPH) 0 0% 3 Healthcare-Associated Infections (National Healthcare Safety Network) 0 0% 4 Patient complaints to hospital 1 100%

77. Quality of care 1 Joint Commission Accreditation Quality Report (such as asthma care, immunization, stroke care) 0 0% 2 Medicare Hospital Compare (such as complications, readmissions, medical imaging) 1 100% 3 Maternity care (such as C-sections, high risk deliveries) 0 0% 4 High-risk surgeries (such as aortic valve replacement, pancreatic resection) 0 0% 78. Resource use and patient satisfaction 1 Patient experience/satisfaction scores (eg. HCAHPS - Hospital Consumer Assessment of Healthcare Providers and Systems) 1 100% 2 Resource use (such as length of stay, readmissions) 0 0% 3 Inpatient care management (such as electronically ordering medicine, specially trained doctors for ICU patients) 0 0% 79. Other 2 N/A the hospital did not share performance information with the PFAC 0 0% 3 Other 0 0% 80. Please describe other hospital performance information: 81. Please explain why the hospital shared only the data you checked in the previous questions: The hospital shared data that was relevant to what PFAC members were working on. Data was also shared to PFAC members at their request. Data that was not shared was either not requested by PFAC members or was not relevant to their current projects 82. Please describe how the PFAC was engaged in discussions around these data above and any resulting quality improvement initiatives: PFAC was engaged in many different ways. PFAC members attended monthly manager's meetings in which they were updated on system goal progress and current system initiatives/projects. Many individuals visited PFAC meetings to present their progress to PFAC and ask for their feedback. PFAC members worked on various project throughout the medical center that related to the above data such as patient wait times and readmission/discharge. PFAC members also joined many standing committees this year that discussed these data topics. 83. National Patient Safety Hospital Goals 1 Identifying patients correctly 0 0% 2 Using medicines safely 0 0% 3 Using alarms safely 0 0% 4 Preventing infection 1 100% 5 Identifying patient safety risks 0 0% 6 Preventing mistakes in surgery 0 0%

84. Prevention and errors 1 Hand-washing initiatives 0 0% 2 Checklists 0 0% 3 Fall prevention 0 0% 4 Care transitions (e.g., discharge planning, passports, care coordination, and follow up between care settings) 0 0% 5 Team training 0 0% 6 Electronic Health Records related errors 0 0% 7 Safety 1 100% 8 Human Factors Engineering 1 100% 85. Decision-making and advanced planning 1 Informed decision making/informed consent 1 100% 2 Improving information for patients and families 1 100% 3 Health care proxies 0 0% 4 End of life planning (e.g., hospice, palliative, advanced directives) 0 0% 86. Additional quality initiatives 1 Rapid response teams 0 0% 2 Disclosure of harm and apology 0 0% 3 Integration of behavioral health care 0 0%

87. Other 2 N/A the hospital did not share performance information with the PFAC 0 0% 3 Other 0 0% 88. Please describe other initiatives: 89. Were any members of your PFAC engaged in advising on research studies? 1 Yes 1 100% 2 No 0 0% 90. In what ways are members of your PFAC engaged in advising on research studies? Are they: 1 Educated about the types of research being conducted 0 0% 2 Involved in study planning and design 1 100% 3 Involved in conducting and implementing studies 0 0% 4 Involved in advising on plans to disseminate study findings and to ensure that findings are communicated in understandable, usable ways 0 0% 5 Involved in policy decisions about how hospital researchers engage with the PFAC (e.g. they work on a policy that says researchers have to include the PFAC in planning and design for every study) 0 0% 91. How are members of your PFAC approached about advising on research studies? 1 Researchers contact the PFAC 1 100% 2 Researchers contact individual members, who report back to the PFAC 0 0% 3 Other 0 0% 5 None of our members are involved in research studies 0 0% 92. Please describe other ways that members of your PFAC are approached about advising on research studies:

93. About how many studies have your PFAC members advised on? 1 1 or 2 1 100% 2 3-5 0 0% 3 More than 5 0 0% 5 None of our members are involved in research studies 0 0% 94. The following individuals approved this report prior to submission (list name and indicate whether staff or patient/family advisor): Dan Wolpert - Family Co-Chair 95. Describe the process by which this PFAC report was completed and approved at your institution (choose the best option). 1 Collaborative process: staff and PFAC members both wrote and/or edited the report 0 0% 2 Staff wrote report and PFAC members reviewed it 1 100% 3 Staff wrote report 0 0% 4 Other 0 0% 96. Please describe other process:

97. We post the report online. 1 Yes, link: 1 100% 2 No 0 0% Yes, link: https://www.umassmemorialhealthcare.org/umass-memorial-medical-center/giving/patient-and-family-advisory-council 98. We provide a phone number or e-mail address on our website to use for requesting the report. 1 Yes, phone number/e-mail address: 1 100% 2 No 0 0% Yes, phone number/e-mail address: 774-441-6742 99. Our hospital has a link on its website to a PFAC page. 1 Yes, link: 1 100% 2 No, we don t have such a section on our website 0 0% Yes, link: https://www.umassmemorialhealthcare.org/umass-memorial-medical-center/giving/patient-and-family-advisory-council

100. Please provide an email address if you would like to receive a confirmation with a copy of this report after the report is submitted: ana.mechlin@umassmemorial.org