Section I: Requesting Organization Information

Planetree International Designation Criteria

2016-2017

APPLICATION FOR PLANETREE MERIT AWARD for Achievement in Person-Centered Care

Section I: Requesting Organization Information

Date of Application:

Name of Organization:

Designation Site Visit Coordinator (Name & Title):

Phone: Email: Fax:

Organization Type:

¨ Acute Care Hospital

¨ Behavioral Health Hospital

¨ Continuing Care Community

¨ Integrated Site/Healthcare System

¨ Other. Please describe:

Date of Last Planetree Progress Assessment or Gap Analysis:

If applicable, date of last Planetree Merit Award conferred:

Level Awarded: ¨ Bronze ¨ Silver ¨ Gold (Planetree Designation)

Award Tier Being Sought*:

¨ Bronze ¨ Silver ¨ Gold (Planetree Designation)

*Sites must identify what award tier is being sought. Only that tier will be awarded, e.g. sites applying for one level will not have the option of being awarded the preceding level nor the subsequent level based on the documentation provided.

Section II: Self-Assessment

To initiate the Planetree Merit Award assessment process, this Application must be accompanied by a completed Self-Assessment Tool with all supporting documentation required for the award level sought provided in an electronic format and one hard copy.

By signing below (name of applicant organization) formally initiates its application for recognition through the Planetree Merit Award Program with the goal of achieving recognition by Planetree at one of three levels: Bronze, Silver or Gold (which equates to Planetree Designation as a Patient-Centered Hospital or a Resident-Centered Community). The organization agrees to pay the cost of all applicable fees, including the application review fee and, if applicable, the reasonable, associated travel expenses and the site evaluation fee (Planetree affiliates may apply prepaid consultation funds toward the evaluation fee). By signing this Application, the organization waives and releases Planetree, its officers, directors, agents, servants and employees from any and all claims, demands, actions, lawsuits, and damages that may arise from or relate to, directly or indirectly, the survey and recognition process. Moreover, the organization recognizes and confirms that the award of Bronze, Silver and Gold-level recognition requires compliance with established criteria published by Planetree and that it waives any attempt at recourse in the event such recognition is denied, suspended, or terminated for failure to meet the conditions established by such criteria.

Duly authorized signatory Date

©Planetree 2016. All Rights Reserved. 28

Planetree International Designation/Tiered Recognition

Self-Assessment Tool 2016-2017

Planetree International Merit Award Self-Assessment Tool

For Organizations Applying for Bronze, Silver, or Gold Level Recognition from Planetree

Revisions in red take effect January 1, 2016

Organizations interested in pursuing Tiered Recognition or Designation should complete the following questionnaire (with the appropriate number and type of baseline and elective criteria based on the recognition tier being sought) to assess their organization’s status as it relates to the standards for each level. Upon the determination to move ahead with the application process, the questionnaire and supporting documentation should be submitted electronically and in hard copy to Planetree along with the Merit Award Application.

Setting / Bronze (75%) / Silver (88%) / Designation (Gold) (100%)
Continuing Care / 40 (20 baseline; 20 elective) / 47 (24 baseline; 23 elective) / 53 (all required)
Behavioral Health / 38 (19 baseline; 19 elective) / 45 (23 baseline; 22 elective) / 51 (all required)
Acute Care / 38 (19 baseline; 19 elective) / 44 (22 baseline; 22 elective) / 50 (all required)

A NOTE ABOUT THE INTEGRATED CRITERIA

The Planetree International Designation criteria are designed to be applicable to all healthcare providers. In some cases, however, specific criteria may apply differently in various healthcare settings (acute care, continuing care, behavioral health, etc.), and not all criteria apply to all settings. If not otherwise noted, the criteria are applied consistently across settings and the questions and documentation requests in this self-assessment should be completed by all applicants. Questions and documentation requests indicated as applying only to behavioral health settings or continuing care settings need only be satisfied by applicants serving those specified populations. If a site is inclusive of a number of settings, all the applicable criteria will be applied as appropriate, e.g. behavioral health criteria will be applied to a behavioral health unit within an acute care hospital.

By submitting this completed Self-Assessment and the accompanying required documentation to Planetree, Inc., a site formally initiates the process of applying for recognition from Planetree for Meaningful Progress, Significant Advancement, or Excellence in Person-Centered Care.

The Self-Assessment Tool includes questions to answer and additional documentation requirements to demonstrate implementation of specific criteria. Sites are required to submit one hard copy of the completed self-assessment with documentation, as well as an electronic version (via email, disc or flash drive). The self-assessment must be submitted in English to Planetree’s Designation staff.

Mail Signed Application and Self-Assessment to: / Email Self-Assessment to:
Christy Davies, Designation Coordinator
Planetree
130 Division Street
Derby, CT 06418
USA /

Upon receipt of the completed Self-Assessment and the required documentation, Planetree will schedule a conference call with the applicant site to review next steps.

Section I: Structures and Functions Necessary for Implementation, Development, and Maintenance of Person-Centered Concepts and Practices

Tiered Recognition / Criteria / Questions Requiring Response / Required Documentation /
Required for Bronze and Silver / 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.) / 1.  When was this task force initiated?
2.  How often does it meet?
3.  How are ideas and input from patients/residents incorporated into the work plans of this task force?
4.  Do members of the medical staff participate on this task force? If no, describe efforts to expand medical staff representation on this task force.
5.  How are committee members prepared and oriented to the role they will play? / A.  Copies of minutes from the task force’s last three meetings.
B.  A current task force membership list, which includes each member’s name, title, and department/role. Identify which staff are non-supervisory and which are supervisory, and which members are patients/residents/family members.
Required for Bronze and Silver / 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. / 6.  What is the coordinator’s name and job title?
7.  Approximately how many hours per week does this person spend on person-centered tasks and responsibilities?
8.  Summarize the person-centered activities coordinated by the contact person within the last twelve months. / C.  Coordinator’s job description
Elective for Bronze and Silver / 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. / 9.  How is information on person-centered care efforts shared with your governing body (e.g. highest authority that has governance responsibility) on an ongoing basis?
10.  How do you communicate information about person-centered care with patients/residents and their family members?
11.  As changes occur in the organization (e.g., board, senior leaders, coordinator), what are your plans for maintaining and transferring knowledge about your person-centered philosophy of care?
12.  What clinical, operational and financial metrics do you monitor to gauge progress in person-centered care implementation? With whom do you share this information? With the leadership team? With employees? With the governing body? With the patient/resident advisory council or equivalent? Others?
13.  How have you aligned person-centered care initiatives with your organization’s current strategic and/or operational plan? / D.  A copy of your person-centered care dashboard, or other reporting mechanism regularly updated to monitor implementation progress and related outcomes
E.  A copy of your organization’s current strategic and/or operational plan (or the executive summary)
Elective for Bronze Required for Silver / 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. / 14.  Do you have a patient/resident or community advisory council in place?
·  If yes, when was it established? How often does it meet? How are the participants recruited and selected? Who serves as the consistent link between the council and the governing body (i.e. regularly participates in meetings of both groups)? Is this person a staff or external community member? Provide at least 2 specific examples of ways the council’s input helped to drive ongoing improvement efforts.
·  If no, what other formalized mechanism is in place to obtain regular input from patients/residents and community members? Provide at least 2 specific examples of ways the input obtained through this system has helped to drive ongoing improvement efforts.
15.  What linkages exist between the patient/resident/community advisory council (or equivalent) and the multi-disciplinary task force that oversees implementation of person-centered care?
16.  Do current and/or former patients/residents currently serve as active members on teams in place to address specific patient-/resident-centered initiatives? If yes, summarize patients’/residents’ involvement on these teams. If no, describe efforts to expand patient/resident representation on these teams. / F.  Agendas and minutes from the last two meetings of the patient/resident/ community advisory council (or equivalent).
Elective for Bronze and Silver / I.E: Leadership exemplifies approaches that motivate and inspire others, promote positive morale, enhance performance of others, and model organizational values. / 17.  How are leaders new to the organization ingrained in its culture of person-centered care?
18.  How are leaders within the organization held accountable for exhibiting behaviors that reflect the values of person-centered culture change, specifically their effectiveness in communicating a vision, inspiring others, promoting positive morale and engaging others in organizational culture change?
19.  What opportunities, formal and/or informal, exist for leaders to interact with frontline staff, including staff working at night and on weekends?
20.  What opportunities, formal and/or informal, exist for leaders to interact with patients/residents and families? / G.  A list of any supervisory or leadership training conducted over the past two years.

Section II: Human Interactions/Independence, Dignity and Choice

Tiered Recognition / Criteria / Questions Requiring Response / Required Documentation /
Required for Bronze at 50%
Silver 70% / 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. / 1.  Describe your staff retreat process (length, agenda, location, facilitators, frequency, and participation rates), and if you do not hold 8-hour retreats, describe how you engage employees and educate them about person-centered care perspectives, sensitize them to the patient/resident experience and support changes in attitude and culture that move the organization toward a more holistic approach to care.
2.  What percentage of staff has completed retreats or the equivalent to-date? (If it is 85% or less, please describe your plan to provide retreats for the remaining staff.)
3.  Are you continuing to offer staff retreats to all new employees?
4.  Are volunteers invited to participate in retreats or an alternative program specific to person-centered care?
5.  Do non-employed members of your medical staff participate in staff retreats or other person-centered initiatives? / H.  Retreat agenda/curriculum /
Required for Bronze and Silver / 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. / 6.  Beyond retreats, describe educational opportunities offered to employees to routinely reinforce person-centered care concepts, practices and behaviors.
7.  Do you offer second-level or ongoing staff retreats? If yes, please describe.
8.  Please describe any additional educational opportunities offered to your employees that reinforce person-centered concepts, practices, and behaviors and build competence among staff to address the evolving needs of the community.
9.  What teams are currently in place to address person-centered initiatives and what is the function of each?
10.  How is frontline, non-supervisory staff supported in participating in these teams?
11.  How are ideas and input from patients/residents incorporated into the work plans for these teams?
12.  Do members of the medical staff participate as active members on these teams? If yes, summarize their involvement on these teams. If no, describe efforts to expand medical staff representation on these teams.
13.  How is the work of these teams communicated organization-wide? / I.  A list of each of your initiative teams, along with member names and job titles and/or role (e.g. patient/resident, family member). Please indicate how long each team has been active and how often they meet. /
Elective for Bronze Required for Silver / 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. / 14.  How are new employees oriented to the organization’s culture of person-centered care upon hire and how are they sensitized to the perspective of patients/residents as part of their orientation to the organization?