Patient/Family Member on Quality Oversight Committee. The Most Important Seat at the Table Christy D. Jordan, RN, JD, Vice President, General Counsel and Government Relations Sherry Sweek, RHIA, CPHQ, CPMSM, Director, Quality Improvement Southeast Georgia Health System August 20, 2014

Session Learning Objectives 1.Discuss incentive to add patient/family member to Quality Oversight Committee. 2.Outline the steps taken to implement the change. 3.Identify the confidentiality and considerations of adding a patient/family member to committees.

Southeast Georgia Health System Two hospitals: Brunswick-312 beds, Camden- 40 beds Two Nursing Homes: Brunswick-232 beds, St. Marys-78 beds Three Immediate Care Centers Physician Practices: over 120 providers in primary care and specialty care practices 2,300 team members

Reporting Structure Glynn Brunswick Hospital Authority Quality Committee of Authority Patient Safety Events (Sentinel Events, Event Trending, Culture of Patient Safety Survey, Work with GHA HEN Quality (Inpt and Outpt Measures, Value Based Purchasing, HAC, Readmissions, Infections, Nursing Home report cards) Service Excellence (Press Ganey, HCAHPS, Discharge Calls, Complaints & Grievances) Camden Advisory Committee Quality Committee Membership -2 members of Authority, 1 designated as chair -1 member from Advisory -VPs: Operations, Patient Care Services, CFO, General Counsel, HR, Physician Practices -Directors, Quality, Service Excellence, Risk -2 Physicians -2 Patient/Family representatives

Background Summer 2011 Five Year Strategic Plan –Quality, Outcomes, and Customer Service 1 of 5 areas of focus –Action step: involve patient and/or family member in oversight committees on Customer Service, Patient initiatives, or new programs by 3 rd quarter 2014 FY2015 Business Plan –Establish Patient & Family Centered Care (PFCC) into the culture of SGHS by 2015 as evidenced by compliance with parameters established by the Patient & Family Centered Care model by April 2015

Making It Happen Idea and plan was reviewed with Vice President and CEO to gain support and buy-in. Short list of potential representatives was created by Director, Service Excellence. Quality Committee members were solicited for names of potential candidates. Potential candidates were phoned by Director, Service Excellence to fill two slots. Resumes were received and reviewed by VP, CEO, and Director, Service Excellence. Orientation conducted by Directors, Service Excellence and Quality Improvement. Confidentiality form completed by all members of Quality Committee. Packets send out six days before meeting and turned in at end of meeting.

QUALITY COMMITTEE As a member of the Quality Committee, I understand that I have access to confidential and sensitive information. I recognize that I serve as a member of the Quality Committee and support the integration of performance improvement, patient safety, and patient care outcomes. I place these responsibilities over my personal or professional interests. As a member of this committee, I realize the importance of confidentiality and maintaining the confidentiality of performance improvement data, root cause analysis, and information discussed in the meetings. At the end of the meeting, I shall return any hand-outs to the Committee Chair or designee. Also, I agree: To make no copies or distribute any confidential documents to anyone To make no disclosures of confidential information or discussions outside of the meeting To make no comments or references to confidential information shared or discussed in the meetings To notify the Committee Chair of any unauthorized inquires or comments I understand that my breach of the Agreement may compromise the interests of Southeast Georgia Health System. In the event of such a breach, I understand that my actions may result in: Dismissal from my committee assignment Loss of available legal protections including loss of indemnification for any litigation costs and expenses Disciplinary action as deemed appropriate pursuant to the hospital’s policy Other appropriate legal action Printed Name:________________________________________________________ Signature:_____________________________________ Date:_________________

Impact of Patient/Family Member on Quality Committee April 2014: informed Quality Committee of the two patient/family representatives joining as of May May 2014: completed orientation and conducted first meeting with patient/family representatives. Established expectations and role of committee members at May Quality Committee. Modified packet to ensure reports are side to side for easier comparison. Good discussion of non-punitive response to errors from 2014 Culture of Patient Safety survey. Patient/family members have helped committee to focus on the important things and spend some time discussing issues and potential resolution. Quality Committee chair is a retired CNO from a large organization. She encourages equal voice from all members and facilitates meaningful discussion.

Questions & Answers