Despite evidence that family support helps patients and that patients want to share in deciding who can visit them, and despite regulations from both the Centers for Medicare and Medicaid Services and the Joint Commission requiring hospitals to allow patients to decide who can visit them and provide emotional support, many clinicians-nurses and physicians alike, and particularly in critical care-remain resistant to the notions of "inclusiveness" and "shared decision making." To address this resistance, Baylor Health Care System (BHCS) in Dallas made a commitment to the spirit and the letter of open visitation, undertaking a study in which 12 of its 13 hospitals sought to identify and eradicate obstacles to reach a predefined "ideal" level of success.

The researchers conducted a system-wide baseline assessment in September 2010, gathering data on various components of open visitation, such as the presence of welcoming, informative signage; documentation of a patient's primary support person in the medical record; and verification of written guidelines to orient patients and their families to their rights and responsibilities. The baseline assessment revealed that BHCS was only 56% of the way to ideal open access.

The assessment also revealed opportunities for improvement. The assessment tool was customized according to unit type. A list of frequently asked questions was posted on the physician portal. Patient information forms, educational material, Web sites, and signage were examined for inconsistent communication. And staff's concerns about privacy and liability were addressed on an ongoing basis, including the mistaken belief that open visitation referred to all possible visitors-rather than a primary support person.

An October 2011 assessment showed that, with six quarters of steady improvement, the system had moved from 56% to more than 82% of the way to the predefined ideal. Patient surveys provided further evidence of the effectiveness of the policy changes. For example, the percentage of patients who felt that nurses always treated them with courtesy and respect increased from 85.9% at the beginning of open access to 88.4% almost two years later, and the percentage who felt that nurses explained things in a way that the patient could understand increased from 72.9% to 81.4%. Perhaps most importantly, staff began to view the primary support person as a partner in care rather than as a liability.-David Carter

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