Picker Institute, Inc. A LWAY S E V EN T S ® FOR THE O PTIMAL PATIENT EXPERIENCE: A N ATIONAL STRATEGY FOR ADVANCING PATIENT AND FAMILY CENTERED C AREAdvancing Excellence in Patient-Centered Care Through Education, Research and the Dissemination of Best Practice Strategies
Page 2 Picker Institute, Inc. Always Events® Challenge Grants ProgramPicker Institute is dedicated to enhancing the delivery of patient- and fam-ily-centered care throughout the U.S. healthcare system. In furtheranceof its mission, Picker Institute has adopted an organizing principle focusedon 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 “Those aspects of the patient healthcare professionals and the delivery sys- and family experience that tem.” should always occur when patients interact with health- care professionals and the Picker Institute’s Always Events® (AE) Re- delivery system.” 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 achievingselected Always Events® that can be replicated across a variety ofhealthcare delivery settings, and thus contribute to widespread improve-ments in patient- and family-centered care. This program is being carriedout by twenty-one illustrious institutions across America. This booklet pro-vides a brief overview of these initiatives. For more information, please goto: http://alwaysevents.pickerinstitute.org Picker Institute MissionPicker Institute Inc. is an independent nonprofit organization dedicated tothe global advancement of the principles of patient– and family- centeredcare. Picker Institute sponsors research and education in the fields ofpatient-centered care in support of and in cooperation with educationalinstitutions and other interested entities and persons. The Institute’s mis-sion is to foster a broader understanding of the concerns of patients andother healthcare consumers, and of the theoretical and practical changesneeded to facilitate a more patient– and family-centered approach. As aworld 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 educationprograms, awards, research and dissemination of evidence-based knowl-edge focused entirely on fostering continued improvement in healthcarefrom the patient’s perspective.
Page 4 Picker Institute, Inc. 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 programdesigned 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 thisinitiative is to enhance and ensure pediatric residents’ preparedness toelicit 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 ProtocolAlways Event(s): Always provide the patient with a SMART dischargeprocess. 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; createurgency and expectation for use with patients, families, and caregivers;disseminate findings, and promote this discharge protocol as a nationalstandard.
Always Events® Page 5 Cleveland Clinic Principal Investigator: Jennifer Ramsey, MDProject Title: Unmet expectations regarding ICU patient outcomes: Iden- tification and management of at risk familiesAlways Event(s): Always assure that medical intensive care unit patientsand 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 improveunderstanding of critical illnesses and the rights and responsibilities ofcritically 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 communicationAlways Event(s): Always communicate with, inform and respect thepatient in every patient/family encounter, through behaviors such as:1) Introducing yourself and describing the reason you are there ateach encounter. 2) Addressing and referring to patients by the namethat they choose; not by their disease. 3) Treating those whom youserve with the same respect you would wish them to show you. Thisinitiative 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.
Page 6 Picker Institute, Inc. Health Care For All Principal Investigator: Deborah Wachenheim Project Title: Patients and Families Improving Hospital DischargeAlways Event(s): This initiative will create Always Events that will, inpartnership 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 (andtheir caregivers) and those managing the discharge have a full andshared 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 HandoffsAlways 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 layerof safety by allowing the patient to communicate potential safety con-cerns. Inova has convened a quality-improvement team to develop a newstrategy for conducting the shift-to-shift handoff, one that standardizesprocedures 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 patientsand their families the opportunity to participate in the handoff process.
Always Events® Page 7 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 beingdischarged 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 ProjectAlways Event(s): Always listen to and involve the patient in their caretransitions. 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 onesetting to another. By directly engaging patients in their care planning, thisinitiative seeks to reduce rates of avoidable re-hospitalizations and medi-cal /medication errors, and improve patient and caregiver well-being alongthe continuum of care.
Page 8 Picker Institute, Inc. March of Dimes Principal Investigator: Liza Cooper, LMSW Project Title: Close to MeAlways 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 provenhealth benefits for mother and baby and is indicated as one of the mostcomforting activities by NICU families. Close To Me is the interventionprogram being implemented to increase the early onset and frequency ofkangaroo care in NICUs. Close To Me is a comprehensive set of aware-ness and educational activities, tools and products designed to increasethe early onset and frequency of kangaroo care and other positive holdingexperiences in a NICU. Massachusetts General Hospital Principal Investigator: Gaurdia Banister, RN, PhD Project Title: Always Know Your Caregiver/Always ResponsiveAlways Event(s): Ensure that patients always know who is in charge oftheir care, and that providers are always responsive to the needs of theirpatients and their families and that patients always get help when theyneed 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 patientwelcome video; 3) “face sheets” -- to describe who is taking care of thepatient and, 4) White boards – in each patient room that detail who istaking care of the patient and other pertinent information.
Page 9 Always Events® Northeast Valley Health Corporation Principal Investigator: Ursula Baffigo, MD Project Title: Team Up for HealthAlways Event(s): Always help prepare patients for their office visitsthrough the Making the Most of Your Visit (MMV) form. Spread utilizationof the MMV tool from the pilot site to all 7 of the NEVHC primary healthclinics. Patients complete the form while in the waiting room prior to eachvisit. The 2 questions are: 1) How am I managing my health; 2) What do Iwant to ask my doctor today. Planetree/Griffin Hospital Principal Investigator: Michael Lepore, PhDProject Title: Same Page Transitional Care: Creating a Template for Op- timal TransitionsAlways Event(s): Patients will always have the opportunity across health-care settings to utilize a portable personal health record embedded withactionable patient-driven information, to ensure patients, their healthcareproviders and their family members are on the same page with regard tothe patient’s healthcare needs, priorities, and lifestyle. Specific aims ofthis initiative include: (1) heightening patients’ and informal caregivers’confidence in managing healthcare needs, (2) improving the quality ofcommunication, coordination, and collaboration across care settings, and(3) reducing the frequency of unnecessary re-hospitalizations.
Page 10 Picker Institute, Inc. Quality Partners of Rhode Island Principal Investigator: Stefan Gravenstein, MD, MPH Project Title: Enhancing medication safety through PictureRxAlways Event(s): The family-patient team will always receive medicationeducation using the teach-back method and then prior to discharge thepatient will receive a visual medication schedule. Quality Partners will usePictureRx software, which results in a Visual Medication Card. This usespictures to explain what medications the resident is taking, how to take itand why. Prior to leaving the facility the patient and family member will begiven multiple copies of the VMS both for personal use and to share withthe individuals’ primary care physician at their follow up appointments. Saint Joseph Hospital Foundation Principal Investigator: Wendy Rockey, RN, MBA Project Title: Comfort & Pain Relief MenuAlways Event(s): Patients will ALWAYS be offered every option and/orcombination of options for pain control and comfort. Nurses will ALWAYShave a more comprehensive conversation about pain & comfort withevery patient. This proposal is to create and implement, as an AlwaysEvent, 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 cancreate a comprehensive pain & comfort plan.
Page 11 Always Events® St. Jude Children’s Research HospitalPrincipal Investigator(s): Alicia Huettel, MSN, RN & Patricia Aiken, MBA Project Title: Parent Mentor ProgramAlways 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 thechild’s treatment including the transition into survivorship or bereavement,2) to provide the family the opportunity of acceptance, while facilitatingcoping mechanisms and hope, 3) empowering providers and the family asa partner and in their communication with St. Jude staff in their child’streatment, and 4) providing a resource of services offered by St. Jude andthe 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 DementiaAlways Event(s): The Always Event will be that patients with dementiaand their families receive care that is targeted to the patient’s type andstage of dementia. This initiative is designed to improve the care of hospi-talized patients who have dementia. The overall goals are to enhancepatient 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.
Page 12 Picker Institute, Inc. University of Minnesota Amplatz Children’s Principal Investigator: Cheristi Cognetta-Rieke, RN Project Title: My StoryAlways Event(s): Upon every admission and transition in care a ques-tionnaire-based interview will occur between the intake nurse, the patientand the patient’s family or friends. Development and implementation of amultifaceted 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 usedby all care team members. Implementing MyStory as an Always Event aschildren are admitted to the hospital will ensure we capture the “story” ofeach child and use the information to involve children in care decisionsand care planning. The MyStory application will be built into the electronicmedical 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 AngelsAlways Event(s): This initiatives Always Events include: Always allowingand encouraging the patient to be the center of the care team- Care TeamTwittering; 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 deliverythrough improved communication and improved transitions in care, withinthe hospital setting and between pre-hospital, hospital, and post-hospitalservices.
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 PreventionAlways Event(s): Patients and families will always receive informationand education to facilitate autonomy, self-care and health promotion. Thiscommunication strategy educates patients as to how they can partner withthe health care team to prevent a fall during their stay. This study willevaluate the effectiveness of adding patient and family engagementstrategies across a multi-linguistic, automated delivery platform to reducefalls in hospitalized patients. A generic falls video will be produced that isappropriate to be shown in hospitals across the country. This video will betranslated 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 NeonatesAlways Event(s): Our proposal for the Always Event Grant is aimed atthe consistent use of an innovative, systematically applied end-of-life pro-gram by all members of our neonatal interdisciplinary team to supportpatients and families during the transition from curative to palliative care,infant demise, and bereavement. Our intention is to advance the role ofparents from visitors to partners and decision-makers who are activelyinvolved in caring for their critically ill infant. There are several modes ofcommunication between healthcare providers and families underlyingTransitions. Our multidimensional approach will include enhancements inverbal, non-verbal, written, electronic, and symbolic modes of providingcompassionate effective communication to families.
Page 14 Always Events® Henry Ford Health System Principal Investigator: Rhonna Shatz, D.O. Project Title: Dementia Screening for Senior PatientsAlways Event: HFHS will develop a new “Always Event” that will screenpatients 70 years and older for dementia as part of their annual primarycare health exams. Physicians will also utilize an NIH developed web-based smart survey tool to assess mood, behavior, daily living activitiesand review caregiver distress. Should the patient exhibit any signs of aneurological impairment following the cognitive screen, the doctor wouldinitiate a full dementia assessment guided by EMR templates that can bedownloaded or utilized and saved on-line as an office note. This programwill involve training and preparing Primary Care Physicians to observesenior adult patients during regular office visits to determine whether anundiagnosed neurological condition, especially Alzheimer’s disease, ispresent. “Through the patient’s eyes.”
Page 15 Picker Institute, Inc.To our friends—It is our observation that in the United States today, the quality, value and equityof 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 goalsof 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 tothe 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 makinghealthcare patient‐ and family‐centered simply have not done the job. What isneeded 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 initiativeaimed at significantly elevating the standard for the optimal patient experience inhospitals and medical practices throughout the United States. The new standardestablishes an expectation that certain elements of the patient experience willhappen for all patients all of the time. These Always Events® refer to aspects ofthe 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 businessoutcomes. We at Picker Institute believe that the patient experience is vitallyimportant in its own right, and that it signals the very respect and inclusion of thepatient and family in the care process without which true healing cannot occur.The call, for Picker Institute, is clear: We must translate our collective knowledgeinto action, and we must call our healthcare systems to a higher standard andgive them the information and support they need to sustain it.We think the answer is equally as clear: Every patient deserves, and shouldreceive, 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 healthcareexperience 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 thekind of healthcare system everyone deserves. Lucile O. Hanscom J. Mark Waxman, Esq. Executive Director Chairman of the Board
Page 16 Always Events® Always Events® National Steering CommitteeKaren Adams, PhD, Vice President, National Quality Forum, NationalPrioritiesBarbara Balik, RN, Ed.D, Senior Faculty, Institute for Healthcare Im-provementKatherine Browne, MBA, MHA, Deputy Director/COO, Aligning Forcesfor Quality, Center for Healthcare Quality, George Washington UniversityMedical CenterJoyce C. Clifford, PhD, RN, FAAN, President and CEO, The Institute forNursing Healthcare LeadershipEric A. Coleman, MD, MPH, Professor/Director of Medicine, Care Transi-tions ProgramNancy Foster, PhD, Vice President, Quality and Patient Safety Quality,American Hospital AssociationThomas James III, MD, Corporate Medical Director, Humana Inc.Beverley Johnson, President and CEO, Institute for Patient- and Family-Centered CareGregg S. Meyer, MD, Senior Vice President for Quality and Safety, Mas-sachusetts General HospitalKen Mizrach, Director, VA Medical Center East Orange, New JerseyDebra Ness, President, National Partnership for Women & FamiliesPeggy O’Kane, President, National Committee for Quality AssuranceJohn Santa, MD, Director, Consumer Reports Health Ratings Center,Consumers UnionGerald M. Shea, Assistant to the President of Internal Affairs, AFL-CIOBarbara Packer, Managing Director, COO, The Arnold P. Gold Founda-tionJim Conway, MS, FACHE, Senior Fellow, IHI, Adjunct Faculty, HarvardSchool of Public HealthPaul Cleary, PhD, Dean, Yale School of Public HealthLiaison to the Always Events National Steering Committee:Carolyn Clancy, MD, Director, Agency for Healthcare Quality and Re-search
Always Events® Page 18 Always Event® Guiding ThemesMajor 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 fourcriteria 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.
Picker Institute, Inc. Page 19 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 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 Board of DirectorsJ. Mark Waxman, Esq., ChairmanStephen C. Schoenbaum, M.D., Vice ChairmanSamuel Fleming, Treasurer and SecretarySir Donald Irvine, MD, FRCGP, FRCP, F.Med.SciDavid C. Leach, M.D., Former Executive Director, ACGMEGail L. Warden, MHA, President Emeritus, Henry Ford Health SystemLucile Hanscom, Executive Director11 Main Street, 4th FloorPO Box #777Camden, Maine 04843Tel 1.207.236.0157 1.888.680.7500Fax 126.96.36.19970Email firstname.lastname@example.orgWebsite http://pickerinstitute.org http://alwaysevents.pickerinstitute.orgAlways Events Consulting TeamDale Shaller, MPA, Principal, Shaller Consulting GroupCarrie Brady, JD, MA, Independent ConsultantPicker Institute StaffHannah Honor, Grants Coordinator email@example.comKathy Cassidy, Financial Director firstname.lastname@example.orgCarolyn Marsh, Communications Director email@example.com