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UMass Memorial Medical Center Patient and Family Advisory Council Annual Report: October 2009 – September 2010

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UMass Memorial Patient and Family Advisory Council Annual Report October 2009 – September 2010   The UMass Memorial Medical Center Patient and Family Advisory Council was established in February 2010 with its first meeting March 23, 2010.

Purpose & Goal: UMass Memorial Medical Center is committed to providing patients with the highest quality, safest, patient and family centered care every day. The Patient and Family Advisory Council (PFAC) works in partnership with leaders and staff of UMass Memorial to improve care, enhance services and enrich the overall patient and family experience within the medical center. UMass Memorial recognizes that patients and family members are the “experts” on patient and family centered care. The PFAC provides patients and family members a voice in the decisions that affect how they receive care. The PFAC will advise the medical center on matters including, but not limited to: Patient and provider relationships, Policies and procedures related to care and caring, Quality improvement initiatives, and Patient education on safety and quality matters to the extent allowed by state and federal law.

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Membership: Current or former patients and family members are eligible to serve as Council members. Patients and family members work with select UMass Memorial leaders and staff that include the Chief Quality Officer, Chief Nursing Officer, Chief Medical Officer, Senior Director Quality & Patient Safety, Director Patient Experience, a physician of the Medical Group, a project manager from the department of Quality & Patient Safety and administrative support. Patient and family members must be at least eighteen years of age and demonstrate commitment to the purpose and function of the Council. Potential PFAC members were identified by medical center physicians, nurses, social workers, interpreter services staff and staff of the Quality and Patient Safety Department. Interested candidates were interviewed by members of the Department of Patient Experience to understand what types of services the candidate had received, specific areas of interest for improvement, unique skills of the member, and the member’s perspective on key elements of patient and family centered care. Through this process members were evaluated for: Their interest in servicing on the PFAC Ability to speak candidly among a diverse group of patients and hospital staff Good listening skills, able to listen to diverse opinions Respect of other’s ideas/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.

For the inaugural year of the PFAC, members were expected to attend monthly meetings, scheduled from 6 pm to 8 pm, March through September. Members were encouraged to become active members of select UMass Memorial committees, work groups, Lean improvement projects, and Planetree patient centered care initiatives. A minimum of 50% of Council members were patients or family members. Patient and family members completed a PFAC application and upon acceptance were enrolled as volunteers and completed a specified orientation that included but not limited to: Overview of UMass Memorial Medical Center: Mission, Vision and Values Overview of the PFAC “Our Commitments” Experience of successful PFACs (Dana Farber Cancer Institute – presented by 2 emeritus members of their council)

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HIPAA Safety and Security Emergency Management Utility Management Infection Control Patients and family members were offered to serve one year with the option to extend the term another year at their discretion. Roles of the members may include but are not limited to: Participation on committees, task forces, value streams, advisory boards; Review of publicly-reported quality or 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 nonclinical staff, in-service programs, and health professional trainees; Any other role in accordance with policies and procedures.

Governance: For the inaugural year of the PFAC the Director of Patient Experience and a Project Manager from the Department of Quality and Patient Safety served as co-chairs at the request of the patient and family members. The council’s request was honored with the expectation that at least one patient or family member would be elected as a co-chair by December 2010.

PFAC Member Engagement & Accomplishments, March – Sept 2010: The PFAC members identified opportunities for improvement and have engaged in hospital committees to improve quality, safety and patient experience. PFAC Vision and Mission developed by PFAC sub-group, accepted by PFAC (8/24/10) PFAC Charter: Sub-group of PFAC convened in August 2010 to finalize charter Greeter Program: PFAC members volunteering to assist in greeting and escorting patients, visitors and guests at UMass Memorial Wayfinding/Signage: Guided final decisions for signage and elevator enhancements to facilitate wayfinding. PFAC members participated in Pathways Project with Capital Planning and collaborated with Capital Planning in assessing improvement processes related to icons/symbols for signage and pathways within our University and Memorial Campuses. Improvement process initiated at University Campus August 2010.

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Care of Families of Trauma Patients: PFAC members participated in development of brochure for care of the families of trauma patients in the emergency department New Ambulatory Care Center Oncology Clinic: PFAC member worked with the Oncology staff to assess layout & design of new Oncology suite at the Ambulatory Care Center (ACC). Member participated in the Ribbon Cutting Ceremony and opening remarks for ACC on 9/15/10. Failure Modes and Effective Analysis (FMEA): Why Patients Arrive to the Wrong Campus for Services/Appointments PFAC member working with FMEA team to redesign patient appointment letters Discharge Process: PFAC member engaged in the “Discharge Value Stream� LEAN Project. The goal is to identify issues that delay discharge, assess how to remove wasteful delays and improve the timeliness of discharge. A multi-disciplinary team was assembled to address timeliness and quality issues related to the discharge process. This team met for a 3 day working session to review the current process, outline the ideal scenario, and to identify the countermeasures that will allow us to move from one to the other. Sub-groups have been formed to devise the countermeasures. The PFAC member is a participant on 5 such teams, focusing on making improvements in areas of: patient education, the PDI & Discharge Summary content, communication of the care plan, management of patient expectations and physician/patient interactions on day of discharge. Planetree Staff Retreat participation: PFAC members participate in Planetree Retreats with staff and physicians. The retreats promote patient and family centered care. Planetree Patient Centered Care Steering Committee: PFAC member served as liaison to this committee. Interpreter Service Workgroup: Improvements recommended by PFAC members to reduce the time to locate telephonic equipment to access interpreters. PFAC members are active participants on implementation task force which is ingoing.

Evaluation: Without feedback there is no learning. The PFAC members are periodically asked to evaluate the effectiveness of the meetings, appropriateness of agenda items, strengths of the PFAC and opportunities to strengthen the PFAC. Ongoing improvements are implemented based on this feedback.

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ADDENDUM:

PFAC Application Mission & Vision Draft Charter Work Plan

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UMass Memorial Medical Center Use Only Date application received by volunteer services : ____________ Application forwarded for review to: _____________________________ Date: __________

UMass Memorial Medical Center Patient and Family AdvisoryCouncil/Committee (PFAC) Membership Application Thank you for your interest in the Patient and Family Advisory Council/Committee. In order to be eligible to serve as a member of the PFAC either you or a family member must have received care within the UMass Memorial Medical Center. All applicants must successfully complete the UMass Memorial Medical Center (UMMMC) registration process of our Volunteer Services Department, this includes, but is not limited to: a health screening which includes TB screening, a criminal background check (CORI), a formal interview process, as well as a mandatory volunteer orientation. All of your information will be treated as confidential. Membership on the Council/Committee requires attendance at scheduled meetings. Please PRINT all information clearly: Name: _________________________________________________

Date of birth: ____________________

Mailing Address: _______________________ City/State/Zip Code: __________________________________ Telephone number(s): Please circle preferred phone number and best time to reach you: Home: ___________________ Cell: ____________________ Work: _______________________________ E-mail address: _____________________________________

Fax:

_______________________________

Please indicate if you are: (Check all that applies)  Patient with past/present care at UMass Memorial Medical Center  Family member of patient with past/present care at UMass Memorial Medical Center Family member’s name & relationship to you: ________________________________________________ At which UMass Memorial Medical Center campus(es) have you or your family member received care? University (Lake Ave. North) Memorial Hahnemann Other: __________________________________ Which Council/Committee(s) are you interested in joining?

 Council: General inpatient and outpatient adult and pediatric care  Committee: list interest(s): ___________________________________________________________ _________________________________________________________________________________ Why would you like to become a Council/Committee member? ________________________________________________________________________________________ __________________________________________________________________________________ ____________________________________________________________________________________________ ____________________________________________________________________________________________ ____________________________________________________________________________________________ ____________________________________________________________________________________________ ____________________________________________________________________________________________ Page 1of 2

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UMass Memorial Medical Center PFAC Membership Application Conditions of Volunteer Services (Please read before signing) Criminal Record Information Any applicant for volunteer service with a sealed record on file with the commissioner of probation may answer “no record” with respect to an inquiry herein relative to prior arrests, criminal court appearances or convictions. In addition, any applicant for volunteer service may answer “no record” with respect to an inquiry relative to prior arrests, court appearances and adjudications in all cases of delinquency or as a child in need of services which did not result in a criminal conviction. Have you ever been convicted of a felony? Yes No If yes, please give date & explain: ____________________________________________________________________________________________ _____________________________________________________________________________________________ Have you been convicted of a misdemeanor with the past 5 years? (Do not include a first conviction of drunkenness, simple No assault, speeding, minor traffic violations, affray or disturbance of the peace). Yes If yes, please give date & explain__________________________________________________________________

I certify that the statements made in this application are true and correct and have been given voluntarily. I understand that I will not be paid for my services as a volunteer member of the Patient and Family Advisory Council/Committee. I agree to abide by the guidelines of Volunteer Services, to respect patient confidentiality, and to uphold the mission and standards of UMass Memorial Medical Center. I understand that membership on the Patient and Family Advisory Council/Committee will be based upon approval from Volunteer Services, Employee Health, Director of Patient Experience and Council Co-Chairs. Professional staff will choose members/volunteers they feel are best suited for the Advisory Council/Committee based on interviews and group consensus. I understand that membership on the Council/Committee requires my commitment to attend scheduled Council/Committee meetings. Generally a one (1) year commitment is required unless otherwise determined by the Council or Committee you will be working with. _______________________________ Applicant’s Printed Name

_____________________________ Applicant’s Signature

____________ Date

For those applying as a family member: To assure compliance with Federal HIPAA regulations, family members must include patient’s name and obtain his/her permission signature to indicate that s/he understands and is in agreement that you may use his/her name and/or medical history in your capacity as Council member. _______________________________ Patient’s Printed Name

_________________________________ Patient’s Signature

___________ Date

If you have any questions related to completing this application please contact: The Department of Quality and Patient Safety at 508-421-1579, Monday-Friday 8:30am-4pm.

Please return completed application to: Volunteer Services, UMass Memorial Medical Center, University Campus, 55 North Lake Ave, Worcester, MA, 01655 Attention: PFAC OR E-mail to Volunteer Services at : MedCtrVo@umassmemorial.org

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UMass Memorial Medical Center Patient and Family Advisory Council Vision and Mission VISION The UMass Memorial Patient and Family Advisory Council (PFAC) seeks to foster a culture of care and caring where patients are nurtured in body, mind and spirit.

MISSION The Patient and Family Advisory Council seeks to promote safe and comprehensive patient and family centered care through:  The furtherance of compassionate and respectful provider-patient partnerships in care,  The inclusion of families/friends as defined by the patient,  The understanding of, respect for, and accommodation of diversity in family life, values, beliefs, customs and practices,  The encouragement of effective two-way communication,  The provision of personalized patient and family education available in ways that the patient/family understands,  The creation of a peaceful and healing environment,  The engagement of the larger community as partners in facilitating access to care and injury/disease prevention,  The involvement of patients and families in improving programs and services,  The consistency of care and caring for every patient, every family, everybody, everywhere. Adopted: 8/24/10

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UMASS MEMORIAL MEDICAL CENTER DRAFT – To be finalized by PFAC 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 (UMMMC), the PFAC assist the UMMMC 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

UMMMC is 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 UMMMC 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 UMMMC staff are eligible to serve as PFAC members. Members must be at least eighteen years of age and demonstrate commitment to the vision and mission of the PFAC. 1. A minimum of 50% of Council members are patients or patient family members. 2. All members must be in compliance with UMMMC 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 that routinely miss meetings may be removed or replaced at the discretion of the co-chairs. 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% of the membership. 1 of 3

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UMMMC Patient and Family Advisory Council Charter  Patient/Family Members: 1.

Potential members must submit a Patient and Family Advisory Council application to Volunteer Services.

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Preliminary interviews will be conducted by a member of the Patient Experience Department or designee.

3.

Potential candidates will be invited to attend a PFAC meeting.

4.

The co-chairs, with consideration of comments from the Council, 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 UMMMC required annual training.

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Council member terms: length of term will vary in order to achieve staggered rotation; terms will range 2-3 years to maintain consistency in membership (October 1st – September 30th).

UMMMC Staff Members: UMMMC members will be appointed by leadership of UMMMC. Associate Members: Associate members may be patient/family members or community members who participate in the work of the Council without voting privileges. Associate members must be approved for membership as outlined above. Associate members may represent the Council on committees and projects if their volunteer status is current and active. Emeritus Members: Council members who have completed their term may apply for emeritus membership. Upon acceptance, they will be welcome at all Council meetings and will continue to represent the council on committees and projects if their volunteer status is current and active. They will not have Council voting privileges. Section IV

Officers:

*Nomination Procedure: Candidates for positions will be nominated from Council members having at least one year of experience as a Council member. A nominating committee may be selected by the council. 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: The Council will have two co-chairs; a minimum of one must be a current (within 5 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 Council members, setting meeting agendas, facilitating meetings, and reporting to the CPC.

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UMMMC Patient and Family Advisory Council Charter  *Inaugural years:  UMMMC 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, the Council will have the discretion to adjust the cochair 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 9 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 5 years. 3. The PFAC shall report to CPC and provide written updates, including accomplishments of the council, at least annually. 4. The UMMMC 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 on-going orientation and training at least annually. 6. This Charter shall serve as policies and procedures for the council unless stated otherwise in a separate document.

Original: 12/2009, Revised 4/2010, 9/2010

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Patient and Family Advisory Council Work Plan UMass Memorial is committed to the implementation of a Patient and Family Advisory Council to be effective by October 1, 2010. The Patient and Family Advisory Council Work Plan, or the Plan, has been developed incorporating the requirements specified in the Department of Public Health, Hospital Licensure Regulations 105 CMR 130.1800 and 105 CMR 130.1801. The Plan documents a schedule to implement the Patient and Family Advisory Council in August 2010, however, UMass Memorial reserves the right to implement sooner at its discretion. Progress on the Plan will be reported to the Patient Experience Steering Committee. The following requirements will be incorporated into the development of the Plan: Regulation 105 CMR 130.1800 A. Establish a Patient and Family Advisory Council to advise the hospital on matters including, but not limited to:  Patient and provider relationships,  Institutional review boards,  Quality improvement initiatives, and  Patient education on safety and quality matters 2. Establish a Council no later than October 1, 2010. 3. Written report outlining the hospital’s plan to establish a Council no later than 9/30/09. 4. By October 1, 2010 and annually thereafter, prepare a written report documenting the hospital’s compliance with 105 CMR 130.1800 and 130.1801 and describing the Council’s accomplishments during the preceding year. 5. The reports will be publicly available through electronic or other means, and to the DPH upon request. Regulation 105 CMR 130.1801 A. Develop and implement written policies and procedures for the Council, which shall address, at a minimum, the following: 1. Purpose(s) and goals. 2. Membership including qualifications, selection, retention, term of service, and duties and election of officers. The Department recommends that the chair or co-chairs be current or former patient(s) or family member(s), or a staff person and a patient or family member. 3. Orientation, training and continuing education for members of the Council. 4. Roles of members of the Council, which may include the following as examples: A. Participation on committees, task forces, advisory boards; B. Review of publicly-reported quality information; C. Participation on committees addressing patient safety; D. Participation on search committees and in the hiring of new hospital staff; E. Participation in reward and recognition programs; F. As co-trainers for clinical and nonclinical staff, in-service programs, and health professional trainees; and G. Any other role in accordance with policies and procedures. 5. Responsibilities of members of the Council, including policies that address confidentiality of patient information. B. Required policies and procedures. 1. The Council shall meet at least quarterly. 2. Minutes of Council meetings shall be maintained for a minimum of 5 years. 3. Minutes of Council meetings including Council accomplishments shall be transmitted to the hospital’s governing body. 4. At least 50 percent of the Council members shall be current or former patients or family members and should be representative of the community served by the hospital.

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PFAC IMPLEMENTATION - ACTIVITIES/WORK

Target/ Actual

Status - Comments

PLANNING: Convene Core Team Purpose and goals for the PFAC Determine structure of the PFAC and draft policies & procedures Determine PFAC logistics Determine Committees / Hospital Events PFAC members might join Determine PFAC support requirements Draft Charter and/or Operating Guidelines

Determine Membership & Officer Guidelines

Create Recruitment Criteria for PFAC members Develop Orientation, Training, Continuing Education for PFAC members/ advisors Maintaining Success with PFAC – Tracking Accomplishments

10/30/09 8/5/09 11/27/09 12/09 11/27/09 12/09 11/27/09 12/09 11/27/09 12/09 11/27/09 12/09 1/8/10 11/27/09 12/09 1/8/10 11/27/09 12/09 1/8/10 11/27/09 12/09 2/26/10 2/5/10 Start 3/15/10 9/30/11

Complete Charter Drafted Structure complete, policies in development Charter Drafted Draft complete Absorbed with current staffing Charter Drafted

Charter Drafted

Draft complete Orientation Session scheduled 2/23/10 Initiated 3/15/10 Final report Due 9/30/2011

IMPLEMENTATION: Recruit Council members

4/16/10 2/20/10

Interview/evaluate prospective Council members

5/21/10 2/15/10

Final selection of initial Council members

5/21/10 2/15/10

Provide orientation, training, continuing education to Council members Establish agenda for 2-3 meetings

8/13/10 3/15/10 9/3/10 2/15/10

Training session scheduled 2/23/10 Completed, refer to final agendas

PFAC OPERATIONAL: PFAC Meeting Minutes to Hospital Board (CPC)

09/30/10

PFAC Annual Report Available

09/30/10

A detailed Plan will be kept during implementation and is available upon request.

Submitted by: Denise Skrocki, MS, RN Director Patient Experience Initiated 9/17/09, Status 10/15/10

Not Started On Schedule Falling Behind Behind Schedule Complete

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PFAC 2010 Annual Report