PFE Success Story Submission Form

Partnership for Patients (PfP) Engaging Patients & Families: Success Story Submission Form Background Information Dear Patient and Family Engagement Leaders:

The Partnership for Patients (PfP) is seeking best practices and success stories on effective patient and family engagement from patients, families, hospitals, and federal and private partners. The goal is to recognize those who are doing good work, as well as to identify practices that can be shared and emulated by other hospitals. The stories and best practices collected will be developed into case studies and shared among hospitals and other partners by the PfP PFE Affinity Group to support the rapid spread of best practices. Below are some examples of story topics that you might consider sharing.

Please see the template Success Story Submission Form on page 2 for your reference. Please submit this information electronically to your NYSPFP Project Manager.

Examples of Story Topics

 Harm prevented (good catches and near misses)  Patient-provider teamwork (steps taken to produce patient-desired outcomes and illustrated by a personal story)  Lessons learned from medical errors: how hospital processes and procedures have changed and improved to avoid similar mistakes in the future or deliver better care  Stories that relate to the five metrics hospitals report on: 1. Planning checklists: Prior to admission, hospital staff provides and discusses a discharge planning checklist with every patient that has a scheduled admission. 2. Shift changes: Hospitals conduct both shift change huddles for staff and do bedside reporting with patients and family members. 3. Hospital person or functional area responsible for PFE: Hospital has a person or functional area dedicated and proactively responsible for PFE and systematically evaluates PFE activities. 4. PFE committee/advocate on team: Hospital has an active PFE committee or at least one former patient that serves on a patient safety or quality improvement team. 5. Patient on governing/leadership board: Hospital has at least one or more patients who serve on a governing and/or leadership board and serves as a patient representative.  Stories that relate to the 10 Hospital Acquired Conditions (HACs) targeted by the Partnership for Patients, as well as preventing “Harm Across the Board” (HAB): 1. Adverse Drug Events, 2. Catheter-Associated Urinary Tract Infections, 3. Central Line Associated Blood Stream Infections, 4. Injuries from Falls and Immobility, 5. Obstetrical Adverse Events, 6. Pressure Ulcers, 7. Surgical Site Infections, 8. Venous Thromboembolism, 9. Ventilator-Associated Pneumonia/Events, and 10. Readmissions

Last Updated: August 2013 1 Contact Information Name: Click here to enter text. Hospital: Click here to enter text. Email: Click here to enter text. Title: Click here to enter text. Phone: Click here to enter text. Date: Click here to enter text.

Success Story Information

1. Your Story: Briefly tell us your story of patient and family engagement and how it helped improve safety, quality, and patient-centered care in your hospital. Click here to enter text.

2. Why was change needed within your organization/what sparked the need for a new or improved program? Please provide any examples as appropriate. Click here to enter text.

3. How did the hospital implement the PFE program that is responsible for this success story? (e.g., What department or individuals championed this program? What approvals were needed? What specific actions were taken? Were there costs involved?) Click here to enter text.

4. Improvement Measures: Please provide any specific measurements that you feel demonstrate care is safer. Click here to enter text.

5. Pearls/Insights: Please describe your biggest insights about what worked and why it worked. What were the defining moments that produced these results? Click here to enter text.

6. Challenges and Successes: What challenges did you encounter when implementing changes? What strategies did you use to overcome these challenges? Click here to enter text.

7. Vulnerable Populations: Vulnerable populations are defined as those who may need adjusted service because of (including but not limited to): disability status, income (payor status), race, ethnicity, language, religion, sexual orientation, veteran status, or poor access to health care services. Does your story include examples of how the needs and concerns of vulnerable populations were considered? Click here to enter text.

8. Sustaining the Vision: What have you done to sustain the changes implemented? What is your vision or the hospital’s future plan for engaging patients and families? Click here to enter text.

9. Quotes: Please provide a quote from a patient or family advisor and/or a hospital executive describing their perspectives on your story. Click here to enter text.

10. Commitment to Share: Please provide the names and contact information for individuals we may contact if additional information is needed. Is there an advisor or leader in your hospital who would be willing to serve as a resource for other hospitals that wish to learn from your story? Click here to enter text.

11. Resources: Please provide examples or attach copies of relevant tools or other materials that you used to bring about change in your hospital. Click here to enter text.

Last Updated: August 2013 2 Once you have completed this form, please save it to your computer and email it to your NYSPFP Project Manager.

Last Updated: August 2013 3