Room for improvement there is no pf input into

Room for improvement
There is no P/F input into
personnel for the facility
Environment & Design The environment somewhat
supports family presence
There is no P/F input into
clinical design projects
Information/Education There are numerous links to
patient resources
There are no P/F educators
Diversity & Disparities The facility does have many
assistance programs for the
underserved
The educational material is
limited to the 3 most popular
languages in the community
Charting & Documentation Patients and family have
access to an information
portal they can comment on
There is no ability for P/F to
individually chart in the
current EMR
Care Support Patient families have the
ability to activate a rapid
response without staff
Visiting hours are restricted in
most areas of the hospital
Care Pain is managed as a top
priority with patient input
The P/F are not involved in
every aspect of care

ORGANIZATIONAL LEADERSHIP 5
Area of Improvement
The area of patient-centered care that this section will focus on wit be in the domain of
care support. At this time family members do not have 24/7 access to the patient on every unit of
the hospital. This is currently restricted to the ICU’s and the emergency room. Labor and
delivery has a similar policy but still does not allow all family to have unlimited access to the
patient. Allowing family members to be at the patient bedside may be expected in some cultures,
and adapting the policy to be culturally inclusive can assist in patient outcomes and elevate the
diversity of the facility.
Improvement Strategy
The strategy to improve the current policy will start with the creation of a
multidisciplinary team. This team would address the current limited policy and aid in the creation
of a more culturally diverse and inclusive policy. The team members should include medical
staff, security personnel and others that have a stake in the policy changes. The members could
include physicians, nurses, security officers, and patient family members. Having a diverse
multidisciplinary team will assist in the development of new and different ideas based on
discipline, ethnic background and time with the patients.
System or Change Theory
In order for the multidisciplinary team to bring about this change in the noted weakness a
change theory was selected to assist them. The theory that was chosen was that of Lewin
(unfreezing, moving, and refreezing). According to Sullivan (2012) this theory focuses on
“behavior as a dynamic balance of forces working in opposing directions within a field (such as
an organization). Driving forces facilitate change because they push participants in the desired

ORGANIZATIONAL LEADERSHIP 6
direction. Restraining forces impede change because they push participants in the opposite
direction” [ CITATION Sul12 \l 1033 ]. Using this change theory as an outline the team will
tackle the changes needed to implement open visiting hours at the facility.