International Patient and Family Centrered Care Conference #2

Collaborating with patient and family advisory council during major budget cuts and work redesign – Vanderbilt University Medical Center, Nashville TN

So I was drawn to this group not only to listen to Tennessee accents but also to hear how an organisation has partnered with consumers in one of the most difficult aspects of health care – budget cuts. The increasing pressure on the health dollar is a universal issue. Care costs more, and with the increase in non-communicable diseases across the western world we are seeing surges in demand for health care. We are not immune to this in Canberra. And as much of our health care is funded through taxation and co-payments the title of the presentation is apt: we are all in this together. So how can consumers contribute to these touch decisions?

Terrell Smith is from Alabama and her gorgeous accent didn’t disappoint! We do not want to talk about budget cuts in health care but it is a reality in the US. This is looking at academic medical centres as health reform which is having a tremendous impact on these services.

Fee for service model dominates the US health system, although this is better described as a a disease treatment system in the US and not a health care system. This payment model did not present incentive for keeping you well. Doctors were requesting more tests to confirm diagnosis in response to the increased rates of litigation. So defensive medicine is alive and well. But there is a disparity of health outcomes in the US, those people who have money and education have a longer life expectancy.

There is waste in the health system. 40c in the health dollar in the US is spent on chronic conditions and 15-20% is spent on potentially avoidable complications. So better management of people with these diseases and improving the design of services is one of the ways in which improvements can be made for the bottom line as well as health outcomes.

University medical centres have three areas of focus: Healthcare, research and education. Cleveland Clinic 44,000 employees and staff account for half of the costs.

Moody’s investors service shows declines in revenue in hospitals for the past ten years, so who would invest in health care at the moment?

How can value based care change this? Vanderbilt is looking to focus on consumers receiving everything they need and nothing they don’t.

Vanderbilt quietness initiative 40% wake you up lab tests might not be critical and they are looking to reduce these. Has two benefits, improves the patient experience and protects sleep but also removes the costs of pathology that is unnecessary and not contributing  to improving patient care.

The AAMC Framework Continuum of care Vanderbilt Heart’s Proposed Interventions along AAMCs framework was put on the screen and it showed that patient and family engagement was core to

Clear communication has to be on everyone’s radar and health literacy is critical to improve, shared decisions making, teach back

Council volunteers to teach the nurse to practice teach back.  A great investment of time – are your patients

Vanderbilt experienced $130m in reduction last year. This financial year they will reduce by a further $150m. Not sure what proportion this is of their total budget but it seems like a lot of money to me!

Reduced 1000 FTE, early retirement and had to lay 400-500 people off. No accrual vacation, did not accrue 3 days of vacation, ended sick leave cash out if you left the org, drug utilisation, discretional spending (cell phones), travel if you are speaking at a conference, put off minor construction.

Wanted to add another element to considering this work as there are things that the staff cannot see.

Maryann was Chair of the Advisory Council for four years. You can lower cost of health care by having patient and family advisors (who are volunteers) and listening to their views on your service.  Maryanne is a CPA and health care is a learned proposition for her and it is incredibly meaningful to her.

There are three Advisory Councils at Vanderbilt. One for Children’s Hospital. The one for the adult hospital started on 2006 and is vital to leadership of the hospital. Also have a Council for Behavioural Care (psychiatric hospital). The CEO and Chief Nursing Officer are there for each meeting. They respond as necessary but mostly are listening. They investigate all the issues the Council picks up. There is good communication and it is a trusted relationship.

All three Councils were brought together to consider the issues around the billing process. The billing process is an area for improvement in most hospitals across America.

One man accesses multiple clinics but is never checked in the same way. This began a focus on standardising the appointments processes.

They put up a SLIDE that provided an overview of the Clinic Operating Model Redesign: Access, check in, wait times, physician encounter and check out and follow up. Good questions on this slide to consider the patient experience

Call management for ambulatory care clinics (eg diabetes, heart) – there were 940,000 calls annually and there was a 25% abandonment rate. There was no performance measurement. But after the redesign there was 4% abandonment and active daily management and data tracking.

Our Promise to You: Vanderbilt Patient and Family Promise. Took all of the pillars that Vanderbilt is based on and applied this to patient experience. We make those we serve our highest priority. This is a really nice idea and I am definitely going to follow this up for heath services when I get back to Canberra.

They hold Council meeting open forums on a quarterly basis where they discuss recent hospital and clinic experiences with senior leadership. They also have the opportunity to share what they are hearing for the community. And in turn they can give correct information to their friends and networks. Also discuss issues of interest to the Council regarding perceived needs. Discussions are generally positive, looking at ways to improve rather than dwelling on those

They are widely represented on hospital committees including Patient Education Council, Patient Experience and Service Improvement Council, HCAHPS Improvement Working Group, Quality and Safety Council, Food Service Advisory Committee, My Health at Vanderbilt, Strategic Planning Design Shops, PCORI Research Grant Steering committees.

Introduction to patient promise is part of the staff induction and they also talk about the importance of patient and family centred care. Clear communication and teachback are promoted to all staff in induction.

Question: How do you support your patient advisors? They do this by helping How to tell your story in 3 minutes.

Question: How do you recruit to your Council? Put out a call to social workers, physicians, nurses and ask them to nominate someone who they have had contact with who they think would be good to participate in the Advisory Council.

Darlene Cox
@darlenecox

International Patient and Family Centred Care Conference #1

There are over 700 people registered for the conference. There are 300 people from nine provinces across Canada and many people from the US. There are people from ten other countries to share experiences and insights including Afghanistan, Cameroon, Denmark, Qatar, Sierra Leone UK and Australia.

The conference started with a traditional Salish welcome and blessing from Elder Roberta Price.

The health professionals attending the conference work within and across disciplines with patients and families. There is 170 patient and family advisors. These individual are partners for improvement and transformation and grateful the work they do to improve health services. Need to build the depth of partnerships with consumers so that we can improve the safety and quality of health care.

Now I had thought I would tweet throughout the conference but there is no wifi! And as I have come from afar I have not organised internet access from my phone. So, instead I will blog. Excuse the typos and incomplete sentences. I will correct these (in time).

Mr TerryLake, Minister of Health of British Colombia

Health care developed around big buildings where you went when you were broken and you came out foxed. So focussed on moving patients through the big system that we forget about the person experiencing care and their families. When we put patients at the centre of care we change the dynamics. It is a cornerstone in the Ministry of Health strategic plan and they strive to deliver care that is built around the individual and not around the provider and not about the administration. He has committed to a sustained focus on improving services to meet the needs of families. Moving from disease focus to patient focussed and recognised that there will need to be a change management approach to support health professionals as well as patients and families to embrace the change. When you are trying to get through your day and get all your tasks done you can be task focused but you need to stop and think about the ae that you are delivering. Put the brakes on and think in the moment.

Patients as Partners in BC focuses on helping patients manage their own care and gave them an opportunity to learn more about the health system.

They have navigators for indigenous people as well as cancer care. They provide support for things like arranging transport, medication and discharge planning. Interesting, I think the role of health navigators is a growing area as care becomes more complex and fragmented across settings and we become sicker. We have certainly been talking about the need for this role in Canberra. Mostly these roles are filled by RNs (known as care coordinators) but I think there is scope to have consumer peer workers too.

Better together campaign proud to be blazing a trail to remove restrictions on visiting hours. St Pauls Hospital (Providence Health) are first in BC to drop the visiting hour restrictions. Patients and families engaged in help to fill in the blanks and advocate on their behalf. Infection rates drop when visits visit freely and staff engagement improves, rates of fall decrease and there is a reduction in medical error, emotional hard inconsistencies in care and transition to other settings.

Dianne Doyle, CEO of Providence Health Care

Culture of care and the deep commitment of Providence Health Care to patient and family centred care. This started 4 years ago where IPFCC reviewed Providence work and assessed structures and provided recommendations. Strategic planning identified patient centred care as a strategic priority using the experience of the Institute and developed an action pan. This is about bedding patient and family partners and set a plan to have 100 people in these roles across the organisations. The Board has two patient and family partners and sit as members of quality and accountability committee of the board and also a Patients as Partners. This group developed the Family Presence Policy (visitation). They have also considered how their staff present to visitors and families and patient and standardisation of uniforms has been introduce and name tags so that names and roles is easily identified., Communication is important work and they get a great deal of feedback,. They have developed patient information and cardiac is doing journey mapping. Code Help is an opportunity to ensure that 24/7 that if they feel that they are not getting the are that they need that they can phone to make sure their expectations and needs are being met.

This is not about public relations, they are serious about reflecting on patient care. The retreat with senior staff includes patients and family members to share their stories about how the service failed their families.

There are three areas they are developing: started bed site multidisciplinary handover, now include patients in recruitment of staff and developing indicators to monitor impact their work is making

Ms Leilani Schweitzer - https://twitter.com/LeilaniS

Firstly, let me say that this was one of the most remarkable speeches I have heard. And in my 15+ years in the consumer movement I have heard many stories and listened to many speeches about th need to improve the quality and safety of health care.

What follows are my notes from Leilani's speech.

Leilani shared the story of her loss. Her 20 month old son, Gabriel, died. She started by saying that on Thursday he was sick and on Tuesday he was dead. Alarms interrupted her sleep. She had already experienced sleeplessness at the local hospital in reno before they had been transferred. She was relieved they were at Stamford. The nurse turned off the sound of the monitors next to his bed so taht they could both sleep a little bit. Unknowingly the nurse, acting out of compassion, had done more, she hadn’t only turned off the alarms next to Gabriel's bed but also at nurses’ station.  So when Gabriel’s heart stopped beating there were not sounds to alert staff to this. Several minutes had passed and she was jerked awake to a room full of people and panic. This happened as there was not a safeguard in the alarm system.

Leilani is a health care outsider, like me she does not have a medical degree and has not spent countless hours in medical rotations. She says she could never undertake the difficult job that doctors and nurses do. Her son’s story is her credential and she tells it to make a difference. She tells the story to shift peoples’ thinking and because, she says, we need a new narrative.

But where does improvement and change happen? We are stuck between the way things are and the way we want them to be. We want our heads in the clouds ad our feet firmly on the ground. How to we shift the ground and bring the two together?

Leilani shared her wish list – now I didn’t see this due to my poor eyesight but I will certainly check it out as there was laughter in the room.

Choose to listen. Choose to be transparent. You don’t have to agree to the status quo.

We cannot have a health system that is based on the needs of clinicians. We need to have a system that meets the needs of patients, clinicians and administrations. We need to value everyone’s insights and perspectives. Clinicians’ motivations cannot be ignored. They bring their struggles motivations and humanity to the hospital everyday along with their skills and expertise. We need to honour their role as we need to value the experience and insight that consumers bring.

This is the only way we can understands the issues and find real, long term solutions to these intractable problems.

Sometime the power is not in the story but in the telling of the story. We need to encourage people to tell their stories and encourage staff to listen. We need health services to hear every story and not only the loudest and not only the ones that confirm their assumptions. These stories are the truth of the environment. We cannot listen to them in isolation because they all overlap. We need to track the issues

Leilani works as Patient Liaison, she works with people when there are has not gone according to plan. She has learnt that the first telling, the first quick account tells us very much. It is only after many tellings and research that we learn the whole story. People need to understand all aspects of their medical care, particularly the parts that did not go according to plan. She works with the vulnerability of patients and families as well as staff.

Stamford investigated and let all other hospitals using this system know about the dangers. They looked further than the nurse’s actions.

Leilani advocates for transparency as it helps us identify system errors and act to fix them. Transparency is a lens. It can help us understand where we want to go, where we need to go.

Understanding the environment is critical to improving the quality and safety f health care. In Gabriel’s case there were issues around the programming of the alarms, alarm fatigue, and a nurse’s call for help was not responded to,

 A young doctor spoke nervously at her. This doctor was hopelessly unprepared to deal with the situation. Leilani eventually told her to shut up. Death is a full stop for a patient in a hospital bed bit it is a terrible beginning for everyone left in the room. Hospitals should extend their care to these people as fall out is slow, painful and toxic. It is also contagious.

We need to stop protecting patients from understanding the dangers in health care. We are the most untapped resources in health care, we have so much to offer as we have so very much to gain. We cannot help if we do not know the full story. Change is so slow and this can be discouraging although Leilani is optimistic.

This was a spectacularly powerful story full of forgiveness, compassion and kindness. There were many tears in the audience.  I felt privileged to hear her speak

Darlene Cox

@darlenecox

Nurse Endoscopy

In June I attended the Victorian Health Care Quality Association showcase on award winning innovative practice. My previous report is on the HCCA blog.

The innovation showcase was an event put on by the Victorian Healthcare Quality Association, the Centre of Research Excellence in Patient Safety, the Victorian Department of Health and the Australasian Association for Quality in Health Care. It was held in St Kilda over two days, and show cased quality improvement initiatives which have won major awards across Australia over the previous 12 months

Sylvia Constantinou, a Nurse Endoscopy at the Austin Hospital, gave an overview of the nurse endoscopy services in Victoria. This is related to the Health Workforce Australia work on Extended Scope of Practice for health professionals.

In the state of Victoria endoscopy nurses are advance practice nurses and have been credentialed to deliver this service. They scope independently and with access to gastroenterologists. They are not nurse practitioners. This is a new pathway for nurses in Australia but has been happening overseas for some time (the UK has been doing this for 20 years.)

Why nurse endoscopists?

Bowel cancer is a preventable disease. Early detection results in cure. There has been a bowel cancer screening program put in place but there I an increasing number of requiring screening with a colonoscopy. There is a growing awareness in the community of familial links. Yet with this awareness it is the second most common cancer in men and women in Australia.

Austin Health was part of the National Bowel Cancer Screening Program since 2002, when the pilot. In Victoria there were 188,000 screened. 6000 were faecal occult blood positive. Of these one third will show cancerous cells.

This year there will be 4.8 million people eligible for screening.

Austin, Alfred, Monash and Western have all been implementation sites as part of Health Workforce Australia program. The Victorian Government funded the State Endoscopy Training Centre (SETC) and the goal is to train 15 nurse endoscopists to work at ten public hospitals.

The Austin Hospital has a large gastro hospital and perform almost 3000 colonoscopies per year with more than 2000 people waiting. At the Austin 12% of colonoscopies are completed by the There are 29 doctors and colorectal surgeons and they perform 79% of the colonoscopies

There are two nurse endoscopists in Victoria and independently practices and there are three trainees as part of the HWA project. The theoretical training is provided by University of Hull in the UK.

Austin Health have a useful FAQ on nurse endoscopy online.

It seems clear that there is a role for nurses working in this area with extended scope. We need them to be safe and procedurally efficient. We also need a career path as well as need for education, support and supervision.  With the demise of HWA I hope this program of work is not shelved as the functions are absorbed into the Department of Health

Darlene Cox

Managing and Enhancing Care Co-ordination in Chronic Disease Management

Speaker: Jan Ironside

June 20 2014

On Friday 20 June, HCCA in collaboration with the Chronic Care Program at the Canberra Hospital hosted a health issues group on how to better manage your chronic conditions and what services the Chronic Care Program provide to the community in order to achieve this.

The growing ageing population has led to an increase in the number of people developing and living with chronic conditions. This has brought up global concerns as there are limited resources to accommodate for the increase in patients. In response to this growing health issue, the Clinical Care Program has trialled a successful project that focuses on better self-management and person centred care.

The project works to maintain patient safety, ensuring that people are informed decision makers and more in control of their health. The Chronic Care Program categorises people using their level of need; category 1 for high needs and category 2 for low needs. This enables staff to prioritise and appoint the appropriate amount of time to each of their patients, improving efficiency but not decreasing the quality of care received.

All people referred to the program by nurses or general practitioners are contacted immediately by an assigned care co-ordinator and are categorised as category 1. The care co-ordinator assesses the living environment of the person through a home visit and helps them to create a care plan that is specific to their needs. They can also make any appointments the person may need and can accompany them for extra support. Phone calls are made regularly to the person to ensure they are on track with their plan and self-managing their condition.

Once the person has become familiar with their care plan and have gotten into a regular routine, the person graduates from category 1 to category 2. Category 2 allows people to have more independence with managing their condition. Phone calls become less regular and the care co-ordinator slowly becomes less involved in their care routine.  Once the person feels in control of managing their condition without much assistance from their care co-ordinator, either the co-ordinator or the person can recommend to be taken off the program.  

Alongside this project, the Chronic Care Program have collaborated with the CSIRO in a nationwide trial of the Tele-health home monitoring devices that further educates and supports people with chronic conditions to manage their health and improve their quality of life. The devices allow people to self-monitor and measure their blood pressure, blood sugars, lung capacity, body weight and temperature and perform a basic Electrocardiogram (ECG). This information can then be transmitted securely through a high-speed internet connection (provided by the CSIRO) to health professionals who can assist the person with any concerns they may have via a telephone call. This helps to reduce the number of unnecessary hospital and doctor visits and the costs that are associated.

With the success of their trial, the Chronic Care Team hope to increase their capacity to expand this promising program. For more information, contact the Chronic Care Program on 02 6244 2222.

By Khalia Lee

HCCA Administration Assistant

Job Vacancy

Project Officer

Health Infrastructure Program

(SCHADS Community Worker Level 5)

Do you care about the quality and safety of health services? Are you interested in planning and project management? Can you work independently and use your initiative? Are you resourceful and like a challenge?

We are looking for someone to  join our staff team working on the Health Infrastructure Program (HIP).

The Project Officer will work under limited supervision by the HIP Coordinator to

• Support Consumer Representatives on a range of committees involved in decision making for the HIP;
• Represent HCCA on a range of committees involved in decision making for the HIP;
• Network with consumer and community groups to further consumer involvement in informing decisions regarding the HIP.  This will include outreach to marginalised and vulnerable communities (including but not limited to: people living with chronic conditions, who have low socio economic status or are disadvantaged, are from culturally and linguistically diverse backgrounds, have a disability, young people and children);
• Liaise with ACT Government about opportunities for consumer involvement in HIP activities; and
• Work closely with consumer and community organisations to ensure opportunities for engagement of health consumer representatives in HIP activities.
• Help ensure the work of HCCA on the HIP is effective and meets the requirements of the Service Funding Agreement with the ACT Government.

This is a full time position but there is potential to negotiate on hours. This is a contract position until 30 June 2016, in line with our Service Funding Agreement with the ACT Government. Other conditions of employment will be based on the Social, Community, Home Care and Disability Services Industry Award 2010 (SCHADS).

HCCA promotes a healthy work-life balance and is committed to offering employees a supportive family friendly working environment.

Selection Criteria

1. Excellent communication and interpersonal skills to effectively communicate information and ideas, work cooperatively with others, and negotiate and advocate on behalf of consumers. 
2. Demonstrated ability to manage complex projects effectively including experience in project management
3. Excellent time management skills and demonstrated ability to manage competing priorities and achieve work outcomes
4. Understanding of governance principles and committee processes
5. Strong understanding of community development and experience in community engagement, including the capacity to represent the organisation in public forums and facilitate meetings, information sessions and workshops
6. Demonstrated ability to plan, organise and facilitate workshops, information sessions, discussion groups and public meetings.
7. Proven ability to develop and maintain strong networks and partnerships with key stakeholders including people from diverse language and cultural backgrounds.
8. Demonstrated understanding of the barriers and opportunities which exist in achieving systemic change
9. Computer literacy including experience with MS Office and Internet research skills

DESIRABLE QUALIFICATIONS:

10. Relevant tertiary or other recognised qualifications
11. Current drivers licence.

All applications must include:

1. A covering letter stating your intention to apply for the position and addressing the selection criteria listed below.

2. A current CV.

3. Information for two Referees. (Name, Title and Organisation, Relationship to applicant, contact telephone, contact email address)

Applications close on Monday 21 July 2014 and should be addressed to:

Darlene Cox

Executive Director, HCCA

100 Maitland St Hackett ACT 2602

Full details are on the HCCA website:

http://www.hcca.org.au/about-hcca/staff