ABSTRACT Healthcares economic challenges, corporate mergers, and technological innovations marked the last decade of the 20th

century. Both consumers and providers of maternity care faced dramatic changes in reimbursement, which threatened the quality and scope of care provided to childbearing women, children, and families. For nurses in some institutions, this meant decreases in the number of RNs caring for patients and challenges to meet patients needs with the focus on a black bottom line, fiscal profitability rather than on the patient. New Yorks Mount Sinai Hospital adopted a philosophy of patient-focused care. This article describes the 5year journey to redesign a traditional, provider-focused obstetric and pediatric program, into a new patientfocused, family-centered maternal-child healthcare center. The process, opportunities, challenges, and outcomes of this ongoing work demonstrate that a scholarly, data-driven, patient-focused process can result in improved quality, and increased patient and staff satisfaction, while decreasing costs. Key Words: Family-centered; Maternity Care; Patient-focused.

Creating Patient-Focused, Family-Centered,Maternal-Child and Pediatric Healthcare

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n 1995 Mount Sinai Hospital (MSH) changed its care delivery model to patient-focused care (PFC). Changing the philosophy of a large, urban, tertiary care, academic medical center from a provider- to a patient-focused model was a daunting challenge. This article describes the creation of patientfocused maternal-child healthcare. The process, challenges and opportunities, and outcomes, as experienced by the clinical and operational directors (the coleaders of the redesign effort in maternal-child health) are shared. Historically, maternity care and childbirth occurred in the home and in the company of family and caring women. As childbirth moved into hospitals in the late 19th and early 20th centuries, families were unwelcome. The economically volatile healthcare environment of the 1990s gave rise to dramatic changes in healthcare delivery models and hospitals. Reengineering, right-sizing, and downsizing became commonplace. Many hospitals chose to use family-centered care to increase births and market shares. Incorporation of the family into maternal-child health requires a shift in philosophy, from institution- or provider-focused to patient-focused, family-centered care.
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Kathleen Leask Capitulo, DNSc(c), RN, FACCE, and Marta Cuellar Silverberg, MBA

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CE
MSH had been esteemed in the academic and scientific communities. However, when asked for their impressions, patients responded that staff at Mount Sinai are very smart, but they are not nice. Patient satisfaction was fair, with the satisfaction of the Womens and Childrens Division ranking lowest in the medical center. The MSH embarked on a project to radically change the culture of the hospital by adopting a model of PFC. PFC places the patient at the center of the healthcare system and builds services and processes to better meet the needs of the patient and family. Utilizing a decentralized model of governance, PFC pushes decision making to the local level, empowering staff to make clinical and economic decisions in redesigning the processes, practices, and environment of care. tured policies and procedures, and (f) installing technological, financial, or personnel systems that support the restructured environment (Kremitske & West, 1997, p. 23). These steps were applied in the redesign efforts at MSH.

Goals
The goals of the MSH redesign to PFC included: improving quality of care, within a framework of total quality management; improving patient satisfaction; improving staff satisfaction; increasing continuity; and decreasing costs. Quality of care was the overriding principle, and it guided the project. Improving staff satisfaction was essential. Staff satisfaction was measured biannually using a written survey, as well as through focus group interviews at the local level. All levels of staff participated in every redesign team, in the selection of leaders, and in newly created hospital and nursing committees. Most recently, a multi-disciplinary task force of employees restructured employee benefits resulting in enhanced healthcare coverage. Additionally, we formalized an employee recognition and appreciation program with participation of staff from all areas of the institution. Staff were encouraged to participate and to appreciate and recognize their colleagues and their own contributions to the hospital, patients, and community. Another redesign objective was to reduce costs. The hospital planned to achieve $30 million in annual savings due to the elimination of costly layers of bureaucracy, redesign of inefficient systems, decentralization of authority, and multiskilling of ancillary staff. With process redesign, including clinical initiatives such as a Pediatric Asthma Pro-

Care Centers
The project began in 1995 with the creation of eight Care Centers, based upon patients clinical needs. These Care Centers were: Cardiac, General Medicine, G.I and Surgical Specialties, Maternal-Child Health, Oncology, Neuroscience and Restorative, Perioperative, and Psychiatry/Mental Health. The composition of the Care Centers was based on data from inpatient admissions, rather than on provider preferences. Consequently, the sizes of the Care Centers varied, with Maternal-Child and General Medicine being the largest. The reengineering process occurred over a period of 2 years, beginning with inpatient services. Later, the related ambulatory care practices were integrated, creating a continuity model. The Patient Focused Care Association (PFCA) identifies the restructuring steps as: (a) understanding the organizations baseline in factual terms, (b) reaggregating patients and staff, (c) decentralizing services appropriately, (d) designing job roles to the work needs and positioning those into multidisciplinary teams, (e) documenting the restruc-

Figure 1: Table of Organization.

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ject, the cost savings amounted to over $500,000 per year for the Maternal-Child Care Center.

Redesign
Mount Sinais management team began the project by reengineering themselves. The table of organization was redrawn. In Nursing, the levels of Vice President, Associate Director, Clinical Director, Assistant Director, Supervisor, Senior Clinical Nurse, and Staff Nurse were consolidated to: Vice President, Clinical Director, Clinical Nurse Manager, and Clinical (staff) Nurse (see Figure 1). A new Vice President of Nursing with a strong background in professional practice was recruited by the hospital to redirect and strengthen the nursing service. Leadership for each Care Center would be provided by two codirectors: one a Clinical Director and one an Operational Director. The Clinical Director was to be a role clearly defined as a registered nurse with a minimum of a Masters degree in nursing and demonstrated leadership and expertise in a clinical specialty. The nurse would be responsible for all clinical services within the Care Center. The Operational Director, prepared at the Masters level in business administration, would be responsible for the business and support functions. Together, the codirectors would manage the Care Center, which encompassed all decentralized services, creating a mini-hospital. Care Center Directors assumed responsibilities previously held by centralized administrative personnel, such as support services, quality assessment and improvement, addressing patient complaints, marketing, labor relations, and risk management. The first order of business for the codirectors was to assemble a management team within the Care Center. For Maternal-Child Health, it included the selection of 12 clinical nurse managers, one for each patient care unit and outreach/educational programs, and two Operational Managers, one for business (which included admitting, unit receptionist, and billing staff) and one for support (which included housekeeping, transportation, and supply management). Each manager would have administrative and financial responsibility for the decentralized departmental budgets and 24-hour responsibility. Absent were charge nurses or assistant nurse managersrelics of the old hierarchical system. Evening, night, and weekend leadership support was redesigned. The role of the off-shift Nursing Administrator, reporting to a Clinical Director, was created. The new administrative role was realigned within the Care Center structure to cover two Care Centers while on duty. The former title of Supervisor, reporting to a separate Evening/Night Director, was eliminated. The new administrative role, for which incumbent supervisors were invited to apply, reported directly to the Clinical Director, thus creating one management team.
Kathleen Leask Capitulo is Clinical Director, Maternal-Child Health Care Center, and Associate Hospital Director, Mount Sinai Medical Center, New York. She can be reached via e-mail: DrKathieRN@hotmail.com Marta Cuellar Silverberg was Operational Director, Maternal Child Health Care Center, and Associate Hospital Director, Mount Sinai Medical Center, New York.

Once the majority of the management team was established, the Care Center leadership met on several occasions to develop a common vision and philosophy for MaternalChild Health (see Figure 2). The new leadership team agreed that a core value of the Care Center was family-centered care. Families are at the heart of caring for women and children. According to Bolman and Deal (1997, p. 346), caringone persons compassion and concern for anotheris both the purpose and the ethical glue that hold a family together...A caring family, or community, requires servant-leaders who serve the best interests of the family and its stakeholders. Thus, we began to design a new, caring, family-centered philosophy for patients and staff. The vision and philosophy of the Maternal-Child Health Care Center was consistent with the mission of the hospital (founded in 1862 to serve New Yorks poor immigrant community): provide service to the community, quality care, research, and education. To design each Care Center, interdisciplinary teams were convened. For inpatient Maternal-Child Health, which included 220 inpatient beds and 5,000 annual births, this represented four teams that worked over a period of 15 months. Initially, two teams were charged: one for Labor and Delivery (L&D) and another for Postpartum services. Both teams ran simultaneously and were led by one of the Codirectors and facilitated by a group leader expert in PFC

Figure 2: Maternal-Child Health Care Center Vision.

The Mount Sinai Maternal-Child Health Care Center will be a leader in providing all aspects of care to children, women, and childbearing families. This will be accomplished through patient-focused care and the utilization of all resources at Mount Sinai. Outreach to the community will be pivotal in the restoration and maintenance of health. Through an interdisciplinary family-centered approach, the Care Center will provide families with care, treatment, and education, which will enable them to return to the community and maintain health. Philosophy: The Maternal Child Health Care Center will provide: I A continuum of quality care, provided through the model of patient-focused care. I A caring and friendly, family-centered environment. I An atmosphere for optimal adjustment, growth, and development of our clients and their families. I Respect for all families, traditional and nontraditional, as families are the stabilizing unit of society. I Primary Nursing, coordinating care through collaboration. I Outreach to the community. I Health education and maintenance to our clients, their families, our community, and professional health colleagues. I Scholarly clinical practices based upon and supportive of research. I A fiscally responsible environment. I Care that meets the individual cultural and spiritual needs of clients and their families.

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redesign. Membership on the team consisted of representatives from each discipline, department, and service within the area being redesigned, as well as the Clinical and Operational Managers. In addition to nursing and business operations, core services would be decentralized, including Social Work, Utilization Management, Respiratory Therapy, Pharmacy, Nutrition, Physical Therapy, Occupational Therapy, Child Life, Communication Disorders, Housekeeping, Admitting, and Transportation. Calculation of resources to be decentralized was accomplished by analysis of the history of the areas use of corresponding core services over the past year. For example, assuming that the inpatient obstetric units had consumed $400,000 in housekeeping services for the past year, $400,000 from the core housekeeping department would be reallocated to the Care Center less savings of 10% to 15% for staff positions and 30% for supervisory positions. Therefore, the Care Center would receive 10% to 30% less of the resources, for assuming 100% of the decentralized activity. Key savings and improvements would be accomplished by process redesign subgroups of the redesign teams, which would identify opportunities to change traditional, often bureaucratic, processes and redesign them to increase efficiency and enhance value for patients. Redesign teams met weekly for 4 consecutive hours. Leaders, facilitators, and subgroups met more frequently, reviewing the work in progress. Monthly presentations were made to an Executive Reengineering Committee, chaired by the Hospitals Director. To inaugurate each team, each member participated in a 2-day workshop lead by a professional facilitator skilled in PFC and group process.

Figure 3: Obstetric Process Redesign Teams.

I I I I I I I I I I I I I I I I I I I I Registration Preadmission Intake Labor and Delivery Surgery Schedule Mother/Baby Nursing Assessment Transfer of Mother and Baby Together Amenities Breastfeeding Visiting Hours Stocking Supplies Surgical scrubOb. Technician Placenta Disposition Birth Certificates Chart Preparation Prenatal Charts: Clinic to Labor & Delivery Food for Labor Coaches Mother-Baby Primary Nursing Breastfeeding Visiting Hours Childbirth Education and Lactation

security for full-time CBU staff employed prior to a mutually agreeable date. The MCH Redesign Teams also identified the need for three additional positions, which were created during the redesign phase:

Job Redesign
Prior to the implementation of the Care Centers, an interdisciplinary committee from all areas of practice created multiskilled, nonprofessional jobs that would be used in the Care Centers. In addition to the leadership and professional positions, three ancillary positions were created:

Materials Coordinator is responsible for ordering, managing, and distributing supplies and equipment.

Obstetrics Technician is responsible for scrubbing in the

L&D operating rooms and providing patient care assistance and transportation. The team agreed that in L&D a surgical technical role was preferred to that of Patient Care Associate. Therefore, nursing assistant positions were converted by the redesign team to Obstetrics Technician and no PCAs were included in L&D. Patient Flow Coordinator is responsible for supervision of the admitting and patient-flow processes. Incumbent staff whose jobs were being eliminated (e.g., Unit Clerks, Nursing Assistants, Registrars, and EKG Technicians) received letters inviting them to apply for the new positions. The new associate positions required passing exams that tested necessary skills for the new positions. A 4week course was given to applicants and individual tutoring was made available, when needed. Managers interviewed candidates and selected applicants based upon length of service, performance history, and skills. Employees who were unable to pass the exams were reassigned to non-Care Center support positions and offered additional training. Unlike the ancillary personnel, staff nurses did not have to reapply for new jobs. The Staff Nurse position was renamed Clinical Nurse to reflect a new nursing professional practice model.
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Patient Care Associate is responsible for assisting nurses

with patient care. This position combined the work previously performed by nursing assistants, EKG technicians, dietary aides, and phlebotomists. Support Associate is responsible for housekeeping and transporting patients. This work combined the work previously done by housekeepers, transporters, and messengers. Business Associate is responsible for unit receptionist work, decentralized admitting, medical record management, and birth and death certificate completion. This position combined work formerly done by unit receptionists, registrars, admitting clerks, and birth certificate clerks. Prior to implementing these positions, agreements with the collective bargaining unit (CBU) representing these jobs were made. These agreements directed the interviewing, education, and selection of current employees for the new positions. The new jobs provided promotional opportunities with increased salaries. The agreements also provided job
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Process Redesign

Figure 4: Obstetric Redesign Team Members.

Labor & Delivery (L&D) Team Postpartum Team

I Clinical Director, Coleader I Operational Director, Coleader Process redesign, totally recreating a process (e.g., I Administrator, non-MCH, Coleader I Postpartum Clinical Nurse Manager, Coleader admitting and visiting paI Clinical Nurse Manager, L&D I Clinical Nurse Manager, Postpartum tients), is an important I Medical Director, L&D I Director of Newborn Medicine component of developing I Clinical Nurse, L&D I Clinical Nurse, Postpartum PFC. Small redesign teams I Operational Manager I Operational Manager created flow charts for I Nursing Assistant, L&D I Nursing Assistant, Postpartum major processes. For exI Blood Bank Supervisor I Assistant Director of Social Work for MCH ample, the original maI Clinical Engineer I Attending Obstetrician, Faculty ternity admitting process I Attending Obstetrician, Faculty I Attending Obstetrician, Voluntary required 18 pages to diaI Attending Obstetrician, Voluntary I Lactation Consultant gram, was inefficient, I Director of Newborn Medicine cumbersome, and was I Social Worker deemed unfriendly by patients. Teams recreated I Social Work Supervisor processes, reducing the I Ambulatory Care Manager, Obstetrics number of steps and elimI Anesthesiologist inating hand-offs to other personnel. For exduring the evening for 2 hours. Husbands were welcomed at ample, in obstetrics 20 process redesign teams were any time during the day. New policies were predicated on a charged (see Figure 3). The teams were comprised of reprenew definition of family: anyone who is designated by the pasentatives from all disciplines and role categories (see Figtient to have a significant role in her or his life. Family visiting ure 4). In the last month of design, the L&D and Postparwas open throughout the day. Children became welcomed tum teams were combined to refine and coordinate the visitors, even in L&D. In Maternity, the new process bands a work of the teams. primary visitor (spouse, significant others, partners, or anyFeedback from patients was key in redesigning the sysone designated by each mother), the mother, and the newtems. Patient-focused group interviews (FGIs) were held for born. Primary visitors are now welcomed at any time, includeach redesign team to elicit suggestions and feedback. At ing 24-hour visiting in single rooms. Recommendations were the beginning of the focus group, participants were told made to families to keep visits short to promote the mothers that were about to redesign the maternity and pediatric rest and to limit the number of individuals in the room at any services and wanted their [patients] input. Two questions one time for safety reasons. were asked: What do we do that we should change? and A major theme of the patient FGIs was the need for lactaWhat do we do well that we should keep? tion support. Hence, a Breastfeeding Committee was launched Groups were facilitated by a focus group expert from that created an institution-wide effort to promote a Baby the Human Resource Department. Care Center Codirectors Friendly environment, the gold standard of the World Health attended as nonparticipant observers. Data were analyzed Organization, recognizing hospitals that support breastfeeding and major themes were identified. Feedback from the FGIs families. Other changes resulting from FGI findings included: were shared at redesign meetings with team members and creating child-friendly menus, and the purchase of rockers, incorporated into the redesigned processes. For example, in clocks, and sleeper chairs in Pediatrics. In Obstetrics, a major Obstetrics, patients voiced their lack of satisfaction with renovation to create single-room maternity care has been visiting hours, which were perceived as limited and puniplanned based on patient input from the FGIs. tive; the lack of a comprehensive breastfeeding program, although they highly valued the lactation consultants; fragPrimary Nursing mented nursing care; the transfer of mother and baby separately from L&D to Postpartum; and the antiquated maA major redesign effort was the adaptation of Cliffords ternity facility. In the Neonatal Intensive Care Unit (NICU), (1990) professional practice model for Mount Sinais Nursparents identified the need for more chairs and clocks, and ing Department, including primary nursing. Oversight for better continuity of nursing care. In Pediatrics, parents and the discipline of Nursing provided by the Vice President for children voiced a desire for a child friendly menu and Nursing as the Chief Nurse Executive, and the Nursing Exmore amenities for patients and parents. ecutive Committee, comprised of the Clinical Directors, DiAs a result of the redesign, visiting-hour policies were drarector of Nursing Professional Practice and Informatics, matically changed and an open, family-centered visiting enviand Director of Nursing Education, Recruitment, and Reronment was created. Previous maternity visiting policies limtention. At a local level, Nursing was under the auspices of ited grandparent and sibling visiting to only 2 hours during each Care Centers Clinical Director. In Obstetrics, a rethe afternoon. Other family and friends were welcomed only design team planned and implemented primary nursing,

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creating a mother-baby nursing model. The Postpartum Units were then renamed Mother-Baby Units. Primary nursing empowered the nursing staff by enhancing the primary nurses accountability and responsibility for coordinating all care for a self-selected caseload of patients. The Clinical Nurse Manager functioned as a coach, mentor, and clinical consultant. Within this model, Clinical Nurses communicate directly with all members of the healthcare team. Physicians no longer walk onto the unit seeking reports on patients from the charge nurse. Instead, a state-of-the-art computerized bed-board system identifies the name of the patient, physician, and primary nurse, and is used to facilitate communication with all disciplines, enhancing direct communication between physicians and primary nurses. In the absence of a primary nurse, an associate nurse is identified. As much as possible, the associate nurses who care for a patient are limited, to promote continuity. The relationship established between a primary nurse and the patient and family is one of the guiding principles of the Nursing Department of MSH (Smith, 1997). Central to the development of the profession of Nursing at MSH was a change in Nursings esprit de corps. Nursing was no longer viewed as a department or a service, but rather as a scholarly, caring Community of Nurses (Smith, 1997), embracing all aspects and levels of nursing practice, from inpatient, ambulatory, and home care clinical nurses; to educators, advanced practice nurses, leaders, and executives. Nurses were accountable for their own practices, with the community of nurses fostering partnerships with nursing and nonnursing colleagues.

tionships. Program content was unit specific. For example, topics in L&D included: fetal monitoring, breastfeeding, bereavement, family-centered care, and patient satisfaction. In Pediatrics, the staff of the newly created RCU received specialized education on asthma, including medications, nebulizer advancement, discharge planning, and patient education. Team-building sessions were held for the unitbased teams, using consultants from the Hospitals Organizational Development Department. Team-building sessions allowed seasoned staff an opportunity to express their losses and concerns about the change and helped them to build new, interdisciplinary relationships, an essential component of the PFC model. A separate group, coordinated by the Director of Nursing Professional Practice and Informatics and a Primary Nursing Steering Committee, oversaw the Primary Nursing initiative, including planning, education, and roll-out. Classes were held for every clinical nurse, nurse manager, and advanced practice nurse prior to the implementation phase of Primary Nursing.

Challenges and Opportunities

Redesign to PFC was replete with challenges. Some members of the Care Center teams had great difficulty in planning and implementing change. At the inception of the redesign meetings, some physicians were skeptical of the autonomy and power embedded in the Care Center Director positions. Some did not want to accept that the Directors were empowered to lead the redesign efforts and implement the necessary changes in patient care delivery systems and processes. Some physicians were adamantly opposed to changing the visiting hours, stating that the hospital must function in loco parentis for patients and limit visits from patients family, children, and friends. Initial meetings about visiting hours were akin to a tennis volley with a key physician opposing any liberalization of visiting and the Clinical Director attempting to build a new family-centered philosophy that did, in fact, welcome open-family visits. As illustrated in Negotiating at an Uneven Table (Kritek, 1994, p. 242), in discussing conflict resolution, it helps to differentiate between those who come to a negotiation to `claim that they must prevail and those who come to a negotiation to `create a solution to the conflict. The physician was claiming and the Clinical Director creating. To resolve the conflict, the discussion was refocused on the bigger issue: creating patient-focused care with satisfied customers. Feedback from patient focus groups was shared as well as a survey of other academic medical centers visiting hours. Allies for the change, including other physicians and the hospitals Director, were identified. Ultimately, visiting hours were changed. While nursing staff in Pediatrics embraced primary nursing, several Postpartum nurses were unhappy about moving into the Mother-Baby model. They voiced opposition to the Manager and the Director. When implemented, some even complained to physicians and a few to patients. Individuals were referred to the vision of the Care Center. While staff
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Pediatrics
The three general Pediatrics units were redesigned from a developmental, age-related model, to a clinical model, creating a Respiratory Unit, a Hematology/Oncology Unit, and a Cardiac/GI and other specialties unit. Initially, several members of the redesign team resisted the concept of a clinical model. Politics, power, and rivalries among the clinical subspecialties denied identification of clinical needs. For example, the idea of identifying an asthma/respiratory cluster of patients was unpopular. However, the work of the team was guided by data. A smaller group of nurses and physicians poured through hundreds of pages of data, validating that asthma and respiratory illnesses were the primary admitting diagnoses in pediatrics. Hence, a Respiratory Care Unit (RCU) was created. The transition to the clinical model would require that specialties and staff be relocated to other pediatric units. At one large meeting that included members of all redesign teams, the decision for clinical allocation of specialties was made. The issue was so highly charged that the group insisted on taking an anonymous ballot. Nurse members of the group called their colleagues to ensure that they would be present to vote.

Education
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were encouraged to verbalize concerns to leadership, it was made clear that it was unacceptable to complain to patients. Coordinating hundreds of members of different disciplines under the umbrella of the Care Center and the direction of one leadership entity does not, in and of itself, make a team. Jones (1997, p. 11) defined teamwork as health care professionals, families, and patients with clearly identified roles working together in partnership via sharing and coordination...facilitated through consultation and communication. Monthly meetings with the Care Center Directors and all professionals, involvement of multiple disciplines in Care Center projects (such as community outreach), and the overall success of the MaternalChild Care Center helped facilitate team spirit and positive working relationships. The initial chaos of redesign was accompanied by positive fanfare in support of staff. Grand opening parties were held for all staff on the official date of a units joining the Care Center. Staff in new associate positions (e.g. Business, Support, and Patient Care Associates), were given upscale, new uniforms. A Care Center newsletter, Families R Us, published all positive letters about staff. Semiannual Care Center award ceremonies honored staff who contributed to teamwork, service, and excellence. The new leadership team followed the principles of team building: to nurture, develop, and build rather than criticize. It recognized that for people to excel and to go beyond previous performance, they must continually learn, stretch themselves, and, on occasion, fail, necessitating support, respect, trust, and nurturing behavior (Kent, Johnson, & Graber, 1996, p. 33).

Physicians
Every redesign team included physician members. From the outset, the Care Center quality assurance and improvement structure required cochairs: the Clinical Director and a physician. Maternal-Child Health was fortunate to have a physician member of both the Pediatric and Obstetric faculty, who shared the Care Centers vision and values, and agreed to serve in that capacity. In the Care Center model, physician participation continued through the development of Physicians Advisory Committees. Initially, two advisory committeesone for Pediatrics and one for Obstetricswere chaired by the Codirectors. The committees were comprised of the Codirectors, all Care Center managers, and voluntary and fulltime physician representatives of the major areas of practice. They functioned as a conduit of information and a forum for physicians to have their opinions and needs heard. Three years later, as Care Centers became more seasoned, the MSHs Board of Trustees attempted to elevate the importance of the physician committees. Hence, the committees were renamed Physician Steering Committees and, in Maternal-Child Health, reconstituted as a combined Pediatric and Obstetric meeting.

Outcomes
The outcome indicators used for evaluating the redesign were quality, patient satisfaction, cost, and medical
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record/chart return. It was important to include chart return because prior to redesign, several medical records were misplaced and, consequently, significant dollars could not be billed to insurers. Results in the first year were positive. For the Maternal-Child Health Care Center, patient satisfaction rose from an overall score of 3.5, on a 5-point scale (5 = Excellent, 4 = Very Good, 3 = Good, 2 = Fair, 1 = Poor) in 1995 before redesign, to 4.1 in 1996 and 1997 after redesign. These changes were statistically significant (p = 0.05). Despite challenges with the oldest facility in the medical center, MaternalChild Health has maintained its lead in patient satisfaction with an overall score of 4.2 in 2000. Patient complaints and complimentary letters were also analyzed. In the first year after implementation of PFC, complaints were reduced by 50% and complimentary letters rose over 100%. Outcomes resulting from the change in delivery system are consistent with Williams (1997, pp. 6162, 67) findings that the model of patient-focused care takes into account the patients perspective of care, which provides for more personalized care. PFC reduces anxiety and enhances patients feeling hope, comfort, confidence, assurance, and mental stability and wellness. Patient-focused care defined as holistic nursing care empowers both the nurse and the patient and provides a healing and growthful atmosphere for the patient. Length of stay was significantly reduced in inpatient pediatrics with the adoption of the clinical model. Grouping patients with similar clinical needs, although from different age groups, gave staff an opportunity to become experts in their area of clinical practice. On the Respiratory Unit, staff became the leaders in the creation of an Interdisciplinary Clinical Pathway (IDCP) for Inpatient Pediatric Asthma. With the staffs enhanced expertise, a 50% reduction in length of stay for pediatric asthma was realized. One year after aggregating respiratory patients on one unit, improvements in clinical care and reductions in length of stay spawned new redesign efforts. The Respiratory Unit (RU), initially 24 beds that frequently overflowed to another Pediatric Unit, no longer needed 24 beds. The unit was relocated to a smaller area, allowing for a census of 12 to 16 patients. This permitted an expansion of the Pediatric Intensive Care Unit (PICU), which badly needed additional beds, having had to refer emergent, tertiary pediatric cases to other PICUs in the city. When aggregated on one unit, we found that the census of asthma patients had predictable seasonality: hospital admissions from late September to Maywith peaks in October, November, and Aprilwith few admissions from June to early September. As a by-product of redesign the Maternal-Child Health Care Center was able to close the RU for a period of 4 months, from mid-May to mid-September, resulting in an annual savings of approximately $600,000. No staff positions were eliminated. Instead, pediatric nurses in the RU were offered voluntary reassignments for the summer to vacant positions on other pediatric units. However, several nurses chose to take 1 or 2 months off without pay. The hospital agreed to continue
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their benefits during that time, with no loss of seniority. This worked so well that the following year, the Clinical Director suggested that the Hospital negotiate with the Nursing bargaining unitthe New York State Nurses Association (NYSNA)to create 8-month nursing positions. Because of the positive experience and the history of no nursing lay-offs in Pediatrics, NYSNA agreed to the 8month positions. Three years after implementation, Primary Nursing has begun to permeate the culture. Consistent with findings by Brider (1992, p. 27), patients are getting more direct care. Unlike other reengineering models in which RNs are being replaced by unlicensed personnel, and RN-to-patient ratios are 1:10 on the day shift and 1:1520 on nights (Fagin, 1999), hours per patient day at MSH have increased slightly, patient satisfaction has improved, and costs have declined. These results are supported by Kovner and Gergen (1998) who found a significant relationship between nurse staffing and quality of care. Unit-based clinical leadership has been essential to the models success. Prior to the implementation of PFC, although there was a long chain of nursing hierarchy, supervisors covered two units. In the MSH model, there is now one Clinical Nurse Manager for each unit. Onsite leadership has many advantages: mentoring of new staff, clinically expert consultation, problem solving, performance improvement, staffing, labor management, staff evaluation, and role modeling. On several units with histories of excessive sicktime usage and concomitant over-time for sick time replacement, the presence of an onsite Clinical Nurse Manager reduced sick-time by one-half and overtime by two-thirds. On a unit with 75 full-time equivalents (FTEs), annual savings exceed $500,000. In some areas (e.g., Obstetrics, PICU, NICU, Pediatric Asthma) Clinical Nurse Managers are supported in their work by Clinical Nurse Specialists (known as Clinical Coordinators at MSH) who provide clinical expertise, consultation, project management, and have input into staffs clinical performance evaluations. Pilon (1998) reported that combining all clinical, business, and support functions into an solitary associate position created competition for associates time for which managers were unprepared. Frequently, the generic associate was forced to decide which task to complete first: feeding a patient or cleaning a room. This was not a problem in The MSH model because the business functions and support functions were delineated within a framework of teamwork. Staff of the Maternal-Child Health Care Center were rewarded twice in the fist 2 years with 6% bonuses based upon an incentive compensation plan linked to the outcome indicators. In a nutshell, patient-focused care is a construct that advocates simplifying the care...by focusing on the expected outcomes for the patient rather than the multiplicity of tasks of each department. Actual dollar savings accrue from the reduction of personnel expense. As personnel are cross-trained, fewer people are needed to fulfill the essential functions...The organization of care delivery patterns yields less hierarchy and [fewer] associated support and clerical personnel (Jones, 1997, pp. 3, 5).
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Continued change in healthcare is inevitable. Stability, job security, and permanence have been etched out of the healthcare vocabulary, and replaced by redesign, change, and restructuring. A proliferation of models for change has confused healthcare leaders, staff, and consumers. Further compounding the confusion is the use of similar or identical names (e.g., patient-focused care) for very different models borne out of different philosophical and conceptual frameworks. The savvy professional and consumer need to look beyond the label, analyze the structure of the model, and critically examine the outcomes. Under scrutiny, many alleged patient-focused care models are, instead, wolves in sheeps clothing. Some, such as the proprietary healthcare chains that now virtually monopolize the southwest, are more obvious; others require a closer look. MSHs journey toward patient-focused care has been challenging, requiring vision, perseverance, commitment, and guts. Yet, it has been, perhaps, the greatest opportunity to create and transform a traditional, albeit complex, health systemthrough a scholarly, participative process into a family and friendly community-like hospital. Like other restructuring and change efforts, our work will never be completed.
Acknowledgments

The authors thank Thomas Smith, MS, RN, Vice President and Chief Nurse Executive, Mount Sinai Hospital, and Hussein Tahan, DNSc(c), RN, for their support in the development of this article.
References
Bolman, L. & Deal, T. (1997). Reframing organizations. San Francisco: Jossey-Bass. Brider, P. (1992). The move to patient-focused care. American Journal of Nursing, 92(9), 2633. Clifford, J., & Horvath, K. (1990). Advancing professional nursing practice: Innovations at Boston Beth Israel Hospital. New York: Springer. Fagin, C. (1999, March 16). Nurses, patients, and managed care. The New York Times, p. F7. Jones, R. (1997). Patient-focused care: what is it? Holistic Nursing Practice, 11(3), 17. Kent, T., Johnson, J., & Graber, D. (1996). Leadership in the formation of new health care environments. Health Care Supervisor, 15(2), 2734. Kovner, C., & Gergen, P. (1998). Nurse staffing levels and adverse events following surgery in U.S. hospitals. Image, 30(4), 315321. Kremitske, D., & West, D. (1997). Patient-focused primary care: A model. Hospital Topics, 75(4) 2228. Kritek, P. (1994). Negotiating at an uneven table. San Francisco: JosseyBass, Inc. Mitford, J. (1992). The American way of birth. New York: Penguin. Smith, T. (1997). Guiding principles for nursing practice. New York: Mount Sinai Hospital. Weber, D., & Weber, A. Reshaping the American hospital. Heathcare Forum, 37, SS1SS9. Williams, S. (1997) Caring in patient-focused care: The relationship of patients perceptions of holistic nurse caring to their levels of anxiety. Holistic Nursing Practice, 11(3), 6168.

ONLINE

Lamaze International http://www.lamaze-childbirth.com/ International Childbirth Education Association, Inc. http://www.icea.org/ Institute for Family Centered Care http://www.familycenteredcare.org/ Maternity Care Coalition http://www.momobile.org/
MCN

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CE
Continuing Education
Creating Patient-Focused, Family-Centered, Maternal-Child and Pediatric Healthcare
General Purpose: To describe the transition of a large, traditional, provider-focused obstetric and pediatric program into a patient-focused, family-centered, maternalchild healthcare center. Learning Objectives: After reading this article and taking this test you will be able to: 1. Outline concepts helpful in understanding the process of transforming a maternity service into a family-centered model of care. 2. Discuss the various steps and phases involved in the redesign process. 3. Outline the roles and responsibilities of specific staff positions in the new model. To earn continuing education (CE) credit, follow these instructions: 1. Read the article on page 298. Complete sections A, B, and C* on the enrollment coupon below (or a photocopy). Each question has only one correct answer. 2. Send the coupon with your $14.95 registration fee to: Continuing Education Department, Lippincott Williams & Wilkins, Inc., 345 Hudson Street, 16th Floor, New York, NY 10014. Within six weeks youll be notified of your test results. A passing score for this test is 11 correct answers. If you pass, you will receive a certificate of completion. If you fail, you have the option of taking the test again at no additional cost. This continuing nursing education (CNE) activity for 2 contact hours is provided by Lippincott Williams & Wilkins, which is accredited as a provider of continuing education in nursing by the American Nurses Credentialing Centers Commission on Accreditation and by the American Association of Critical-Care Nurses (AACN 9722), Category O. This activity is also provider approved by the California Board of Registered Nursing, Provider Number CEP11749 for 2 contact hours. Lippincott Williams & Wilkins is also an approved provider of CNE in Alabama, Florida, and Iowa, and holds the following provider numbers: AL #ABNP0114, FL #FBN2454, IA #75. All of its home study activities are classified for Texas nursing continuing education requirements as Type I. *In accordance with Iowa Board of Nursing administrative rules governing grievances, a copy of your evaluation of this CE offering may be submitted to the Iowa Board of Nursing.

HOURS

MCN CE also available online at www.NursingCenter.com

b. the previous years consumption for each service plus 10% to 30% of that amount. c. the previous years consumption for each service minus 10% to 30% of that amount. 9. Work previously performed by transporters and messengers is now the responsibility of a. patient care associates. b. support associates. c. business associates. 10. Supervising the admitting process is now the responsibility of a. patient care associates. b. business associates. c. patient flow coordinators. 11. As a result of patient focus groups, the codirectors learned that obstetric patients wanted more a. chairs. b. clocks. c. visiting hours. 12. New policies at the Maternal-Child Health Care Center were based on defining the family as a. all relatives. b. anyone who chooses to visit a particular patient. c. anyone patients identify as having significant roles in their life. 13. In the new model, nursing is viewed as a a. service. b. community. c. department. 14. One of the key outcome indicators used to evaluate the redesign was a. chart return. b. staff satisfaction. c. physician acceptance. 15. According to Jones (1997), patient-focused care defines its focus as a. the multiplicity of integral tasks. b. increased support personnel. c. patient outcomes.

2. The restructuring steps outlined by the Patient-Focused Care Association (PFCA) include all the following except a. understanding the organizations cultural structure. b. reaggregating patients and staff. c. designing job roles that fulfill work needs. 3. Restructuring the maternal-child service was guided by the overriding principle of a. staff retention. b. risk reduction. c. quality of care. 4. In addition to the staff nurses, staffing was restructured to include which of the following three layers of management? a. clinical director, clinical nurse manager, and supervisor b. clinical director, assistant director, and clinical nurse manager c. vice president, clinical director, and clinical nurse manager 5. Two codirectors staff each care center in the new design, one with expertise in the appropriate clinical nursing specialty and the other credentialed and experienced in a. managed care. b. business administration. c. holistic health. 6. A traditional role that was eliminated in the redesign was that of a. unit receptionists. b. charge nurses. c. admitting staff. 7. The Maternal-Child Health Care Centers vision specifies providing families with which of the following? a. care, treatment, and education b. service, dignity, and health promotion c. care, financial support, and customer service 8. Budgetary allowances for core services equaled a. the previous years consumption for each service.

Questions
1. The patient-focused care model

employs which of the following models of governance? a. autocratic b. decentralized c. hierarchal

Lippincott Williams & Wilkins, Inc., CE Home Study Enrollment Coupon

Creating Patient-Focused, Family-Centered, Maternal-Child and Pediatric Healthcare
CE Credit: 2 Contact Hours Fee: $14.95 Registration Deadline: December 31, 2003
Please check all that apply: LPN, RN, CNS, NP, CRNA, CNM, Other ___________ SS#________________________ Are you certified? Yes No Certified by:_____________________ Telephone #:__________________________ Name (Last) _________________________________ (First)_____________________ (MI____ Address _____________________________________________City_____________________ State____________Zip ______________ State of Licensure #1 _______________________ License Number #1 ___________________ State of Licensure #2 _______________________ License Number #2 ___________________ Position Title __________________________________________________ Area of Specialty _______________________________________________

Test Responses: Darken one box for your answer to each question.
1. a b c 2. a b c 3. a b c 4. a b c 5. a b c 6. a b c 7. a b c 8. a b c 9. a b c 10. a b c 11. a b c 12. a b c 13. a b c 14. a b c 15. a b c

1. Did this CE activitys learning objectives relate to its general purpose? Y N 2. Was the journal home study format an effective way to present the material? Y N 3. Was the content current to nursing practice? Y N 4. How long did it take you to complete this CE activity? _____hours 5. Suggestions for future topics ______________________ ______________________________________________

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VOLUME 26

NUMBER 6

November/December 2001