Required for Bronze and Silver I.A: A multi-disciplinary, site-based task force or committee structure is established to oversee and assist with implementation and maintenance of practices. Active participants on the task force include: Patients/residents and/or family members; A mix of and management staff; A combination of clinical and staff (Note: For home care providers, this task force is based out of the administrative office / staff headquarters.) When was this task initiated? How often does it meet? How are ideas and input from patients/residents incorporated into the work plans of this task force? Do members of the medical staff participate on this task force? If no, describe efforts to expand medical staff representation on this task force. How are committee members prepared and oriented to the role they will play? Copies of minutes from the task force’s last three meetings. A current task force membership list, which includes each member’s name, title, and department/role. Identify which staff are and which are supervisory, and which members are patients/residents/family members. Required for Bronze and Silver I.B: A person-centered care coordinator or point of contact person is appointed who is able to commit the time required to coordinate related activities on an ongoing basis. This individual will have direct access to, and support from, senior level What is the coordinator’s name and job title? Approximately how many per week does this person spend on person-centered tasks and responsibilities? Summarize the person-centered activities coordinated by the contact person within the last twelve months. Coordinator’s job description supervisory
decision makers to remove barriers as needed, properly resource and align this strategic priority within the organization. Elective for Bronze and Silver I.C: Goals and objectives related to care are developed at least annually, supported by the patient/resident partnership council and key organizational stakeholders, and progress on objectives is shared with the governing body with a frequency commensurate with the reporting schedules for comparable strategic priorities. How is information on person-centered care efforts shared with your governing body (e.g. highest authority that has governance responsibility) on an ongoing How do you communicate information about person-centered care with patients/residents and their family members? As changes occur in the organization (e.g., board, senior leaders, coordinator), what are your plans for maintaining and transferring knowledge about your person-centered philosophy of care? What clinical, operational and financial metrics do you monitor to gauge progress in person-centered care implementation? With whom do you share this information? With the leadership team? With employees? With the governing body? With the patient/resident advisory council or equivalent? Others? How have you aligned person-centered care initiatives with your organization’s current strategic and/or operational plan? A copy of your care dashboard, or other reporting mechanism regularly updated to monitor implementation progress and related outcomes A copy of your organization’s current strategic and/or operational plan (or the executive summary) Elective for Bronze Required for Silver I.D: Community and patient/resident perceptions are incorporated in the planning and implementation of person-centered programmatic elements. Patients/residents/family members are meaningfully engaged in these efforts, and structures are in place Do you have a patient/resident or community advisory council in If yes, when was it established? How often does it meet? How are the participants recruited and selected? Who serves as the consistent link between the council and the governing body (i.e. regularly participates in meetings of both groups)? Is this person a staff or external community member? Provide at least 2 specific examples of ways the council’s input helped to drive ongoing improvement efforts. Agendas and minutes from the last two meetings of the patient/resident/ community advisory council (or equivalent).
Do members of the medical staff participate as active members on these teams? If yes, summarize their involvement on these teams. If no, describe efforts to expand medical staff representation on these teams. How is the work of these teams communicated Elective for Bronze Required for Silver II.C: Person-centered care concepts, practices, and initiatives are provided for all new and volunteers as a part of orientation. In continuing care environments, residents and family members are included in a meaningful way in the new employee orientation program. In addition, the new resident/family orientation includes an introduction of care concepts and how concepts are realized within the community. How are new employees oriented to the organization’s culture of person-centered care upon hire and how are they sensitized to the perspective of patients/residents as part of their orientation to the organization? How are members of the medical staff oriented to the organization’s culture of person-centered care? Continuing Care Applicant Question: How are residents and family members involved in the new employee orientation program? A copy of your new employee and new volunteer orientation agenda(s), indicating where and how person-centered concepts, initiatives and expectations are shared with staff and volunteers Continuing Care Applicant Requirement: A copy of your new resident/family orientation agenda, indicating and how resident-centered concepts, initiatives and expectations are shared with new residents and their families
Elective for Bronze and Silver II.H: Open, direct, and compassionate communication is demonstrated among all members of the organization. This includes having a documented process or system in place to fully and empathetically disclose when an adverse event, sentinel event, or unanticipated outcome occurs to patients/residents (and family members as appropriate.) Describe the approaches employed by the organization to keep all staff informed of organizational priorities. What mechanisms are in place for staff, patients/residents and family members to voice their ideas and suggestions for improvement? Describe the processes in to provide support to staff affected by an adverse event. Describe the organization’s approach for disclosing unanticipated outcomes to patients/residents (and family members as appropriate). Is this approach to disclosure formalized in a policy? How is staff educated about this approach to disclosure? Describe processes in place for encouraging patients/residents and families to communicate with staff about concerns related to their safety and/or care. How are these processes for communicating concerns communicated to patients/residents and family members? If available, a copy of the organization’s disclosure policy. Elective for Bronze and Silver II.I: Administrative processes, including billing processes, as applicable, are transparent, respectful and responsive to the needs of patients/residents and families. Describe changes that have been made to administrative processes (including billing, as applicable) to better meet the of patients/residents and families. How were changes informed by the perspectives of patients/residents and family members? None.
Elective for Bronze and Silver II.J: The organization balances safety considerations with being supportive of patient/resident empowerment, independence, and dignity. Provide at least two specific examples of how the organization’s focus on safety is balanced with being supportive of patient/resident empowerment, independence and dignity. What processes are in for staff to provide education to patients/residents on the implications of choices that may pose a safety or health risk? None. Elective for Bronze and Silver II.K: Continuity of care and accountability for patients/residents is maximized and maintained for the duration of one’s care, including during transitions between levels of care and across discrete episodes of care. Patients/residents and families are involved in shift-to-shift communication in a manner that meets their individual preferences and needs. Describe mechanisms integrated into hand-off processes that facilitate caregivers’ having the information they need to enhance continuity of care setting-to-setting, and Describe opportunities for patient/resident and family involvement in communications. (Examples include conducting change of shift report at the bedside and reviewing a patient’s/resident’s bio as part of the hand-off process.) Describe how your organization works with other healthcare providers in your area to enhance continuity of care during transitions of care. None.
and of the patient/resident, organizations are obliged to find other ways of sharing up-to-date information with them on their diagnosis, care and other clinical information. Elective for Bronze and Silver III.B: Patients/residents and families (with patient/ resident consent) are provided with information and support needed to be as involved as they choose in coordinating their care across settings, among multiple providers, and across discrete episodes of care. What tools are provided to patients/residents and families to support them in managing their medical information and coordinating their medical care among multiple physicians? What other processes are in place to support patients/residents and families in managing their medical information and coordinating their medical care among multiple physicians? How does the organization support families’ participation in preparing the patient/resident for their next level of care? None. Elective for Bronze and Silver III.C: Patients/residents are provided with discharge/transition instructions in a manner that accommodates their level of understanding, in a language that they understand, and includes family members in the discharge process as patient/resident desires. Describe the process for providing patients/residents with discharge/ transition instructions. What processes are in place for assessing patients’/residents’ comprehension of these instructions? (E.g. Teach Back, Ask Me 3, etc.) How does the organization support families’ participation in the discharge/transition process? Samples of documents integrated into care processes to support the discharge/transition process. Acute Care Applicant Requirement: Please provide your hospital-wide 30-day readmission rate for the last 12 months
visual privacy, temperature/thermal comfort. What efforts have been made to maintain a pleasant smelling environment? Describe the organization’s approach to overhead paging. For continuing care settings, describe opportunities for residents to personalize their living environment. Elective for Bronze and Silver VI.D: As for future renovations and remodeling are developed, symbolic and real barriers are minimized and open communication and human interactions are prioritized. Specific changes demonstrate how environment of care design supports the healing environment. Provide specific examples of how symbolic and real barriers have been removed from patient/resident care settings. Describe the characteristics of your nurses’ stations that promote open communication and human interactions. Describe your healing spaces, gardens, staff respite areas, family lounges, unit-based kitchens/pantries, and/or libraries. How is the availability of these spaces communicated to patients/residents and families? If applicable, how is the organization integrating new technologies to support a person-centered culture? Examples include technology that promotes effective communication, partnership with caregivers, continuity of care, family involvement and quality of life. None. Elective for Bronze and Silver VI.E: A patient/resident and visitor navigation plan provides a clear and understandable pathway for patients/residents and visitors to their destinations. Patient/resident input informs the navigation plan. In continuing care settings, signage in resident rooms is kept to a minimum. Do patients/residents and visitors become lost easily in your building or on your campus? If yes, how do you address this? Describe ways that patients/residents have been involved in the development and/or evaluation of your navigation plan. None.
Elective for Bronze and Silver VI.I: Patients/residents and staff have access to nature. Describe healing spaces in your building(s) or on your campus that provide patients/residents/staff with access to nature. None. Elective for Bronze and Silver VI.J: Lighting is provided that is appropriate for the required task or function, promotes a safe environment for staff and patients/ residents and is supportive of patient/resident, comfort, control and security. What type of lighting is provided in the corridors? Overhead fluorescent? Indirect? Does have task lighting at their work areas to perform their duties appropriately? Are there low-level lights in patient/resident rooms for staff to check on them at night? Can patients/residents control the lighting in their room for reading, visiting with family, etc.? Can the corridor lights be dimmed or controlled for lower levels during quiet time and at night? None. Elective for Bronze and Silver VI.K: Protocols are in place for reducing coercive intervention. Describe your protocols for reducing coercive intervention and supporting healing interventions that promote quality of life. None. Elective for Bronze Required for Silver (only for continuing care and behavioral health applicants) VI.L–In continuing care and behavioral health sites: Common spaces are available and feature a sense of spaciousness and light. In addition, they satisfy patients’/residents’ needs for both private spaces and spaces that support social interaction and Describe design features in common spaces that satisfy patients’/residents’ for both privacy and social interaction. None. Section VII: Arts Programs/Meaningful Activities and Entertainment Tiered Recognition Criteria Questions Requiring Response Required Documentation
address the cultural and spiritual needs of staff. Provide examples of specific accommodations that have been made to integrate patients’/residents’ cultural into their care and treatment. Section IX: Integrative therapies/paths to well-being Tiered Recognition Criteria Questions Requiring Response Required Documentation Elective for Bronze and Silver IX.A: Patients are supported in understanding and accessing a range of treatment options, including those considered complementary or alternative to local standards. Patients receive support from the care team to integrate such options into their treatment regimen, as appropriate. Describe how complementary/integrative therapies have been integrated into the way care is provided within your organization. Describe the healing modalities available to patients/residents and include how long each has been in active practice. Describe how you have determined the needs and interests of your patients/residents who wish to have access to complementary/integrative healing modalities. Include how this is done at an organizational level as well as at an individual level. None. Required for Bronze and Silver IX.B: Clinicians assess the skills and ability of each patient/resident and family member to their health care needs, and resources are available, as needed, to enhance skills and abilities, particularly for those with chronic conditions. Describe the organization’s approach to supporting patients/residents in chronic disease management. Describe patients’/residents’ access to wellness and health management opportunities and services. When appropriate, how does the organization facilitate and encourage physical activity within and around its building(s) and campus? Describe how caregivers assess patient/resident/family member abilities to self-manage their care needs. Continuing Care Applicant Question: Describe residents’ access to wellness and health management opportunities and services. None.
Required for Bronze and Silver XI.E: Staff and patient/resident/family members are actively involved in the design, ongoing assessment and communication of performance improvement efforts. The organization consistently utilizes data to identify and prioritize improvement over time. How is performance improvement information communicated to staff? To patients/residents? To the external community? Policy/Procedure for sharing multi-method performance improvement information with all stakeholders, inclusive of, at a minimum, focus group feedback, satisfaction surveys, and quality outcomes.