Problem Addressed

• Patient involvement as key element of patient-centered care: As a part of patient- and family-centered care, the Institute for Family-Centered Care stresses the importance of giving patients and family members a meaningful role in the health system and incorporating patient and family perspectives into efforts to improve care processes.^1,2
• Unrealized potential of patient/family member advisers: One way for patients and/or family members to become involved is to have them serve as "advisers" who have direct input and influence on policies, programs, and practices affecting care and services for patients and families.³ However, relatively few institutions have taken this step, with most instead seeking feedback from patients and families in a very limited way,² such as through satisfaction surveys.

Description of the Innovative Activity

• Patient advisory councils: Both hospitals within the Georgia Health Sciences University have an institution-wide patient advisory council made up of current or former patients and/or family members. Practice sites within the two hospitals and their affiliated ambulatory clinics each have a similar council. The children's hospital also has a children's advisory council made up of pediatric patients and their siblings. Patients and/or family members will also serve on a system-wide executive advisory council that is currently being created. For each of these councils, patient advisers serve as chairperson, cochairperson, and secretary (who takes notes during meetings). Each council includes a staff person who acts as a facilitator, along with physicians and administrators who participate on an ad hoc basis. Institution-wide advisory councils meet monthly. Some advisory councils set their own agendas, but others have their agendas set by hospital or unit leaders. From 2007 to 2011, the number patient advisers increased from 178 to 242 and family faculty advisers increased from 26 to 28. In 2011, 1,943 total hours were served by patients and family advisers.
• Patient adviser input: Patient advisory councils examine and offer input on a wide array of issues concerning health care delivery and the patient experience; examples include:
  • Anesthesiology staffing: Patient advisers expressed concern about inadequate anesthesiology staffing, citing safety and communication problems. The anesthesiology department had been requesting budget approval for an additional anesthesiology slot for years; patient adviser concern finally led to approval of the additional position in the budget.
  • Medication dispensing: Several patient adviser suggestions to improve the safety of medication dispensing have been adopted, including opening the medication at bedside, reviewing medications with patients and/or family members prior to administration, and double-checking with physicians when patients question medication use.
  • Patient handoffs: Patient advisers expressed concerns about inadequate communication during transfers from the emergency department to an inpatient bed, and from ambulatory clinics to the hospital. Suggested changes that ended up being implemented include performing handoffs in the presence of the patient and family while enabling them to be a part of the process.
  • Patient- and family-centered care rounds: To improve communication, a patient adviser served with hospital doctors and staff to develop a patient- and family-centered rounding program in which all providers involved in a patient's care come to the patient's bed to solicit input from the patient and his or her family; rounds occur at scheduled times so that patients know when to expect them and so that caregivers and families can plan to be present. Although the patient rounding initiative has ended, patient advisers still periodically round with nurse managers on the units to observe care and talk with patients and families to obtain suggestions for improvement.
  • "Doc Talk Card”: Patient advisers developed a “Doc Talk Card” that patients use to guide their conversations with physicians. The card has space to list questions for the doctor, personal followup responsibilities, medications, care instructions, and information on followup appointments.
  • Patient-friendly invoices: Patient advisers noticed that the average patient could not understand the physician's bill. In conjunction with physicians, these advisers designed a new invoice that looks like a credit card bill, and crafted a letter to be sent to patients in cases of late payment that includes a number to contact for additional information or clarification.
  • Communications about preventing H1N1: A hospital staff member in charge of H1N1 vaccines wanted to hang signs in the front of the hospital reminding visitors not to enter if they had flu symptoms. The patient advisory council reviewed the sign and strengthened the language, suggested the creation of a press release to highlight the hospital’s leadership in preventing the spread of H1N1, and recommended that a reminder about flu symptoms be included in automated telephone appointment reminders to patients.
  • “Kid-friendly” facilities: Pediatric patient advisers have offered feedback about artwork and hospital activities. They also conduct food taste tests twice each year; their feedback led to the opening of an onsite McDonald's restaurant.
• Hospital committee participation: Patient advisers sit on every committee in the adult hospital, children’s hospital, and ambulatory clinics. Committees meet with varying frequency. These committees oversee operations and strategy related to Joint Commission accreditation, patient safety, medical school curriculum, and facility design, including the design of a new dental school and cardiovascular center. Patient advisers serve as full participants in each committee. They also, at their own initiative, visit the waiting room, hospital units, and other areas to observe the environment and talk with patients as a way of gathering information to inform their contribution on the committees.
• Peer support: Some patient advisers work with individual patients who request such assistance. For example, a cancer or knee replacement patient may be given contact information for a patient adviser who previously received similar treatment. Some units (including hematology oncology, gynecology oncology, and head/neck oncology) operate peer support groups in which patient advisers meet with current patients to explain treatments, answer questions about their personal experiences with the disease and treatment, and provide other support.
• Educating and training staff: Patient advisers serve as “family faculty” who train hospital staff about patient-centered care and participate in medical school classes and resident orientation sessions. In these roles, patient advisers talk about their experiences as a patient, discuss the role of the patient advisory councils, and provide examples of how to work with the advisers. For example, one patient adviser teaches a class for first-year medical students on the delivery of bad news, a class for third-year medical students on palliative care, and a course for first-year nursing students and critical care nurses on patient-centered care.
• Participation in research, conferences, annual award: Some patient advisers become involved in research. For example, patient advisers currently participate in a study of methods for teaching patients to use their medical records to improve care delivery and outcomes. In the past, advisers have developed a checklist of observable criteria that can be used to determine whether clinicians are incorporating the core concepts of patient-centered care (dignity and respect, information sharing, participation, and collaboration). Patient advisers also help to design and implement an annual conference on patient- and family-centered care sponsored by the health system. Finally, patient advisers can nominate physicians, nurses, and other staff for an annual award recognizing their commitment to patient-centered care. A subset of patient advisers reviews these nominations and selects six individuals to receive the award at the annual conference.

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Innovator Disclosures

Results

• Higher patient satisfaction: Patient satisfaction, as measured by a Press-Ganey satisfaction tool, increased from 83.5 (mean score on a scale of 0 to 100) in fiscal year 2001 (July 2000 to June 2001) to 88.7 in fiscal year 2009—a statistically significant increase. Although not all of the increase in patient satisfaction can be directly attributable to the patient advisory program, hospital leadership and program leaders believe these improvements are due significantly to the patient adviser program. In fact, patient satisfaction has increased significantly in several units following implementation of the program, suggesting a direct relationship between use of the unit-based patient advisers, implementation of adviser-suggested improvements, and satisfaction increases on the unit; for example, scores in one unit rose from the 10th percentile before implementation to the 95th percentile 1 year later.
• Contributing to better overall performance: Program leaders believe the program has contributed to improvements in the following measures of overall performance: scores on Joint Commission inspections, market share, profit margins, costs per adjusted admission, mortality rates, and days in accounts receivable. For example, the chief executive officer directly attributes patient volume increases to the patient advisory program. Although other smaller initiatives played a role in these improvements as well, the patient adviser program represents the only widespread, major initiative adopted throughout the hospital, and hence is considered to be largely responsible for this success.
• Strong evaluations for family faculty members: Family faculty score higher than medical school faculty on course evaluations from medical students.

Evidence Rating (What is this?)

Context of the Innovation

Planning and Development Process

• Selecting patient advisers: Faculty, staff, students, or existing patient advisers can recommend someone for a new patient adviser position by sending the candidate's name to the Director of Family Services Development. Advisers must either be or have been a Georgia Health Sciences University patient or a patient's family member. Those who recommend someone as a potential adviser contact the individual to let him/her know about the nomination and to expect a call from the hospital about the program. The Director of Family Services Development then contacts the individual to gauge his or her interest.
• Screening, training, and orienting new advisers: Individuals interested in serving as patient advisers undergo a background check, sign a confidentiality statement, receive a tuberculosis test, complete training on Health Insurance Portability and Accountability Act (HIPAA) and safety issues, and go through an orientation process about the health system and its policies and procedures. Applicants also sit in on council meetings before officially becoming an adviser to confirm their interest. Once accepted into the program, new patient advisers receive informal “on-the-job” training and may be mentored by an existing adviser.
• Presenting data: Qualitative and quantitative data presented to system leaders on an ongoing basis ensures high-level support for the program.

Resources Used and Skills Needed

• Staffing: The program is staffed by the Director of Family Services Development and an administrative assistant, both of whom work full-time on the program. Patient advisers volunteer their services, with the exception of those serving as faculty (who may choose to receive a stipend for their work, although most decline to do so).
• Costs: Not including salaries, the program has an annual budget of approximately $20,000, primarily to cover supplies, family faculty stipends, travel, conference expenses, learning labs and presentations to other medical centers.

Funding Sources

Tools and Other Resources

Getting Started with This Innovation

• Ensure leadership support: Program success depends on the support that leaders exhibit for patient and family member involvement; these leaders need to communicate to all clinicians and staff the importance of understanding the patient's perspective in providing high-quality care and in stimulating ongoing quality improvement. Program developers can ensure leadership support by presenting data and stories that illustrate the patient advisers' impact. For example, one leader at the hospital who had initially dismissed the patient advisory program as "warm and fuzzy" became a strong supporter after viewing patient satisfaction, patient volume, and other data.
• Seek out best practices: Schedule site visits at institutions known for providing patient-centered care and attend patient-centered care conferences to learn about best practices.
• Start small: Begin with one patient advisory council, and then branch out to other units/departments once the first has taken root.
• Focus initially with low-cost suggestions: Many patient adviser suggestions do not cost (and might even save) money. Implementing these suggestions first is a way to bolster support from administrators.
• Train advisers on confidentiality: Administrators may be worried about revealing negative or challenging hospital circumstances in front of patient advisers. To overcome this concern, train patient advisers on confidentiality and inform administrators that such training has taken place.

Sustaining This Innovation

• Recognize staff who provide patient-centered care: Solicit patient adviser feedback regarding staff who provide patient-centered care, and then recognize these individuals publicly. This recognition helps to support culture change and highlight the role of the patient advisers.
• Include advisers in all meetings: If the hospital does not include patient advisers in meetings at which critical topics (such as patient safety) are discussed, patient advisers will see their role as superficial, and hence may become less willing to volunteer time or offer input.
• Act on feedback: Consider all patient adviser suggestions, and then either act on them or explain to the adviser why they are not feasible. This approach demonstrates to patient advisers that their feedback is taken seriously and thus keeps them engaged in the process.
• Express appreciation: Regularly express appreciation for the efforts of patient advisers, highlighting how their contributions make a difference. Such feedback will keep them enthusiastic about participating.
• Include the community: Let the community know about the role of patient advisers and other patient-centered initiatives, thus underscoring the hospital's concern about providing clinical care in a way that best serves the needs of patients.