1. 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 ARE
Advancing Excellence in Patient-Centered Care Through Education,
Research and the Dissemination of Best Practice Strategies

2. Page 2 Picker Institute, Inc.
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
“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 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
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.

3. Always Events® Page 3

4. 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 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.

5. Always Events® Page 5
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.

6. Page 6 Picker Institute, Inc.
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.

7. 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 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.

8. Page 8 Picker Institute, Inc.
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.

9. Page 9 Always Events®
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.

10. Page 10 Picker Institute, Inc.
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.

11. Page 11 Always Events®
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.

12. Page 12 Picker Institute, Inc.
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.

13. 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.

14. Page 14 Always Events®
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.
“Through the patient’s eyes.”

15. Page 15 Picker Institute, Inc.
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

16. Page 16 Always Events®
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

17. Page 17 Picker Institute, Inc.

18. 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.

19. 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

20. Picker Institute Board of Directors
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
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