Spaulding Rehabilitation Hospital Boston 2014 Patient and Family Advisory Council Annual Report

Transcription

1 Spaulding Rehabilitation Hospital Boston 2014 Patient and Family Advisory Council Annual Report Hospital Name: Spaulding Rehabilitation Hospital Boston Date of Report: October 1, 2014 Year Covered by Report: September 2013 June 2014 Year PFAC Established: 2010 Staff PFAC Contact (name and title): Daniel Meninger, Chair, Program Director Spinal Cord and Brain Injury Programs Staff PFAC Contact and Phone: (617) PFAC Organization 1. Does your PFAC have by-laws and/or policies and procedures? If so, please attach them with your report or send a link to access them on-line. The council has a charter that was developed and approved during the term. The charter is included in the bottom of this document. 2. How do you recruit PFAC members? Members are recruited through the recommendation of the clinical teams, hospital leadership and quality/compliance department. 3. Is the PFAC chair or co-chair a patient or family member? No, currently the position is solely held by a hospital member. 4. If there is a hospital staff chair or co-chair, what hospital position does that person hold? The hospital staff chair also holds the position of Program Director for Spinal Cord and Brain Injury Programs. 5. Are at least 50% of PFAC members current or former patients or family members? Yes 6. What hospital department supports the PFAC? What is the hospital position of the PFAC staff liaison? The hospital department that supports PFAC is the Quality and Compliance Department. The front line direct care staff liaison for the was occupied by a staff physical therapist, who vacated the position in May 2014 due to her resignation. Other hospital staff on the council during this term was a staff Psychiatrist as well as a Quality and Compliance Specialist. 7. Does the hospital reimburse PFAC members for any costs associated with attending meetings and/or provide any other assistance (e.g. free parking, child or elder care, translation or interpretation services, conference calls, meals, mileage reimbursement or other travel stipends, etc.)? PFAC members are provided with free parking and a meal as part of the request to serve on the council. 8. The PFAC regulations require every PFAC to represent the community served by the hospital. What is your PFAC/hospital doing to comply with this requirement? Spaulding pulls from the community to have representation on the hospital council. Current and former patients, as well as family members, serve on the council. Additionally, the hospital maintains relationships with several community organizations that work to improve access to information, recreation and employment, youth transitions and the arts. PFAC, when requested by either party, is able to review information and provide feedback on services offered and impact on patients during the hospitalization and post discharge. Organizations that maintain strong relationships with the hospital, for example, are the Greater Boston Chapter of the National Spinal Cord Injury Association and the Massachusetts Chapter of the Brain Injury Association.

2 9. Who sets agendas for PFAC meetings? The PFAC agendas are set with the membership at the meetings. Suggestions are brought by various hospital departments and are agreed upon at the conclusion of the meeting, set for the upcoming meeting. Suggestions are also taken by the members of the council based on topics that are discussed. 10. Does the PFAC have subcommittees? If yes, please list and describe them. No, there are no subcommittees within the current structure of PFAC. 11. How does the PFAC interact with the Board of Directors (Check or circle all that apply) a. PFAC submits annual report to Board. Yes b. PFAC submits meeting minutes to Board c. PFAC member(s) attends Board meetings d. Board member(s) attends PFAC meetings e. PFAC member(s) are on board-level committee(s) f. None of the above g. Other, periodic updates, as requested by the hospital, in department director and quality and safety committee 12. Is there a PFAC section on the hospital website? Yes 13. Does your PFAC use social media and if so, how? Other than a section on the website, no other social media is used by PFAC. Orientation and Continuing Education 14. Describe the PFAC orientation for new members. Include in description how often it is given, by whom, and the content covered. Please include any requirements for PFAC members as hospital volunteers (e.g. hospital volunteer trainings, immunizations, CORI checks, TB checks, etc.). New members are contacted by a current hospital member of PFAC. The council, including intent and structure, are reviewed. Prior annual reports are shared and individual new members are matched with a mentor if desired. All members complete a privacy agreement at the start of the new term. PFAC Impact and Accomplishments 15. The law allows a hospital to engage its PFAC in a broad consulting role. Did the PFAC provide advice or recommendations to the hospital on any of the following areas specifically mentioned in the law (Check or circle all that apply)? a. Patient and provider relationships: a. Invited a former patient to speak about her experience as a patient through the recent hospital, using her input and feedback to help develop content for agendas moving through the year and strengthening the team approach to delivering care.

3 b. Institutional review boards c. Quality improvement initiatives: a. Worked with departmental and program leadership on review of the Strength Book and contents with ongoing improvements to content and usability. b. Worked with Director of Nutrition and Food Services on recent improvements made in the department from the perspective of the consumer and patient. c. Ongoing review of Press Ganey data and how initiatives in the hospital impact the overall score and action items for continued improvement. d. Worked with marketing and communication teams on review of the new website through focus groups and content review e. Worked with information services representatives on edutainment content to be used during inpatient stay, focusing on education and entertainment available for patients and families f. Worked with Director of Case Management on a family support fund, a donation to the hospital designed to help strengthen communication for families of patients in rehab. g. Initial discussions about changes to leave of absence policy and improving education and awareness to patients and families. d. Patient education on safety and quality matters 16. Did PFAC members engage in any of the following activities mentioned in the law? (Check/circle all that apply): a. Members of task forces. No b. Members of standing hospital committees that address quality (list committees and how many PFAC members serve on each). No c. Members of awards committees. No d. Members of advisory boards. No e. Participants on search committees and in the hiring of new staff. No f. Co-trainers for clinical and nonclinical staff, in-service programs, and health professional trainees. No g. Participants in reward and recognition programs. No 17. Was any of the following public hospital performance information shared with the PFAC? (Check/circle all that apply.) a. Serious Reportable Events. No b. Healthcare-Associated Infections. No c. Department of Public Health (DPH) information on complaints and investigations. No

4 d. Staff influenza immunization rate. No e. Other hospital performance information shared: please describe Outcome of CARF and Joint Commission surveys, ongoing review of Press Ganey data received on a quarterly basis. 18. Did PFAC quality of care initiatives relate to any of the following state or national quality of care initiatives: (Check/circle all that apply?) a. Healthcare-associated infections. No b. Rapid response teams. No c. Hand-washing initiatives. No d. Checklists Yes, with regards to involving patient in the use of the Strength Book e. Disclosure of harm and apology. No f. Fall prevention. No g. Informed decision making/informed consent. No h. Improving information for patients and families Yes, ongoing with the Strength Book as well as the edutainment process i. Health care proxies/substituted decision making. No j. End of life planning (e.g., hospice, palliative, advanced directives). No k. Care transitions (e.g., discharge planning, passports, care coordination & follow up between care settings). Yes, ongoing discussion about hand off care between inpatient and outpatient as well as between acute care and rehab. l. Observation status for Medicare patients. No m. Mental health care. No n. Other-please describe 19. Describe the PFAC s specific accomplishments in relation to quality of care initiatives during the past year. Please note for each initiative undertaken, a. did the idea arise directly from the PFAC Or b. did a department, committee or unit request PFAC input on the initiatives? PFAC contributed to the redesign of the Strength Book, an internal tool utilized to provide information to patients and families upon admission to the hospital. PFAC specifically reviewed pages in the book targeting setting and communicating goals and how they are perceived by the

5 intended audience, either patient or family. This initiative was done at the recommendation of hospital. At the request of PFAC, the Director of Nutrition and Food Services attended a meeting to discuss many of the concerns raised through Press Ganey survey results, through patient complaints, or direct experience as a patient or family member. At the request of the hospital representation on PFAC, Press Ganey results are routinely reviewed on a quarterly basis to identify ranking and trends. Discussions lead to future agenda items to address quality improvement initiatives and projects. PFAC Annual Report 20. Does the hospital share the PFAC annual reports with PFAC members? Yes, after the annual report is completed, it is shared with the membership for review and discussion. 21. How do you make the PFAC report accessible to the public? The contact information for the hospital PFAC member is listed on the website, and can provide a copy of the PFAC report. Additionally, the report is listed on the website. Goals 22. Does your PFAC set goals? If yes, what are they? (Please list.) (Note: As your PFAC sets goals, you should keep in mind the requirements and recommendations in the Massachusetts PFAC law and regulations.) PFAC s main goal over the past year has been member recruitment and retention. Efforts have focused on changing meeting times to accommodate improvements in attendance and to allow for better commute time to the meeting.