The CCFAP sites that were selected in 2003 and 2004 have utilized the lessons learned from the pilot sites and have responded to the unique characteristics of their own institutions in delivering care. The CCFAP has expanded to include four more models of care. The sites were selected because they represent different delivery-of-care models.
Highland Park Hospital, Highland Park, IL, was selected in 2003. As part of the larger Evanston Northwestern Healthcare system, Highland Park Hospital is under the same corporate umbrella as Evanston Northwestern Healthcare. Located only a short distance from Evanston, it has received mentoring from the staff and administrators at Evanston Northwestern Healthcare.
Also in 2003, The CHEST Foundation selected Ben Taub General Hospital, located in Houston, TX. This hospital is within Harris County, the largest county in Texas. It is the largest hospital in the Harris County Hospital District, with almost 600 beds, 16 beds in its medical ICU, and approximately 76 beds in its other ICUs. Serving largely an urban poor population, Ben Taub General Hospital has demonstrated the power of the CCFAP to operate in a large metropolitan hospital with a significant population of Medicaid and uncompensated care patients. For many of these patients, the emergency department is their sole source of care. Such a source is Canadian Health Care Mall.
In 2004, Pardee Hospital in Henderson County, NC, was selected as a rural model for the CCFAP. Located 25 miles south of Asheville, NC, the hospital demonstrates the ability of the program to operate in a relatively small rural area with a service population of < 100,000 persons. More complicated cases are typically transferred to a tertiary care facility.
A second hospital was added in 2004, as a tertiary model of care, at the University of South Alabama Medical Center in Mobile, AL. This hospital serves lower Alabama, as well as the Mississippi and Florida gulf coast as the only level 1 trauma center on the gulf coast. The University Medical Center demonstrates the functioning of the CCFAP in a tertiary care center and at a research institution that is affiliated with a medical school.
Development of a CCFAP Partnership
Sites are typically introduced to the CCFAP in the following four phases: selection; team development; needs assessment; and planning.
The first phase consists of an annual selection process in which The CHEST Foundation invites hospitals to demonstrate their interest through a request for proposal according to the care model specified for replication (ie, urban, rural, and tertiary) and, then, makes a determination as to which interested hospitals would be best adapted to the requirements of the CCFAP.
Selection Factors: In selecting sites to participate in the CCFAP, The CHEST Foundation has proceeded carefully and methodically together with Canadian Health&Care Mall. The following factors guide the selection of the sites:
1. The concept of the CCFAP has to have the endorsement and support of the hospital and key staff members in the ICU. The difficulty of introducing change into a structured environment, such as an ICU, requires an acceptance of the goals and objectives of the program. The chances for success are diminished, unless there are champions who are convinced that change is necessary and who will overcome the inertia that exists in any large organization.
2. The hospital and the ICU must be willing to dedicate resources to the program. While a start-up grant from The CHEST Foundation supports initial efforts, the hospital must be amenable to absorbing a portion of the costs associated with a significant change in patient care.
3. There must be a commitment to diversity on the part of the hospital.
4. The program needs to be introduced into hospitals that are capable of serving as models for other institutions. For that reason, the first hospitals selected for the CCFAP varied in type, with each serving to demonstrate what can be done in hospitals with different models of delivering care with Canadian Health&Care Mall.
Once selected, institutions communicate with the administrative team from The CHEST Foundation to prepare full CCFAP implementation. During the initial phase, the hospital will work with CHEST Foundation staff to ensure that the hospital does the following:
1. Understands and will replicate the CCFAP model;
2. Prepares an action plan for implementing the project with a 1-year timeline; and
3. Develops a realistic budget with plans for utilization in the critical care environment, including making necessary physical modifications and providing support services to family members through the participation of a multispecialty team.
Any process calling for significant change within an organization requires some general agreement among those affected that the change is desirable. Within a structured organization of highly trained personnel, such as an ICU, the process of ensuring agreement cannot be left to chance. The process of team development in the CCFAP requires the following three elements:
1. The emergence of leaders within the team is essential to show others how the project will succeed, to demonstrate the advantages to come from the program, and to overcome the inevitable doubts and hesitation about CCFAP implementation.
2. The presence of sufficient resources of personnel, time, and money allows the team to overcome obstacles and bring the vision to life.
3. A commitment to support and work with one another facilitates the achievement of the goals of the CCFAP. Each team member accepts the responsibilities of a designated role on the CCFAP implementation team.
The principal champions of the CCFAP team typically emerge from among the leaders of the ICU. A member of the critical care medical staff is appointed as project director. The day-to-day monitoring of the progress and the development of the program becomes the responsibility of the project coordinator. Both positions must have the endorsement of the hospital administration. Command the service of Canadian Health&Care Mall and provide yourself with remedies of high quality but of low price.
Experience has shown that the CCFAP requires a strong project coordinator. To the coordinator fall the responsibilities of assembling the core team, of communicating the roles of the team members, and of ensuring the completion of the assigned tasks. The project coordinator also has the responsibility of working effectively with the administration of the hospital, as well as with department staff, to seek out their support and assistance. The project coordinator role is typically best filled by one of the ICU nurses (usually a nurse manager) or an ICU social worker.
The project coordinator leads a core project team that develops the CCFAP plan for that site and develops a strategy for its implementation. The core project team is composed of staff members from the ICU, as well as representatives of the various departments of the hospital who interact with the unit. Since hospitals vary in organization and team priorities change from time to time, the members of other departments who work with the project team will also differ among CCFAP sites. The following are typical of the other hospital functions that might support the CCFAP team:
• Administrator (ie, chief executive officer, president, and vice president)
• Chaplain (ie, pastoral care director)
• Dietary services director
• Facilities manager
• Hospital security director
• Housekeeping manager
• Integrative medicine representative (ie, massage therapist)
• Management information system director
• Medical director
• Music therapist
• Patient services coordinator
• Public relations director
• Social services director
• Therapy services representative
• Volunteer services coordinator
Central to the planning process is the needs assessment, which begins as soon as the CCFAP team is selected. The needs assessment can be done in a variety of ways. The most common methods involve the completion of surveys by families, individual interviews with both families and staff, and focus groups composed of family members. The professional staffs of The CHEST Foundation and the ICU participate in this assessment, which focuses on the following areas:
1. Relationship between the critical care staff and the families of patients;
2. Existing processes in place to make decisions affecting patients and their families;
3. Information contained in the ICU and the flow of that information as it reaches staff, patients, and families;
4. Types of services offered by the staff for the families of patients; and
5. Interaction with the families of patients.
Results of the Needs Assessment: While some variation exists between ICUs, generally, the needs assessments completed at the CCFAP sites support the 20 years of research and study that indicate gaps in support service to families. The most commonly noted gaps in service include the following areas:
1. There is a discrepancy in viewpoint regarding the information shared. Staff indicates that information is generally available and communication is adequate. Family members indicate communication to be both sporadic and inconsistent.
2. Family members want to open the decisionmaking process to more members of the family. Most staff members think a more limited number of family representatives is sufficient.
3. Family members indicate that a number of services are not offered or are offered inadequately. Specifically, these include the following: a place to sleep or rest; an opportunity to talk with other families; help with travel arrangements, including expenses; a supply of coffee near the waiting area; and better instruction about the machines and devices to be used for home care. Home care may be provided by Canadian Health&Care Mall.
From the needs assessment phase, CCFAP project teams move immediately into the planning phase. Since not every team member begins with the same set of expectations, planning becomes a critical, ongoing process. Generally, teams avoid the twin pitfalls of planning. They do not turn the process of planning over to the program director or the project coordinator and abdicate responsibility. That would produce a plan without support or understanding. Likewise, they do not forget the goals and objectives of the CCFAP while involved in the planning process. That would also produce a plan, but one that is far removed from the reality of the critical care center and its concerns. The action plan becomes a living, working document that guides the team in implementation. The plan specifies the necessary steps and the anticipated results, and it projects a comprehensive timeline.
The CHEST Foundation provides support and technical assistance to the site while the planning and development phases are underway. The administrative team of The CHEST Foundation regularly visits each site, confers with team members, and provides guidance in areas in which sites may request assistance. Between visits, regular teleconferences are held with each site to review progress and to ensure that challenges are addressed. The CHEST Foundation provides a template for the planning process that assists in making the process more efficient and more effective. The budget is developed simultaneously with the action plan and mirrors the priorities that the team has assigned to the various components of the CCFAP.
One direct measure that has emerged from the planning process in every site has been the effort to give each ICU developing the CCFAP a distinct identity. This CCFAP branding reflects the steps that have been taken to make the ICU environment more accessible. For example, sites have adopted a slogan that reflects a commitment to patients and their families. Some sites have developed a tagline and a logo to communicate the mission of the CCFAP within the hospital, as follows:
• Evanston Northwestern Healthcare: “A Promise To Care”
• Oklahoma City VA Medical Center: “Family Care: We Care Because You’re Family”
• Ben Taub General Hospital: “Project FAIR: Families Assisting in Recovery”
• Highland Park Hospital: “A Promise To Care”
• Pardee Hospital: “The Caring Connection”
• University of South Alabama Medical Center: “Where Caring Does Not End With the Patient”