Patient and FamilyAdvisory Council

Annual Report 2016

Promoting Patient- andFamily-Centered Care

Collaboration:

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SuburbanPatientandFamilyAdvisoryCouncilMembers

PatientandFamilyAdvisors StaffAdvisors

StephenBokat DianeColgan,MD,MedicalStaffChair

EllenSueBrown EuniceD’Augostine,MSN,RN,NursingDirector,AdultMedical

ElsieDurland KimberleyKelly,MBA,RN,Director,CriticalCare

HowardGilson JosephH.Linstrom,VPOperations

JuneGraff AmirNader,MD,ProgressiveCardiacCareUnitMedicalDirector

JoelHirschhorn JenniferRaynor,Director,Pharmacy

CarolHollins AtulRohatgi,MD,AssistantMedicalDirector,HospitalistGroup

KittyJones JackySchultz,MSN,RN,ExecutiveVPandInterimPresident

BarbaraKahl LeighAnnSidone,*MSN,RN,OCN,CENP,VP/ChiefNursingOfficer

DeborahKovach BethVanderscheuren,Manager,OfficeofPatientandFamilyExperience(throughDecember2015)

BarrieKydd

BeverlyLabourdette

TobyLevin*

DanMoskowitz

BelleO’Brien

VickiStearn

SarahSteinberg

SahibaZubairi

MarkZweig

*PFACCo-Chairs

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Toprow:DianeColgan,MD;AtulRohatgi,MD;AmirNader,MD;KimKelly,MBA,RN.Fourth

row:MarkZweig;HowardGilson;EuniceD’Augostine,MSN,RN;KittyJones;JuneGraff.Third

row:BelleO’Brien;DeborahKovach;JoelHirschhorn;ElsieDurland.SecondRow:VickiStearn;

BarbaraKahl;SarahSteinberg;Ellen-SueBrown;TobyLevin(Co-Chair).Frontrow:Stephen

Bokat;JoeLinstrom;LeighAnnSidone,MSN,RN,OCN,CENP(Co-Chair).

NotPictured:CarolHollins;BarrieKydd;BeverlyLabourdette;DanMoskowitz;JenniferRaynor;

JackySchultz;andSabihaZubairi.

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PFACCo-ChairandVP/ChiefNursingOfficerLeighAnnSidonepresentedthe2016PFACPatient-

andFamily-CenteredCareLeadershipAwardtoExecutiveVPandInterimPresidentJacky

SchultzandPFACCo-ChairTobyLevin.

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SuburbanHospitalPatientandFamilyAdvisoryCouncil

AnnualReportJune2016

Collaboration:PromotingPatient-andFamily-CenteredCare

I.Introduction

SuburbanHospital’sPatientandFamilyAdvisoryCouncil(PFAC)ispleasedtoissueitsfourthAnnual

Report.1Thisyear’sreportsummarizesthePFAC’sactivitiesfromAugust2015throughJune2016,a

periodofgrowthandmaturity.Duringthistime,thePFACfocusedonpromoting“collaboration,”oneof

thefourcoreconceptsofpatient-andfamily-centeredcare(PFCC).2ThroughPFACparticipationacross

Suburban’squality,safety,andservicecommittees,councils,andinitiatives,PFACenthusiastically

supportsSuburbanleadership’seffortstobuildaPFCCcultureatSuburbanHospital.ThisPFCCjourney,

whichPFACinconjunctionwithleadershipbeganinearnestin2012,willbeongoinganddynamic,

changingtomeettheneedsofpatients,families,andstaff.Itssuccesssometimesmaybedifficultto

measure,butevidenceisgrowingthatPFCCproducesmultiplebenefits:3

• Reductioninmedicationerrors;

• Fewerpatientreadmissions;

• Improvedhealthoutcomesforpatients;

1TheearlierPFACAnnualReportsareavailableathttp://www.hopkinsmedicine.org/suburban_hospital/about_the_hospital/patient_family_advisory_council/.ThefirstAnnualReportprovidesinformationaboutpatient-andfamily-centeredcare,thehistoryoftheestablishmentofSuburban’sPFAC,andadescriptionofitsinitialprojects.ThesecondAnnualReportsummarizestheprogressmadeimplementingthe2013-2014StrategicPlan.ThethirdAnnualReportfocusesonPFAC’seffortstobuildacultureofPFCCthrougheducationandcommunicationprograms.2SuburbanhasadoptedthePFCCcoreconceptsarticulatedbytheInstituteforPatient-andFamily-CenteredCare:Respectanddignity:Healthcarepractitionerslistentoandhonorpatientandfamilyperspectivesandchoices.Patientandfamilyknowledge,values,beliefs,andculturalbackgroundsareincorporatedintotheplanninganddeliveryofcare.InformationSharing:Healthcarepractitionerscommunicateandsharecompleteandunbiasedinformationwithpatientsandfamiliesinwaysthatareaffirminganduseful.Patientsandfamiliesreceivetimely,complete,andaccurateinformationinordertoparticipateeffectivelyincareanddecision-making.Participation:Patientsandfamiliesareencouragedandsupportedinparticipatingincareanddecision-makingattheleveltheychoose.Collaboration:Patientsandfamiliesareincludedonaninstitution-widebasis.Healthcareleaderscollaboratewithpatientsandfamiliesinpolicyandprogramdevelopment,implementation,andevaluation;inhealthcarefacilitydesign;andinprofessionaleducation,aswellasinthedeliveryofcare.www.ipfcc.org3SeefirstPFACAnnualReportaswellasthefollowingarticlesdocumentingthesebenefits:AgencyforHealthResearchandQuality:http://www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/engagingfamilies/howtogetstarted/How_PFE_Benefits_Hosp_508.pdfTheClevelandClinic:https://hbr.org/2013/05/health-cares-service-fanaticsAmericanHospitalAssociation:http://www.aha.org/content/00-10/resourceguide.pdf

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• Greaterpatientandfamilysatisfactionwiththeircareandexperience;and

• Greaterstaffsatisfactionwiththeirwork.

ConcreteevidenceofSuburban’seffortstopromoteculturechangeisseenbytrackingimprovements

usingthefederalCentersforMedicareandMedicaidHospitalConsumerAssessmentofHealthcare

ProvidersandSystems,betterknownbyitsacronym“HCAHPS.”4TheHCAHPSSurveyisastandardized

nationalsurveyinusesince2006tomeasurepatients'perspectivesofhospitalcare.5InApril2015,CMS

addedHCAHPSStarRatingstoitssurveyanalysis.TheStarRatingsprovideaneasywayforconsumersto

usethesurveyinformation.ConsumerscanviewtheStarRatingsat

https://www.medicare.gov/hospitalcompare.Suburbanhasprogressedfromitsinitialtwo-starrating

(outofapossible5)tothree-stars,andiscontinuingtoseeimprovementsintheunderlyingmeasures

eachquarter.6

Suburbanleadershipbelievesthatthegrowingculturechange—onethatputspatientsandfamiliesat

thecenterofcareandholdsstaffaccountabletoworktogetherasateamandtoberespectfuland

responsivetoeachother—islargelyresponsibleforthisimprovement.ThePFAChasplayedacentral

roleinpromotingacultureinwhichpatientsandfamiliesarepartnersinpatientcare—treatedwith

respectanddignity—andreceivingthehealthinformationtheyneedtoparticipateindecision-making

abouttheirconditionandtreatment.ThisthemeofpartnershipflowsthroughouttheworkofthePFAC

andisevidentinthecollaborativeroleithasplayedthisyear,workingwithstaffonovertwenty-five

committees,collaboratives,andcouncils.IntheearlyyearsoftheCouncil,manystaffwereunawareor

evenreluctanttobringpatientfamilyadvisorsintotheirunits,departments,andinitiatives.Now,

however,thePFAC’scontributionsgroweachyearasmoreandmorehospitalstaffrequestpatient

familyadvisorparticipationintheirinitiativesandoperations.Bybringingthepatientfamilyvoiceinto

departmentalandhospital-widecommitteesandprograms,PFCCcanbecomeembeddedintohospital

policiesandoperations.

II.PFACOrganizationalDevelopments

InOctober2015,thePFACrevieweditsCharteroriginallydraftedin2012.Thevision,mission,andmembers’responsibilitieswereupdatedtobettercapturetheCouncil’sroleatSuburban.Thenew

4ForinformationaboutHCAHPS,seethefactsheetathttp://www.hcahpsonline.org/Files/HCAHPS_Fact_Sheet_June_2015.pdf5Thesurveyincludessevengroupsofquestionsregarding:(a)howwellnursesanddoctorscommunicatewith

patients;(b)howresponsivehospitalstaffaretopatients’needs;(c)howwellhospitalstaffhelppatientsmanage

pain;(d)howwellthestaffcommunicateswithpatientsaboutnewmedicines;(e)whetherkeyinformationis

providedatdischarge;and(f)howwellpatientsunderstoodthetypeofcaretheywouldneedafterleavingthe

hospital.Inaddition,twoindividualitemsaddressthecleanlinessandquietnessofpatients’rooms,andtwoglobal

itemscapturepatients’overallratingofthehospitalandwhethertheywouldrecommendittofamilyandfriends.

6Foradescriptionofhowthestarsarecalculated,seehttp://www.hcahpsonline.org/Files/HCAHPS_Stars_Tech_Notes_April_2016.pdf

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charterincreasesthesizeoftheCounciltoupto20patientfamilyadvisorsand10staffadvisors,withagoalofmaintainingaratiooftwopatientfamilyadvisorsforeverystaffadvisor.Anominatingcommitteewascreatedtoconducttheco-chairelectionandreappointmentofadvisors.SeeAttachmentAforthenewCharter.7TheendofthisyearalsomarkedachangeinPFACleadership.AttheJune2016meeting,TobyLevinsteppeddownasthePFAC’sfirstco-chairafterservingsince2012.SheintendstoremainactiveontheCouncil.ThePFACunanimouslyelectedStephenBokattoatwo-yeartermasco-chair.LeighAnnSidone,theVP/ChiefNursingOfficer,willcontinuetoserveasthestaffco-chair.III.SourcesofCultureChangeatSuburban

Manythoughtleadersinhealthcarehavepointedoutthat“culturechange”isajourneyandnota

destination.8Progresstowardculturechangehasbeenveryevidentthispastyearinthecontributionsof

theOfficeofPatientandFamilyExperience(OPFE)andSuburbanleadership’seffortstoimprovestaff

communicationwithpatientsandfamilies.TheOPFE’sfirstmanager,BethVanderscheuren,before

leavingSuburbaninDecembertoassumeasimilarrolefortheJHCommunityPhysicians,playeda

leadingroleinpromotingseveralinitiativestoimprovethepatientandfamilyexperience.Bethworked

withPFACtoimprovethepatientandfamilyexperienceintheSurgicalLounge.Thevolunteersstaffing

theSurgicalLoungeweretrainedtoprovidefrequentupdatestofamilieswaitingwhiletheirlovedones

underwentsurgery.PatientfamilyadvisorshelpedBethimplementspecialprojectstoliftpatients’

spiritsonfestiveholidayssuchasValentine’sDay.BethalsoworkedwithSuburbanleadershipto

improvethepatientexperiencebygivingunitmanagerscustomizedreportsoftheirHCAHPSscoresso

thattheycouldtargetareasforimprovementandrewardtheirstaffsasscoresimproved.Inaddition,

sheworkedwithHumanResourcesandrepresentativesfromotherdepartmentstodeviseanEmployee

RecognitionprogramtosupportimplementationofSuburban’sStandardsofBehavior,whichguide

employees’interactionswithpatients,families,andstaffandserveasakeycomponentoftheiryearly

evaluation.

Suburbanlaunchedtwomajorinitiativestostrengthencommunicationskillsacrosstheentirehospital.

FirstistheLanguageofCaring®,whichSuburbanbeganinsummer2015withplanningand

implementationinitiallyledbyOPFE.Thisprogramwillcontinueuntilallstaff,excludingphysicians,

completetheprogram’stenmodules.9AnumberofPFACpatientfamilyadvisorsparticipatedas

facilitatorsintroducingtheprogram’sconceptsduringtheJumpStartphaseofthelaunch.

7Availableonlineathttp://www.hopkinsmedicine.org/suburban_hospital/about_the_hospital/patient_family_advisory_council/council_charter.html8https://www.isixsigma.com/implementation/change-management-implementation/making-journey-toward-culture-change-healthcare/9http://www.languageofcaring.comThemodulescoversuchcommunicationskillsas:“practiceofpresence,acknowledgingfeelings,showingcaringnonverbally,explainingpositiveintent,theblamelessapology,thegiftofappreciation,andsayitagainwithheart.”Theoverarchingconcept,however,istodelivermessagesthatare

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Second,spearheadedbyPFACStaffAdvisorandMedicalStaffChairDr.DianeColgan,Suburban

physiciansandnursepractitioners,aswellascommunityphysicianswithprivilegesatSuburban,will

receivetrainingthroughthePEARLScommunicationprogram.10Startinginthefallof2015,Dr.William

MaplesoftheInstituteofHealthcareExcellencetrainedsome12Suburbanphysiciansfrommultiple

departmentsandNancyMiller,DirectoroftheMedicalStaffOffice,astrainersinthePEARLSprogram.

TheacronymPEARLSstandsforpartnership,empathy,acknowledgment,respect,legitimation,and

support—which,whencombined,helpthehealthcareprovidercommunicatemoreeffectivelywith

patientsandfamilies.Dr.Maplescontendsthatthekeydriversthatdetermineexcellenceinpatient

experienceandengagementare“theabilityofthephysicianandcaregiverstobepresent,listentothe

patientsandeachother,demonstraterespectandcompassion,andconveytothepatientthathe/she

understandstheconcernsraisedbythepatient.”11Thispeer-to-peercurriculumisnowbeingtaughtby

Suburban’sownteam,andanumberofPFACpatientfamilyadvisorshaveparticipatedwithstaffduring

thesetrainingsessions,providingapatientandfamilyvoicewhilelearningfromthephysiciansabout

someoftheirmostdifficultcommunicationexperiences.HCAPHSscoresforphysiciancommunication

arealsoimproving,andmaybeinpartduetothistraining.

AthirdeffortisnowunderwayunderthedirectionofSuburban’shospitalistleadersMedicalDirectorDr.

EricParkandAssistantMedicalDirectorDr.AtulRohatgi.Attherequestofthehospitalists,thePFAC

helpeddesignandconductinterviewswithinpatientsandtheirfamiliesabouttheirexperienceof

hospitalistcare.Eightpatientfamilyadvisorsconductedseveralroundsofinterviewsonthreeunitsthis

spring.Therespondentsareanonymous;nopersonallyidentifiablepatientinformationisrecordedon

thequestionnaire,protectingtheprivacyoftherespondent.Theinterviewerdoesrecordthenameof

thespecifichospitalistunderreview.Thequestionsareopen-endedandinvitetherespondenttonot

onlyevaluatethequalityofhisorherhospitalist’scommunication,butalsotoasktherespondentto

providedetailsaboutthehospitalist’sspecificbehaviorsthatresultedintheirassessment.Drs.Parkand

Rohatgithenusetheseinterviewreportswiththeindividualhospitaliststogivethemfeedbackontheir

communicationskills,bothstrengthsandareasforimprovement.

Withthisyear’srenewedemphasisonimprovingstaffandphysiciancommunication,Suburbanis

alreadyseeingimprovementsinitsHCAPHSscores.Asmoreandmorestaffreceivetrainingand

feedbackregardingthequalityoftheircommunicationwithpatientsandfamilies,Suburbanlikelywill

seecontinuingimprovementsnotonlyinscores,butalsoinhealthoutcomesasimproved

communicationresultsinfewermedicalerrors,betterpatientandfamilyunderstandingofconditions

framedasaHeart-Head-Heart™sandwich,inwhichthestaffmemberbeginsacommunicationwitha“heart”messageconveyingcaringandempathy,followedbya“head”messagereflectinginformation,explanation,fixes,plans,andthencloseswithanotherheartcommunication.Theintendedresultisthatpatientsandfamiliesfeelthestaffmember’scompassionandwillrespondmorepositivelytotheinformationprovided.10http://www.healthcareexcellence.org/2016/04/creating-culture-excellence-effective-compassionate-

communication/11http://blog.prccustomresearch.com/the-problem-with-patient-experience

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andtreatment,andbetterdischargeplanningandtransitiontohome.ThePFACwillcontinuetosupport

alleffortstoimprovecommunication,asitisthenumberoneprerequisiteforPFCC.

IV.PFACCollaborationacrossSuburban

TheInstituteforPatient-andFamily-CenteredCaredefines“collaboration”asfollows:

Patientsandfamiliesareincludedonaninstitution-widebasis.Healthcareleaderscollaborate

withpatientsandfamiliesinpolicyandprogramdevelopment,implementation,andevaluation;

inhealthcarefacilitydesign;andinprofessionaleducation,aswellasinthedeliveryofcare.12

Includingthepatientandfamilyvoiceacrossthehospital’soperationsisnecessarytocreateacultureof

PFCC.InaPFCCculture:

• Patientsandfamiliesparticipatewithstafftomakedecisionsthataffectthequalityandsafety

ofpatientcare.

• Thedrivingforceforthedeliveryofhealthcareistheprioritiesandchoicesofpatientsandtheir

families.13

• ThestafflistenstothevoicesoftheirpatientsandfamiliesandengagesWITHthemratherthan

makingdecisionsABOUTandFORthemwithouttheirvoicesatthetable.

Overtime,participationofPFACpatientfamilyadvisorsonSuburbancommittees,collaboratives,

councils,andinitiativeshasbecomeroutine.Intheearlyyears,itwaschallengingtoidentifyhowPFAC

couldinteractwithSuburban’scomplexoperationalstructure.Moreover,PFACwasanunknownentity

tomoststaff,andthehospital’sPFCCmissionwasjustevolving.Overthepasttwoyearsadramatic

changeoccurred;patientfamilyadvisorsarewidelyrepresentedinhospitalmeetings,andstaffnow

initiaterequestsforPFACrepresentativestoparticipateontheirteams.Thischangeistheresultof

Suburbanleadership’ssupportforPFACparticipation,aswellasthegrowingreputationthatpatient

familyadvisorsaretrustedteamparticipantswhobringamuch-neededperspectivetoproblemsolving

andthedecision-makingprocess.

Thefollowingchartidentifiesthemanydifferentorganizations—committees,collaboratives,councils

andteams—onwhichpatientfamilyadvisorsnowparticipate:

12http://www.ipfcc.org/faq.html

13IPFCC,RecognizingtheDrivingForces,10.2010.

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PFACCollaboration

OrganizationName Purpose

AdministrativeServicesRepresentative(ASRs)Team

Amongtheirduties,ASRsprovideorientationforMyGetWellKitandschedulepost-hospitalizationmedicalappointments

ArmstrongInstitutePatientandFamilyCenteredCareClinicalCommunity

RepresentativesofallJohnsHopkinsMedicine(JHM)PFACsparticipatetopromotepatient-andfamily-centeredcareandharmonizePFACsacrossthesystem

CampusEnhancementProjectUserGroups Serveonmultipleusergroupsonthedesignofthenewbuildingincludingpatientrooms,lobby,diningservices,conferencecenter,wayfinding

ClinicalDecisionUnitAdvisoryCouncil PFACrepresentativesmeetwithunitleaderstoprovideadviceonunitinitiatives

ComprehensiveUnit-basedSafetyProgram(CUSP)Committees

CUSPsidentify“defects”andanalyzerootcausesanddevisesolutions.CUSPgoalistobuildastrongpatientsafetyculture.A“defect”isanythingthatmightleadtopreventablepatientharm.

CrossContinuumCollaboration Carecoordinationwithoutsiderehab,long-termcarefacilities,assistedlivingfacilitiesandhomehealthcareservices

DeliriumTeam PartofNursing’sEvidenceBasedCouncil.Identifyinginitiativestoreducedelirium

DiabetesChampions Anursingteamfocusedondiabeteseducationforstaffandpatients

DischargePlanningandReadmissionCommittee

Interdisciplinarygroupworkingtoimprovethedischargeprocessandpatientandfamilyeducation

EarlyAmbulationTeam Interdisciplinarygrouptosupportpatientmobility

EmergencyDepartmentCollaborative EDstaffmeettoreviewEDoperationsinpursuitofspeedy,safeandeffectivepatienttreatment.

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EpicWorkGroups:

(1)JHMPatient-FamilyCenteredDesignTeam

(2)JHMAVSWorkGroup

(1)System-wideworkgrouptoimproveMyChart–patient/familyportal

(2)System-wideworkgrouptoimprovetheAfterVisitSummary(AVS)

EthicsCommittee Smallgroupofphysiciansandothersdiscussethicalissuesraisedbypatientcare

FallsTeam PartofNursing’sQuality,Safety,andServiceCouncilfocusingonreducingtheincidenceoffalls

InfectionControlCommittee Reviewincidenceofinfectionsandhowtoreducethem

IntensiveCareCollaborative InterdisciplinarymeetingtoreviewmetricsforperformanceanddiscussissuesandinitiativestoadvancedeliveryofcaretoICUpatients

MedicalQualityCommitteeoftheBoard Boardcommitteeresponsibleforreviewingqualityofmedicalcare

MERIT(MedicationErrorReductionImprovementTeam)

PartofNursing’sQuality,SafetyandServiceCouncilfocusingonreducingmedicationerrors

MobilityInitiative Interdisciplinarymeetingtopromotepatients’earlymobility

Patient&FamilyEducationCommittee PartofNursing’sProfessionalDevelopmentCouncilfocusingonimprovingpatientandfamilyeducation

PatientEducationCouncil,JHM PatienteducationandplanofcareinterdisciplinaryworkgroupfocusingonimprovementstoEpic

PharmacyandTherapeuticsCommittee Interdisciplinarymeetingtoreviewpharmacyanddrugprocessesandpractices

ProgressiveCardiacCareUnit(PCU)Collaborative/UnitNursingCouncil

InterdisciplinarymeetingtodiscusssafetyissuesandresolutionsaffectingthePCU/PCUnursingteammeetstoimproveunitoperations

ProviderQualityCommittee Interdisciplinarymeetingtodiscussreadmissionanddischargeprocess

QualityandPatientSafetyCommittee InterdisciplinarymeetingtobriefHospitaldepartmentandunitleadersonqualityandsafetyprojectsandmetrics

Readmissions Interdisciplinarymeetingtoreviewandcoordinateinitiativestoreducereadmissions

ServiceofRemembrance Plansannualspringmemorialservicetohonorpatientswhodiedtheprioryear

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Inadditiontoitsparticipationonthesevariousoperationalteams,thePFACpromoteseducationand

implementationofPFCCthroughthefollowingactivities,manyofwhichwerefirstdescribedinits2015

AnnualReportandareongoingcommitments:

• ParticipateinNewEmployee(monthly)andVolunteer(periodic)Orientations;briefnewstaffand

volunteersonPFCCandtheroleofPFAC.

• AwardannuallythePFACLeadershipinPatient-andFamily-CenteredCareAward.Begunin2014,eachspringPFACpresentstheawardattheAnnualMedicalStaffawardsreception.Thisyear’srecipientswerePFACCo-Chair,TobyLevin,andlongtimePFACstaffadvisorandExecutiveVPandInterimPresident,JackySchultz.

• ReviewhospitalanduniteducationalmaterialsaspartofthePatientandFamilyEducation

Committee(e.g.,PalliativeCare,Oncology,ClinicalDecisionUnit,andDiabeteseducation)

• PromoteimprovementinPhysicianCommunicationbyestablishingthePFACPatientandFamily

Faculty.TheFacultyconsistsofpatientandfamilyadvisorswhohavecommunicationtrainingorare

skilledcommunicatorsandhaveexpertisebecauseoftheirexperiencesasapatientand/orfamily

memberofapatient.TheymayalsohaveexpertiseonhowtoimplementthecoreconceptsofPFCC.

Facultyconductedobservationsofhospitalistsandintensiviststoprovidefeedbackon

communicationskillsandmetwithphysicianleaderstodiscussadditionalrolesin2016-2017.

Interviewedpatientsandfamiliesaboutthecarereceivedfromthehospitalists,andhospitalist

leadersprovidedthisfeedbacktotheirteam.Alsoworkedwiththehospitalistteamtodevelopa

videoexplainingtheroleofthehospitalist,whichisnowavailableat

http://www.hopkinsmedicine.org/suburban_hospital/medical_services/care_team/hospitalists/.

• AttendandparticipateatperiodicSuburban’sLeadershipDevelopmentForumsandNursing

Retreat,aswellasArmstrongInstitutePatientSafetySummitandJHMTownHalls.

• ContinuestaffeducationaboutPFACandPFCCforunitsanddepartments.Mostrecenteducation

involvedEnvironmentalServicesandRegistration.Prioreducationincludedtheparkingattendants

andthehospitalsecurityteam.FutureeducationmayincludeDiningServices,Radiology,and

PhysicalTherapy.

• WorkwiththedirectorsoftheMarketingandPublicRelationsDepartment,theFoundation,and

CommunityHealthandWellnesstoeducatethecommunityaboutpatient-andfamily-centered

careandPFACthroughNewDirections,theSuburbanwebsite,andothercommunityoutreach

efforts.

• ContinuetorecruitnewPFACmembers,butwithafocusongreaterdiversity.Improveorientation

ofnewmembers.

• IncollaborationwithSuburban’sleadership,updatedSuburban’sFamilyPresencePolicytoinvite

patient’scarepartnertoremain24/7withonlylimitedexceptions.(Policyispostedonhospital

website.)

• WorkedwiththePatientandFamilyEducationCommitteeondraftversion2.0ofMyGetWellKit,anawardwinning,interactivetooltoeducatepatientsandfamilyabouttheirstayandtoempower

themtobeactivedecisionmakersinhealthcare.AlsoworkedwiththePatientandFamilyEducation

CommitteetodevelopadraftOutpatientHandbookandapatientorientationguideforBehavioralHealth,usingtheKitasamodel.

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• Incollaborationwithnurseleadersandstaffnurses,patientfamilyadvisorscontinuetodoobservationstosupportimplementationofBedsideShiftReport(BSR)onallunits.Theoriginalpilot,whichpatientfamilyadvisorshelpeddevelopforthePCU,wasincrementallyexpandedtoallunits.(Pilotplanningincludedresearch,implementationplanning,producingtrainingmaterials,participationintraining,anddesignofpreandpostimplementationofBSRquestionnairesandcompetencymetrics.)PatientandfamilyadvisorsconductBSRobservationswhenrequestedbyunitstohelpimproveandsustaintheprogram.

• WorkwiththePalliativeCareProgramtopromoteinformationaboutpalliativecareandend-of-life

conversationsanddecision-makingonSuburban’swebsite.Seenewresourcesandpagesatlinks

below.

PalliativeCare:

http://www.hopkinsmedicine.org/suburban_hospital/medical_services/specialty_care/palliative

-care/

HospiceCare:

http://www.hopkinsmedicine.org/suburban_hospital/medical_services/specialty_care/palliative

-care/hospice_care.html

CompassionateDecisionMaking:

http://www.hopkinsmedicine.org/suburban_hospital/planning_your_visit/patient_medical_info

rmation/compassionate_decision_making.html

Astheabovechartandsummarydemonstrate,patientfamilyadvisorsareactivepartnerswithstaffin

manyareasofthehospital’soperations,helpingtobuildthePFCCcultureatSuburban.PFACwill

continuetoworkwithSuburbanleadershiptoensurethatthiscollaborationisexpandedtoadditional

units,departments,andnewinitiatives.

V.JohnsHopkinsMedicine(JHM)System-WideDevelopments

AsnotedinitspriorAnnualReports,JHMdesignatedPFCCasoneofitssixstrategicprioritiesfor2014-

2018.14TofosterPFCCacrossthesystem,theJHMArmstrongInstitutefacilitatedcreationofthe

“PatientandFamilyCenteredCareCommunity(PFCCC),”asystem-widecommunityofrepresentatives

fromeachofJHM’s17PFACs.Thisyear,itsSteeringCommittee,onwhichfourSuburbanPFACadvisors

serve,createdorientationtoolsfornewPFACadvisors,includingaslidepresentationandaguide.The

PFCCCprovidesavehicleforharmonizingtheworkofthePFACsacrossthesystemandenablestheolder

PFACs,suchasSuburban’s,tosharetheirexpertisewithothers.Inaddition,LisaAllen,JHM’sfirstChief

PatientExperienceOfficer,isanactiveparticipantinthePFCCCandsharesinformationabout

implementingthisstrategicpriority.

Overthecomingyear,thePFCCCwillfocusonthreepriorities:(1)increasePFACcollaborationby

creatingacentralrepositoryforsharingcouncilaccomplishments,bestpractices,andstrategicgoals.

Thiswillbeavirtualvehiclesuchasanonlineforumorintranetsite;(2)increasetheparticipationof

14ThefullJHMStrategicPlanisavailableathttp://www.hopkinsmedicine.org/strategic_plan/

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patientfamilyadvisorsinquality,safety,andservicecommitteesandinitiativesattheirrespective

hospitalsandatthesystemlevel;and(3)createfocusgroupstocapturethevoiceoftheunder-served

andunder-representedpatientpopulationsacrossthesystem.

VI.LookingForward2016-2017

AsthePFACmovesintoitsseventhyear,thePFACiscommittedtoworkingonfiveadditionalgoals.The

PFACwill:

1.Workcollaborativelyoninitiativestoimprovecareforourelderlypatients,whorepresenta

largepercentageofSuburban’spatientpopulation,andinparticular,useresourcesavailable

throughNursesImprovingCareforHealthsystemElders(NICHE).

2.ContinuetoparticipateinusergroupstoprovideinputintoSuburban’sCampusEnhancement

Project,includingplanstocreateaPatientandFamilyResourceCenter.

3.CollaborateoninitiativestosupportSuburban’sapplicationtobecomeaMagnetrecognized

hospital.15

4.Continuetoconduct(a)BedsideShiftReportobservationstoenhancethequalityofnursing

communicationwithpatientsandfamiliesand(b)interviewswithpatientsandfamilies

regardinghospitalistcareandcommunication.

5.WorktoenhancethePFACwebpagetoincludePFCCresourcesforthecommunity.

ThePFACisveryproudofitscontributionstoSuburbanHospital.Eachyearhasbroughtgrowthin

membershipandincreasedPFACparticipationacrossthehospitalorganization.ThePFACisparticularly

excitedtoworkwiththenewleadershipoftheOfficeofPatientandFamilyExperiencetofurtherstaff

understandingofPFCCandstaff’sabilitytocommunicateitsmotto—caring,compassion,andhealing—

topatientsandfamilies.

15TheMagnetRecognitionProgramwasdevelopedbytheAmericanNursesCredentialingCenter,asubsidiaryof

theAmericanNursesAssociation,torecognizehealthcareorganizationsthatprovidetheverybestinnursingcare.Itisthehighestlevelofrecognitionthatanorganizationcanreceiveforqualitynursingcare.

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AttachmentA

PatientandFamilyAdvisoryCouncil(PFAC)CharterVisionStatement:

Bycreatingapatient-andfamily-centeredculturethatinvolvesacollaborativepartnershipamong

patients,families,16hospitalleadership,andstaff,ourpatientswillexperienceexcellentclinical,

compassionate,andsupportivehealthcare.

MissionStatement

Promotethesafety,quality,andpositiveexperienceofcare.

Fostermutuallybeneficialpartnershipsamongcaregivers,clinicians,patients,andfamilies.

Embedpatient-andfamily-centeredcareintohospitalpolicies,practices,procedures,andprograms.

PFACCouncilResponsibilities

Identify:Identifybestpracticesinpatient-andfamily-centeredcareinSuburbanHospitalandthehealth

careindustry,andsharethesebestpracticesacrosstheorganization.

Advise:Workinanadvisoryroletoenhancesafetyandqualityofhealthcareandtheexperienceof

care,byadvancingthepracticeofpatient-andfamily-centeredcareatSuburbanHospital.

Participate:Bringthepatientandfamilyperspectivetocommittees,councils,andinitiativesincluding,

butnotlimitedtoPFAC,patientsafetyandqualityimprovement,facilitydesign,serviceexcellence,

ethics,andeducationcommittees.

Support:SupportstaffandSuburbanHospitalleadershipinpatient-andfamily-centeredcareactivities

andinitiatives.Actasasoundingboardforimplementationofprogramsacrossthehospital.

16“Family”meanswhomeverthepatientchoosesashisorher“carepartner,”whetherarelative,life

partner,friend,orpaidcaregiver.Familyprovidessupport,comfort,andimportantinformationduringthehospitalstayaswellaswhenthepatientreturnshome.

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Represent:RepresentpatientandfamilyperspectivesaboutthehealthcareexperienceatSuburban

Hospitalandmakerecommendationsforimprovement.

Educate:Promotepatient-andfamily-centeredcareeducationacrosstheorganization.

Participateintheplanningandimplementationofstaff,physician,andvolunteereducationandtraining

aswellaspromotepatientandfamilyeducation.

CollaboratewithSuburbanHospitalstafftofacilitatepatientandfamilyaccesstoindividualhealth

recordsandtoSuburbanHospital’ssafetyandqualityperformance.

Evaluate:Evaluatehowpatient-andfamily-centeredcareimprovesthequalityandsafetyoutcomesfor

patientsandtheirfamilies,andtheirexperienceofcare.

StructureandMembership

ThePFACwillconsistofupto20PatientFamilyAdvisorsfromthecommunity,representingthediversity

oftheSuburbanHospitalcommunity,andnomorethan10SuburbanHospitalStaffAdvisors.Thegoalis

tomaintainaratiooftwoPatientFamilyAdvisorsforeveryStaffAdvisor.

ThePFACwillbeledbytwoCo-Chairs:anelectedPatientFamilyAdvisorandanappointedmemberof

theseniorhospitalleadership.TheChiefNurseOfficer,orhis/herdesignee,andtheheadoftheOfficeof

PatientandFamilyExperience,orhis/herdesignee,willbemembersofthePFAC.Co-Chairtermswillbe

twoyears,whichmayberenewedthroughthere-nominationprocessdescribedbelowformultiple

terms.

Co-ChairswillselectStaffAdvisorstoensuremultidisciplinaryrepresentation.

PatientFamilyAdvisorApplicationandNominationProcess

SuburbanHospitalstaffandcurrentPFACmembersareencouragedtoidentifypotentialPatientFamily

Advisorsandinvitethemtosubmittherequiredapplicationform.

TheCo-ChairsandseveralPFACmembersselectedbytheCo-Chairswillinterviewapplicantsand

determinewhethertorecommendtheapplicantforfullPFACapproval.TheCo-Chairswilldistributethe

applicationalongwiththebasisfortheirrecommendationtothePFACforavote.Approvalrequiresa

majorityofthePFACmembership.

MembershipCriteriaforPatientFamilyAdvisors

• Haverelevantexperienceaseitherapatientorfamilyofapatient.

• ContributetomaintainingadiversePFAC,representingSuburban’sdiversepatientpopulation.

• AbletofulfilltheRolesandResponsibilitiesofthePFACoutlinedinthisCharter.

• Committoserveforatwo-yearterm.

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TheNominatingCommittee

• TheCo-ChairswillselectthreetofivePFACmemberswhoagreetoserveastheNominatingCommitteeforaone-yearterm.

• TheNominatingCommitteewillconductallaspectsoftheCo-ChairelectionaswellastheprocessofreappointmentofPFACmembers.

• TheNominatingCommitteewillinvitePFACmemberstonominatecandidatesforthePatientFamilyAdvisorCo-ChairfromamongthecurrentPatientFamilyAdvisors.TheelectionwillbebywrittenballotattheJunemeetingoraspecialelectionmeetingwithadequatenoticeaboutthecandidatesandtheelection.Memberswillhavetheopportunitytosubmit,byemailormail,aproxyballotreceivedfromtheNominatingCommitteeinadvanceoftheelection.Selectionwillbebyamajorityvoteoftheentiremembership.

• ThePatientFamilyCo-Chairwillbeelectedforatwo-yearterm,andmaybere-nominatedbythesameelectionprocessassetoutabove.

• TheNominatingCommitteewillreviewPFACmembers’termsandrequestsforreappointment.IftheCommitteedoesnotrecommendreappointmentofamember,theCommitteewillsetoutthebasisforrecommendingagainstreappointmentandsubmittheirrecommendationtotheCo-Chairsforreviewandconsideration.IftheCo-Chairsagreewitharecommendationnottoreappointthemember,thedecisionwillbeprovidedtothememberalongwiththebasisforthedecision.

TermsofAppointment

• Thetermofmembershipandreappointmentwillbetwoyears.Councilmembersmayrequesttobereappointed.Amember'stermbeginsthemonthfollowingappointmenttotheCouncil.

• Resignationwillbesubmittedinwritingorviae-mailtotheCo-Chairs.

• Vacanciesmaybefilledduringtheyearasneeded.

RolesandResponsibilities

CouncilAdvisors:

• AttendeachPFACmeeting,attendviateleconferenceifunabletoattendinperson,ornotifytheCo-Chairsinadvanceifunabletoparticipate.

• ParticipateinprojectsandinitiativesthattakeplaceoutsideoftheregularPFACmeetings.

• Usethemember’sexperienceandinsightstoinformthehospitalaboutthepatientandfamilyexperienceatSuburbanandwaysitcouldbeimproved.

• Participateinavarietyofinformation-gatheringactivitiestounderstandothers’experiences,suchasdiscussionswithpatientsandfamilymembers,openforums,focusgroups,andsurveys.

• Serveonhospitalcommittees,councils,andinitiatives.

• Engagethoughtfullyandconstructivelyaroundtheissuesandideasdiscussedatmeetings.

• RespecttheuniquebackgroundandperspectiveofeachPFACmember.

• Berealisticandmindfulofthehospital’sbudgetary,regulatory,andlegalconstraints.

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Co-Chairs

• PlanandleadeachPFACmeeting.

• CommunicateactivitiesandrecommendationsofthePFACtotheleadershipofSuburbanHospital.

• WorkwithhospitalleadershipandstafftoidentifywaysforPFACtocollaborateonhospitalcommittees,councils,andinitiatives.

• EmpowerPatientFamilyAdvisorstobeactiveparticipantsinhospitalcommittees,councils,andinitiatives.

• Reviewonanongoingbasistheliteratureonpatient-andfamily-centeredcareandprovideleadershipandeducationforPFACmembersandthehospitalorganizationreflectingthisever-growingfieldofresearchandknowledge.

• PrepareanannualreportincollaborationwiththePFACmembers.

OrientationandTraining

PFACwillprovidealladvisorswithpatient-andfamily-centeredcareorientationandtraining.Patient

FamilyAdvisorswillalsoreceivehospitalorientationastoitsmissionandgoals,aswellasitsrelevant

safety,privacyandconfidentialityrequirements.PatientFamilyAdvisorswillberequiredtoobtainTB

testingandanannualfluvaccinationasisrequiredforallhospitalvolunteers.

Confidentiality

PatientFamilyAdvisorswillsignaconfidentialitystatement.PFACmemberswillnotdiscussordisclose

anypersonalorconfidentialinformationaboutpatients,staff,orhospitalbusinesswithanyoneother

thanPFACmembersandhospitalpersonnelworkingwithPFAC.Memberswillprotectconfidential

informationfromdisclosureandadheretoallapplicablefederalHIPAAstandardsandguidelines.

PFACMeetings

Meetingswillbeheldonaregularbasisonadayandtimethatbestmeetstheschedulesofmembers.

Meetingsareopentonon-members.

Agenda:MeetingagendawillbesetbyconsultationbetweentheCo-Chairs,inconsultationwithPFAC

membership,andwillbedistributedtothePFACmembershippriortoeachmeeting.

MeetingMinutes:TheminuteswillbedisseminatedinatimelymannertoallPFACmembersandwillbe

retainedforaminimumof5years.ThearchiveoftheminuteswillbeavailableintheOfficeofPatient

andFamilyExperience.

Attendance:AllmembersofthePFACwillmakeeveryattempttoattendeverymeetingduringtheir

termandwillnotifytheCo-Chairsiftheyarenotabletoattendascheduledmeeting.

Quorum:Aquorumisatleast50%ofthepatientandfamilyadvisorsand50%ofthestaffadvisors.

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InclementWeather:MeetingswillbecancelledduetoweatherfollowingtheMontgomeryCounty

publicschoolclosingannouncements.

Termination

TheCo-Chairsreservetherighttodismissanymemberswhodonotfulfilltheirresponsibilitiesunderthe

Charter.IfamembermissesthreescheduledmeetingswithoutnotifyingtheCo-Chairs,thiswillbe

consideredaresignationfromPFAC.

LastupdatedOctober12,2015.