Sick, Scared and Separated from Loved Ones
A Report on NYS Hospital Visiting Policies and How Patient Centered Approaches Can Promote Wellness and Safer Healthcare
A Report by
New Yorkers for Patient & Family Empowerment and the
New York Public Interest Research Group
Summary of Findings and Recommendations
Hospital patients are people whose lives have been interrupted because of a significant and often frightening medical issue. From the moment they enter that hospital door, their world changes. They are surrounded by strangers who give them instructions and warnings that they may or may not fully understand. They are inundated by noise from machinery, beeps from electronic devices, bright lights, and the bustling voices of hospital staff, while sharing a room with someone they've never met before. Even with efforts to mitigate these disruptive factors, a hospital experience is disorienting.
Visits from loved ones and friends help patients cope. A visiting "support person" can also help patients monitor their care and prevent prescription errors and other mistakes. And this visitor involvement can help facilitate better continuity of care after the patient leaves the hospital.
Indeed, the Joint Commission ("TJC"), which accredits hospitals based on medical and safety standards, urges patients to ask a trusted family member or friend "to be your advocate" and "stay with you, even overnight" at the hospital to "help make sure you get the correct medicines and treatments." The Commission's concern is well-founded. Little has changed since the Institute of Medicine's disturbing 1999 report, To Err Is Human, which found that the number of Americans dying each year from medical errors was roughly equivalent to the downing of one jumbo jet each day. The U.S. Department of Health & Human Services Inspector General's 2010 report found that one out of every seven hospitalized Medicare beneficiaries is seriously harmed in the course of their care, and at least 44% of these events are preventable. The Commission's advice is important for patients and hospitals.
But there is a rub: A patient's support person can provide important information, observations and warnings to medical personnel, helping to avert wrongs such as prescription errors — only if the hospital does not bar the door to the patient's room.
A new national policy is now in place to help keep the patient's door open to family, friends and designated visitors. In 2011, the federal government adopted new rules grounded in evidence that family-centered visiting policies promote quality of care, healthcare efficiency and more positive patient outcomes. The rules recognize that patients have a right to the presence of family members or other support persons, and declare that hospitals must justify their restrictions on visiting. Thus, hospitals should implement "evidence-based" policies, rather than just adhere to familiar past practices.
This report presents findings and recommendations based on a review of visiting policies and website communications for the 99 acute care hospitals in New York State having 200 or more "staffed beds." This report finds significant, unexplained variations in:
- Visiting hours and restrictions on visitation;
- Consistency with the patient's legal right to choose priority visitors whether or not they are members of the patient's "immediate family"; and
- Transparency and clarity of website communications.
Our research reveals that many of the surveyed hospitals still take a restrictive, controlling approach to patient visitation even though more patient-centered policies already are in place at others.
Some Hospitals Provide Many More Hours of Visiting than Others
In a ten-point rating evaluating a hospital's total general (medical/surgical) visiting hours, availability of morning/evening time, and website notices of flexibility for parents, support persons or other visitors, the vast majority fare poorly, scoring only between one and four. More specifically:
- Four hospitals received a "perfect 10," and seven hospitals received a high score of "9" or "8."
- Four hospitals received a zero score, meaning the hospital offered fewer than eight hours of daily visiting time and provided no notice of an opportunity for flexibility.
- 39% of the hospitals provide 10 or more hours of visiting time per day, with 11 of these offering some form of 24-hour "open" visitation.
- In contrast, 11% provide visiting hours that would result in only seven hours or fewer of available daily visiting time for the patient, although some of these provide notice of the potential for flexibility for parents/guardians or other visitors.
- A surprising 22% provide no visiting hours in the morning and fail to disclose any potential for flexibility, even for a patient's support person. If the patient or support person does not ask for and obtain flexibility, hospital staff — including doctors who often visit hospital patients in the morning — may miss important observations, warnings or information about the patient that the family member, domestic partner or trusted friend could call to their attention.
- Hospitals usually will allow a parent to stay with a child patient overnight in general medical/surgical units (although only half post this option on their websites), but some hospitals are more restrictive regarding parental presence if the child is in the Intensive Care Unit.
Many Hospital Websites Contravene the Patients' Legal Right to Choose Priority Visitors
Federal Department of Health and Human Services regulations pursuant to Medicare and Medicaid (effective January 18, 2011), and a New York State regulation (effective December 22, 2010), now mandate that patients have the right to choose which visitors have priority if visitation is severely restricted. The patient's choice may include family members, a domestic partner or companion (regardless of gender), a spiritual counselor, a trusted personal care aide or other friends.
- 26% of the hospital websites make public statements contrary to New York State and federal policy, with 23 hospitals claiming to limit certain types or times of visitation to "immediate family," "close family" or "family" and three adding only the category of "significant other."
- Only 11 hospitals take the initiative on their websites to inform patients or visitors that patients have the right to choose and prioritize visitors (regardless of family affiliation or gender) under conditions of significant visitation restriction.
Rules on Children as Visitors Vary, with Little Apparent Rhyme or Reason
This review found widely divergent rules for child visitors, with the basis for differences unclear.
- 43% of the hospitals prohibit or strongly "discourage" visitation by children, with the age cutoff for defining "children" inexplicably ranging from 11 to 16 years old.
This can be an unpleasant surprise for parents — for 18 of the 99 hospitals, personnel stated specific age restrictions when the hospital was telephoned, yet the hospital failed to post a notice of the age restriction on its website or in an automated pre-recorded telephone message.
- In contrast, 50% of the hospitals allow children to visit, with only about a quarter of these facilities requiring prior authorization or limiting the length of such visits. (For the remaining hospitals, staff responded to the question with, "it depends," or similar answers.)
New York Hospitals Could Significantly Improve Their Websites' Usefulness to Visitors
A hospital's website is its most public document, available to anyone with computer access even if the person lives far away and must travel to see a hospitalized loved one. In today's Internet age, website viewers should be able to access visiting policies that are accurate, helpful and easy to find. Yet a third of the websites contained inaccurate hours or failed to disclose a restriction against child visitors, and:
- On a 10-point scale assessing the availability and quality of information for visitors, no hospital website received a perfect "10"; the highest score was "8," achieved by just eight hospitals.
- 27% received a website score of only "3" or lower, with seven receiving a score of zero.
- New York City Health & Hospitals Corporation ("HHC") facilities scored particularly low. Of the 11 HHC hospitals on this list, five earned a score of "3" or lower, with one of these at zero. Yet HHC's Bellevue Hospital Center in Manhattan fared much better, with a score of "7."
Most of the websites fail to remind visitors to take important health precautions to improve safety.
- Less than a quarter of the hospital websites (24 out of 99) — warn prospective visitors who have a cold, the flu or other illness not to come to the hospital. While this precaution may seem obvious, many people go to work with cold or flu symptoms.
- Only eight take the opportunity on their visiting-policy webpages to inform visitors directly of the need to wash their hands before entering the patient's room. While warnings are posted via signs in the hospital, the website can and should provide important reinforcement given the challenge of changing human habits to reduce harmful hospital-acquired infections.
Recommendation #1 (Visiting Hours Flexibility): If a hospital allows a family member/support person to stay overnight in the hospital with an adult patient, its visiting policy should state this. If the hospital does not currently permit 24-hour visitation for a support person, it should evaluate the potential for adopting a more accommodating policy, looking to more flexible hospitals for guidance.
Recommendation #2 (Parent's Right to Stay With a Child): A parent or guardian should be entitled to remain with a child patient on a 24-hour basis. The hospital should also ensure that this flexibility is discussed, personally and directly, with parents/guardians as well as posting the policy on its website.
Recommendation #3 (Morning Hours): The hospital should provide a substantial amount of visiting time in the morning, and explain the evidence-based reasons for any restrictions on morning hours.
Recommendation #4 (Accommodating Day-time Workers): The hospital should provide more than two hours of visiting time after 6 p.m., to accommodate day-time workers and address patients' evening needs, while advising visitors of the need to be considerate of a roommate's desire for rest.
Recommendation #5 (Patient's Right to Choose): The hospital's written policy should state that the patient has the right to choose who can and cannot visit, and also which individuals will be treated as priority support persons if visitation is restricted. Any policy references to visitation being restricted to "family only" should be corrected immediately to clarify that priority visitors may include other support persons as chosen by the patient.
Recommendation #6 (Children as Visitors): The policy should state any rules restricting children as visitors, and remind parents that they must supervise their children carefully. Hospitals that prohibit children as visitors should evaluate the potential for adopting a more accommodating policy, looking to more flexible hospitals for guidance. Policies that restrict teenagers, in particular, should be questioned.
Recommendation #7 (Health Advisories): The policy should instruct that anyone with a cold, a rash, a fever, the flu or other communicable disease should not visit the hospital. It should remind visitors to wash their hands before entering and after leaving the patient's room. It should disclose any restrictions or guidance on bringing food, latex or Mylar balloons, or flowers to the hospital, or wearing perfume.
Recommendation #8 ("Evidence-based Policies"): All restrictions on visiting should be evidence-based, and hospitals should explore all reasonable alternatives to address an issue before choosing to restrict the patient's access to the support of family, a companion, or friends.
Recommendation #9 (Involving Stakeholders): In developing visiting policies, hospitals should obtain input not only from administrators, but also from front-line staff involved in patient care and social services, patients and their families/support persons, and health consumer advocates.
Recommendation #10 (Website Information/Consistency): Visiting policies that are outdated or routinely ignored should be updated. All sources of information on the policy must be consistent. All staff/volunteers in administration, intake, the "floor," and the emergency room should know the policy.