Healthcare 2 (2014) 258–262
Contents lists available at ScienceDirect
Healthcare journal homepage: www.elsevier.com/locate/hjdsi
Into Practice
Opening the ICU doors Michael E. Westley, Joan M. Ching n, Shirley A. Sherman, Ian A. Smith Virginia Mason Medical Center, Clinical Administration, 1202 Terry Ave. #320, Mailstop: R3-320, Seattle, WA 98101, United States
art ic l e i nf o
a b s t r a c t
Article history: Received 19 June 2014 Received in revised form 16 September 2014 Accepted 2 October 2014 Available online 4 November 2014
Family member presence may contribute to the healing of hospitalized patients, but may also be in conflict with the perceived needs of delivering intensive care. We detail our experience with “opening the doors” of the intensive care unit (ICU), allowing family members to be present and participate in the care of loved ones without restriction. “Opening the doors” challenged the traditions, legacy and sense of professional entitlement that were a part of ICU culture and generated considerable initial resistance among nurses and physicians. We describe our “opening the doors” transformation to more patient- and family-centered care in four steps: (1) enlist support of administrative and local leaders; (2) create a collective aim; (3) test on a small scale, and (4) scale up after initial successes. Preparing ICU staff so that they are comfortable with more “on stage” time (i.e., greater family presence) was critical to our success. “Opening the doors” now serves as a guiding vision to organizing the ICU’s work. & 2014 Elsevier Inc. All rights reserved.
Keywords: Intensive care Family Communication
1. Background One quiet Saturday morning in 2005, the red, posted sign that had for many years barred entry to our Intensive Care Unit (ICU) fell to the ground. Team members stopped short of re-hanging the sign when they thought about the changes that were going on behind the closed doors to improve the patient and families’ experiences. This small incident symbolized our eight year journey to “open the doors” of the ICU, inviting family members to participate in the care of their loved ones regardless of the time of day, and the activities of the physicians and care team.
2. Organizational context Our doors had been closed prior to 2005. At that time, we were a 31-bed mixed medical and surgical ICU in a hospital with 17,000 annual inpatient admissions. For medical admissions, our ICU was staffed by a dedicated intensivist during the day and medical residents at night, while surgery patients were cared for by surgery faculty and residents. Also at that time, we were in the process of developing an operations structure built around Lean manufacturing techniques and the Toyota Production System (TPS) to healthcare.1–3 TPS focuses not only on removing waste from processes but also intensely listening to customers. For us, that meant listening to n
Corresponding author. E-mail address: [email protected] (J.M. Ching).
http://dx.doi.org/10.1016/j.hjdsi.2014.10.002 2213-0764/& 2014 Elsevier Inc. All rights reserved.
our patients and their families who repeatedly said we were not meeting their needs because they wanted to be together regardless of location or intensity-of-care. Our goal was to “open the doors” of the ICU, and reorganize our work around the needs of our patients and families, rather than around our needs as providers.
3. Problem: Despite tradition, genuine need to open doors Prior to 2005, our ICU was structured in a traditional manner, physician- and nurse-centric with limited visiting hours for families. Efforts to promote patient safety and privacy further reinforced the legacies of a physical divide (e.g., closed doors that excluded family members and friends) as well as procedural barriers that dictated when a family must leave (e.g., medical rounds, nursing shift report, prior to central line placement). We routinely required family members to leave because we believed that stressed family members would behave badly, impede our already overburdened work flow, and adversely impact care to their loved one.4 Without realizing it, we allowed tradition (i.e., the doors have always been closed) and our experiences with a few, difficult families to unquestionably accept the need to limit family presence.5 Over time we became more aware that this traditional model was badly disconnected from the needs of our patients. The Institute of Medicine emphasized that families serve as a healing influence by providing comfort, connectedness, energy, selfesteem and wisdom;6 there is little or no evidence to indicate that the practice of family member presence is detrimental to the
M.E. Westley et al. / Healthcare 2 (2014) 258–262
259
Table 1 Comparison of a closed versus “open ICU”. Dimension
Closed ICU
“Open ICU” concept
Examples
Family/visitor experience First impressions
Doors closed; “keep out”
Doors open; “come in”
Family/visitor presence
Assumes family will have unreasonable, burdensome expectations and will frequently interrupt; provider has discretion to dismiss family from patient’s room
Provides mutual support and relief of suffering; allowed to remain during hand-offs, multidisciplinary rounds, bedside procedures and overnight
Physical space
Provider’s work environment; large “cone Patient’s home where family and friends of silence”, emphasis on order and control freely come and go as they please
Way finding; sensitivity to patientcentered privacy Family/visitors asked to leave only for genuine privacy or safety concerns; family oriented to conditions for remaining in room for procedures (e.g., may sit in chair, wear mask, hold questions) Family presence may not disrupt individual patient care or that of other patients
How work is completed Information flow
Family’s role in patient care
Priorities Shared decision making Power Care and privacy preferences
Welfare
Periodic batches of information; “We’ll let Real-time exchange of information in you know what we want you to know” front of patient and family; “We have nothing to hide” Clear expectations, anticipatory coaching, Case-by-case approach for allowing family members to participate in patient's and ongoing support allow greater family participation care Provider-centered; efficiency Patient- and family-centered; healing for both patient and family Hierarchical and guarded; providers favored over families/visitors Care providers do what they believe is best for the patient
Family welcome at multi-disciplinary rounds; family spokesperson updates other family/friends Family given opportunities to participate in care Patient/family and ICU team mutually develop daily care plan
Leveled playing-field; trust, openness
Patient/family and ICU team collaborate on how decisions will be made Family members guide care and degree of Care and level of privacy consistent privacy based on what they believe their with patient/family’s values loved one would want Paternalistic; assumes patient and family Patient and family are capable of Providers support anticipatory will experience exhaustion, and providers regulating and caring for one another information and support need protection from families/visitors
ICU ¼ intensive care unit.
Fig. 1. Progressive steps to “open ICU doors”.
patient, the family or the health care team.7 Indeed family member presence during invasive procedures or resuscitation should be offered as an option to appropriate family members.7,8 Yet at the same time, dedicated nurses and physicians struggled with the idea of delivering efficient, safe care with family members always present. “Families slow us down, interrupt our work, and keep us from saying what we need to say to one another,” one ICU nurse confessed. But when the same staff were asked what they would want if their family member was in the ICU, their answers were similar to their patients and families’: “Don’t force us out! Unless there are genuine privacy or safety concerns, we want to be with our loved one.” By 2004, our senior leaders and ICU nursing and physician leaders envisioned a much more “open ICU,” but they also knew that an edict or mass “roll out” would not work with clinical staff (Table 1). The challenge became how to engage staff to not only think differently about the policies that separated families from loved ones but to also test new ways of organizing their work. We needed staff to literally transform how we provided care so family would not only be a visiting presence but also an active part of the care team. The challenge was to engage staff to overcome the traditions, legacy, and sense of professional entitlement that had been a part of our ICU culture for many years. Recognizing this as a widespread problem, the Institute for Healthcare Improvement (IHI)
challenged ICUs across the country to “open the doors”, to reexamine visitation policies, encourage more open and regular communication between families and care providers, and allow family members to share in decision-making.4 In 2011, the National Quality Strategy, a component of the Affordable Care Act, set three of its six priorities around (1) ensuring that each person and family are engaged as partners in their care; (2) promoting effective communication and coordination of care; and (3) making care safer by reducing harm caused in the delivery of care.9 Improving health and health care quality depended upon us changing how we viewed ourselves and our customers (patients and their families).
4. Solution: We will “open the doors” “Opening the doors” was not a single event in our ICU's history but the culmination of many steps in a long journey (Fig. 1). It served as our guiding vision as our staff grew more comfortable with fewer restrictions to the family's presence at the patient's bedside. Our ICU approached each change in four steps: (1) enlist support of administrative and local leaders; (2) create a collective aim; (3) test on a small scale; and (4) scale up once processes succeed.
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M.E. Westley et al. / Healthcare 2 (2014) 258–262
4.1. Step 1: Enlist support of administrative and local leaders The ICU physician and nurse leadership team knew that “opening the doors” would not be easy, and that mistakes would be made. We sought and received assurance from senior leaders outside of ICU’s walls that they would support the “open door” aim. We identified and engaged local nurse and physician leaders, not only those with formal administrative roles, but also respected, experienced clinicians to whom other staff looked for leadership. Though time consuming, these one-on-one conversations were critical, and without the full commitment of this interdisciplinary “informal” leadership team, “opening the doors” would not have been possible. 4.2. Step 2: Create a collective aim Without a clear, collective aim that made sense to our staff, we could not eliminate the barriers that separated our patients and families, impeded regular, open exchange of information, and discouraged families from taking an active part in decisionmaking processes. To help staff better understand why this change was necessary and to overcome outdated traditions, legacy, and sense of professional entitlement, we began by telling stories. We told how we had a tradition of being at the cutting-edge of family-centered care. In 1955, we became one of the first hospitals in the country to allow the family to remain in the room during labor and delivery.10 If we could do that, we surely could find ways to have family present in the ICU 50 years later. We told recent patient stories and showed videos of families reflecting on how both access and barriers to our ICU impacted them. We shared learnings from family surveys that told us that little frustrates them more than inconsistencies in our visitation policy (particularly with staying overnight) and when and how they receive progress reports on their loved one. We actively listened to our staff as many appeared to grieve over the loss of control from yet another externally imposed change. However, a handful of staff had already embraced the “open ICU” concept (i.e., intensive care physician group and some ICU nurses), and they supported those who felt threatened by a
more liberalized policy on family presence. While there was open and vigorous dialogue around the plan to liberalize family presence, leaders never wavered from the aim, “We will open the doors.” Staff input was nevertheless necessary if the change was to be a real improvement for patients and families as well as for staff.
4.3. Step 3: Test on a small scale We implemented the “open ICU” through a series of small tests of change using P-D-S-A cycles, including family presence during multidisciplinary rounds, during nursing shift report, overnight, and during procedures. We invited clinicians to participate, to evaluate the effects of each step, and to provide unvarnished, continuous feedback.4 One example is how we tested and scaled up family presence during daily medical multidisciplinary rounds. We initially trialed family presence during rounds with one physician and one nurse leading the “open ICU” effort. After rounds, the team debriefed with the family present and asked what went well, what could be improved, and what did we learn? From this, we learned, for example, that family would routinely interrupt the rounds unless we began with a brief orientation script (Sidebar 1). Small tests like this led to immediate learning and the opportunity to quickly incorporate that learning into the new process.
4.4. Step 4: Scale up once processes succeed The process was gradually expanded, bringing in different nurses, different physicians, and different families, while always gaining feedback from the experience so the process could be changed appropriately. The rounding teams learned that once family members were oriented to the process, not only did they provide valuable patient information but they also saved everyone time. Summarizing what the family needed to know added an average of only 2–3 min to the end of rounds because the family understood much of what had already been said. We shared the results of these P-D-S-A cycles with the entire ICU team, resulting in both increased interest and willingness to participate in testing new processes.
Sidebar 1. Family scripts developed by physicians and nurses to welcome and orient family members to ICU activities.
M.E. Westley et al. / Healthcare 2 (2014) 258–262
We also used small tests as we began to prepare nurses to include families in twice-daily nursing shift report. Since no one nursing hand-off process existed in our ICU, our nursing staff agreed upon a standard process for information exchange and created a reporting “tool” that further positioned them for success in daily multidisciplinary rounds. Nurses created a script to orient families to their role in shift report (Sidebar 1). When family members understood the purpose of shift report and the importance of holding questions to the end, nurses found they could efficiently exchange important patient care information without dismissing a family member’s concern. Likewise families felt more confident about the continuity of nursing care as their own experiences and insights were incorporated into a comprehensive shift report about their loved one (e.g., the appropriate analgesia for dressing changes, timing of physical therapy based on the patient’s sleep/wake cycle). Developing and spreading standard process and quality communication techniques like these took time but were absolutely essential for all staff to feel comfortable and confidant in front of families.
5. Lessons for the field: Beyond scaling up Some staff members resisted the changes. When staff asked when we would be able to stop with the changes, we honestly answered, “Never”. In contrast to large-scale, programmatic changes, our experience has shown that small changes embedded into ongoing work produce the most meaningful improvements. It begins by rapidly responding to staff’s concerns about broken processes, quickly establishing theories about why they aren’t working, and then testing changes that may result in improvements.11 For example, we learned that when we first opened the ICU's physical doors, families could not find their way, so we quickly needed to improve way finding. Within 24 h of problem identification, staff hung home-made signs with directional arrows at the entryway and prompts for first-time visitors to go to the nurses’ station. A compass stenciled on the hallway floor provided directional cues for north- and south-facing rooms to enable visitors to navigate their own way on the unit. By the time an official, way-finding consultant appeared in the ICU, staff had already tested options that worked. We also learned that an “open ICU” required a new, comprehensive family orientation process beyond the “welcome” signs so that families would know what was expected of them. No single process could reach every family member so the team designed posters, a hospitality bag, as well as a personalized bedside orientation to cover a range of issues. Key orientation issues for discussion with family members included: patient privacy and medical safety needs, posted patient daily goals, overnight sleeping options for family members, orientation to multidisciplinary rounds and RN shift report, and large family crowd control. We also worked with families to identify a family spokesperson.
6. Behind the doors Despite years of preparation prior to opening the doors, we did not anticipate all of the changes associated with greater family presence.5 “I don’t like feeling as if I'm always ‘on stage’,” protested one staff member. To feel safe and confidant “on stage”, our nurses and physicians needed skills that few had acquired in their formal education, particularly communication techniques like tailoring explanations to the individual family and asking about preferences rather than making assumptions.12 We solicited input from patients and family members and incorporated what mattered to them (e.g., clarity, authenticity, compassion) into our staff
261
development processes. Staff also needed written standard processes so that all nurses, physicians, residents, and therapists knew what was expected from each of them during multidisciplinary rounds, nurse shift report, etc. Thus, a daily part of the ICU’s routine was practicing and receiving feedback on communication skills (e.g., what could be discussed with family as opposed to being better left unsaid or privately shared). Without such support and development, staff will resist being put in uncomfortable situations in front of the patient and family. Patient and family advisory councils, though not well established when we began this work, may also provide important support to staff in fostering a trusting partnership with patients and families.13 Such a group could aid staff in understanding and dealing with the “on stage” experience. Sustaining our “open ICU” gains required an ongoing process to orient and train new providers and staff who weren’t familiar with the concept. All new providers must be oriented to what it means to be “on stage” and what it takes to be successful when “on stage”. Successful adoption of these behaviors depends upon current staff modeling and teaching from home-grown scripts about the family’s role, how families are oriented to rounds, how rounds are conducted, nursing shift report, procedures, etc. All clinicians must be willing to give and receive feedback regarding their contribution to make the family’s presence successful. Lastly we learned to identify early on families who were not coping with the ICU’s open environment (e.g., confrontational behavior, aggression toward staff) so that staff could be protected both physically and psychologically from harm. While disruptive families were rare, front-line staff needed to have a reliable, timely process to manage their safety and to know that outside resources would be deployed when they were needed.
7. Conclusion Today the doors to our ICU remain open to family members, and the old, red sign has been replaced with welcoming information. “Opening the doors” has helped to minimize the barriers that physically separated patients and their loved ones, impeded access to regular exchanges of information, and interfered with decisionmaking. Our experiences add to an evolving standard of practice focused on the needs of families of ICU patients such that the ICU’s “unit of care” has become both patient and family.5 References 1. Bush RW. Reducing waste in US health care systems. JAMA. 2007;297(Feb (8)):871–874. 2. Kenney C. Transforming Health Care: Virginia Mason Medical Center's Pursuit of the Perfect Patient Experience. New York, NY: Productivity Press–Taylor & Francis Group; 2011. 3. Ohno T. Toyota Production System: Beyond Large-Scale Production. New York City, NY: Productivity Press; 1998. 4. Berwick DM, Kotagal M. Restricted visiting hours in ICUs: time to change. JAMA. 2004;292(Aug (6)):736–737. 5. Levy MM. A view from the other side. Crit Care Med. 2007;35(2):603–604. 6. Institute of Medicine. Integrative Medicine and the Health of the Public: A Summary of the February 2009 Summit. Washington, DC: The National Academies Press; 2009. 7. Bell L. The AACN practice alert on family presence: visitation in the adult ICU. American Association of Critical Care Nurses. 〈http://www.aacn.org/WD/practice/ docs/practicealerts/family-visitation-adult-icu-practicealert.pdf〉; November 2011 (accessed August 26, 2014). 8. ENA Emergency Nursing Resources Development Committee. Clinical practice guideline: family presence during invasive procedures and resuscitation. Emergency Nurses Association, Des Plaines, IL. 〈http://www.ena.org/practiceresearch/research/CPG/Documents/FamilyPresenceCPG.pdf〉; 2012 (accessed August 26, 2014). 9. Report to Congress: national strategy for quality improvement in health care. US Department of Health and Human Services, Washington, DC. 〈http://www. ahrq.gov/workingforquality/nqs/nqs2011annlrpt.htm〉; 2011 (accessed March 7, 2014).
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10. Glinn B. A father sees his child born. Life Mag. 1955(Jun):133–138. 11. Institute for Healthcare Improvement, How to improve. 〈http://www.ihi.org/ resources/Pages/HowtoImprove/default.aspx〉; 2014 (accessed June 6, 2014). 12. Curtis JR, White DB. Practical guidance for evidence-based ICU family conferences. Chest. 2008;134(Oct (4)):835–843.
13. American Hospital Association. Strategies for leadership—resource guide. Institute for Family Centered Care, 〈http://www.aha.org/content/00-10/resource guide.pdf〉; 2014 (accessed August 26, 2014).
Contents lists available at ScienceDirect
Healthcare journal homepage: www.elsevier.com/locate/hjdsi
Into Practice
Opening the ICU doors Michael E. Westley, Joan M. Ching n, Shirley A. Sherman, Ian A. Smith Virginia Mason Medical Center, Clinical Administration, 1202 Terry Ave. #320, Mailstop: R3-320, Seattle, WA 98101, United States
art ic l e i nf o
a b s t r a c t
Article history: Received 19 June 2014 Received in revised form 16 September 2014 Accepted 2 October 2014 Available online 4 November 2014
Family member presence may contribute to the healing of hospitalized patients, but may also be in conflict with the perceived needs of delivering intensive care. We detail our experience with “opening the doors” of the intensive care unit (ICU), allowing family members to be present and participate in the care of loved ones without restriction. “Opening the doors” challenged the traditions, legacy and sense of professional entitlement that were a part of ICU culture and generated considerable initial resistance among nurses and physicians. We describe our “opening the doors” transformation to more patient- and family-centered care in four steps: (1) enlist support of administrative and local leaders; (2) create a collective aim; (3) test on a small scale, and (4) scale up after initial successes. Preparing ICU staff so that they are comfortable with more “on stage” time (i.e., greater family presence) was critical to our success. “Opening the doors” now serves as a guiding vision to organizing the ICU’s work. & 2014 Elsevier Inc. All rights reserved.
Keywords: Intensive care Family Communication
1. Background One quiet Saturday morning in 2005, the red, posted sign that had for many years barred entry to our Intensive Care Unit (ICU) fell to the ground. Team members stopped short of re-hanging the sign when they thought about the changes that were going on behind the closed doors to improve the patient and families’ experiences. This small incident symbolized our eight year journey to “open the doors” of the ICU, inviting family members to participate in the care of their loved ones regardless of the time of day, and the activities of the physicians and care team.
2. Organizational context Our doors had been closed prior to 2005. At that time, we were a 31-bed mixed medical and surgical ICU in a hospital with 17,000 annual inpatient admissions. For medical admissions, our ICU was staffed by a dedicated intensivist during the day and medical residents at night, while surgery patients were cared for by surgery faculty and residents. Also at that time, we were in the process of developing an operations structure built around Lean manufacturing techniques and the Toyota Production System (TPS) to healthcare.1–3 TPS focuses not only on removing waste from processes but also intensely listening to customers. For us, that meant listening to n
Corresponding author. E-mail address: [email protected] (J.M. Ching).
http://dx.doi.org/10.1016/j.hjdsi.2014.10.002 2213-0764/& 2014 Elsevier Inc. All rights reserved.
our patients and their families who repeatedly said we were not meeting their needs because they wanted to be together regardless of location or intensity-of-care. Our goal was to “open the doors” of the ICU, and reorganize our work around the needs of our patients and families, rather than around our needs as providers.
3. Problem: Despite tradition, genuine need to open doors Prior to 2005, our ICU was structured in a traditional manner, physician- and nurse-centric with limited visiting hours for families. Efforts to promote patient safety and privacy further reinforced the legacies of a physical divide (e.g., closed doors that excluded family members and friends) as well as procedural barriers that dictated when a family must leave (e.g., medical rounds, nursing shift report, prior to central line placement). We routinely required family members to leave because we believed that stressed family members would behave badly, impede our already overburdened work flow, and adversely impact care to their loved one.4 Without realizing it, we allowed tradition (i.e., the doors have always been closed) and our experiences with a few, difficult families to unquestionably accept the need to limit family presence.5 Over time we became more aware that this traditional model was badly disconnected from the needs of our patients. The Institute of Medicine emphasized that families serve as a healing influence by providing comfort, connectedness, energy, selfesteem and wisdom;6 there is little or no evidence to indicate that the practice of family member presence is detrimental to the
M.E. Westley et al. / Healthcare 2 (2014) 258–262
259
Table 1 Comparison of a closed versus “open ICU”. Dimension
Closed ICU
“Open ICU” concept
Examples
Family/visitor experience First impressions
Doors closed; “keep out”
Doors open; “come in”
Family/visitor presence
Assumes family will have unreasonable, burdensome expectations and will frequently interrupt; provider has discretion to dismiss family from patient’s room
Provides mutual support and relief of suffering; allowed to remain during hand-offs, multidisciplinary rounds, bedside procedures and overnight
Physical space
Provider’s work environment; large “cone Patient’s home where family and friends of silence”, emphasis on order and control freely come and go as they please
Way finding; sensitivity to patientcentered privacy Family/visitors asked to leave only for genuine privacy or safety concerns; family oriented to conditions for remaining in room for procedures (e.g., may sit in chair, wear mask, hold questions) Family presence may not disrupt individual patient care or that of other patients
How work is completed Information flow
Family’s role in patient care
Priorities Shared decision making Power Care and privacy preferences
Welfare
Periodic batches of information; “We’ll let Real-time exchange of information in you know what we want you to know” front of patient and family; “We have nothing to hide” Clear expectations, anticipatory coaching, Case-by-case approach for allowing family members to participate in patient's and ongoing support allow greater family participation care Provider-centered; efficiency Patient- and family-centered; healing for both patient and family Hierarchical and guarded; providers favored over families/visitors Care providers do what they believe is best for the patient
Family welcome at multi-disciplinary rounds; family spokesperson updates other family/friends Family given opportunities to participate in care Patient/family and ICU team mutually develop daily care plan
Leveled playing-field; trust, openness
Patient/family and ICU team collaborate on how decisions will be made Family members guide care and degree of Care and level of privacy consistent privacy based on what they believe their with patient/family’s values loved one would want Paternalistic; assumes patient and family Patient and family are capable of Providers support anticipatory will experience exhaustion, and providers regulating and caring for one another information and support need protection from families/visitors
ICU ¼ intensive care unit.
Fig. 1. Progressive steps to “open ICU doors”.
patient, the family or the health care team.7 Indeed family member presence during invasive procedures or resuscitation should be offered as an option to appropriate family members.7,8 Yet at the same time, dedicated nurses and physicians struggled with the idea of delivering efficient, safe care with family members always present. “Families slow us down, interrupt our work, and keep us from saying what we need to say to one another,” one ICU nurse confessed. But when the same staff were asked what they would want if their family member was in the ICU, their answers were similar to their patients and families’: “Don’t force us out! Unless there are genuine privacy or safety concerns, we want to be with our loved one.” By 2004, our senior leaders and ICU nursing and physician leaders envisioned a much more “open ICU,” but they also knew that an edict or mass “roll out” would not work with clinical staff (Table 1). The challenge became how to engage staff to not only think differently about the policies that separated families from loved ones but to also test new ways of organizing their work. We needed staff to literally transform how we provided care so family would not only be a visiting presence but also an active part of the care team. The challenge was to engage staff to overcome the traditions, legacy, and sense of professional entitlement that had been a part of our ICU culture for many years. Recognizing this as a widespread problem, the Institute for Healthcare Improvement (IHI)
challenged ICUs across the country to “open the doors”, to reexamine visitation policies, encourage more open and regular communication between families and care providers, and allow family members to share in decision-making.4 In 2011, the National Quality Strategy, a component of the Affordable Care Act, set three of its six priorities around (1) ensuring that each person and family are engaged as partners in their care; (2) promoting effective communication and coordination of care; and (3) making care safer by reducing harm caused in the delivery of care.9 Improving health and health care quality depended upon us changing how we viewed ourselves and our customers (patients and their families).
4. Solution: We will “open the doors” “Opening the doors” was not a single event in our ICU's history but the culmination of many steps in a long journey (Fig. 1). It served as our guiding vision as our staff grew more comfortable with fewer restrictions to the family's presence at the patient's bedside. Our ICU approached each change in four steps: (1) enlist support of administrative and local leaders; (2) create a collective aim; (3) test on a small scale; and (4) scale up once processes succeed.
260
M.E. Westley et al. / Healthcare 2 (2014) 258–262
4.1. Step 1: Enlist support of administrative and local leaders The ICU physician and nurse leadership team knew that “opening the doors” would not be easy, and that mistakes would be made. We sought and received assurance from senior leaders outside of ICU’s walls that they would support the “open door” aim. We identified and engaged local nurse and physician leaders, not only those with formal administrative roles, but also respected, experienced clinicians to whom other staff looked for leadership. Though time consuming, these one-on-one conversations were critical, and without the full commitment of this interdisciplinary “informal” leadership team, “opening the doors” would not have been possible. 4.2. Step 2: Create a collective aim Without a clear, collective aim that made sense to our staff, we could not eliminate the barriers that separated our patients and families, impeded regular, open exchange of information, and discouraged families from taking an active part in decisionmaking processes. To help staff better understand why this change was necessary and to overcome outdated traditions, legacy, and sense of professional entitlement, we began by telling stories. We told how we had a tradition of being at the cutting-edge of family-centered care. In 1955, we became one of the first hospitals in the country to allow the family to remain in the room during labor and delivery.10 If we could do that, we surely could find ways to have family present in the ICU 50 years later. We told recent patient stories and showed videos of families reflecting on how both access and barriers to our ICU impacted them. We shared learnings from family surveys that told us that little frustrates them more than inconsistencies in our visitation policy (particularly with staying overnight) and when and how they receive progress reports on their loved one. We actively listened to our staff as many appeared to grieve over the loss of control from yet another externally imposed change. However, a handful of staff had already embraced the “open ICU” concept (i.e., intensive care physician group and some ICU nurses), and they supported those who felt threatened by a
more liberalized policy on family presence. While there was open and vigorous dialogue around the plan to liberalize family presence, leaders never wavered from the aim, “We will open the doors.” Staff input was nevertheless necessary if the change was to be a real improvement for patients and families as well as for staff.
4.3. Step 3: Test on a small scale We implemented the “open ICU” through a series of small tests of change using P-D-S-A cycles, including family presence during multidisciplinary rounds, during nursing shift report, overnight, and during procedures. We invited clinicians to participate, to evaluate the effects of each step, and to provide unvarnished, continuous feedback.4 One example is how we tested and scaled up family presence during daily medical multidisciplinary rounds. We initially trialed family presence during rounds with one physician and one nurse leading the “open ICU” effort. After rounds, the team debriefed with the family present and asked what went well, what could be improved, and what did we learn? From this, we learned, for example, that family would routinely interrupt the rounds unless we began with a brief orientation script (Sidebar 1). Small tests like this led to immediate learning and the opportunity to quickly incorporate that learning into the new process.
4.4. Step 4: Scale up once processes succeed The process was gradually expanded, bringing in different nurses, different physicians, and different families, while always gaining feedback from the experience so the process could be changed appropriately. The rounding teams learned that once family members were oriented to the process, not only did they provide valuable patient information but they also saved everyone time. Summarizing what the family needed to know added an average of only 2–3 min to the end of rounds because the family understood much of what had already been said. We shared the results of these P-D-S-A cycles with the entire ICU team, resulting in both increased interest and willingness to participate in testing new processes.
Sidebar 1. Family scripts developed by physicians and nurses to welcome and orient family members to ICU activities.
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We also used small tests as we began to prepare nurses to include families in twice-daily nursing shift report. Since no one nursing hand-off process existed in our ICU, our nursing staff agreed upon a standard process for information exchange and created a reporting “tool” that further positioned them for success in daily multidisciplinary rounds. Nurses created a script to orient families to their role in shift report (Sidebar 1). When family members understood the purpose of shift report and the importance of holding questions to the end, nurses found they could efficiently exchange important patient care information without dismissing a family member’s concern. Likewise families felt more confident about the continuity of nursing care as their own experiences and insights were incorporated into a comprehensive shift report about their loved one (e.g., the appropriate analgesia for dressing changes, timing of physical therapy based on the patient’s sleep/wake cycle). Developing and spreading standard process and quality communication techniques like these took time but were absolutely essential for all staff to feel comfortable and confidant in front of families.
5. Lessons for the field: Beyond scaling up Some staff members resisted the changes. When staff asked when we would be able to stop with the changes, we honestly answered, “Never”. In contrast to large-scale, programmatic changes, our experience has shown that small changes embedded into ongoing work produce the most meaningful improvements. It begins by rapidly responding to staff’s concerns about broken processes, quickly establishing theories about why they aren’t working, and then testing changes that may result in improvements.11 For example, we learned that when we first opened the ICU's physical doors, families could not find their way, so we quickly needed to improve way finding. Within 24 h of problem identification, staff hung home-made signs with directional arrows at the entryway and prompts for first-time visitors to go to the nurses’ station. A compass stenciled on the hallway floor provided directional cues for north- and south-facing rooms to enable visitors to navigate their own way on the unit. By the time an official, way-finding consultant appeared in the ICU, staff had already tested options that worked. We also learned that an “open ICU” required a new, comprehensive family orientation process beyond the “welcome” signs so that families would know what was expected of them. No single process could reach every family member so the team designed posters, a hospitality bag, as well as a personalized bedside orientation to cover a range of issues. Key orientation issues for discussion with family members included: patient privacy and medical safety needs, posted patient daily goals, overnight sleeping options for family members, orientation to multidisciplinary rounds and RN shift report, and large family crowd control. We also worked with families to identify a family spokesperson.
6. Behind the doors Despite years of preparation prior to opening the doors, we did not anticipate all of the changes associated with greater family presence.5 “I don’t like feeling as if I'm always ‘on stage’,” protested one staff member. To feel safe and confidant “on stage”, our nurses and physicians needed skills that few had acquired in their formal education, particularly communication techniques like tailoring explanations to the individual family and asking about preferences rather than making assumptions.12 We solicited input from patients and family members and incorporated what mattered to them (e.g., clarity, authenticity, compassion) into our staff
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development processes. Staff also needed written standard processes so that all nurses, physicians, residents, and therapists knew what was expected from each of them during multidisciplinary rounds, nurse shift report, etc. Thus, a daily part of the ICU’s routine was practicing and receiving feedback on communication skills (e.g., what could be discussed with family as opposed to being better left unsaid or privately shared). Without such support and development, staff will resist being put in uncomfortable situations in front of the patient and family. Patient and family advisory councils, though not well established when we began this work, may also provide important support to staff in fostering a trusting partnership with patients and families.13 Such a group could aid staff in understanding and dealing with the “on stage” experience. Sustaining our “open ICU” gains required an ongoing process to orient and train new providers and staff who weren’t familiar with the concept. All new providers must be oriented to what it means to be “on stage” and what it takes to be successful when “on stage”. Successful adoption of these behaviors depends upon current staff modeling and teaching from home-grown scripts about the family’s role, how families are oriented to rounds, how rounds are conducted, nursing shift report, procedures, etc. All clinicians must be willing to give and receive feedback regarding their contribution to make the family’s presence successful. Lastly we learned to identify early on families who were not coping with the ICU’s open environment (e.g., confrontational behavior, aggression toward staff) so that staff could be protected both physically and psychologically from harm. While disruptive families were rare, front-line staff needed to have a reliable, timely process to manage their safety and to know that outside resources would be deployed when they were needed.
7. Conclusion Today the doors to our ICU remain open to family members, and the old, red sign has been replaced with welcoming information. “Opening the doors” has helped to minimize the barriers that physically separated patients and their loved ones, impeded access to regular exchanges of information, and interfered with decisionmaking. Our experiences add to an evolving standard of practice focused on the needs of families of ICU patients such that the ICU’s “unit of care” has become both patient and family.5 References 1. Bush RW. Reducing waste in US health care systems. JAMA. 2007;297(Feb (8)):871–874. 2. Kenney C. Transforming Health Care: Virginia Mason Medical Center's Pursuit of the Perfect Patient Experience. New York, NY: Productivity Press–Taylor & Francis Group; 2011. 3. Ohno T. Toyota Production System: Beyond Large-Scale Production. New York City, NY: Productivity Press; 1998. 4. Berwick DM, Kotagal M. Restricted visiting hours in ICUs: time to change. JAMA. 2004;292(Aug (6)):736–737. 5. Levy MM. A view from the other side. Crit Care Med. 2007;35(2):603–604. 6. Institute of Medicine. Integrative Medicine and the Health of the Public: A Summary of the February 2009 Summit. Washington, DC: The National Academies Press; 2009. 7. Bell L. The AACN practice alert on family presence: visitation in the adult ICU. American Association of Critical Care Nurses. 〈http://www.aacn.org/WD/practice/ docs/practicealerts/family-visitation-adult-icu-practicealert.pdf〉; November 2011 (accessed August 26, 2014). 8. ENA Emergency Nursing Resources Development Committee. Clinical practice guideline: family presence during invasive procedures and resuscitation. Emergency Nurses Association, Des Plaines, IL. 〈http://www.ena.org/practiceresearch/research/CPG/Documents/FamilyPresenceCPG.pdf〉; 2012 (accessed August 26, 2014). 9. Report to Congress: national strategy for quality improvement in health care. US Department of Health and Human Services, Washington, DC. 〈http://www. ahrq.gov/workingforquality/nqs/nqs2011annlrpt.htm〉; 2011 (accessed March 7, 2014).
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10. Glinn B. A father sees his child born. Life Mag. 1955(Jun):133–138. 11. Institute for Healthcare Improvement, How to improve. 〈http://www.ihi.org/ resources/Pages/HowtoImprove/default.aspx〉; 2014 (accessed June 6, 2014). 12. Curtis JR, White DB. Practical guidance for evidence-based ICU family conferences. Chest. 2008;134(Oct (4)):835–843.
13. American Hospital Association. Strategies for leadership—resource guide. Institute for Family Centered Care, 〈http://www.aha.org/content/00-10/resource guide.pdf〉; 2014 (accessed August 26, 2014).
![[Opening the ICU doors. But step by step].](/assets/img/hold.png)
