Children's hospitals are leading the way in many areas of health care. And adult hospitals are watching, learning and following suit.
By Megan McDonnell Busenbark
From medical research to reimbursement changes, children's hospitals have often learned and adapted strategies from adult institutions. But the pediatric world is leading in other areas—and innovating in ways that can benefit patients of all ages. Here's a look at four areas of health care where pediatric hospitals are out in front—and how the adult health care world is following that lead.
1. Family-centered care
Gone are the days when patients are patients and their families are just families—at least in the children's hospital setting. "They're not guests or visitors anymore—they're partners," says Pat Givens, D.H.A., Ed.M., RN, NEA-BC, senior vice president and chief nursing officer at Children's Hospital Colorado.
In pediatrics, family-centered care is based on the understanding that parents and family members are a child's primary source of strength and support. This approach to care, which became more consistently practiced in the pediatric setting in the 1980s and early 1990s, incorporates patient and family input into clinical decision-making for the child. This is quite a shift from years ago, when traditional care models made observers out of patients and families.
Today, they are active participants, true partners in care. And the adult world is catching on. "We're guests in the lives of patients and families—not the other way around," says Givens. "We're the ones who are privileged and honored to be part of their lives. Conceptually, that's an important thing the pediatric world has taught the adult world."
Rules of (enhanced) engagement
Patient and family involvement is hardwired into the care strategies and processes at children's hospitals, from family-centered rounds where families help shape the child's care plan, to families at the bedside and visiting hours that work best for those families. All these things can benefit adults in the hospital just as much as children, though these ideas caught on faster in the pediatric setting, according to Givens.
Education is one area of long-time pediatric strength that Givens says is really beginning to click in the adult setting. "People have recognized that including family members in pre-hospital education and preparation—as well as education around the hospitalization and post care—is something that is happening more in the adult world now," she says.
Counting on councils
Children's hospitals have increasingly formalized the way they obtain feedback from patient families through the creation of family advisory councils (FACs). Here, family members serve alongside hospital administrators and clinicians to provide input on patient and family experience and satisfaction, care and operations, facility updates, safety initiatives and more. And this is a value-add that adult hospitals are beginning to latch onto as well.
Givens has seen this first-hand because she worked on the adult side of this equation. Before heading to Colorado Children's, she served as chief nursing officer and vice president of patient care services at an adult community hospital. Just last year, the hospital began to assemble an FAC to help better serve their patient population. "The adult world sees how important families are when it comes to patient satisfaction," Given says.
At Colorado Children's, family members engage with the organization on multiple levels, from the FAC and the Youth Advisory Council, to positions on committees such as the Medication Safety Committee and the Quality & Safety Committee of the Board. Families also have roles at the unit level. And as a way to ensure family input on initiatives before they are implemented, the hospital launched a campaign called, "Did you ask a parent?"
"With everything we do, that's one of the questions we ask, 'Have we asked a parent?' 'Have we asked a patient?' 'Have we asked a family?'" says Givens. "It's part of the culture.” A culture that leading adult hospitals, including Mount Sinai Hospital, The Johns Hopkins Hospital and Dana-Farber Cancer Institute, to name a few, are working to emulate through their patient and family advisory councils.
2. Patient safety
Preventable harm occurs even in the best hospitals, and for children's hospitals, patient safety and a focus on improving practices for the best outcomes has long been a top priority. With almost 60 children's hospitals reporting safety events each month, the Child Health Patient Safety Organization (Child Health PSO) enables children's hospitals to share safety event information and experiences to provide early warning of possible harm and speed up the elimination of preventable harm.
As the only federally registered PSO dedicated to children's hospitals that provides federal privilege protections for confidential event reporting, the organization aggregates events so all Child Health PSO member hospitals can learn and drive improvement within their own organizations.
In an effort to share data around safety and adopt an "all teach, all learn" philosophy, the Children's Hospitals' Solutions for Patient Safety Network (CHSPS) and its 100-plus children's hospitals focus on helping children's hospitals emerge as high-reliability organizations, similar to the nuclear power and aviation industries. These industries operate under extremely high-risk situations, but are able to minimize accidents in environments where accidents can be expected.
Throwing competition to the wind
Riley Children's Health at Indiana University Health is a member of the Child Health PSO and CHSPS. The team there has seen significant results since joining the networks. The hospital has reduced patient falls with injury, surgical site infections, catheter-related urinary tract infections—and decreased central line-associated blood infections by 21 percent, according to Elaine Cox, M.D., medical director of infection prevention and patient safety officer at Riley Children's.
She says these results are, in large part, attributable to a shared willingness among children's hospitals to set competition aside—no caregiver wants to see harm repeated. "There isn't ever a time when we should be competing with any hospital on patient safety," says Cox. "It's just not something we should be doing."
Taking the right road
Riley Children's is a children's hospital within the Indiana University Health System, an entity of 10-plus adult hospitals, and a system that is paying close attention to the patient safety results Riley Children's has achieved. "The adult side is emulating a lot of the safety efforts, and that kind of thing is happening all over the country," Cox says.
The adult hospitals in the system participate in a weekly safety event call with Riley Children's, and the teams share information both ways. In a recent meeting, Cox says, one of the adult hospital representatives said their patient safety story is similar to that of Riley Children's; it was "just a few years behind."
Despite the lag, the adult hospitals in the system are seeing decreases in harm like they never have before, Cox says, as they follow the children's hospital's lead on patient safety. "I'm proud that children's hospitals lead this charge of safety, but I'm also proud it's really not about children's hospital or adult hospitals, it's about all hospitals," says Cox. "That's a great direction for all of us to be moving."
3. Care coordination and collaboration
Care coordination—the deliberate organization of patient care activities between two or more participants involved in that patient's care to ensure proper delivery of services—is practiced in health care institutions around the country, large and small, adult and pediatric. But children's hospitals have had an edge.
"Children's hospitals have excelled in the process of doing the care mapping and the coordination," says Byron Atkinson, vice president and leadership adviser at B.E. Smith in Lenexa, Kansas. "Some of the adult hospitals had been leading the charge on those things, but they did take a lot of that from the literature from pediatric centers."
Coordinating complex care
With a growing population of pediatric patients with complex medical conditions—there are now more than 3 million nationwide, and Medicaid covers two-thirds of them—children's hospitals have placed an emphasis on organizing health care services across multiple providers to maximize resources and create the best possible outcomes.
To inform sustainable change in health care delivery through new payment models supporting better care, smarter spending and healthier children, 10 children's hospitals, in partnership with Children's Hospital Association, were awarded a three-year, $23 million Health Care Innovation Award from the Center for Medicare and Medicaid Innovation. The CARE Award study will test coordinating resources effectively for children with medical complexity.
While the work happening within the CARE Award will help identify best practices and spread those ideas to the larger community of children's hospitals, some hospitals are looking to their peers to help them build or improve on their coordinated care programs.
"We have taken quite a few models from other organizations and adapted them," says Marla Silliman, senior executive officer of Florida Hospital for Children and Florida Hospital for Women, and chief operating officer of Florida Hospital Orlando. "We don't have time to reinvent an idea, so we learn from and tweak what other children's hospitals have successfully implemented."
For Florida Hospital for Children, this strategy evolved into its Coordinated Care for Kids program, a medical home to about 200 medically complex children. Patients are assigned a care coordinator who manages all aspects of their care plan. The program includes a day hospital where patients have access to their medical team on short notice, helping them avoid trips to the emergency room. The program also houses a complex care clinic, a pediatric palliative care team and multidisciplinary clinics. These multidisciplinary clinics treat hundreds of children per year.
Collaborating to transition care
When Bruce Barnett began working with cystic fibrosis (CF) patients more than 30 years ago, there wasn't much need for a transitional program to adult care. "When I started in CF, the average patient only lived to be about 10 years old," says Barnett, M.D., vice president, medical affairs of ProMedica Toledo Children's Hospital, a part of the ProMedica health system in Ohio. "Now, the average life expectancy is 42 years, and we see it going up every year. We've seen incredible breakthroughs in care for this population."
Medical breakthroughs prompted the Cystic Fibrosis Foundation to adopt new standards of care for its maturing patient population. ProMedica Toledo Children's Hospital's Cystic Fibrosis Center of Northwest Ohio was among the first in the nation to participate in a pilot transitional program sponsored by the CF Foundation. The objective of the program, launched in 2015, is to prepare pediatric CF patients to become self-sufficient partners in their care as they enter adulthood.
Patients enter the transition program when they turn 18, and they receive a checklist of 18 goals they must accomplish before they "graduate" at age 21. The checklist includes mastering skills and concepts essential to their ongoing care, from ordering and managing their prescriptions, to interacting with their care team and navigating health insurance.
Of course, the patients don't go it alone. The pediatric and adult CF care teams at ProMedica work together for a seamless transition of care.
The initial meetings are joint visits between the patient and both sets of care providers so everyone is on the same page regarding the care plan and objectives. Subsequent appointments are increasingly led by the adult caregivers, with the pediatric specialists on hand to assist as needed.
"This is truly patient-centered care," says Paula Grieb, RN, vice president of patient care services and chief nursing officer at ProMedica Toledo Children's Hospital. "We are helping these patients transition over a three-year period from a completely dependent state: 'My parents have handled everything for me,' to 'I'm an adult with an adult chronic disease, and I know how to handle it on my own.'"
4. Facilities and the healing environment
For Diane Osan, the design of hospital facilities is personal. When her daughter was 6 months old, she required emergency surgery when 40 centimeters of her intestine slid into itself, causing a blockage. This was about 25 years ago, and things were much different then.
"Children's hospitals have long had words like hope, joy and guardianship in their mission statements," Osan says. "But back then, most of their environments did not reflect that mission. They were not colorful, they were not cheerful. Maybe there were a few Disney decals on the walls, but that's about it."
Osan says the hospital halls were hard to navigate as she and her husband sought food and rest during their daughter's hospital stay. All of this stuck with her as a parent going through the nightmare of having a seriously ill child—and as an architect.
"I saw how important the design of a hospital was, and how we could make a difference in some of the most important moments in people's lives with the right design," says Osan, who is now CEO of FKP Architects, a Houston-based architecture firm that specializes in health care, science and education.
Family and patient friendly
Today, children's hospitals are known for their distinctive environments, which include right-sized equipment, distraction therapy, child life professionals and more. From bright, cheery rooms and fish tanks in lobbies, to X-ray machines that look like giraffes, pediatric facilities are created with calm and comfort in mind.
This helps young patients feel safe, more comfortable and less scared. Adult institutions are starting to see that kids aren't the only ones who benefit from this type of healing environment. "On the facility side, children's hospitals have been groundbreaking and way ahead of adult medicine," says Osan. "It's only during the last five years that we're seeing adult medicine catch up."
Case in point: Osan and her team built bubble columns in a children's hospital's waiting room. The bubbling water features combine the movement of bubbles and LED lighting to create visual interest. Soon thereafter, Osan and her team built something similar—a bubble wall with the feel of a waterfall—in an adult health care facility nearby. This is just one example of how adult institutions are rethinking facility design with patient and families in mind, something that children's hospitals grasped years ago.
Adult medicine is also learning that having the family at the bedside has benefits. "Families can be an active partner in the health care processes, produces better outcomes," she says. So the adult institutions, Osan says, are racking up the ways in which they are following children's hospitals when it comes to facility design to create a more patient- and family-friendly environment. Here's a rundown:
- Reconfiguring patient room size, space around the bed and space for accommodations like couches so families can stay overnight and spend time at the bedside more comfortably
- Designing separate spaces for family members outside the patient room where caregivers can rest and recharge
- Identifying rooms where care teams can educate patients and families—something children's hospitals have embraced for some time
- Identifying spaces for pet, massage, art or music therapies
- Creating rooftop gardens for respite or end-of-life moments for patients with their families
- Transforming offices into more collaborative work environments to facilitate team-based care—another trend that has transitioned from children's hospitals to adult medicine
Whether they're creating a healing environment or leading the way in family-centered care, care coordination or patient safety, children's hospitals will continue to set an example for adult hospitals to follow.
Megan McDonnell Busenbark is a writer and founder and principal of Encore Communications LLC, in New Fairfield, Connecticut. Send questions or comments to firstname.lastname@example.org.