To evaluate the impact of having families spend the night in the ICU or present during rounds, Kates says that during his time as the director of the University of Chicago Children's Hospital the medical staff leadership instituted a pilot in the PICU where half the patients' families would have unlimited access and the other half would not. Senior leaders, physicians, nurses, and other staff evaluated the results and decided that the right thing to do for all of the patients was providing 24-hour visitation. "We actually went through a process to evaluate it, because there were initial concerns raised," says Kates.
But just because new processes are developed doesn't mean there won't be pushback from staff members and physicians. Constant reinforcement is necessary, says Powanda, using the opening of their childbirth center in 1987 as an example. During the first week, a 12-member Italian family was waiting for the arrival of a new baby in the organization's first family room. They were playing cards and ordered pizza, wine, and beer for dinner. The nursing staff was distraught that the family was making noise, playing games, eating, and drinking in a hospital, says Powanda. "We said to staff, 'If they left here at 5:30 p.m. and went home, what would they be doing—playing cards, talking, and having pizza, wine, and beer." But a week later, Powanda was called down again because a new father got off work, came in at 12:30 a.m., and woke up his wife and new baby. "That is their routine. He wasn't interfering with the mom and baby, but the nurse's routine," Powanda says. "Those are the kind of things that are built into healthcare that are hard to break."
"If you have to put limits on where families can go, then you are more concerned about yourself than patients," Eytan says, adding that rounding should be done at the bedside with the patient and family present—not in a break room or at a nursing station. "There is really nothing in the medical record that I have to say that the patient and their family can't hear," he says.
Does that mean nurses or physicians may have to admit an error in front of the patient and family members? Yes. But admitting that you missed an antibiotic dose, for instance, will likely result in that error not happening again. Hospitals that have embraced an open and transparent and patient-centered environment have found huge gains in safety and quality, says Eytan.
"One of the hardest decisions in healthcare is transparency," he says. "If there is something that I'm not doing right, I'd much rather the family tell me then have the patient not get what they need. I'd rather be embarrassed than hurt someone."
Any good negotiation is characterized by starts and stops, reluctant compromises, and lines drawn in the sand, but hopefully at the end both parties walk away in agreement, if not happy. But what happens when the radiology group you've contracted with for 20 years refuses to budge in demands for higher compensation, or the obstetrics practice is unable to continue emergency coverage? Sometimes, hospital leaders have no choice but to walk away—or watch silently as physicians do the walking.
Losing physicians, however, raises serious questions. Will the hospital be able to find replacements? How much margin can the hospital sacrifice in order to maintain coverage and meet physicians' resource or compensation demands? Will the physicians rub salt in the wound by going to a competitor?
They are tough questions to answer, but the key is asking them before the negotiations even begin.