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UMass Memorial Medical Center Patient and Family Advisory Council Annual Report: October 2010 – September 2011


UMass Memorial Medical Center Patient and Family Advisory Council

Annual Report October 2010-September 2011

Purpose and Goal In 2011 UMass Memorial revised their former Medical Center Mission, Vision and Values to a new, all encompassing, system-wide, UMass Memorial Health Care hospitals Mission, Vision and Values. The values guide decision-making, are inclusive of patient and family members and consists of: consistently excelling at patient-centered care; acting with personal integrity and accountability; respecting one another; effecting change through teamwork and system thinking; and supporting our diverse communities.

In its quest to embody these values, UMass Memorial Medical Center seeks the insight of its patients and their family members. As such, the Patient and Family Advisory Council (PFAC) provides a voice for patients and family members by working 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. 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


In June the PFAC identified short-term (3 to 6 month) priorities for itself for driving change within UMass Memorial. The two areas identified for this purpose were improvement of facility cleanliness and increased engagement between medical center personnel and PFAC members.

Membership The membership of PFAC is comprised of current or former patients or their family members who are at least 18 years of age, and UMass Memorial leaders and staff. Membership has been sustained. After serving 12 months or greater, four patient/patient-family members resigned and two new patient/patient-family members joined the PFAC. Two of the members that resigned have stayed active in subcommittee work. The charter adopted this year stipulates that a minimum of 50% of PFAC members be patients or patient-family members. The current 24-member PFAC is comprised of 33% leaders and staff, 8% patient/patient-family members who are also UMass Memorial employees, and 59% patient/patient-family members. The leaders and staff who actively participate in the PFAC include the Chief Quality Officer, Chief Nursing Officer, Chief Medical Officer, Associate Chief Quality Officer, Senior Director Quality and Patient Safety, Director Patient Experience, a physician of the Medical Group, a project manager from the Department of Quality and Patient Safety and administrative support. Procedures regarding membership are set out in the new charter, which was approved by the Council in January 2011. It contains conditions of membership regarding training, orientation, confidentiality, participation, and voting. Membership types include the voting Full membership and the non-voting Associate membership. All current members are full members, but as new members are added to the Council, they will become Associate members first; then become eligible for full membership after three months and when a full member position opens up. Member terms are 2 to 3 years staggered to maintain consistency in membership as the Council rolls into its second full year.


Monthly Council meetings were held on the fourth Tuesday on the month 6pm-8pm with the exception of December. 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).

Council members continued their participation in UMass Memorial committees, work groups, Lean improvement projects, Planetree patient-centered care initiatives, as well as, became involved in new UMass Memorial initiatives. PFAC Members have also participated in PFAC formation activities, such as, writing a charter, developing a website, writing new member guidelines, and developing communication processes. By April, according to conditions of the charter, an expectation was set that members participate in an initiative outside of monthly meetings. They continue to be offered involvement throughout the medical center. Their 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.

Due to the resignation of a few members, two new members were recruited. The PFAC project manager and the patient/family co-chair interviewed new member candidates. Candidates were evaluated for: •

Types of UMass Memorial services the candidate had 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

The two new members who joined completed an application, and upon acceptance were enrolled as UMass Memorial volunteers. They completed all volunteer requirements and received training on: •

HIPPA

Safety and security

Emergency management

Infection control

Procedures regarding parking/ID badge

In the inaugural year all PFAC members were oriented as a group. Recently a PFAC patient/family member subcommittee has been formed to develop a formal process for assimilating new members. At this writing, the new member orientation guidelines are still under discussion.

Governance In September 2010, a patient/patient-family member of the PFAC was selected by the current co-chairs and unanimously approved by the Council to serve as co-chair. The Director of Patient Experience continues to serve as the other co-chair. A Project Manager from the Department of Quality and Patient Safety supports the co-chairs.

PFAC Member Engagement & Accomplishments The PFAC members have identified opportunities for improvement and have engaged in hospital committees to improve quality, safety, and patient experience.


For their recognition of outstanding work, PFAC members received the UMass Memorial Champions of Excellence Quality Care Team Award in 2011!

On-going participation in established committees: •

Planetree/Patient Experience Steering Committee: Four PFAC patient/family members participate in this committee to provide both consultation and review of Planetree initiatives.

“Human Interaction/Communication” Component Team: Two PFAC patient/family members and two PFAC leader members participate in this subcommittee of the Planetree Steering Committee which is comprised of UMMMC staff, managers and patient/family members. 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.

Psychiatric Inpatient Planning Committee: One PFAC patient/family member participates in this committee to implement wellness initiatives at all care sites and transform services into recovery oriented services. One of their current projects is to plan for the relocation of a Psychiatric Treatment Center, redesign appropriate patient care services, and design the new center consistent with the Planetree principles of healing design.

Other committees/workgroups/Initiatives: •

Family Centered Trauma Care Initiative: Two PFAC patient/family members worked with the Emergency Department Trauma workgroup to improve the greet and communication process for families of Level One and Level Two trauma patients. As part of this work, they reviewed and offered feedback on the new UMass Memorial Children’s Medical Center “A Guide for Family and Friends of the Young Trauma Patient” and UMass Memorial “A Guide for Families and Friends of the Trauma Patient” that is used with adult trauma patient families or friends.

Wayfinding/Signage: Three PFAC patient/family members have continued to partner with Capital Planning to improve signage and pathways at three campus sites.


Quality and Patient Safety External Web site update: A PFAC patient/familymember worked collaboratively with Quality and Patient Safety staff to update this external site.

Facebook /Social Marketing 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. Launch scheduled for Fall 2011. Www.facebook.com/umassmemorial

PFAC Cleanliness Improvement Partnership with Housekeeping: Three PFAC patient/patient-family members work collaboratively with the Housekeeping Department through rounding and manager meeting participation.

Patient Education Committee: Three patients of UMMMC are assisting UMMMC with review and improvement of inpatient education materials.

“Ask Me” Greeter Program: Two PFAC patient/family members participate in the greeter “Ask Me” Program.

LEAN Training & Participation in Lean Projects/Value Stream Mapping (VSM) •

Discharge VSM and multiple A3s: One PFAC patient/family member participates in this project to improve timeliness of and quality of discharge.

Interpreter A3 Workgroup: The workgroup was formed after a PFAC member shared his story and identified opportunity for improvement in telephonic interpretation wait time. Two PFAC patient/family members and two PFAC staff members participated in this project to reduce inpatient wait time for telephonic interpreter services.

Ambulatory Internal Referral VSM and A3: One patient/family member and two PFAC leaders participate in this project to improve referral time and process for referrals from Primary Care and ED to specialty clinics .

Inpatient Flow VSM and multiple A3s: One PFAC patient/family member participates in this project to reduce the amount of time it takes for a patient in the emergency department to be admitted to a floor and the floor to discharge a patient once discharge plan determined.

3 PTC Move VSM: One PFAC patient/family member participates in this project to assess and plan for space and the environment to move Psychiatric services to a new location


Educational role of PFAC members: •

“The Healing Nature of Tenderness and Compassion in Caring for the Ill,” a one-hour program held for UMMMC staff 12/7/10 and 12/10/10. Three panelists participated in the presentations and open dialogue with attendees: a PFAC patient, PFAC family member/caregiver and a health provider/clergy.

• PFAC member participation in Planetree: Patient Centered Care Staff Retreats: Patient/family members have added the patient perspective to these retreats; which has opened dialogue and collaborative exploration of possible patient- and family-centered care initiatives/improvements. Twelve PFAC members have participated in a Planetree retreat. •

Interpreter A3 to be presented at the 2011 International Conference on Medical Interpretation (IMIA) at the Harvard Medical School on October 1, 2011. The presentation entitled "Plan-Do-Study-Act: Methodology to Improve Patient-Family Center Care" , describing the Interpreter A3 Workgroup and the impact the patient voice can have on improving care, will be made by a PFAC staff member and Interpreter Service staff.

Subcommittee work and projects within PFAC: •

PFAC Web: Eight PFAC subcommittee members collaborated with the Marketing and Communications Department to develop and launch both an external and internal PFAC Web site. www.umassmemorial.org/pfac

PFAC Orientation Subcommittee: Nine PFAC patient /family members established PFAC orientation process and materials.

PFAC patient /family member access to UMMMC Internet: Core group of five PFAC patient/family members and two UMMMC staff members worked with Information System staff to established PFAC member pathways/links with UMMMC Internet for the purpose of Share Drive communication and review of Hospital Newsletters, etc. Currently this group is in the process of revising the pathway to make more “user friendly.”

HCAHPS Interpretation project: All PFAC members began a project to provide to UMMMC staff a patient/family interpretation, through the patient lens, of the HCAHPS questions

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


PFAC 2011 Annual Report