Donald Berwick, MD, MPP
Former President and CEO
Institute for Healthcare Improvement
Cambridge, Massachusetts, USA
I would like to make a rather bold suggestion regarding "visiting hours" in critical care units. After several years of work in the IOM "Chasm" report
context, ongoing instruction from Susan Edgman-Levitan and other true experts in authentic "patient-centeredness," many exchanges with scholars in service industries, and study of leading-edge redesign efforts like Planetree, I have come to believe strongly that visiting restrictions of any type in intensive care units are relics, which will be proven to be unnecessary, and potentially even harmful to the trajectory of healing, communication, and patient safety.
My challenge is that some hospitals execute a two-month trial of entirely open visiting in a Critical Care Unit.
I believe that it is rational, humane, and even, to a responsible extent, "evidence based" to do away with visiting restrictions in critical care units entirely. At the very least, "customization" to the specific requests of individual patients would be much more consistent with authentic patient-centeredness than any blanket restrictive policy would be.
I have no illusions about the various forms of concern and opposition that such a trial would invite at first, but I would predict success. Here are the elements of the trial I recommend:
- Institute a totally unrestricted visiting policy in an ICU for families, friends, and loved ones; by "totally unrestricted," I mean totally unrestricted;
- Allow any patient who requests it to customize a personal restriction, implemented at the bedside, not through a central control system; track these requests;
- Track "things gone wrong" attributed to open visiting as one measure of possible negative effects of the policy, and conduct daily reviews of "things gone wrong" to develop mitigating plans without compromising the openness of the policy;
- Collect positive stories and examples of favorable side effects of openness, such as innovations in enlisting visitors in the care system;
- Improve the experience of the visitors, themselves, by asking them for ideas and running tests.