LANETREE INTERNATIONAL DESIGNATION CRITERIA AND ...

Copyright Planetree 2016 1

PLANETREE INTERNATIONAL DESIGNATION CRITERIA AND IMPLEMENTATION

GUIDANCE Adopted December 2015 (Revisions (in bold) to take effect January 1, 2016

About The International Designation Criteria

Planetree created the Designation Program to recognize health care providers around the world that have embraced and implemented person-centered care in a comprehensive manner. Based on the core elements of person-centered care identified and practiced by Planetree affiliates around the world, the Designation Program provides a practical, operational framework for evaluating the organizational systems and processes necessary to sustain organizational culture change. For each core element, Planetree developed specific criteria that must be met in order to demonstrate that an organization has implemented that aspect of person-centered care. Designed to provide a level of consistency in what it means to be person-centered while still accommodating cultural nuances and continuing to promote individuality and innovation in the delivery of care, the criteria were developed with extensive input from an International Patient Partnership Council, Planetree’s International Designation Committee, Planetree’s International Partners, Planetree Visionary Design Network, and a variety of internal and external stakeholders. The criteria are designed to be applicable to all health care providers, irrespective of size, location or formal affiliation with Planetree; however, the scope and breadth of these criteria reflect the experiences of sites that have been engaged in an ongoing, focused effort to cultivate a culture of person-centered care over the period of several years.

The criteria are organized into eleven sections. Within each section, there are several criteria that reflect fundamental principles of a person-centered culture. To achieve Designation, an organization must demonstrate that it is satisfying each one of the criteria; each carries equal weight. The numbered criteria appear in the left-hand column of the chart below, with the 2016 revisions in bold. To support organizations in understanding the underlying intent of each criterion and identifying practical approaches for operationalizing the principle, “Implementation Guidance to Clarify Intent” has been provided, as appropriate (columns #2 and #3 below). Note that the practices presented as “Implementation Guidance” are potential ways that the criteria can be satisfied, but they are not meant to be prescriptions of the only way the criteria can be met. Applicant organizations are invited to propose alternate approaches for addressing the criteria.

PLANETREE INTERNATIONAL DESIGNATION CRITERIA

REVISED JANUARY 2016


Criteria (Revisions (in bold) to take effect January 1, 2016)

Implementation Guidance to Clarify Intent: Acute Care Settings

Implementation Guidance to Clarify Intent: Continuing Care

Definitions

SECTION I: STRUCTURES AND FUNCTIONS NECESSARY FOR IMPLEMENTATION, DEVELOPMENT, AND MAINTENANCE OF PERSON-CENTERED CONCEPTS AND PRACTICES

I.A: A multi-disciplinary, site-

based task force or committee

structure is established to

oversee and assist with

implementation and maintenance

of person-centered practices.

Active participants on the task

force include:

Patients/residents and/or family members;

A mix of non-supervisory and management staff;

A combination of clinical and non-clinical staff

(Note: For home care providers, this task force is based out of the administrative office / staff headquarters.)

The task force has

representation from all

stakeholder groups, including

patients and families.

Minimum of 2 patient or

family member participants

Note: Family member

participation is not to the exclusion of the patient as a replacement for their perspective (unless directed by the patient), but can provide an additional perspective.

Residents are provided the opportunity to participate in decision making processes that affect operations in their home.

The task force has representation from all stakeholder groups, including residents and families.

For home care providers, this

task force is based out of the administrative office / staff headquarters.

Minimum of 2 resident or family member participants

Note: Family member participation is not to the exclusion of the resident as a replacement for their perspective (unless directed by the patient), but can provide an additional perspective.

All stakeholders= inclusive, as applicable, of the governing body, administration, physicians, management, staff, volunteers, patients/residents and families

Family=defined by patient/resident







Definitions

I.B: A person-centered care coordinator or point of contact person is appointed who is able to commit the time required to coordinate related activities on an ongoing basis. This individual will have direct access to, and support from, senior level decision makers to remove barriers as needed, properly resource and align this strategic priority within the organization.

A patient-centered care

coordinator or point person is

designated to champion and

coordinate related activities.

A patient-resident-centered care coordinator or point person is designated to champion and coordinate related activities.

Related activities=any activity, initiative, or program that is related to the implementation/enhancement of person-centered care







Definitions

I.C: Goals and objectives related to person-centered care are developed at least annually, supported by the patient/resident partnership council and key organizational stakeholders, and progress on objectives is shared with the governing body with a frequency commensurate with the reporting schedules for comparable strategic priorities.

The organization’s commitment to patient-centered care is reflected in its mission statement, organizational chart and/or formal core values.

Information on patient-centered care implementation and progress is shared regularly with key organizational stakeholders, including the governing body. Goals and objectives related

to patient-centered care are adopted as part of the organization’s strategic plan.

Metrics related to patient-centered care implementation are regularly reported to the governing body.

Members of the governing body are provided with opportunities to interact directly with patients and families.

The organization’s commitment to resident-centered care is reflected in its mission statements, organizational chart and/or formal core values.

Information on resident-centered

care implementation and progress is shared regularly with key organizational stakeholders, including the governing body. Goals and objectives related to

resident-centered care are adopted as part of the organization’s strategic plan.

Metrics related to resident-centered care implementation are regularly reported to the governing body.

Members of the governing body

are provided with opportunities

to interact directly with

residents and families.

All stakeholders= inclusive, as applicable, of the governing body, administration, physicians, management, staff, volunteers, patients/residents and families Governing Body=Board of Directors/Trustees, and/or the highest level of leadership within the applicant organization that influences strategic priorities.







Definitions

I.D: Community needs and patient/resident perceptions are incorporated in the planning and implementation of person-centered programmatic elements. Patients/residents/family members are meaningfully engaged in these efforts, and structures are in place that promote partnership between patients/residents/family members and the organization’s leadership and governing body. There is evidence that this partnership has resulted in a visible difference in the operations of the organization.

An active patient/family advisory council meets regularly and provides input and reactions on current practices, new initiatives and the strategic plan/direction for the organization.

Patients/community members serve as active members on a standing committee(s).

An active resident/family advisory council meets regularly and provides input and reactions on current practices, new initiatives and the strategic plan/direction for the organization.

Residents/community members

serve as active members on a standing committee(s).

Meets regularly= at a minimum, six times per year Family= Those considered family by the patient/resident







Definitions

I.E: Leadership exemplifies approaches that motivate and inspire others, promote positive morale, enhance performance of others, and model organizational values.

A leadership development process is implemented that includes dimensions of effectiveness in communicating a vision, ability to inspire others, commitment to engaging others in organizational culture change, etc.

Leadership development is a process that is shared among formal and informal leaders of the organization.

Opportunities exist for both formal and informal interaction between leadership and staff, including staff working 2nd and 3rd shift.

Examples include leadership rounding on both patients and staff, completion and use of a leadership self-assessment tool that includes dimensions of effectiveness in communicating a vision, ability to inspire others, commitment to engaging others in culture change, etc.

Effective communication mechanisms are in place to keep all staff (including off-site and all shifts) informed about organizational priorities/ challenges and financial, clinical, operational and cultural goals and

A leadership development process is implemented that includes dimensions of effectiveness in communicating a vision, ability to inspire others, commitment to engaging others in organizational culture change, etc.

Leadership development is a process that is shared among formal and informal leaders of the organization.

Opportunities exist for both formal

and informal interaction between leadership and staff, including staff working 2nd and 3rd shift.

Examples include leadership

rounding on both residents and staff, completion and use of a leadership self-assessment tool that includes dimensions of effectiveness in communicating a vision, ability to inspire others, commitment to engaging others in culture change, etc.

Effective communication mechanisms are in place to keep all staff (including off-site and all shifts) informed about organizational priorities/ challenges and financial, clinical, operational and cultural goals and vision. Examples: Town Hall Meetings, Leadership Rounds, Intranet, Shared Meeting Minutes,







Definitions

vision. Examples: Town Hall Meetings, Leadership Rounds, Intranet, Shared Meeting Minutes, Daily Stand Ups

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

Daily Stand Ups

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

SECTION II: HUMAN INTERACTIONS/INDEPENDENCE, DIGNITY AND CHOICE II.A: All staff, including off-shift and support staff, as well as employed medical staff, are given an opportunity to participate in a person-centered retreat experience, or a comparable experiential PCC immersion program, with a minimum completion rate of 85%. Site-based volunteers, independent contract employees, and non-employed medical staff members are invited to participate in this experience.

To calculate the percentage, divide the number of current employees who have completed the full retreat experience by the total number of current employees (including part-time, off-shift, and support staff.

To calculate the percentage, divide the number of current employees who have completed the full retreat experience by the total number of current employees (including part-time, off-shift, and support staff.

Retreat Experience= An experiential opportunity for engaging and sensitizing staff to the patient/resident and family experience, while promoting relationship-building across departments and between organizational tiers.

II.B: All staff members, including employed physicians, nurses, other health care providers, and others who provide support and care are oriented, regularly educated about, and encouraged to participate in person-centered initiatives.

Active teams are in place that address patient-centered initiatives. They meet regularly and include non-supervisory staff, patient, and family member input

Active teams are in place that address resident-centered initiatives. They meet regularly and include non-supervisory staff, resident, and family member input.

Open discussion formats (learning circles) are used to solicit insights from residents, non-supervisory staff, and families.

Family= Those considered family by the patient/resident







Definitions

II.C: Person-centered care concepts, practices, and initiatives are provided for all new staff and volunteers as a part of orientation. In continuing care environments, residents and family members are included in a meaningful way in the new employee orientation program. In addition, the new resident/family orientation includes an introduction of resident-centered care concepts and how those concepts are realized within the community.

A comprehensive presentation on patient-centered care concepts, practices and initiatives is provided for all new staff as part of new employee orientation.

A comprehensive presentation on resident-centered care concepts, practices and initiatives is provided for all new staff and new residents as part of their orientation.

Residents participate in the presentation of orientation information related to resident-centered care and organizational expectations.








Definitions

II.D: Staff has the autonomy to personalize the patient/resident and family experience to meet the expressed needs and preferences of those receiving care.

Structures are in place that give frontline staff autonomy over the decision-making processes that affect their work. An example is implementation of a shared governance model.

Clinical units conduct internal audits and create performance improvement plans that address the patient experience and clinical outcomes.

Teams are self-managed and self-directed, e.g. caregivers are empowered to make decisions with the resident that is receiving care.

A consistent or personal assignment format is implemented.

Neighborhoods/households conduct internal audits and create performance improvement plans.

Other specialties (housekeeping dining, recreation) are also consistently placed in the same neighborhood/ household to readily attend to preferences of those residents.

Traditional schedules are modified to honor resident choice and preference.

A process aligned with each resident’s individual preferences is in place to contact residents’ family on a regular basis to communicate progress and/or “positive events.”








Definitions

II.E: A mechanism is in place to provide staff support services that include elements identified by staff as priority areas.

Examples may include: access to support services

such as meals-to-go, relaxation and stress

reduction programs/services, space is available for staff to

decompress away from patients and families,

emotional support such as bereavement services and staff support groups

Provision of ergonomic support measures used to ensure physical well-being of staff and injury prevention.

Examples may include: access to support services such

as meals-to-go, relaxation and stress reduction

programs/services, space is available for staff to

decompress away from residents and families,

emotional support such as bereavement services and staff support groups

Provision of ergonomic support measures used to ensure physical well-being of staff and injury prevention.







Definitions

II.F: Human resource systems, including job descriptions and evaluations, reflect the organization’s person-centered care philosophy and values. There is evidence that patient/resident/family feedback is considered as part of hiring, coaching, and evaluation of staff.

Human resource systems,

including job descriptions,

evaluations and staff selection

tools/criteria, reflect the

organization’s resident-centered

care philosophy, behavioral

expectations, and/or core values.

Employee evaluations include

peer input.

Work behavior assessments

include specific criteria that

evaluate employee patient-

centered contextual

performance.

Other examples include

behavioral standards,

recruitment and retention

efforts, staff selection tools and

criteria and conducting team

interviews.

Human resource systems, including job descriptions, evaluations and staff selection tools/criteria, reflect the organization’s resident-centered care philosophy, behavioral expectations, and/or core values.

Employee evaluations include peer input.

Interview processes include interviews with residents and with staff.

Employee evaluations include resident input.

Work behavior assessments include specific criteria that evaluate employee patient-centered contextual performance.

Other examples include behavioral standards, recruitment and retention efforts, staff selection tools and criteria and conducting team interviews.

II.G: Organizational stakeholders involved in creating a person-centered environment are recognized and acknowledged for their work.

Staff is routinely acknowledged for their good work by leadership, by peers, and by patients and families.

Staff is routinely acknowledged for their good work by leadership, peers, residents, and families.

The recognition program extends to all stakeholders, including employees, volunteers, private caregivers, and families.








Definitions

II.H: Open, direct, and compassionate communication is demonstrated among all members of the organization. This includes having a documented process or system in place to fully and empathetically disclose when an adverse event, sentinel event, or unanticipated outcome occurs to patients/residents (and family members as appropriate.)

A process is in place for

providing support as necessary

to patients and families affected

by an adverse event.

Staff has opportunities to

participate in bereavement

services and support groups.

A process is in place for providing support as necessary to residents and families affected by an adverse event.

Staff has opportunities to participate

in bereavement services and

support groups.

Daily Stand-Up=A daily team meeting held to provide a status update to team members Family= Those considered family by the patient/resident

II.I: Administrative processes, including billing processes, as applicable, are transparent, respectful and responsive to the needs of patients/residents and families.

Focus groups are held to solicit feedback on administrative processes.

Financial navigators are available to assist patients/families understand and manage billing (or other administrative) processes.

Cost estimating tools are available.

Mystery shopper programs monitor for respectful, helpful interactions with those with administrative inquiries.

A process is in place to educate and support patients and families through the billing (or other administrative) process.

Focus groups are held to solicit feedback on administrative processes.

Financial navigators are available to assist residents/families understand and manage billing (or other administrative) processes.

Cost estimating tools are available. Mystery shopper programs monitor

for respectful, helpful interactions with those with administrative inquiries.

A process is in place to educate and support residents and families through the billing (or other administrative) process. This may include detailed bills without coding, monthly or quarterly education on billing practices and clear explanation of billing practices in the resident/family orientation.







Definitions

II.J: The organization balances safety considerations with being supportive of patient/resident empowerment, independence, and dignity.

Patients and families are provided with risk agreements to inform, educate and document any choices that may result in risk.

It is the policy of the site to hold quality of life discussions to inform and educate patients on the risk(s)/benefit(s) when patient choice conflicts with the standards of care.

Resident and families are provided with risk agreements to inform, educate and document any choices that may result in risk.

It is the policy of the site to hold quality of life discussions to inform and educate patients on the risk(s)/benefit(s) when resident choice conflicts with the standards of care.

Staff receives education on focusing on strengths and how to maximize independence for all residents.

A process is in place to educate residents and family members on the risk of choices that are made contrary to traditional treatment plans.

Example for clarification: not providing a regular diet to a resident who is refusing to eat a pureed diet. What is the risk if s/he eats the regular diet and what is the risk if we do not provide it?







Definitions

II.K: Continuity of care and accountability for patients/residents is maximized and maintained for the duration of one’s care, including during transitions between levels of care and across discrete episodes of care. Patients/residents and families are involved in shift-to-shift communication in a manner that meets their individual preferences and needs.

Patients/family members are able to participate in shift-to-shift communication, e.g. bedside shift report.

Patients and families are able to participate in rounds.

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.

Care conferences are scheduled in a manner that facilitates family participation.

Processes are in place for developing patient bios and reviewing them during hand-offs.

Opportunities exist for patients and families to meet with multiple members of their health care team (including the nurse and physician) at one time, e.g. a care conference.

Residents and families are able to participate in change of shift report.

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

Residents/family members are able to participate in shift-to-shift communication, e.g. bedside shift report.

Processes are in place for developing resident bios and reviewing them during hand-offs.

Family=those considered family by the patient/resident

Care Conference= Meeting held 24-48 hours after an admission with (at a minimum), the patient/resident, family member, physician and nurse. Goal is to discuss early the plan of care and patient/resident goals.







Definitions

II.L: Staff engages patients/residents, family, and/or their advocates in the care planning process, and ensures that treatment goals are aligned with the patient’s/resident’s documented personal goals and preferences.

A process is in place to identify, communicate and honor patient preferences.

Preferences and choices are integrated into the patient’s plan of care and caregivers are informed of preferences and choices.

Patients are able to make requests for when certain procedures will be performed (blood draws, taking vitals, etc.) to accommodate their personal schedule and routine.

A process is in place to identify, communicate and honor resident preferences.

Residents are involved in care planning.

Preferences and choices are integrated into the resident’s care plan and regularly reviewed for accuracy. Teams are informed of preferences and choices routinely.

A resident-directed medication pass process is in place.

Residents are able to make requests for when certain procedures will be performed (blood draws, taking vitals, etc.) to accommodate their personal schedule and routine.

Plans of care are written in the first person and reflect resident goals in language that residents and families can understand.

Goals are interdependent upon one another and do not stand alone by discipline. All disciplines are achieving the same goals through a variety of interventions.

A process is in place to accommodate family members’ participation in the care planning process as evidenced by flexible hours, use of technology, and other creative ways to make meeting accessible.








Definitions

II.M: The professional development/ advancement of staff is supported.

Personal and professional development programming for staff is offered.

Examples may include: the empowerment of

frontline work teams, internal training and

promotion tracks (e.g., career ladders),

flexible scheduling to enable educational pursuits,

an actively utilized tuition reimbursement program, etc.

Personal and professional development programming for staff is offered.

Examples may include: the empowerment of frontline

work teams, internal training and promotion

tracks (e.g., career ladders), flexible scheduling to enable

educational pursuits, an actively utilized tuition

reimbursement program, etc.

II.N. In continuing care environments, systems and practices are in place to foster among residents and families a sense of belonging, individuality, ownership and pride.

Residents have an opportunity to participate, as appropriate, in a retreat experience or an equivalent to support them in internalizing resident-centered care concepts and to enhance sensitivity to the needs of the entire long-term care community.

Residents are provided with a choice of where they are going to live and with whom

A process is in place to limit the number of room changes a resident may experience.

Residents/family members and staff discuss options and make an appropriate choice of living conditions.







Definitions

SECTION III: PROMOTING PATIENT/RESIDENT EDUCATION CHOICE AND RESPONSIBILITY III.A: During their care, patients/residents and families (with patient/resident consent) are provided education and access to a wide range of information in a manner that they understand, to support them in making informed choices. A policy and documented process is in place to offer and provide to patients/residents access to their record and plan of care while they are being treated, and they are supported in understanding and amending the information contained within. There is evidence that this offer/process to access is communicated to every patient upon admission or when appropriate.

Note: In certain settings, such as behavioral health, when sharing such information may be detrimental to the health and well-being of the patient/resident, organizations are obliged to find other ways of sharing up-to-date information with them on their diagnosis, care and other clinical information.

Patients have access to up-to-date documentation about their personal health information, diagnoses, plan of care and other clinical information. Examples include proactive sharing of the active medical record and the care plan.

Patient education materials appropriate for readers of varying literacy levels and for speakers of different native languages are readily available.

An on-site consumer health resources library is maintained.

Patients and families are invited to access an existing medical library.

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.

Plans of care are written in language that patients and families can understand.

A process is in place by which patients and family may request additional information on their diagnosis, treatment options, etc., and those requests are accommodated.

Residents have access to up-to-date documentation about their personal health information, diagnoses, plan of care and other clinical information. Examples include proactive sharing of the active medical record and the care plan.

An on-site consumer health resources library is maintained.

Residents, family and staff have access to a range of educational materials, including written information on their diagnosis and community information resources. These materials are available for readers of varying literacy levels and for speakers of different native languages.

Residents 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.

Education program is documented and care plans document choice with regular review of choice and education.

A process is in place by which residents and family may request additional information about their health and wellness, and those requests are accommodated.

Family=those considered family by the patient/resident Example of goal interdependence for clarification: If resident is choosing to work on ambulation, what interventions from recreation, nursing, dietician will support this goal.







Definitions

III.B: Patients/residents and families (with patient/ resident consent) are provided with information and support needed to be as involved as they choose in coordinating their care across settings, among multiple providers, and across discrete episodes of care.

Patient Navigators provide assistance to patients and families to coordinate their care.

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

Patient/family caregivers are provided with coaching to support them in their role.

Resident Navigators provide assistance.

Residents are provided with tools for tracking their medical information and medications.

Resident/family caregivers are provided with coaching to support them in their role.

III.C: Patients/residents are provided with discharge/transition instructions in a manner that accommodates their level of understanding, in a language that they understand, and includes family members in the discharge process as patient/resident desires.

Patients and families are encouraged to participate in discharge planning from the beginning of hospitalization.

Processes are in place to schedule a patient’s first follow-up appointment with their primary care physician or specialist prior to discharge.

Discharge/transition summaries are provided to next level of care, and there is accountability for sending and receiving information.

Post-discharge/transition calls or visits are implemented.

Medication reconciliation processes are in place.

Meaningful discharge instructions are provided and processes are in place to reinforce and assess comprehension of the information.

A process is in place for discharge/transition planning to begin upon admission, as appropriate.

Processes are in place to schedule first follow-up appointment with their primary care physician or specialist prior to discharge.

Discharge/transition summaries are provided to next level of care, and there is accountability for sending and receiving information.

Post-discharge/transition calls or visits are implemented.

Medication reconciliation processes are in place.








Definitions

SECTION IV: FAMILY INVOLVEMENT IV.A: A flexible, 24-hour plan for family presence is mutually developed between patient/resident and the care team. Exceptions may include psychiatric facilities, NICU, and in cases of communicable disease. Restrictions to visitation are determined by the treatment plan, agreements with roommates, patient/resident preferences, and the rationale for any restrictions is clearly communicated to patients/residents and families.

Overnight accommodations are available to loved ones wishing to stay overnight with a patient.

Family members are able to remain with the patient (with patient consent) during change of shift.

Family members are able to remain with the patient during codes and resuscitation.

Comfortable spaces, equipped with a variety of positive diversions, are available for family use.

Accommodations are made easily for intimate visits by a spouse/ partner.

Family members are able to remain with the resident during codes and resuscitation.

Comfortable spaces, equipped with a variety of positive diversions, are available for family use.

Programs are implemented to enhance the visitation experience for both visitors and residents, and appropriate accommodations are made to support visitation as it relates to a variety of resident/family needs, including visitation by a spouse or partner, visitation at the end of life, visits to residents with dementia, etc.


IV.B: When mutually agreed upon and clinically appropriate, staff encourages families to participate in the emotional, spiritual and physical care and support of the patient/resident.

Formalized training/education is available for a patient’s loved one who may be providing routine care following discharge. An example is a Care Partner Program. Examples include guest food

trays, programs to offer social and emotional support to families, and accommodations to support family’s presence at their loved one’s bedside at end-of-life.

Formalized training/education is available for a resident’s loved one to be actively involved in the resident’s care and life. An example is a Care Partner Program. Examples include guest food

trays, programs to offer social and emotional support to families, and accommodations to support family’s presence at their loved one’s bedside at end-of-life.

Care Partner Program= A comprehensive formalized approach to involving families in all aspects of the patient’s/ resident’s care, and tailored to the needs and abilities of the organization and its facility.







Definitions

IV.C: A process is in place to encourage patients/residents and families to communicate with staff about any concerns related to their care and safety, and includes a specific commitment/path to resolution of concerns.

Patients are made aware of how

to raise a concern related to

patient safety and/or their care

while they are hospitalized.

A process is in place by which a family member may initiate a rapid response team.

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

SECTION V: DINING, FOOD, AND NUTRITION V.A: A system is in place to provide patients/residents, families and staff with access to a variety of fresh, healthy foods. Patients’/residents’ personal preferences and routines around dining are considered and accommodated to the extent possible, including but not limited to meal times, dietary restrictions, religious beliefs and cultural norms.

Patients are able to make requests for when meals will be served to accommodate their personal schedule and routine.

Patients have a choice of what to eat.

Food is available for patients and families 24 hours a day.

Healthy food is available to all staff, including those who work on weekends and on nights.

Input from patient/family advisors guides menu planning.

Food options are available to meet the preferences of different ethnic groups.

Restaurant style, family style or buffet style dining has been implemented; Tray style dining has been eliminated.

Residents are able to choose the time of their meal.

Residents are offered a variety of menu choices at each meal.

Food is available for residents and families 24 hours a day.

Healthy food is available to all staff, including those who work on weekends and on nights.

Food options are available to meet the preferences of different ethnic groups.

A process is in place to continually review the number of restricted diets in use.

Therapists support a resident’s choice related to food texture.







Definitions

V.B: The dining experience maintains patients’/residents’ dignity, enhances socialization and supports independence while supporting individual preferences.

Examples include: implementation of a

restorative dining program, the provision of finger food, supporting staff and patients

in dining together providing opportunities for

patients to assist with meal preparation, as appropriate

Menu planning includes regular resident participation.

Residents assist with the chores associated with dining. (Ex: table setting, clearing plates, etc.)

Examples include: implementation of a restorative

dining program, the provision of finger food, supporting staff and residents

in dining together providing opportunities for

residents to assist with meal preparation, as appropriate

SECTION VI: HEALING ENVIRONMENT: ARCHITECTURE AND DESIGN VI.A: The built environment incorporates evidence-based principles of healing healthcare design, and is updated as appropriate based on feasibility. As updates and renovations occur, they incorporate evidence-based principles to enhance safety and security of patients/residents, visitors, and staff.

The organization is able to demonstrate the application of credible research to informing design and operation through the submission of a bibliography of cited references. Additionally a Post Occupancy Evaluation conducted by a third party evaluator not part of the original design team a minimum of six months after the space has been occupied.

The organization is able to demonstrate the application of credible research to informing design and operation through the submission of a bibliography of cited references. Additionally a Post Occupancy Evaluation conducted by a third party evaluator not part of the original design team a minimum of six months after the space has been occupied.







Definitions

VI.B: Users of the space are actively involved in a design process.

Patients and family members participate on design teams.

Renovation and construction plans are shared with patient/family partners for ideas and feedback.

Staff has opportunities to provide input into design or renovation of their work spaces.

This should include focus groups with patients, families, physicians and staff, mock-ups, research based on community demography and/or a research basis that supports the continuum of care

Residents and family members participate on design teams.

Renovation and construction plans are shared with resident/family partners for ideas and feedback.

Staff has opportunities to provide input into design or renovation of their work spaces.

This should include focus groups with residents, families, physicians and staff, mock-ups, research based on community demography and/or a research basis that supports the continuum of care

VI.C: Patients/residents have choices or control over their personal environment, including: personalization of their

space electrical lighting, access to daylight, noise and sounds, visual privacy, temperature/thermal

comfort.

Patients are able to adjust the lighting and temperature within their room on their own.

For hospitals with semi-private rooms, accommodations are available for patients to have a private conversation.

Patient rooms have views to the outdoors.

Common areas are available in which patients and visitors may congregate.

Overhead paging has been eliminated (with the exception of emergencies).

Processes are in place to support residents’ self-expression in their personal spaces.

Community/public spaces are decorated to the preferences of the residents who live there.

Residents are able to adjust the lighting and temperature within their room on their own.

Resident rooms have views to the outdoors.

Common areas are available in which residents and visitors may congregate.

Overhead paging has been eliminated (with the exception of emergencies).







Definitions

VI.D: As plans for future renovations and remodeling are developed, symbolic and real barriers are minimized and open communication and human interactions are prioritized. Specific changes demonstrate how environment of care design supports the healing environment.

Elements of the built environment include: Open and collaborative nurses’

stations Family Lounges Unit-Based Kitchens Implementing principles of

universal design Private consultation areas,

family lounges, Nourishment centers for family

and visitor use Reduction of access-limiting

signage.

A self-directed living environment is implemented. (Ex: neighborhood and/or household model)

Medication carts have been eliminated.

Elements of the built environment include: Open and collaborative nurses’

stations Spas in place of institutional

bathing rooms Family Lounges/Kitchens Implementing principles of

universal design Private consultation areas, family

lounges, Nourishment centers for family

and visitor use Reduction of access-limiting

signage.







Definitions

VI.E: A patient/resident and visitor navigation plan provides a clear and understandable pathway for patients/residents and visitors to their destinations. Patient/resident input informs the navigation plan. In continuing care settings, signage in resident rooms is kept to a minimum.

Components of the navigation plan should include: progressive disclosure, wayfinding that uses

universally understood symbols so that it is understandable to a variety of end users regardless of language of origin or physical ability

Destination markers, clear sightlines with visual

wayfinding markers such as architectural details, pattern or artwork,

kiosks and/or the provision of handheld maps

Clear, understandable signage Color coding and symbol

signage Signage reflects primary

languages of populations served, and uses icons to aid in comprehension.

Patient/family advisors have been consulted to develop or refine the patient and visitor navigation scheme.

Signage of an institutional nature is minimized in residential settings.

Non-institutional components of the navigation scheme may include destination markers, architectural details and artwork

Signage reflects primary languages of populations served, and uses icons to aid in comprehension.







Definitions

VI.F: Physical access to the building is barrier-free and convenient for those served.

Ample accessible parking is available adjacent to entrances.

The availability of handicapped-accessible parking is adequate to meet need.

Valet service is offered. Shuttles or golf carts transport

visitors to and from the building. Public transportation is easily

accessible. Bike racks and walking paths are

available. Accommodations are provided for

battery-powered vehicles. Entryways are well-lit and secure. The availability of wheelchairs at

entrances meets need.

Ample accessible parking is available adjacent to entrances.

The availability of handicapped-accessible parking is adequate to meet need.

Valet service is offered. Shuttles or golf carts transport

visitors to and from the building. Public transportation is easily

accessible. Accommodations are provided for

battery-powered vehicles. Bike racks and walking paths are

available. Entryways are well-lit and secure. The availability of wheelchairs at

entrances meets need.

Barrier-free= Structural or architectural design that does not impede use by individuals with special physical needs

VI.G: The environment is designed to accommodate privacy needs in a culturally appropriate way and provides for patient/resident dignity and modesty, particularly in common areas, check-in/registration, check-out/billing, patient/resident rooms and bathrooms.

Patient rooms and bathrooms accommodate patients’ privacy.

Consultation space is private. Patients’ privacy needs are

accommodated in gowned waiting areas.

Resident rooms and bathrooms accommodate residents’ privacy.

Consultation space is private.







Definitions

VI.H: The organization is able to demonstrate its commitment to the promotion of holistic community health through environmental stewardship.

Green cleaning products, equip-ment and lighting choices that decrease mercury, copper, etc. are used.

Efforts to decrease energy consumption for lighting, heating and cooling can be documented.

A recycling program is in place. Efforts are underway to decrease

use of paper memorandums and bulletins.

Pleasant smelling, non-toxic cleaning products are used.

Sustainable approaches to construction, renovation and ongoing operation and maintenance of the facility as well as encouraging environmentally-friendly practices in staff work (e.g. reduction of interior and exterior pollutants, conservation of re-sources, preserving green space etc.)

Green cleaning products, equipment and lighting choices that decrease mercury, copper, etc. are used.

Efforts to decrease energy consumption for lighting, heating and cooling can be documented.

A recycling program is in place. Efforts are underway to decrease use

of paper memorandums and bulletins. Pleasant smelling, non-toxic

cleaning products are used.

Sustainable approaches to

construction, renovation and

ongoing operation and maintenance

of the facility as well as encouraging

environmentally-friendly practices

in staff work (e.g. reduction of

interior and exterior pollutants,

conservation of re-sources,

preserving green space etc.)

VI.I: Patients/residents and staff have access to nature.

The built environment includes indoor, safe outdoor or rooftop gardens.

The built environment includes landscaped patios, terraces, courtyards, atria and natural elements.

The built environment includes indoor, safe outdoor or rooftop gardens.

The built environment includes landscaped patios, terraces, courtyards, atria and natural elements.







Definitions

VI.J: Lighting is provided that is appropriate for the required task or function, promotes a safe environment for staff and patients/ residents and is supportive of patient/resident, comfort, control and security.

Task lighting is incorporated into staff work stations.

Bedside reading lights are provided for patients.

Corridor lighting can be dimmed or controlled for lower levels during quiet times and at night.

Low-level lights in patient rooms minimize patient disruption when staff checks on them at night.

Task lighting is incorporated into staff work stations.

Bedside reading lights are provided for residents.

Corridor lighting can be dimmed or controlled for lower levels during quiet times and at night.

VI.K: Protocols are in place for reducing coercive intervention.

A comfort room, Snoezelen or low-stimulation environment is provided.

A comfort room, Snoezelen or low-stimulation environment is provided.

VI.L–In continuing care and behavioral health sites: Common spaces are available and feature a sense of spaciousness and light. In addition, they satisfy patients’/residents’ needs for both private spaces and spaces that support social interaction and decision-making.

Common areas provide an environment that encourages conversation, interaction, and relationship development.

Common area space is balanced with private space areas for visitation, meditation, etc.

SECTION VII: ARTS PROGRAM/MEANINGFUL ACTIVITIES AND ENTERTAINMENT







Definitions

VII.A: Arts, entertainment, and life enrichment activities are designed with and in response to the interests and input of patients/residents, families, and staff. The programming is meaningful and evidence-based (as appropriate) to enhance wellness, health, enjoyment, and to support a holistic approach to treatment goals. Active participation by staff, patients/residents, and families is encouraged, as appropriate.

A range of diversionary activities are available to patients and families. Components of a comprehensive arts and entertainment program may include: musical performances, visual arts, crafts activities, animal visitation, bedside reading, and access to technology

Supervisory and non-supervisory staff participates on an arts and entertainment team.

Input from Patient/Family Partnership Council guides development of arts and entertainment programming.

Examples may include a Journey of Dreams program, journal writing programs, mentor programs and partnerships with academic institutions.

A Life Stories program may be implemented.

Components of a comprehensive arts and entertainment program may include: musical perfor-mances, visual arts, crafts, animal visitation, bedside reading, and access to technology

A flexible transportation system is provided that enables residents to satisfy personal wishes, participate in off-site activities and volunteer.

Recreation staff provides education, regularly, to all stakeholders on the options for engagement through visits, care, and informal interactions.

Residents are active participants in the development of and implementation of arts and entertainment programs.

Families are engaged in the community through activity implementation and planning.

All stakeholders in the community have opportunities to share passions and lead activities.

A program that creates

opportunities for residents to

realize hopes and dreams is

implemented.

Examples may include a Journey of Dreams program, journal writing programs, mentor programs and partnerships with academic institutions.

A Life Stories program may be

Life Stories Program= collection and compilation of individuals’ personal histories into a format to share with others as a way to get to know the patient/resident at a more human level.







Definitions

implemented. Residents have opportunities in

the organization to teach and to learn.

Residents have access to a full array of concierge and on-site services.

Life stories and responses to care are used to individualize care for persons with cognitive impairment.







Definitions

SECTION VIII: SPIRITUALITY AND DIVERSITY VIII.A: Accommodations are made to support the cultural norms, spiritual needs, and other beliefs of patients/residents with documentation in the treatment plans. Human resource policies/protocols address the cultural and spiritual needs of staff.

Spiritual assessments are conducted on admission.

Sacred spaces are available on-site for both quiet contemplation and communal worship.

A variety of spiritual resources are available for patients, families and staff.

Resources are available to staff to educate them on different cultural beliefs/traditions related to health and healing.

Caregivers are empowered to accommodate patients’ cultural routines/beliefs/traditions.

Cultural routines/traditions of stakeholders are celebrated as applicable.

A pastoral care program is developed.

Spiritual assessments that assist residents in defining and communicating their spiritual preferences are conducted on admission.

Sacred spaces are available on-site for both quiet contemplation and communal worship.

A variety of spiritual resources are available for residents, families and staff.

Individualized reflection services are held when a resident dies.

Stakeholders are supported through diversity education that may include topics of generational differences, gender, race, spiritual, and cognitive differences.

Cultural routines/traditions are celebrated as applicable for community members from specific diverse populations.

A pastoral care program is developed.








Definitions

SECTION IX: INTEGRATIVE THERAPIES/PATHS TO WELL-BEING IX.A: Patients are supported in understanding and accessing a range of treatment options, including those considered complementary or alternative to local standards. Patients receive support from the care team to integrate such options into their treatment regimen, as appropriate.

A formal integrative or complementary medicine program is established.

A process is developed for responding to patient requests for in-hospital treatment by the patient’s/ existing practitioner(s).

A Health Resource Center includes information on complementary/ integrative therapies.

Examples could include: providing direct services, developing a process for

responding to patient requests for in-hospital treatment by the patient’s existing practitioner(s)

evaluation of patients herbal remedies as part of the medication reconciliation process

Processes are in place for residents to choose to participate in a variety of integrative or complementary medicine approaches.

Holistic and complementary therapies such as massage, aromatherapy, chiropractic care, and healing touch are offered on a routine basis for the treatment of sleeplessness, pain, adverse behavioral responses, and decrease appetite.

A Health Resource Center includes information on complementary/ integrative therapies.

Examples could include: providing direct services, developing a process for

responding to resident requests for in-hospital treatment by the patient’s existing practitioner(s)

evaluation of resident herbal remedies as part of the medication reconciliation process

Complementary Medicine=One of numerous designations for diverse medical practices not routinely taught in medical school, and not incorporated into conventional medical practice.

IX.B: Clinicians assess the skills and ability of each patient/resident and family member to self-manage their health care needs, and resources are available, as needed, to enhance self-management skills and abilities, particularly for those with chronic conditions.

Holistic wellness programs are offered, such as nutrition counseling and stress management.

Programs are implemented that support patients in chronic disease management.

Examples may include use of shared decision making tools, health coaching and collaborative care conferences.

Physical and mental fitness opportunities are available.

Holistic wellness programs are offered, such as nutrition counseling and stress management.

Examples may include use of shared decision making tools, health coaching and collaborative care conferences.







Definitions

IX.C: Patients’/residents’ daily care is provided with gentleness and in recognition of the importance and health benefits of physical contact and human touch, as appropriate based on the person’s preference.

Examples of caring touch include massage, healing touch, therapeutic touch and Reiki.

Beyond implementation of formal caring touch programs, patients’ daily care is provided with gentleness.

Examples of caring touch include massage, healing touch, therapeutic touch and Reiki.

Beyond implementation of formal caring touch programs, residents’ daily care is provided with gentleness.

IX.D: A plan is developed and implemented for providing holistic and dignified end-of-life care, as appropriate.

Processes are in place to support staff through grief and loss.

A plan is developed and implemented for providing holistic and dignified end-of-life care that includes clinical care and pain management, as well as psychosocial and spiritual support.

Processes are in place to support residents and staff through grief and loss.

A plan is developed and implemented for providing holistic and dignified end-of-life care that includes clinical care and pain management, as well as psychosocial and spiritual support.

SECTION X: HEALTHY COMMUNITIES/ENHANCEMENT OF LIFE’S JOURNEY X.A: Based on the interests and needs of the community, a plan is developed to improve community health.

The organization collaborates with local agencies on provision of direct services, educational information, or referral.

Free health-related lectures, wellness clinics, health fairs, etc. are routinely offered to the public.

A community health care needs assessment is conducted.

The organization collaborates with local agencies on provision of direct services, educational information, or referral.

Free health-related lectures, wellness clinics, health fairs, etc. are routinely offered to the public.

Stakeholders are offered the opportunity to volunteer or participate in community events.

Examples include provision of direct services, educational information, or referral and collaboration with local agencies.







Definitions

X.B: The organization works with other local healthcare providers across the continuum of care to improve care coordination, communication and information exchanges around the needs of each patient/resident and family, especially during transitions of care.

The organization works with other local providers across the continuum of care to improve the patient experience and enhance transitions of care.

The organization works with the local hospital and other providers across the continuum of care to improve the patient experience and enhance transitions of care.

X.C–Applies only to continuing care sites: The move-in process is managed to maximize connections within the community and to minimize the stress associated with the transition.

Practice and physical and/or virtual environment are supportive of contributing to resident preferences related to feelings of connectivity to loved ones and community.

SECTION XI: MEASUREMENT XI.A: Data is gathered to measure quality of care, patient/resident safety, the patient/resident experience and the staff experience, and the organization can demonstrate how the data is being used to enhance quality and safety and to improve the patient/resident and staff experience.

Quality, safety, quality of life, and patient and staff (including physician) experience data are routinely collected, analyzed and compared to available benchmarks.

If organization is internationally or nationally accredited, it serves as a proxy.

Staff experience includes physicians.

Quality, safety, quality of life, and resident and staff experience data are routinely collected, analyzed and compared to available benchmarks.

If organization is internationally or nationally accredited, it serves as a proxy.

Staff experience includes physicians.







Definitions

XI.B: Performance data on organizational indicators related to efficiency and clinical and service excellence are made available to the public to support consumers in making informed health care choices.

XI.C: The organization conducts regular (at least every 18 months) focus groups or other organized methods to gather meaningful information from patients/residents, family and staff members. The results are shared at a minimum with senior management, the governing body, staff, and patients/residents and family members.

Focus groups are conducted by an independent facilitator. Results are shared with, at a minimum, senior management, the governing body, staff, and patients and family members

Focus groups are conducted by an independent facilitator. Results are shared with, at a minimum, senior management, the governing body, staff, and residents and family members

All stakeholders have opportunities to participate in learning circles.

All stakeholders= inclusive, as applicable, of the governing body, administration, physicians, management, staff, volunteers, patients/residents and families

Regular = at a minimum, every 18 months

Governing Body= highest authority that has governance responsibility Family=defined by patient/resident







Definitions

XI.D: The organization regularly solicits information from staff about safety concerns and uses the information generated to improve safety practices in the organization. The organization assesses its safety culture, has a process for encouraging staff to report quality and safety issues, and takes necessary or appropriate action(s) in response to reported quality concerns.

A survey is conducted to assess its safety culture at a minimum once every two years.

A survey is conducted to assess its safety culture at a minimum once every two years.

XI.E: Staff and patient/resident/family members are actively involved in the design, ongoing assessment and communication of performance improvement efforts. The organization consistently utilizes data to identify and prioritize improvement over time.

An active continuous quality improvement process is in place in the organization

A system is established to broadly communicate performance improvement information to all members of the hospital community and to the public.

Front line staff and patients/families are included in the improvement process.

An active continuous quality improvement process is in place in the organization.

A system is established to broadly communicate performance improvement information to all members of the continuing care community and to the public.

Residents, family and front line staff are decision-makers and are included in the improvement process.

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