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Documente Cultură
Creating Patient-Focused,
Family-Centered,Maternal-Child
and Pediatric Healthcare
I
n 1995 Mount Sinai Hospital (MSH) changed its care delivery model to patient-focused care (PFC). Changing the philosophy of a large, urban, tertiary care, academic medical
center from a provider- to a patient-focused model was a
daunting challenge. This article describes the creation of patientfocused maternal-child healthcare. The process, challenges and
opportunities, and outcomes, as experienced by the clinical and
operational directors (the coleaders of the redesign effort in maternal-child health) are shared.
Historically, maternity care and childbirth occurred in the
home and in the company of family and caring women. As childbirth moved into hospitals in the late 19th and early 20th centuries, families were unwelcome. The economically volatile
healthcare environment of the 1990s gave rise to dramatic
changes in healthcare delivery models and hospitals. Reengineering, right-sizing, and downsizing became commonplace. Many
hospitals chose to use family-centered care to increase births and
market shares. Incorporation of the family into maternal-child
health requires a shift in philosophy, from institution- or
provider-focused to patient-focused, family-centered care.
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MSH had been esteemed in the academic and scientific
communities. However, when asked for their impressions,
patients responded that staff at Mount Sinai are very
smart, but they are not nice. Patient satisfaction was fair,
with the satisfaction of the Womens and Childrens Division ranking lowest in the medical center. The MSH embarked on a project to radically change the culture of the
hospital by adopting a model of PFC. PFC places the patient at the center of the healthcare system and builds services and processes to better meet the needs of the patient
and family. Utilizing a decentralized model of governance,
PFC pushes decision making to the local level, empowering
staff to make clinical and economic decisions in redesigning
the processes, practices, and environment of care.
Care Centers
The project began in 1995 with the creation of eight Care
Centers, based upon patients clinical needs. These Care Centers were: Cardiac, General Medicine, G.I and Surgical Specialties, Maternal-Child Health, Oncology, Neuroscience and
Restorative, Perioperative, and Psychiatry/Mental Health.
The composition of the Care Centers was based on data
from inpatient admissions, rather than on provider preferences. Consequently, the sizes of the Care Centers varied,
with Maternal-Child and General Medicine being the largest.
The reengineering process occurred over a period of 2 years,
beginning with inpatient services. Later, the related ambulatory care practices were integrated, creating a continuity model.
The Patient Focused Care Association (PFCA) identifies
the restructuring steps as: (a) understanding the organizations baseline in factual terms, (b) reaggregating patients
and staff, (c) decentralizing services appropriately, (d) designing job roles to the work needs and positioning those
into multidisciplinary teams, (e) documenting the restruc-
tured policies and procedures, and (f) installing technological, financial, or personnel systems that support the restructured environment (Kremitske & West, 1997, p. 23).
These steps were applied in the redesign efforts at MSH.
Goals
The goals of the MSH redesign to PFC included:
improving quality of care, within a framework of total
quality management;
improving patient satisfaction;
improving staff satisfaction;
increasing continuity; and
decreasing costs.
Quality of care was the overriding principle, and it guided the project. Improving staff satisfaction was essential.
Staff satisfaction was measured biannually using a written
survey, as well as through focus group interviews at the local level. All levels of staff participated in every redesign
team, in the selection of leaders, and in newly created hospital and nursing committees. Most recently, a multi-disciplinary task force of employees restructured employee benefits resulting in enhanced healthcare coverage. Additionally, we formalized an employee recognition and appreciation
program with participation of staff from all areas of the institution. Staff were encouraged to participate and to appreciate and recognize their colleagues and their own contributions to the hospital, patients, and community.
Another redesign objective was to reduce costs. The hospital planned to achieve $30 million in annual savings due
to the elimination of costly layers of bureaucracy, redesign
of inefficient systems, decentralization of authority, and
multiskilling of ancillary staff. With process redesign, including clinical initiatives such as a Pediatric Asthma Pro-
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Redesign
Mount Sinais management team began the project by
reengineering themselves. The table of organization was redrawn. In Nursing, the levels of Vice President, Associate
Director, Clinical Director, Assistant Director, Supervisor,
Senior Clinical Nurse, and Staff Nurse were consolidated
to: Vice President, Clinical Director, Clinical Nurse Manager, and Clinical (staff) Nurse (see Figure 1).
A new Vice President of Nursing with a strong background in professional practice was recruited by the hospital to redirect and strengthen the nursing service. Leadership for each Care Center would be provided by two codirectors: one a Clinical Director and one an Operational Director. The Clinical Director was to be a role clearly defined as a registered nurse with a minimum of a Masters
degree in nursing and demonstrated leadership and expertise in a clinical specialty. The nurse would be responsible
for all clinical services within the Care Center. The Operational Director, prepared at the Masters level in business
administration, would be responsible for the business and
support functions. Together, the codirectors would manage
the Care Center, which encompassed all decentralized services, creating a mini-hospital. Care Center Directors assumed responsibilities previously held by centralized administrative personnel, such as support services, quality assessment and improvement, addressing patient complaints,
marketing, labor relations, and risk management.
The first order of business for the codirectors was to assemble a management team within the Care Center. For Maternal-Child Health, it included the selection of 12 clinical
nurse managers, one for each patient care unit and outreach/educational programs, and two Operational Managers, one for business (which included admitting, unit receptionist, and billing staff) and one for support (which included housekeeping, transportation, and supply management). Each manager would have administrative and financial responsibility for the decentralized departmental budgets
and 24-hour responsibility. Absent were charge nurses or assistant nurse managersrelics of the old hierarchical system.
Evening, night, and weekend leadership support was redesigned. The role of the off-shift Nursing Administrator,
reporting to a Clinical Director, was created. The new administrative role was realigned within the Care Center
structure to cover two Care Centers while on duty. The
former title of Supervisor, reporting to a separate
Evening/Night Director, was eliminated. The new administrative role, for which incumbent supervisors were invited
to apply, reported directly to the Clinical Director, thus creating one management team.
Kathleen Leask Capitulo is Clinical Director, Maternal-Child Health Care
Center, and Associate Hospital Director, Mount Sinai Medical Center, New
York. She can be reached via e-mail: DrKathieRN@hotmail.com
Marta Cuellar Silverberg was Operational Director, Maternal Child Health
Care Center, and Associate Hospital Director, Mount Sinai Medical Center,
New York.
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Once the majority of the management team was established, the Care Center leadership met on several occasions
to develop a common vision and philosophy for MaternalChild Health (see Figure 2). The new leadership team
agreed that a core value of the Care Center was family-centered care. Families are at the heart of caring for women
and children. According to Bolman and Deal (1997, p.
346), caringone persons compassion and concern for
anotheris both the purpose and the ethical glue that hold
a family together...A caring family, or community, requires
servant-leaders who serve the best interests of the family
and its stakeholders. Thus, we began to design a new, caring, family-centered philosophy for patients and staff. The
vision and philosophy of the Maternal-Child Health Care
Center was consistent with the mission of the hospital
(founded in 1862 to serve New Yorks poor immigrant
community): provide service to the community, quality
care, research, and education.
To design each Care Center, interdisciplinary teams were
convened. For inpatient Maternal-Child Health, which included 220 inpatient beds and 5,000 annual births, this
represented four teams that worked over a period of 15
months. Initially, two teams were charged: one for Labor
and Delivery (L&D) and another for Postpartum services.
Both teams ran simultaneously and were led by one of the
Codirectors and facilitated by a group leader expert in PFC
November/December 2001
redesign. Membership on the team consisted of representatives from each discipline, department, and service within
the area being redesigned, as well as the Clinical and Operational Managers.
In addition to nursing and business operations, core services would be decentralized, including Social Work, Utilization Management, Respiratory Therapy, Pharmacy, Nutrition, Physical Therapy, Occupational Therapy, Child
Life, Communication Disorders, Housekeeping, Admitting,
and Transportation. Calculation of resources to be decentralized was accomplished by analysis of the history of the
areas use of corresponding core services over the past year.
For example, assuming that the inpatient obstetric units
had consumed $400,000 in housekeeping services for the
past year, $400,000 from the core housekeeping department would be reallocated to the Care Center less savings
of 10% to 15% for staff positions and 30% for supervisory positions. Therefore, the Care Center would receive
10% to 30% less of the resources, for assuming 100% of
the decentralized activity.
Key savings and improvements would be accomplished
by process redesign subgroups of the redesign teams,
which would identify opportunities to change traditional,
often bureaucratic, processes and redesign them to increase efficiency and enhance value for patients. Redesign
teams met weekly for 4 consecutive hours. Leaders, facilitators, and subgroups met more frequently, reviewing the
work in progress. Monthly presentations were made to an
Executive Reengineering Committee, chaired by the Hospitals Director. To inaugurate each team, each member
participated in a 2-day workshop lead by a professional
facilitator skilled in PFC and group process.
Registration
Preadmission
Intake
Labor and Delivery Surgery Schedule
Mother/Baby Nursing Assessment
Transfer of Mother and Baby Together
Amenities
Breastfeeding
Visiting Hours
Stocking Supplies
Surgical scrubOb. Technician
Placenta Disposition
Birth Certificates
Chart Preparation
Prenatal Charts: Clinic to Labor & Delivery
Food for Labor Coaches
Mother-Baby Primary Nursing
Breastfeeding
Visiting Hours
Childbirth Education and Lactation
security for full-time CBU staff employed prior to a mutually agreeable date.
The MCH Redesign Teams also identified the need for
three additional positions, which were created during the
redesign phase:
Job Redesign
Prior to the implementation of the Care Centers, an interdisciplinary committee from all areas of practice created
multiskilled, nonprofessional jobs that would be used in
the Care Centers. In addition to the leadership and professional positions, three ancillary positions were created:
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Process
Redesign
Postpartum Team
Attending
Obstetrician,
Faculty
Attending Obstetrician, Voluntary
required 18 pages to dia Attending Obstetrician, Voluntary
Lactation Consultant
gram, was inefficient,
Director of Newborn Medicine
cumbersome, and was
Social Worker
deemed unfriendly by patients. Teams recreated
Social Work Supervisor
processes, reducing the
Ambulatory Care Manager, Obstetrics
number of steps and elim Anesthesiologist
inating hand-offs to
other personnel. For exduring the evening for 2 hours. Husbands were welcomed at
ample, in obstetrics 20 process redesign teams were
any time during the day. New policies were predicated on a
charged (see Figure 3). The teams were comprised of reprenew definition of family: anyone who is designated by the pasentatives from all disciplines and role categories (see Figtient to have a significant role in her or his life. Family visiting
ure 4). In the last month of design, the L&D and Postparwas open throughout the day. Children became welcomed
tum teams were combined to refine and coordinate the
visitors, even in L&D. In Maternity, the new process bands a
work of the teams.
primary visitor (spouse, significant others, partners, or anyFeedback from patients was key in redesigning the sysone designated by each mother), the mother, and the newtems. Patient-focused group interviews (FGIs) were held for
born. Primary visitors are now welcomed at any time, includeach redesign team to elicit suggestions and feedback. At
ing 24-hour visiting in single rooms. Recommendations were
the beginning of the focus group, participants were told
made to families to keep visits short to promote the mothers
that were about to redesign the maternity and pediatric
rest and to limit the number of individuals in the room at any
services and wanted their [patients] input. Two questions
one time for safety reasons.
were asked: What do we do that we should change? and
A major theme of the patient FGIs was the need for lactaWhat do we do well that we should keep?
tion support. Hence, a Breastfeeding Committee was launched
Groups were facilitated by a focus group expert from
that created an institution-wide effort to promote a Baby
the Human Resource Department. Care Center Codirectors
Friendly environment, the gold standard of the World Health
attended as nonparticipant observers. Data were analyzed
Organization, recognizing hospitals that support breastfeeding
and major themes were identified. Feedback from the FGIs
families. Other changes resulting from FGI findings included:
were shared at redesign meetings with team members and
creating child-friendly menus, and the purchase of rockers,
incorporated into the redesigned processes. For example, in
clocks, and sleeper chairs in Pediatrics. In Obstetrics, a major
Obstetrics, patients voiced their lack of satisfaction with
renovation to create single-room maternity care has been
visiting hours, which were perceived as limited and puniplanned based on patient input from the FGIs.
tive; the lack of a comprehensive breastfeeding program,
although they highly valued the lactation consultants; fragPrimary Nursing
mented nursing care; the transfer of mother and baby separately from L&D to Postpartum; and the antiquated maA major redesign effort was the adaptation of Cliffords
ternity facility. In the Neonatal Intensive Care Unit (NICU),
(1990) professional practice model for Mount Sinais Nursparents identified the need for more chairs and clocks, and
ing Department, including primary nursing. Oversight for
better continuity of nursing care. In Pediatrics, parents and
the discipline of Nursing provided by the Vice President for
children voiced a desire for a child friendly menu and
Nursing as the Chief Nurse Executive, and the Nursing Exmore amenities for patients and parents.
ecutive Committee, comprised of the Clinical Directors, DiAs a result of the redesign, visiting-hour policies were drarector of Nursing Professional Practice and Informatics,
matically changed and an open, family-centered visiting enviand Director of Nursing Education, Recruitment, and Reronment was created. Previous maternity visiting policies limtention. At a local level, Nursing was under the auspices of
ited grandparent and sibling visiting to only 2 hours during
each Care Centers Clinical Director. In Obstetrics, a rethe afternoon. Other family and friends were welcomed only
design team planned and implemented primary nursing,
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Pediatrics
The three general Pediatrics units were redesigned from a
developmental, age-related model, to a clinical model, creating a Respiratory Unit, a Hematology/Oncology Unit,
and a Cardiac/GI and other specialties unit. Initially, several
members of the redesign team resisted the concept of a
clinical model. Politics, power, and rivalries among the clinical subspecialties denied identification of clinical needs.
For example, the idea of identifying an asthma/respiratory
cluster of patients was unpopular. However, the work of
the team was guided by data. A smaller group of nurses
and physicians poured through hundreds of pages of data,
validating that asthma and respiratory illnesses were the
primary admitting diagnoses in pediatrics. Hence, a Respiratory Care Unit (RCU) was created. The transition to the
clinical model would require that specialties and staff be relocated to other pediatric units. At one large meeting that
included members of all redesign teams, the decision for
clinical allocation of specialties was made. The issue was so
highly charged that the group insisted on taking an anonymous ballot. Nurse members of the group called their colleagues to ensure that they would be present to vote.
Education
Prior to the implementation phase of redesign, all staff
were involved in educational programs, preparing them for
their new roles, interdisciplinary work, and building relahttp://www.nursingcenter.com
303
Physicians
Every redesign team included physician members. From the
outset, the Care Center quality assurance and improvement
structure required cochairs: the Clinical Director and a
physician. Maternal-Child Health was fortunate to have a
physician member of both the Pediatric and Obstetric faculty, who shared the Care Centers vision and values, and
agreed to serve in that capacity.
In the Care Center model, physician participation continued through the development of Physicians Advisory
Committees. Initially, two advisory committeesone for
Pediatrics and one for Obstetricswere chaired by the
Codirectors. The committees were comprised of the Codirectors, all Care Center managers, and voluntary and fulltime physician representatives of the major areas of practice. They functioned as a conduit of information and a forum for physicians to have their opinions and needs heard.
Three years later, as Care Centers became more seasoned,
the MSHs Board of Trustees attempted to elevate the importance of the physician committees. Hence, the committees were renamed Physician Steering Committees and, in
Maternal-Child Health, reconstituted as a combined Pediatric and Obstetric meeting.
Outcomes
The outcome indicators used for evaluating the redesign
were quality, patient satisfaction, cost, and medical
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record/chart return. It was important to include chart return because prior to redesign, several medical records
were misplaced and, consequently, significant dollars
could not be billed to insurers. Results in the first year
were positive. For the Maternal-Child Health Care Center, patient satisfaction rose from an overall score of 3.5,
on a 5-point scale (5 = Excellent, 4 = Very Good, 3 =
Good, 2 = Fair, 1 = Poor) in 1995 before redesign, to 4.1
in 1996 and 1997 after redesign. These changes were
statistically significant (p = 0.05). Despite challenges
with the oldest facility in the medical center, MaternalChild Health has maintained its lead in patient satisfaction with an overall score of 4.2 in 2000. Patient complaints and complimentary letters were also analyzed. In
the first year after implementation of PFC, complaints
were reduced by 50% and complimentary letters rose
over 100%.
Outcomes resulting from the change in delivery system
are consistent with Williams (1997, pp. 6162, 67) findings that the model of patient-focused care takes into account the patients perspective of care, which provides for
more personalized care. PFC reduces anxiety and enhances patients feeling hope, comfort, confidence, assurance, and mental stability and wellness. Patient-focused
care defined as holistic nursing care empowers both the
nurse and the patient and provides a healing and growthful
atmosphere for the patient.
Length of stay was significantly reduced in inpatient pediatrics with the adoption of the clinical model. Grouping
patients with similar clinical needs, although from different
age groups, gave staff an opportunity to become experts in
their area of clinical practice. On the Respiratory Unit, staff
became the leaders in the creation of an Interdisciplinary
Clinical Pathway (IDCP) for Inpatient Pediatric Asthma.
With the staffs enhanced expertise, a 50% reduction in
length of stay for pediatric asthma was realized.
One year after aggregating respiratory patients on one
unit, improvements in clinical care and reductions in length
of stay spawned new redesign efforts. The Respiratory Unit
(RU), initially 24 beds that frequently overflowed to another Pediatric Unit, no longer needed 24 beds. The unit was
relocated to a smaller area, allowing for a census of 12 to
16 patients. This permitted an expansion of the Pediatric
Intensive Care Unit (PICU), which badly needed additional
beds, having had to refer emergent, tertiary pediatric cases
to other PICUs in the city.
When aggregated on one unit, we found that the census
of asthma patients had predictable seasonality: hospital admissions from late September to Maywith peaks in October, November, and Aprilwith few admissions from
June to early September. As a by-product of redesign the
Maternal-Child Health Care Center was able to close the
RU for a period of 4 months, from mid-May to mid-September, resulting in an annual savings of approximately
$600,000. No staff positions were eliminated. Instead, pediatric nurses in the RU were offered voluntary reassignments for the summer to vacant positions on other pediatric units. However, several nurses chose to take 1 or 2
months off without pay. The hospital agreed to continue
November/December 2001
http://www.nursingcenter.com
ONLINE
Lamaze International
http://www.lamaze-childbirth.com/
International Childbirth Education
Association, Inc. http://www.icea.org/
Institute for Family Centered Care
http://www.familycenteredcare.org/
Maternity Care Coalition http://www.momobile.org/
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Continuing Education
Questions
1. The patient-focused care model
HOURS
b. the previous years consumption for each service plus 10% to 30% of that amount.
c. the previous years consumption for each service minus 10% to 30% of that amount.
9. Work previously performed by transporters and
messengers is now the responsibility of
a. patient care associates.
b. support associates.
c. business associates.
10. Supervising the admitting process is now the
responsibility of
a. patient care associates.
b. business associates.
c. patient flow coordinators.
11. As a result of patient focus groups, the
codirectors learned that obstetric patients
wanted more
a. chairs.
b. clocks.
c. visiting hours.
12. New policies at the Maternal-Child
Health Care Center were based on defining
the family as
a. all relatives.
b. anyone who chooses to visit a particular
patient.
c. anyone patients identify as having significant
roles in their life.
13. In the new model, nursing is viewed as a
a. service.
b. community.
c. department.
14. One of the key outcome indicators used to
evaluate the redesign was
a. chart return.
b. staff satisfaction.
c. physician acceptance.
15. According to Jones (1997), patient-focused
care defines its focus as
a. the multiplicity of integral tasks.
b. increased support personnel.
c. patient outcomes.
CE Credit: 2 Contact Hours Fee: $14.95 Registration Deadline: December 31, 2003
1. a b c
6. a b c
11. a b c
Please check all that apply: LPN, RN, CNS, NP, CRNA, CNM, Other ___________
2. a b c
7. a b c
12. a b c
SS#________________________
Are you certified? Yes No Certified by:_____________________
Telephone #:__________________________
Name (Last) _________________________________ (First)_____________________ (MI____
Address _____________________________________________City_____________________
State____________Zip ______________
State of Licensure #1 _______________________ License Number #1 ___________________
State of Licensure #2 _______________________ License Number #2 ___________________
Position Title __________________________________________________
Area of Specialty _______________________________________________
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3. a b c
8. a b c
13. a b c
4. a b c
9. a b c
14. a b c
5. a b c
10. a b c
15. a b c
November/December 2001