Published in the April 2014 issue of Today’s Hospitalist
DAVID SHULKIN, MD, remembers the moment he decided to put an end to his hospital’s policy of limited visiting hours. Morristown Medical Center in Morristown, N.J., where he serves as president, wanted to introduce a friendlier version of the announcement broadcast at 8 p.m., asking visitors to leave. Dr. Shulkin was asked to review it.
“As I was reading this announcement,” he recalls, “I thought to myself, ‘Why are we doing this at all? No one wants to be asked to leave their loved ones. If they were ready to leave, they would leave on their own.’ So we cancelled the announcement and began figuring out how we could open the hospital to visitors around the clock.”
In April 2012, the medical center unveiled its new open-visitation policy, with friends and family members able to visit patients 24/7. Published online last year by the Journal for Healthcare Quality, the study based on that new policy points out that in the first eight months of the program, the hospital saw more than 14,000 “after-hours” visits. About 80% of those visits took place between 8 p.m. and 10 p.m., with just over half visiting med/surg floors.
To accommodate the new policy, the hospital “a 690-bed tertiary facility “beefed up security for visitors coming between 8 p.m. and 5 a.m. Visitors have to check in with a security guard who not only calls the floor to make sure that a patient wants visitors, but also runs a background check on those visiting.
Open visitation was such a success that other hospitals in the Atlantic Health System, which is Morristown’s parent organization, are now rolling out the same policy. Dr. Shulkin talked to Today’s Hospitalist about his hospital’s new approach.
Why was it important to increase security for after-hours visitors?
We were concerned that because there aren’t as many staff in the hospital at night, there might be security problems. Our biggest concern was disorderly or disruptive behavior.
We put in place a system to control who comes into the hospital at night. During the day, almost anybody can walk in. But after hours, visitors have to check in with security staff. We run a background check on visitors by searching several databases for outstanding felony warrants, restraining orders and other potential issues. It’s a detailed search, but it’s fairly quick.
When we find estranged family members or custodial issues, our security staff doesn’t allow visitors access. We also don’t let in people with felony convictions or restraining orders.
Otherwise, visitors are welcome?
Before visitors are let up, we call the floor to make sure patients want visitors. And if there’s something taking place on the floor, like a cardiac arrest, we ask security to not let visitors up. We’re putting patients’ needs first, the clinical needs of the unit second and visitation third.
During the flu season, for example, we make sure visitors who are coughing and sneezing don’t go up to the floors. Clinical needs always trump visitation.
Out of the 14,000-plus after-hours visits we saw during the first eight months, we denied entrance to only 22 visitors. Eighteen posed a security risk because of outstanding felony warrants or some other issue, and four were denied access by patients. But if even one-third of those 22 had turned out to be a problem on the floor, that could have been enough to sink the whole program.
Did the hospital have to add extra security staff?
We did not. We certainly added to the workload of staff, but no additional staff or expenses.
What was the impact on nurses?
The literature on open-visitation policies indicates that the strongest objections come from nurses. That’s because limiting visiting hours gives nurses some needed down time to care for patients.
So we were concerned about how nurses would react, but I haven’t received a single complaint. I think that’s in part because we got nurses involved in the process very early on. We didn’t come out and say, “We’re going to do this and you should learn to like it.” We asked for nurses’ feedback and their help designing the policy.
We also made it clear that we were changing visiting hours to improve the patient experience, not to make more money or get more work out of employees. I think our staff embraced that message.
When we surveyed 21 nurse managers about the program, all said that it had a positive or very positive impact on the patient experience. We’ve also had nurses tell us that there is often less demand on nursing staff when family members are there to, say, get the patient a washcloth or glass of water.
What kind of patient feedback did you get?
We’ve received a lot of feedback that patients seem to be calmer when family members are around, particularly patients who were confused or disoriented. Being in the hospital can make patients anxious, and it can be socially isolating. The more patients are with people they’re comfortable with and they know care about them, the better it is for the whole healing experience. While we don’t have quantitative data to suggest that, qualitatively we feel that’s exactly what the revised visiting hours are doing.
Your hospital has semi-private rooms. How did that affect allowing after-hours visitors?
If somebody wants to have a visitor and it’s late, we’ll take the patient and the visitor into a patient lounge.
What was the impact on physicians?
We encourage family members to speak up when they have concerns or questions, so extending visiting hours puts additional demands on physicians and residents. But that’s deliberate, and we want that to happen. If there is dissatisfaction, we would rather facilitate a dialogue with the physician at the time, not read about it afterwards in patient satisfaction scores or complaint letters.
Your patient satisfaction scores did go up a little, but the data weren’t statistically significant. Was that a surprise?
Not really. When you look at the questions we ask as part of HCAHPS, it’s not a surprise that visiting hours didn’t make a big impact. We ask if the bathrooms are clean and how well the staff explained medications, so I did not expect to see a spike in satisfaction rates.
What recommendations would you make to hospitals considering open visitation?
Do the homework up front and get all the stakeholders together to plan how and when open visitation should be done, what entrances to use, what kinds of signage the hospital will need, and how to communicate the policy to everyone. And definitely bring nurses into that planning process.
Edward Doyle is Editor of Today’s Hospitalist.
Morristown Medical is certainly not the only hospital looking to extend its visiting hours. A July 2014 article in The New York Times highlights a campaign, Better Together, that is working to “persuade hospitals to eliminate restrictive visiting hours and permit families, broadly defined, to remain with loved ones throughout their stays, even in intensive care units.”