Community needs and patient/resident perceptions are incorporated in the planning and implementation of patient-/resident-centered programmatic elements, and their active involvement is encouraged. All clinical and non-clinical staff, medical staff, and volunteers are involved in the implementation and dissemination of initiatives. Criteria Questions Requiring Response Documentation Required I.A: A multi-disciplinary task force, including patients/residents and family members, is established to oversee and assist with implementation and maintenance of practices. Active participants on the task force include a mix of non-supervisory and management staff and a combination of clinical and non-clinical staff. The group meets regularly (every 4-6 weeks) on an ongoing basis. In continuing care environments, this task force also includes residents and family members. When was your task force initiated? How often does it meet? Are meeting minutes generated? Copies of minutes from the past meetings List of the names and job titles/role (patient/resident, family member) of your steering team members I.B: A patient-/resident-centered care coordinator or person is appointed who is able to commit the time required to champion related activities on an ongoing basis. What is the coordinator’s name and job title? Approximately how many hours per week does this person spend on patient-/resident-centered tasks and responsibilities? Coordinator’s job description I.C: Patient/resident, family and staff focus groups are conducted on-site by Planetree or another qualified, independent vendor periodically (recommended interval is at least every 18 months), and the results are shared at a minimum with senior management, the governing body, and staff. Please list the dates of your most recent patient-/resident-centered focus groups with patients/residents, families, and staff. How were the findings shared and with whom? A summary report on the findings of your most recent focus groups with patients/residents, families and staff
I.E: An ongoing mechanism is in to solicit input and reactions from patients/residents, families, and the community on current practices and new initiatives, and to promote partnership between these stakeholders and the organization’s leadership and governing body. This may be achieved via an active patient/resident/ family or community advisory council with regular meetings (at a minimum six times a year) and access to decision-makers, or some other effective mechanism to obtain regular input from patients/residents and community. Participation is representative of the community served. Do you have a patient/resident or community advisory council place? If yes, when was it established? How often does it meet? How are participants 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 community member? If no, what other formalized mechanism is in place to obtain regular input from patients/ residents and community members? Minutes from the last two advisory council meetings I.F: Leadership exemplifies approaches that motivate and inspire others, promote positive morale, mentor and enhance performance of others, recognize the knowledge and authority of others and model organizational values, as demonstrated in focus groups with staff, employee experience survey results and the adoption of transformational leadership practices. Describe any transformational leadership practices adopted in the organization. Examples include leadership rounding on both patients/residents and staff, completion and use of a leadership self-assessment tool that includes dimensions of effectiveness in communicating a vision, ability to inspire others, commitment to engaging others in culture change, etc. List any supervisory/leadership training conducted over the past two years Section II: Interactions/Independence, Dignity and Choice Objectives: Staff is supportive and respectful of all patients/residents and their families, and management is supportive and respectful of all staff. All staff members see themselves as caregivers in a multi-disciplinary team approach. making
II.D: A comprehensive presentation on care concepts, practices and initiatives is provided for all new staff 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 resident-centered care concepts and how those concepts are realized within the community. 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 concepts, initiatives and expectations are shared with staff and volunteers Continuing Care Applicant Requirement: A copy of your new resident/family orientation agenda, indicating where and how concepts, initiatives and expectations are shared with new residents and their families II.E: Active teams are in place that address patient-/resident-centered initiatives, and include participation by non-supervisory staff and, as appropriate, patients/residents and families. How are ideas and input from patients/residents incorporated into the work of these teams? A list of each of your initiative teams, along with member names and job titles and/or role (e.g. resident, family member). Please indicate how long each team has been active and how often they meet II.F: Formalized processes are in place to promote continuity, consistency and accountability in care delivery, and which allow staff the opportunity and responsibility for personalizing care in partnership with each patient/resident. Please describe your care delivery or work design How does the approach promote continuity in the patient/resident experience? How are staff who work most closely with patients/residents given a voice in how care is delivered? N/A
II.G: A mechanism is in to provide staff support services that include elements identified by staff as priority areas. Examples include access to support services such as relaxation and stress reduction programs/services, space to recharge away from patients/residents and families, emotional support such as bereavement services and staff support groups and provision of ergonomic support measures in order to ensure physical well-being of staff and injury prevention. Describe your “care for the caregiver” plan. How did you ensure that diverse perspectives informed the development of this plan? N/A II.H: Human resource systems, including job descriptions and evaluations, reflect the organization’s patient-/resident-centered care philosophy. Other examples include behavioral standards, recruitment and retention efforts, staff selection tools and criteria and conducting team interviews. In continuing care environments, residents play a role in the hiring and evaluation of staff. How do your organization’s human resources systems reflect your patient-/resident-centered care philosophy? Continuing Care Applicant Question: How does the organization involve residents in the hiring and evaluation of staff? Sample job descriptions and evaluation tools; please provide a sample for a clinical and non-clinical position Data on organizational vacancy and turnover rates for the past several years
II.N: Effective 24-hour and communication processes are in place to ensure patients’/residents’ individualized needs are evaluated, discussed, and met. 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 provide personalized care. Describe opportunities for patient/resident and family involvement in these shift-to-shift communications. (Examples include conducting bedside rounds and reviewing a patient’s bio as part of the hand-off process.) N/A II.O: Effective communication mechanisms are in place to engage all staff (including off-site and all shifts) in dialogue about organizational priorities. Describe the approaches employed by the organization to keep all well-informed of organizational priorities. What mechanisms are in place to ensure this communication is reciprocal? N/A
II.P: Staff engages patients/residents, family and/or their advocates in the care planning process. Examples may include use of shared decision tools, health coaching and collaborative care conferences. Processes are in place for integrating patients’/residents’ preferred routines and rhythms of daily life into care plans (e.g., accommodations to preserve existing sleep patterns, plans for providing assistance with waking up and going to bed, eating, exercise, etc.). Staff support the engagement of patients/residents and family in the care planning process. What systems are in place to support the engagement of patients/residents and families in the care planning process? When there is more than one choice for treatment, what processes and tools do caregivers employ to explain choices and determine which option the patient (and family, as appropriate) feels is best for them? How are the choices made documented? What, if any, shared decision making tools are used by the organization? What processes are in place to integrate patients’/residents’ health and wellness goals, preferred routines and rhythms of daily life into care plans? N/A II.Q: The professional development/ advancement of staff is supported. Examples include the empowerment of frontline work teams, internal training and promotion tracts (e.g., career ladders), flexible scheduling to enable educational pursuits, an actively utilized tuition reimbursement program, etc. Describe how the professional development and advancement of staff is supported. N/A II.R–Applies only to continuing care sites: In continuing care settings, residents are given an opportunity to participate, as appropriate*, in a retreat experience or an equivalent to assist with internalizing resident-centered care concepts and to enhance sensitivity to the needs of the entire community. Resident retreats are conducted at a minimum annually. (* Exceptions include those clinically unable to participate.) Describe your resident retreat process (length, agenda, location, facilitators, frequency and participation and if you do not hold retreats, please describe how you engage residents and provide them with an experiential training to enhance their understanding of resident-centered care concepts. N/A
III.A-Behavioral Health Application: In behavioral health settings, decisions about the extent of the clinical information shared and the mechanism used for sharing this information are made on an individualized basis. A range of options are available for sharing such information, including the medical record and the treatment plan, to ensure that patients of varying competency levels have access to information that will help them to understand their symptoms, diagnosis and treatment. When was your policy related to sharing clinical information with patients approved or put into place? How long has it been an active practice? Please describe the different ways (mechanisms and processes) that a patient’s clinical information may be shared with him or her as well as the factors that may influence how such information is shared. How is staff educated about the policy and practice related to sharing patients’ clinical information with them? How do you monitor staff communication to patients of this choice, and patient participation levels? Describe the mechanisms in for patients to document their comments and for caregivers to access those comments. How is the opportunity to document their comments communicated to patients? A copy of your approved policy
implemented to enhance the visitation experience for visitors and residents? Criteria Questions Requiring Response Documentation Required IV.A-Behavioral Health Application: In behavioral health settings, visiting are consistent with the patient’s treatment plan and flexible to accommodate patient and family visitation preferences. Restrictions to visitation are determined by the treatment plan and patient preferences, and the rationale for any restrictions is clearly communicated to patients and families. How long has flexible visitation been in place at your organization? How is this policy communicated to patients and families? Describe other ways that the organization actively supports family’s presence. Examples may include programs to offer social and emotional support to loved ones. A copy of your visitation policy IV.B-Acute Care and Continuing Care Application: A comprehensive formalized approach for partnering with families in all aspects of the patient’s/resident’s care, and tailored to the needs and abilities of the organization, is developed. An example is a Care Partner Program. How long have you had a comprehensive, active family involvement program, such as Care Partners, and in which areas of the hospital or LTC community is this in practice? How are patients/residents and families made aware of this? A copy of your family involvement policy IV.B-Behavioral Health Application: A comprehensive formalized approach to providing families with psychoeducation and, when clinically appropriate, involving them in the patient’s care, is developed and tailored to the needs and abilities of the organization. An example is a Care Partner Program. How long have you had a comprehensive, formalized family involvement program, such as Care Partners? How are patients and families made of this? A copy of your family involvement policy IV.C: A process is in to encourage patients/residents and families to communicate with staff about any concerns related to their care, including any concerns related to patient/resident safety. Describe your processes for encouraging patients/residents and families to communicate with about concerns. N/A IV.D-Applies only to continuing care sites: A process aligned with each resident’s individual preferences is in place to contact residents’ family on a regular basis to communicate progress and/or “positive events.” Describe your processes for contacting residents’ family members to communicate progress and/or positive events. N/A
The interests of the communities served for alternative, complementary and integrative healing modalities are addressed and supported. Staff members and patients/residents, as clinically appropriate, are provided with caring touch in the health care environment. Patients’/residents’ wellness needs are approached holistically. Criteria Questions Requiring Response Documentation Required IX.A: A broad range of healing modalities, including those considered complementary to Western or traditional modalities, are offered to meet the needs of patients/residents. These offerings are based on an assessment of the interests and current utilization patterns of patients/residents and medical staff in such complementary and integrative healing modalities. Examples could include providing direct services, developing a process for responding to patient/resident requests for treatment by the patient’s/resident’s existing practitioner(s), and evaluation of patients/residents’ herbal remedies as part of the medication reconciliation process. 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. N/A IX.B: A plan for caring touch is developed and implemented as appropriate. (Exceptions include behavioral health patients.) Examples of caring touch include massage, healing touch, therapeutic touch and Reiki. Beyond implementation of formal caring touch programs, patients’/residents’ daily care is provided with gentleness. How is caring provided to patients/residents, family and staff in your organization? Describe any additional efforts undertaken to promote gentleness in the daily care provided to patients/residents. N/A Criteria Questions Requiring Response Documentation Required IX.C: Patients’/residents’ health and wellness needs are approached holistically and in consideration of the person’s expressed health goals and priorities. Caregivers assess the Describe the organization’s approach to supporting patients/residents in chronic disease management. N/A
ability of each patient/resident and family member to self-manage their health care needs, and support is available, as needed, to enhance self-management abilities. Examples include home monitoring, health coach support, programs that support patients/residents/family in chronic disease management, stress management, nutrition, etc. 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. IX.D-Applies only to acute care and continuing care sites: A plan is developed and implemented for providing holistic and dignified end-of-life care. The plan includes clinical care and pain management, meaningful education about advance directives, and psychosocial and spiritual support. What practices around death and dying have you implemented to support and enhance this process? Examples include a White Rose Program, a nourishment cart for loved ones and a Reflection Program. N/A Section X: Healthy Communities/Enhancement of Life’s Journey Objectives: Sites extend their activities outside the walls of their organizations in ways that positively impact the health of the communities they serve. Wellness programs, including chronic disease prevention and management programs, maximize the quality of life for all members of the community. Criteria Questions Requiring Response Documentation Required X.A: Based on the interests and needs of the community, a plan is developed to improve community health. Examples include provision of direct services, educational information, or referral and collaboration with local agencies. Describe how you have assessed, determined, and are meeting the public health needs and interests of your community. N/A