Lawrence General Hospital Annual Report Patient and Family Advisory Council October 1, 2014 through September 30, 2015 PFAC Contact: Theresa Sievers, MS, RN, CPHQ, CPHRM One General Street Lawrence, MA 01842 978-683-4000
About Lawrence General Hospital Lawrence General Hospital is a 189-bed private, non-profit community hospital providing the Merrimack Valley & southern New Hampshire regions with high quality, high value medical care for the whole family. For more than 135 years, the extremely dedicated doctors, nurses and staff of Lawrence General have been committed to strengthening our Hospital and our community. Lawrence General Hospital is proudly affiliated with both Beth Israel Deaconess Medical Center and Floating Hospital for Children at Tufts Medical Center. These affiliations ensure our patients have an expanded roster of specialty services and clinics available locally, greatly decreasing the need to travel to Boston for high quality care. Mission Serving nearly 300,000 patients annually, Lawrence General Hospital is driven by the mission of delivering comprehensive health care to patients by ensuring access to high-quality care, the latest technologies and caring, personalized treatment. In addition to over 500 local primary care and specialist providers, Lawrence General offers physicians, specialists and services on-site from a variety of tertiary clinical partners, including Beth Israel Deaconess Medical Center and Floating Hospital for Children at Tufts Medical Center. As the Merrimack Valley's leading regional health care system, Lawrence General is committed to enhancing the delivery and coordination of care, and to improving health outcomes for patients and communities served. Vision Become a stellar regional health system known for the highest quality, highest value, service, efficiency, and compassionate care. Values To achieve the highest levels of quality and patient satisfaction, the Hospital's philosophy of care focuses around these four core values: Quality - The Hospital continually strives for excellence in all areas of patient care, enabled through an ongoing quality improvement process Integrity - The Hospital builds honest and ethical relationships. Compassion - The Hospital, through its physicians and caregivers, offers care to address each patient's unique physical, emotional and spiritual needs. Service - The Hospital goes the extra mile to provide a level of medical care and customer service that exceeds the expectations of our patients and visitors. Additional information about Lawrence General Hospital may be found on the website at www.lawrencegeneral.org 2
PFAC: History, Mission Statement Purpose The Patient and Family Advisory Council at LGH held the first meeting in September 2009. Since then it has maintained its original mission statement as follows: The Patient and Family Advisory Council at Lawrence General Hospital is committed to bringing patients, families and hospital staff together to build a partnership of advisors, who will help to design and implement programs and policies that will improve the services and care delivered. In 2014, the PFAC revised its bylaws to include its purpose/goals as follows: Implement Change - Review data related to the Hospital's quality of care or patient experience and offer suggestions for improvement Establishment of Goals - Strengthen communication among patients, families/guests, caregivers and staff, through the development of specific goals based on areas in need of attention from the patient and family perspective. Member Committee Placement - Continuously work on placing members on other hospital committees or task forces in order to further the work of the Council. Community Representation - Serve as an important link between LGH and the community it serves by maintaining a diverse membership. PFAC Structure and Composition The Council consists of patients and family members, community organization representative members, hospital senior management and staff members, and Board of Trustees members. There are 20 council members in total; eleven patient / family members (55%); two community organization representatives (10%); two Board of Trustee members (10%) five hospital senior leaders / staff members (25%). All Council members collaborate to provide input and support in implementing decisions that impact how LGH delivers care to patients and families. An ongoing goal is to ensure that the PFAC represents the diversity of the population served by LGH. Currently, the PFAC Chairperson is the Vice President, Quality and Patient Safety. The Council has had ongoing discussions inviting the patient and family representatives to serve in a leadership role on the Council. Recruitment, Membership and Qualification As a guiding principle, as noted above, the PFAC strives to ensure representation consistent with the diversity in our community and of the population served by LGH. Recruitment efforts are ongoing and involve an application, phone screening, and/or in-person interviews. Potential members are recruited through recommendations from current PFAC members, physicians in the community and/or hospital staff. In 2014, LGH began using social media, specifically, Facebook to increase public awareness about the PFAC, and encourage those interested in learning more about the Council to contact the Hospital. Interested parties may also attend a PFAC meeting as a guest prior to making a commitment to join the Council. 3
Council members are selected with the following qualifications in mind: Patient/family members who receive care, treatment and services at LGH; Community organization representative within the primary service area; Demonstrated ability to work collaboratively and share experiences; Demonstrated ability to respect diversity and opinions of others; and Desire to improve the patient and family experience PFAC Orientation New members submit an application and are interviewed by the PFAC Chairperson and presented to the Committee for approval. Once new members are selected, they attend the full day LGH orientation required by new LGH staff members. The orientation program includes information about the hospital s history, clinical care services and programs, infection prevention and control, patient privacy (HIPAA) and quality, patient safety and patient experience improvement efforts. The PFAC mission and bylaws are reviewed; a confidentiality agreement is signed as well as a conflict of interest statement. PFAC Meetings The Council meets every other month, at least five to six times a year, for one and a half hours. LGH provides Council members with lunch and valet parking at no cost. The Chairperson develops the agenda for the meetings in collaboration and with input from the Council members. There is time built in to the meeting agenda for Council members to provide feedback about specific experiences if desired. The Council designated two members to serve on the hospital-wide Cultural Diversity Committee over the past year. The Council is committed to increasing involvement in ongoing Hospital committees, teams and work groups in our journey to improve the patient and family experience of care. PFAC Member Hospital Participation The PFAC has played a significant role in many programs and ongoing Hospital initiatives contributing to care decisions made on behalf of patients and families. Specifically, members are provided with the opportunity to make recommendations to the Hospital regarding patient and provider relationships, quality improvement initiatives, and patient education on safety and quality matters. Many of the quality of care initiatives over the past year were related to the improvement of information for patients and families, meals, way-finding, end of life planning, and care transitions. Council member participation on Committees and other hospital initiatives has provided invaluable information in making improvements. A specific example is improvement made for patients who are hard of hearing and deaf brought to light by a patient / family member serving on the Cultural Diversity Committee. The Council recognizes the opportunity to increase participation over the next year. Fiscal Year 2015 Accomplishments and Educational Opportunities In addition to providing advice and guidance on improving many aspects of the patient experience, Council members have provided ongoing feedback about their personal experiences and the experiences of the family members. The hospital leadership and staff on the Council take the feedback very seriously and often discuss the feedback heard first hand during many other forums and meetings. Hearing from patients in their o wn voice has provided rich feedback and is proving to be so valuable that hospital leaders and staff are now asking to have representation on their committees, teams and work groups. Over the past year, guest speakers presented on a variety of topics that were selected with input from the Council members:
Cultural Diversity Committee Opening of Andover Medical Center facility Hospital Signage Construction Update CHART Community Hospital Acceleration, Revitalization and Transformation Grant from the Health Policy Commission Marketing and LGH Brand Elevation PFAC Annual Report Summary PFAC members participated in the development of this year's annual report to help set the goals for 2016, and to create the strategies necessary to transform the Council and improve the patient experience. Below are some of the goals that were identified for the upcoming year: Increase efforts to review patient care practices and policies to make suggestions on Hospital practices to improve patient and family experience. Increase public recognition of the PFAC for their accomplishments. Develop activities that help nurture continued interest in council membership. Develop workshops to provide staff and families the opportunity to get to know each other and increase their understanding of Council role and responsibilities. Simplify the PFAC meeting agenda items and discussions to promote a more relaxed environment, develop rapport and encourage interactivity among all members. The Council also suggested that we regularly set aside the 15 minutes of each meeting for a member to share his/her most recent experience as a patient and/or as a family member.
Lawrence General Hospital Patient and Family Advisory Council Bylaws/ Council Charter Article 1. Mission Statement The Patient Family Advisory Council at Lawrence General Hospital is committed to bringing patients, families and hospital staff together to build a partnership of advisors, who will help to design and implement programs and policies that will improve the services and care delivered. Article 2. Purpose/Goals Section 1. Implement Change: Review data related to the hospital quality of care or patient experience and offer suggestions for improvement. Section 2. Establishment of Goals: Strengthen communication among patients, families/guests, caregivers and staff, through the development of specific goals based on areas in need of attention from the patient and family perspective. Section 3. Member Committee Placement: Continuously work on placing members on other hospital committees or task forces in order to further the work of the Council. Section 4. Community Representation: Serve as an important link between LGH and the community it serves by maintaining a diverse membership. Article 3. Structure and Membership The PFAC will consist of up to 20 members total: patients/family or community organization members, hospital senior leadership and staff members and hospital trustees. The committee endeavors to have an equal number of patients/family or community organization members and hospital representatives. A Quarum will be considered with a minimum of 2 patients/family or community organization members and 2 staff members or hospital trustees. The PFAC strives to maintain a diverse membership, representative of the population that LGH serves. Article 4. Nomination and Application Process Section 1. Membership Recruitment: The hospital will engage in active recruitment efforts in order to ensure diverse representation. Recruiting efforts will be ongoing to ensure patients and families are aware of the Council. Such activities will include but are not be limited to: canvassing hospital staff, including physicians, posting of information throughout the hospital, on the hospital's web site, contacting community groups, and engaging local media. Section 2. Membership Criteria: Patient/family members must have received services at Lawrence General Hospital or must be affiliated with the Community the hospital serves. Members are expected to be active participants in council activities and support the PFAC publicly. They will be familiar with healthcare issues and initiatives. Members may be asked to participate on committees or projects that may require an additional time commitment. Members are required to RSVP for meetings. Section 3. Membership Selection: The Council may recommend patients, family members, or hospital staff for Council membership. Interested parties complete an application. Interested parties may also attend a PFAC meeting as a guest prior to making a commitment to join the Council. PFAC staff members will review the application and interview each candidate via telephone or in person (preferred). The initial membership will be determined by the PFAC steering committee, based on review of the applications, interviews with candidates and consideration of the Commonwealth's regulation applicable to the development of Patient and Family Advisory Councils in Massachusetts Hospitals. Thereafter, future members will be selected by the PFAC membership committee, which will consist of two patient/family members and two members representing the hospital in addition
to the Council Chair and Co-Chair. The PFAC membership committee will be responsible for interviewing and recommending future members for Council approval via a majority vote. Section 4. Membership Responsibilities: Participate in the formation and evaluation of PFAC yearly goals and objectives and be an active participant in Council activities. Be an advocate for all patients and families by identifying and representing their needs and concerns. Maintain patient confidentiality according to Health Insurance Portability and Accountability Act (HIPAA) guidelines at all times. Plan, facilitate and guide the work of the LGH PFAC. Be willing to consider additional opportunities for involvement beyond the monthly meeting. Participate in meeting discussions and activities. LGH staff members will act as the hospital liaisons to the Council. Section 5. Membership Terms: One year commitment, renewable each year for as long as the member wishes to continue and is in good standing. A minimum three year term is recommended but not required. Individual members should indicate their individual preference for continued membership at the end of each year. Council members may renew past their three-year recommended term if mutually agreed to. Article 5. PFAC Meetings Regular meetings of the Patient and Family Advisory Council will be held the second Tuesday of every other month from 12:30 pm to 2:00pm unless otherwise ordered, presuming the presence of a quorum. Each meeting will be 1.5 hours in length. Section 1. Agenda: Meeting agenda will be set by the designated chair and/or co-chair and distributed to the Council prior to each session. Section 2. Minutes: Meeting minutes will be kept and distributed to all PFAC staff and patient/family members at or prior to the the next meeting. Council minutes will be retained for a minimum of 5 years. Section 3. Attendance: Members of the council are expected to make every effort to attend every session during their term. It is expected that members will commit to attend a minimum of 75% of the Council meetings. Members who are unable to meet this requirement will be offered early withdrawal. If they wish to remain involved they may do so with the approval of the Council, but certain privileges may be temporarily suspended. Ultimately, membership on the Council is at the discretion of the Hospital and will be based on the effectiveness, feedback, and support provided by each member. Section 4. Quorum: An official meeting will require the presence of a minimum of one-half of the members to be called to order. Section 5. Voting: Votes may be conducted electronically for most items, except where specifically requested to be in person. Electronic votes will require a response (yes, no or abstain) from a quorum of members. Article 6. Confidentiality All members will be required to sign a confidentiality statement. Out of respect to fellow Council members and Lawrence General Hospital's privacy practices and HIPAA, discussing any information deemed personal or confidential cannot be done outside of the Council. Article 7. Early Withdrawal Council members wishing to step down from the Council or request a leave may do so at any time. The Council may elect to add a replacement for a member who has stepped down or to leave the position open until the next rotation membership as long as the Council has a minimum of 15 members, greater than 50 % of which will be patients, family members or community leaders. Otherwise, recruitment efforts will continue to fill the open membership positions.