Patient and Family Advisory Council (PFAC) ANNUAL REPORT SEPTEMBER 30, 2013

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Patient and Family Advisory Council (PFAC) ANNUAL REPORT SEPTEMBER 30, 2013 I. Meeting December 13, 2012 (Fourth Quarter) A. Power point review of 2012 was presented by Mary Herman Coppoli 1. Fairlawn s 25 th anniversary 2. Successful completion of Joint Commission surveys, recertification in Stroke specialty and new certification in brain injury and Parkinson disease rehabilitation 3. Our status as Healthsouth Hospital of the year 4. Marketing overview 5. Staff development, including CRRN training 6. Support groups: stroke and brain injury caregiver 7. Pet Therapy 8. Community outreach 9. Retirements and losses B. The WITH book (Wellness Information and Tools for Health) presented to PFAC members for their review and evaluation. As a corporate initiative, we are unable to delete any information in the book, however, we may add to it. C. Hospital signage was also discussed with PFAC members. Signage improvements have been approved and included in capitol for next year. We will continue to solicit input from PFAC members going forward. D. PFAC member suggestions 1. A member inquired about our interest in evidence-based training workshops for hospital staff. She will forward information to the group.

2. A second member discussed a program she recently attended on patient-centered care and suggested there would be many areas that would be applicable to our hospital. She will also forward information to the group. II. III. Meeting first quarter cancelled due to weather Meeting April 4, 2013 (Second Quarter) A. WITH notebook feedback suggestions were obtained from PFAC members 1. All suggestions will be taken into consideration, unless it is a corporate requirement a. Front bullet outlining purpose of the book b. Folder in the book for educational flyers c. Page with case manager and clinician name and contact info d. Numbering of pages for easier access e. Customize with Fairlawn info on cover f. Home program needs explanation, as well as discharge g. Under communication, add Fairlawn OPD info h. Strategically place book around hospital i. Advertising loop about book on hospital tv channel j. Stickers with patient name on front of book B. 2013 Diversity report shared with PFAC members 1. Review of annual booklet provided for all staff. 2. Discussion about planned events, including national Day of prayer, which with encompass the theme of healing this year C. Step up to excellence program outlined for PFAC members 1. Healthsouth Northeast region trial 2. Opportunity to recognize staff and improve patient satisfaction, safety, and going above and beyond their work 3. Online program with point levels 4. Staff can also recognize eachother, but any points have to be approved by management D. Outpatient satisfaction program reviewed with PFAC members 1. Outpatient satisfaction is not currently measured by Press Ganey 2. Solicitation from this group to help identify measures for patient satisfaction

3. OPD department will come up with a satisfaction survey of their own to be distributed to outpatients at the end of their treatment E. New testimonials are currently in process IV. Meeting July 11, 2013 (Third Quarter) A. PFAC members were given a tour of the newly renovated OPD department 1. Department updated to match inpatient 2. Reconfigured staff space and documentation area 3. Converted one room to a new exam room and physician space B. Media specialist presented information on a Fairlawn wall display for the hospital lobby and solicited feedback from council members 1. Wall display will include timeline and other historical timelines 2. Three different versions of wall displays for review by PFAC to solicit feedback 3. Chosen version promoted hospital as more cutting edge rather than dated C. Media specialist discussed the production of two new testimonials for the Fairlawn Brought Me Back campaign 1. Currently four finalists being considered for inclusion 2. Solicited feedback from PFAC r/t most appropriate stories D. Discussion with PFAC members on the discharge to community initiative. Soliciting feedback for the next meeting for members on what areas to focus on to get patients back home, from their perspective. 1. Increased focus for getting patients back into the community 2. Solicited feedback from members on potential areas for improvement 3. Also requested feedback r/t potential education critical for patients and families for discharge. E. Next meeting to be held fourth quarter, most likely in December Fairlawn Rehabilitation established a Patient and Family Advisory council (PFAC) as set out in the hospital licensure regulation at 105 CMR 130.1800 & 1801.

The focus of the PFAC is to facilitate patient and family participation in hospital care and decisionmaking, information sharing, policy and program development to include the Institute for Family Centered Care core concepts of dignity and respect, information and sharing, participation and collaboration. The hospital is utilizing the published guide on PFAC s developed by the Agency for healthcare Research and Quality (AHRQ), the Patient-Centered Care Improvement Guide developed by the Planetree Organization and the Picker Institute and the hospital regulations for licensure as resource materials. The hospital has recognized the established requirements and developed of a plan by September 30, 2009, developed the council by October 1, 2010, and prepared the written annual report October 1, 2010 which was publicly available through electronic or other means. Reports were also provided to the Hospital Board. PLAN OUTLINE V. Council membership (completed, although more non-hospital members being sought) A. Size of Council 1. Council limited to 8-10 members 2. Council consists of at least 50% patient/family members B. Hospital leadership 1. Hospital CEO C. Council chairmanship 1. Project Coordinator will serve as a Co-chair of the Council 2. A patient/family member may be identified as Co-chair

D. PFAC Project Leader 1. Hospital Executive Vice President E. PFAC Project Coordinator 1. Hospital Director of Marketing Operations F. PFAC Physician Champion 1. Hospital Medical Director G. Patient/Family Members 1. Current or former patients or family members 2. Representative of the community the hospital serves 3. Were determined by December 31, 2009 4. Project coordinator oversees membership solicitation 5. Membership applications were utilized VI. Scope of the PFAC (d) A. Scope was developed as to specific, clear and concise focus B. Scope also includes what we will not be addressing VII. Budget and Organizational Support (d) A. Council meetings will be held on-site B. Refreshment will be provided by the hospital

C. Stipends will not be provided to patient/family council members D. Office and other supplies will be credited to the Administrative budget VIII. Council meeting schedule A. Council will meet on a quarterly basis B. First council meeting was an orientation meeting held on June 23, 2010 C. Minutes of council meetings are taken by council scribe (PJB) D. Minutes are maintained for a minimum of 5 years as required E. Minutes of meetings are presented to the hospital board IX. Development of policy and procedures completed and include: A. Purpose, goals and objectives of council consistent with hospital mission and vision B. Requirements, roles and responsibilities for membership 1. qualifications, selection, retention, terms of service, duties and election of officers C. Other roles of membership that may include: 1. participation on hospital committees, task forces, advisory boards 2. review of publicly reported quality information 3. participation on committees addressing patient safety issues 4. participation in search committees and hiring in new hospital staff 5. participation in reward and recognition programs 6. co-trainers for clinical and non-clinical staff, inservice programs, and health professional trainees 7. any other role in accordance with hospital policies and procedures

D. Requirements for orientation, training and continuing education for council members E. Handling of confidential patient information with signed confidentiality statements F. Defined availability and capability of technological support G. Utilization of data and methods H. Evaluation and outcome measures X. Project Timeline TOPIC TARGET DATE COMMENTS Council membership - Leadership - Co-chairs - Project leader - Project Coordinator - Physician Champion - Patient/family members Not that the role has been identified, assigned project coordinator will work with the team to solicit patient and family membership for the council. Scope of PFAC The scope of the council was determined, and includes a clear and concise focus and determination of what the council will not be addressing

Budget and Organizational Support Hospital Leadership/organizational support obtained. No specific budget was set up due to the size of both the facility and the council. Costs will be credited to the administrative budget for supplies and refreshment Council meeting schedule Council will be meeting quarterly. Specific scheduled dates with input from committee members are: November 20, 2010, March 24, 2011, July 28, 2011 September 15, 2011 (changed to September 29, 2011, and December 15, 2011. Development of policy and procedures d Policies and procedures for the council were developed and the roles have been assigned. Form development - Council mission/vision - Information sheet - Application - Confidentiality statement - Council ground rules - Meeting evaluation d d d d d Mission/vision and information sheet were presented to council members with an application for membership. Confidentiality statements were completed. Ground rules were reviewed at first meeting Evaluation for first and subsequent meetings XI. Brief overview of scheduled meeting November 20, 2010 A. PFAC Report due October 1, 2010 reviewed B. Confidentiality statement, policy, purpose, mission and vision presented and accepted C. Former patient elected as co-chair of the committee D. Calendar dates set for ensuing year E. Presentation of status of Press Ganey patient satisfaction data and orientation to members F. Input/feedback received from community members XII. Brief overview of scheduled meeting March 24, 2011 A. New year, new beginnings B. Revision of collateral materials needed with input from community members

C. Review of marketing brochure D. Plan for obtaining new pictures on hospital grounds with community members E. Discussion about web design, with input from community members F. Discussion about lobby re-design XIII. Brief overview of scheduled meeting July 28, 2011 A. Continued discussion about marketing topics from last meeting B. Discussion about improving relationships as a joint venture, and tie in collateral materials C. Reviewed pictures taken this summer to determine which ones to use D. Introduced the topic of Fairlawn s 25 th anniversary next October. E. Discussion a patient reunion to coincide with it, also highlighting our technology F. Input from community members considered in all anniversary activities XIV. Brief overview of scheduled meeting September 29, 2011 A. Final draft of brochure presented for review by community members B. Continued discussion on 25 th anniversary C. Introduction to our internal newsletter The Voice D. Discussion about inclusion of an article about the PFAC and its members, as well as activities the group is working on E. Community feedback gathered for continued improvements and projects. XV. Next meeting to be held December 15, 2011 off campus. A. Final copy of hospital newsletter The Voice with article Our PFAC: Who they are and what they do B. d marketing brochure presented to PFAC for their approval and approved C. Overview of new website design, soliciting input from PFAC members D. Meeting schedule and topic areas for 2012 discussed E. Holiday meeting: Food and fellowship XVI. Meeting April 26, 2012 (1 st Quarter) A. LCD presentation of new Fairlawn website based on PFAC input B. Roll out of Fairlawn Brought Me Back.com 2 TV commercials presented to the group, first aired on April 13, 2012 C. Overview of Fairlawn Brought Me Back Campaign D. Fairlawn Testimonials presented to PFAC with their approval E. Overview of signage project that will need PFAC input

XVII. Meeting June 14, 2012 (2 nd Quarter) A. Presentation of new CNO Judy Chuli B. Addition of new member Mary Aleksiewicz as a PFAC member C. PFAC member tour of the facility to review signage with recommendations by PFAC members to be presented to hospital management for inclusion in the capitol budget for next year XVIII. Fairlawn open house 25 th Anniversary September 20, 2012 (Third Quarter) A. PFAC members highlighted during presentations at anniversary celebration