Background 

Kingston General Hospital (KGH) describes itself as a “community of people working together to transform the patient and family experience through innovative and collaborative approaches to care, knowledge and leadership” (KGH 2016). As the Southeastern Ontario centre for complex-acute and specialty care, and home to the Cancer Centre of Southeastern Ontario and 24 regional satellites, it serves more than 500,000 people living in a predominantly rural area of 20,000 square kilometres. Affiliated with Queen’s University, KGH is one of Ontario’s 24 academic hospitals (CAHO 2016). 

Patient Engagement 

KGH’s commitment “to ensure the voice and perspectives of patients are at the table for every decision that has material impact on patients and families” began in 2010, and was an imperative created to support a major cultural change. At the time, KGH was facing significant financial issues, high infection rates, low public confidence and poor staff morale, and the Ontario government had placed it under investigation and, later, under supervision. A new chief executive officer (CEO) was recruited and, with support from a new board of directors and key leaders, active steps were immediately taken to ensure financial recovery and to create a new model of care aimed at setting the stage for long-term, sustainable change.

More than 2,000 internal and external stakeholders, including patients and families, participated in a consultation process that informed KGH’s new strategy: “Strategy for Achieving Outstanding Care, Always.” The strategy presented a compelling vision of KGH as a patient-centred, dynamic research hospital, and a leader in interprofessional practice and education; in addition, it provided the context and direction for KGH’s efforts to realize its vision (KGH 2015a). Action plans and accountability systems were put in place to ensure KGH’s strategy was brought to life in every part of the organization. A new model of care was a core feature of the strategy and, true to the commitment of including patients and families in every decision affecting them, patients and families were partners in the design, launch and ongoing monitoring of patient- and family-centred care (PFCC). KGH realized that in order to deliver on their commitment to “transform the patient’s experience through a relentless focus on quality, safety and service” (KGH 2015a), the model of care needed to be expressed in a way that resonated with patients and staff. Hence, in partnership with patient-experience advisors (advisors), a simple and memorable definition for PFCC was crafted: “Respect Me, Hear Me, Work With Me” (KGH 2015a).

KGH now receives significant attention related to its focus on patient engagement, partnerships for care and quality improvement. In addition to providing advice and hosting site visits from over 200 organizations, KGH has gained media attention with respect to its innovative family presence policy, and national and international speaking engagements of its leaders and advisors. KGH has also received numerous awards. “More important than any award, however, is the knowledge that every patient, every day is part of this complete transformation of how we work and deliver care at KGH,” said KGH’s CEO, Leslee Thompson.

Key Strategies to Support Patient Engagement

Organizational design and service improvement

KGH’s CEO serves as an ambassador for patient engagement and, in this role, describes her approach as “solving problems differently through ‘patient-centred leadership.’” She recognized that leaders needed new tools and tactics; therefore, Thompson developed a checklist to support the inclusion of patients in planning and decision-making through purposeful leadership behaviours and encouraged its adoption. Questions that served as a checklist for the patient-centred leadership domains of inclusion, assessing, learning and sharing included:

• Inclusion: Did I include patients in decisions that affect them? If not, did I find a way to ensure that their voice is heard?
• Assessing: Did the questions I raised about statistics or numbers “people-ize” the issue, or put a face on the numbers, so that we have an understanding of what the numbers mean from a patient perspective? (For example, when examining hospital-acquired infection rates, the question becomes, “How many people came into our hospital this week without an infection and we gave them one?”)
• Learning: What did a patient teach me today? (This requires direct conversation with two to three patients a week.)
• Sharing: Have I shared a story about something that made a positive difference to the experience of patients?

Patient engagement at KGH has moved beyond consultation-level engagement methods, such as patient survey feedback and patient focus groups, to a richer experience of collaborating and partnering with patients and families. Education and training, for both staff and patients, have been key to supporting this collaboration. Advisors are supported with orientation, education and integration into their role, as is the case with any other team members at the hospital. Both staff and advisors receive education regarding KGH’s strategy, the principles and practices of PFCC, continuous-improvement cycles and Lean methodology.

At least one advisor, and ideally more, is included as a member of hospital working groups and committees focused on fulfilling KGH’s strategy to achieve outstanding care, always – with a particular emphasis on patient safety and quality initiatives. Advisors are typically recruited through the patient relations program and/or by staff or other referrals. KGH has developed clear role descriptions for advisors, and advisors are clear about their role in shaping improvement: to share and provide advice from their experience. As one advisor noted, “We are present to keep patients and families front of mind, … not to advocate for a particular solution or say you need to do this.”

Desired outcomes articulated in the KGH strategy – such as engaging patients in all aspects of quality, safety and service improvement initiatives, eliminating preventable harm and eliminating preventable delays – led staff to partner with advisors on work to reduce specimen collection errors, reduce patient falls, improve hand hygiene rates and improve identification and communication practices. Advisors, often through the KGH Patient and Family Advisory Council (PFAC), are involved in the formulation of the annual corporate plan, which is aligned to KGH’s strategy as well as to the Ontario Ministry of Health and Long-Term Care’s mandated Quality Improvement Plan. They also receive regular reports on the hospital’s performance against those plans, including the hospital’s safe reports (critical incidents) and patient satisfaction surveys.

Direct care

In support of the KGH strategy, each annual corporate plan includes an improvement initiative that advances both the core concepts of PFCC (respect and dignity,  information sharing, participation, collaboration) and efforts to partner with patients and families. In 2015, the PFAC, composed of 12 advisors and five staff, identified five core standards that support partnership and improved patient communications, safety and risk mitigation at the bedside:

• Identification badges: All staff (including physicians and volunteers) wear name badges at chest level to facilitate patients identifying who is engaging with them.
• Purposeful hourly rounding: Every patient is seen and assured minimal assessment and comfort measures on a regular, predictable basis.
• Effective communication: This is aligned with the Cleveland Clinic’s Communicate with H.E.A.R.T. program (PEAG 2015).
• Bedside communication board/whiteboard: This is updated at least every shift with key information that staff and patients and family wish to exchange.
• Patient-led feedback forums: Former patients share their experiences of hospitalization with those who had been directly involved. Staff then identify and, with advisors, co-design and conduct continuous-improvement cycles.

Accountabilities for each standard are clearly assigned, and evidence of the adoption of these standards is audited. Organization-wide performance is reported (at minimum on a quarterly basis) to the board of directors and posted on KGH’s website. KGH also supports patients in becoming active participants in their care and takes deliberate steps through information materials and direct discussion to activate engagement. Patients engage in ways that improve safety in the hospital, such as reminding hospital staff to wash their hands, reviewing medications with staff and asking questions about their care if they are unclear.

KGH leadership has been essential to operationalizing the care philosophy of “Nothing about me without me.” When the new KGH strategy was launched in 2015, several conditions that support patient engagement were already in place. They included having strong CEO and senior-level support for the concepts of PFCC and the patient-partnerships value proposition; a strong internal and external motivation to change, along with a road map to transforming the patient experience; organizational champions who understood PFCC and were close to direct care involved in redesigning the interprofessional care model; three patients who agreed to become involved and instrumental in defining the advisor role and terms of reference for the PFAC; and an emerging relationship with colleagues in a centre in the US (Augusta University Health System) who shared their PFCC journey. (See the Augusta University Health System case study in this collection.)

As work on transforming the patient experience unfolded, KGH put in place the infrastructure that directly and indirectly supported the strategy’s desired outcomes. For example, the staff and volunteers at KGH were recognized as an enabling factor in its implementation. As work on revising recruitment, orientation and education initiatives evolved, patients partnered in the redesign and change (e.g., providing opening remarks at orientations, drafting PFCC-sensitive language in role descriptions and participating on staff interview/hiring panels). As the performance improvement framework evolved – with clear annual goals, improvement priorities and metrics, and internal and external reporting requirements – it was influenced by both staff and patients.

Engagement at this level preceded the standards that eventually became mandated through Ontario’s Excellent Care for All Act. In the view of Eleanor Rivoire, KGH’s former executive vice-president and chief nursing executive, “KGH leaders recognized early in the unfolding of the strategy that, contrary to what many anticipated at the outset, partnering with patients accelerated change rather than impeding it. Having patients at the table changed the nature and tone of discussion, and quickly ensured that the focus remained on the needs of those receiving care and services.” Today, KGH has identified its “winning conditions for meaningful patient engagement” (Box 1), and continues to share its experience broadly with all who are interested in transforming the patient experience. 

Box 1. KGH’s winning conditions for meaningful patient engagement

Impact

According to KGH’s CEO, her hospital “is a very different place today than it was six years ago; budgets have been balanced, operating efficiencies achieved, patient safety and quality of care has improved, and the momentum of patient focused change continues to deepen within the organization. It is the deliberate and focused combination of activities that have improved performance. … There is not a linear relationship between any one performance metric and the other, but without purposeful, meaningful patient engagement these results could simply not have been achieved in such a short period of time.”

Early evidence demonstrating that partnering with patients and families is leading to improvement includes changes to visiting policies, patient satisfaction scores and the hand hygiene program. On the matter of visiting policies, patients had expressed concern over limited visiting hours, leading KGH to eliminate visiting hours and introduce the practice (supported by a corporate policy) of family presence.

Working groups, including advisors, also focused on a range of patient safety and quality improvement initiatives. For example, advisors helped to shape key elements of KGH’s hand hygiene program: posting hand hygiene rates on units, creating audit systems and developing and sharing videos with staff in which patients and families share their experience, and the impact of, hospital-acquired infections. In the wake of these changes, hand hygiene compliance rates improved from 34% to 96%, and hospital-acquired infection rates dropped significantly over the same three-year period. These improvements have been sustained to date. Finally, when KGH converted to contract food services as part of its financial planning, patients strongly influenced decisions, from menu options to menu design (readability), and patient satisfaction with food has since improved.

The PFAC and advisors are involved in efforts to improve the hospital’s overall performance. Advisors are part of the corporate safety and management committees, and the PFAC receives the same quarterly updates on corporate performance, patient satisfaction and safety reports (critical incidents) as program directors and board members. Daryl Bell, PFCC lead at KGH, emphasized that the development of the PFCC program is bigger than any one individual safety initiative; it is a change in the way the hospital looks at patient safety: “Ultimately, by partnering with patients and families, we determine if the care we provide is safe and if we have the information needed to make well-informed decisions. We could not have transformed our organization without the passion of our Advisors to make for a better and safer patient experience.” Striking a similar note, Thompson asserted, “Patients have stronger, more influential real-time voices … which helps KGH staff think in new ways and improve.”

Summary

The KGH strategy grounded the organization’s work on transforming the patient experience. Whereas patients have previously been described as an untapped resource, KGH strives to ensure patients and families are supported as active and valued partners. In addition, maintaining clear accountability within the organization for PFCC and patient engagement has enabled the influence and impact that advisors have at KGH. There is a clear advisor role description, and advisors and KGH staff have a shared understanding of their respective roles. Advisors share and advise based on their experience, bring and keep the voice of the patient front of mind, and challenge the status quo. In the words of one advisor, “There must be understanding of the premise of partnership – a shift from traditional paternalism and power imbalance while ensuring there is no expectation of abdication of individual/professional responsibility.”

Infrastructure specific to PFCC and patient engagement supports the presence of advisors as partners, particularly as the number of advisors and their engagement on committees, teams and projects grows. KGH has committed space and resources to support recruitment, orientation/education, mentorship, integration and advisors. The hospital is also deliberate in freely sharing its experience, in part because its journey was similarly influenced by the generous spirit of its Augusta University Health colleagues. KGH’s executive team believes that the transformation of patient experience at every level, including the healthcare system, will be enabled and accelerated by such open knowledge exchange.

Advisors are influencing the healthcare system beyond the reach of KGH through engagement with activities, councils and foundations at regional and provincial levels. Nevertheless, broad debate continues at KGH regarding the extent to which PFCC and patient engagement ought to be mandated. The lived experience of KGH is that if PFCC is approached as the right thing to do (versus “the thing that must be done”), and there is commitment to ensure supportive organizational conditions are in place, there will be increased capacity, enhanced culture and improved outcomes for patients and families and staff.

This case study was researched and written in 2015 as part of research commissioned by the Federal Advisory Panel for Healthcare Innovation to inform their report: Unleashing Innovation: Excellent Healthcare for Canada (https://www.healthycanadians.gc.ca/publications/health-system-systeme-sante/report-healthcare-innovation-rapport-soins/index-eng.php).

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