Introduction
The patient- and family-centered care (PFCC) is an innovative delivery model for realigning different components of the healthcare system for optimal clinical outcomes. Fundamental to the prioritization of provider resources is a comprehensive strategic plan for promoting a hospital’s focus on quality improvement, financing options, and reimbursement, among others. This paper analyzes various aspects of PFCC in a healthcare setting, including business practices, self-assessment, an area of improvement and strategy, financial implications, and functions of the multidisciplinary team, among others.
Business Practices
Besides their primary role as caregivers, providers must learn to manage care delivery as an enterprise to succeed in the complex healthcare environment. In the era of PFCC, a patient is viewed as a consumer. As such, each step of the “patient-provider interaction” must be aligned with the “revenue cycle” to avoid revenue loss (Gill, Leslie, & Marshall, 2016, p. 308). Business practices adopted by healthcare organizations in the areas of pre-service management (patient registration), the process of care, integrity practices, billing services, and administrative functions are geared towards minimizing risks, improving quality, and increasing patient satisfaction, which are core metrics of PFCC. Additionally, providing medical care in a home-like environment and patient/family involvement in the care process are common practices adopted by providers to attract more clients.
Regulatory requirements by the Centers for Medicare and Medicaid Services (CMS) center on inpatient admissions. Claims denials and penalties tied to the length of stay and readmission rates have led to a more accountable, patient-centered care in facilities. In this changing environment, hospitals have adopted models – call centers and telemedicine – that promote patient access and care continuity in community settings to improve outcomes (Roussel, Harris, & Thomas, 2016). The need to improve reimbursement has also impacted PFCC. In this regard, hospitals have made improvements in financial (collection rates), technical (applications), and operational (staff-patient ratio) components across practices (Roussel et al., 2016).
Inpatient experience is linked to reimbursement. Hospitals are under pressure from value-based care to enhance efficiency, increase patient satisfaction, and lower medical costs (Gill et al., 2016). Quality and performance measures have created a patient-centric culture. The Affordable Care Act has removed barriers to greater coverage through tax subsidies (Gill et al., 2016). Additionally, the bundled payment model has encouraged health insurance firms and hospitals to collaborate to maintain high patient satisfaction scores and coordinate care transition to benefit from federal reimbursement.
Self-Assessment Tool
The completed PFCC is provided as a separate document.
Setting Description
The healthcare setting used in the PFCC is Mercy Hospital (MH), which is a part of the Allina Health System. MH is a 447-bed capacity hospital situated in Coon Rapids, Minnesota (AllinaHealth, 2017). As general acute care and not-for-profit facility, it offers inpatient diagnostic and specialty services in mental health and emergency and cardiovascular care, among others. MH has two campuses: Mercy and Unity, which before 2016 operated as an independent hospital (AllinaHealth, 2017). It was opened in 1965 to serve the residents of over 20 north metro cities (AllinaHealth, 2017). Over the years, the hospital has continued to grow, introducing new services and medical technologies into its fold.
MH primarily serves the community living in Anoka County. The region lies adjacent to north metro cities. It offers care to more than 100,000 patients annually (AllinaHealth, 2016). Demographically, the county has a surface area of 422 square miles and a population of about 344,150, which is higher than the state and the national average (AllinaHealth, 2016). The median age is 37 years with about 22% of the people aged below 18 years (AllinaHealth, 2016). Anoka County is a multi-racial area. About 16% of the population is black, Asian, and Latino, while 4% of the people are non-English speakers (AllinaHealth, 2016). The area has a high burden of obesity with 65% of its adult residents being obese (AllinaHealth, 2016). Additionally, most of the people lack adequate health insurance coverage.
Strengths and Weaknesses
Leadership/Operations
MH’s commitment to providing patient/family-centered care is embodied in its three-year Community Health Needs Assessment (CHNA). The facility’s 2017-2019 CHNA contains a clear statement of its commitment to the over 340,000 people living in the county (AllinaHealth, 2016). Another of MH’s strengths lies in its promotion of PFCC through 22 focus groups open to all community members. It collaborated with the Improve Group in 2016 to identify priority areas: chronic disease (obesity) prevention, mental health, and senior care (AllinaHealth, 2016). The main weakness of this domain is that patient/family inclusion in hospital policy and clinical decisions are limited.
Mission, Vision, Values
MH’s mission is to serve communities “by providing exceptional care” to geared towards disease prevention, health restoration, and patient comfort (AllinaHealth, 2016, p. 4). Its vision is to prioritize the patient, offer quality care, provide a healing environment, and collaborate with community-based health organizations. Its core values of integrity, respect, trust, compassion, and stewardship show that the facility is committed to the patient/family-centered care and friendly or ethical practices. The mission and vision also indicate a clear focus on the patient, but their weakness is that they fail to include the hospital staff – a critical part of the PFCC. This gap may affect the morale and satisfaction of healthcare professionals.
Advisors
MH’s strength in this domain lies in collaborating with community healthcare organizations and associates to identify and address health priorities for the residents. Family advisory councils also exist at MH. Thus, the advice from these entities is implemented to improve health outcomes. However, the failure to include patient/family in hospital committees and quality and safety grounds are notable weaknesses in this domain.
Quality Improvement
MH’s quality initiatives are a part of its culture. It promotes patient/family participation in quality improvement (QI) teams and health promotion workshops and screenings (AllinaHealth, 2016). MH also collaborates with community-based organizations such as the YMCA to improve the health knowledge of the people. However, the patient/family voice in operational goals and participation in quality/safety meetings are low.
Personnel
MH engages family and patients in the staff recruitment and development process. Through collaborative efforts that bring together representatives from the hospital, community healthcare organizations, and other institutions, the hospital can align its human resources to identified health priorities (AllinaHealth, 2016). It uses community health needs assessments to develop and implement hospital-specific programs, such as flu vaccination, that improve population health. However, limited patient/family participation in interview panels and involvement in new staff orientation are the main weaknesses in this domain.
Environment and Design
MH only works with community-based organizations and conducts focus groups and employee surveys to design data-driven projects. Thus, the views of patients, families, and staff are considered in the development of multidisciplinary programs. However, major weaknesses related to this domain can be noted. First, patient/family participation in the development of these initiatives is limited. Second, though MH implements various interdisciplinary programs, there is no evidence that its care environment supports direct patient/family participation in these activities.
Information/Education
MH offers secure patient portals that allow access to individual health records and other resources. The information one can view includes lab results, visit history, medication list, and payments made, among others. The facility also encourages safe email communication by patients to the physician’s office after a clinical encounter. MH also posts health information and resources on website and partner organizations for the public to access. However, the patient/family’s role as educators or faculty for clinicians is limited.
Diversity and Disparities
The hospital maintains a profile of the patient population (Anoka County) it serves. The health needs of the various racial/ethnic groups, which are identified through CHNAs, inform its outreach programs. MH also provides timely access to free medical interpreter services to non-English speakers. Navigator programs (outreach) and educational materials/activities – community focus groups, meetings, and workshops – are available to minority (Asian, black, and Latino) patients who are at risk of chronic diseases (obesity).
Charting and Documentation
MH’s patient portals facilitate easy access to personal health information by the patient/family upon obtaining the required consent (AllinaHealth, 2016). It also promotes patient engagement after a physician visit. However, patient/family involvement in charting is low.
Care Support
MH’s strengths in this domain include allowing families 24-hour access to the patient room and involving them in rounds and bedside changeover at the end of a shift. Additionally, patient/family support and presence during rescue events as well as disclosure in case of a medication error are promoted in the facility. Patients also receive an up-to-date medication history at every visit. However, the utilization of the rapid response system by the patient/family is low.
Care
Patient/family involvement in clinical decisions is high at the hospital. MH considers patients and families a critical part of its healthcare team. As such, they are regarded as partners in care. Family engagement in care planning and transition to community settings is another major strength of MH. Through consultation with families and referrals to specialists, the facility ensures optimal management of pain and chronic illnesses for better post-discharge outcomes.
Area of Improvement
One critical area of PFCC that requires improvement is calling the rapid response team (RRT). Currently, in the facility, only clinicians can activate the RRT system – a process gap that could lead to adverse clinical outcomes. However, family members have a distinctive understanding of their sick relative, and thus, can recognize early signs of exacerbations that would warrant specialized care from the RRT. Therefore, granting them the right to call this team in non-intensive care units would lead to the patient- and family-centered care, where they are treated as partners in care.
Improvement Strategy
The improvement strategy proposed is the family-initiated rapid response (FIRR). The approach will enable concerned families or visitors to call for specialized care from the rapid response teams. Improved awareness of the FIRR can enhance the use of this system and increase “family satisfaction, patient safety, and outcomes” (Bavare, Thomas, Elliott, Morgan, Graf, 2017, p. 2). FIRR would ensure timely interventions to avert adverse events.
System or Change Theory
The FIRR strategy will be applied in MH to empower families to use this system. The first step (unfreezing) will involve creating an advisory council comprised of patient families, Anoka community representatives, a nurse, a physician, and an ER team member. The body’s role will be to develop an informational poster in each patient room that communicates the FIRR criteria – triggers, debriefs, and callbacks (Albutt, O’Hara, Conner, Fletcher, & Lawton, 2017). In the next step (changing), patients/families, nurses, and physicians will receive education/training on the detection of patient deterioration to promote the utilization of this system. Standards will also be developed for the FIRR procedure at this stage. The final step (refreezing) will involve integrating FIRR into the safety culture of the institution through the orientation of new patients and families into the system.
The implementation approach adopted is consistent with Lewin’s change theory. This model comprises three steps: unfreezing, changing, and refreezing. Successful implementation of this program will empower patients/families to use FIRR. According to Bavare et al. (2017), improved utilization of this system in non-intensive care units can lead to increased family satisfaction, safe patient care, and clinical outcomes.
Financial Implications
The expenditure on this program may be insignificant compared to the financial returns. The implementation costs of the FIRR strategy would come from establishing the advisory council, developing the informational poster, and patient, family, and staff education. Significant cost savings will result from averted adverse events – decreased mortality – and CMS penalties. Improved clinical outcomes – family satisfaction and patient safety scores – will also contribute to increased reimbursements under the value-based system.
Methods
The effectiveness of patient/family activated escalation will be evaluated using three methods. First, pre and post-implementation surveys of patient and family satisfaction with the FIRR strategy will be conducted. Higher post-intervention satisfaction scores (reduced family concerns over patient safety) relative to baseline will indicate that the program was successful. Second, a significant decrease in mortality rates and serious events and an increase in ICU transfers after the system is implemented will demonstrate that FIRR enhances patient monitoring. Third, an increase in the number of family-initiated calls per week will be an indication of improved utilization of FIRR. This method will also measure false-positive calls to evaluate family deficiencies in the detection of warning signs.
Multidisciplinary Team
An integrated team approach will be used in the implementation of the FIRR strategy in the oncology unit at MH. The core members will include a unit manager an oncologist, a radiologist, a unit nursing manager, patients, and families. The makeup of this multidisciplinary team will ensure management and supervise rapid response services at the unit. The role of the oncologist will provide leadership and guidance on the development of a vital signs chart and FIRR escalation process at the unit. The radiologist will educate patients and families about curative or palliative care, recognition of symptom exacerbations, and local escalation pathways. The unit manager will serve the role of a nurse champion to promote buy-in and support from the nursing staff. Consistent with the PFCC model, patients/families will participate in the co-design of the system.
Team Diversity
Cultural diversity is an important component of multidisciplinary care (MDC) teams. Socio-cultural and linguistic competence is critical for enhanced access and acceptability of health care services and safe care delivery (Sullivan, 2017). For this reason, racial and ethnic groups in Anoka County will be considered in this team. It will comprise of representatives (patients, families, or medical staff) from white, black, Asian, and Latino populations. The multicultural approach will improve team communication and cultural competence to promote minority patient/family utilization of FIRR services (Sullivan, 2017). The inclusion of members from different linguistic backgrounds will increase the acceptability of this system among culturally diverse patients and families and address disparities in care.
Leadership Theories
The transformational leadership model (TLM) is considered the most appropriate theory for the multidisciplinary team. This approach is effective in rallying staff towards a certain goal and humanizing the healthcare environment (Roussel et al., 2016). It comprises elements of staff empowerment, shared governance, decision-making, and vision, and rewards for improved performance. Active management style, an approach consistent with TLM, will be used to develop the multidisciplinary team that will implement the FIRR strategy (Sullivan, 2017). Embedded within this model are charismatic, inspirational, and visionary qualities of a transformational leader. Using this leadership style, team members will have opportunities to explore the warning signs that warrant a FIRR call and patient monitoring process. The professional roles, mandates, and perspectives will also be aired during team meetings to create a shared vision. The approach will also allow the involvement of patients/families in a collaborative establishment of FIRR goals.
Implementation of Strategy
The implementation work will involve four basic steps: creating a vital signs chart, developing guidance or policy, unit audit to identify barriers, and staff, patient, and family education. If family utilization of warning signs and escalation of response is to increase at MH, effective clinical leadership is required. The oncologist will spearhead policy and process development and resource/equipment mobilization for the project. He/she will also create a vital signs chart in collaboration with other team members. Consistent with a collaborative model of leadership, the oncologist will work with the nurse manager in policy formulation to accelerate the adoption of FIRR in the unit. Their role will also include an ongoing evaluation of the system to identify enablers and barriers. Education and training of the nursing staff, patients, and families will be the responsibility of the radiologist.
Communication to Organization
The FIRR strategy and its outcomes – improved family satisfaction and patient safety – will be communicated through multiple channels to disseminate a coherent message to internal stakeholders – staff and management. They will include newsletters, email updates, and webinars. Other communication channels that will be used are social media and company meetings. The aim will be to raise awareness about the FIRR strategy among employees and the management by aligning the messaging with MH’s mission and vision.
Tools for the Team
Self-assessment can help team members adopt positive teamwork behaviors that are critical for quality and safe patient care (Gordon et al., 2016). A specific tool for this purpose is the TeamSTEPPS, a self-report measure appropriate for multidisciplinary teams (Gordon et al., 2016). The approach supports the self-evaluation of perceived performance in areas of leadership, support, and communication, among others. The tool will help the team develop self-assessment skills in several teamwork domains critical to the successful implementation of the FIRR strategy.
Conclusion
Patient- and family-centered care focuses on patients and their families as core partners in care. A healthcare environment using the PFCC model will achieve higher family satisfaction and patient safety scores. MH has major strengths in the 10 domains explored. However, the limited family-initiated rapid response (FIRR) was identified as a significant weakness. With the appropriate leadership style and support, a multidisciplinary team can help implement a FIRR strategy to achieve optimal clinical outcomes.
References
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Bavare, A. C., Thomas, J. K., Elliot, E. P., Morgan, A. C., & Graf, J. F. (2018). Family- initiated pediatric rapid response: Characteristics, impetus, and outcomes. Journal for Healthcare Quality, 40(2), 103-109. Web.
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Roussel, L. A., Harris, J. L., & Thomas, T. (2016). Management and leadership for nurse administrators (7th ed.). Burlington, MA: Jones & Bartlett Learning.
Sullivan, E. J. (2017). Effective leadership and management in nursing (9th ed.). Upper Saddle River, NJ: Pearson.