Wheaton Franciscan-St. Joseph is a participant in the IHI Learning and Innovation Community on Improving Outcomes for High-Risk and Critically Ill Patients. In addition to several registered nurses, the project team also includes the following members:

Barb Rogness, RN, MS, Director of Quality
Kerry Henrickson, MD, Medical Director and Intensivist, ICU
Mary Jo Kohout, RN, MSN, Nursing Director of ICU
Ann Smith, RN, BSN, Unit Patient Care Supervisor
Laurie Brennan, RN, BSN, Unit Patient Care Supervisor
Maureen T. Greene, RN, CNS, ICU and Nurse Research Coordinator
Rose Parisi, RN, BSN, Nurse Case Manager
Laura Schlechta, RT, Respiratory Therapy Supervisor
Jodie Jaeger, RT, Respiratory Therapy Supervisor
Jennifer Popies, RN, MS, Clinical Educator

Project Team Leads:
Margaret (Peg) Schulz, RN, BSN
Deb Valdivieso, RN, BSN

Within the next six months (December 2008-May 2009), implement flexible visiting hours in the intensive care unit (ICU).

• Implement flexible visiting hours in the ICU as a new hospital policy (Yes/No)
• Number of Prideline calls, grievances, and compliments (as a measure of patient and family satisfaction with visiting hour enhancements)

• Developed and published the ICU staff vision statement: “Our goal is to give you access to your loved one in this time of need as much as we possibly can. We understand that the healing process will include the love and support from you ― the family!”
• Communicated the availability of the Prideline: This phone line is available to patients and family members to disclose problems, concerns, and compliments related to the patient’s care. Calls are screened by administrative personnel and addressed by patient advocates and risk staff. Information about the Prideline service is distributed in the patient rights information at the time of admission.
• Developed and shared new guidelines for extended visiting hours in the ICU: The expanded visiting hours (10:00 AM to 9:00 PM) were communicated to the patient and family verbally and also through written materials. (Previously, ICU visiting hours were 11:00 AM to 7:00 PM.) In addition, the expanded visiting hours allow the family to visit in pairs during evening off-hours, and the extended morning visitation hours provide the family with the opportunity to be on the unit during multidisplinary rounds (daily from 9:30 AM to 11:00 AM).
• Instituted a shared governance approach for the expanded visiting hours: The ICU Shared Governance Committee took the proposed ICU visitation hours to the Operations and Practice Council for approval. This process included a literature review regarding visitation policies.
• Developed and implemented the patient Spokesperson Sheet: A Spokesperson Sheet is completed for each ICU patient to identify one or two designated contacts for the patient, who then work with the care team to plan individual visiting guidelines for the patient, support the patient by including the family as part of the caregiver team, and act as primary contacts to receive phone updates on the patient’s condition. The goal for implementing a Spokesperson Sheet was to assure confidentiality of patient information, along with proper and timely contact information. Restriction of visitors is occasionally requested and this assists in that process.
• Administered the ICU staff survey on the new visitation policy: A questionnaire for nursing staff and physicians was used to determine barriers and benefits of the enhanced visiting hours. Barriers were addressed directly via in-services directed at best practice, conflict resolution measures, enhanced communication skills, and other positive guidance to promote this change.
• Hired a new intensivist in July 2008, who helped attain physician buy-in with the new visitation policy.
• Due to staff concerns about safety during off-hours visiting, the team has been working closely with security to screen all off-hours visitors.

Flexible visiting hours were implemented in early December 2008. The ICU Visitation Guidelines and changes have resulted in a positive change for families to visibly participate and interact in the care and understanding of the patient condition. Consistency of implementation continues to be a barrier. We know that inconsistent implementation can undermine staff and physician appreciation for the benefits of this improvement project.

Lessons Learned:

• The importance of ongoing staff discussion to address concerns about patient care delivery and privacy/safety considerations
• Positive feedback from the family/patient survey about the expanded visiting hours has resulted in increased trust between nurses/physicians and families
• Consistency and “scripted” explanations among nursing, physicians, and family improve communication
• Using a shared governance approach to empower nurses to affect change is important to achieve long-lasting change and positive outcomes
• Recognition that staff resistance to expanded ICU visitation hours is often grounded in a protectiveness of nursing care delivery and concerns for patient rest and recovery

Next Steps:

• Integrate the family into multidisciplinary daily rounds by September 2009
• Utilize family conferencing documentation to assess frequency, discussion content, and outcomes to link visitation with active participation through discussion of goals of treatment
• Since our Press Ganey satisfaction score information only seeks ICU patient discharge information (n=3 approximately), we seek to use an in-department family/patient survey to determine satisfaction scores by September 2009
• Post results from staff survey on their impression of the expanded visiting hours by August 15, 2009

Maureen T. Greene, RN, MS, CNS-BC, ACNP-BC
ICU and Nurse Research Coordinator
Wheaton Franciscan-St. Joseph
Maureen.Greene@wfhc.org