Patient-partnered care framework

Introduction

Across the health care industry throughout the world, the requirement for greater involvement of the patient and their families is becoming more evident. As a key marker of high quality health care, providers are extending a partnership with patients and their families to identify and satisfy the full range of a patient’s requirements and preferences. More and more patients are becoming health literate; when confronted with disease or illness, they will turn to the internet and other sources for information. When patients now arrive at their health care provider’s office, they do so with both voice and vocabulary, seeking dialogue and wanting to be engaged.

Much of the literature to date has supported a shift to the concept of patient- and family-centred care, which puts the patient at the forefront of their health care, ensures they retain control over their own choices, helps them make informed decisions, and supports a partnership between individuals, families, and health care service providers. Within Canadian Forces Health Services Group (CF H Svcs Gp), we strive to take this one step further and develop a culture that formally recognize patients as being full partners in their care through the development and implementation of a Patient-Partnered Care (PPC) framework.

Through patient and family involvement, and with the support of the chain of command, CF H Svcs Gp hopes to gain their insights and perspectives to better plan and deliver care to our patient population. The concept includes the patient as a full partner, with their own skill and expertise, as well as direct reportable knowledge. The patient’s input includes everything from their own situation to the overall health care system. The patient will be our partner, not just a beneficiary of the services we provide. Ultimately, we want to see better care, designed and improved, with the help of the patient’s perspective. This framework provides an approach to the planning, delivery, and evaluation of health care that is grounded in mutually beneficial relationships among patients, families, and health care practitioners by truly partnering with patients and families. Although PPC will be integrated in our efforts as an organization, initiatives at the clinic level will be dependent on a variety of factors, including leadership, culture, and the patient population.

Definitions

Patient: A person entitled to receive care within the Canadian Forces Health Services.

Patient engagement: The involvement in their own care by individuals (and others they designate to engage on their behalf), with the goal that they make competent, well-informed decisions about their health and health care and take action to support those decisions.

Patient experience: How patients perceive and experience their care. Hear what is being said, measure the experience, and develop the capacity to use the information to change practice, policies, and rules.

Family: Two or more persons who are related in any way (biologically, legally, emotionally) including immediate relatives and other individuals involved in the person’s support network or circle of support. Family includes an individual’s extended relatives, their partners, friends, advocates, guardians, and other representatives. For our patient population, this also includes the patient’s chain of command, colleague, or peer. The patient defines the makeup of their family and has the right to include or not include family members in their care, and also has the right to redefine the makeup of their family over time.

Guiding principles of patient-partnered care

To support a culture of PPC, CF H Svcs Gp is committed to adopt the following guiding principles in our approach to care.

Promote respect: Proactively listen to, honour, and respect patient and family perspectives and choices. Patient and family knowledge, values, beliefs, and cultural backgrounds are incorporated into the planning and delivery of care.

Share information: Communicate and share information with patients, families, and chain of command in appropriate, useful, and affirming ways. To enhance informed decision-making and to ensure patients, families, and the chain of command are true partners in care, timely, complete, and accurate information is provided.

Encourage participation: Patients and families are encouraged and supported to participate in care and decision making to the level they choose.

Support collaboration: Health care leaders and providers establish a partnership with patients, families, and the chain of command to collaborate in areas such as policy and program development, implementation, design, evaluation, professional education and care delivery.

Challenges with patient-partnered care

Some of the most common challenges related to partnering with patients include shifting the culture, and by extension provider and patient behaviour, and actually integrating patient-partnered care into practice.

The culture of an organization needs to shift from one where the focus is on individual services delivered by professionals to one of integrated, collaborative care. Although CF H Svcs Gp has already begun this transformation, there still remains many concerns from leaders, healthcare providers, and patients that may prevent the advancement in culture that is desired.

Healthcare providers and leaders may be concerned that

• Patient perspective might differ and lead to unwanted change
• Patients may not have the required knowledge to participate meaningfully
• Patients may lose confidence in the organization while learning about and discussing challenges
• Patients may not respect privacy and information confidentiality

Patients, however, may also have fears in participating because:

• Healthcare providers are the experts and patients traditionally defer to their advice and direction
• Responsibility and accountability will be shifted onto the patient
• Patients might not have the confidence, knowledge, and ability to be partners
• Patient input may not be used to actually make decisions

Making patient-partnered care a priority in practice may prove to be difficult because of other competing priorities and the high demands on healthcare providers at the point of care. With limited health care resources, identifying opportunities for and engaging patients in a meaningful way seems like a daunting task. This framework intends to support the organization and its people in this endeavour through setting the tone, creating a supportive environment, and providing resources and suggestions on how to better partner with our patients.

Patient-partnered care practices

Four patient-partnered care practices are outlined in this framework to assist the organization in the pursuit of patient-partnered care.

1. Leadership in fostering PPC

To be truly effective at partnering with our patients, we must engage in activities as part of a long-term and comprehensive vision of organizational culture change. Leaders, at all levels of the organization, determine, guide, and communicate the vision of our organization and therefore, their engagement is crucial. The behaviours and values of our leaders will set the tone for implementing PPC within the CF H Svcs Gp. Leaders need to set the example and communicate openly, solicit and respond to input from staff, patients, and families, and ensure that their staff have the resources and flexibility needed to provide PPC. Examples of specific activities include:

• PPC Assessment: Use an assessment tool (Annex A) to identify where your clinic isacross the continuum of PPC. Through this tool, areas of achievement and areas forimprovement can be identified, highlighting initiatives that could be shared or developed respectively.
• Unit/detachment orientation: welcome address or presentation by clinic leadership during orientation ensure that new employees are familiar with leadership, emphasize leaders’ commitment to PPC, and set the stage to cultivate positive working relationships.
• Meetings: Set the context of meetings with a reminder of the organization’s values or how every day health care providers are making a difference in the lives of patients. Including patient and staff stories in meetings assists in setting the tone by making the point that all items up for discussion should consider the impact on the patient experience.
• Performance appraisals: PPC expectations can be communicated and documented in performance appraisals so that staff are aware of their role and responsibility.
• Reward and recognition: Recognition can be in the form of public acknowledgement of a staff member in a newsletter for how they made an impact on a patient, family member or another staff member, or it can be the opportunity for them to share "their story" in front of the management team.
• Learning Opportunities: Create a mutual learning environment for patients and their families, healthcare providers, and administrative personnel to provide opportunities fortraining on, testing of, and adapting best practices in patient-partnered care.
• Leadership support: Leaders should champion new policies and process that strengthen patient-partnered care. Through promoting and supporting opportunities for patient partners to be meaningfully engaged, work can be towards patient engagement at all decision making levels.

2. Caring for patients together

The capacity and ability of patients and their families to participate in their health care will vary due to several factors including experience, background, and personal choice. Patients and families will have different requirements for information, decision making, and involvement; and not all patients will wish to participate.

CF H Svcs Gp personnel can follow some of the following suggestions to engage patients, improve their experience, and improve outcomes.

Educate patients: Educate and empower their patients about their rights, responsibilities and behaviours that support PPC. “Our partnership with you” is a document that outlines these key factors and can be distributed through various means to our patient population (Annex B). Ensure patients are encouraged to ask questions about their care, get involved, and be part of the care team. Patients often have to make difficult decisions about their treatment without the benefit of knowledge and experience. They can often rely on their personal values and experiences, as well as those of others in making their decisions; or look to publically available information about their treatment options that may not be relevant to their condition or situation. Discussing the evidence-based options and rationale for treatment, and not trying to accommodate all of the patient’s desires, serves multiple purposes; the most important being minimizing harm from ineffective treatment.

Identifying responsibilities and common goals: Ensure care teams identify common goals, and identify the roles and responsibilities of each member of the team. Identify a point person to communicate with the patient and family.

Communicate: Below are some simple ways to improve communication with our patients and their families:

• Make sure patients and their families know who you are – introduce yourself with your name and position
• Communicate with families in the official language of their choice
• Be aware of the individual’s background, including their culture, ethnicity and religion
• Ask questions and listen to the patient and family’s opinion
• Respect the patient and family’s privacy and confidentiality
• Ask patients if we are meeting their needs
• Make sure they know about the service before they arrive (if applicable) and what to expect/bring
• Remember to explain the meaning of medical/ dental terms/ acronyms
• If teaching or providing instructions – make sure they are clear and concise
• Involve families in handovers/ transitions of care

3. Improving health care together

Health care organizations are increasingly turning to the voice of patients and families to better guide their efforts to satisfy patient’s needs and expectations. There is no better way to understand what patients want from their health care providers than to ask, and then listen to what they have to say. Patients and families perceive what we do differently; they are able to give us a different perspective about what we do, how we do it, and how we can improve. As patients’ and families’ needs may evolve over time, efforts to engage patients and families in defining quality care must be ongoing versus a one-time meeting. Some methods to solicit feedback and engage patients in improvement initiatives include:

Greater involvement for the patient and families: Increase involvement in day to day work, including their participation on relevant working groups and committees (policy and procedure consultations, review/input on key strategies etc). Seek those that would be willing to help, especially shortly after a relevant experience. Publicly solicit their involvement in general, or on particular initiatives being pursued at the clinic. Annex C is an example of a poster that can be displayed within the clinic or via electronic means (e.g. website) seeking patient involvement. Willing patients and families can be involved in activities such as focus groups and committees, participate in interviews (both formal and informal), or provide personal stories.

Patient experience questionnaires: One of the most common ways to solicit patients’ feedback about their care experience is the use of patient satisfaction surveys. These surveys, which can be customized, and can be conducted in person, over the phone, or via virtual means can be an effective way to collect timely information from a broad base of your patient population. The CF H Svcs Gp patient experience questionnaire (PEQ) will be one source of information, but will be at a very high level. The use of short and targeted questionnaires to a specific issue or quality initiative may be an effective mechanism to gain information from key stakeholders.

Create feedback loops: Measurement tools and feedback loops should be utilized that inform progress on PPC activities to all stakeholders.

4. Managing health care together

Patient-partnered care is about developing an equal partnership with patients and their families at all levels. This includes their involvement in decision making about service delivery, policy, program development, and evaluation. One of the most effective ways is to engage the patient, and their family (which includes their chain of command) where applicable, in an advisory capacity. Patients and families can provide valuable insight to the organization and contribute to establishing and maintaining effective systems to facilitate and monitor patient, healthcare provider, and community perspectives. This can be done by involving them in an existing committee or creating a standalone patient and family advisory committee. Annex D provides an example of a Terms of Reference for a patient and family advisory committee that outlines functions and criteria for membership. It is suggested that if a patient and family advisory committee be created at the local level, it support both the medical and dental clinic at that location.

Conclusion

This framework provides a consistent definition and approach to PPC to be used across CF H Svcs Gp. Further development of the PPC framework will be supported by the Quality and Patient Safety team. All partners, including our patients, families and the chain of command, have the responsibility to embrace a patient-partnered approach to care and engage in initiatives to achieve this pursuit. By implementing this framework in all that we do, CF H Svcs Gp will advance our culture to support our patients and families through mutually beneficial partnerships.

Resources

The following are resources that can provide more information about initiatives and strategies to engage patients and families in health care. These resources were used in the development of the CF H Svcs Gp PPC framework.

• Institute for Patient and Family Centred Care, http://www.ipfcc.org/
• Canadian Patient Safety Institute, Engaging Patients in Patient Safety, http://www.patientsafetyinstitute.ca/en/toolsresources/patient-engagement-inpatient-safety-guide/pages/default.aspx
• Health Quality Ontario, Engaging Patients. http://www.hqontario.ca/Engaging-Patients
• Alberta Health Services, The Patient First Strategy. http://www.albertahealthservices.ca/info/Page11981.aspx
• Saint Elizabeth Health Care, Person and Family Centred Care. https://www.saintelizabeth.com/Services-and-Programs/Research-Centre/Personand-family-centred-care.aspx
• British Columbia Ministry of Health, Patients as Partners. http://www2.gov.bc.ca/gov/content/health/about-bc-s-health-caresystem/partners/patients
• Help your patients engage in their health care, https://www.ahrq.gov/professionals/quality-patient-safety/patient-familyengagement/index.html

Annex A - Partnering with patients and families: A patient-partnered care self-assessment

This assessment can be completed by the clinic leadership team or other group which includes administrative and clinical leaders, managers, frontline staff, and patient and family advisors. The group can then discuss responses and develop an action plan.

Adapted from “Partnering with Patients and Families: An ambulatory practice self-assessment”, Institute for Patient- and Family-Centred Care; and “Patient-Centered Care Improvement Guide”, Picker Institute

Leadership in fostering patient-partnered care

The organization’s commitment to patient-partnered care is formally and consistently communicated with patients, families, staff and leadership (e.g. mission, vision, values).

• Agree or Disagree
• Priority for Change (Low - High): 1, 2, or 3

Expectations for a patient-partnered environment are clearly stated and proactively shared with staff.

• Agree or Disagree
• Priority for Change (Low - High): 1, 2, or 3

Staff view patients and families as essential members of the health care team.

• Agree or Disagree
• Priority for Change (Low - High): 1, 2, or 3

Patient-centred behavior expectations are included in job descriptions and performance evaluations tools.

• Agree or Disagree
• Priority for Change (Low - High): 1, 2, or 3

Staff at all levels, clinical and non-clinical, have the opportunity to voice their ideas and suggestions for improvement.

• Agree or Disagree
• Priority for Change (Low - High): 1, 2, or 3

Opportunities exist for both formal and informal interaction between leadership and staff.

• Agree or Disagree
• Priority for Change (Low - High): 1, 2, or 3

Orientation and education programs prepare all staff for collaboration with patients and families in care and decisionmaking.

• Agree or Disagree
• Priority for Change (Low - High): 1, 2, or 3

Caring for patients together

Patients and their families, according to patient preference, are encouraged and supported to participate in their care planning and decision-making.

• Agree or Disagree
• Priority for Change (Low - High): 1, 2, or 3

Patients are encouraged to define their family or other care partners who will be involved in care and decision-making.

• Agree or Disagree
• Priority for Change (Low - High): 1, 2, or 3

Patients are afforded privacy at all times during tests, appointments and/or procedures/treatments at the clinic.

• Agree or Disagree
• Priority for Change (Low - High): 1, 2, or 3

The design and signage of the clinic creates a positive and welcoming impression for patients and families.

• Agree or Disagree
• Priority for Change (Low - High): 1, 2, or 3

Cultural and spiritual practices of patients and families are respected and incorporated into care planning and decision-making.

• Agree or Disagree
• Priority for Change (Low - High): 1, 2, or 3

Systems are in place to assist patients and families in knowing who is providing their care, and what the role is of each person on the care team.

• Agree or Disagree
• Priority for Change (Low - High): 1, 2, or 3

Tools are provided to patients to help them manage their medications, medical appointments and other health care needs.

• Agree or Disagree
• Priority for Change (Low - High): 1, 2, or 3

Processes are in place by which patients and family may request additional information on their diagnosis, treatment options, etc.

• Agree or Disagree
• Priority for Change (Low - High): 1, 2, or 3

Patients have access to their medical record while they are being treated, and are assisted in understanding the information contained within.

• Agree or Disagree
• Priority for Change (Low - High): 1, 2, or 3

Patients are made aware of the opportunity to review their medical record with the support of a health care professional.

• Agree or Disagree
• Priority for Change (Low - High): 1, 2, or 3

Improving health care together

Patients and family members have been invited to share their experiences with your clinic in focus groups.

• Agree or Disagree
• Priority for Change (Low - High): 1, 2, or 3

Patients and family members serve on committees and working groups to improve care delivery.

• Agree or Disagree
• Priority for Change (Low - High): 1, 2, or 3

Patients are made aware of how to raise a concern related to patient safety and/or their care.

• Agree or Disagree
• Priority for Change (Low - High): 1, 2, or 3

Patients and families are encouraged to ask questions, and systems are in place to capture questions that arise when caregivers are not present to answer them.

• Agree or Disagree
• Priority for Change (Low - High): 1, 2, or 3

Managing health care together

Patients and family members have been invited to participate on a Patient and Family Advisory Council in your clinic.

• Agree or Disagree
• Priority for Change (Low - High): 1, 2, or 3

The input provided by patients and families is used to guide the organizations strategic direction.

• Agree or Disagree
• Priority for Change (Low - High): 1, 2, or 3

Opportunities exist for leadership to interact directly with patients and families.

• Agree or Disagree
• Priority for Change (Low - High): 1, 2, or 3

Annex B - Brochure

Download: Patient-Partnered Care Framework - Brochure (PDF, 2,178 Kb)

Our partnership with you

Together, we can foster a culture of respect, compassion, and competent care.

As our patient, we want you to:

• Communicate openly and honestly with your health care providers about any of your health concerns and carry out all treatment recommendations
• Attend all scheduled appointments and participate actively in decisions about your care
• Be fully informed about all aspects of your care and be able to respect and receive a second opinion if desired
• Utilize CAF health care facilities whenever possible
• Inform CAF health services authorities of any medical or dental care received outside of CAF facilities
• Inform your chain of command of your medical or dental employment limitations
• Actively pursue healthy living, maximize personal resiliency, make wise life-choices, seek support services early, and fully engage in clinical care when needed

As your health care providers, we will:

• Engage you and your families to ensure their understanding and meaningful participation
• Respect your choices
• Monitor and evaluate service and quality with input from you and your families
• Invite you and your family representatives to help us improve health care delivery
• Partner with you and your families to design and deliver services with you in mind
• Treat you with respect at all times and in the official language of your choice
• Ensure your chain of command understands your medical or dental employment limitations and provide advice and support on how best to manage them
• Support safe, quality patient care by following best-practices and using a collaborative team approach.

We will always be ready to respond to your needs and values. Let’s partner together to ensure you are getting the best care and treatment possible.

Our mission is your health - Partner with us.

Annex C - Poster

Get involved.

Help us to improve your care.

Real feedback, real change, real improvements

Canadian Forces Health Services Group is looking for volunteers to provide a patient's perspective in various projects and initiatives. Volunteers would be providing direct feedback that would go towards improving programs and quality of care for all Canadian Armed Forces members.

To find out more about how to get involved, please contact: ______________________________

Annex D - Patient and Family Advisory Committee

Purpose

The Patient and Family Advisory Committee (PFAC) will advise clinic leadership, healthcare providers, and administrative staff on policies, practices, planning, and delivery of patient-partnered care. Specific areas of committee involvement may include:

• Advising on policies, practices, and the application of patient-partnered principles;
• Assisting in educating both staff and the public around patient-partnered principles and practices; and
• Bringing a patient and family voice to advance patient-partnered care and patient engagement throughout the organization.

Authority

The PFAC will report to the [unit/detachment name – medical and dental] leadership team. The PAFC will seek approval at the intermediate and/or strategic level headquarters for any initiatives that may have the potential to impact the policy or programming within the Canadian Forces Health Services Group (CF H Svcs Gp). The PFAC will also liaise with the CF H Svcs Gp Quality and Patient Safety Advisory Committee (Q&PSAC) as required.

Principles

The principles of patient-partnered care represent the foundational framework by which CF H Svcs Gp engages with patient and family partners. These principles are:

• Promote respect: Proactively listen to, honour, and respect patient and family perspectives and choices.
• Share information: Communicate and share information with patients, families, and the chain of command in appropriate, useful, and affirming ways.
• Encourage participation: Patients and families are encouraged and supported to participate in care and decision-making to the level they choose
• Support collaboration: Health care leaders and providers establish a partnership with patients, families, and the chain of command to collaborate in areas such as policy and program development, implementation, design, evaluation, professional education and care delivery.

Functions

1. Promote collaboration between CF H Svcs Gp personnel and the greater community (including the chain of command) toward enhanced involvement of patients and their family members in the planning and delivery of care across the organization.
2. Represent patient and family perspectives about their healthcare experience within CF H Svcs Gp and making recommendations for improvement.
3. Work in an advisory role to enhance patient-partnered care.
4. Identify and encourage best practices in patient-partnered care.
5. Act as a sounding board when reviewing and supporting patient-partnered initiatives andactivities.
6. Evaluate the role of the PAFC in improving outcomes for patients and their families.
7. Contribute to and support nominations to recognize outstanding staff efforts supporting patient-partnered care
8. Encourage staff, patient, and family efforts to support healthy lifestyle and wellness initiatives.
9. Review and provide feedback on patient focused communication strategies and education.

Membership

The Group is co-chaired by a representative from the medical and dental clinics. This representative will ideally be a manager or supervisor. Depending on the focus of the meeting, the representatives will take turns chairing the meetings. Co-chairs do not have voting privileges. The chair of the meeting will engage in the following types of activities:

• Develops and finalizes Agenda
• Invites guest speakers
• Will arrange for staff to provide extra information on certain topics (if needed)
• Records the minutes of each meeting
• Keeps the minutes as a permanent record
• Informs the members of the next meeting
• Maintains oversight on membership

The PAFC membership consists of 5 to 7 patients or family members (exclusive of CF H Svcs Gp personnel) who:

• Have a variety of patient/family health service related experiences
• Bring diversity to the Committee with respect to their age, gender, rank, occupation, background, culture, and health care experiences
• Bring other skills, abilities, and experiences to help advance the work of the Committee
• Have a desire to work collaboratively with the medical and dental clinics in improving the quality, safety, and experience of care

Members of the PAFC will be invited to join by a co-chair. New members will be recruited as needed throughout the year to maintain membership. Staff of the clinics are asked to recommend patients or family members for the PAFC.

Membership is for a two-year term. Members missing more than 3 meetings without notice will be contacted by the co-chair in order to re-evaluate their ability to commit to the PAFC. Members wishing to terminate their membership are asked to provide one month notice to the co-chair.

Other CF H Svcs Gp staff maybe invited to attend as requested. The Clinic Manager/Commanding Officer, Base/Wing Surgeon, and Dental Detachment Commander, Regional Quality & Patient Safety Officer, and Regional Surgeon will be ex–officio members of the committee.

Quorum

Consensus will be the preferred method for decision-making for unit/detachment level initiatives or development of recommendations to the intermediate or strategic headquarters. When necessary a simple majority of 50% +1 will be used.

Meetings

The PAFC will meet a minimum of four (4) times per year and at the call of the chair. Minutes will be maintained and distributed to all patient and family advisory members and posted on the local shared drive and other areas to be determined.

Amendments

Amendments may be made to these terms of reference at any regular meeting of the PAFC, by a 2/3 vote providing the suggested changes have been read at the previous meeting.