C158_Task1

Running Head: ORGANIZATIONAL LEADERSHIP 1 C158 Task 1: Organizational Leadership and Interprofessional Team Development

ORGANIZATIONAL LEADERSHIP 2 C158 Task 1: Organizational Leadership and Interprofessional Team Development Healthcare organizations operate like any business, and must meet regulatory requirements and accounting standards in order to conduct their operations safely and successfully. While private and publicly held companies have a duty to their owners to create profits through the sale of healthcare services, non-profit organizations also aim to create efficient operations that do not generate excess waste or loss. The following analysis of Keck Medicine of USC, an academic medical center and large care organization, outlines how business practices, regulatory requirements and reimbursement can impact the delivery of patient-family- centered care. I selected Keck Medicine of USC for this interprofessional team development project because they are one of the most highly respected research institutions and medical practices in California, and have a longstanding commitment to patient-family-centered care. Established in 1885, the Keck School of Medicine is the oldest medical school in Southern California. The USC Choi Family Patient-Centered Care Program, created in 2016, further strengthens the commitment that Keck Medicine has to providing patient-family-centered care. However, the organization can continue to improve its delivery of patient-family-centered care by addressing the current weaknesses and strengths of care delivery within the system. Keck Medicine uses the Consumer Assessment of Healthcare Providers and Systems Clinician & Group Survey (CG-CAHPS) to calculate star ratings for its providers and to offer areas for improvement. Keck Medicine provides care for those with public insurance like Medicare and Medi-Cal. The Centers for Medicare and Medicaid Services offer compensation for patient care services as well as value-based programs for outstanding performance and performance improvement in areas such as Hospital Readmissions Reduction, Physician Value-Based Modifiers, and Skilled Nursing Facility Value-Based Programs. Patient-family-centered care is a model based on close, ongoing collaboration between the patient, the family, and the care team. Rather than simply taking orders or instructions, families are encouraged to give their input and guide the treatment plan in a way that ensures quality care for the individual patient. Although Keck

ORGANIZATIONAL LEADERSHIP 4 emphasizing all four of these aspects of patient care, Keck Medicine of USC can cement its commitment to providing quality, loving care. Leadership / Operations Keck Medicine has a clear statement of commitment to Patient Family Centered Care and Patient/Family partnerships (Keck Medicine Center of USC, 2021). Although data on the delivery of patient-family-centered care is available, it is difficult for patients and families to easily access it through the organization’s website or help desk. The CG-CAHPS survey provides patients the opportunity to respond to the treatment they received while under the care of Keck Medicine. The USC Choi Family Patient-Centered Care Symposium offers the opportunity for healthcare professionals in the local area to study and train, but it is aimed at staff, rather than patients and families within the community. Keck Medicine does include some input from patients and families in its policymaking activities. If bioethical issues are involved, a bioethics committee including professionals from “medicine, nursing, social services, clergy, law, ethics and administration” will convene to address the concerns of any petitioner, including a patient or family member (Keck Medical Center of USC, 2019). As part of the larger research institution, the “Department of Family Medicine strives to advance knowledge in family and community medicine and to develop methods of primary care that are effective, efficient and accessible” (Keck School of Medicine of USC, 2021). The USC Health System Board oversees and governs Keck Medicine of USC and all associated patient care activities, and the three hospitals are governed by two separate governing boards. The information for the Board of Governors is publicly available, and individual members could be contacted with patient or family concerns. The organization is accountable to the community through its Community Benefit Report and Plan, which is issued annually (Keck Hospital of USC, 2020). However, it is unclear if direct input from patients and families is part of the Governing Board’s routine activities.

ORGANIZATIONAL LEADERSHIP 5 Mission, Vision, Values Patient-family-centered Care forms a central part of the Mission and Values of Keck Medicine of USC. The Values include: “compassion, while building positive relationships with our colleagues, our patients and their families,” and “authentic communication with our colleagues, our patients and their families” (Keck Medicine of USC, 2021). The staff division, Nurses of USC, endorses “holistic, culturally-sensitive… respectful…individualized [care]…focused on exceeding expectations and improving outcomes through strong advocacy, effective decision-making, and collaborative, interprofessional partnerships” (“Professional Practice Model,” 2021). A Patient Bill of Rights and Responsibilities is included in the patient information handbook, and enumerates 26 specific rights afforded to patients, including the ability to file complaints and grievances within the organization and through state regulatory agencies. However, the language used is somewhat technical, and it is quite long, which may be hard to understand for some patients or families. Translation services are available, but patients will likely receive a copy of the Patient’s Bill of Rights in English (and/or Spanish) only (Keck Medical Center of USC, 2019). Advisors The patients and families served by Keck Medicine of USC play an important advisory role, and the organization has both strengths and weaknesses within this area. Patients and families do not serve directly on hospital committees, but they play an active role in the deliberations and actions of the ethics committee at Keck Medicine of USC. Ethics consultations can be requested by patients and family members without physician approval. The Ethics Committee Chair is easily reached by any concerned family members or patients via a publicly-facing email address. Despite evidence showing that involving family members improves rounding for both patient and provider, it is unclear whether this is standard procedure at Keck Medicine of USC (Indiana

ORGANIZATIONAL LEADERSHIP 7 patient family council, but do not generally personally participate in these meetings. IHI, NPSF, and other industry standards association meetings are attended by staff, but patients and families do not play a role in these meetings. Keck Medicine of USC is highly committed to quality improvement, and has undertaken numerous QI programs over the years to reduce negative outcomes and promote positive outcomes among their patients. If patients and families could participate further in these QI initiatives, Keck Medicine of USC could solidify its assurance that their care is truly patient-family-centered. Personnel Personnel at Keck Medicine of USC are highly committed to patient-family-centered care. There is an expectation for collaboration with patients and families in employee job descriptions & performance appraisals. Patients and family members do not generally participate on interview teams or search committees. Although new patients and families are greeted by staff, the reverse is not generally true. The exception would be the patient family council, which can play a small role in staffing. Staff and physicians are highly prepared for & generally supported in providing patient-family-centered care throughout their practice. Overall, personnel are well trained, but could be more involved with patients and families in terms of hiring and performance evaluation. Environment and Design Patient/Family participate in clinical design projects such as designing signage to direct staff, patients, and visitors through the hospital. The environment at Keck Medicine of USC strongly supports patient and family presence, participation, and interdisciplinary collaboration. Meditation gardens are available and resource rooms for families that include basic office supplies are also available, facilitating patient and family presence and participation (Keck Medical Center of USC, 2019). Since the medical group covers multiple buildings and offices, it is important to involve families in environmental design across these different environments.

ORGANIZATIONAL LEADERSHIP 8 Information / Education An extremely useful and accessible web portal is available to patients and families to view and request medical records, post messages, and acquire other important information. Although some clinicians may provide their email to patients or families, it is unclear whether this is standard practice at Keck Medicine of USC, and it likely depends on the individual clinician. Patients and families do serve as educators as part of the patient and family council, which instructs staff about incorporating patient and family perspectives into the facility’s design and workflow. Patients and families have access to resource rooms at the hospitals and other resources within the different facilities of Keck Medicine of USC, but additional facilities could be provided that enable families to learn and contribute to learning at Keck Medicine of USC. Diversity & Disparities Los Angeles, California has a diverse population that is approximately 50% Hispanic, 25% White, 12% Asian and 8% Black ("The Demographic Statistical Atlas of the United States", 2021). Keck Medicine of USC is a research institute, and carries out careful and conscientious collection and measurement of race, ethnicity, and language of its patients. Interpreter services are provided upon request. There is a navigator program for minority and underserved patients with regards to clinical trials, and Keck Medicine of USC is dedicated to serving a diverse patient population. One weakness is that educational materials for patients and families could be difficult to understand, and are not available in every language (though translations are available for common languages spoken in California). There is a street medicine team that focuses on providing underserved patients and also a grant program called “Primary Care for Vulnerable Populations” that aims to assist in training providers to “work with vulnerable populations, support wellness in providers, address inequities in health care…implementing and studying programs related to street medicine and social justice, within the Primary Care Physician Assistant Program curriculum” (Norman, 2019).

ORGANIZATIONAL LEADERSHIP 10 families during acute care, but could still do more to inform patients and families and involve them in care process. Care Keck Medicine of USC is an outstanding care provider that aims to engage patients and families in collaboration, treat them with respect, listen to their concerns, involve them in care planning and discharges. Patients and families are encouraged to contribute to the care process and supported by staff. Management of care is handled by a specialist case manager, who works together with physicians, nurses, and the interdisciplinary team to ensure patient-family-centered care for every individual who enters the facility. This is an area of strength with minimal weaknesses noted. Area of Improvement One area that Keck Medicine of USC can improve is to directly involve patients and families in the administrative and care delivery process above and beyond the current collaborative efforts being undertaken. This would mean including a current patient and family member in all Board Meetings, allowing patients and families to safely enter information into a patient’s chart, and increasing the interaction between administrative and medical staff, patients, and families through training sessions, onboardings, and other opportunities for collaboration. Although a great effort is made to pay lip-service to patient and family-centered care, it is unclear how much direct involvement patients and families truly have in the planning and administration of this health provider. Large donors, businesspeople, academicians, and administrators tend to set top-down policies that claim to include the community on their surface, but do not truly involve the unheard voices of patients, families, and other community members. Enacting policies to directly include patients and families in hospital administration is analogous to the involvement that parents and guardians have in schools through organizations like the Parent-Teachers Association. Patient Family Councils are a great start, and even more involvement would generate additional innovation for Keck Medicine of USC in terms of patient-family-centered care.

ORGANIZATIONAL LEADERSHIP 11 Bringing a broad array of patients into the discussion can provide new perspectives and may enhance the future delivery of care for the diverse community of Los Angeles, California. Strategy to Increase Patient-Centeredness In order to further increase the commitment to patient-family-centered care at Keck Medicine of USC, a team will be assembled comprised of specialists from key areas of the organization. Keck Medicine of USC is focused on research, surgery, cancer treatment, and outpatient treatment. In order to increase the patient-family- centered care delivery for each of these areas, a team leader from each area will be paired with a patient and family member who will collaborate on this change project. Additionally, one patient and one family member will be assigned to each meeting of the hospital and overall governance boards. The goals will be to increase patient satisfaction ratings and to decrease or limit mortality and hospital readmissions. These process changes will be evaluated over time by tracking critical outcomes, examining patient satisfaction surveys and carrying out knowledge, attitude and practice surveys of staff pre- and post-change. System and Change theory The US Institute for Healthcare Improvement (IHI) Model for Improvement combines repeated measurements and incremental change evaluations using the model of the plan-do-study-act cycle (Dixon- Woods, 2019). The Plan-Do-Study-Act model provides a framework to evaluate the effectiveness of small changes. IHI suggests developing an objective, measurable aim and a framework for evaluation as well as an outline of how the change will produce the result and how the change plan will be executed. Since Keck Medicine of USC already has funding provided for patient-family-centered care improvement programs, this theoretical model will provide the structure needed to carry out incremental testing and evaluation of the proposed changes. In the planning stage, evidence will be acquired from the research literature and from within the facility. The John’s Hopkins Evidence-Based Practice model and The National Database of Nursing Quality Indicators provide specific ways to measure these two types of data, respectively. Data for baseline patient

ORGANIZATIONAL LEADERSHIP 13 revenues are adversely impacted by any changes, they can be paused or rolled back during the act phase of the plan-do-study-act cycle. Not only is Keck Medicine of USC is a primary source of revenue, it employs many members of the community with rewarding roles caring for their neighbors. Evaluation Methods   Patients, families, and staff will be surveyed for satisfaction. Staff will be assessed for their knowledge, attitude, and practices towards patient-family-centered care. This survey will be administered using the hospital’s current framework for quality improvement, which routinely administers patient and family satisfaction surveys. Data collection and analysis will be carried out collaboratively. The patient or family member paired with the data science team leader will contribute to this process in a way that preserves patient safety and confidentiality. Staff will be surveyed on their knowledge, attitude, and practice concerning patient-family-centered care. At the end of the program, a comprehensive report will be prepared and disseminated as part of the act portion of the cycle. Multidisciplinary Team The team will include team leaders from each area of focus and a patient or family member that is involved with that discipline. For example, a patient previously enrolled in a clinical study could be paired with the research team leader. The team member for the research area will be a nursing data scientist or nursing quality improvement specialist. This nursing leader will help to acquire and process data, interacting with the quality improvement team. The surgical improvement team will be led by a surgeon who is paired with a patient or family member who has undergone surgery. Their role will be to bring a patient’s perspective to improving surgical practice with the aim of reducing mortality and hospital readmissions following surgical procedures. The oncology improvement team will be led by a nursing oncologist, and the outpatient treatment and discharge improvement team will be led by a clinical nurse manager. These expert leaders will also be paired with a patient or family member appropriate to their area of focus. The oncology team leader will explore how cancer patients

ORGANIZATIONAL LEADERSHIP 14 can provide expertise and new perspectives for care providers. The outpatient improvement team leader will be paired with a patient or family member who has experienced transitional care. In addition to these four primary areas of focus, a leader of the nursing staff, a social worker or patient’s rights advocate, and an accounting and budgeting specialist will assist with the execution of this project. The nursing staff leader will advocate for staff and interact with floor nurses as needed to carry out the program. The social worker or patient’s rights advocate will ensure ethical standards are upheld while protecting the patients and family members who are involved in administrative work through this program. The accounting and budgeting specialist will assist with developing budgets and assessing costs. In total, the interdisciplinary team will involve twelve people: four leaders, four patients or family members paired with experts, and three support staff who will assist with program administration. One of the patient or family members will be given the opportunity to present findings to the organization’s board meetings, and will be selected based on the findings of the study portion of the plan-do- study-act program. Cultural Diversity Cultural diversity within the team supports patient-centered, culturally competent care by providing a diverse pool of health care providers that can fulfill patients' individual care preferences. Keck Medicine is located in one of the most diverse areas in the United States, draws from a diverse talent pool of medical professionals and serves a highly diverse community of patients. Diversity can pose both challenges and opportunities within healthcare in terms of teamwork, communication, and patient care (Crawford, Candlin, & Roger, 2017). Leadership Theory In developing my team, the ideal to strive towards is the transformational leadership model. As an academic institution, Keck Medicine is uniquely situated at the forefront of evidence-based medicine, and has more freedom to experiment with new paradigms of care delivery than other organizations that are more

ORGANIZATIONAL LEADERSHIP 16 the performance improvement team, helping to administer surveys and implement lower-level changes. This program will require time and financial investment from key leaders within Keck Medicine of USC. Communicating the Strategy and Intended Outcomes The strategy will be initially disseminated through the symposiums that are dedicated to improving patient-family-centered care at Keck Medicine of USC. This is accessible to professionals in the community, but not the general public. The four team leaders will present the strategy, data collection methods, and goals of the program. They will solicit input from the community, including students, fellow practitioners, and community members. The board meetings will provide the best opportunity to present the strategy and intended outcomes to the organization’s top leadership. The organization’s ethics committee will provide oversight regarding the selection of participants and critical outcomes for this project. The strategy will be presented to the public through a press release and an article posted to the organization’s website. Keck Medicine of USC encourages other organizations to follow their practice model when it has been shown to improve patient care outcomes. The findings will be disseminated to the wider community through an official whitepaper that other institutions can consult when planning their own practice changes. Self-Assessment Tool There are many tools available to assess team members. The Family-Centered Care Questionnaire- Revised (FCCQ-R) can be used to objectively evaluate staff members regarding their commitment to patient- family-centered care (Coyne, Murphy, Costello, O’Neill, & Donnellan, 2013). Staff satisfaction can be evaluated using the Job Satisfaction Scale for Clinical Nurses (JSS-CN (Lee, Eo, & Lee, 2018). These self-assessment tools will assist the team to measure whether this program changed their knowledge and feelings towards patient- family-centered care and whether it impacted their overall job satisfaction. Working closely with patients and families is associated with improved workflow and better care compared to working without the input of these

ORGANIZATIONAL LEADERSHIP 17 collaborators. These surveys can provide individual feedback for participants, and can also be aggregated by the data science team leader.

ORGANIZATIONAL LEADERSHIP 19 Keck School of Medicine of USC. (2021) Clinical Research . Retrieved 20 January 2021, from https://nurses.keckmedicine.org/professional-practice-model/ Lee, B. S., Eo, Y. S., & Lee, M. A. (2018). Development of job satisfaction scale for clinical nurses.  Journal of Korean Academy of Nursing ,  48 (1), 12-25. Marshall, E. (2010).  Transformational leadership in nursing: From expert clinician to influential leader . New York, NY: Springer Palmer, S. (2016). Building a culture of engagement as the foundation for patient experience: On the road with keck medicine of USC. Retrieved 13 January 2021, from https://www.theberylinstitute.org/page/ONTHEROAD0316 PFCCPartners. (2021). Health Systems. Retrieved 19 January 2021, from https://pfccpartners.com/los-angeles- county-department-of-health-services/ The Demographic Statistical Atlas of the United States. (2021). Retrieved 28 January 2021, from https://statisticalatlas.com/place/California/Los-Angeles/Race-and-Ethnicity University of Southern California. (2019).  University of southern california financial report . Los Angeles: University of Southern California. Retrieved from https://about.usc.edu/files/2019/02/USC-FY18- Financial-Report.pdf

ORGANIZATIONAL LEADERSHIP 20 Appendix A. Patient-and Family-Centered Care Organizational Self-Assessment Tool Patient- and Family-Centered Care Organizational Self-Assessment Tool Elements of Hospital-Based Patient- and Family-Centered Care (PFCC) and Examples of Current Practice with Patient and Family (PF) Partnerships Domain Element 1 Low to High Do not know Leadership / Operations Clear statement of commitment to Patient Family Centered Care and Patient/Family partnerships 1 2 3 4 5X Explicit expectation, accountability, measurement of Patient Family Centered Care 1 2 3 4X 5 Patient/Family inclusion in policy, procedure, program, guideline development, Governing Board activities 1 2 3X 4 5 Mission, Vision, Values Patient Family Centered Care included in Mission, Values, and/or Core Values 1 2 3 4X 5 Patient/Family “friendly” Patient Bill of Rights and Responsibilities 1 2 3X 4 5 Advisors Patient/Family serve on hospital committees 1 2 3 4 5 X Patient/Family participate in quality and safety rounds 1 2 3 4 5 X Patient and family advisory councils 1 2 3 4 5X Quality Improvement Patient/Family voice informs strategic / operational aims/goals 1 2 3X 4 5 Patients/Families active participants on task forces, QI teams 1 2 3 4 5 X Patient/Family interviewed as part of walk-rounds 1 2 3 4X 5 Patient/Family participate in quality, safety, and risk meetings 1 2 3X 4 5 Patient/Family part of team attending IHI, NPSF, and other meetings 1 2 3X 4 5 Personnel Expectation for collaboration with Patient/Family in job descriptions & Policies in Performance Appraisal Process 1 2X 3 4 5 Patient/Family participate on interview teams, search committees 1 2X 3 4 5 Patient/Family welcome new staff at new employee orientation 1 2X 3 4 5 Staff/physicians prepared for & supported in Patient/Family Centered Care practice 1 2 3 4X 5 Environment And Design Patient/Family participate fully in all clinical design projects 1 2X 3 4 5 Environment supports patient and family presence and participation as well as interdisciplinary collaboration 1 2 3 4X 5