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Institutional Assessment: ICU Open Visitation

By: Kalyn Skinner, Lynn Carroll, Lauren Studdard, and Tara Fountain Auburn University/ Auburn University Montgomery

Nature of the Change Assessment Theories Description of Stakeholders National Policies and Mandates Problems associated with Change Vested Interest Human Drivers Resource Implications Project Evaluation

Overview

Change in policy allowing unrestricted visitation of family members to the Intensive Care Unit (ICU) at East Alabama Medical Center

Complex change involving many stakeholders “I believe that it is rational, humane, and

even, to a responsible extent, evidence-based, to do away with visiting restrictions in critical care units entirely,” –Donald Berwick, MD. (former President of Institute for Healthcare Improvement (IHI) (IHI,2011)

Nature of the Change

Lewin’s Change Theory (Kristonis,2005) 3-step change theory

Unfreezing, moving, and refreezing Roger’s Diffusion of Innovation

(Kaminiski,2011) People adopt to new idea, product,

practice, or philosophy Lippitt’s Phases of Change Theory

(Kristonis,2005) Focuses on change agent rather than the

evolution of the change itself

Theories of Change

Comparison: All assess a need for change. All are rational and goal oriented. All describe methods to first identify a change,

consider factors in making the change, and implementing the change.

Contrast: Lewin’s model focuses on the change itself, with

driving and restraining forces. Lippitt’s model focuses on the change agent. Roger’s model focuses on the people making the

change.  

Compare and Contrast

Lewin’s Change Theory: Stage 1: Unfreeze the existing behavior, Creates a need for change

Roger’s Diffusion of Innovation Theory: Stage 1: Become aware of the new idea/need for change.

Lippitt’s Phases of Change Theory: Stage 1-3: Need for change identified, Capacity for change identified, Motivation for change assessed

Analysis of Theories: Assessment

A need for change is assessed:

Lewin’s Change Theory most applicable to our topic.

Unfreezing: Unfreezing the existing situation (Restricted visiting hours in the ICU). Consists of driving forces and restraining forces.

ICU Open Visitation Policy and Change Theory

Lewin’s Theory of Change

Patient’s desires/Patient satisfaction Visitors provide reassurance/comfort Family provide psychological support/important

historical data and input on patient care/encouragement and assistance to staff

Builds Trust Positive reinforcement Family can visit at their convenience (visiting hours

do not interfere with family’s employment/other activities)

Holistic care (involving the family) Family unshielded from extent/severity of patient

illness

Driving Forces(Rollins,2005)

Patient privacy/confidentiality Critical condition of patients Creates more demand on nurses Behavior of family members (threatening,

controlling) Visitor traffic flow Stressful/hectic environment Management of visitors Low staffing High patient acuity

Restraining Forces(Rollins,2005)

Patients Families All hospital employees Physicians Healthcare Organization

Significant Stakeholders

Presidential Memorandum in 2010 The Center for Medicare and Medicaid

Services Conditions of Participation (CoPs)

Joint Commission (JCAHO) Patient’s rights chapter of Joint

Commission Standards

National Mandate and Policy

Resistance is inevitable Physicians, nurses, support

staff Feel that an “open door” will

impede work flow and possibly lead to greater error from distraction and family involvement

Resistance to Change

Change is Vital Lewin’s Theory of change

Force field analysis Increase knowledge Strategies for decreasing resistance

How to Create Change

Education Set Guidelines for families

Rules must be clear Staff-patient communication Mandate from Medical

Executives to MD’s regarding compliance with change

Strategies for Addressing Resistance

Nurses Families Healthcare System

Administrators

Parties with Vested Interest

Families Management ICU committee Administrators Nursing staff JCAHO CMS

Human Drivers

Belonging / Love  Control/Security  Diversity/Change  Recognition/ Significance  Achievement  Challenge/ Growth  Excellence Responsibility/ Contribution 

Human Emotional Drivers

Nurses Support Staff Physicians

Human Resistors

Employee training and education Palliative care team, unit-specific Increase security More materials for family

accommodation Signs to display new policy and rules

Resource Implication

Map out the causal chain Understand context Anticipate heterogeneity Rigorous evaluation of impact Rigorous factual analysis

Theory-Based Impact Evaluation (White,2009)

Satisfaction survey Patient and family

Internal survey Employee Satisfaction Increase or decrease in infection

rates, etc.. Focuses on intervention theory Allows for review of information for

updates and changes to policy as needed

Evaluation

References  

• Bell, L. (2011). Family presence: Visitation in the adult ICU. Retrieved from American Association of Critical Care Nurses website: http://www.aacn.org/WD/practice/docs/practicealerts/family-visitation-adult-icu-practicealert.pdf

• Berwick, D. M., & Kotagal, M. (2004). Restricted visiting hours in icus: Time to change. Journal of the American Medical Association, 292(6), 736-737. http://doi: 10.1001/jama.292.6.736

• Cypress, B. S. (2010). The intensive care unit:Experiences of patients, families, and their nurses. Dimensions of Critical Care Nursing, 29(2), 94-101. http://doi:10.1097/DCC.0b013e3181c9311a

• Center for Medicare and Medicaid Services (2010). Medicare and Medicaid programs: Changes to the hospital and critical access hospital conditions of participation to ensure visitation rights for all patient. Federal Registry, 75(223), 70831-70844. Retrieved from http://www.gpo.gov/fdsys/pkg/FR-2010-11-19/pdf/2010-29194.pdf

• Institute for Healthcare Improvement (2011). A challenge accepted: Open visiting at the ICU in Geisenger. Retrieved from http://www.ihi.org/knowledge/Pages/ImprovementStories/AChallengeAcceptedOpenVisitingintheICUatGeisinger.aspx

• Joint Commission (2011). Patient-centered communication standards for hospitals:R3 report requirement, rationale, preferences (3). Retrieved from http://www.jointcommission.org/assets/1/18/r3%20report%20issue%201%2020111.pdf

• Kaminski, J. (2011). Diffusion of innovation theory. Canadian Journal of Nursing Informatics, 6(2). Retrieved from http://cjni.net/journal/?p=1444.  

• Kristonis, A. (2005). Comparison of change theories. International Journal of Scholarly Academic Intellectual Diversity, 8 (1), 1-7. Retrieved from http://qiroadmap.org/download/Phase%201%20Resources/Kritsonis,%20Alicia%20Comparison%20of%20Change%20Theories.pdf

• Mitchell , G. (2013). Selecting the best theory to implement planned change. Nursing Management, 20(1), 32-37. Retrieved from http://rcnpublishing.com/doi/abs/10.7748/nm2013.04.20.1.32.e1013

• Porter- O'Grady, T., & Malloch, K. (2010). Quantum leadership:Advancing innovation, transforming healthcare (3rd ed.). Sudbury, MA: Jones & Bartlett Learning.

• Rollins, G. (2005). Open all hours. H&HN: Hospitals & Health Networks, 79(1), 20-21. Retrieved from http://ehis.ebscohost.com.spot.lib.auburn.edu/ehost/detail?vid=3&sid=1210ff09-77c0-4e38-

• Secretary of Health and Human Services (2010). Respecting the rights of patients to receive visitors and to designate surrogate decision makers for hospital emergencies:Presidential Memorandum-Hospital Visitation. Retrieved from Office of the Press Secretary website: http://www.whitehouse.gov/the-press-office/presidential-memorandum-hospital-visitation

• Treasury Board of Canada Secretariat (2012). Theory-based approaches to evaluation:Concepts and practices. Retrieved from http://www.tbs-sct.gc.ca/cee/tbae-aeat/tbae-aeat-eng.pdf