Guide to Patient and Family Engagement

Organizational Context

In the preceding section, we discussed patient, family, and provider characteristics and factors that might affect the adoption, use, and success of hospital-based efforts to increase patient and family engagement and to inform the development of the Guide. As shown in the framework that guided this scan (Exhibit 1), individual-level factors, while crucial, are only part of the picture. Equally important to developing the Guide and to understanding potential barriers and facilitators to its implementation is the organizational context within which these individuals will be trying to operationalize the activities of the Guide.

Hospitals are complex systems in which many types of individuals—health professionals, patients, and families—work together within the context of specific organizational structures and processes. In addition, a clear implication from the previous section is that patient and family engagement in hospital safety and quality will require changes in knowledge, perspectives, behaviors, and roles for virtually everyone—patients, families, and health professionals. Given the relative lack of experience with strong patient engagement in general, and in hospitals specifically, we must address at least three strategic questions to create an effective Guide:

1. What will motivate hospitals to adopt patient and family engagement practices as an innovation? What are the key external and internal drivers to generate adoption of the Guide?
2. How do hospital structures and processes affect hospitals' ability to implement change and support individuals in desired behaviors?
3. What are the key factors to consider in determining how to successfully adopt, implement, and sustain change at the hospital organizational level?

In this section, we discuss the overarching question of how organizational context influences patient and family engagement in hospital safety and quality. We begin by discussing external and internal motivators of organizational change. We then discuss the organizational structures and processes that affect the ability of organizations to implement and sustain change and to support individuals, including patients, family members, and hospital staff, in engaging in new behaviors. We conclude with a discussion of organization-level strategies to facilitate successful and sustainable implementation.

The discussion in this section does not reflect a complete analysis of the literature related to organizational change and context; such a review is outside the scope of this scan. For this scan, we focused on key concepts from the literature on organizational change and quality improvement that are most applicable to understanding how organizations will adopt, implement, and sustain the types of interventions and activities we are likely to include in the Guide.

Generally, the evidence in this section represents lessons learned from literature on organizational learning, innovation, and change in health care—particularly as they relate to quality improvement. As such, the literature often reflects a broader perspective on organizational context and change instead of specific findings related to the organizational implementation of patient and family engagement. The majority of the evidence comes from case studies. Where specifically noted, the evidence in this section is supplemented with information from interviews with key informants, many of whom are organizational health care leaders. Exhibit 7 summarizes the strength of evidence with regard to organizational culture.

Motivators of Organizational Change

Organizational motivators are systems, events, or environmental characteristics that create a "desire to make an effort toward a particular target."⁸⁰ They can occur either externally or internally to the organization and drive change by creating sufficient need and desire.

External Motivators

Here we highlight six key external motivators:

1. Desire to mimic competitors.
2. Health care legislation or mandated policies.
3. Leadership from influential bodies.
4. Alignment of financial incentives.
5. Public reporting.
6. Accreditation and awards.

Desire to mimic competitors. Health care organizations adopt initiatives, such as patient- and family-centered care or patient and family engagement, not only to achieve internally generated goals but also to keep up with competitors or imitate top performers. The motivators can be the desire to improve performance, increase market share, and the like.

Existing organizations whose actions have increased the visibility of patient and family engagement and provided a potential cadre of hospitals for others to mimic include the Dana Farber Cancer Institute, MCG Health, Children's Hospital of Philadelphia, Emory Health System, and Planetree hospitals, among others.

Legislation or state and national policies that mandate changes in care or the care experience. Motivation to adopt practices related to patient and family engagement may also come in the form of State- or national-level policy mandates. For example, in 2007 the State of Massachusetts enacted legislation (Senate Bill No. 1277) designed to promote health care transparency and facilitate consumer-provider partnerships.⁸¹ One component of this legislation requires all hospitals in the State to establish Patient and Family Advisory Councils (PFACs) by October 2010 to provide meaningful input into hospital policy and management. Hospitals must also establish rapid response teams (RRTs) trained to assess and stabilize a patient's condition, educate and support medical staff, and assist with communication among the attending medical staff and the patient and family. Hospitals must allow a patient and/or the family to activate the RRT whenever they detect deterioration in the patient's condition.

Leadership and guidance from influential bodies. External motivation may also come from pressures or "pushes" from external organizations. Conway suggests several critical organizations that are promoting patient and family engagement, including consumer advocacy organizations (e.g., Consumers Advancing Patient Safety, the Institute for Family-Centered Care, the American Association of Retired Persons); quality organizations (e.g., Hospital Quality Alliance, Leapfrog Group); government entities (e.g., AHRQ, the Centers for Medicare & Medicaid Services); and other private and public entities (e.g., the Institute of Medicine, Institute for Healthcare Improvement).⁸² Some of the most influential actions have come from the Institute of Medicine (IOM), which identified "patient centeredness" as one of six core attributes of high-quality care.9 The IOM has consistently placed patient centeredness as a fundamental focus of all efforts to reform and improve the U.S. health care system. Many other organizations have followed the IOM's lead. AARP advocates for quality initiatives, including the use of evidence-based, shared decisionmaking to improve care.⁸³ The World Health Organization (WHO) encourages partnerships among patients, their families, and health care workers to promote various quality initiatives in health care settings.⁸⁴ National Priorities Partners, a group representing 28 organizations with an interest in improving health care, also identified patient and family engagement as a national priority.⁸⁵ The advocacy and guidance these organizations provide help create an atmosphere in which doing anything less than accomplishing true patient-centered care is poor-quality health care.

Alignment of financial incentives. Health care purchasers continue to strive to become active purchasers of care by providing financial incentives for the provision of efficient, high-quality, and safe clinical care.^86-88 Payers are increasingly being offered models for value-based purchasing (VBP) or pay-for-performance, where incentives include payments based on factors such as attaining predetermined clinical and service targets, improvement toward target levels, or rankings against other specified benchmarks.^86,87 Negative incentives, such as penalties assessed to hospitals for not meeting targets, may also be included.⁸⁹

Elements of VBP were incorporated into national policy in 2006 when Congress mandated that beginning in FY 2009, the Secretary of Health and Human Services (HHS) would develop a pay-for-performance program for hospitals that receive payments from the Medicare program.^86,90 Under this pay-for-performance program, "a hospital's ability to provide superior clinical outcomes and an exceptional patient experience will be directly linked to reimbursement."⁹¹ Many experts also believe that this program will help solidify the economic incentives to providing patient- and family-centered care and enhancing service for the patient.

Changes in reimbursement that incorporate payment penalties for events or conditions that should not occur also can help facilitate changes in the hospital care experience for patients.^87,92 For example, the Centers for Medicare & Medicaid Services (CMS) has developed a list of 10 conditions that are preventable during the course of a hospital stay. If a patient develops one of these conditions, CMS will no longer pay an extra amount for the care related to the potentially avoidable condition.⁹² Consequently, CMS's policy motivates hospitals to avoid financial losses by taking action to avoid the occurrence of avoidable conditions.

Public reporting of quality performance information. Public reporting of quality and safety information (one of the tenets of value-based purchasing) is another motivator for hospitals to improve performance on clinical or patient experience outcomes. A key objective of public reporting is to increase accountability of health care organizations by providing consumers and purchasers with the information they need to make more informed decisions about where they receive care or how they purchase care.

A highly influential comparative quality reporting effort that can motivate hospitals to focus on patient and family engagement is Hospital CAHPS (HCAHPS), the first national standardized publicly reported survey of patients' perspectives of hospital care. Many of the measures captured in the HCAHPS survey, including communication with providers, hospital environment, and discharge information, reflect critical elements of patient and family engagement. CMS has put in place a financial incentive for hospitals to participate in the HCAHPS program—a 2 percent reduction in the annual payment update for inpatient hospital services if they do not provide HCAHPS data.⁹³

To date, the greatest impact of public reporting initiatives has been on quality improvement. A 2008 review of the literature evaluated results from 45 articles to examine the effects of public reporting on quality of care. The authors found that the strongest effect of public reporting on hospital quality has been to increase quality improvement activity.⁹⁴ Studies examining the effects of HCAHPS public reporting have shown that HCAHPS is creating the incentive for hospitals to engage in quality improvement and is having a resulting impact on clinical care and patient satisfaction outcomes.⁹³ Other studies have found that States that publicly report morbidity and mortality rates after cardiac surgery have experienced more rapid declines in mortality rates than States that do not publicly report such measures.⁹⁵ However, studies have not demonstrated a strong and consistent association between the public reporting of quality information and the resulting effect on consumer choices.⁹⁴

Public reporting of safety information is still in a nascent stage. Although reporting of hospital infection rates is currently occurring and soon will be the practice in 27 States, only 16 of these States make reports publicly available.⁹⁶ Because this reporting is new, evidence on its impact is still emerging. However, in Pennsylvania, an early leader in public reporting of hospital infections, infection rates dropped 8 percent between the first and second years of reporting.⁹⁷

Accreditation and awards. Prestigious awards such as the Malcolm Baldrige National Quality Award engender organizational change.⁹⁸ The Joint Commission (JC), the national accrediting body for many health care institutions (including hospitals), is also highly influential. The JC has developed national patient safety goals for hospitals that support patient and family involvement and improved patient and provider communication. Specifically, the JC has identified goals for hospitals that include improving the effectiveness of communication among caregivers, improving medication accuracy, reducing hospital-associated infections, reducing risk of harm from patient falls, and preventing hospital-associated pressure ulcers.^99,100

Internal Motivators

Empirical work on quality improvement suggests that although external motivators are important, unless they reflect mandates to change (e.g., in the form of legislation), they are typically insufficient—"internal" organizational motivation to change or improve is also required.¹⁰¹

1. The occurrence of a sentinel event.
2. The business case for patient and family engagement.
3. The desire to improve quality and safety performance.
4. Stories from patients and families.
5. Altruism.

Sentinel event. One of the most powerful internal motivators for change unfortunately can be the occurrence of a sentinel event, defined by the JC as "any unanticipated event in a health care setting resulting in death or serious physical or psychological injury to a person or persons, not related to the natural course of the patient's illness."¹⁰² Sentinel events create a sense of urgency within the institution and highlight system deficiencies; and, they can be used as an opportunity to begin addressing these deficiencies.¹⁵ For example, during a 3-year period at the Dana Farber Cancer Institute (DFCI), one woman died and another was severely injured due to an overdose of chemotherapeutic drugs.^103,104 The errors were a result of protocol breakdowns, inefficient error reporting, and lack of quality assurance leadership, supervision, and oversight. Because of these tragic occurrences, DFCI enacted many substantial changes to improve safety and quality, including establishing mechanisms for partnering with patients on an organizational level (e.g., on PFACs and decisionmaking committees).^103,104

Sentinel events also lead to external pressures to change. In the example discussed above, DFCI received both regional and national media attention after its sentinel events.¹⁰⁴ Additionally, accreditation may require an active response to a sentinel event.¹⁰²

Business case. Another change motivator is the desire to improve financial performance, which requires recognition of the "business case" for a specific initiative or change. A business case for change requires the alignment of costs and benefits within the same entity (i.e., a positive financial return that accrues to the same organization that makes the program investment).¹⁰⁵ The benefits must also occur within a period that is short enough to be valued by that entity. In the case of patient and family engagement or patient- and family-centered care (PFCC), the "business case" argument is that PFCC can lead to outcomes that improve financial performance, including shorter length of stay, decreased emergency department visits, statistically significant lower costs per cases, decreased malpractice claims, and improved patient adherence.⁸² Nonfinancial measures contributing to the business case for patient engagement/PFCC include the enhanced reputation of the organization, increased satisfaction among employees (which in turn leads to greater retention and opportunities for recruitment), brand identity, and increased market share and performance relative to competitors.⁹¹

Desire to improve quality and safety performance. The desire to improve performance on quality and safety also may result from perceived or real poor organizational performance—or may simply reflect dissatisfaction with the status quo.¹⁵ For example, MCG Health System in Augusta, GA, performed an internal assessment that revealed that the care being delivered addressed primarily the needs of providers and did not adequately respond to patients' and families' needs and concerns. Although there was no external mandate to change the care experience, it was important to MCG to deliver care consistent with the tenets of patient- and family-centeredness. Thus, in 1993, the organization began a transformative process that ultimately resulted in PFCC becoming the core business model for the organization.¹⁰⁶

Stories from patients and families. For many organizations, understanding how patients and family members experience their hospital stay can highlight opportunities for change and improvement.¹⁰⁷ Surveys such as HCAHPS allow hospitals to capture information about patient experiences of care, but this quantitative data can lack the richness and contextual detail of more qualitative information. As a way to augment more quantitative data, the Planetree Patient-Centered Care Improvement Guide highlights the importance of routinely sharing with staff patient and family stories and their suggestions for change.¹⁰⁸ Selected hospitals in the United Kingdom have embraced this idea and are currently using narratives from patients and their families to inform service improvements through a process known as the Discovery Interview Process. Proponents suggest that this method is a potentially powerful approach for informing quality improvement.¹⁰⁹

Sharing patient stories was a particular motivator for many of the organizations represented in our own key informant interviews—the organizations found that these stories were invaluable in understanding how the experience an organization intends to provide matches the reality of how patients actually live through it.

Altruism: It's the right thing to do. Finally, individuals' (and organizations') inherent desires to do the right thing and provide high-quality care are powerful motivators.⁸⁰ Many health professionals note that their personal motivation for entering the health care profession was to help others.⁸² Conway argues that increasing the focus on the patient and increasing PFCC is "just the right thing to do," and that the desire to do the right thing is crucial to change.⁸² In interviews with 15 primary care practices in Ohio, Litaker and colleagues noted common motivators for change included the desire to "serve the needs of a vulnerable population" and "provide high-quality care."⁸⁰

Factors that Influence the Ability to Implement and Sustain Change

In this section, we discuss organizational context, or those factors that affect the ability of a hospital to promote, support, and sustain patient and family engagement.¹¹⁰ These factors, discussed below, include the hospital's structure (e.g., size, profit and teaching status, medical staff organization, nursing staff organization) and processes (e.g., experience with patient and family engagement, existing quality/safety culture, leadership, hierarchy, slack resources, absorptive capacity, internal alignment).

Organizational Structure

Here, we discuss structural factors of hospitals that affect the initiation, implementation, and sustainability of change initiatives. The structure of a health care organization comprises the internal environment in which any intervention is implemented. Building on the work of Donabedian¹¹¹ and the Institute of Medicine's Crossing the Quality Chasm,⁹ it has long been understood that organizational structure has an impact on care processes and, ultimately, on both organizational outcomes (e.g., efficiency, effectiveness) and patient outcomes (e.g., mortality, morbidity, patient experiences).

Structural aspects of a hospital that can influence the ability to initiate and sustain change include the size of the hospital, profit or academic status, and medical staff organization. Larger organizations often have better access to resources (e.g., money, expertise, skills) than smaller organizations. However, as organizational size increases, coordination and communication become more difficult. Thus, larger health care organizations may have resource advantages but also a greater challenge in implementing, integrating, and sustaining an intervention.^112,113

With regard to profit status, if there is a perceived positive business or strategic case for change, for-profit hospitals may be more likely to aggressively pursue an initiative than not-for-profit hospitals. Because of this, for-profit hospitals often are able to more quickly adopt innovations and practices that positively affect their financial performance.¹¹³ Similarly, academic medical centers may be more likely to adopt an innovation, in part because they may have more resources but also because the implementation of innovation is consistent with their mission to learn.^114,115

In this section, we discuss five key internal motivators:

The organization of medical staff also can affect leverage of the hospital in initiating and sustaining change. One factor is the relationships between various units or levels of the organization. The few empirical studies that exist on this topic suggest that some types of organized delivery systems that are centralized or moderately centralized may have advantages relative to freestanding hospitals with respect to quality improvement and patient outcomes.¹¹⁶ Another factor is whether the hospital employs a staff model, in which financial incentives are aligned and under the control of the hospital, or a community practice model. In staff models, hospitals pay the salaries of physicians who are part of the organization—meaning that everyone shares the same incentives for hospital performance and goals.¹¹⁷ In contrast, community-practicing physicians may work with multiple hospitals and therefore competing incentives. Hospitals that employ a staff model often have more levers for change. For example, hospitals have the ability to include items related to quality improvement initiatives in job descriptions.¹¹⁷

Unfortunately, although there is general recognition of the potential influence of structural factors such as size, teaching and profit status, nursing staff organization, and medical staff organization on an organization's ability to adopt and sustain innovations, there is insufficient evidence about whether and how these structural factors act specifically as barriers to or facilitators of change.

Organizational Processes

Many other factors affect an organization's ability to implement and sustain change, discussed in this section as organizational processes. These processes include the organization's understanding of and experience with patient and family engagement, the existing quality and safety culture, leadership, hierarchy, the existence of slack resources, absorptive capacity, and internal alignment.

Understanding of and experience with patient and family engagement. An organization's baseline understanding of concepts related to patient and family engagement, along with previous experience, affects its ability to initiate, expand upon, or improve engagement initiatives. For health care organizations to understand how to succeed with patient and family engagement, they need to have a clear understanding of what engagement is and what success would look like. This may be more complicated than it seems, particularly for organizations with less experience. Although there are accepted definitions of patient- and family-centered care and patient and family engagement,¹¹⁸ the concepts of patient and family engagement may be construed and operationalized in different ways by different organizations. Developing an organizational understanding of patient and family engagement therefore involves understanding what behaviors are required, who is involved, why it should be implemented, and when and where changes must take place. The development of this understanding reflects both experiences and future capacities for change.

Existing culture, including quality and safety culture. Culture refers to the norms, values, beliefs, and behaviors of an organization that reflect and shape how things are done within the organization.¹¹⁰ Evidence from the patient safety and quality improvement literature suggests that organizational culture greatly influences the ability to engage in quality and safety improvement initiatives.^119,120 In general, organizations that embrace continual learning and evaluation by emphasizing accountability and responsibility in a nonpunitive way will find it easier to implement and sustain new interventions.¹²¹

Value for quality and continual improvement. One important aspect of organizational culture in facilitating the uptake of new initiatives is the value placed on quality and continual improvement. Successful health care organizations recognize that change is a given, and that true quality improvement is proactive, not reactive.^122,123 A culture conducive to quality improvement will encourage, if not require, continual evaluation of how the organization is performing, learning, and making efforts to improve on current practices.¹²⁰ Generally speaking, hospitals with a more developed and mature quality improvement perspective report better implementation of strategies to improve patient centeredness.¹²⁴

Experience. Past efforts at and experience with undertaking change are important resources, with evidence suggesting that the success of past efforts shapes the willingness of individuals to act on future opportunities for change.⁸⁰

Positive safety culture. Within an organization, a "positive" patient safety culture can also improve patient safety, decrease medical errors, and facilitate greater buy-in from staff for patient safety initiatives.¹²³ This culture of safety involves embracing the viewpoint that errors point to failings of systems rather than individuals—and that errors are an opportunity to correct these systemic failings.¹²⁵ In addition, a culture of safety demands accountability of all individuals at all levels,¹²¹ effective communications between hospital team members,^121,126,127 active patient participation,¹²⁶ and a proactive stance of looking toward the future rather than reacting to past failures.¹²³ Another critical aspect of a positive patient safety culture is a transparent and nonpunitive approach to patient safety, whereby medical errors are discussed openly and viewed as learning and change opportunities—as opposed to opportunities for individual punishment.¹²⁵

Leadership. The organizational change literature suggests that strong leadership, specifically the presence of individuals who advocate for and participate in initiatives, increases the likelihood of learning, innovation, and sustained change.^82,128 The leadership exhibited within an organization may be formal—leaders who lead by virtue of a title—or informal—individuals who do not have titles but who are nonetheless regarded as thought leaders.⁸⁰ It also may come at a variety of levels, including from senior management/executives, the board of directors, and physicians, nurses, and other staff.⁸²

Senior management. The literature suggests that the engagement of and leadership by formal senior management directly affect the success of quality improvement activities generally^129,130 and patient- and family-centered care specifically.¹³¹ To establish a culture of supportive change, senior management should serve as models for staff by taking a personal interest in the quality improvement initiative, advocate for improvement, have relationships with clinical staff, disseminate data from the initiative, and procure resources to support improvement.¹³²

The patient safety literature shows that senior management advocacy for learning, combined with support in the form of organizational structures and infrastructure, can establish an environment in which patient safety initiatives flourish.¹³³ Moreover, as mentioned above, aligning the organization with the change is an important function of senior management.^134,135 Senior management needs to lead staff by setting expectations and resolving conflicts and tension between organizational units and departments.¹²³ A further tenet of positive leadership is direct interaction with staff, patients, and their families.¹¹⁷

To lead patient safety improvement, senior management must be visible and must take an active role in quality improvement.¹³⁶ The importance of top management to effecting change cannot be overemphasized—a nationwide survey of 162 Veteran's Health Administration hospitals found that hospitals in the top quartile of quality improvement implementation had significantly higher commitment from top management, along with managers who had a clear vision for quality improvement and an orientation toward change.¹³⁷ Other studies have shown that committed hospital leadership—which means leaders who provide clarity about goals and expectations, establish infrastructure, provide resources, and institutionalize a quality improvement culture—is a key motivating factor for physicians.¹¹⁷

Board of directors. The engagement of hospital boards and trustees in quality and safety initiatives is another critical element of change.^138,139 Conway suggests that involvement of the board of directors in organizational change and quality improvement should include setting goals and aims, creating infrastructure, gathering data, establishing measures, changing the environment with policies and culture, and establishing accountability.^117,138 In short, the board of directors helps "set the tone" for the entire organization.

Clinical leadership. A third type of leader—the clinical leader—also plays a crucial role in championing organizational change and quality improvement. Physician involvement in quality improvement and other initiatives can be critical to their success.¹⁴⁰ As a side benefit, leadership engagement by physicians may lead to increased professional satisfaction.¹⁴¹ Mastal specifically argues that the role of the Chief Nursing Officer is also pivotal in ensuring the success and sustainability of quality and safety efforts.¹⁴²

Hierarchy. In almost all cases, an overly hierarchical culture emphasizing rules, regulations, and reporting relationships is negatively associated with the implementation of quality improvement and related practices.¹⁴³ Models of change, such as the Studer Group's three-stage journey to creating a culture of excellence, suggest that breaking down vertical thinking and hierarchy is an important step toward increasing service excellence and patient satisfaction.¹⁴⁴ These ideas are supported by research findings. For example, an investigation by Litaker and colleagues demonstrated that at primary care practice sites in which the allocation of power was perceived as being shared, potential avenues for change were openly sought and discussed.⁸⁰ In addition, an investigation by Keroack and colleagues found that high performance in academic medical centers was associated with a structure that blended central control (i.e., centralized goals) and decentralized responsibility (i.e., the ability to implement tactics as desired).¹⁴⁵ In addition to being a barrier to change initiation, hierarchy also can affect professional communication and team collaboration, thus acting as a barrier to effective implementation.¹⁴⁶

Slack resources. Slack resources refer to a cushion of excess resources that the organization can use in a discretionary manner.¹⁴⁷ Three types of slack resources are: available, resources not yet committed; recoverable, resources that can be recovered and made available through redesign; and potential, future resources that can be generated. The presence of slack resources may be a facilitator for innovation in that they lessen organizational risk associated with change.¹⁴⁷ Likewise, when financial resources are limited, the lack of resources may be used as a justification for avoiding change opportunities or maintaining the status quo.¹⁴⁸ For example, Litaker and colleagues conducted an ethnographic study of 15 primary care practices in Ohio and discovered that in practices where finances were perceived as scarce or constrained, opportunities for change were viewed as a potential drain on already tenuous finances and subsequently were avoided or resisted.⁸⁰

Internal alignment. Internal alignment refers to consistency of plans, processes, information, resource decisions, actions, results, and analysis to support key organizational and change-specific goals.¹⁰¹ Alignment throughout all levels and facets of the organization increases the likelihood of learning, innovation, and change, in addition to providing greater potential for rapid implementation and movement.^101,134 In Litaker's study of 15 primary care practices, the alignment of incentives and motivations led to more efficient use of resources and a greater openness to creating and exploring change.⁸⁰ In practices with aligned incentives, this alignment created the ability to spend time working in a coordinated fashion to attain similar goals.

Absorptive capacity. Greenlaugh and colleagues define an organization's absorptive capacity as the ability to identify, capture, interpret, share, reframe, and recodify new knowledge; to link it with its own knowledge base; and to put it to appropriate use.¹⁴⁹ It also includes the qualities and characteristics that enable an organization to "modify both its technical aspects and its values and/or beliefs regarding how it operates," along with the ability of an organization to recognize, understand, and evaluate the possibilities for learning and change that are available to them.⁸⁰ Precursors of absorptive capacity include the knowledge and skills of key staff and the organization overall.

Implementation of Organizational Change

The literature on organizational learning, innovation, and change also provides insights on successful implementation strategies to be used when trying to foster change. These tactics are important when considering the sustainability of the change. We conclude this section with a discussion of organization-level strategies to facilitate successful and sustainable implementation, separating our discussion into two parts: (1) pre-implementation strategies to foster change and (2) implementation and sustainability strategies to foster change.

Pre-implementation Strategies to Foster Change

Conduct an initial assessment. In addition to capturing a picture of where the organization stands in relation to the proposed change, the process of conducting an initial organizational assessment itself can help inform participants about the core concepts and strategies being assessed.^150,151 Several self-assessment tools relate to patient and family engagement, including the following:

• Patient- and Family-Centered Care: A Hospital Self-Assessment Inventory. Developed by the Institute for Family-Centered Care (IFCC), this assessment inventory is designed to help hospital and health system leaders, trustees, medical staff, and employees determine priorities for change and improvement by assessing how the institution operationalizes patient- and family-centered care.¹⁵²
• Patient- and Family-Centered Care: Organizational Self-Assessment Tool. Developed by the Institute for Healthcare Improvement (IHI) in conjunction with the National Initiative for Children's Healthcare Quality (NICHQ), this assessment tool helps organizations assess their current practices in relation to elements of hospital-based PFCC.¹⁵¹
• Checklist for Attitudes about Patients and Families as Advisors. This IFCC-developed tool is intended for organizations to explore staff and physicians' attitudes about partnering with patients and family members on an organizational level (e.g., as members of advisory councils and other hospital committees).¹⁵³

In addition, AHRQ's A Decisionmaker's Guide to Adopting Innovations is a more general tool designed to help health care organizations determine whether an innovation will be a good fit by raising questions to consider (e.g., should the innovation be done, can it be done, how will it be done).¹⁵⁴

Develop and foster a shared vision. Organizational literature widely recognizes the importance of having a clear vision and mission associated with proposed change.^150,155 A clear vision comes from top leadership, but ideally it should reflect the perspectives and input of all involved parties (e.g., clinicians, staff, patients, family members).¹⁵² A strong vision can facilitate growth and improvement by creating a pathway for change and fostering a shared sense of purpose. In an analysis of six health care organizations, leaders at top-performing hospitals all reported creating a shared sense of purpose by prioritizing critical elements of patient care in their mission.¹⁴⁵

Develop a clear plan for implementation. Developing a clear plan for implementation involves building on the organization's vision by enacting an overarching strategy on patient-centered care and engagement and creating specific measurable goals.^156,157 The implementation plan should consider which projects meet organizational feasibility criteria;¹⁵⁷ take into account challenges, constraints, and potential barriers to implementation and sustainability;¹⁵⁰ and consider how to build on past successes.¹⁵⁸ An environmental scan may be a helpful activity in identifying these challenges.¹⁵⁷

Obtain buy-in. Buy-in, or support, at all levels, including top leadership and administration to frontline staff, is critical to successful implementation.¹⁵⁷ If the change vision does not come from top leadership, these individuals must be educated, motivated, and brought on board. If change does come from the top levels, it is still important to have buy-in from all parties, including staff at all levels, patients, and family members. The process of obtaining buy-in can be facilitated by a clear articulation of the vision, desired goals, and implementation plan.¹⁵⁷

Provide infrastructure and resources. Prior to implementing change, it is crucial to set up an infrastructure to minimize conflicting priorities, provide clear lines of authority, and establish accountability.¹⁵⁹ Adequate resources must also be identified and made available for all planning and implementation activities. These resources may include funding, time for staff training, opportunities for staff participation, and physical space.¹⁶⁰

Align internal incentives for participation. As noted above, incentives (financial and otherwise) play a significant role in motivating entities to change and obtaining buy-in. Creating internal incentives for participation or aligning the new initiative with existing incentives fosters change. For example, performance reviews or bonuses for meeting patient engagement goals or conducting activities can be tied to implementation goals and objectives.¹³⁴

Establish partnerships. Establishing partnerships both within and external to the organization can help new initiatives gain a foothold. Hospitals can benefit from forming partnerships and strategic alliances with key stakeholders (i.e., those individuals or groups who have an investment in the success of the organization along with the capacity to influence how the organization acts). This may include individuals and groups internal and external to the organization.⁸⁰

Consider sustainability. The consideration of long-term needs, plans, and intervention sustainability should be taken into account early in the planning process. Early consideration of these issues allows the organization of data collection, leadership support, infrastructure, and incentives to support sustainment.^134,157

Implementation Process Activities to Foster and Sustain Changes

Engage staff at all levels. Staff members should be engaged during both the planning and the implementation processes. During the development phase, using inter- or multidisciplinary teams may help obtain needed buy-in, while helping change be more sustainable. In addition, staff may be engaged by opening the doors to two-way communication and providing staff with mechanisms to provide input and feedback. Another way to engage staff is to create short-term wins—i.e., opportunities for positive results and successes at an early stage.⁷² In general, staff are more likely to be engaged if they feel as though the work is meaningful and that positive outcomes or impacts are likely to result from the change.^43,161 Actual positive experiences in turn help to further motivate staff in a reinforcing cycle.⁴³

Demonstrate executive commitment. Executive Level Walkarounds are an intervention developed in the patient- and family-centered care arena to demonstrate senior management commitment and leadership.¹³⁶ During these walkarounds, leaders make announced or unannounced visits to facilities (or departments or units within these facilities) to observe and talk with staff and physicians in a nonthreatening environment about quality and safety issues. The overarching objectives of walkarounds are to connect top executives with frontline staff and to demonstrate to clinicians and staff that leadership is committed to patient safety.^136,162 Walkarounds also provide opportunities for leadership to articulate these commitments and to identify opportunities for improvement. Moreover, they can improve the safety climate and safety culture while engaging frontline staff and patients and their families.¹³⁶163

Engage an internal champion. Just as important as strong leadership from the top levels is the presence of physician or other clinical champions. Champions, particularly among physicians, are critically important in creating forward movement on quality improvement initiatives.^117,164 Champions are respected by their peers within their area of expertise and can help achieve buy-in among staff by engaging with them on a different level than top management.

Communicate clearly and consistently throughout the process. Although it is important to communicate goals and priorities prior to implementation, it is equally important to continue communicating clearly throughout the life cycle of the intervention. Staff members are more likely to sustain their engagement with an initiative if they are kept apprised of what the organization is doing and informed about the status of progress toward initial goals.¹⁵⁰ With regard to clinical staff, one effective message to emphasize throughout the process is that the initiative is not merely administrative in nature—rather, the purpose of the intervention and the larger goal should be framed in terms of improved patient outcomes.¹¹⁷

Collect data (feedback and measurement). Data also should be collected to assess progress toward improvement and implications for sustainability. Studies show that top performers in areas such as quality and safety or patient- and family-centered care set goals and measure progress toward them,^145,165 and that hospitals that provide timely feedback to staff are more likely to foster quality improvement.¹⁶⁴ The data collected during the initiative should help to show whether goals and objectives are being met and should be reported so that the data help implementers, leadership, and stakeholders understand the improvement.¹⁵⁷ In addition, to make the numbers meaningful and important, staff must see how their specific actions feed into the data.¹⁶⁴ Finally, accountability for performance and change should be built into the data collection and reporting process.¹⁵⁰

Integrate and sustain. Although many factors affect the sustainability of an intervention, the literature suggests that integration into an organization is the best way to sustain a change or its outcomes, processes, or practices.¹³⁴ The ability to achieve integration results from many of the factors discussed above, including internal alignment of goals, rewards, performance measures, and the creation of organizational policies. Moreover, leadership support is essential in sustaining the change.¹³⁴

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