The Challenge
When families are welcome to visit their loved ones in healthcare facilities, patients tend to do better. A growing body of evidence indicates that traditional visiting hours limiting the presence of family members can have negative effects on quality, costs and outcomes.
Patient- and family-centred care is an approach to the planning, delivery and evaluation of healthcare that recognizes the importance of partnerships between healthcare providers, patients and families. It redefines relationships in healthcare by emphasizing collaboration at all levels of care and in all healthcare settings. The family presence policy innovation is a practical step healthcare organizations can take to deliver more patient- and family-centred care.
Better Together: Partnering with Families is a campaign that began in the United States when the Institute for Patient and Family Centered Care encouraged hospitals to review their visiting policies and recognize the key role families play in improving patient outcomes – rather than viewing families simply as visitors.
CFHI has championed the Better Together movement in Canada, bringing together a coalition of leading quality, safety and patient organizations to spread the family presence innovation across Canada. In 2015, CFHI released a study revealing that fewer than one-quarter of Canadian hospitals had accommodating visiting policies. CFHI also launched the Better Together: Partnering with Families e-Collaborative to support organizations as they develop and implement new family presence policies. From May 2016 to March 2017, the e-collaborative supported 11 healthcare organizations from across the country in their policy development; conservatively, more than 62,600 patients per year stand to benefit from this change. It provided educational content, coaching and access to a pan-Canadian network for organizations as they pursued changes to family presence policies and patient-centred practices.
One team that took part in the collaborative was Harbour View Hospital, located in Sydney Mines, Nova Scotia. Although Harbour View is a small and close-knit organization, staff were frustrated by what they perceived as a culture of poor communication and collaboration. They felt they were working in silos. In early 2016, the organization recognized that change was needed and embarked on a improvement program.
The Solution
Harbour View Hospital has a diverse client population; one side of the facility houses 28 long-term care beds, while the other side provides rehabilitation and restorative care for up to 21 clients. There is also an adult day program that operates Monday to Friday.
Harbour View’s client population is served by an equally diverse interprofessional staff that includes nursing, occupational therapy, physical therapy, recreation, social work, orthotics, hearing and speech, dietary and others. Also contributing to the care and well-being of clients are support staff in administration, environmental services and engineering.
When the hospital decided to improve interprofessional collaboration to break down the institution’s perceived silos, they surveyed clients and families in the hospital’s rehabilitation program about what they felt could be improved.
The result was surprising. The overwhelming message was that clients wanted their families and loved ones more involved in their care. “The issue did end up being about communication – between professionals (clinicians), clients and families,” said Angela Stairs, Director for Rehabilitation Services for the Nova Scotia Health Authority Eastern Zone. “That was our huge ‘a-ha’ moment.”
Harbour View learned that families wanted more information on the day-to-day routine and treatment plans for their loved ones. “For example, families would come into the hospital and ask their loved one, ‘Did you walk today?’” said former Harbour View client Debbie Brennick. “If they hadn’t, the family member would wonder why not.”
Although clients were achieving breakthroughs and milestones, families were not able to see the small steps because they were unaware of or did not understand the full care plan. Visiting hours did not support family presence during the day, when care was being delivered. “There was a big disconnect,” says Brennick. “The survey showed us clearly that families didn’t feel included. They felt they were welcome as visitors only, and not as true partners in caring for their loved ones.”
Armed with this information, Harbour View did a full walk-about of the facility to identify areas for improvement in client-centred care. “We discovered right away that we had some challenges to address,” said Lorna O’Grady, Manager of Resident Care at Harbour View.
The building has a single entrance that splits off into two hallways: one leads to the long term care side of the facility, and the other to rehabilitation/restorative care. No signs were posted on the long-term care side about visiting hours, whereas the rehab side had signs posted at the building entrance saying visitors were welcome between 4 p.m. and 8 p.m.
Adding to the confusion were public announcements every day at 8 p.m. asking all visitors to leave. “It was confusing for people who were visiting their families,” said O’Grady. “Families and clients didn’t know what to expect, and staff weren’t happy either. We didn’t realize it at the time, but it was having a really negative impact on everyone.”
In March 2016, CFHI’s call for applications for the pan-Canadian Better Together e-collaborative was the right thing at the right time for Harbour View. “We had the results of our client survey and were thinking about what to do next,” said Stairs.
One telling moment came as the improvement team filled out the application form for the e-collaborative. The question was: On your website, how many clicks does it take to get to your visiting policy? “I tried it myself,” said Stairs. “When I got to 10 clicks and still hadn’t found our policy, I realized that we were long overdue for a change.”
Harbour View joined the e-collaborative in May 2016 and immediately began to make changes. The improvement team set up a steering committee, developed an action plan, designed a new client and family information booklet and set out to revise its family presence guideline to include 24/7 visiting hours for families and loved ones. Harbour View set out specifically to implement a guideline that would meet patient needs – rather than reflect the improvement team’s wants and needs. To ensure this outcome, the improvement team had Brennick survey patients and families to get their input and feedback throughout the process.
The e-collaborative’s regularly scheduled affinity calls were particularly valuable to the organization. They provided opportunities for participating teams to share best practices and discuss solutions to common challenges.
The process of change was challenging at times for Harbour View. Clients and families were onside from the outset, but staff were concerned the new visiting guidelines would adversely affect clients’ privacy, their own professional practice and the delivery of care. To help alleviate concerns, Harbour View organized a series of education sessions for families and staff. The sessions included opportunities for open dialogue, role-playing, and for staff, families and clients to ask questions and suggest improvements.
Results
Harbour View Hospital has seen many changes as a result of the collaborative – at the facility level and beyond.
Most important, the hospital’s steering committee completed a final version of its Family Presence Guidelines. Stairs reported that in preparing for an Accreditaiton Canada survey, every standard related to involving patients and families in care design and delivery received favourable notice by the accreditation team.
The Family Presence Guidelines include a 24/7 visiting guideline. Immediately after it was implemented, it became clear to the improvement team that having family members present was helpful for everyone. Staff now report that having an extra pair of hands and eyes helps provide consistent care, and is especially valuable in transitioning care from the facility to home. Staff members are embracing the change, clients are generally more relaxed and families are happy to be involved in planning care for their loved ones.
Shortly after implementing its 24/7 visiting guideline, the recreation department purchased a shuffleboard that is used daily by clients and their families. Family members are regularly attending care-planning sessions and they are welcome, all day, every day.
“The hallways are buzzing with activity,” said O’Grady. “Our staff are thrilled with having families so involved.” In addition, Harbour View has removed the visiting hour signs at the front entrance. “That’s hugely symbolic. We’re proud of the work we’ve done.”
Sustainability and Spread
Harbour View has implemented a sustainability program that includes orienting all new staff to the hospital’s Family Presence Guidelines, as well as all new clients and families.
The facility engages in ongoing conversations with client families and staff about the Family Presence Guidelines and provides intermittent education and refreshers for staff – including video tape education to ensure it is accessible to everyone.
Harbour View’s Family Presence Guidelines have been adopted by the Nova Scotia Health Authority, which spans the entire province of Nova Scotia.
Meanwhile, the Nova Scotia Health Authority, which spans the entire province of Nova Scotia, came into being in 2015. As a relatively young organization, “the Health Authority is looking to improve patient and family engagement,” said Stairs. “We invited a provincial representative to join the steering committee when we were developing our Family Presence Guidelines.”
In late 2017, the guidelines created by Harbour View were still being spread across the province, and were in the process of getting further stakeholder feedback and refinement. The eventual goal is to transform the guidelines into a full-fledged provincial policy.
Jackie Paquet, a Resident at Harbour View, plays shuffleboard with his family in Harbour View’s new family space.
Client Peter Primeau, along with his wife Linda and daughter Kira spend the open hours enjoying each other’s company and relaxing as a family.
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Freida MacAskill and her husband Daniel spend quality time together during her stay at Harbour View, just as they would at home. Clients and families at Harbour View can relax after actively participating in rehabilitation programming and discharge planning together.
Licensed Practical Nurse, Wanda Romeo looks at the overview of the Gab’n & Rehab’n program Harbour View instituted for their clients and families. The program allows current and former clients, along with their families, to talk about their rehabilitation goals, make plans for discharge and reintegration, and to support each other along the way.