To comply with new TJC standards, toss out restrictive visitation policies

Create processes that support participation of families, other partners in care

A set of guidelines for changing hospital visitation policies and practices released in August 2010 by the Bethesda, MD-based Institute for Patient-and Family-Centered Care (IPFCC) will help health care institutions meet standards for patient-centered communication issued by The Joint Commission and set to take effect in January 2011, says Joanna Kaufman, RN, MS, an information specialist with IPFCC.

In particular, the template addresses two standards created to enhance patient-centered communication. These standards, which appear in the section on patients' rights, read as follows:

— The hospital allows a family member, friend, or other individual to be present with the patient for emotional support during the course of stay.

— The hospital prohibits discrimination based on age, race, ethnicity, religion, culture, language, physical or mental disability, socioeconomic status, sex, sexual orientation, and gender identity or expression.

According to Kaufman, hospitals would definitely comply with these two standards by using "Guidelines for the Presence and Participation of Families and Other Partners in Care — A Template" to revamp restrictive visiting policies.

The implementation of this policy could impact the duties of patient education managers in several ways. They may be asked to use their expertise in clear communication to assist in providing information to patients and families about open visiting policies and what they entail. Clarification on the role of a partner of care may fall to the education department.

Patient education managers may be asked to produce educational materials on ways a partner in care can assist in patient safety efforts by asking clinicians if they have washed their hands before examining the patient or inquiring about the medications the patient receives to ensure the patient receives the right medicine.

In addition, the guidelines for changes in visitation policies could improve patient education, because four ears are always better than two, says Kaufman. Having a family member or designated partner present during teaching — listening and actively involved — is a way to reinforce the message, she adds. To support patient education further, the hospital could ask patients to identify a "partner in care" who will participate in the education that takes place during the hospital stay.

The initial report, titled "Changing Hospital 'Visiting' Policies and Practices: Supporting Family Presence and Participation," states that in order to change the prevailing view of families as visitors, they must be "respected as part of the care team — never visitors — in every area of the hospital, including the emergency department and the intensive care unit."

The guidelines for creating patient- and family-centered visitation policy suggests institutions develop systems and processes to "determine which family and friends the patient designates as 'partners in care,' and how they will be involved in care and decision-making as part of the admission process."

This may be the time when someone may be designated to participate in any education regarding the patient's care following discharge, says Kaufman. The person whom a patient designates to be present for comfort may or may not be the person who will monitor medications or assist with a special diet at home and thus be involved in education, she adds. Patients may need to be informed about the various ways family and friends can be involved, so they can make informed decisions.

In order to develop good policy on the presence and participation of families and other partners in care and materials to help educate on these policies, patients and families must be involved, says Kaufman. A consumer's point of view must be part of the process.

Kaufman adds that should a patient arrive at the hospital emergency department unconscious, staff should welcome whoever has arrived with the patient. This may be the next-door neighbor, but he or she should be allowed contact with the patient and valued as a source of information about key people the patient may want as partners in care.

Educating on roles

There are several ways a patient education manager can be valuable in implementing new policies and practices that support family presence and participation, according to Kaufman.

For example, the recommendations for change created by a task force of 14 people that included patients and their families suggest that institutions "provide guidance for patients and their families and other 'partners in care' that will help them be respectful of other patients and families who share the same patient room." Information on how to share rooms respectfully could be an area of education.

Also encouraged is providing information to families and other partners in care on "how to support the patient during the hospital stay and during the transition to home and community care." Details on supportive measures could be written up as an information sheet to reinforce education provided by the clinicians.

Clarification on what are considered disruptive behaviors and unsafe practices need to be provided for patients, families, other partners in care, and front-line staff.

"Having open visitation and involving patients and families doesn't mean there are not any rules," says Kaufman. What the IPFCC has found is that when patients are involved with the creation of policy, instructions, and plans, the rules are designed for the greater good of all patients. Therefore, this input strengthens the policy.

Kaufman explains that should a family protest because policy allows only one person to spend the night with the patient, they can be told the rules were created with patient and family input to serve most people with respect to the nurses and physicians in the hospital, as well as patients and families.

There may be areas of the hospital where special rules need to be applied, such as a newborn nursery, which may be locked to prevent babies from being stolen, says Kaufman. In these cases, families need to understand they may have to ring a bell before coming to see a new baby. Kaufman says there should be dialogue and discourse about the rules with patients and families along with written explanations.

Another area in which patient education managers might help patients and their partners in care is within the realm of good communication. Patients, families, and partners in care need to know they have the right to ask questions about the care being given.

In addition to helping patients and their partners in care understand their rights, patient education managers can help them better understand what questions they might ask to improve care and safety, says Kaufman.

Kaufman was one of the authors of the guidelines, and she says they support the philosophy of the IPFCC, which recognizes patients and families as essential members of the health care team.

The guidelines support a memo written by President Barack Obama to the Secretary of Health and Human Services in April 2010 that indicates a hospitalized patient has the right to decide who can visit them, participate in their plan of care, and make decisions for them in medical emergencies.

Kaufman said one reason the memo was written was to protect same-sex partners who were not allowed into the hospital room, because they were not recognized as husbands or wives. Sometimes people died without seeing the people they loved, she added.

The memo came out at the same time the IPFCC was conducting a large training seminar in Dallas. It was shared with the audience, and the nurses, physicians, administrators, and families in attendance asked if the institute could create a task force to address the concerns of the president. Although the policy was in the making for a long time, the memo provided a catalyst, said Kaufman.

Changes to visitation policies need hospitalwide participation, according to the IPFCC. An interdisciplinary committee should be involved in implementing, monitoring, and evaluating the guidelines. Committee members should include patient and family advisors and representatives from clinical areas, patient relations, security, housekeeping, dietary, risk management, and other relevant departments.


• Joanna Kaufman, RN, MS, Information Specialist, Institute for Patient-and Family-Centered Care, 7900 Wisconsin Ave., Suite 405, Bethesda, MD 20814. Telephone: (301) 652-0281. E-mail: Web site: (The document "Changing Hospital 'Visiting' Policies and Practices: Supporting Family Presence and Participation" that includes the guidelines for writing policy can be downloaded from this website.)