Making Partnerships with Patients and Families a Driving Force for Change in a Health Sciences University

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Making Partnerships with Patients and Families a
Driving Force for Change in a Health Sciences
University

• Pat Sodomka, Nettie Engels and Roman Cibirka
• Medical College of Georgia University and Health
  System

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Focus on Key Words
Leadership
Business case
Leadership
Measurement
Outcomes
Education
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Learning Objectives

• Identify rationale and business case for
  transforming philosophy
• Understand strategies, challenges and barriers
• Identify measurements and outcomes
• Describe requisite key leadership roles

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Statement of Problem

• Antiquated educational model
• Siloed, lacking PFCC culture of caring
• Provider-centered, hidden curriculum

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Solution

• Create a sustainable culture change in health
  provider education model and health care delivery
  mechanism
• Continuous, Circuitous Reinforcement Model

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What will we show?

• 14 year history of transformation
• Leadership and students driving change
• Integrated use of patients as faculty
• Development of Institutional level Center
• Culture assessment
• Leadership Academy
• Development of international recognition

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Opportunities (a.k.a. Obstacles)

• Resistance to change
• Vertical leadership support
• Peer mentoring
• Establishing linkages

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Outcomes

• Improvements in patient, family and staff
  satisfaction
• Enterprise wide culture change
• Improved staff retention
• Reduction in medical errors and costs of care
• Improved student satisfaction and learning
  outcomes

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14 History of PFCC at MCG
"Culture does not change because we desire to
change it. Culture changes when the organization
is transformed the culture reflects the
realities of people working together every
day. Frances Hesselbein The Key to
Cultural Transformation, Leader to Leader (Spring
1999)
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Remaking American Medicine, 2006
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Who are we?

• Founded 1828 - 8th oldest
• The only Health Sciences University in the 34
  institution University System of Georgia
• 5 Schools (Medicine, Allied Health, Nursing,
  Dentistry, Graduate Studies)
• Tertiary Academic Medical Center
• 632 bed - Adult and Childrens hospitals,
  Ambulatory Care Center, Radiation Therapy Center
• 110 specialty clinics Georgia and South
  Carolina
• 22,217 Admissions
• 455,707 Ambulatory Care Visits

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To this.
From this.
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Patient/Family Centered Care Positively Impacts

• Patient Safety
• Quality and Outcomes
• Cost Effectiveness

Patient/Family Satisfaction Staff
Retention/Satisfaction Reducing Risk/Malpractice
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Cues from theInstitute of Medicine

• Between the health care we have and the
  healthcare we could have, lies not just a gap,
  but a chasm.

Crossing the Quality Chasm
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6 Quality Aims Institute of Medicine
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Institute of Medicine Health Care in the 21st
Century

• Care is based on continuous healing
  relationships Safety is a system property
• Care is customized according to patient needs and
  values Transparency is necessary
• The patient is the source of control Need
  s are anticipated
• Knowledge is shared and information flows
  freely Decision making is evidenced-based
• Waste is continuously decreased Cooperati
  on among clinicians is a priority

10 Rules in Health Care
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In Action at the Bedside

• In Action at the System Level

The 10 Rules
Involving Expert Patient Advisors
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OR BUDS
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Partnering with 150 Patient/Family Advisors

• Health System Advisory Councils

• 4 Institutional Councils
• CMC Family Advisory
• MCG Health Partners
• Childrens Advisory
• PPG Advisory

• 6 Program Level Councils
• MS Clinic
• Behavioral Health
• Cancer Center
• Family Medicine
• Perinatal
• Cystic Fibrosis

MCG Health Partners
Kids ART
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Partnering with 150 Patient/Family Advisors

• Hospital Committees
• Patient Safety Campaign
• Facilities Projects
• Medication Reconciliation
• Tobacco Cessation
• Speak-Up Campaign
• Equipment and Safety Committees
• Quality and Safety Committees
• Patient-Centered Medical Record

• Academic Activities
• Family Faculty
• Essentials in Clinical Medicine
• Communication Lab
• Life (Learning in Family Environments)
• Curriculum Development

• Family Advisory Council

Patient-Centered Medical Record
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Organization of Patient Advisors and Advisory
Groups
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MCG Health Partners Organization
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Results Patient Satisfaction
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Nursing Practice Focus Change

• Open medication at the bedside
• IDs checked (armband plus patient confirmation)
• Patient told name of medication and indication
• If patient questions, double check
• Review medication each time given with patient /
  answer questions

MCG Health Partner Dialogue - 2005
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Results Quality and Safety
HCAPHS REPORT (October 2006 June 15, 2007)
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Neurosciences Center of Excellence Results

• Patient Satisfaction 10th ? 95th percentile
• Staff vacancy rate 7.5 ? 0 have waiting
  list 5 RNs
• Length of stay decreased 50 in Neurosurgery
• Discharges increased 15.5
• 62 decrease in medication errors
• Perceptions of the unit by doctors, staff, and
  house staff

• Capacity for continuous improvement enhanced
• Use of restraints decreased
• Moved to staff self scheduling
• Staff owns the culture deviations addressed
• Staff protects the new culture

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Results Student Assessment of Family Faculty

• This is really a great part of the curriculum
  to remind us of the effects of compassion from
  the physician, the value of building a real
  relationship. It means a lot to be reminded of
  the choice we have to treat the patient, or to
  merely treat the disease.
• See what being a caregiver really meant.Really
  personalized what families go through.
• Its really good to put a face on the diseases we
  study.
• It motivates me to go study. Because of their
  misdiagnosis, I want to be the best possible
  physician I can be for my patients.
• The family-centered perspective is often lost in
  all of the content of medical school. It is good
  to have this experience.

November 2003 October 2006
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Results Student Assessment of Family Faculty

• 29 Classes // 1,161 student evaluations
• 18 presentations to School of Medicine
• 7 presentations to School of Nursing
• 4 presentations to School of Allied Health
  Sciences

• Presentations rated for
• Content
• Organization
• Presentation Scale of 1 4
• 1 poor
• 2 fair
• 3 good
• 4 - excellent

Average score 3.82
November 2003 October 2006
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Measurement Faculty and Staff Attitudes and
Beliefs
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Results Risk Management
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Results Overall Health System Performance
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Results Impact on Costs
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Outcome Graduate Medical EducationInvolvement
of Residents in PFCC Efforts

• In Childrens Hospital Culture Shift has
  aligned the Overt and Hidden Curriculum
• In Adult Hospital Residents in Neurology and
  Neurosurgery saw an immediate positive effect and
  began to initiate leadership1

• Rahimi, Hamilton, Alleyne, Choudhri Lee, AANS
  Bulletin, 2006, Vol 15, No. 3, pp 12-15

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Outcome Graduate Medical Education

• The biggest impact family centered care has had
  on my practice is the ability that I have to make
  partnerships with families I work with
• I never realized most physicians never talk to
  their patientsthey just tell their patients what
  to do
• (It is) the way I take care of my patients that
  makes the difference.

MCG Graduate in Pediatrics practicing in North
Carolina (2005)
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Outcome Graduate Medical Education

• Scott Rahimi, M.D.
• Chief Neurosurgery Resident
• Lead Author

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Strategies

• Involvement and development of strong advisor
  base
• Learning Laboratories and Conferences
• Always feature patient panel
• Integrate advisors into operations
• Use existing and new projects
• Use early adopters and empower champions to lead

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Barriers

• Attitudinal
• Clinical System
• Academic and Research Activities

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Attitudinal Barriers

• Fear that patients and families suggestions are
  unreasonable
• Fear that patients and families will compromise
  confidentiality
• Belief that a customer service program is
  sufficient to ensure patient satisfaction and
  involvement
• Perceived lack of evidence for patient- and
  family-centered practices

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Attitudinal Barriers

• Belief that patient- and family-centered care is
  not necessaryWe are knowledgeable, caring
  professionals. We know whats best for our
  patients. We are all patients.
• Belief that patient and family-centered care is
  time-consuming and costly resource

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Attitudinal Barriers

• Lack of understanding and skills for
  collaboration
• health care professionals, administrators,
  patients and families
• Leaders lack of understanding in patient- and
  family-centered care benefits
• Organizations unprepared to provide patient and
  family members training or support to effectively
  participate

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Organizational Barriers

• Lack of guiding vision
• Tendency to implement either
• a top down approach with insufficient effort
  dedicated to building staff commitment
• tendency to implement a grass-roots effort that
  lacks leadership, commitment and support
• Organizational culture
• Insufficient fiscal resources or competing
  priorities
• Inadequate organizational leadership

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Key Leadership Roles

• Health System CEO
• University President and Provost
• The Deans
• Practice Group CEO
• Chief, Graduate Medical Education
• Key Leader Each School
• Nursing and Ambulatory Care Executives
• Infrastructure Leaders
• Human Resources, Facilities, IT,
  Legal/Compliance, Quality and Safety

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Leadership Academy

• Purpose
• Recognition
• Resource Development
• Cross Disciplinary Communication
• Leadership Development
• Promotion of PFCC Culture Change

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RAM

• Remaking American Medicine video

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PFCC Logic Model
Proximal Effects

• More knowledgeable
• Better disclosure
• Listening in both directions
• Feeling understood
• More bidirectional empathetic statements
• Understanding common goals
• Shared values
• More family involvement

Patient/Family Clinical Team
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PFCC Logic Model
Proximal Effects

• More patient activation
• More effective self care at home
• More adherence with treatment
• More family/friends support for adherence
  lifestyle changes
• Fewer complaints
• Decreased length of stay
• Greater staff satisfaction
• Decreased medication errors
• Enhanced staff awareness

Next Proximal Outcome
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PFCC Logic Model
Proximal Effects

• Less turnover
• Recruit better people
• Better job satisfaction
• Fewer health claims be staff
• Improved self-management behaviors
• Fewer missed appointments
• Fewer dropouts
• Increased loyalty
• Increased trust in delivery system

Next Proximal Outcome
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PFCC Logic Model
Proximal Effects

• Fewer outpatient visits
• Greater access of supportive services and
  information
• Better access
• Decreased wait time
• Improved responsiveness
• Better satisfaction
• More appropriate utilization - ability to
  self-triage
• Less ER use
• Less complications/readmits
• Patient safety at home

Next Proximal Outcome
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PFCC Logic Model
Proximal Effects
Overall Health Outcomes

• Less depression
• Less disability
• Improved health status
• Less absenteeism/More productivity
• Decreased health care spending
• Less stress for patients and families
• Improved family functioning

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- A Survivor is born a Faculty -
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Who am I?

• Wife, Mother, Grandmother, Sister, Aunt, Cousin -
  Patient and Family
• Public school and University educator
• Community leader
• Survivor giving back to the System that created a
  second chance, so others can benefit too

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How do I (we)?

• Patient advisory council
• Family faculty
• Faculty recruitment team member
• Guest lecturer
• Facilities management and design

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What do (we)?

• Speak locally, regionally and nationally
• Select beds for hospital
• Facilities design
• Opportunities for families in recovery
• Develop medication protocols
• Provide patient amenities
• mirrors over beds, finger foods, hand wipes,
  non-leaking cups

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Where do I (We go from here)?

• Communication
• Deeply embedded PFCC values
• Enable an environment of continuous PFCC quality
  improvement

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Curriculum Integration

• ACADEME The Ivory Tower
• Built on a heritage of traditional dogma
• Impeded by the heritage that made it strong
• Difficult to transform
• Bureaucracy and process slows progress

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Barriers

• Dogma
• Academic Process
• Traditionalism
• Resistant senior faculty and staff

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Starting Point

• Infiltrate academic medical center campus
• Create focal areas of interest and action
• Communication strategies
• Top Down and Bottoms Up

Stop short of mandates
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Early Steps

• Family Centered Care Consultants visit campus
• SOME administrative support

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Early Efforts

• Deans Council Endorsement
• Identified campus leader
• Faculty Focus Groups from each school
• And interested hospital personnel
• Verbal Administration Support

Lukewarm campus faculty support
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Early Successes

• Development of patient surveys
• Isolated curriculum integration
• Signage removed

Continued Barriers
Many faculty have little clinical experience Hard
to identify impact and need
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Faculty Responses

• Why?
• We are too busy
• Whats in it for me?
• Weve been doing it for years this way, why
  change?
• Does it matter for accreditation?
• Who is going to fund it?
• Does it matter for promotion or tenure?

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Student Group Presentations

• Tremendous Impact - One dinner whetted appetites
• Deans, Faculty, Senior Administration
• Early Crumbling of Ivory Tower
• Initiation of Bottoms Up approach

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Effective Curriculum Integration

• Seamlessly woven concepts that reach all students
• Core element to the learning outcomes for all
  disciplines

PFCC values
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Seize the First Opportunity!

• Professionalism Forum
• Every August
• Mandatory attendance for all first year students
• Topics on professionalism and PFCC
• Great introduction to concepts and campus beliefs
  in PFCC

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Its NOT about you anymore! D. Rahn, President

• It really stressed the importance of treating
  the patient and not just the illness. We have to
  remember there is a person in that body, with
  feelings, dreams, hopes and expectations.
• It made me stop and realize that academics are
  important,
• but our experiences are what ties us to our
  patients.

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Educational Initiatives

• L.I.F.E. Course (Learning in Family Environments)
• Essentials of Clinical Medicine curriculum
  revision
• Various Other Electives and guest lectures
• Use of the Family Faculty Directory
• Interdisciplinary Course
• Post Masters certificate program

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.A students perspective on L.I.F.E.

• Students learn the day to day challenges
  patients and families face. It helps (us) better
  appreciate the gravity and seriousness of medical
  problems and the impact they have in peoples
  everyday lives.
• This is a lesson that cannot be taught in the
  classroom.

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Family Faculty Directory

• Comprehensive Listing of Patient Advisors
• Nothing more powerful than an actual patient
• Captivates and motivates the soul of a student
  like no instructor can

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Curriculum Integration

• Seamless integration into didactic learning
• Woven into existing curriculum
• Stand alone Interdisciplinary Course
• Woven into what we do at all levels - didactics
  reinforced in the clinical enterprise

Straighten the road to learning
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PFCC Interdisciplinary Course

• 800 students to participate - 4 schools
• Hybrid design - online, classroom focused
  instruction
• Discipline specific breakout sessions

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PFCC Interdisciplinary Course

• Scheduling logistics within existing lockstep
  curriculum
• Business model - viability
• Assessment and outcomes

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Cognitive Learning The Clinical Years

• It has been said that the woven fabric can be
  unraveled after 3 days in the wrong clinical
  experience.
• Lions learn best through modeling and play

• Often students close the didactic chapter of
  learning at the clinical door.
• It is imperative PFCC values are reinforced
  similar to important diagnostic or physiologic
  considerations.

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Cognitive Learning The Clinical Years

• It has been said that the woven fabric can be
  unraveled after 3 days in the wrong clinical
  experience.
• Crucial to reach all levels of the clinical
  enterprise!
• Standardize clinical faculty, preceptors and
  external rotation sites

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Early Successes Generate MomentumFurther
administrative support

• Development of Center for Patient and Family
  Centered Care
• Focused on total enterprise enhancement
• Quality
• Patient safety
• Interdisciplinary collaboration

Embodies the MCG vision to stride towards premier
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Center Outcomes

• Education
• Profound curricular integration
• Early culture change to facilitate long term
  revisions to the practice model
• Research
• Outcomes
• Logic Model
• Culture
• Information technology
• Evidence-based design

• Clinical service
• Escalated patient satisfaction
• Growth of patient volume
• Enhanced community awareness

• Defined Strategic Plan

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