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First Street Family Health is a small, rural primary care practice in Salida, CO. When they received funding to redesign their practice structure as part of the Comprehensive Primary Care Initiative, one of their assigned objectives was to improve patient and family engagement—in order to increase the involvement of patients and their families in the decision-making processes. As a small practice, it was often easy for the First Street Family Health team to feel they knew their patients well and were doing everything to make their patients happy and satisfied. They were surprised to find out how much improving engagement with patients could also improve the performance of their practice.
The practice first attempted to engage patients with patient satisfaction surveys. But without experience in survey design to glean appropriate data or interpret responses, they didn't find the surveys very useful. In many instances, surveys were incomplete and it was obvious that patients were not giving them much thought. Few patients used the surveys as a venue for delivering constructive criticism. So the practice decided to try something totally new—create a Patient and Family Advisory Council (PFAC).
Under the tutelage of a consultant from The National Partnership for Women and Families, First Street Family Health began building their PFAC. First, they assembled a team of staff members, including the nurse care coordinator, a physician, a physician's assistant, front desk staff, medical assistants, and back office staff. Next, they asked each of the practice's four clinicians to list 10 people whom they felt would be interested in participating in the PFAC and would do a good job as an advisor. They selected patients from each clinician's panel who best represented their community's demographics. They included patients and family members who were retired, parents, young, old, male, and female.
Many patients thought it was unusual for the medical practice to ask their advice on how to provide more patient-centered care, but they were receptive and excited about the opportunity to contribute. They explained how they felt honored that their doctor or nurse recommended them for this responsibility. It helped that Salida is a small community. The connection between practice members and the patient and family advisors is often personal—the advisor may be the bagger at the local grocery, the baseball coach for a practice member's child, or the realtor who sold a practice member their first home.
At the first PFAC meeting, the group covered the concept and goals of the council, established ground rules, and discussed privacy issues. The next several meetings still felt like a warm-up and the work was slow to build. Patients were initially hesitant to do anything other than compliment the practice during the meeting. Because of this reluctance, the initial agenda topics were guided by the patient satisfaction surveys. Once the patients felt they had permission to give criticism, they were more candid and the meetings became more productive.
“What we think they want or what we think will be helpful is not always what they want. Patients need to understand what's going on behind the scenes, what goals we have and why, and what restrictions a practice faces that they can't change. This is eye-opening on both sides,” says Dr. Meggan Grant-Nierman, who serves on the PFAC as physician advisor.
The First Street Family Health PFAC has tackled issues of all sizes, from minor decisions like whether the front desk staff should wear a uniform as opposed to business casual attire, to big projects like the design of the new office space. Two projects that stand out as particularly successful due to PFAC guidance are the revamping of the phone triage system and the design of the new office space.
The phone triage system was something that the practice had been working on improving for years. They didn't want to put patients on hold, but there were times the team couldn't get to every call. Over the years, they tried adding more phone lines, hiring more front desk staff, and introducing standard scripts. They even experimented with an automated answering system. The PFAC tackled this issue with enthusiasm and came up with a hybrid solution. When a patient calls, they hear an automated message where the first option is to press a digit to speak with a person. Clinicians and front desk staff were thrilled with the outcome. This early success instilled confidence in the PFAC's ability to contribute in a meaningful way. Now, when challenges come up during practice leadership meetings, the solution is often “ask the PFAC.”
The PFAC also made a difference in the redesign of the office space. When the building was designed, the practice believed it would be appropriate to install a glass partition between the lobby and the reception desk. They thought that this separation would make patients feel more comfortable because their privacy was being respected. But when the PFAC toured the new layout their reaction was quite unexpected. They found the glass to be “rude”—it was a physical barrier that kept them closed off from the practice staff. In addition, they noticed the glass gave staff a false sense of privacy, making the staff think that patients in the waiting area couldn't hear them. Several PFAC members overheard staff having private conversations, some of which made patients feel uncomfortable. The glass was subsequently taken down and the open layout is now working well for everyone. Had the practice hired a consultant to work on the design of the space, they could have received the same feedback but spent hundreds of thousands of dollars in the process. In fact, the practice concludes they would have likely saved more money had they consulted the PFAC earlier in the design process.
Momentum can be difficult to maintain. To keep the PFAC engaged, the practice has taken innovative approaches and selected novel projects. For example, they had a PFAC member pretend to be a new patient. The “patient” evaluated every step along the way: finding a parking spot, entering the building, filling out the forms, and so on. This triggered a project to recreate the new patient paperwork in a way that made it both more useful for the practice and easier for the patients to understand. The practice also recently tasked the PFAC with redesigning the practice website to make it more user-friendly and appealing to patients. The PFAC has been able to evolve as progress is made and the focus shifts to other elements of the practice that can improve.
Although the practice requested that advisors commit to a one-year term for the PFAC, the term varied based on what people were able to commit to. Some people drop off when they've completed their term, while others stay on. Fortunately, the turnover has been staggered, which has helped ensure continuity in the work. As people drop off the PFAC, First Street Family Health continues to keep balance in mind. In the PFAC's next iteration, the practice is trying to find ways to engage single parents, members from the Hispanic population, and Medicaid patients to more accurately reflect the diversity in their community.
Patients, clinicians, and staff have all been pleasantly surprised with the impact the PFAC has had on practice improvements. Having a PFAC is less complicated than they anticipated, and it has not been difficult to run the council or engage patients. “The patients have spoken and this is what is meaningful for them. This carries a different weight, and changes are well-received because they're not just coming from the doctors.” The team strives to convey how valuable the PFAC's contributions are to the practice and recognizes them as a powerful collaborative force. First Street Family Health is now involving the PFAC in some of the more serious work of the practice, including quality improvement initiatives related to payment reform.
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