2012 PFAC Annual Report

UMass Memorial Medical Center Patient and Family Advisory Council Established March 2010

Annual Report: October 2011 – September 2012

Web site: www.umassmemorial.org/pfac E-mail:

PFAC@umassmemorial.org

UMass Memorial Medical Center Patient and Family Advisory Council Annual Report: October 2011-September 2012

Purpose and Goal Patient and Family Centered Care remains at the core of the Mission, Vision and Values of UMass Memorial Medical Center (UMMMC). The Patient and Family Advisory Council (PFAC) works as a true partner with the Medical Center to bring the patient voice and perspective to improve quality and patient safety, enhance services, and enrich the overall patient and family experience within the UMass Memorial.

The PFAC advises UMass Memorial on matters including, but not limited to: Patient and provider relationships Policies and procedures related to care and caring Quality improvement initiatives Patient education on safety and quality matters to the extent allowed by state and federal law This year the PFAC identified two main priorities to help drive change within UMass Memorial; these were to work in partnership to enhance facility cleanliness and increase PFAC engagement with medical center personnel. The dedication of PFAC members, along with the Medical Center commitment to patient and family centered care, laid the foundation for the collaborative work to address these goals. These and other initiatives are outlined in the “Engagement and Accomplishment� section of this report.

Membership PFAC membership is comprised of current or former patients or family members who are at least 18 years of age, and UMass Memorial leaders and staff. Membership is reflective of users/providers from a variety of services (inpatient and ambulatory) and of the diverse populations served by the Medical Center.

The UMass Memorial Medical Center PFAC had its first meeting in March 2010. During the course of this year, the PFAC worked to achieve a staggered membership term. Some members reached the end of their term and new members were recruited. The charter stipulates that 50% of PFAC members be patients or family members; we have sustained a more than 50% patient/family member representation since inception. At the close of this year membership included nineteen patient or family members and eight Medical Center leaders or staff. In addition there were two former patient/family members that assist with projects on an as needed basis. The Medical Center membership includes: the Chief and Associate Chief Quality Officers, Chief Nursing Officer, Associate VP of Quality, Patient Safety and Experience, the Director Patient Experience, a physician of the Medical Group, project manager from the Department of Quality and Patient Safety and administrative support.

Procedures regarding membership are outlined in the PFAC Charter (Attachment I), which is reviewed annually. It specifies conditions of membership regarding training, orientation, confidentiality, participation, and voting. Membership types include Full voting membership and the non-voting Associate membership. Member terms are 2 to 3 years staggered to balance new ideas of incoming members and gain from the experience of existing members.

Monthly Council meetings were held on the fourth Tuesday on the month 6pm-8pm with the exception of December and September. In lieu of the September meeting, PFAC members attended an UMass Medical School/Medical Center film screening related to health care challenges in the United States. Each meeting had a quorum; minutes are on file and have been shared with the Clinical Performance Council (the governing body to which of the UMMMC PFAC reports).

In addition to the UMass Memorial Medical Center “over arching” Patient and Family Advisory Council, there are some local Patient/Parent & Family Advisory Councils representing specialty services and/or practice sites. These include: The Children’s Medical Center Family Advisory Council, Neonatal Intensive Care Unit (NICU) Family Advisory Council, Pediatric Intensive Care Unit (PICU) Family Centered Care Committee, Barre Community Health Center Patient Advisory Council and Plumley Village Health

Services Patient Advisory Council. The Hahnemann Family Health Center Patient Advisory Council is in the process of implementation.

Council structure and membership is outlined below: Children’s Medical Center Family Advisory Council – encompasses all Children’s Medical Center disciplines.

- Re-established in October 2011 - Fourteen members: 9 Parent members and 5 Medical Center members - Meet 2nd Tuesday of the month 6pm-8pm NICU Family Advisory Council - Established in December 2010 - Nineteen members: 10 Parent members and 9 Medical Center members - Meet 2nd Wednesday of the month 7pm-8:30pm PICU Family Centered Care Committee - Established in 2007 - Nineteen members: 11 Parent members, 2 Teen members and 6 Medical Center members.

- Meet first Wednesday of the month 6pm-7:30pm Barre Community Health Center Patient Advisory Council - Established in March 2012 - Twenty six members: 23 Patient/Family members and 3 Health Center members - Meet bi-monthly; 2nd Wednesday of the month 6pm-7:30pm Plumley Village Health Services Patient Advisory Council - Established in October 2011 - Twelve members: 8 Patient members and 4 Health Center members - Meet quarterly; evening meetings 1 ½ hours Each respective Council has a defined process for selecting Council members. General, considerations include: Types of UMass Memorial services the candidate/family member has used Specific areas of interest for improvement Unique skills of the candidate Perspective on key elements of patient and family-centered care

Interest in serving on the PFAC Good listening skills and ability to listen to diverse opinions Respect of other’s ideas and perspectives Ability to use own experience to educate and learn and to see beyond own experience Realistic expectations Diversity, representation of patients and families served by UMass Memorial All council members must apply for and be approved as Medical Center volunteers through the Volunteer Office. Volunteer on-boarding includes initial and annual training related to: Infection control Safety and security HIPAA (Health Insurance Portability and Accountability Act) & confidentiality Emergency management Procedures regarding parking/ID badge

Governance Each Council has its own governance. The UMass Memorial Medical Center PFAC has co-chairs; one is a patient/family member and the second is the Director of Patient Experience. A Project Manager from the Department of Quality and Patient Safety supports the co-chairs.

PFAC Member Engagement & Accomplishments Collectively, our various Patient/Parent and Family Advisory Councils have partnered with the Medical Center to assess, review and strategize on how to improve the patient experience in the multifaceted spectrum of services within our health care system. Our essential and valued patient/family member council members have rolled up their sleeves and worked in tandem with the Medical Center on patient centered care initiatives.

Patient/Family member council roles may include but are not limited to: Participation on committees, task forces, value streams, advisory boards; Review of publicly-reported quality and patient experience information; Participation on committees addressing patient safety;

Participation on search committees and in the hiring of new hospital staff; Participation in reward and recognition programs; As co-trainers for clinical and non-clinical staff, in-service programs, and health professional trainees; Any other role in accordance with policies and procedures.

UMMMC PFAC Engagement & Accomplishments: “Human Interaction/Communication” Component Team: One PFAC patient/family member is an active participant of this team. The purpose of the committee is to promote compassionate and respectful human interaction, encourage family presence, and implement strategies to improve communications that are easily understood by patients and families. The PFAC member has done formal presentations to the PFAC and Patient Experience Steering Committee regarding team progress, such as the implementation of a service recovery model at a pilot practice site.

PFAC Partnership with Housekeeping: Three PFAC patient/patient-family members work collaboratively with the Housekeeping Department through rounding (looking at the facility through the “patient’s lens”). Monthly team meetings were held with patients-family members, housekeeping staff and nursing to look at venues to enhance patient/visitor first and lasting impression related to facility cleanliness and engage all staff in promoting facility cleanliness.

Pathway/Signage: Three PFAC patient/family members have continued to partner with Capital Planning to improve signage and pathways at three campus sites. In recognition of their work, the “Pathway” team and its members received a UMass Memorial Champions of Excellence Award for Quality Care in September 2012.

Psychiatry Partnerships: One PFAC member actively participates on two Psychiatry Teams.

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Inpatient Planning Committee: The goal of this improvement team is to assess and implement recovery oriented services within psychiatry. The PFAC member has been engaged in assessing and making recommendations related to a recovery model and “healing designs” for the upcoming relocation of one of the Medical Centers inpatient Psychiatric Treatment Centers.

- Emergency Mental Health Value Stream: The goal of this team is to reduce the wait time for patients in Emergency Mental Health and enhance the patient experience.

Marketing and Communication/PFAC Facebook Workgroup: Four PFAC Patient/Family members worked with the Marketing and Communications Department to help define the content, approach and launch of the UMass Memorial Facebook page; launched September 2011. In May 2012, the New England

Society for Healthcare Communicators awarded this group the 2012 Lamplighter Gold Award in recognition of the strategic planning and PFAC involvement in the launch and content of the UMass Memorial Facebook page. www.facebook.com/umassmemorial Community Relations African Community Outreach/Education Assessment Team: Two PFAC members expressed an interest in working with the Community Relations Dept. to educate the various immigrant African populations about health care in the US and how to access care. This workgroup involves these PFAC members, other community representatives and Medical Center staff to assess a possible initiative. This group is in the early stages of meeting.

Patient Partner Program: Two PFAC members and four other patient partners participate in the “Patient Partner Program” that started in the Fall of 2011. This program provides a patient-patient companionship and friendly visit that is a positive distraction to our inpatients.

“Ask Me” Greeter Program: One PFAC patient/family member welcomes and assists visitors in one of our cardiac care units with directions and general information related to this unit.

Cardiology Phone Workgroup: One patient/family members participated in this project. This PFAC member worked on a team that improved phone service to patients calling the cardiology for ambulatory care appointments. In recognition of their work, the Ambulatory Cardiology Phone Service Team and its members received a UMass Memorial Champions of Excellence Award for Quality Care in September 2012.

Radiology Phone Project: One of our PFAC members identified a need to make the Radiology phone system more “customer focused”. The Radiology team worked with this PFAC member to simplify and improve the phone system for patients calling Radiology; creating a more customer focused system.

Emergency Department – Inpatient “Lean” Team and Workgroups: One PFAC member participated in three workgroups for this project.

- Caring for Boarding Patients in the Emergency Department: Established comfort items for patients and improved a variety of processes within the Emergency Department to streamline care. In recognition of their work, this team and its members received

a UMass Memorial Champions of Excellence Award for Quality Care in September 2012.

- Emergency Department (ED) Transitions to Inpatient (Acute Care): Improved overall workflow to enhance interdepartmental communication to facilitate smooth transitions from the ED to the inpatient setting. In recognition of their work this team

and its members received a UMass Memorial Champions of Excellence Award for Quality Care in September 2012.

- Timely Transitions from ED to Inpatient setting: This workgroup is on-going and has the goal of reducing the time a patient waits for transfer from the ED to an inpatient bed, when a room is ready.

Quiet at Night Campaign: One PFAC member is working with Medical Center Staff to assess “quiet at night” and implement initiatives to help promote a quieter, healing environment for our patients at night. Additional PFAC members and Children’s Medical Center Family Advisory Council members have participated in photo shoots to help augment this campaign.

PFAC and Children’s Medical Center Family Advisory Council (CMC-FAC) Patient Experience Video: Both the PFAC and CMC-FAC identified communication as an area of improvement for the Medical Center. The PFAC and CMC-FAC worked collaboratively to make a video that tells “their story” about their experiences (what went well & should be replicated, as well as, when things did not go well, what could have improved the experience). The final edits are in progress.

This powerful video will bring the patient-family voice to staff and engage staff to make the patient experience positive; underscoring that every interaction is meaningful. It will be used in a variety of educational and process improvement venues.

Lung Cancer: Hope, Health and Healing 11/16/11: One of the PFAC members spoke at this Cancer Education Program about the patient perspective of coping with a lung cancer diagnosis.

“Escape Fire” film on the American Health Care System screening 9/18/2012: Two PFAC members, along with Medical School and Medical Center staff, participated in a post film screening panel discussion related to this film. The American Medical Student Association and the Institute for Healthcare Improvement, in conjunction with the UMass Medical School and UMass Memorial Medical Center, presented an advanced screening of this the film Escape Fire: the Fight to Rescue American Healthcare. Many of our Medical Center PFAC/FAC patient-family members attended this film screening.

Information Services Patient Portal Committee: In 2011, Two PFAC members attended a presentation by a Patient Portal vendor as Information Services began exploring the possibility of creating a patient portal for the Ambulatory electronic medical record. These meetings are due to resume in Fall 2012 and will also include members of the Children’s Medical Center Family Advisory Council.

Wrong Campus Failure Modes & Effects Analysis (FMEA) Committee: One PFAC member continued participation with a workgroup to revise the appointment reminder letter. This group was an outgrowth of a FMEA committee begun in 2010 to explore why patients arrive at the wrong campus of the 3-campus medical center.

In addition, the PFAC was consulted to assess the letter and offer suggestions for improvement.

Other non-PFAC Patient Centered initiatives involving patients at UMass Memorial: Patient Experience Steering Committee: Four patient/family members participate in this committee to provide both consultation and review of patient centered care progress and initiatives within the Medical Center.

Caring Talents Program: One patient donates his time every two months to play classical guitar in lobbies or designated units. Several other volunteers also contribute their talents to this program. Music is a universal language that contributes to the healing environment for our patients, visitors and staff.

Children’s Medical Center Family Advisory Council (CMC-FAC) Engagement and Accomplishments: Partnerships with other Medical Center PFAC-FACs: The CMC-FAC had their kickoff meeting in October 2011. The PFAC, NICU Family Advisory Council and PICU Family Centered Care Councils presented overviews about their respective councils and provided Q&A sessions for CMC-FAC members to inquire about these councils and familiarize parent members with council roles, etc.

Pediatric Menu Improvement Team: Several CMC-FAC parent members worked with food services and nursing to enhance and improve inpatient Pediatric menu offerings and graphics. Seven day menu changes have been finalized and approved by the CMC-FAC. Lily’s Pad Design Committee: One PFAC member worked with Capital Planning and Pediatrics to help design a waiting area for children that have compromised immune systems.

Staff Appreciation Initiative: Several CMC-FAC parent members formed a subcommittee to look at a venue for CMC-FAC to recognize nurses from the varied units (inpatient and ambulatory) within the Children’s Medical Center at UMass Memorial.

Members submitted some of their favorite photos, a vote was taken and the “winning photos” were enlarged, framed and will have recognition plaques affixed to present to the nursing staff to promote healing environments in their respective break rooms.

Facebook and Injury Prevention Information: One CMC-FAC member suggested that Facebook post injury prevention information for parents and others. This PFAC member is working with the Injury Prevention Team and Marketing to assess and implement this initiative.

Neonatal Intensive Care Unit (NICU) Family Advisory Council Engagement and Accomplishments: NICU “Tour”: A NICU parent member suggested that in addition the in person NICU tour that parents receive when their infant is in NICU that a tip sheet be developed to help parents remember where things are and to navigate the unit. This was done and is now augments the in person tour.

Parent Journal Committee: NICU parent members are working with staff to revise the current parent handbook into a more user-friendly, educational binder that will serve the child and family long past their NICU stay.

Greeter Program: NICU parents requested that greeters be present to welcome and greet visitors to the NICU. This program has been implemented.

Thanksgiving Day Celebration: NICU FAC facilitated a Catered breakfast and afternoon desserts for parents and siblings.

Mothers Day Celebration: NICU FAC facilitated personalized pictures framed at each mother’s bedside to celebrate Mothers Day. Kangaroo Care Committee: NICU parents are engaged in this committee that is actively working on a brochure that will be given to every NICU family to educate about the benefits of Kangaroo Care. Kangaroo Care, also known as skin-to-skin holding, is a special way of holding a baby against your chest so that the parent and baby have close contact with each other. The baby looks like he or she is in a pouch on the parents’ chest like a Kangaroo. Kangaroo Care is used in NICUs throughout the world to support parent-infant bonding.

Scrapbooking Committee: This committee is in an early stage of development. The goal is to offer a scrapbooking program for parents of infants that are in the NICU. This group has utilized the Medical Center Facebook page to seek supply donations.

Pediatric Intensive Care Unit (PICU) Family Centered Care Engagement and Accomplishments: Parent/Guardian rounding with medical team: PICU parent members and medical staff members were the catalyst to implement this practice in 2012. This has enhanced parent/guardian involvement in care planning and improved communications with care givers.

Fish Boards added to Patient Rooms: Another initiative prompted by the PICU Council. These boards explain the roles of staff members. Implemented October 2011.

Murals in the PICU entrance: PICU parent member involvement in the selection of the ocean theme to promote a healing environment.

Comfort Measures for patients and family: PICU parent members were instrumental in facilitating the purchase of several “comforts” for PICU through donations. These include: adjustable stools for families at the bedside, I pod docking stations, noise reducing head phones , eye masks for sleeping and a blanket warmer. pod do Staff Connections: PICU parents worked with staff to orchestrate the addition of staff pictures on the hallway board in October 2011. This helps familiarize parents with staff.

Other PICU Parent-Staff Initiatives in Progress: - Web camera for parents/guardians to view child while in PICY from home - Parent video to include in parent/family orientation to PICU

Barre Community Health Center Patient Advisory Council Engagement and Accomplishments: Check-in / Check-out Process Redesign: Patient members worked with staff to improve workflow and reduce wait time for patients Patient Privacy Enhancement: Advisory council recommended and facilitated moving the operatory from the front waiting area to a more private setting.

Welcome and Greeting: Advisory council recognized the need for additional volunteers to welcome, greet and help direct patients and their families. This patient centered initiative has improved the patient experience of navigating services at Barre Community Health Center. The council is currently assessing signage as well.

Plumley Village Health Services Patient Advisory Council Engagement and Accomplishments: Medication Refill Process: the Patient Advisory group provided essential input and feedback, from the patient perspective, about how to improve the process.

Recommendations were incorporated and the process has been improved.

Waiting Area Improvements: Patient and staff members assessed the waiting area and made several enhancements. These include: book shelf with free donated books for children to take home, new wall mounted DVD for patient educational materials and children’s movies and the addition of new toys for varied ages and developmental needs of children.

Outreach and Wellness Program Team: Patient members worked with staff to identify needed program/materials/services. Outcomes included: a healthy cooking class and nutritional resources. Nutrition education posters were added to waiting area and an on-site nutritionist is now available one afternoon a week.

Plumley Village Health Fair: Six patient members helped plan and participated in the Plumley Village Health Fair.

PFAC Visitation to other organizational PFACs: This year the UMass Memorial Medical Center PFAC visited the Milford PFAC. In turn the Milford PFAC plans to attend a UMass Memorial Medical Center PFAC meeting.

Evaluation Formally and informally, PFAC members are periodically asked to evaluate the effectiveness of meetings and appropriateness of agenda items.

Attachment I

UMASS MEMORIAL MEDICAL CENTER Patient and Family Advisory Council Charter Section I

Purpose

The Patient and Family Advisory Council (PFAC), through its mission, is dedicated to assuring the delivery of the highest standards of comprehensive and compassionate health care. By partnering with UMass Memorial Medical Center, the PFAC assists the UMass Memorial Board of Trustees (Board) in carrying out its responsibilities as they relate to the evaluation and improvement of the quality and safety of patient care.

Section II

Reporting

UMass Memorial a charitable, non-profit corporation governed by the Board. The PFAC reports to the Clinical Performance Council (CPC) which, in turn reports to the Patient Care Assessment Committee (PCAC) of the Board.

Section III

Recruitment, Selection and Membership

Recruitment UMass Memorial PFAC members, patient/family representatives, hospital staff and community organizations will help recruit and recommend potential PFAC members who reflect the diversity of those served by the Medical Center.

Membership Patients, family members and UMass Memorial staff are eligible to serve as PFAC members. Members must be at least 18 years of age and demonstrate commitment to the vision and mission of the PFAC. 1. A minimum of 50 percent of PFAC members are patients or patient family members.

2. All members must be in compliance with UMass Memorial requirements for annual training.

3. New members will complete an on-boarding orientation.

4. All members will honor their confidentiality agreement by refraining from discussing any information deemed personal or confidential outside the council meeting. A breach of confidentiality is grounds for immediate dismissal.

5. All members are expected to attend scheduled meetings. Members who routinely miss meetings may be removed or replaced at the discretion of the cochairs.

6. PFAC members are expected to serve on other hospital committees/ workgroups.

7. Members may request a leave of absence. The co-chairs will evaluate these requests and follow up with the requesting member to reach a final determination.

8. If a member resigns or is unable to complete their term, co-chairs may recruit a replacement for the remainder of the former member’s term.

9. A quorum must be present (physically or telephonically) for voting purposes and is defined as a minimum of 50 percent of the membership.

Patient/Family Members: 1. Potential members must submit a Patient and Family Advisory Council application to Volunteer Services.

2. Preliminary interviews will be conducted by a member of the Patient Experience Department or designee either in person or by phone.

3. Potential candidates will be invited to attend a PFAC meeting.

4. The co-chairs, with consideration of comments from the other members of the PFAC, will determine the candidate’s eligibility for membership.

5. All members must be in compliance with the requirements for active volunteer status, which includes, but is not limited to, required annual training.

6. New members will be brought on according to the New Member Guidelines.

7. PFAC member terms: Length of term will vary in order to achieve staggered rotation; terms will range two to three years to maintain consistency in membership (October 1 to September 30).

UMass Memorial Staff Members: UMass Memorial members will be appointed by Medical Center leadership.

Associate Members: Associate members may be patient/family members or community members who participate in the work of the PFAC without voting privileges. Associate members must be approved for membership as outlined above. Associate members may represent the PFAC committees and projects if their volunteer status is current and active.

Emeritus Members: PFAC members who have completed their term may apply for emeritus membership. Upon acceptance, they will be welcome at all PFAC meetings and will continue to represent the council on committees and projects if their volunteer status is current and active. They will not have PFAC voting privileges.

Section IV

Officers:

*Nomination Procedure: Candidates for positions will be nominated from PFAC members having at least one year of experience as a PFAC member. A nominating committee may be selected by the PFAC. Nominations will also be accepted from the floor prior to election. *Election Procedure: Officers will be elected by the affirmative vote of the majority of the members present and voting.

Chairmanship: PFAC will have two co-chairs a minimum of one must be a current (within five years patient/family member). *Chair terms will be two years and will begin on alternating years.

Should the term of the co-chair extend beyond his/her membership term, his/her membership term will extend to the end of his/her co-chair term.

The co-chairs’ responsibilities will include: providing leadership for the PFAC members, setting meeting agendas, facilitating meetings and reporting to the CPC.

*Inaugural years: UMass Memorial staff will serve as co-chairs until a patient/family member co-chair is in place.

Co-chairs will nominate replacement co-chair candidates for ratification by majority of the members present and voting.

For the first three years of the PFAC, it will have the discretion to adjust the co-chair terms as needed to achieve staggered terms.

Other officer positions may be established, as needed.

Section V:

Duties, Functions and Responsibilities

1. The PFAC shall meet a minimum of nine times a year, at least once per quarter.

Co-chairs shall have the authority to cancel meetings for good cause.

2. Minutes will be recorded, approved by PFAC members, shared with CPC and retained for a minimum of five years.

3. The PFAC shall report to CPC and provide written updates, including accomplishments of the council, at least annually.

4. The UMass Memorial PFAC will provide a liaison to other advisory committees/councils to share information and prevent duplication of effort.

5. The PFAC will define new member and ongoing orientation and training at least annually.

6. This charter shall serve as policies and procedures for the PFAC unless stated otherwise in a separate document.

Adopted 1/25/11 Revised 10/25/11