The Commonwealth of Massachusetts

Executive Office of Health and Human Services
Department of Public Health
Division of Health Care Quality
99 Chauncy Street, 2nd Floor, Boston, MA 02111
617-753-8000

DEVAL L. PATRICK
GOVERNOR
TIMOTHY P. MURRAY
LIEUTENANT GOVERNOR
JUDYANN BIGBY, MD
SECRETARY
JOHN  AUERBACH
COMMISSIONER	

Circular Letter: DHCQ 09-07-514 

TO: 		Chief Executive Officers 
All Hospitals Licensed Under 105 CMR 130.000
 
FROM: 	Paul Dreyer, Ph.D. 
Bureau Director 

DATE: 	July 8, 2009
 
RE: 		Patient and Family Advisory Councils 

The purpose of this letter is to inform hospitals of their obligation to establish a Patient and Family Advisory Council (PFAC), as set out in the hospital licensure regulation at 105 CMR 130.1800 & 1801, effective June 12, 2009. A copy of these sections is enclosed.  The regulations require each hospital to establish a PFAC by October 1, 2010; and each hospital must prepare a report outlining its plan to establish a PFAC no later than September 30, 2009. 

Beginning on October 1, 2010, each hospital must prepare an annual report documenting compliance with the PFAC requirement and describing the PFAC’s accomplishments during the preceding year.  The hospital must make the September 30, 2009 plan and October 1st annual reports publicly available through electronic or other means, and to the Department upon request. 

The regulations require hospitals to adopt and implement policies and procedures that govern a PFAC’s goals, membership, training, roles and responsibilities.  Hospitals will also be required to establish and implement policies and procedures for the duties and election of officers, as well as policies that address the handling of confidential patient information to the extent allowed by state and federal law. The Department interprets these regulations to require hospitals to form hospital-wide PFACs to accomplish the activities outlined within the regulations. In addition, the Department recommends that the PFAC be chaired by a current or former patient or family member, and if there are co-chairs, that at least one co-chair be a current or former patient or family member.
 
The formation of a PFAC is intended to facilitate patient and family participation in hospital care and decision-making, information sharing, and policy and program development. The Institute for Family Centered Care has identified core concepts of patient and family-centered care as dignity and respect, information sharing, participation and collaboration.

The Institute for Family Centered Care is a valuable resource for materials in developing a PFAC (www.familycenteredcare.org). Hospitals such as Cincinnati Children’s Hospital also have helpful documents on their websites (www.cincinnatichildrens.org and www.danafarber.org).  The Agency for Healthcare Research and Quality has published a guide on PFACs (www.ahrq.gov/qual/advisorycouncil/).  And the Picker Institute and the Planetree Organization have published a free Patient-Centered Care Improvement Guide (www.planetree.org).

In addition to the written materials above, the Coalition for the Prevention of Medical Errors is organizing a series of audio conference call programs to focus on strategies and tools to help hospitals develop a PFAC.  This series of calls is scheduled to begin in July. Please visit the Coalition’s website (www.macoalition.org) for more information.

If you have any questions regarding implementation of the PFAC regulations, please contact Tracy Gay at tracy.gay@state.ma.us, or (617) 624-5424.

105 CMR 130.1800:  Patient and Family Advisory Council
(A)  A hospital shall establish a Patient and Family Advisory Council to advise the hospital on matters including, but not limited to, patient and provider relationships, institutional review boards, quality improvement initiatives, and patient education on safety and quality matters to the extent allowed by state and federal law. 
(1)	A hospital shall establish a Council no later than October 1, 2010.
(2)	No later than September 30, 2009, a hospital shall prepare a written report outlining the hospital’s plan to establish a Council by October 1, 2010.
(3)	No later than October 1, 2010 and annually thereafter, a hospital shall prepare a written report documenting the hospital’s compliance with 105 CMR 130.1800 and 130.1801 and describing the Council’s accomplishments during the preceding year.  
(4)	The hospital shall make the reports required in 105 CMR 130.1800(A)(2) & (3) publicly available through electronic or other means, and to the Department upon request.   

130.1801:  Policies and Procedures for Patient and Family Advisory Council
(A)  A hospital shall develop and implement written policies and procedures for the Council, which shall address, at a minimum, the following:
(1)  The Council’s purposes and goals.
(2)  Membership of the Council including qualifications, selection, retention, term of service, and duties and election of officers. The Department recommends that the chair or co-chairs be current or former patient(s) or family member(s), or a staff person and a patient or family member.
(3)  Orientation, training and continuing education for members of the Council.
(4)  Roles of members of the Council, which may include the following as examples:
	(a) participation on hospital committees, task forces and/or advisory boards;
	(b) review of publicly-reported quality information;
	(c)  participation on committees addressing patient safety issues;
	(d)  participation on search committees and in the hiring of new hospital staff;
	(e)  participation in reward and recognition programs;
	(f)  as co-trainers for clinical and nonclinical staff, in-service programs, and health professional trainees; and
	(g)  any other role in accordance with the hospital’s policies and procedures.
(5)  Responsibilities of members of the Council, including policies that address confidentiality of patient information.  

(B)  Required policies and procedures.
(1)  The Council shall meet at least quarterly.
(2)  Minutes of Council meetings shall be maintained for a minimum of five years.
(3)  Minutes of Council meetings including Council accomplishments shall be transmitted to the hospital’s governing body.
(4)  At least 50% of the Council members shall be current or former patients or family members and should be representative of the community served by the hospital.