Patient and Family Advisor Application Form
The Patient and Family Advisory Committee (PFAC) of Smith County Memorial Hospital (SCMH) is a collaborative effort that brings together patients, families, staff, and providers to enhance the overall experience for everyone involved. It serves as a vital mechanism for seeking and learning from the patient and family perspective, promoting a culture of patient and family-centered care, and guiding the implementation of programs, services, and policies to improve quality and safety outcomes. The PFAC aims to create a welcoming and inclusive environment where the patient voice is embedded in every aspect of care. By fostering partnerships and open communication, we work towards identifying opportunities for improvement, strengthening patient and family-centered care, and ultimately enhancing the delivery of high-quality and safe care. Patient and family advisors are volunteers who provide valuable feedback, advocate for patient needs, and work with the SCMH healthcare team to improve the patient experience. Through their active involvement, the PFAC strives to be solution-oriented and increase satisfaction for all involved.
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First Name *
Last Name *
Street Address *
City *
State *
Zip Code *
Home Phone *
Cell Phone *
Email *
The following questions will help us to get to know you better. 
Are you a... *
When was your care experience at Smith County Memorial Hospital? *
Which unit(s) provided care for you or your family member: (check all that apply) *
Required
Are you available to commit 4 hours per month to being a patient and family advisor? *
Are you available to serve as an advisor for at least 1 year? *
What does a Patient and Family Advisory Committee do?
  • Help develop or review informational materials for patients and family members.
  • Help improve the patient and family role in care decision making.
  • Help improve the hospital facilities (for example, patient care areas, family waiting rooms, signage).
  • Review procedures and provide input to improve the hospital's admission process.
  • Review procedures and provide input to improve transitions in care (for example, between hospital units or discharge from hospital to home).
Why do you want to become a patient and family advisor? *
Please describe any specific things that doctors or hospital staff did or said while you or your family member were in the hospital that were helpful to you or your family. *
Please describe any specific things that doctors or hospital staff could have done differently to be more helpful while you or your family member were in the hospital. *
Have you ever been convicted of a felony? *
If yes, please identify under what name, location, date, charge, and current status of charge. 
I certify the statements made in this application are true and I understand the misrepresentation and/or withholding of information may result in the rejection of this application or my discharge if discovered after volunteer service begins. Current PFAC members will interview and choose volunteers they feel are best suited based on group consensus.
We invite you to digitally sign your name to join our Patient and Family Advisory Committee.
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