Patient engagement in Accreditation Required Organizational Practices (ROPs): A Bruyère Rapid Review
Hospitals in Ontario are required to involve patients in developing quality improvement plans, and to meet accreditation requirements. Accreditation Canada standards have incorporated the principles of patient and family centred care which involves a true partnership between the health care providers and the patients and their family members.
Bruyère is committed to providing patient and family centred care and has engaged patients and families through a Patient and Family Advisory Council (PFAC). In preparation for an assessment by Accreditation Canada in 2019, Bruyère is seeking to engage patients and families at all levels of the organization as recommended by Accreditation Canada, the Canadian Foundation for Healthcare Improvement (CFHI), as well as Health Quality Ontario (HQO).
This rapid review was undertaken to assess exemplar models of patient engagement. We first reviewed frameworks for patient engagement such as the IAP2 (International Association for Public Participation) and the ICPM (Interprofessional Collaborative Practice Model). We then considered the following six organizations suggested by the clinical champions on the basis of achieving a reputation as exemplar models of patient engagement and with similar purpose and structure to Bruyère Continuing Care (e.g. multiple specialties and sites): Cleveland Clinic, Mayo Clinic, Virginia Mason, Kingston General Hospital, North York General Hospital and St Elizabeth Care.
We identified the following organizational factors, described by HQO and CFHI, to guide our assessment of the PFAC across the five organizations: 1) governance, 2) accountability, 3) communication, 4) training, 5) roles and responsibilities, and 6) recognition.
Comparison of Bruyère Continuing Care to these five organizations across these characteristics are described in the report. For example, Bruyère Continuing Care is a leader amongst this group of organizations in recognizing the contributions of their PFAC members. The report also identifies areas which can be strengthened at Bruyère, such as accountability structures to implement and assess the impact of PFAC contributions.
Implications for practice
- Based on the review of six successful hospital-based models of patient and family engagement:
- This report serves as a self-evaluation tool that can be used by leadership at Bruyère Continuing Care and its PFA to set priorities and develop standardized processes
- There was little evidence available on how to initiate patient engagement in specific departments/clinics. However, some organizations are willing to share their experiences and provide guidance and support such as Cleveland Clinic, Mayo Clinic, Virginia Mason, St Elizabeth Care. Bruyère Continuing Care may consider partnering with such organizations.
Implications for research
- There is a need for more research and scholarly publication about lessons learned from efforts to enhance patient and family engagement in health care organizations.
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Hospitals in Ontario are required to involve patients in developing quality improvement plans, and to meet accreditation requirements. Hospital accreditation programs are systematic assessment of hospitals against accepted standards. Accreditation Canada standards have incorporated the principles of patient and family centred care which involves a true partnership between the health care providers and the patients and their family members. The Accreditation Required Organizational Practices (ROPs) are evidence-informed essential practices that organizations must have in place to enhance patient safety and minimize risk. There are six patient safety areas, each with their own goal. Safety culture, communication, medication use, work life or workforce, infection control and risk assessment.
Bruyère is committed to providing patient and family centred care and has engaged patients and families in improving quality of care through the Patient and Family Advisory Council (PFAC). Bruyère has used the IAP2 (International Association for Public Participation) model to engage patients and their families. See Appendix 1 for details about the IAP2 model.
The current structure of the Bruyère PFAC has been developed in consultation with the patients and families.
In preparation for an assessment by Accreditation Canada in 2019, Bruyère is seeking to engage patients and families at all levels of the organization as recommended in the Accreditation ROPs and by the Canadian Foundation for Healthcare Improvement (CFHI), as well as Health Quality Ontario (HQO).
Some ways in which patients and families could be involved include:
- Monitor and evaluate services and quality with input from clients and families
- Co-design services with health care providers and clients
- Include client and family representatives on advisory and planning groups
- Include clients and families as part of a collaborative care team
- Partner with clients in planning, assessing, and delivering their care
This rapid review was undertaken to provide evidence of models of patient and family engagement in healthcare and their impact on the patients and organizations.
To assess experiences of hospitals or health care settings with a reputation as exemplar models of patient engagement.
We defined the question in consultation with the clinical champions.
Eligibility and selection criteria
We included articles that described the experiences of hospitals or healthcare settings which have achieved a reputation as exemplar models of patient engagement.
We used the following keywords in Google and Google scholar search engines to identify relevant articles on models of patient and family engagement of specific health organizations identified by the clinical champions which have achieved a reputation as exemplar models of patient engagement. These organizations also have a similar purpose and structure as Bruyère Continuing Care (e.g. multiple specialties and sites).
- Patient engagement survey
- Patient engagement case studies
- Patient engagement case reports
- Patient engagement report
- Patient engagement case studies Canada
We also searched websites of the specific health organizations identified by the clinical champions. These included Cleveland clinic, Kingston General Hospital, Mayo clinic, North York hospital, St Elizabeth Care, and Virginia Mason.
The case studies were not appraised for quality since the purpose is to assess different experiences with patient engagement.
Different guidelines are available for patient engagement in health care settings, such as HQO, CFHI, and AHRQ (Agency for Healthcare Research and Quality). We do not review those in detail here since the purpose of this review is to assess experiences of hospitals or health care settings which have achieved a reputation as exemplar models of patient engagement. We adapted our framework for assessing the case studies from these guidelines, i.e. governance, communication, training, roles and responsibilities, and recognition.
Synthesis of Findings
Five of the six health organizations we identified use patient and family advisory councils/committees (PFAC) as a method of patient engagement to promote patient and family centred care: Cleveland clinic, Virginia Mason, Mayo clinic, Kingston General Hospital, and North York hospital. St Elizabeth Care offers education workshops to all employees to promote patient and family centred care.
The PFAC structure in these organizations operated at different levels, such as at the senior leadership level or at the level of individual departments.
Governance details are described in Table 1. Members had to be former patients or their family members. Recruitment was through surveys of discharged patients; or recommendations by staff. Former patients or family members could also apply directly by contacting the Patient Experience Office or completing online application forms. Potential members are interviewed to determine which roles are appropriate for them and their willingness to participate.
The frequency of meetings varied across the five organizations from quarterly to monthly.
Some PFACs had shared leadership between staff and patient and family advisor (e.g. Kingston General, North York) whereas others were led by staff (Mayo clinic, Cleveland clinic).
Membership ranged between 10-20 per PFAC with more patient/family advisors than staff except for Mayo Clinic where there were 50% patients and 50% staff.
The PFACs had different reporting relationships. In KGH and Mayo clinic, the PFAC reported to a leadership committee whereas in North York and Cleveland Clinic, the PFAC reported to the Patient Experience Office.
For accountability, a report was shared with governance to ensure that the recommendations of the PFAC were implemented in Kingston General. In Cleveland clinic, the staff lead reported back to the PFAC on progress of implemented programs. In North York, Patient Experience specialists ensured that recommendations were implemented in the clinical programs.
Open and unbiased communication is encouraged between the patients/family and staff across all five organizations. Different channels are used such as forums, calls, emails, online tools, and social media.
Different training sessions were organized for staff and for PFAC members using various formats such as face-to-face and online training modules.
Orientation sessions were held for council/committee members before their meetings.
Training programs on Patient- and Family-Centred Care standards for staff and volunteers.
Training in communication tools for staff to provide the skill set and re-enforcement to better engage patients, families and each other (e.g. the H.E.A.R.T. [Hear, Empathize, Apologize, Respond, Thank] communication tool created by Cleveland Clinic, also used by Kingston General).
Resources for training can be obtained from different organizations, such as St Elizabeth which was one of our selected case studies because it is a leader in providing training to health care organizations (including staff and patients) about how to strengthen patient engagement in organizational practices (resources available described below).
5. Roles and responsibilities
There were similar roles and responsibilities across the organizations such as:
- To partner with staff to promote patient and family-centered care
- Share their experiences and insights to help improve patient services and programs
- Evaluate policies, programs and practices to help identify opportunities to improve patient and family satisfaction
- Review or help create educational or informational materials
Coverage of parking and/or meals was often used as a token of appreciation for PFAC members. In addition, Bruyère is planning to recognize the commitment and contribution of a PFAC member and a team/individual towards enhancing and improving patient and family care experience as part of the Partner in excellence awards.
Resources for Training
St Elizabeth provides PFCC education through workshops to all employees both regulated and unregulated, as well as support staff, management, supervisors of direct care providers and care coordinators in the health care organization. St Elizabeth has developed a tool kit for implementing PFCC education across health care organizations in which they describe their experience.
All stakeholders were involved in the planning and implementation phases and included representatives from senior leadership team, middle management (supervisors of direct care providers and support staff and clinical educators), direct care providers (e.g. nurses, rehabilitation professionals, personal support workers, health care aides) and support staff (e.g. housekeeping, food services, custodial, office workers) as well as patients and family members.
Different versions of workshop education content and format were developed for target audiences (leadership team, regulated care providers, unregulated care providers and support staff) and a generic version for interdisciplinary groups of employees. It was found that additional versions were needed for physicians, volunteers and care coordinators.
Application of Evidence/Implementation
Health care organizations are engaging patients and their family more and more in healthcare quality improvement strategies through PFACs. However, many organizations are struggling with how best to fully engage patients and their family as there is a variety of patient engagement models and guidance. Various factors can also influence the extent to which patients and their family engage such as fear, uncertainty, low health literacy, and provider reactions or support; and finding the right people who are committed and able to contribute meaningfully could be challenging. Investments in patient engagement efforts varied with the size and commitment of the organizations. Some organizations have a committed budget for running the PFAC while others do not. The top five resources organizations invested in are: survey and feedback tools, interpreter services, parking, training and patient education.
Some success factors and lessons learned in the implementation process have been shared and include the following:
Patient and family engagement practices should be used across the organization and include everyone in every department and service. The leadership and other stakeholders across the organization should support patient engagement and patient and family centered care.
Staff should be committed and accountable across the organization.
Having and maintaining a patient experience department or team.
Focus on measuring, achieving and reporting on results and having a reporting structure.
Patient and family advisors should have a clear description of their role from the start and they should receive training to be able to share their experience and meaningful ideas for quality improvement.
Start the council by working on issues they have identified as important to them and by seeking their advice on hospital initiatives. Have the council work on concrete projects with measurable outcomes within a short period (e.g. one year); such as developing a policy.
Use evaluations after every meeting to assess its effectiveness and ensure open communication with the council and explain why their recommendations may not have been implemented.
Strengthening communication connections within and outside the organization.
It is helpful for organizations interested in forming a council to connect with hospitals with exemplar models to understand the commitment, purpose and usefulness of such a resource.
Strengths and limitations
We used the patient engagement models and guidance to develop a systematic approach to summarize the details on patient engagement structures and processes in six exemplar organizations.
We limited our assessment to the six healthcare organizations suggested by the clinical champions. We limited our search for information about these organizations to their organizational websites and Google and Google scholar search engines, and may have missed additional information.