Engaging Patients to Improve Outcomes

1. Engaging Patients to Improve Outcomes Essential Hospitals Engagement Network July 25, 2013

2. Our new Name We’ve rebranded! The National Association of Public Hospitals and Health Systems is now America’s Essential Hospitals. Although we’ve changed our name, our mission is the same: to champion hospitals and health systems that provide the highest quality of service to all by achieving the best health outcomes for every patient, especially those in greatest need. The new name underscores our members’ continuing public commitment and the essential nature of our work to care for the most vulnerable and provide vital community services, such as trauma care and disaster response. This is an exciting time for us and our members, as we lean forward into new care models, opportunities and challenges of reform, and quality and safety innovations that often take root in our member systems. Our new website address: www.EssentialHospitals.org

3. “Q&A” and Chat Please use the “Q&A” or Chat tools on the webinar screen to type in your questions or comments at anytime during this event.

4. Raise your Hand To raise your hand – you must be in the “Participants” pane. Your line will be un-muted to ask your question. Once your question has been answered, plus un-raise your hand.

5. Speaker information John W. Young, RN, MBA Improvement Coach Essential Hospitals Engagement Network

6. Today’s agenda • Background • Practice Improvement Teams: Pearls for effective partnerships – Cambridge Health Alliance (Cambridge, MA) • Measurement and telling the story: Institute for Patient- and Family-Centered Care (Bethesda, MD) • Reaction from an EHEN member: Harbor-UCLA Medical Center • Q & A

7. Partnership for Patients (pfp) • A public-private partnership to help improve the quality, safety and affordability of health care for all Americans, funded by CMS Innovation Center through the Affordable Care Act • PfP Goals: • Decrease 9 preventable hospital-acquired conditions (HACs) by 40 percent • Infections (CLABSI, CAUTI, SSI, VAP) • Morbidity from immobility (falls, pressure ulcers, VTEs) • Adverse events (drugs, obstetrical) • Reduce preventable readmissions by 20 percent • Engage patients and families to accomplish harm reduction goals

8. Essential Hospitals Engagement Network (EHEN) • The PfP funds 26 Hospital Engagement Networks (HENs) to provide a wide array of initiatives and activities to improve patient safety. • HENs represent 3,700 hospitals nationwide. • Essential Hospitals Engagement Network (EHEN) is the only HEN in the PfP community focused on serving society’s most vulnerable populations • Special Focus: increasing health equity

9. Speaker information Somava Stout, MD Vice President of Patient Centered Medical Home Development Cambridge Health Alliance Principal Faculty - Leadership, Management and Innovation, Harvard Medical School Center for Primary Care Ziva Mann, MA Customer Lead Cambridge Health Alliance

10. Patient Partnership in PIT Teams - Lessons LearnedJuly 25, 2013 Ziva Mann Patient Partner on PIT Team Customer Lead, CHA Soma Stout VP PCMH Development, CHA @challiance

11. Cambridge Health Alliance 100,000 underserved patients, served by integrated care delivery system (10 clinics, 2 hospitals, specialty sites) Public health Community Health (7 Cities) Customers

12. Why? • We need to improve healthcare substantially, in order to meet the needs of our patients. • We can only come to the right solutions if we are designing with the patient. • NCQA core competency – every patient centered medical home has to meaningfully engage patients in the redesign of healthcare.

13. Models for partnership

14. Goal • Create practice improvement teams from a cross-section of staff and patients. • Patients and families working with clinic staff to make primary care more effective. • Core principle of patient centered medical home transformation: to design with rather than for the patient.

15. Steps Along the Journey • Systemwide Patient and Family Advisory Council formed. • Had health center patient and family advisory councils, but not sustained. • Walking in the Patient’s Footsteps • Patient and family partners as part of PCMH practice improvement teams piloted. • Spread this approach throughout primary care.

16. What we learned: • Patient-professional partnerships led to more effective redesign of care. • Patient/Family Partners were intimately involved with practice redesign at every step: from observing the patient experience, to piloting proposed changes to staff training, to design of practice improvements. • We found potential mistakes earlier and got much deeper and richer feedback. • It was challenging, and required team-building, trust and facilitation on both sides. • Learned that we often needed to fix the basic improvement process itself for all team members.

17. Building trust and partnership • Becoming aware of power/hierarchy and how to equalize as much as possible. • Healthcare team members were anxious about patients seeing the “sausage being made” and wouldn’t want to be seen there anymore. • Patients worried about offending their healthcare team by criticizing the clinic and about tokenism.

18. Who is an effective patient partner? • “experience from existing programs suggests that important considerations are the patients' abilities to: • work with the health care team • their breadth of experience with the health care setting • their ability and willingness to communicate concerns • [their] ability to represent patients and families broadly rather than focus narrowly on a particular issue.”1 • In addition, we look for leadership, listening skills and availability 1. Scholle SH, Torda P, Peikes D, Han E, Genevro J. (2010). Engaging Patients and Families in the Medical Home. (Prepared by Mathematica Policy Research under Contract No. HHSA290200900019I TO2.) AHRQ Publication No.10-0083-EF. Rockville, MD: Agency for Healthcare Research and Quality.

19. Foundation of readiness Lifecycle of Customer Partnership Departure Recruitment Team Integration Ongoing support

20. Foundation of readiness • Leadership engagement to partner with patients in systemwide design processes. • Shared vision and agreement of what the improvement work is and what role the improvement team and patient partners will play. • Understanding of the role customer partners will play and address their concerns. • Trust, relationships, and effective structures and processes within the Practice Improvement Team: • If not, relaunch your teams to develop this. • Need at a basic level: agreement about shared purpose, norms of collaboration and an understanding of who the people in the room are and what they bring to the table. • Streamlined HR onboarding process for customer partners. • Funding, if needed. • Ongoing support and resources available to help teams and patient partners to develop. 12

21. Recruitment: Slow down to go fast • Identify 4-5 potential patient partners. • Have an informational call to introduce the concept and invite several potential patient partners to an interview. • Explaining: who we are, team goals, team projects to date, patient partner role in these. • Interview several patient partners and see if the partner is interested and able. • Show value: What would make it easier for you to participate? • Clarify mutual expectations. • Select final patient partners; consider other roles such as Advisory Council membership or focus group participation for those who are not accepted. • Sign agreement.

22. Team integration: where am I and who am I? • Orient the patient partner to the clinic structure, systems in place, goals for improvement. • Orient the patient partner to the shared purpose of the team, team resources, and the “norms for collaboration.” • good opportunity to revisit this for the whole team • if you never developed these, consider relaunching your team • Orient to shared concepts and language the patient partner may not yet understand: jargon is a dialect! • Review team’s work to date and the patient partner’s role in these. • Provide a mentor (ombudsperson) and a team buddy.

23. Ongoing Support (for as much of the team as possible) • Building skills:active listening, managing conflict, telling your story, looking beyond your backyard, understanding improvement and change management. • Connecting partners: networks of shared effort to catalyze change; peer mentorship.

24. Departure • Debrief with the customer partner and the team. • Conduct an exit interview • Identify possible alternate opportunities for participation • Departure feedback questionnaire • Assure no change in the relationship as it relates to their care and to the practice. • Express appreciation. • Identify opportunities for future engagement.

25. How customer partners have helped change our system • Helped set the agenda for improvement • Lead the team (co-chair) • Refill process, access, new patient orientation, better care transitions, patient-centered care coordination process • Give depth to the patient experience and improvement processes • Redesign of Walking In the Patient’s Footsteps to formally assess effectiveness of patient-centered interactions • Break impasses and catalyze a move forward • Shared care plans for mental health • Adoption of patient portals, social media • Be an active partner/leader in creating the change • Revised pediatric patient instructions to be readable to patients • Redesigned waiting rooms, mental health referrals • Educational events for patients, online resources for parents

26. Contact Information • Ziva Mann • zmann@challiance.org • Soma Stout • sstout@challiance.org

27. Resources • Society for Participatory Medicine and the Journal of Participatory Medicine www.participatorymedicine.org • Institute for Patient- and Family-Centered Care. www.IPFCC.org • NICHQ (PFAC toolkit and “Powerful Partnerships”) www.nichq.org • Coming soon! Our toolkit on partnering with patients on QI teams. Safety Net Medical Home Initiative www.safetynetmedicalhome.org • And your biggest resource--YOU!

28. Questions / Comments

29. Speaker information Beverley H. Johnson President/CEO Institute for Patient- and Family-Centered Care

31. Patient- and Family-Centered Care: Approaches to Measurement Beverley H. Johnson IPFCC President and CEO America’s Essential Hospitals Safety Network HEN July 25, 2013

32. In our time together . . . • Discuss ways to collaborate with patients and families in developing a sustainable monitoring system to track outcomes of patient- and family-centered practice. • Learn strategies to measure patient- and family perceptions of care as well as the process and impact of partnering with patient and family advisors.

33. Patient- and Family-Centered Core Concepts • People are treated with respect and dignity. • Health care providers communicate and share complete and unbiased information with patients and families in ways that are affirming and useful. • Patients and families are encouraged and supported in participating in care and decision-making at the level they choose. • Collaboration among patients, families, and providers occurs in policy and program development and professional education, as well as in the delivery of care.

34. Patient and Family Engagement Patient and family engagement is a strategy for building a patient- and family-centered system of care. It is a priority consideration and essential to health reform at four levels: At the clinical encounter…patient and family engagement in direct care, care planning, and decision-making. At the practice or organizational level, patient and family engagement in quality improvement and health care redesign. At the community level, bringing together community resources with health care organizations, patients, and families. At policy levels locally, regionally, and nationally.

35. Individuals responsible for organizational measurement and dashboards create opportunities to involve patients and families in their work.

36. Patient and family advisors meet annually with senior leaders responsible for strategic planning to discuss the organization's dashboard and other measures for patient- and family-centered care. Semi-annual reports are submitted on the composition and work of the patient and family advisory council and other advisor endeavors. Bronson Medical Center Kalamazoo, Michigan

37. Families as Full Research Partners — King County Blended Funding Project Children’s Mental Health Program Vander Stoep et al, The Journal of Behavioral Health Services & Research, 1999.

38. University of Michigan Health System Quality Measures Using the STEEP Framework, health care should be patient-centered: Patients' ratings of care. Patient complaint and commendation trends. % compliance with advance directives. Health Education Resource Center statistics. # of patients and family members on health system committees and advisory groups. Interpreter services: # of requests. # of languages provided. • Strong, et al, The Joint Commission Journal on Quality and Safety, 2009.

39. Happy Health System Patient- and Family-Centered Care DashboardDecember 2013 PATIENT AND FAMILY ADVISORS 00 advisors and 00.00 hours and name of Patient and Family Advisory Councils (PFACs) 00 Committees/teams with advisors Committee name(s) 00 Partnership Oversight Committee Meetings 00 Staff/clinicians involved with collaborative endeavors Issues or types of issues addressed/resolved: Media Coverage: PATIENT/FAMILY PERCEPTIONS OF CARE (HCAHPS and Custom Questions Survey) How often did nurses listen carefully to you? How often did nurses explain things in a way you could understand? How often did doctors listen carefully to you? How often did doctors explain things in a way you could understand? Degree to which patient and family were able to participate in decisions about your care. How well staff explained their roles in your care. Degree to which the staff involved/supported your family in planning and managing care. Degree to which your choices were respected to have family members/support persons with you during your care. Patient preferences included in transition planning. Before leaving hospital, patient understands his/her responsibilities for managing his/her health. Patient understands purposes of medications. STAFF SURVEY AND RETENTION RATE Happy Hospital is committed to patient- and family-centered care at all levels of the organization. 00% Partnering with patients and families and engaging them in care planning and decision-making leads to better clinical outcomes and more efficient use of health care resources. 00% Involving patient and family advisors as part of improvement teams and in program development is beneficial. 00% Retention Rate PHYSICIAN SURVEY AND RETENTION RATE Happy Hospital is committed to patient- and family-centered care at all levels of the organization. 00% Partnering with patients and families and engaging them in care planning and decision-making leads to better clinical outcomes and more efficient use of health care resources. 00% Involving patient and family advisors as part of improvement teams and in program development is beneficial. 00%  Retention Rate PFCC SELF-ASSESSMENT ONLINE SURVEY

40. Degree to which you and your family were able to participate in decisions about your care. How well staff explained their roles in your care. Degree to which the staff involved/supported your family in planning and managing care. Degree to which your choices were respected to have family members/support persons with you during your care. Degree to which staff respected your family’s cultural and spiritual needs. NOTE: These questions, developed in partnership with patient and family advisors, are in the Public Domain and included in Press Ganey Custom Questions. Measuring Patient and Family Perceptions of Care

41. Please share one positive example from your recent office visit/hospital experience. Please share one example that could have been improved. If you could make one change in the care you received, what would it be? Another Approach to Learning about Patient and Family Perceptions of Care (postcard or interview format)

42. Pilot Unit for Patient- and Family-Centered CareMCG Neuroscience Results 2004-2010 • Patient Satisfaction – 10th to above 90th percentile. • Length of stay decreased – 50% in Neurosurgery. • Reduction in medical error by 62% for 2004-2006; 65% for 2006-2010. • Discharges (volume) increased 15.5%. • Staff vacancy rate – 7.5% to 0%; 5-7 RN’s on waiting list. • Change in perceptions of the unit by doctors, staff, and house staff.

43. Contra Costa Regional Medical Center and Health Centers held a value stream mapping event to improve behavioral health emergency care involving patient and family advisors, community providers, and Medical Center staff. Reduction by 50% in average number of psychiatric patients who left ED prior to receiving care; Saved 255 staff hours per month spent on obtaining patient medical clearances in the ED; and Reduction in assaults/aggressive acts reported in the ED. The percent of patients going back into the community with a full discharge plan has gone from 50% to 90%; and The percent of patients being discharged on multiple psychotropic drugs has been reduced. Measuring QI Projects with Patient/ Family Advisor Participation

44. Measurement of the Process and Impact of Patient and Family Advisory Councils

45. Measurement should be a regular agenda item for Patient and Family Advisory Councils. • An annual report should be produced to measure and tell the story of the process and outcomes of partnering with patient and family advisors.

46. http://www.ipfcc.org/advance/topics/annual-reports.html Patient and Family Advisory Council Annual Reports • Patient and Family Advisory Councils: A Review of 2011 PFAC Reports • Available from the Health Care for All at: www.hcfama.org

47. Include the number of: Patient and family advisors involved as well as their roles and activities. Clinical areas represented. Staff involved in collaborative endeavors. Issues addressed, products developed, classes taught, peer support programs coordinated, and other activities—describe these issues, materials, activities, and outcomes (when available). Meetings held with community leaders, government agencies, potential funders, accreditors, others. Develop an Annual Report to Share the Story and Profile Benefits of Partnering with Patients and Families

48. Summarize evaluations of classes taught to other patients, families, students, staff, physicians, new employees. Count the # of people who participate in classes. Capture quotes from participants in classes. Summarize stories that they share. Include changes in patient/family perceptions of care and clinical indicators. Take photographs (or scan) of products, activities, changes in physical spaces. Maintain a collection of all the products developed collaboratively. Record the # of media activities where advisors are featured. Develop an Annual Report to Share the Story and Profile Benefits of Partnering with Patients and Families (cont’d)

49. New IPFCC Resources with Information on Measurementhttp://www.ipfcc.org/resources/guidance/index.html