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Emergent Models of Implementation and Communication^*

The Critical Care Family Assistance Program

^* From the Wellington Consulting Group, Ltd (Dr. Dowling), Gold Canyon, AZ; and The CHEST Foundation (Ms. Lederer), Northbrook, IL.

Correspondence to: Jane Dowling, PhD, the Wellington Consulting Group, Ltd, 8406 E. Canyon Estates Circle, Gold Canyon, AZ 85218; e-mail: janedowling{at}msn.com

Key Words: critical care • communication model • family satisfaction • implementation model • program integration

	Introduction

TOP Introduction Implementation Model CCFAP Communication Model References

 
Based on the different iterations of the Critical Care Family Assistance Program (CCFAP), two emergent models have been identified by the evaluation team. The implementation model can be utilized to describe each implementation style, as well as to identify issues and opportunities associated with the implementation of the CCFAP in various hospital environments.

The communication model can be used to address the issue of using a coordinated approach that links communication on three levels. The CCFAP communication model facilitates and enhances face-to-face communication by addressing all of the family’s needs through both verbal and nonverbal methods before and after the face-to-face meetings. Both models are presented and discussed in this article.

	Implementation Model

TOP Introduction Implementation Model CCFAP Communication Model References

 
Overall, the implementation model is intended to be heuristic in nature, assisting in examining and comparing the integration of the CCFAP. The implementation model comprises implementation elements, each of which is numbered and includes questions that are intended to spark exploration. The accompanying rubric has been developed as a way of measuring the degree of implementation.

Component I: Preparation for CCFAP Implementation
Implementation Element 1: Vision: Someone associated with a given institution must have at least some fundamental concept of how the CCFAP framework might produce desirable change in the ICU and hospital. Ideally, this concept translates to a clear, easy-to-articulate vision. The following key questions are associated with vision:

1. How do we expect/anticipate the CCFAP framework to change the ICU and the families and patients we serve?
   
2. What is the optimal way to introduce the CCFAP to the families, patients, and staff in the organization?
   
3. What is the anticipated timeframe for bringing the vision to reality?
   
4. What obstacles might stand in the way of the vision becoming a reality?
   
5. What is the best way to overcome any obstacles that might exist or be anticipated?
   
6. What resources are needed to bring about the vision?
   
7. What is the most persuasive element of the vision?
   
8. What is the most effective way to communicate the vision?
   

Implementation Element 2: Energy and Influence of CCFAP Champions: Any successful initiative requires at least one champion who thoroughly believes in the endeavor, stands behind it, and represents the initiative positively and persuasively to everyone involved in patient care. Ideally, at least one primary champion is a member of the management team of the hospital. This vote of confidence propels others in the hospital to participate actively. The following key questions are associated with the energy and organization of champions:

1. Who among the staff or stakeholders of the organization demonstrates a primary commitment to implementing the CCFAP?
   
2. What is the most effective method of marshalling the energy of champions to generate enthusiasm about the initiative?
   
3. What is the most effective mode of organizing champions of the initiative?
   

Implementation Element 3: Planned Integration Approach: Effective implementation of the CCFAP initiative typically brings with it numerous anticipated and unanticipated findings and outcomes. For example, one type of planned effort, project team meetings, often leads to a high level of enthusiasm in the ICU. Every planned endeavor is likely to bring about several more unplanned results that would have been difficult to anticipate. Inspiration from a CCFAP team meeting reporting on the results of relaxing the visiting hours for families may lead to revisiting the visiting hours policy for the ICU. The following key questions are associated with the planned integration approach:

1. What specific marketing activities (eg, presentations, meetings, vocabulary usage, pamphlets, or brand name posters in hallways) are likely to generate understanding and commitment to the CCFAP among families, patients, and staff?
   
2. What is an effective way of formally involving the people whose perspectives and ideas are needed to launch this initiative?
   
3. What lessons that were learned from implementing other initiatives in this hospital need to be reviewed as the CCFAP initiative is planned and put into place?
   
4. What do members of the hospital staff need to know during the planning phases of the CCFAP implementation?
   
5. What is an effective way to inspire people to "buy in" to the CCFAP for the organization?
   

Implementation Element 4: Buy-In of Staff: A corollary to the energy and influence of organizational champions is the level of commitment by staff of the hospital, specifically the ICU. This commitment is a primary contributing factor to the planning and preparation for implementing the CCFAP framework. It should be noted that a fragmented approach to the CCFAP sends a message to staff that only a portion of family needs are deemed important enough to be addressed by the hospital. The CCFAP framework communicates that family satisfaction issues and staff commitment to addressing those issues permeates all aspects of patient care. True organizational commitment to the CCFAP model necessitates participation from all staff and departments. The following key questions are associated with commitment by staff:

1. To what extent are staff members knowledgeable about the CCFAP model?
   
2. Is there a designated individual or individuals who serve as project coordinators for the CCFAP?
   
3. To what extent have staff members contributed to the design of the implementation of the CCFAP by the organization?
   
4. To what extent do staff perceive the CCFAP framework to be valuable for the organization and the families and patients it serves?
   
5. To what extent are there issues among staff members relative to the appropriateness and effectiveness of the CCFAP?
   
6. If there are issues and concerns among staff relative to the appropriateness or utility of the CCFAP, what processes are in place to address them?
   

Component II: Institutional Processes
Implementation Element 5: Organizational Commitment: The implementation of the CCFAP requires extensive organizational commitment to ensure the full alignment of the CCFAP key elements with the goals and objectives of the critical care units in the hospital. The successful implementation of the CCFAP necessitates buying in to the key elements of the CCFAP model, along with agreement on the activities that are designed to support the institutionalization of those elements. The following key questions are associated with organizational commitment:

1. To what extent does the organization demonstrate its commitment to the key elements associated with the CCFAP?
   
2. What are the levels of commitment provided by the organization for the full implementation of the CCFAP?
   
3. What systems and processes are in place to refresh and renew the commitment by the staff to implementing the CCFAP?
   
4. What systems are in place for rewarding staff for effective support of the CCFAP?
   

Implementation Element 6: Organizational Communication: The implementation of the CCFAP requires extensive organizational communication to ensure a full understanding of CCFAP key elements. The successful implementation of the CCFAP necessitates the clarification of the key elements of the CCFAP model. The following key questions are associated with organizational communication:

1. To what extent do families, staff, and administration share an understanding of the importance of the key elements of the CCFAP?
   
2. To what extent do staff and administration routinely confer about effective ways of implementing the CCFAP?
   
3. What patterns of communication are in place for clarifying the successful accomplishment of family-related objectives in the organization?
   
4. In what ways do the staff receive ongoing advisement of important CCFAP-related issues?
   
5. What systems are in place to provide staff the opportunity to share successes in implementing the CCFAP?
   

Implementation Element 7: Linkage to and Integration With Existing Programs and Initiatives: Given the scarcity of time faced by staff and administration, integrating the CCFAP into existing family-related programs and initiatives associated with the community, hospital, or other organization is important. This reduces the need to "sell" the initiative as a separate entity, while providing for a potentially broader level of participation. Ideally, combining the CCFAP model with related initiatives, programs, and other institutionalized elements that provide the foundation of the hospital culture ensures greater success for the CCFAP. The following key questions are associated with linking the CCFAP to existing programs and initiatives:

1. What existing programs, events, activities, or initiatives can the CCFAP enhance?
   
2. What specific things can the CCFAP do to improve on these programs or activities?
   
3. What elements are present in existing programs that would complement the CCFAP?
   

Implementation Element 8: Feedback and Measurement of Change Concerning CCFAP Implementation: Among the most important elements of CCFAP implementation are measurement and feedback surrounding changes in family satisfaction, family perception of care, staff and family behavior, attitudes, and organizational culture in the presence of CCFAP focus. Hospitals can benefit from a clear assessment of change associated with implementing the CCFAP. The following key questions are associated with linking measuring change and delivering feedback associated with CCFAP implementation:

1. What measurement system exists to determine change in satisfaction, attitude, and behavior, as well as organizational culture, in response to the CCFAP initiative?
   
2. What formal feedback system exists to provide families, staff, and administrators input on changes in response to the CCFAP?
   
3. What aspects of family satisfaction, patient care, staff behavior, and attitude need to be measured in association with the CCFAP implementation?
   
4. What differences in families, patients, and staff have been noted since the implementation of the CCFAP?
   
5. What differences in the culture of the organization have been noted since the implementation of the CCFAP?
   
6. What differences in family and staff attitudes have been noted since the implementation of the CCFAP?
   
7. What systems for delivering feedback concerning measurement are in place within the organization?
   
8. To what extent do feedback mechanisms provide for response to change by all levels of the organization?
   

Component III: Support and Integration Elements
Implementation Element 9: Reinforcement and Recognition of CCFAP Team Planning and Development: An important element of the CCFAP implementation is the extent and type of reinforcement and recognition of planning and development efforts among CCFAP team members. Propelling the recognition and utilization of CCFAP elements necessitates effective and frequent reinforcement and support of team efforts by supervisors and hospital administration. The following key questions are associated with reinforcement and recognition associated with CCFAP implementation:

1. In what ways are the efforts of the CCFAP team reinforced within the organization?
   
2. Is there a formal system of recognition for staff innovation, planning, and development?
   
3. To what extent are project team members reinforced by immediate supervisors for innovation, planning, and development in the implementation of the CCFAP?
   
4. To what extent does other staff reinforce the CCFAP team for its development and implementation efforts?
   
5. To what extent does the hospital administration reinforce the innovation, planning, and development by the CCFAP team?
   
6. To what extent are systems allowed to evolve and change to meet the needs of the CCFAP team planning and development efforts?
   

Implementation Element 10: Family Involvement: The involvement of families in supporting and implementing the CCFAP in the ICU represents a critical component of the CCFAP initiative. Family involvement in the initiative facilitates integrating key elements of the CCFAP through the ongoing assessment of family-based needs and their perceptions of quality of care and communication. The following key questions are associated with family involvement in CCFAP implementation:

1. To what extent are families involved in the planning and development of key elements of the CCFAP?
   
2. What is the nature of family involvement?
   
3. To what extent are family needs and perceptions assessed?
   
4. What is the nature and type of communication with families relative to supporting and enhancing the CCFAP in the organization?
   
5. What vehicles exist for ensuring consistency in messages relative to the CCFAP given to families by nurses, physicians, support staff, volunteers, and administration?
   

Implementation Element 11: Hospital Community Participation and Support: The degree to which the hospital community becomes involved with and supports the CCFAP initiative in the hospital and ICU is important for both the implementation and the sustainability of the model. Not only is financial and other support provided helpful, the consistency of the message makes a statement to all families about their importance to the hospital in the care of all patients. The following key questions are associated with hospital participation in and support of the CCFAP implementation:

1. What measures are in place to communicate the CCFAP initiative to members of the hospital community?
   
2. What opportunities for support and contribution are communicated proactively to the hospital community?
   
3. What provisions have been made for ensuring that alignment exists between the hospital mission and the CCFAP initiative?
   
4. To what extent does the hospital community actively support the CCFAP initiative and its key elements?
   
5. In what ways are the hospital community and the CCFAP initiative aligned?
   

Summary of Implementation Elements
Table 1 provides a summary of the three major categories of elements that comprise the descriptive model of CCFAP implementation in hospital critical care units. These elements facilitate description and prediction of the level of integration and sustainability, as well as opportunities for enhancing the CCFAP initiative within a given organization.

	CCFAP Communication Model

TOP Introduction Implementation Model CCFAP Communication Model References

Families appear to have a beneficial impact on the patient’s response to treatment. They act as buffers for patient anxiety and serve as valuable resources for patient care. However, when family anxiety is high, the family may be unable to support the patient and may transfer its anxiety to the patient. Unmitigated family anxiety may manifest itself in distrust of the hospital staff, noncompliance with the treatment regimen, anger at and dissatisfaction with care, and most dramatically, lawsuits.¹

Because the responses of families to critical illness have implications for the family, patient, and health-care staff, everyone involved benefits when a climate can be created that is conducive to good communication both with families and among the staff. Decision making is enhanced and interventions can be designed to ensure that optimal family functioning is supported.

The results of the CCFAP are showing significant differences in the family perception of family treatment and care and increases in satisfaction with communication when the CCFAP communication model (Table 2 ) is applied in the ICU.

Educational Information: Examples of this category include the provision of information on procedures or treatments that might be observed in an ICU or information on specific diseases or medical conditions. Within the CCFAP model, the communication modes used for educational information include preprinted information booklets, pamphlets on specific diseases or conditions, and videotapes. The educational information is also provided through computers in information kiosks that are set up in the family waiting room.

Anticipatory Information: This category consists of materials that staff has anticipated that families will want to have once a loved one is admitted to the ICU. This information is provided through sheets with frequently asked questions; family notebooks containing lists of area restaurants, transportation services, hotels, and other community resources; and an ICU information sheet that includes specific policies and procedures related to the ICU.

Reinforcement Information: This type of information is provided as support to information that families may have received via a conference with the physician or ICU team. The information reinforces what was said and is provided in either a printed or electronic format.

Contact Information: Contact information is provided to the families through business cards listing the ICU team members and their contact numbers, and through the use of an ICU team bulletin board. The bulletin board has the picture, name, and contact information of each team member.

Level Two: Information To Meet Family Needs
Communication at this level provides specific information, specific facts, and explanations to the family member that the family member needs and has requested. The primary purpose of this level of communication is to increase understanding and, at the same time, to promote feelings of support and assurance. Successful communication at this level reduces anxiety in the family member. Communication with family members at this level can be categorized into two types of family conferences.

Individual conferences include those scheduled with the physician where the family might receive specific details regarding the patient’s condition or an explanation regarding a procedure or treatment. In this case, communication increases the family member’s understanding and, it is hoped, reduces anxiety. Individual conferences can also be scheduled with individual ICU team members to accomplish the same objective.

Support conferences are a way of providing information and explanations as a follow-up to an individual conference. The support conference can also consist of a group meeting with support service staff, such as a social worker and a chaplain, along with other families. The communication accomplished through these conferences is designed to promote feelings of support, as well as to reduce anxiety in family members.

Level Three: Information Through Nonverbal Communication
Nonverbal communication provides comfort and support via touch, physical gesturing, space/proximity, appearance, and time. This type of communication promotes feelings of comfort, caring, and support, and reduces anxiety. Four areas support this level of communication through the CCFAP:

Integrative therapy includes massage therapy, music therapy, and pet therapy within the CCFAP model at the various model sites. Each of these therapies promotes feelings of comfort, caring, and support, and has been shown to reduce anxiety and stress in the family member.

Physical environment involves the design of the space where family members wait. Attributes of the CCFAP physical environment that are related to comfort, caring, and support include comfortable waiting rooms, sleeping rooms, and consultation/grieving rooms, and relaxing materials such as books, audiotapes or music CDs and players, games, a children’s corner, and a computer information kiosk that is located in the family waiting room.

Hospitality services are provided through the CCFAP and include food vouchers, transportation/parking vouchers, lodging discounts, and bereavement trays that include snacks for grieving families. These tangible gestures provide comfort and support to family members, reduce concern about financial matters, and indicate that the hospital cares about the welfare of the family member.

Hospital policy regarding visiting hours represents nonverbal communication through the regulation of time. The CCFAP sites have instituted flexible visiting hours and have received feedback from families acknowledging that their stress has been reduced by being able to visit their loved one in the ICU outside the parameters of the restricted visiting hours.

	Footnotes

 
Abbreviation: CCFAP = Critical Care Family Assistance Program

	References

TOP Introduction Implementation Model CCFAP Communication Model References

 

1. Danielson, CB Hamel-Bissell, B Winstead-Fry, P eds. Families health, and illness: perspectives on coping and intervention 1993 CV Mosby Co. St. Louis, MO:

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