{ institutional assessment: icu open visitation by: kalyn skinner, lynn carroll, lauren studdard,...
TRANSCRIPT
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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