Family Engagement

Using High Reliability to Ensure Safe and Fair Visitation Policies

Health care organizations have struggled to craft effective visitation or “family presence” policies since the first days of the pandemic, when most barred nearly all visitors. That was understandable at the time. Now, two years later, family presence is often still restricted, especially when hospitals are stretched beyond capacity.

In a recent essay, Tejal Gandhi, M.D., M.P.H., chief safety and transformation officer at Press Ganey, suggests organizations apply the science of “high reliability” to the issue of family presence. Acknowledging that it was rational to curtail visitation early on, “given the uncertainties and the PPE shortages,” Dr. Gandhi describes the “valiant efforts” of many individuals and organizations to keep patients and families connected. Videoconferencing can provide a lifeline, but technology is not a good solution for some families and can result in negative, unintended consequences.

In addition to the emotional and practical support that in-person visits provide, Dr. Gandhi details ways in which visitors can protect patients from medical error. These are familiar lessons, drawn from experience and research; lessons that Dr. Gandhi and other safety experts have been conveying for years.

Those lessons about the importance of having a loved one, a trusted advocate at the bedside have apparently been lost or at least put on hold during the crisis brought on by the pandemic, which represents a stress test that our health care system has in some ways failed. Family presence is one aspect of patient experience and safety that was cast aside under stress. Dr. Gandhi reports that some of her safety colleagues have heard clinicians say they find it easier to care for patients when visitors are kept away. She quotes a clinician/journalist as saying, “Even the language being used is different—words used to describe patients are not the same as when families were at the bedside.”

While family presence guidelines developed during this period offer helpful strategies and checklists for re-engaging with families, Dr. Gandhi turns to high reliability science in search of ways to embed respect and partnership with families as a foundation of patient care. We need to anchor patient and family engagement in organizational culture so that it will withstand the next shock to the system —the next stress test — as well as the slow-rolling stress of adapting to endemic COVID-19 in the near future.

Dr. Gandhi applies five well-known principles of high reliability (as identified by Karl Weick and Kathleen Sutcliffe) to visitation processes and offers examples of what implementation might include:

  1. Commitment to resilience. Display a sincere commitment to family presence even in times of crisis. And on a granular level, prioritize having adequate resources (supplies and staffing) to safely help people enter and exit facilities using appropriate infection control practices.
  2. Deference to expertise. Include patients and family members as full partners on committees developing family presence policies.
  3. Preoccupation with failure. Record and measure the role of family presence/absence in safety events (e.g., falls, healthcare-acquired infections). Add visitation as a contributing factor to event reporting systems and investigations.
  4. Sensitivity to operations. Review issues related to visitation during regularly scheduled safety huddles. Create flexible policies that allow for necessary adjustments and have a plan for communicating with patients and family members when policies change.
  5. Reluctance to simplify interpretations. Accept that this work is complex. Adapt policies to patient and family circumstances when needed. Collect and monitor data, watching for unintended consequences, including inequities.

In conversation with Patient Safety Beat, Patricia McGaffigan, one of Dr. Gandhi’s former colleagues at the National Patient Safety Foundation and the Institute for Healthcare Improvement, agrees that the pandemic has underscored the need to “hardwire” patient safety in health care:

Our experience with COVID-19 has reinforced the importance of habitual excellence in safety. It’s not something we can pause, not something we can afford to say, “Well, we’ll skip that today.” More than ever before, safety needs to be hardwired into our way of working. We must commit in both spirit and action to the safety of patients, families and the workforce as the essential foundation of health care; it’s why we come to work every day.


Susan Carr Susan Carr is a medical editor and writer specializing in patient safety and engagement. In addition to curating the EngagingPatients blog, she produces publications for the Betsy Lehman Center in Boston and the Society to Improve Diagnosis in Medicine. Susan lives and works in Lunenburg, Massachusetts.

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