Abstract
Vidant Health, a private, not-for-profit health system in Eastern North Carolina, began a system-wide quality transformation in 2006. A key strategy in the transformation was increasing the engagement of patients and families, including the establishment of Patient Family Advisory Councils. Meaningful partnerships with patients and families accelerated improvement efforts and sustained performance excellence over time.
A private, not-for-profit health system formed in the late 1990s, Vidant Health is comprised of primary and specialty physician office practices in more than 70 locations; a 909-bed flagship academic medical center; 7 community hospitals; an ambulatory surgery center; and home health, hospice, and wellness service providers. Vidant Health serves 1.4 million people in a 29-county region of Eastern North Carolina. The region is largely rural and poor; an estimated 16% of people are living in poverty, and approximately 18% of residents are uninsured. Many communities in this region have little or no public transportation, and more than 80% of the region is designated as medically underserved by the federal government. As the largest health system in such a region, Vidant Health plays a critical role in improving the quality of life for its residents.
In 2006, a series of errors resulted in a patient death following a blood incompatibility event at Vidant Health's academic medical center, Vidant Medical Center (VMC). Multiple visits by state regulators followed, and findings cited deficiencies in quality improvement and lack of oversight by the governing body. This serious safety event was pivotal in the quality journey of the health system, and it galvanized the board and senior leaders to place intentional focus on patient safety, performance improvement, and patient experience.
Specific methods were used to drive changes, including an emphasis on developing meaningful partnerships with patients and families. Like many organizations, Vidant Health had a long history of patient-family engagement in the Children's Hospital and the Regional Rehabilitation Center, and Patient Family Advisory Councils (PFACs) had been established in those clinical areas. A turning point in the expansion of these methods came in the spring of 2007 when an employee of the VMC Regional Rehabilitation Center shared her family's experiences with the Vidant Health senior executive team. The employee's brother had been hospitalized in an adult intensive care unit, and the health system's visitation policy restricted her family's access to her brother to 15-minute increments, 6 times a day. These restrictions also limited access to information and heightened fear and anxiety for her brother, family, and friends. Unfortunately, because of the system's restrictive visitation policy, her brother died alone with no family by his side.
After hearing this employee's experiences firsthand, the system's executive team and physician leaders committed to advance patient-family partnerships across the Vidant Health system. Principles of partnerships were embedded in key documents including Vidant Health's strategic plan and its long-range quality plan. An Office of Patient and Family Experience was also established at VMC in 2008 to educate leaders and staff on patient-family engagement. One action of this office was to organize staff champions and patient-family advisors in an effort to eliminate the restrictive visitation policy; this policy was replaced by flexible guidelines that promote and support family presence and participation.
Expanding to a System-Wide Focus
In 2009, a Vidant Health Corporate Office of Patient and Family Experience was established to guide the development of these principles across the entire health system. Speakers from the Institute for Patient- and Family-Centered Care (IPFCC) and the Institute for Healthcare Improvement (IHI) provided educational programs and a board retreat to support early efforts. An assessment of current and desired states of patient-family engagement was conducted in every entity. The IHI noted that, of the 7 leadership leverage points, the leverage point with greatest potential to drive the long-term transformation of the entire system is “Put Patients and Families on the Improvement Team” [1]. Patient-family advisors were thus recruited in every Vidant Health entity, and PFACs were developed at each entity as a way to engage advisors in this meaningful work.
Patient advisors are people who use their personal experiences as a lens to see how care and experiences might be improved. They are not so positive that they cannot identify opportunities to improve, nor are they so negative that they cannot move beyond their personal experiences to focus on system-level improvement. A comprehensive on-boarding process for advisors includes risk management screening, establishing confidentiality agreements, and occupational health clearance [2]. Patient advisors are recruited by providers, frontline staff, and leaders.
As the chairs of PFACs at each Vidant Health entity, patient experience leaders coordinate PFAC agenda topics, provide education, and align advisors' work with entity and system priorities. Representatives from each entity's PFAC also serve on the Vidant Health Patient-Family Experience Team. This system-wide team serves as the leading force in continuing to drive development of meaningful partnerships and to engage advisors in work that is central to the mission of Vidant Health. Accomplishments of the PFACs have included implementation of a family presence policy, implementation of patient/family activated emergency response teams, development of way-finding improvements, development of the patient portal My Chart, and development of quality content for the Vidant Health website.
Based on the long-range quality plan and our evolving patient-family engagement work, board members began to hear quality concerns directly from patients and families in 2010. The first patient to share her experiences with ventilator-associated pneumonia (VAP) stated to the board, “That scorecard you see every month, I am one of those VAPs.” This patient's compelling story set the stage for having a patient advisor on the board. A patient advisor now serves on the Board Quality Committee for Vidant Health and VMC to provide the unique perspective of patients and families in every meeting. Patients and families share their experiences of care with the board as a regular agenda item. The board views this as a key strategy to drive performance improvement and to stay in touch with frontline care.
Embedding Advisors in Existing Decision-Making Structures
As the partnerships between patient-family advisors and our system matured, we have begun to embed patient advisors in existing committees, work groups, and decision-making structures. For example, patient advisors are members of our regional quality coordination group. This group of quality leaders from across the health system meets monthly to drive multiyear quality strategies and to assure alignment of approaches system-wide. Patient advisors serve on this group and add their unique perspective and ideas at every meeting.
Patient advisors also participate on the Population Health Steering Committee and on associated workgroups. These teams are helping us transform the clinical enterprise from an episodic, fee-for-service–based system to a longitudinal, relationship-based one in which patients and families are fully engaged as partners in their care. New approaches to patient engagement and management of chronic disease in the community setting are evident in the recently adopted Vidant Health patient engagement model depicted in Figure 1 [3].
Vidant Health Patient Engagement Model
Today more than 120 advisors partner in meaningful work at every level of the organization. Advisors serve on performance improvement teams, make safety rounds, serve as faculty in education programs, interview applicants for key positions, and develop and edit patient education materials. Advisors are engaged in the work of key committees at the entity and corporate level. As we continue to evolve and patient advisor engagement and partnerships become the norm, we are embedding advisors on existing and newly formed decision-making groups and moving away from separate PFACs. We also guard against having only one patient advisor on any team, committee, or workgroup. Assuring more than one patient advisor in a group avoids the appearance of tokenism and assures representation in the face of illness or changing life circumstances for advisors.
A Chinese proverb says, “A journey of a thousand miles begins with a single step.” This is true for the establishment of patient advisor roles and PFACs. You can start by engaging one patient or family member to work on a meaningful project in your organization. Asking a patient advisor to review written or web-based patient education material or engaging an advisor in a construction project are great places to begin. You do not have to have a PFAC or have advisor role descriptions and orientation materials finalized. You just have to start the partnership.
Also, many organizations and publications exist to help you get started. Seek out the work and publications from the IPFCC [4], the Agency for Healthcare Research and Quality [5], and the IHI [6] as you begin this work. The resources will help in your planning, and they can help you to avoid common pitfalls in the early stages of this work.
Conclusion
In the years since that pivotal patient death in 2006, Vidant Health has become a leader in quality. Strategic planning set an ambitious agenda for the health system's quality work and continues to drive action today. Engaging patients in quality work at all levels—as partners on performance improvement teams, in safety rounds, in quality improvement committee meetings, and in the boardroom—has been a deliberate strategy and a significant part of the quality transformation at Vidant Health. The transformation has resulted in more than 120 patient advisors partnering with leaders, physicians, and frontline staff in safety and quality work. The system has achieved an 85% reduction in serious safety events [7], a 62% reduction in hospital-acquired infections, a score of 98% on the core measures of optimal care evaluated by the Centers for Medicare & Medicaid Services, and performance in the top 20% based on the Hospital Consumer Assessment of Healthcare Providers and Systems. From the bedside to the boardroom, the improvement in quality is evident across Vidant Health's 8 hospitals; 70 physician practices; the ambulatory surgery center; and home health, hospice, and wellness services.
A lesson learned by Vidant Health and the patients and families we serve is that this type of cultural change takes time. Factors that were critical in the success of our system's transformation include the presence of a committed board and leaders, the presence of aggressive written plans for execution of strategies, the identification of executive and physician sponsors, the establishment of functional areas and individuals for oversight, the engagement of staff, and the establishment of meaningful roles for patient-family advisors at all levels of the organization.
Many factors make it difficult to maintain a focus on zero events of preventable harm and exceptional patient experiences. However, the work to develop board literacy in quality and to establish meaningful partnerships with patients and families has enabled Vidant Health to maintain constancy of purpose in the quality agenda even as we expand our work beyond the walls of the hospital to engage new partners in the community. Sustaining the changes made since 2006 and spreading methods to new care venues in the ambulatory setting are on Vidant Health's current quality agenda.
Establishment of meaningful partnerships with the people who have the most at stake in this work—the patients and families we serve—has been transformational in our organization. These partnerships have driven us to accelerate the pace of change, to embed patient advisors in the operations of our organization, and to achieve greater quality and safety outcomes. We continue to strive for our ultimate goal of zero events of preventable harm, 100% optimal care, and exceptional patient experiences every time for every patient we serve.
Acknowledgments
Potential conflicts of interest. J.D.W. is an employee of Vidant Health.
- ©2015 by the North Carolina Institute of Medicine and The Duke Endowment. All rights reserved.
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