Changing Hospital Visiting Policies: From Families as “Visitors” to Families as Partners

From the Institute for Patient- and Family-Centered Care, Bethesda, MD (Ms. Dokken, Ms. Kaufman, and Ms. Johnson), Anne Arundel Medical Center, Annapolis, MD (Dr. Perkins), Contra Costa Regional Medical Center & Health Centers, Martinez, CA (Ms. Benepal, Ms. Roth, and Vidant Health, Greenville, NC (Ms. Dutton and Ms. Jones).

Abstract

• Objective: To describe a campaign to eliminate restrictive hospital visiting policies and to put in place policies that recognize families as partners in care.
• Methods: Descriptive report.
• Results: Many hospitals still have “visiting” hours that limit family presence, often counter to patient preferences. To change the concept of families as visitors and eliminate restrictive hospital visiting policies, the Institute for Patient- and Family-Centered Care (IPFCC) launched the campaign Better Together: Partnering with Families, calling on all hospitals to welcome families 24 hours a day and transform their policies and approaches to care so that patients’ families and loved ones are included in care and decision making, according to patient preferences. As part of the campaign, IPFCC recognized 12 hospitals that exemplify success in eliminating restrictive visiting policies and have changed the concept of families from  “visitors” to partners. Leaders at these hospitals attest to the benefits of the changes through improved experience of care and other outcomes. Three exemplar hospitals are highlighted in this article and share their processes of change as well as key learnings and outcomes.
• Conclusion: Hospital policies and practices that encourage and support families as partners in care are essential to patients’ health, well-being, and safety.

Many families are restricted from the bedsides of loved ones because of hospital visiting policies [1–3]. Restrictive policies are often based on long-held beliefs that the presence and participation of families interferes with care, exhausts patients, is a burden to families, spreads infection, or violates HIPAA. However, there is no evidence to support those beliefs. In fact, isolating patients at their most vulnerable time from the people who know them best places them at risk for medical error, emotional harm, inconsistencies in care, and lack of preparedness for transitions in care [4,5]. Jackie Gruzenski’s story “Behind a Locked Door” (printed below) affectingly describes the impact of restrictive policies on a couple's last days.

Fortunately, a growing number of hospitals are lifting these restrictions. But opening the door is not enough. Hospitals need to change the concept of families as “visitors” to families as partners in care. Changing policies is a foundational step in creating a patient- and family-centered culture where families are recognized as essential to patients’ health and well-being and where they are respected as allies for quality and safety.

In response to this critical need for change, in June 2014 the Institute for Patient- and Family-Centered Care (IPFCC) launched the campaign Better Together: Partnering with Families. IPFCC, founded in 1992, is a nonprofit organization that provides essential leadership to advance the understanding and practice of patient- and family-centered care [6]. Emphasizing the importance of family presence and participation to quality and safety, the campaign seeks to eliminate restrictive “visiting” policies and calls upon hospitals to include families as members of the care team and to welcome them 24 hours a day, 7 days a week, according to patient preference [7]. The goal of the campaign is to change visiting policies in 1000 hospitals by 2017. Partnering with IPFCC in this initiative are the American Society for Healthcare Risk Management, American Association of Critical Care Nurses, National Partnership for Women & Families, New Yorkers for Patient and Family Empowerment, Health In Aging Foundation, and the Canadian Foundation for Healthcare Improvement.

Anne Arundel Medical Center

A regional not-for-profit hospital founded in 1902, Anne Arundel Medical Center in Annapolis, MD, provides acute inpatient and outpatient care to residents of 4 counties in Maryland. A 380-bed facility, Anne Arundel has a cancer institute, heart and vascular institute, joint center, spine center, and a women’s and children’s center. In April 2011, the hospital completed a $424 million expansion project, which included a pediatric emergency room, an expanded general emergency room, 50 new patient beds, and 8 new operating rooms.

In 2010, based on a desire to concretely implement the principles of patient- and family-centered care, leaders at Anne Arundel began working with patient and family advisors and initiated a process to change the hospital’s restrictive visiting policy. Now, there are no restrictions on family presence anywhere in the hospital, from ICUs to medical/surgical units to other clinical areas. Patients have the power to choose who they want to stay with them—24 hours a day, 7 days a week. According to Anne Arundel’s policy, each patient determines who is defined as “family.” A “Revisiting Visiting” task force, comprising support staff, providers, and patient and family advisors, worked for 9 months to develop the new family presence policy and support its implementation.

With Anne Arundel leadership encouragement and support, patient and family advisors  participated in all phases of the development and implementation of the new family presence policy and in other ways to advance the practice of patient- and family-centered care. The advisors also participated in the process to change the way nurse change of shift report was conducted, and they made recommendations for changes in the directional signs throughout the hospital. New signs, featuring a pineapple (a symbol of hospitality) and the words “Welcome Families” replaced old ones displaying the former restrictive visiting policy.

Supporting patient and family involvement in transitions in care is an integral aspect of implementing family presence policies and practices. Through an “Always Events” grant from the Picker Institute (for information about the Always Events program, see www.ihi.org/Engage/Initiatives/PatientFamilyCenteredCare/Pages/AlwaysEvents.aspx), patient and family advisors, staff, and providers at Anne Arundel developed the SMART discharge protocol, which includes a simple 5-item checklist that is reviewed and discussed with the patient and family prior to discharge. SMART is an acronym for Signs, Medications, Appointments, Results, and Talk. In its work, the SMART team built on current evidence, created urgency and expectation for use with patients, families, and caregivers, disseminated findings, and promoted the protocol as a national standard. The tool is available at www.ihi.org/resources/Pages/Tools/SMARTDischargeProtocol.aspx.