1. Institutional Assessment: ICU Open Visitation
By: Kalyn Skinner, Lynn Carroll, Lauren Studdard, and Tara Fountain
Auburn University/ Auburn University Montgomery

2. Overview 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
ICU Visitation

3. Nature of the Change
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)
Evidence has shown that unrestricted presence and participation of a support person can enhance patient and family satisfaction when admitted to the ICU. Unrestricted presence can improve communication, facilitate better understanding of patient condition, enhance staff satisfaction, and improve patient centered care (Bell,2011).
EAMC currently has a closed visitation policy that allows visitors access to patients 5 times a day at 30 minute intervals. Many family members are very uncomfortable leaving their loved one’s side, and many find it difficult to make the set visitation times. Implementing a policy that allows family presence all hours of the day will increase patient and family satisfaction. Family members will be able to come and go when it is convenient for them.

4. Theories of 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
Lewin’s Change Theory: 3-Step Change Theory
Unfreezing:
Involves finding a method to let go of an old pattern that is counterproductive.
Necessary for overcoming strains of resistance and group conformity.
Achieved by increasing driving forces and decreasing restraining forces.
Moving:
Involves a process of changing thoughts, feeling, or behavior that is more productive.
Refreezing:
Involves establishing the change as a new habit, so now it is the “standard”.
Without refreezing, it is easy to go back to “old ways”.
Roger’s Diffusion of Innovation Theory
Refers to the process that occurs when people adopt a new idea, product, practice, or philosophy.
Initially, only a few are open to the new idea and adopt its use. As the word is spread, more people become open to the idea and adopt its use.
“The Diffusion of Innovation theory is a very important theory that can serve administrators, information technologists, nursing informatics experts, and change agents well…respect and consideration for all involved stakeholders is intertwined with robust strategies for implementing innovative change” (Kaminski, 2011, conclusion section, para.1 )
5 Categories of Adopters:
Innovators: The Change Agents
Early Adopters: Visionaries
Early Majority: Pragmatists
Late Majority: Conservatives
Laggards: Skeptics
5 Stage Adoption Process
Awareness: Exposure to the new idea
Interest: Interest in the new idea
Evaluation: Application of idea to current situation
Trial: Performing a trial of the new idea
Adoption: Continue the new idea into practice
Lippitt’s Phases of Change Theory:
Focuses more on change agent than the evolution of the change itself.
7 Stages:
Diagnose the problem.
Assess the motivation and capacity for change.
Assess the change agent’s motivation for change.
Develop action plans and strategies.
Select the appropriate role for the change agent.
Maintain the change.
Gradually terminate from helping relationship.

5. Compare and Contrast 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.

6. Analysis of Theories: Assessment
A need for change is assessed:
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
When assessing for change, these three theories provide similar instruction. In order for change to take place, a need for change must be identified.

7. ICU Open Visitation Policy and Change Theory
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.
In reviewing the assessment aspect of these three change theories, we found…

8. Lewin’s Theory of Change
Picture adapted from (Mitchell,2013, p.33)

9. Driving Forces (Rollins,2005)
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

10. Restraining 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

11. Significant Stakeholders
Patients
Families
All hospital employees
Physicians
Healthcare Organization
Patients and families will benefit from an open visitation policy. Evidence has shown that patients prefer to be given a choice for visiting preference and that most prefer to have family near for support(Cypress,2010).
In order to receive reimbursement from the Center for Medicare and Medicaid Services (CMS), hospitals must meet standards set by the Joint Commission (JCAHO). In 2011, JCAHO released a practice change that called for patient-and family-centered care that would allow patients to choose whether they wanted to have family present or not. This standard set by JCACO must be met in order for certification to be received. Therefore, the hospital must implement this change in policy in order to continue to be reimbursed.
Physicians will benefit from this change in that they will be able to provide better communication with families and understand the patients better from additional patient information obtained from the family.
Overall compliance with these change will assist the healthcare organization in meeting the Institute of Medicines (IOM) standards of care and increase hospital overall patient satisfaction. “Systems by which health care is delivered and financed must be designed to ensure that care is safe, effective, efficient, equitable, and tailored to each individual’s specific needs and circumstances” (as cited in Porter O’Grady & Malloch,2010, p.290).

12. National Mandate and Policy
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
In 2010, a Presidential Memorandum called upon the Department of Health and Human Services to create new rules for Medicare and Medicaid participating hospitals to expand patient rights. Included was a mandate that would require patient respect regarding the patients’ right to choose who may visit while they are an inpatient of a hospital (Obama,2010).
The rules require hospitals to have written policies and procedures detailing patients’ visitation rights, as well as situations when hospitals may restrict patient access to visitors based on reasonable clinical needs. One provision of the rule states that all visitors chosen by the patient must be able to enjoy full and equal visitation privileges consistent with the wishes of the patient (Obama,2010).
The rules update the Conditions of Participation (CoPs), which are the health and safety standards that all Medicare and Medicaid participating hospitals (and critical access hospitals) must meet. The rules are applicable to all patients of those hospitals regardless of payer source.
The Centers for Medicare and Medicaid Services (CMS) have approved and issued these new rules. The Joint Commission (formerly the Joint Commission on Accreditation of Healthcare Organizations, JCAHO) has joined forces with CMS, adding these rules to their Patient Rights Chapter of Joint Commission Standards (CMS,2010, JCAHO,2011)

13. Resistance to Change 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 is an inevitable part of any change. Change takes individuals out of their comfort zones, increases stress, and changes workflow leading to resistance ( Mitchell,2013)
Many healthcare associates are afraid that opening the ICU to visitors will impede their ability to get things done.
Nurses may feel loss of power or control as their workload and worries increase, in an already demanding environment (Berwick & Kotagal, 2004).

14. How to Create Change Change is Vital Lewin’s Theory of change
Force field analysis
Increase knowledge
Strategies for decreasing resistance
Planned changed in a healthcare organization is a necessary thing but is often times very challenging. The use of a change theory framework can be utilized by change agents to help the the change be more successful (Mitchell,2013).
Force field analysis is a framework for problem solving developed by Lewin that illustrates restraining forces cannot be removed but can be countered by increasing driving forces (Mitchell,2013).
The restraining force placed from the hospital staff resistance to this change cannot be removed without an increase in knowledge. Change agents must provide individuals with education and rationales on why this change is necessary and how it will benefit their patients.
Strategies for decreasing resistance must be established.

15. Strategies for Addressing Resistance
Education
Set Guidelines for families
Rules must be clear
Staff-patient communication
Mandate from Medical Executives to MD’s regarding compliance with change
An extensive communication program will be used to educate both family and staff on the true meaning and purpose of open visitation.
Important guidelines will be drafted to give to each family that will inform them of rules and regulations (IHI,2011)
Families will be educated on the appropriate time to approach the physician and when it is best to let their loved ones rest.
The nurses and physicians will also still reserve the right to remove the family member if they feel the patients status is declining or their presence is truly impeding patient care.
Reassure families that if they leave the unit, we will immediately call them if there is a change in patients status.
Education will be provided to all staff on how to best communicate with families, including how to ask family to leave if needed.
Physicians will understand and be more compliant with change if medical executives approach them with the change and explained to them the need and importance of this change.

16. Parties with Vested Interest
Nurses
Families
Healthcare System Administrators
Nurses will be required to educate families more often and more extensively, while trying to meet the needs of the families as well. Other areas of concern will be safety for employees and patients, infection control, patient privacy, and patient comfort. If nurses are allowed to allocate visiting hours per individual case, they must maintain fairness between families. 
Families may feel a gain in power over the control of their loved one’s care and the overall situation of having a family member in ICU. 
The health system will feel accomplished in providing care based on the patient-centered model and consumer-driven economy, and it may see gains in the financial aspect, as well as patient satisfaction and value-based purchasing. This will best be accomplished by applying the combination of Lewin’s change theory and quantum leadership strategy and proactively addressing employee resistance to change by incorporating education and sensitivity training before implementing visiting policy changes.

17. Human Drivers Families Management ICU committee Administrators
Nursing staff
JCAHO
CMS
50% of nursing staff feels that open visitation policy will be a positive change for the ICU
Family presence in the ICU will also give them a better understanding of their family members condition, and will help them understand the severity and complexity.
Human Drivers
Achieved differently per individual
Do not have equal importance or may change in rank of importance
Especially influenced by traumatic life events
Seek constant fulfillment of drivers whether by negative, neutral or positive means
Influenced by time, experience, environment, culture and peers

18. Human Emotional Drivers
Belonging / Love 
Control/Security 
Diversity/Change 
Recognition/ Significance 
Achievement 
Challenge/ Growth 
Excellence
Responsibility/ Contribution 
By understanding human drivers and how they are influenced, nurses may be better equipped to handle the psychosocial and emotional responses of patients and their families because of and during their experience in the ICU.

19. Human Resistors Nurses Support Staff Physicians
Some physicians feel that open visitation will cause them to be over-run with family questions.
Seasoned nurses that have been working in the ICU for many years are very uncomfortable with family presence in the room. They have become adjusted to having a closed door policy and find it very disruptive and “unsafe” to have families in their way.

20. Resource Implication Employee training and education
Palliative care team, unit-specific
Increase security
More materials for family accommodation
Signs to display new policy and rules
Financial implications of training employees for change
Increased security for increased risk of adverse situations
More materials to accommodate families, (i.e., snacks, cups, blankets, etc.)

21. Theory-Based Impact Evaluation (White,2009)
Map out the causal chain
Understand context
Anticipate heterogeneity
Rigorous evaluation of impact
Rigorous factual analysis
Theory-Based Impact Evaluation (White,2009)
Map out Causal chain
Links the theory of change (Conceptual change) to how the intervention is expected to impact the organization
Understanding context
Crucial to understanding program impact
The social, political, economic setting where the change takes place
Context for this project is hospital setting, which is a social environment with many individuals that have varying views
Political influence placed by CMS and JCAHO
Anticipate Heterogeneity
Impact of intervention may vary according to intervention design, socio-economic setting, and individuals involved
Detailed policy and procedure will assist in providing a design that is uniform for all patients
Patients and their families come from a wide variety of socio-economic backgrounds. Education level and family values may have a huge impact on success of change.
Nurses and physicians resisting the change with negative attitudes and complaints will also affect the success of change.
Rigorous evaluation of Impact
Collections of qualitative data using satisfaction survey for staff, families, and patients
Factual analysis
Compare patient satisfaction surveys from pre-intervention to post- intervention to determine the quality of change

22. Evaluation 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
Theory-based evaluation in the form of satisfaction surveys should be utilized.
Patients and their families should be asked to complete a satisfaction survey. This survey would provide information to the hospital regarding their success toward patient- and family-centered care initiatives. Assessment of the family’s ability to assist with care planning, clarifying information, and re-enforcement of patient education can be utilized for on-going updates and changes. (Treasury Board of Canada Secretariat,2012).
The institution as well should have internal surveys to include continuous assessment of infections and infection risks, staff safety, patient privacy, and increased workload for the staff. Employee satisfaction is important to ensure a harmonious environment.

23. References
Bell, L. (2011). Family presence: Visitation in the adult ICU. Retrieved from American Association of Critical Care Nurses website:
Berwick, D. M., & Kotagal, M. (2004). Restricted visiting hours in icus: Time to change. Journal of the American Medical Association, 292(6), /jama
Cypress, B. S. (2010). The intensive care unit:Experiences of patients, families, and their nurses. Dimensions of Critical Care Nursing, 29(2),
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), Retrieved from
Institute for Healthcare Improvement (2011). A challenge accepted: Open visiting at the ICU in Geisenger. Retrieved from
Joint Commission (2011). Patient-centered communication standards for hospitals:R3 report requirement, rationale, preferences (3). Retrieved from
Kaminski, J. (2011). Diffusion of innovation theory. Canadian Journal of Nursing Informatics, 6(2). Retrieved from  
Kristonis, A. (2005). Comparison of change theories. International Journal of Scholarly Academic Intellectual Diversity, 8 (1), 1-7. Retrieved from
Mitchell , G. (2013). Selecting the best theory to implement planned change. Nursing Management, 20(1), Retrieved from
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), Retrieved from
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:
Treasury Board of Canada Secretariat (2012). Theory-based approaches to evaluation:Concepts and practices. Retrieved from