ALWAYS EVENTS® FOR THE OPTIMAL PATIENT EXPERIENCE:

A NATIONAL STRATEGY FOR ADVANCING PATIENT AND FAMILY CENTERED CARE

Picker Institute, Inc.

Advancing Excellence in Patient-Centered Care Through Education,

Research and the Dissemination of Best Practice Strategies

Picker Institute, Inc. Page 2

Always Events® Challenge Grants Program Picker Institute is dedicated to enhancing the delivery of patient- and fam-ily-centered care throughout the U.S. healthcare system. In furtherance of its mission, Picker Institute has adopted an organizing principle focused on the concept of Always Events®. Always Events® are defined as “those

aspects of the patient and family experience that should always occur when patients interact with healthcare professionals and the delivery sys-tem.”

Picker Institute’s Always Events® (AE) Re-search Agenda provides matching grants in support of the development and implementa-

tion of innovative projects designed to demon-strate how the Always Events® concept can be implemented in practice. The overall intent of the demonstration projects is to encourage develop-ment and adoption of strategies, programs, and processes for achieving selected Always Events® that can be replicated across a variety of healthcare delivery settings, and thus contribute to widespread improve-ments in patient- and family-centered care. This program is being carried out by twenty-one illustrious institutions across America. This booklet pro-vides a brief overview of these initiatives. For more information, please go to:

http://alwaysevents.pickerinstitute.org

“Those aspects of the patient and family experience that should always occur when patients interact with health-care professionals and the

delivery system.”

Picker Institute Mission

Picker Institute Inc. is an independent nonprofit organization dedicated to the global advancement of the principles of patient– and family- centered care. Picker Institute sponsors research and education in the fields of patient-centered care in support of and in cooperation with educational institutions and other interested entities and persons. The Institute’s mis-sion is to foster a broader understanding of the concerns of patients and other healthcare consumers, and of the theoretical and practical changes needed to facilitate a more patient– and family-centered approach. As a world leader in these efforts, and in the measurement of patient experi-ence, Picker Institute is recognized as an important resource for informa-tion, advice and assistance. In keeping with this reputation and in fulfill-ment of its mission, Picker Institute supports the advancement of the pa-tient– and family-centered care approach through a variety of education programs, awards, research and dissemination of evidence-based knowl-edge focused entirely on fostering continued improvement in healthcare from the patient’s perspective.

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Picker Institute, Inc. Page 4

American Academy of Pediatrics

Principal Investigator(s): Aditee Narayan, MD, MPH, FAAP;

Marcia Jackson, PhD

Project Title: Family Feedback—Always! (FFA)

Always Event(s): This initiative will develop and assess a pilot program designed to facilitate communication strategies used by pediatric resi-dents for always eliciting feedback from the families they serve in continu-ity clinics—“Family Feedback—ALWAYS! [FFA]”. The overall goal of this initiative is to enhance and ensure pediatric residents’ preparedness to elicit feedback from families in all patient encounters.

Anne Arundel Health System

Principal Investigator(s): Sherry B. Perkins, PhD, RN

& Mitchell Schwartz, MD

Project Title: The SMART Discharge Protocol

Always Event(s): Always provide the patient with a SMART discharge process. With the involvement of patients and families, providers will de-velop a simple, universal, 5 item checklist as a SMART Discharge Proto-col℠. (SMART is an acronym for: Signs, Medications, Appointments, Re-

sults, and Talk with me.) Providers will build on current evidence; create urgency and expectation for use with patients, families, and caregivers; disseminate findings, and promote this discharge protocol as a national standard.

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Cleveland Clinic Principal Investigator: Jennifer Ramsey, MD

Project Title: Unmet expectations regarding ICU patient outcomes: Iden-tification and management of at risk families

Always Event(s): Always assure that medical intensive care unit patients and families always understand and engage in their care. This will be ac-complished by healthcare provider behaviors, such as: (1) Timely, ongo-ing, clear, consistent and compassionate communication. 2) Medical deci-sion-making aligned with patient values, care goals, and treatment prefer-ences. 3) Family care that includes liberal visiting and practical, emo-tional, spiritual and bereavement support. 4) Written materials to improve understanding of critical illnesses and the rights and responsibilities of

critically ill patients and their families.

Dartmouth-Hitchcock Medical Center Principal Investigator(s): Jonathan T. Huntington, MD, PhD &

Sandra Dickau, RN, MS Project Title: Implementation of a set of Always Events that will

increase communication

Always Event(s): Always communicate with, inform and respect the patient in every patient/family encounter, through behaviors such as: 1) Introducing yourself and describing the reason you are there at each encounter. 2) Addressing and referring to patients by the name that they choose; not by their disease. 3) Treating those whom you serve with the same respect you would wish them to show you. This initiative will develop and implement an educational practice interven-tion and improvement program to promote and evaluate the compe-tency of frontline clinical nurses with a set of observable and behav-ioral Always Events.

Always Events®

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Health Care For All

Principal Investigator: Deborah Wachenheim

Project Title: Patients and Families Improving Hospital Discharge

Always Event(s): This initiative will create Always Events that will, in partnership with the PFACs and STAAR teams at Massachusetts hospi-tals, a discharge process that consistently and meaningfully engages pa-tients (and their caregivers) in identifying the patient’s needs at home. The project will result in a process where those being discharged (and their caregivers) and those managing the discharge have a full and shared understanding of the patients’ needs, abilities and access to assis-tance post-discharge.

Inova Health Systems

Principal Investigator: Mary Ann Friesen, PhD, RN, CPHQ

Project Title: Developing a Patient-Centered Approach to Handoffs

Always Event(s): Patients will always be included in the ISHAPED shift-

to-shift hand-off process at the bedside, as this will add an additional layer

of safety by allowing the patient to communicate potential safety con-

cerns. Inova has convened a quality-improvement team to develop a new

strategy for conducting the shift-to-shift handoff, one that standardizes

procedures and incorporates a bedside component. Entitled

“ISHAPED” (I=Introduce, S=Story, H=History, A=Assessment, P=Plan,

E=Error Prevention, and D=Dialogue), this strategy also provides patients

and their families the opportunity to participate in the handoff process.

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Iowa Health System

Principal Investigator: Gail A. Nielsen

Project Title: Always Use Teach Back!

Always Event(s): The Always Event is to always listen to the patient dur-

ing hand-offs by encouraging teach-back opportunities—during hospitali-

zation and upon arrival in the next care setting. Always use the Teach-

back method. IHS will develop and implement an “Always Use Teach-

back!” toolkit for the three care settings encountered by patients being

discharged from the hospital: hospital discharge, primary care follow-up,

and home health support.

Lahey Clinic

Principal Investigator: Elizabeth Collins, M.D.

Project Title: Transitions of Care Partnership Project

Always Event(s): Always listen to and involve the patient in their care

transitions. This community partnership project ensures that patient-

provider communication occurs and will improve the delivery of patient-

centered care at each step in the discharge or transfer process from one

setting to another. By directly engaging patients in their care planning, this

initiative seeks to reduce rates of avoidable re-hospitalizations and medi-

cal /medication errors, and improve patient and caregiver well-being along

the continuum of care.

Always Events®

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March of Dimes

Principal Investigator: Liza Cooper, LMSW Project Title: Close to Me

Always Event(s): March of Dimes considers kangaroo care, or skin‐to‐skin holding of the premature infant by the parent as an Always Event® that is discrete, affordable and measurable. It has numerous proven health benefits for mother and baby and is indicated as one of the most comforting activities by NICU families. Close To Me is the intervention program being implemented to increase the early onset and frequency of kangaroo care in NICUs. Close To Me is a comprehensive set of aware-ness and educational activities, tools and products designed to increase the early onset and frequency of kangaroo care and other positive holding experiences in a NICU.

Massachusetts General Hospital

Principal Investigator: Gaurdia Banister, RN, PhD Project Title: Always Know Your Caregiver/Always Responsive

Always Event(s): Ensure that patients always know who is in charge of their care, and that providers are always responsive to the needs of their patients and their families and that patients always get help when they need it. Strategies to be implemented will include but will not be limited to: 1) rounding strategies to support and model the importance of timely re-sponses to patients’ needs and their requests, 2) production of a patient welcome video; 3) “face sheets” -- to describe who is taking care of the patient and, 4) White boards – in each patient room that detail who is taking care of the patient and other pertinent information.

Picker Institute, Inc.

Northeast Valley Health Corporation

Principal Investigator: Ursula Baffigo, MD

Project Title: Team Up for Health

Always Event(s): Always help prepare patients for their office visits through the Making the Most of Your Visit (MMV) form. Spread utilization of the MMV tool from the pilot site to all 7 of the NEVHC primary health clinics. Patients complete the form while in the waiting room prior to each visit. The 2 questions are: 1) How am I managing my health; 2) What do I want to ask my doctor today.

Planetree/Griffin Hospital

Principal Investigator: Michael Lepore, PhD Project Title: Same Page Transitional Care: Creating a Template for Op-

timal Transitions

Always Event(s): Patients will always have the opportunity across health-care settings to utilize a portable personal health record embedded with actionable patient-driven information, to ensure patients, their healthcare providers and their family members are on the same page with regard to the patient’s healthcare needs, priorities, and lifestyle. Specific aims of this initiative include: (1) heightening patients’ and informal caregivers’ confidence in managing healthcare needs, (2) improving the quality of communication, coordination, and collaboration across care settings, and (3) reducing the frequency of unnecessary re-hospitalizations.

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Quality Partners of Rhode Island

Principal Investigator: Stefan Gravenstein, MD, MPH

Project Title: Enhancing medication safety through PictureRx

Always Event(s): The family-patient team will always receive medication education using the teach-back method and then prior to discharge the patient will receive a visual medication schedule. Quality Partners will use PictureRx software, which results in a Visual Medication Card. This uses pictures to explain what medications the resident is taking, how to take it and why. Prior to leaving the facility the patient and family member will be given multiple copies of the VMS both for personal use and to share with the individuals’ primary care physician at their follow up appointments.

Saint Joseph Hospital Foundation

Principal Investigator: Wendy Rockey, RN, MBA

Project Title: Comfort & Pain Relief Menu

Always Event(s): Patients will ALWAYS be offered every option and/or combination of options for pain control and comfort. Nurses will ALWAYS have a more comprehensive conversation about pain & comfort with every patient. This proposal is to create and implement, as an Always Event, a “Comfort & Pain Relief Menu” to be offered with every pain/comfort assessment. This will include a broad list of pain relief and com-fort measures for caregiver and patient to discuss together so they can create a comprehensive pain & comfort plan.

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St. Jude Children’s Research Hospital

Principal Investigator(s): Alicia Huettel, MSN, RN & Patricia Aiken, MBA

Project Title: Parent Mentor Program

Always Event(s): The Always Event is proposed as having four goals: 1) to offer each newly diagnosed family at St. Jude a trained parent-mentor, offering support and encouragement throughout the trajectory of the child’s treatment including the transition into survivorship or bereavement, 2) to provide the family the opportunity of acceptance, while facilitating coping mechanisms and hope, 3) empowering providers and the family as a partner and in their communication with St. Jude staff in their child’s treatment, and 4) providing a resource of services offered by St. Jude and the community.

University of California San Francisco

Principal Investigator: Carla Graf, RN, MS, PhD(c)

Project Title: Improving Patient and Family Centered Care for Hospitalized Persons with Dementia

Always Event(s): The Always Event will be that patients with dementia and their families receive care that is targeted to the patient’s type and stage of dementia. This initiative is designed to improve the care of hospi-talized patients who have dementia. The overall goals are to enhance patient and family-centered care by partnering with families to guide pa-tient care, improving family knowledge and readiness regarding the hospi-tal experience, and fostering continuity across the different sites of care.

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University of Minnesota Amplatz Children’s

Principal Investigator: Cheristi Cognetta-Rieke, RN Project Title: My Story

Always Event(s): Upon every admission and transition in care a ques-tionnaire-based interview will occur between the intake nurse, the patient and the patient’s family or friends. Development and implementation of a multifaceted intervention, MyStory, to have all care interactions with chil-dren begin with a meaningful conversation between care providers, pa-tients, and families. MyStory will capture the patients’ values, preferences, and expressed needs, and document it where it can be viewed and used by all care team members. Implementing MyStory as an Always Event as children are admitted to the hospital will ensure we capture the “story” of each child and use the information to involve children in care decisions and care planning. The MyStory application will be built into the electronic medical record that is used throughout our system of hospitals and clinics. The “story” of each individual patient will be used as a consistent ap-proach to involving the child in the delivery of patient care.

PFCC Innovation Center at the University of Pittsburgh Medical Center

Principal Investigator: Anthony M. DiGioia, III, M.D.

Project Title: Care Team Twittering and Guardian Angels

Always Event(s): This initiatives Always Events include: Always allowing and encouraging the patient to be the center of the care team- Care Team Twittering; Always keeping patients and family members informed- “Guardian Angels”; and, Always knowing the discharge plan and beyond- Transitions in Care Experiences. These two initiatives will focus on im-proving patient- and family-centered care experiences and delivery through improved communication and improved transitions in care, within the hospital setting and between pre-hospital, hospital, and post-hospital services.

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Always Events® Page 13

Vanderbilt University Medical Center

Principal Investigator: Terrell Smith, RN, MSN Project Title: Effective Communication and Collaboration with

Patients and Families for Falls Prevention

Always Event(s): Patients and families will always receive information and education to facilitate autonomy, self-care and health promotion. This communication strategy educates patients as to how they can partner with the health care team to prevent a fall during their stay. This study will evaluate the effectiveness of adding patient and family engagement strategies across a multi-linguistic, automated delivery platform to reduce falls in hospitalized patients. A generic falls video will be produced that is appropriate to be shown in hospitals across the country. This video will be translated into Spanish, Arabic, Kurdish and Somali.

Yale-New Haven Children’s Hospital

Principal Investigator: Janet Parkosewich, DNSc, RN, CCRN Project Title: Premature Life Transitions: A Patient- and Family-

Centered End of Life Care Program for Neonates

Always Event(s): Our proposal for the Always Event Grant is aimed at the consistent use of an innovative, systematically applied end-of-life pro-gram by all members of our neonatal interdisciplinary team to support patients and families during the transition from curative to palliative care, infant demise, and bereavement. Our intention is to advance the role of parents from visitors to partners and decision-makers who are actively involved in caring for their critically ill infant. There are several modes of communication between healthcare providers and families underlying Transitions. Our multidimensional approach will include enhancements in verbal, non-verbal, written, electronic, and symbolic modes of providing compassionate effective communication to families.

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Henry Ford Health System

Principal Investigator: Rhonna Shatz, D.O. Project Title: Dementia Screening for Senior Patients

Always Event: HFHS will develop a new “Always Event” that will screen patients 70 years and older for dementia as part of their annual primary care health exams. Physicians will also utilize an NIH developed web-based smart survey tool to assess mood, behavior, daily living activities and review caregiver distress. Should the patient exhibit any signs of a neurological impairment following the cognitive screen, the doctor would initiate a full dementia assessment guided by EMR templates that can be downloaded or utilized and saved on-line as an office note. This program will involve training and preparing Primary Care Physicians to observe senior adult patients during regular office visits to determine whether an undiagnosed neurological condition, especially Alzheimer’s disease, is present.

Always Events®

“Through the patient’s eyes.”

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To our friends— It is our observation that in the United States today, the quality, value and equity of healthcare are not what they might be. The disparities of race, ethnicity, resi-dence, education and income are widespread, and the future of the core goals of our healthcare system is in crisis. At Picker Institute, we believe that consistently high‐quality healthcare for every-one cannot become the norm without making the patient’s perspective central to the design and delivery of the care program. Yet too often neither the patients themselves, nor their families, have been in-vited to participate in this conversation. The traditional approaches to making healthcare patient‐ and family‐centered simply have not done the job. What is needed now is to make a quantum leap from the old ways to a healthcare sys-tem that truly sees and acts “through the patient’s eyes.” In response to this challenge, Picker Institute has embarked on a new initiative aimed at significantly elevating the standard for the optimal patient experience in hospitals and medical practices throughout the United States. The new standard establishes an expectation that certain elements of the patient experience will happen for all patients all of the time. These Always Events® refer to aspects of the patient experience that are so important to patients and families that health-care providers should always get them right. Improving the patient experience is often linked to bettering clinical or business outcomes. We at Picker Institute believe that the patient experience is vitally important in its own right, and that it signals the very respect and inclusion of the patient and family in the care process without which true healing cannot occur. The call, for Picker Institute, is clear: We must translate our collective knowledge into action, and we must call our healthcare systems to a higher standard and give them the information and support they need to sustain it. We think the answer is equally as clear: Every patient deserves, and should receive, an optimal experience. This truth should lie at the heart of the health-care system. Ultimately, of course, the patient is the judge of whether the total healthcare experience has been optimal. We are excited by the potential of this bold ap-proach to this challenge, and we hope you will join us in working to achieve the kind of healthcare system everyone deserves.

Lucile O. Hanscom J. Mark Waxman, Esq. Executive Director Chairman of the Board

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Always Events® National Steering Committee

Karen Adams, PhD, Vice President, National Quality Forum, National Priorities

Barbara Balik, RN, Ed.D, Senior Faculty, Institute for Healthcare Im-provement

Katherine Browne, MBA, MHA, Deputy Director/COO, Aligning Forces for Quality, Center for Healthcare Quality, George Washington University Medical Center

Joyce C. Clifford, PhD, RN, FAAN, President and CEO, The Institute for Nursing Healthcare Leadership

Eric A. Coleman, MD, MPH, Professor/Director of Medicine, Care Transi-tions Program

Nancy Foster, PhD, Vice President, Quality and Patient Safety Quality, American Hospital Association

Thomas James III, MD, Corporate Medical Director, Humana Inc.

Beverley Johnson, President and CEO, Institute for Patient- and Family-Centered Care

Gregg S. Meyer, MD, Senior Vice President for Quality and Safety, Mas-sachusetts General Hospital

Ken Mizrach, Director, VA Medical Center East Orange, New Jersey

Debra Ness, President, National Partnership for Women & Families

Peggy O’Kane, President, National Committee for Quality Assurance

John Santa, MD, Director, Consumer Reports Health Ratings Center, Consumers Union

Gerald M. Shea, Assistant to the President of Internal Affairs, AFL-CIO

Barbara Packer, Managing Director, COO, The Arnold P. Gold Founda-tion

Jim Conway, MS, FACHE, Senior Fellow, IHI, Adjunct Faculty, Harvard School of Public Health

Paul Cleary, PhD, Dean, Yale School of Public Health

Liaison to the Always Events National Steering Committee:

Carolyn Clancy, MD, Director, Agency for Healthcare Quality and Re-search

Always Events®

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Always Events® Page 18

Always Event® Guiding Themes

Major themes identified: Communication: This broad theme refers to the exchange and sharing of

information among the various members of the health care team, including communications between patients/families and providers, as well as among providers collectively responsible for patient’s care. Communication is a theme constant with any interaction may have with the health care system.

Transitional Care Experience: Care transitions refers to experiences of

patients as they move from one provider or health care setting to another (for example, from primary care doctor to specialist, from hospital to home, long term care or rehabilitation facility, and from emergency department to inpatient unit).

Criteria for selecting Always Events®: Within two core areas, Picker Institute and the NSC further identified four criteria that should guide the selection of Always Events:

Important: Patients have identified the experience as fundamen-tal to their care;

Evidence-based: The experience is known to be related to the

optimal care of and respect for the patient; Measurable: The experience is specific enough that it

is possible to accurately and reliably determine whether or not it occurred; and

Affordable: The experience can be achieved by any organiza-tion without substantial renovations, capital expenditures or the purchase of new equipment or technology.

The Eight Picker Principles of Patient-Centered Care:

Respect for patients’ values, preferences and expressed needs

Coordination and integration of care

Information, communication and education

Physical comfort

Emotional support and alleviation of fear and anxiety

Involvement of family and friends

Continuity and transitions

Access to care

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An excerpt form Always Events— Turning Never Events into a Smile

“Always Events® implies a system that looks not at

what is wrong with medical care today but searches for the elements that are “right,” i.e. those valued by most

patients. By identifying the elements that should always occur from the patient perspective, then systems can be

re-engineered to ensure that they do, in fact, always happen.”

- Tom James, MD

Picker Institute, Inc.

J. Mark Waxman, Esq., Chairman Stephen C. Schoenbaum, M.D., Vice Chairman Samuel Fleming, Treasurer and Secretary Sir Donald Irvine, MD, FRCGP, FRCP, F.Med.Sci David C. Leach, M.D., Former Executive Director, ACGME Gail L. Warden, MHA, President Emeritus, Henry Ford Health System

Picker Institute Board of Directors

Lucile Hanscom, Executive Director 11 Main Street, 4th Floor PO Box #777 Camden, Maine 04843 Tel 1.207.236.0157 1.888.680.7500 Fax 1.207.236.3570 Email lhanscom@pickerinstitute.org Website http://pickerinstitute.org http://alwaysevents.pickerinstitute.org Always Events Consulting Team Dale Shaller, MPA, Principal, Shaller Consulting Group Carrie Brady, JD, MA, Independent Consultant Picker Institute Staff Hannah Honor, Grants Coordinator hhonor@pickerinstitute.org Kathy Cassidy, Financial Director kcassidy@pickerinstitute.org Carolyn Marsh, Communications Director cmarsh@pickerinstitute.org