Profiles of Change
Dartmouth-Hitchcock Medical Center
Dartmouth-Hitchcock Medical Center (DHMC), located on a 225-acre campus in Lebanon, is New Hampshire's only academic medical center. DHMC is nationally recognized as "high-performing" in 22 specialties by the U.S. News & World Report 2012-13 Best Hospitals survey and was ranked in the top 50 for its care in gynecology in the U.S. News & World Report's 2011-2012 America's Best Hospitals for the fifth consecutive year and the ninth time since 1995. DHMC achieved Magnet recognition for nursing excellence in 2003, and in 2009 received its re-designation as a Magnet hospital. Dartmouth-Hitchcock is the recipient of numerous other awards.
Patient- and Family-Centered Care-Initial Steps
It takes only a few committed people in a large organization to start the patient- and family-centered care ball rolling. In 2005, the Director of the Office of Care Management attended the Institute's intensive training seminar, Hospitals and Communities Moving Forward with Patient- and Family-Centered Care. She came back energized, and the following year a Dartmouth-Hitchcock team—including nurses and social workers—attended the Institute's next training seminar. Their team learned that DHMC already had in-house experts on patient- and family-centered care when, while at the seminar, they saw Bill Edwards, a DHMC physician, on a video talking about patient- and family-centered care at the Children's Hospital at Dartmouth.
Upon returning from the seminar, the Director of the Office of Care Management, and a small team of Seminar attendees, including the Continuing Care Manager of the Bridge Program (a transitional care program to help geriatric patients recently discharged from the hospital, or those at risk of being hospitalized, live successfully at home), met with a pediatrician and a social worker from the Boyle Community Pediatrics Program. The Boyle Community Pediatrics Program (see sidebar) is a champion of patient- and family-centered care at the Children's Hospital at Dartmouth (CHaD). According to CHaD, "at its heart, family-centered care is about dignity and respect for children and their families. The participation and collaboration of children and families in all aspects of CHaD—clinical care, education, and quality improvement—demonstrates CHaD's commitment to the families... serve[d]."
This small team joined forces with the Boyle Pediatrics Program, determined to actively pursue advancing the practice of patient- and family-centered care at Dartmouth-Hitchcock. The team focused on enhancing the care delivered to elders in the community and within DHMC. Initially this group looked at CHaD's successes to learn how a committed team could advance patient- and family-centered care. They established an acting steering committee—a larger interdisciplinary group to reflect a broad representation of individuals and positions to act as "champions" for change. Members included staff from inpatient and outpatient programs, palliative care, chaplaincy, general internal medicine, library services, physicians, a hospitalist, resident and staff educators, patients, nurses, social workers, and community members.
Focus Groups Engaged and Patient/Family Advisor Role Developed
This acting steering committee, grappling with the best way to begin demonstrating partnership, convened focus groups, in part, to help define patient- and family-centered care and to determine if the community would support Dartmouth-Hitchcock's efforts to provide patient- and family-centered care. Members of the Steering Committee recruited participants—from the community, local senior centers, and assisted living facilities—and facilitated and staffed each of nine focus groups, which included 60 people from nine communities.
Using the information gleaned after defining patient- and family-centered care, and seeking input from these focus groups on program ideas under consideration to improve eldercare, the committee considered how best to proceed: "Should the focus be from the ground up? Do we continue with the growing groundswell? Do we look outside? Do we go to leadership to get a mandate from the top?" The committee decided to develop a patient/family advisor role, and to imbed advisors in decision-making committees. The Committee intended to learn from, and use these success stories as examples of partnerships, and collect data to show effectiveness.
Design/Build Project Includes Patient and Family Advisors
During the spring of 2007—in what turned out to be an important initial step—a member of the acting steering committee and a community member, met with the Vice President for Clinical Services who was involved in designing a new outpatient facility. They discussed patient- and family-centered care and requested that a patient or two join in the design/build workgroup for this new structure. The VP agreed and, as a result of the VP's support, the design/build project manager partnered with the steering committee member and a community member. The three defined the role of patients and families as advisors on the workgroup, and—working collaboratively with a team of VPs—interviewed the first patient and family members (later named patient/family advisors). Together they defined the attributes and role of patient/family advisors, found the right individuals to serve in these roles, and invited them to work as full-fledged members of a decision-making work group. This "experiment" demonstrated the achievability and effectiveness of partnerships with patients and their families.
Patient- and Family-Centered Steering Committee Becomes Official
The inclusion of patient/family advisors in the Design/Build project was so successful that the Steering Committee sought official recognition from the Performance Improvement Coordinating Committee (PICC), a key subcommittee of the Board of Governors, responsible for quality and safety throughout DHMC with authority to sanction quality improvement projects. The Steering Committee sought PICC approval to pursue the provision of patient- and family-centered care at DHMC as a quality improvement initiative. PICC pronounced the multidisciplinary acting steering committee of "in-house experts" as an official Steering Committee, and agreed to promote the inclusion of patients as members of working committees. PICC encouraged the growth of the patient/family advisor role, and announced that DHMC's new strategic plan under discussion included patient- and family-centered care. With this approval from PICC, the Steering Committee actively sought out those departments, projects, and providers thought to be ready to invite patient and family advisors into their work. The Steering Committee developed a job description for patient/family advisors, and teamed with Dartmouth-Hitchcock Volunteer Services to create a volunteer position, a system for recruitment, training, placement, and support for patient/family advisors.
DHMC's Mission/Vision Statement Includes Provision of Patient- and Family-Centered Care
In 2007, DHMC approved a new mission/vision statement that included as its first goal to "Provide Patient- and Family-Centered Care" with an "[u]nwavering commitment to provide care that is coordinated, effective, efficient, compassionate and safe." Staff and community interest grew and commitment to advance patient- and family-centered care was strong.
In the winter of 2008, representatives of the Steering Committee—including the Continuing Care Manager of the Bridge Program, a patient/family advisor, a physician, the Boyle Pediatrics team, and the Director of Care Management—informed the hospital leadership of the patient- and family-centered accomplishments to date, as well as the general acceptance of, and excitement for, this culture change displayed by the community and staff. These representatives sought the leadership's support for—and recognition of—the importance of patient and family partnerships. As a result, the Chief Nursing Officer (CNO) and the VP for Patient Care joined the patient- and family-centered care team. Leadership encouraged this team to contact committees responsible for defining institutional priorities under the new strategic plan to ask them to include patient/family advisors in their process. Many did.
Ultimately, a combination of working from the ground up and including leadership support fostered the notion of patient and family involvement and partnering at all levels of care.
With the aid of the CNO, the patient- and family-centered care team invited all the system-wide VPs and patient/family advisors to a two-day leadership retreat—led by Bev Johnson, President and CEO of the Institute for Patient- and Family-Centered Care. This opportunity provided time to:
- Define patient- and family-centered care concepts;
- Share stories of exemplary organizations practicing patient- and family-centered care;
- Design what patient- and family-centered care would look like at DHMC; and
- Explore next steps.
Leadership embraced the concepts and gave the team the green light to make patient- and family-centered care a reality organization-wide!
By April 2008, DHMC had eight patient/family advisors working on committees throughout the hospital. The successful integration of advisors into endeavors such as the design/build project resulted in multiple requests for patient/family advisors to join other work. An Executive Committee for Patient- and Family-Centered Care, a subgroup of the larger committee—consisting of staff, leadership, a medical resident, and a patient/family advisor—formed to continue strategic planning to broaden the delivery of patient- and family-centered care. The Committee is continually working to create systems that would imbed patient- and family-centered care principles at every opportunity. Examples include incorporating these principles into staff education, staff orientation (including general orientation for all new employees), and incorporating behavioral expectations into measurable patient- and family-centered care performance standards.
DHMC Funds Permanent Patient- and Family-Centered Care Staff and Establishes Council
In September 2008, the Patient- and Family-Centered Care Executive Committee met with the PICC, requesting permanent staffing and the budget necessary to support efforts to advance patient- and family-centered care throughout DHMC. The Executive Medical Director and Medical Director for Quality and Safety linked patient- and family-centered care to the 2009 Quality Improvement targets, citing a direct connection to the 2009 Joint Commission requirements, and recommended funding for the requested staff. As a result, DHMC provided funding for three permanent staff positions, one full-time Patient- and Family-Centered Care Coordinator, one part time Patient- and Family-Centered Care Manager, and one part time Patient- and Family-Centered Care Medical Director.
Goals for these newly funded staff positions include:
- Educating all DHMC staff and clinicians about patient- and family-centered care;
- Expanding the number of patient/family advisors;
- Teaching staff how partnering with patients and families positively impacts quality and safety;
- Educating patients and families to increase their understanding that they—the patients and families—are partners on the care team.
In 2009, DHMC created the Patient- and Family-Centered Care Advisory Council to continue the work of the initial Steering Committee. The Council has approximately 19 members and is chaired by the Patient- and Family-Centered Care Manager. The council membership includes 9 patient/family advisors, physicians, staff, the Vice President for Patient Care, and the Chief Quality and Compliance Officer. This group meets monthly and is working on the Patient- and Family-Centered Care Policy Statement and defining both the work of the Council and the role of Dartmouth-Hitchcock leadership in the work of the Council.
The work of embedding the patient and family voice continues to grow. As of October 2010, there were approximately 130 actively engaged patient/family advisors. These advisors participate in a variety of ways as fully participating members of hospital committees and teams, such as interviewing candidates for key positions.
Office of Patient- and Family-Centered Care
The Patient- and Family-Centered Care Office is involved in a variety of Initiatives, including:
- Incorporating principles of patient- and family-centered care into the two-day orientation for new employees;
- Developing an education subcommittee of the Advisory Council focused on health literacy as well as the redesign, future design, and content development of materials given to patients and families;
- Playing a video to residents at orientation, featuring Co-President of DHMC, Thomas Colacchio, MD, to show what patient- and family-centered care truly means in practice;
- Creating a video in collaboration with the Chief Nursing Officer for nursing staff;
- Teaching about patient- and family-centered care in the Combined Experienced Nurse Orientation for RN's and LPN's;
- Implementing a module on patient- and family-centered care in the E-learning testing modules mandatory for all staff;
- Incorporating principles of patient- and family- centered care into the code of conduct job descriptions, and behavioral expectations to be used to evaluate staff;
- Working to imbed the principles of patient- and family-centered care (by demonstrating patient- and family-centered care behaviors) into modules used in Simulation Center for training, e.g. delivering bad news, codes, communication, bedside rounding;
- Implementing changes in nursing education to include patient- and family-centered care in the curriculum and to include patient/family advisors as family faculty;
- Contributing teaching and planning resources to The Dartmouth Institute for Health Policy and Process Improvement (TDI):
- Teaching in the TDI Medical Microsystems classes, showing how to build patient- and family-centered care elements into fundamental process planning; and
- Working with TDI's Microsystem Academy leaders to build strategic planning, patient- and family-centered care content, and working knowledge of ways to create partnerships between professionals and patient/family advisors.
- Playing a major role in the process improvement work for Dartmouth-Hitchcock's Regional Primary Care Centers, to develop Medical Home "high value" teams; and
- Working with the Emergency Department to improve patient, family, and staff satisfaction, and quality of care.
The Manager of Patient- and Family-Centered Care reports directly to the Vice President for Patient Care. She also works closely with the Quality and Safety Office assuring the continued tight connection to, and focus on, quality and safety through the Patient- and Family-Centered Care work. The Manager also serves on the Quality and Safety sub-committee, with staff representatives from the entire organization, and soon a patient/family advisor. This group identifies safety risks, develops plans to address those risks, and works to improve the quality of care.
The expansion of partnerships among health care professionals, patients, and families that transpired at Dartmouth-Hitchcock Medical Center in the last several years is inspiring. The thoughtful implementation of patient- and family-centered care represents not only a process change; it is also a major cultural and behavioral change—improving quality, safety, and the experience of care for patients, families, and providers.