Nurse and Nurse Manager Module Display this slide as participants are entering. Welcome participants, guide them to seating. Before we get started, let me just cover a few practical matters such as: Where the restrooms are. Lunch if available. If there will be breaks. Registration paperwork that must be completed and other logistics. Nurse and Nurse Manager Module

Welcome and Introductions Adapt the following as appropriate for group and setting. When all are settled, complete the introductions–yourself, guests, participants, and Patient/Family Advisors if present. OR For Nursing CNE Class setting: If the group is small, ask the participants to introduce themselves and state what they will be doing in their positions at [insert VA facility name]. If the group is large, ask for a show of hands: How many of you will be working on inpatient units? In clinics? In CBOCs? Thank participants for joining today. For more than a decade, there has been growing recognition of the enormous benefits patient- and family-centered care offers to health care organizations, clinicians, staff, patients, and families. As hospitals, practices, and health systems struggle with issues related to quality, safety, cost efficiency, HIPAA and other privacy regulations, workforce capacity, the use of information technology, and the need to renovate or build new facilities, they are recognizing that patient- and family-centered approaches and the perspectives of patients and families are critical to their efforts. TOOLKIT REFERENCE: NURSE MANAGER AND LEADERSHIP TOOLKIT Nurse and Nurse Manager Module

Today’s Session Provide information and tools to continue the process of learning and implementing patient- and family-centered care initiatives within VISN 7. Review the importance of patient- and family-centered nursing practice and how it complements the VA's strategic goals and priorities. Review a toolkit of interactive activities for nurse managers and nurse leaders to apply in nurse education, mentoring, and coaching front-line staff. Discuss how to partner with Veterans and families in developing unit-specific or hospital/clinic policies, programs, and processes with the ultimate goal of improving quality and safety. In today’s session, we will review some general concepts about organizational change, and then will spend the rest of the session using a menu of tools and activities that can be implemented on units, clinics and long-term care facilities to address current and future patient- and family-centered learning and process improvement needs. Review slide. Nurse and Nurse Manager Module

Learning Objectives Align patient- and family-centered care and VA priorities. Review: Nursing-specific best practices in patient- and family-centered care that enhance quality and safety. Ways to partner with Veterans and their families. Ways to individualize care. Identify: Benefits to nurses and all team members. Resources within the hospital, clinic, and national VA Office of Patient Centered Care. The specific Learning Objectives are listed in your handout materials: You should be able to lead classroom training and staff discussions that… Review the slide. Nurse and Nurse Manager Module

Patient- and Family-Centered Care in the Department of Veterans Affairs A fully engaged partnership of Veteran, family, and health care team. Established through continuous healing relationships. Provided in optimal healing environments. In order to improve health outcomes and the Veteran’s experience of care. Let’s first review the context and framework of patient- and family-centered care in the Department of Veterans Affairs. The general goals for the VA’s adoption of patient- and family-centered care principles have been stated this way: Review the slide. Nurse and Nurse Manager Module

The VA’s 12 Patient Centered Care Principles Honor the Veteran’s expectation of safe, high quality, and accessible care. Enhance the quality of human interactions and therapeutic alliances. Solicit and respect the Veteran’s values, preferences, and needs. Systematize the coordination, continuity, and integration of care. Empower Veterans through information and education. More specifically, the VA has now articulated 12 principles of patient-centered care that are, in effect, areas of strategic focus for the VA. They function as a roadmap…they are the key dimensions to focus on for aligned change across the region and the nation. As you see on this and the next slide, these 12 principles basically states “WHAT WE WILL FOCUS ON” in the VHA with regard to patient-centered care. Review this slide and the next, emphasizing the key words. Nurse and Nurse Manager Module

The VA’s 12 Patient Centered Care Principles (cont.) Incorporate the nutritional, cultural, and nurturing aspects of food. Provide for physical comfort and management of pain. Ensure emotional and spiritual support. Encourage involvement of family and friends. Provide an architectural layout and design conducive to health and healing. Introduce creative arts into the healing environment. Support and sustain an engaged workforce as key to providing patient-centered care. Review this slide, emphasizing the key words. Nurse and Nurse Manager Module

Patient- and Family-Centered Care Core Concepts People are treated with respect and dignity. Health care providers communicate and share complete and unbiased information with patients and families in ways that are affirming and useful. Individuals and families build on their strengths through participation in experiences that enhance control and independence. Collaboration among patients, families, and providers occurs in policy and program development and professional education, as well as in the delivery of care. Finally, these are the core concepts of Patient- and Family-Centered Care, which are based upon years of listening to and working with patients and families across the nation. These concepts are a summary of the health care dimensions that are most important to patients and their families, our Veterans and their supportive networks. These core concepts describe the dimensions of the health care experience that we must build in to every encounter with Veterans and their families, in order to meet the goals and strategic focus of the “12 Principles.” Above all, patient- and family-centered care is a partnership that is mutually beneficial to providers and patients and their families, improving the quality and safety of health care across the board. For additional information about these four concepts, there is a “primer” about patient- and family-centered care in your Toolkit, as well as a document with background information and frequently asked questions. Nurse and Nurse Manager Module

Supporting Positive Change Your Role as Coach and Mentor Patient- and family-centered care as a set of values, principles, and practices is not just another “program.” It is a fundamental, transformational change that must take place in all of health care…not just the VA, but everywhere…driven by the imperatives of improving quality and safety, by activated consumers, by dedicated staff willing to engage in new care practices, by health care reform and cost concerns, and because it is the right thing to do. However, in large, complex organizations, it often seems as though there’s a “new wave” breaking over the beach every few months. Long-term employees have learned to let those waves wash over them thinking…“this too shall pass.” Nurse and Nurse Manager Module

“To shoulder the responsibility to change health care…requires one final element of trust–trust in the workforce…Our premise is this: to achieve the health care we want, we will have to re-envision, and largely retrain, the health care workforce, so that they can become citizens in the improvement of their own work.”    Don Berwick 2003  http://newhealthpartnerships.net/provider.aspx?id=1208 New Health Partnerships: Improving Care By Engaging Patients   The tools and information in this session are designed to help you, as nurse leaders and managers, to accomplish this challenging but inspiring goal from Donald M. Berwick, former head of the Institute for Healthcare Improvement, and now the administrator for the Center for Medicare and Medicaid Services in the Obama administration. Review quote. Nurse and Nurse Manager Module

Transformational Change Despite common misperceptions, cultures are not static constructs. They do change, and often rapidly, when there are motivated change agents and a rationale or external pressure that resonates within the culture. Levine and Murray, Cultures of Caregiving, 2004, p. 171 Health care organizations are "complex adaptive systems" and changing culture, processes, and practices is possible, even though difficult. But the shift in health care is well underway toward a system that is more responsive to patients and their family caregivers. Nurse and Nurse Manager Module

Nursing Leaders Are Key Nursing leaders can take advantage of the forces driving change at the "macro" level to make small but important changes in their clinical "microsystems" (the small, interdependent groups of people who work together regularly to provide care for specific groups of patients and their families.) Moving the larger organization may seem like an impossible task, but change can happen at the micro-level, the units, departments, and clinics–at the point of service–working with intact work groups and multidisciplinary teams. Nurse and Nurse Manager Module

Nursing Leader Roles in the Cultural Transformation Promote understanding of how every nurse contributes to creating effective partnerships with Veterans and family members. Serve as role models and coaches for front-line staff in partnering with Veterans and families. Act as change agents by fostering small pilots (rapid cycle change) that can serve as examples for others. Nursing leaders are key to the cultural transformation, by promoting awareness of how every nurse and nurse assistant can impact Veterans and their families. Your role is role model, coach, mentor, and champion of positive change for Veterans, families, and staff. Nurse and Nurse Manager Module

What are some of the changes you have witnessed in your health care careers? Ask the question: Remember when fathers could not be present during childbirth? What else has changed? How did those changes happen? Note: Let people talk about what they have seen…then summarize: So we’ve established that change is inevitable…is constant…and is often incremental–small steps building upon each other over time. And change is, in general, mostly positive in the long run. Nurse and Nurse Manager Module

A Day in the Life of a Nurse Manager ACNS Payroll Residents NPSB Provider Patient Surgeon Laundry Supply Committee Peers Affiliate UNION IRM Education Safety Clerk Family Staff CNE ADPS UM/UR Dietary Engineering Pharmacy Social Worker Case Manager Time Keeper COS And we bring this toolkit to you with respect and regard for your many competing accountabilities, as this slide shows “As if you didn’t have enough to do…!” Nurse Manager’s “Passport to Success” An Orientation Guide July 2009 Nurse and Nurse Manager Module

Leadership Tips Never miss a chance to “connect the dots.” Channel attention through everything–calendars, meetings, project team reviews, rounding, performance feedback, hiring, promotion, recognition. Get patients and family members onto your teams–from the executive suite on to the clinical micro system and improvement project teams. Help your staff "connect the dots.” All who work in the system need to know their part and how it fits into the overall system-level aim. VA priorities and goals, C.A.R.E. principles of customer service, previous ‘cultural transformation’ processes, all are founded on the same basics of improving the health of our United States citizens, and doing so in the most compassionate and supportive ways. One way to keep those dots connected…and the importance of our work in the forefront of everyone’s minds…is to involve patients and their families in collaborative partnerships with staff. “Make it a routine matter to bring patients’ ideas, perspectives, and insights into the room in which we are redesigning their care.” Whether it is through Patient and Family Advisory Councils, or in more ad hoc ways, bring the people you serve into sharp focus at every opportunity. Seven Leadership Leverage Points for Organization—Level Improvement in Health Care, Institute for Healthcare Improvement Innovation Series White Paper 2005, James L, Reinertsen, MD, Michael D. Pugh, Maureen Bisognano Nurse and Nurse Manager Module

Nurse Leader Rounding for Patient- and Family-Centered Care Did our staff explain their roles in your care? Did you get the information you needed and wanted? Was it provided to you in ways you found useful? In ways you prefer? Did we support your family's presence and participation in the ways you wished? Were your observations and concerns about your care respected by our staff? Ask patient- and family-centered questions as you round on your patients. Make note of their comments, and especially ask for staff who are stand outs and positive role models. Also take note of areas for improvement, and feed that into your staff meetings and other staff development sessions. Coach and mentor those who may be having difficulty adjusting to the new ways of working together. TOOLKIT REFERENCE: PATIENT- AND FAMILY-CENTERED CARE NURSE LEADER ROUNDS Nurse and Nurse Manager Module

Reward and Recognize Thank you notes. Patient comments. Thanks from the team. Let the Patient and Family Advisory Council know so they can add their thanks. Send stories to be published in the facility newsletter. Food! Support career development–your patient- and family-centered care champions will grow through continuing education, committee membership, mentoring roles, and special projects. SHARE BEST PRACTICES–and give the credit to the staff who are the best practitioners. Personal thank you notes from leaders and team members have proven to be one of the most appreciated ways to recognize staff. Listed here are others... Review a few additional bullets. Nurse and Nurse Manager Module

Deal With Resistance To Change Facilitate staff involvement in the change. Praise small successes. Do not waste large amounts of energy on those that simply won't or can't change. Explain how the change will benefit people. Teach new skills if new skills are needed. Use team solutions. Organize Brainstorming sessions. Encourage involvement! Assess and set priorities together. Encourage accountability. Encourage pride. Finally, take the long view in terms of resistance to change. It’s tough, but it’s not impossible. Years of organizational research into dealing with resistance to change boils down to a few key points: Maintain a personal attitude that encourages change. (1) Change is inevitable. (2) The only constant is change. (3) Success is based on our ability to predict, cope, and eventually lead change. (4) “If we don’t manage change, then change will manage us.” Focus on the “early adopters”–the change leaders–in your group. Put energy into them, their enthusiasm, their positive approach. Their energy often pulls the others (the “wait and see” group) along. Empathize with those who say “it can’t happen here” (“yes, I can understand how you might see it that way….”) but firmly restate that things will be changing, over time, and you and the organization will be expecting them to come along. Focus on benefits and opportunities, not barriers. The barriers often fall when the opportunities are fostered. Use team approaches. Change is a team sport. These key principles are tried and true. They take patience and perseverance, but over time, the desired change will happen. There are some folks who simply never will “get on board.” Use appropriate HR policies and practices to deal with these staff members after you have given them every opportunity to become part of the new, patient-and family-centered team. Nurse and Nurse Manager Module

Nurse Executive—Dorn VAMC In summary, let’s hear from a Nurse leader in VISN 7 about the importance of modeling the way. Click on black box on slide to activate. NNM slide 20 VC RM4.wmv (Instructor: This is the transcript of the video clip: “Well, the most important thing I can do is to live it and to set the example. I can't expect the staff in the medical center to put the patient and family as the core of what we do if I don't do it myself. I also need to provide the education and the support of patient/family-centered care to make that very important and to really do what I can to weave that into the fabric and the culture of the care that we provide.”) Throughout this session, we will hear from people–patients and staff–who are engaged in making change at VISN 7–and who volunteered to tell us their stories. Nurse and Nurse Manager Module

Practice-Based Team Learning A Framework for Change Practice-Based Team Learning A very important change management strategy is “PRACTICE-BASED TEAM LEARNING.” It is the notion that learning–i.e., changing the way we think, feel, and act–is most successful when it takes place in the context of the learner's current work or professional environment. This learning is most effective when it includes the multi-disciplinary team at every opportunity. Conferences and lectures can provide factual knowledge, a fresh perspective, new information. But in the workplace, the real behavior change happens on the job, in our so-called “real world.” The materials and activities that are outlined in this program and in the Toolkit that accompanies it, are based on the idea of practice-based team learning that is done at the unit or department or team level, where changes are more effectively piloted, adjusted, and hardwired. Nurse and Nurse Manager Module

Stages of Staff Involvement in Change Processes Multiple Leadership Single Leadership Telling Tools: Mailings Press releases, press conferences All other kinds of formal and informal announcements Selling Flyers and brochures Information centers Exhibitions Hotlines Briefings Intranet Coaching Training Testing Pilot interventions Simulations Step-by-step implementation with close monitoring Interviews Testing in communities of practice Consulting Reply forms Hearings and workshops Opinion polls Stakeholder analyses Intranet forums Advisory boards Focus groups Interactive training with consulation Consulting communities of practice Real time strategic change Co-creating “Whole system change”: Open space technology Appreciative inquiry Future search conferences World cafe Planning for real Joint scenario analysis Dialogue Experimenting in communities of practice Required Capacity for Direction Setting and Learning Practice-based team learning is also based on the well-established premise that engagement and active involvement in developing new ways of doing things–whether it is employee’s making change or Veterans making changes for better health–is stronger and more permanent when they are co-creators. Four tools are provided in your Toolkit to assess and set priorities with your team to improve the experience of care for Veterans and their families. Review the slide. TOOLKIT REFERENCES: WHERE TO BEGIN: TOOLS TO ASSESS AND SET PRIORITIES GUIDANCE Degree of Active Involvement Low High © Holger Nauheimer, 2006 – www.change-management-toolbook.com Nurse and Nurse Manager Module

Your Personal Mission Define your values and beliefs about patients and families and the experience of care. Commit personally to the vision, goals, and priorities. Communicate your personal commitment in a way that is sincere and heartfelt. As with so many other things, self-knowledge, and commitment are fundamental to success. Review the slide. Exceptional leaders appeal to the heart, not just the head. Your personal beliefs need to align with what you are asking of your staff. It is indeed “walking the talk.” Nurse and Nurse Manager Module

Nurse Manager and Leadership Toolkit Your Menu of Options Turn to the Where to Start and Using the Toolkit Grid section of your materials. Wait for participants to locate this section in their Toolkit. The Toolkit provides a range of activities for you to use as a trainer or nurse leader, for that “teachable moment,” when you need a quick staff meeting discussion activity to maintain the momentum of patient- and family-centered care in your special project teams, unit, clinic, department, or clinical micro-system. The idea of this Toolkit is to give you–the nurse managers and leaders–the maximum flexibility to maintain ongoing interaction among your team around the concepts, issues, behaviors and processes that comprise a patient- and family-centered approach to care. There is no evidence that a single “lecture” or in-service session results in significant change. Most successful transformational change efforts rely upon ongoing dialog and interaction at many different levels of an organization. These interactions OVER TIME will begin to change group norms. Nurse and Nurse Manager Module

The Toolkit Grid Fundamentals–foundation knowledge suitable for all staff in health care. Clinical practice–of particular value to those with direct clinical responsibilities. Coach and mentor–clinicians, educators, charge nurses, and others who have responsibilities for coaching and guiding other staff, or who produce educational materials and resources for staff or patients and families. Supporting positive change–team leaders, leaders and managers who are likely to be involved in process improvements, policy and procedure development, and new initiatives. The grid in the Toolkit lists the items in the Toolkit. It suggests the level of practice for which the activity is designed, the type of activity, and the materials and equipment needed. The “level” of activities are defined as: Fundamentals: Supportive resources and learning experiences for nurses to help them development successful patient- and family-centered practice. Clinical Practice: Clinical skill and communication strategies for nurses with direct care responsibilities. Coach and Mentor: Clinicians and leaders who regularly support and mentor staff. Supporting Positive Change: Strategies for nurse leaders and managers to support staff with actions for positive organizational change. Of course, these are simply guidelines, not “hard and fast” categories. The Toolkit is designed to give you the most flexibility in implementing staff development strategies over time. The Toolkit format gives nurse leaders flexibility in choosing the kinds of staff development activities that are most suitable for the goals of the learning session and appropriate for the unit/clinic/department/residential care setting. TOOLKIT REFERENCE: USING THE NURSE MANAGER AND LEADERSHIP TOOLKIT—WHERE TO START? Nurse and Nurse Manager Module

The Toolkit Grid Staff Meeting In-Service Reflective Practice Session Task Force or Implementation Team Supplemental Materials For example, take a look at the column labeled “Suitable For.” You’ll see some of these descriptors above. Staff meeting: These are typically quick, focused exercises that a nurse manager or team leader could use as part–or all–of a staff meeting, to help staff focus on what they can do to become more aware of, sensitive to, or knowledgeable about patient- and family-centered practices. These activities typically require little in the way of materials–perhaps a worksheet to duplicate. Each are accompanied by a “trainer” guidance sheet that provides an overview of the activity. In-service: These activities are typically classroom-based, although they can be adapted to staff meetings. These typically require a set of slides and audio-visual equipment. Four slide-based in-service programs are available on the Trainer’s CD in the Nurse and Nurse Manager Module in your trainer manual. These in-service topics will be posted on VA Sharepoint or [insert your facility name] common drive site. Nurse and Nurse Manager Module

The Toolkit Grid, cont’d. Staff Meeting In-service Reflective Practice Session Task Force or Implementation Team Supplemental Materials Reflective Practice Session: This type of activity is designed to provide busy staff with an opportunity to explore and discuss, in a relatively unstructured way, issues relating to the journey toward patient- and family-centered care. Participants learn from each other how to best handle challenging issues, or perhaps come to some conclusions about how to try out a new approach, or to talk about how a new approach–for example, Bedside Nurse Change of Shift Report, or a new discharge planning tool, or a trial of a new Daily Plan of Care process–is working. Task Force or Implementation Team: As you begin to advance the practice of patient- and family-centered care in your areas of responsibility, you may decide that you would like to be more strategic about what to focus on. There are three assessment tool options in the Toolkit that are ideal for determining where to focus the energies of your team. Also included in the Toolkit are background materials ranging from a primer on patient- and family-centered care, information about HIPAA, motivational interviewing information. A comprehensive bibliography is also provided. These are included for your reference and use as you see a need. TOOLKIT REFERENCES: PATIENT- AND FAMILY-CENTERED CARE PRIMER BACKGROUND INFORMATION AND FREQUENTLY ASKED QUESTIONS TOOLKIT SUPPLEMENTALS SECTION RESOURCES Nurse and Nurse Manager Module

Toolkit Activities Share best practices Share what you discover works…and doesn't work Learn from each other Learn from patients and families Throughout this module, we will be referring to the Toolkit and demonstrating several of the activities and exercises. Again, the Toolkit format is designed to give you the most options and the most flexibility in advancing the practice of patient- and family-centered care in your areas of responsibility, as trainers and as leaders. Over time, we are sure that you will think of other tools and activities–we hope you will share them with your colleagues in these training sessions and your peers in your specific facilities. Sharing best practices and learning from each other is, ultimately, how we all learn and grow and move the VA forward. Now let’s turn to another method of learning: personal and professional stories. Nurse and Nurse Manager Module

Personal and Professional Stories In addition to team-based learning strategies, another key technique is to use STORIES of the experience of care. Personal, professional, Veteran, and family stories teach us, more than any academic study, white paper, or PowerPoint, what is important, what is great, and what needs to be improved. Nurse and Nurse Manager Module

Patient–Family Story If you do not have an advisor joining you for today’s session, delete this slide. We are fortunate to have [re-introduce patient/family faculty for this session] join us to highlight important features of care at [insert your facility name] from the patient/family perspective. If more than one advisor: Let’s pause here for a moment to introduce one of our advisors who will be part of our session today. Introduce advisor. Ask advisor…how they became involved in Patient- and Family-Centered Care… Ask advisor to share a few memorable moments in their experience of care at the VA and what it meant to them. Thank advisor for sharing their story and emphasize the importance of learning directly from patients and families about the experience of care. TOOLKIT REFERENCE: TIPS FOR SUPPORTING VETERAN AND FAMILY ADVISORS IN VISN 7 TRAINING Nurse and Nurse Manager Module

VA Priorities The Basics of Patient- and Family-Centered Care Fundamentals VA Priorities The Basics of Patient- and Family-Centered Care Let’s turn now to some of the fundamental background information about patient- and family-centered care. Nurse and Nurse Manager Module

VISN 7 Aligning With VA Priorities VHA Mission Statement VHA Vision VHA Office of Patient-Centered Care - 2010 VHA national patient-centered pilot of five Field-based Implementation Teams (FIT): Birmingham VAMC First, let’s look at the “1000-foot level” view of patient- and family-centered care at VISN 7. VISN 7’s efforts to become more patient- and family-centered is aligned with national Veteran’s Administration priorities including mission and vision statements, and two recent national VA commitments–the first, a national Patient-Centered Care office, established in 2010, and the second, is funding for five pilot or trial-run Field-based Implementation Teams (FIT), including one in VISN 7 at Birmingham. Nurse and Nurse Manager Module

Veterans Health Administration (VHA) Mission Statement Honor America's Veterans by providing exceptional health care that improves their health and well-being. Our MISSION STATEMENT is OUR REASON FOR BEING. It applies to each and every one of us in this room. Key words in this statement shape how we do our work each day…honor…exceptional…improves health AND well-being. Nurse and Nurse Manager Module

Vision Statement Veterans Health Administration (VHA) Veterans Health Administration (VHA) Mission Statement Veterans Health Administration (VHA) Vision Statement VHA will continue to be the benchmark of excellence and value in health care and benefits by providing exemplary services that are both patient centered and evidence based. Briefly highlight the items listed on the slide: Our VISION statement is what we want to achieve–our vision for the future, the goal we are striving for. Remember that this is the vision of the national VHA health system…all Veterans health care–across all VISNs, facilities, and CBOCs are together focused on moving toward this vision. Again, key words are benchmarks of excellence…exemplary services… patient-centered…and evidence-based. Nurse and Nurse Manager Module

Office of Patient-Centered Care and Cultural Transformation General Eric Shinseki, the Secretary of the Department of Veterans Affairs has set forth an inspiring set of VHA departmental goals for Transforming into a 21st Century Organization referenced as the T-21 transformational agenda. These goals include several strategic patient-centered care initiatives overseen by the newly established national Office of Patient-Centered Care and Cultural Transformation, under the Deputy Under Secretary for Health for Operations and Management. VISN 7 is a pioneer in designing and rolling out today’s training across all disciplines in our 9 facilities, to help meet the T-21 transformational goals. Nurse and Nurse Manager Module

FY11 VHA Patient-Centered Care Implementation Plan Establish Regional Centers of Innovations (COI) Four regional host sites for Field-based implementation teams Region 1 – West: Greater Los Angeles HCS (VISN 22) Region 2 – Central: North Texas HCS (VISN 17) Region 3 – South: Birmingham VAMC (VISN 7) Region 4 – Northeast: New Jersey HCS (VISN 3) Washington DC VAMC selected as 5th COI COI's selected based on their advanced PCC practices and culture Each Center of Innovation is allocated funds towards innovative programs and approaches in patient-centered care. Essentially these Centers will be “living labs” where new ideas and approaches will be trialed; programs can be tried, tested, measured for effectiveness, and spread to others. As innovations are developed, what works for one health care facility won’t necessarily work for all, so each facility will be able to tailor to their own unique community and culture. Nurse and Nurse Manager Module

FY 11 ECF Performance Plan Client Satisfaction: PC1 Promoting Excellence in Patient-Centered Care Organizational Performance Goals PC2 Promoting Organizational Health Networks will continually monitor facility performance based upon validated inpatient and outpatient satisfaction metrics. Working in Teams, continuous improvement, and being data driven will support VHA goals of being patient- and family-centered. Supporting excellence in patient- and family-centered care is part of VISN 7’s Executive Career Field performance plan. Leadership involvement includes: Bi-monthly committee conference calls on related topics with our facilities’ Directors, Associate/Assistant Directors, Patient and Family Advisors, Associate Directors for Patient/Nursing Services, Patient/Family Care Coordinators, and Patient Advocates; Additionally there are monthly updates at Executive Leadership Business Meetings with Directors and Chiefs of Staff; AND Monthly site visits to review our data and action plans. As we meet our patient- and family-centered goals, we celebrate our successes with these network office leaders and staff. Additionally, to hear directly from front-line staff, our Network Director attends quarterly Town Hall Meetings and Stakeholder Meetings across the VISN. Nurse and Nurse Manager Module

Three Promises to Veterans VISN 7 Three Promises to Veterans PROMISE ONE: To provide care, second to none– the best care anywhere! PROMISE TWO: To maintain and expand health services wherever possible. PROMISE THREE: To ensure that every Veteran will be personally satisfied with the care that they receive based on the highest quality of outcomes. To begin their commitment, each VISN 7 employee is introduced to the Three Promises to Veterans displayed above. As of this year, each new employee in VISN 7 will also be introduced to the concepts of patient- and family-centered care in the VA in their orientation program. Nurse and Nurse Manager Module

The VA’s 12 Patient-Centered Care Principles Honor the Veteran’s expectation of safe, high quality, and accessible care. Enhance the quality of human interactions and therapeutic alliances. Solicit and respect the Veteran’s values, preferences, and needs. Systematize the coordination, continuity, and integration of care. Empower Veterans through information and education. The 12 principles are, in effect, areas of strategic focus for the VA. They can function as a roadmap…dimensions to focus on for aligned change across the region and the nation. TOOLKIT REFERENCE: THE VA’S 12 PRINCIPLES OF PATIENT CENTERED CARE: PUTTING THE PRINCIPLES INTO ACTION Nurse and Nurse Manager Module

The VA’S 12 Principles (cont.) Incorporate the nutritional, cultural, and nurturing aspects of food. Provide for physical comfort and management of pain. Ensure emotional and spiritual support. Encourage involvement of family and friends. Provide an architectural layout and design conducive to health and healing. Introduce creative arts into the healing environment. Support and sustain an engaged workforce as key to providing patient-centered care. Review slide. Nurse and Nurse Manager Module

Patient- and Family-Centered Care Core Concepts People are treated with respect and dignity. Health care providers communicate and share complete and unbiased information with patients and families in ways that are affirming and useful. Individuals and families build on their strengths through participation in experiences that enhance control and independence. Collaboration among patients, families, and providers occurs in policy and program development and professional education, as well as in the delivery of care. The patient- and family-centered care concepts, which are based upon years of listening to and working with patients and families across the nation, are a summary of the health care dimensions that are most important to them. Above all, Patient- and Family-Centered Care is a partnership that is mutually beneficial to providers and patients and their families, improving the quality and safety of health care across the board. Nurse and Nurse Manager Module

Veteran Advisor—Atlanta Let’s hear from a Veteran about the importance of including a Veteran and their family member as part of the team… Click on black box on slide to activate. NNM slide 42 VC AP5.wmv (Instructor, this is the transcript of the video clip: That’s exactly what it means. It means that the providers, the physicians, the nurses, the other clinicians must respect the will of that family member or that patient to be what I call a “team player,” part of the team in their own care. In fact, who would be more responsible for the person’s care than the person himself, him and her family? And so, if you empower that person, that Veteran, with the information to be an informed team participant, then that’s the kind of participation that we’re looking for. That’s the kind of partnership that we’re looking for and expect.)   Nurse and Nurse Manager Module

Fundamentals Toolkit Items: What’s In It For Us? Mutual Benefits As Staff We Can…! Power of Words C.A.R.E. Connection Fundamentals-related resources in your Toolkit are to support you in building your nursing staff’s foundation level of patient- and family-centered knowledge, skills, behaviors and attitudes. Review this list of Toolkit activities that addressing fundamental knowledge and skills building. For today’s training, we will go through two of these activities. TOOLKIT REFERENCES: WHAT’S IN IT FOR US?—MUTUAL BENEFITS INVOLVING PATIENTS AND FAMILIES IN CARE—AS STAFF WE CAN…! THE WORDS WE USE THE C.A.R.E. CONNECTION: “WRITE YOUR OWN SCRIPT” ACTIVITY AND DISCUSSION Nurse and Nurse Manager Module

The Power of Words Now we will explore a fundamental understanding for all staff at all levels who work in a patient- and family-centered culture…the words we use when we interact with patients, families, and each other. This section can be used as a stand-alone classroom session, or as a staff discussion. It is designed to promote awareness of how our words affect our point of view and thus our behaviors, and how they impact the Veterans and their families who come to us for care. TOOLKIT REFERENCE: THE WORDS WE USE Nurse and Nurse Manager Module

Family Advisor—Birmingham In summary, let’s listen to the engaged and activated family member of a Veteran… Click on black box on slide to activate. NNM slide 45 VC CL5.wmv (Instructor, This is the transcript of the video: Number one, I think it means that they speak directly to us and they don’t use words that we don’t understand, especially the Vets and I’m not belittling any Vet but you’ve got to speak in their language, you know us southerners have a certain little drawl and if you come from somewhere else and you’re dealing with a southerner you talk too fast. We don’t even know what you’re talking about. But they are getting so much better about sitting down, they don’t rush so much and I think we’re getting there when it comes to the doctors and the nurses talking to the patient and not at the patient.) Nurse and Nurse Manager Module

Doctor—Birmingham And from the perspective of a physician, the importance of communicating at a level that people can understand, is also recognized… Click on black box on slide to activate. NNM slide 46 AS3.wmv (Instructor, this is the transcript of the video: We do tend to talk in acronyms, it sometimes saves time and sometimes it’s just out of habit I think, but I think it’s any time you’re talking to someone about anything you want to try to communicate on a level that people can understand. The way I talk to my kids is different than the way I talk to you and the way I talk to my colleagues probably should be different from the way I talk to my patients, and so I think just realizing who your audience is, is the first step and there’s some patients who know the lingo so to speak, I mean maybe they were a nurse or a pharmacist or a physician and they sort of expect you to talk to them that way whereas other patients who don’t. And so I think one tool that I sometimes use when I’m teaching residents or medical students, we talk about sort of just asking the patient what they’re understanding of their illness is and a lot of times as they’re talking about their illness you can get a sense for how much they know, how much they understand and that can be a good sort of starting point for how to know how best to communicate with them.) Nurse and Nurse Manager Module

Awareness of the impact of the words we use unconsciously is a key skill for patient- and family-centered practice. Although acronyms are the most obvious barrier to communication, the words we choose to use make an enormous difference in how patients and families perceive the care they receive, and how we ourselves perceive the care environment. We want to encourage patients and families to understand their choices, make informed decisions, and collaborate with clinicians through care planning and good self-management skills. Yet health care language has not yet evolved to encourage such participation. Think of the many times we use the terms “allow, permit, required, inappropriate.” Whether we realize it or not, we still use “system-centered” language that subtly disempowers the patient and family. Nurse and Nurse Manager Module

Informed Consent….…….Informed Choice Allow….…….Encourage Permit…….…Support Informed Consent….…….Informed Choice Much research has been done on the power of words to shape perceptions. For example, what is the difference between these words? Allow………………………………….Encourage Permit………………………………………Support Informed Consent………………………….Informed Choice Pause for for one or two participants to respond. Think about the difference in meaning between the two words consent and choice. First of all, think to yourself, what they mean to you and how differently each word could make you feel. How do we use the word consent in health care? “Informed consent.” What are its synonyms? Permission, approval, blessing. All of which have implications of authority or allowing the medical world to do something to you. In a patient- and family-centered approach to health care, we want to empower Veterans and families through transparency of information and involvement in the decision-making process. How different is the message of “Please review and sign the Consent Form” to “Please review and sign the Informed Choice” form? Nurse and Nurse Manager Module

Watch your Words  Medical talk “Dialysis is the process of osmosis, diffusion, and ultrafiltration used to restore electrolyte and fluid balance and remove waste products from the blood.” Plain talk “Dialysis is a way to clean the blood now that my kidneys have failed.” And as we all know, health care is full of jargon and acronyms that are understood by professionals and insiders, but seldom clearly communicate meaning to the layperson. What are some other clinical words and phrases that we take for granted…and which many, if not most, patients are really unsure about…and often are afraid to ask for clarification? Nurse and Nurse Manager Module

Words That May Frighten or Confuse Chief Complaint Inform Allowed Informed Consent Demanding and Difficult Analgesic Anti-inflammatory Ambulatory Clinic Discharge NPO For example, here are some ways we can change the words we use to improve communication with Veterans and their families or significant support persons. How could you change these to be more “Plain talk?” Pause for some responses from the participants…record on flip charts. Nurse and Nurse Manager Module

Words That Make It Clearer AVOID USE Chief complaint Problem Conference Analgesic Anti-inflammatory Ambulatory Clinic Patient/family observations or concerns Conference for challenging situations Medicine for pain Reduces swelling Walk-in Clinic Review the slide–refer to the flip charts for additional words generated from the audience. Nurse and Nurse Manager Module

Empowering Words AVOID USE Allow Permit Require Prohibited Should We can't We don't I'll try Offer Choose Support Encourage What do you think? I'm able Your opinion? I'll take you there Part of the team Here are some other words that imply “control” –and their more empowering opposites. Review the slide. Nurse and Nurse Manager Module

The Power of Words: Labeling Words to Avoid Dysfunctional Non-Compliant Uninvolved The words we use in talking to each other about patients and families can often fall into the category of “labeling.” Labeling is difficult to avoid because often it happens unconsciously. However, taking these shortcuts runs the risk of being disrespectful of, or dehumanizing patients and their families. Families who are labeled as demanding and difficult may in fact be acting out because they feel threatened and powerless. The acting out is not done purposely to irritate caregivers, but is an attempt to gain some sense of control. Using this language to describe patients and families will shape other staff’s perceptions and in turn affect their behaviors and attitudes. Labels such as these, when created and then perpetuated, lead to mistaken assumptions, and interfere with communication and the development of productive partnerships between the health care provider, patients, and families. Nurse and Nurse Manager Module

A Brainstorming Exercise The Words We Use A Brainstorming Exercise Now let’s try out an activity that can be done in a classroom setting or as a staff meeting discussion. Break the large group into several smaller brainstorming groups. Ask them to use their worksheet “The Words We Use” as a guide. Ask them to generate as fast as they can a list of words that are “disempowering, negative, jargon, or create a cold and unfeeling impression.” After 3-4 minutes, ask them to generate a list of word/terms that are the opposite. After 3-4 minutes, call time on the brainstorming activity and ask the groups to choose 5 to 7 word choice pairs that were particularly illustrative or surprising to them. Have each group report these word pairs and record on the flip chart. Discuss their perceptions as they went through the activity. Nurse and Nurse Manager Module