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The newest new thing

August 2008

Let’s talk about family-centered care.

I can already hear the groans from some of you: “Not again!” “I’ve tried it, and it didn’t work.” “The residents hate it!” Believe me, those moans will subside–just ask my residents. (Maybe they moan and groan when I’m not around!).

We’ve all heard the complaints about family-centered care and the problems with time management, privacy, too little bedside education. Don’t be discouraged. We’ve all been there. Some of us still struggle with implementation, and there are new challenges to maintaining and growing any system of family-centered care.

First, some background and a clarification.

The Institute of Medicine, in its 2001 “Crossing the Quality Chasm: A New Health System for the 21st Century” , included patient-centered care as one area to develop quality measures. The IOM defined patient-centered care as “providing care that is respectful of and responsive to individual patient preferences, needs, and values and ensuring that patient values guide all clinical decisions.”

The idea is basic and not new: involving patients directly in decisions that affect their health care. Somewhere between the business revolution of the 80s (long live Gordon Gekko!) and the information revolution of the 90s (long live Steve Jobs!), we forgot that patients are sort of important. After we stopped looking at CNBC’s stock ticker, we realized “Hey! This is not ‘the appendicitis’ but ‘Mr. So-and-So, the PATIENT with appendicitis’. Imagine that!

Family-centered care involves patients not only in decisions regarding what tests to undergo or which diagnoses to consider. It expands into the realms of quality assurance and improvement; the re-design of health care enterprise processes; even things like physical plant design and choice of cafeteria food. If the dogma for business is “the customer is always right” (not Gekko’s “Greed is good”), the mantra for family-centered care is “the patients and their family members are at the center of every aspect of the health care delivery system.”

This view is validated by national data that suggest that patient centered care improves health outcomes and patient satisfaction. (The list of references for this last statement is way too long to include here, but I’ll be glad to provide it upon request.). Family-centered–or patient-centered, relationship-centered … every time I turn around, the nomenclature changes, although not the intent–is here to stay. And that is good.

Now here’s the clarification: family-centered care is NOT ONLY bedside rounding.

Yes, bedside rounding is an integral part of family-centered care. The American Academy of Pediatrics, in its policy statement on family-centered care, highlighted the importance of rounds by stating, “In hospitals, conducting attending physician rounds (i.e., patient presentations and rounds discussions) in the patients’ rooms with the family present should be standard practice.”

Bedside rounding consists of several elements, some of which can be adapted to specific situations or institutions. But the bottom line is the same: to invite the patient and/or the family into the conversation regarding their care, and establishing with them the goals to be accomplished during the hospitalization.

Once barriers have been identified to make those bedside rounds happen, then it’s time to move beyond the bedside and bring a family-centered emphasis to other parts of your institution and other aspects of hospitalization.

There are several approaches to this. You can try to recruit a champion among the high-powered players in your organization (preferably a chair or a dean … you know, someone whose title actually means something) to proclaim that family-centered care is The Thing.

If you’re not lucky enough to have such a bigwig, other strategies include: establishing a certification process to label the hospital a “family-centered institution”; creating faculty development tools to spread family-centered care to other departments; and networking with colleagues in the subcommittee of family-centered care of AAP’s hospital medicine section.

Another idea is to involve the medical students early on in their education, so when they come up the ranks, they’ll be used to a family-centered rounding process. The same for anyone who wears a badge that says “ACME Hospital,” including residents, nurses, respiratory therapists and child-life specialists. (Actually, child-life is usually the most family—centered component in a hospital.) Early involvement and buy-in usually create a groundswell of support that will remove many of the real and perceived barriers.

Most importantly, try to create partnership opportunities with patients and families. One way is to create an advisory board, which can offer counseling any time a new hospital-wide initiative–a new parking structure, radiology service or cafeteria menu–is proposed. After all, family-centered care encompasses those areas too.

Oliver Sacks, in the preface to his awesome book “The Man who Mistook his Wife for a Hat and Other Clinical Tales,” wrote that, “To restore the human subject at the centre … we must deepen a case history to a narrative or tale.”

Can we really listen to a patient’s tale behind a closed door? Family-centered care is the way to restore the human subject to the center, so no more moans and groans (unless you’re talking about hyperparathyroidism!)