Several months ago, I wrote about work being done in our ICUs to make them more patient- and family-friendly and responsive.
Each year, the Society of Critical Care Medicine (SCCM) selects one (and only one) hospital or ICU for its Family-Centered Care Award, the purpose of which is to "recognize innovation that improves the care provided to critically ill and injured patients and their families." If you’re not familiar with SCCM, it is the largest multiprofessional organization focused on critical care, with more than 14,000 members in 80 countries. This is an international competition.
I am very proud to announce that BIDMC has received the award, which will be presented in January.
As Dr. Michael Howell, Director of Critical Care Quality, explained to our staff:
Why did Critical Care at BIDMC win this award? Because of your work. Literally hundreds of people have made small, incremental changes to help improve the experience of critical care for our patients and families. Anyone who has had a family member an ICU knows that it’s an extraordinarily trying time. From simulated family meetings for the medical residents, to family pagers in the SICU, to transition-out-of-the-ICU work in CVI, to pro-active rounding of chaplains, there have been a tremendous number of improvements over the past year and a half. Family satisfaction data (which we have meticulously collected) supports this as well. Today, families are more than twice as likely to report that they are completely satisfied with their decision-making role than they were when we started in April 2009, and we’ve seen improvements in other areas as well.
I also want to give special thanks to IHI's Maureen Bisognano, who had a special role in stimulating our activities in this arena. Maureen had a friend in our ICU for some time. Afterwards, she said that the medical care had been extraordinary, but that other aspects of our care were substandard and outdated. She was absolutely correct. Beyond that criticism, she has been a loyal guide in our work.
Here is the more detailed explanation from our award application:
DECIDING WHAT TO IMPROVE: MOVING THE LOCUS OF CONTROL TO PATIENTS AND FAMILIES
Strategically, we believed that how we chose what to improve was tremendously important. To be truly patient/family-centered, patients and families should set our improvement priorities. We therefore developed two initiatives to address this critical issue:
ICU Patient and Family Advisory Council
We believed that ongoing, longitudinal guidance from our patients and families was critical. We therefore assembled the ICU Patient and Family Advisory Council, a group of former ICU patients and family members (of both survivors and non-survivors). Each Council member serves for one to two years. The group meets bi-monthly.
As the first advisory council for our hospital, we consciously sought a model that could be emulated by others. After we identified potential Council members, we had a thoughtful selection process, including in-person interviews by a social worker and by a member of the Critical Care Quality staff. This selection process resulted in a group of patients and families who provides exceptional advice and guidance.
To elicit the best possible guidance, each Council meeting is facilitated using careful focus group methods. Each session focuses on a different aspect of the ICU experience. Examples of topics include (among others): emotional support in the ICU, family meeting curriculum design, waiting room revitalization, overall prioritization of improvement opportunities, and others.
FS-ICU: Family Satisfaction in the Intensive Care Unit
Traditional hospital-wide patient-satisfaction tools (e.g. Medicare’s HCAHPS; Press Ganey) have significant limitations in understanding the ICU experience. However, the FS-ICU is emerging as one of the potential gold standards in assessing families’ ICU experience.1 This rigorously developed survey instrument captures key domains of the ICU experience and has undergone multicenter validation. In addition, the survey has three open-ended questions designed to solicit opportunities for improvement. The FS-ICU is administered to families of ICU survivors within three days of transfer out of the ICU; it is mailed to families of non-survivors several weeks after the patient’s death.
We began administering the FS-ICU in April 2008 (i.e. just over one year after the multicenter FS-ICU’s publication) and have surveyed nearly 400 families to date. Quantitative analysis allows us to detect targets for improvement and to follow improvements over time. Qualitative assessment of the open-ended questions ensures that our Advisory Council’s advice resonates with a broader sample of patients. In addition, because we administer surveys in-person and in near-real-time, our team can perform real-time problem solving and address issues as they arise.
GETTING BETTER: A PORTFOLIO OF FAMILY-CENTERED CRITICAL CARE
Based on themes and specifics gathered from our ICU Patient and Family Advisory Council and the FS-ICU, we began the journey toward comprehensive, meaningful patient- and family-centered critical care. Below is a selection of activities, limited by space:
Simulated Family Meetings: Residents provide a great deal of direct patient care, but the optimal way to train them how to conduct family meetings is not known. We have implemented a program in which all medical house officers (>150 physicians) now rotate through our Simulation Center, receiving didactic and high-fidelity simulation sessions on conducting family meetings. The ICU Advisory Council provided major input into the curriculum for this educational program.
Transitioning out of the ICU: The move from an ICU to a regular floor can be very stressful. Now, when patients transition from the Cardiovascular ICU (CVICU) to the floor, RNs from both areas perform a hand-off with the patient in the room with a focus on pain management requirements. Patients have a direct say in their care and in how their pain is managed.
Including Families on Multidisciplinary Rounds: For several years, families have routinely been invited to stay in the patient’s room during the exam and discussion in many of our ICUs. However, we believe this involvement should be expanded. In October of this year, we will begin a pilot to actively invite and include families on multidisciplinary work rounds. In order to help in moving the field forward, we are planning a meticulous effectiveness evaluation of this strategy, using time/motion analyses and the FS-ICU as outcome measures.
Standardized Communication at ICU Admission: Our Advisory Council provided guidance on what kinds of information was most helpful in the first day of a patient’s stay. This new introductory brochure covers information on staff roles in the ICU as well as the day-to-day logistics of visiting (such as parking). It also provides pointers to additional information and information about how family members should take care of themselves during this trying time.
Spiritual Care: Chaplaincy staff now actively solicit patient/family needs by pro-actively rounding in the ICUs. Spiritual care satisfaction scores have more than doubled (p =0.005). Our chaplaincy was recently covered in a major metropolitan newspaper.
Improving the Critical Care Experience
Waiting Room Revitalization: Our Advisory Council and FS-ICU results identified the waiting room as an important factor in satisfaction and a major opportunity for improvement. In spite of the economic challenges of the past year, our hospital dedicated capital to renovating a waiting room serving three of our ICUs. The renovation was designed with active input from our Patient/Family Advisory Council. Thus, the waiting room (now “Family Room”) included functions that are meaningful to our family. Opened in July 2009, we have seen marked improvement in the FS-ICU scores for the waiting room (p = 0.04).
Family Sleep Room: Providing the ability to stay close to loved ones is important. In tandem with our waiting room revitalization, we created two rooms to provide overnight accommodations for our families.
Eliminating Visiting Hours: Our Critical Care Executive Committee voted unanimously to support open access for families, eliminating formal visiting hours. This helps accommodate family members who work late and allows loved ones to visit at their convenience, rather than at ours.
Untethering Families from the ICU
Family Pagers: Our Advisory Council pointed out the feeling that they had to stay in or near the ICU at all times, in case anything happened. We now provide pagers (think Olive Garden) to families that allow them to go to the coffee shop, cafeteria, and nearby shops with the confidence that we can page them if they are needed. These have received rave reviews from families, nurses, and doctors alike.
Computers for ICU Families: Many families use email and social networking to update extended families and friends. Access to the web and email also allows some family members to keep up with some work/employment duties while being close to loved ones. In addition to ubiquitous wireless internet, we now provide public computers in our revitalized family room. These computers open a customized ICU website which includes links to online medical resources such as SCCM’s Official Patient and Family website.
CarePages: Our hospital contracted with Carepages to provide an infrastructure to support patient- and family-created blogs about their health challenge. These private and personalized web pages allow families to share the latest news with friends and family and receive messages of support, without the time and effort required to call large numbers of people.
This comprehensive, family-guided program focused on improving the family-centeredness of critical care in our nine adult ICUs. We believe there are two measures of evaluating its effectiveness:
Organizational commitment: In this challenging environment, hospitals cannot commit resources to ineffective programs. Besides being featured on our CEO’s blog, our medical center has supported this key effort in several ways. First, a half-time critical care nurse helps lead this work. Without this, our program would not have been successful. In addition, the Division of Critical Care Quality focuses the resources of the Director of Critical Care Quality (an MD) and a Masters-trained Critical Care Project Manager. Finally, we were fortunate to receive the capital support required for our waiting room revitalization.
Improvement in Outcomes: The FS-ICU provides an opportunity to rigorously measure family-centered outcomes of our work. In addition to statistically significant improvements in spiritual care and waiting room scores, we have seen consistent improvements in families’ rating of overall satisfaction with decision-making, which we believe represents a true outcome measure of our improvement work. In the baseline period (n=45 surveys), 40% of families reported complete satisfaction with their decision-making role. In the past six months, 66% of families report complete satisfaction with decision-making (n=95); in the past three months, 82% of families report this highest level of satisfaction (n=34). Mean decision-making satisfaction scores have correspondingly increased from 3.7 to 4.85 (p=0.005 for Spearman correlation between month and mean decision-making score).
1. Wall RJ, Engelberg RA, Downey L, Heyland DK, Curtis JR. Refinement, scoring, and validation of the Family Satisfaction in the Intensive Care Unit (FS-ICU) survey. Crit Care Med. Jan 2007;35(1):271-279.