News & Events

Patient & Family Advisory Council Regulation – Update and Help for Hospitals (MC)

The regulations related to the establishment of a hospital Patient & Family Advisory Council (PFAC) were approved at the Public Health Council meeting on May 13, 2009. While the deadline for establishing a PFAC was extended to October 1, 2010, the deadline for preparing a written report outlining the hospital’s plan to establish a Council is September 30, 2009.

Help for Hospitals – Next Steps
To help hospitals develop a Council, the MA Coalition PFAC Program Committee identified next steps and a timeline associated with this initiative. The next steps include a series of audio conference call programs with much needed strategies and tools to help you develop a PFAC in your organization. Audio conference call dates will be sent to you as soon as they are finalized. The regulations are included below after the timeline.

We welcome your comments and feedback as we work with you to develop a Council by the deadlines established.

Goals Timeline
Establishment of statewide PFAC Program Committee………………April 2009

Program Committee meets to discuss statewide
Audio Conference Series………………………………………………….. May 2009

Distribute approved DPH regulations to Coalition and
Program Committee……………………………………………………….. June 2009

Audio Conference Call Series Agenda Developed…………………..May/June 2009

Establish dates for Audio Conference Series………………..……… June 2009

Send email announcing Audio Conference Series…………………. June 2009

Contact and confirm faculty for Audio Conference #1……………. June 2009

Audio Conference #1 – What are PFACs? What are the
Models and Options Available?………………………………………… July 2009 (date TBD)

Audio Conference #2 – How to Start a PFAC:
Developing a Plan……………………………………………….September 2009 (date TBD)

Audio Conference #3 – More on Establishing a PFAC…….…November 2009 (date TBD)

Audio Conference #4 – How to Overcome Challenges……….January 2010 (date TBD)

Publicize Series and Begin Registration for Conference #1………June/July 2009

Hospitals Complete Plan for Establishment of PFAC………………September 30, 2009

Hospital PFACs Active……………………………………………………October 1, 2010

Hospitals Develop Annual Report Documenting
Compliance with PFAC Requirement and
Accomplishments for Preceding Year……………………………….. October 1, 2010

 

Amendments Relating to Patient and Family Advisory Council

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:
    1. participation on hospital committees, task forces and/or advisory boards;
    2. review of publicly-reported quality information;
    3. participation on committees addressing patient safety issues;
    4. participation on search committees and in the hiring of new hospital staff;
    5. participation in reward and recognition programs;
    6. as co-trainers for clinical and nonclinical staff, in-service programs, and health professional trainees; and
    7. 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 5 years.
  3. Minutes of Council meetings including Council accomplishments shall be transmitted to the hospital’s governing body.
  4. At least 50 percent of the Council members shall be current or former patients or family members and should be representative of the community served by the hospital.