In 1995 Mount Sinai Hospital (MSH) changed its care deliv-ery model to patient-focused care (PFC). Changing the phi-losophy of a large, urban, tertiary care, academic medicalcenter from a provider- to a patient-focused model was a

daunting challenge. This article describes the creation of patient-focused maternal-child healthcare. The process, challenges andopportunities, and outcomes, as experienced by the clinical andoperational directors (the coleaders of the redesign effort in ma-ternal-child health) are shared.

Historically, maternity care and childbirth occurred in thehome and in the company of family and caring women. As child-birth moved into hospitals in the late 19th and early 20th cen-turies, families were unwelcome. The economically volatilehealthcare environment of the 1990s gave rise to dramaticchanges in healthcare delivery models and hospitals. Reengineer-ing, right-sizing, and downsizing became commonplace. Manyhospitals chose to use family-centered care to increase births andmarket shares. Incorporation of the family into maternal-childhealth requires a shift in philosophy, from institution- orprovider-focused to patient-focused, family-centered care.

298 VOLUME 26 | NUMBER 6 November/December 2001

Kathleen Leask Capitulo, DNSc(c), RN, FACCE, and Marta Cuellar Silverberg, MBA

Creating Patient-Focused,Family-Centered, Maternal-Child

and Pediatric Healthcare

ABSTRACTHealthcare’s economic challenges, corporate mergers,and technological innovations marked the last decadeof the 20th century. Both consumers and providers ofmaternity care faced dramatic changes in reimburse-ment, which threatened the quality and scope of careprovided to childbearing women, children, and families.For nurses in some institutions, this meant decreases inthe number of RNs caring for patients and challengesto meet patients’ needs with the focus on a black bot-tom line, fiscal profitability rather than on the patient.New York’s Mount Sinai Hospital adopted a philosophyof patient-focused care. This article describes the 5-year journey to redesign a traditional, provider-focusedobstetric and pediatric program, into a new patient-focused, family-centered maternal-child healthcarecenter. The process, opportunities, challenges, andoutcomes of this ongoing work demonstrate that ascholarly, data-driven, patient-focused process can re-sult in improved quality, and increased patient and staffsatisfaction, while decreasing costs.Key Words: Family-centered; Maternity Care; Patient-focused.

MSH had been esteemed in the academic and scientificcommunities. However, when asked for their impressions,patients responded that “staff at Mount Sinai are verysmart, but they are not nice.” Patient satisfaction was fair,with the satisfaction of the Women’s and Children’s Divi-sion ranking lowest in the medical center. The MSH em-barked on a project to radically change the culture of thehospital by adopting a model of PFC. PFC places the pa-tient at the center of the healthcare system and builds ser-vices and processes to better meet the needs of the patientand family. Utilizing a decentralized model of governance,PFC pushes decision making to the local level, empoweringstaff to make clinical and economic decisions in redesigningthe processes, practices, and environment of care.

Care CentersThe project began in 1995 with the creation of eight CareCenters, based upon patients’ clinical needs. These Care Cen-ters were: Cardiac, General Medicine, G.I and Surgical Spe-cialties, Maternal-Child Health, Oncology, Neuroscience andRestorative, Perioperative, and Psychiatry/Mental Health.The composition of the Care Centers was based on datafrom inpatient admissions, rather than on provider prefer-ences. 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 ambulato-ry care practices were integrated, creating a continuity model.

“The Patient Focused Care Association (PFCA) identifiesthe restructuring steps as: (a) understanding the organiza-tion’s baseline in factual terms, (b) reaggregating patientsand staff, (c) decentralizing services appropriately, (d) de-signing job roles to the work needs and positioning thoseinto multidisciplinary teams, (e) documenting the restruc-

tured policies and procedures, and (f) installing technologi-cal, financial, or personnel systems that support the restruc-tured environment” (Kremitske & West, 1997, p. 23).These steps were applied in the redesign efforts at MSH.

GoalsThe goals of the MSH redesign to PFC included:

• improving quality of care, within a framework of totalquality management;

• improving patient satisfaction;• improving staff satisfaction;• increasing continuity; and• decreasing costs.

Quality of care was the overriding principle, and it guid-ed the project. Improving staff satisfaction was essential.Staff satisfaction was measured biannually using a writtensurvey, as well as through focus group interviews at the lo-cal level. All levels of staff participated in every redesignteam, in the selection of leaders, and in newly created hos-pital and nursing committees. Most recently, a multi-disci-plinary task force of employees restructured employee ben-efits resulting in enhanced healthcare coverage. Additional-ly, we formalized an employee recognition and appreciationprogram with participation of staff from all areas of the in-stitution. Staff were encouraged to participate and to ap-preciate and recognize their colleagues and their own con-tributions to the hospital, patients, and community.

Another redesign objective was to reduce costs. The hos-pital planned to achieve $30 million in annual savings dueto the elimination of costly layers of bureaucracy, redesignof inefficient systems, decentralization of authority, andmultiskilling of ancillary staff. With process redesign, in-cluding clinical initiatives such as a Pediatric Asthma Pro-

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CE

Figure 1: Table of Organization.

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

RedesignMount Sinai’s management team began the project byreengineering themselves. The table of organization was re-drawn. In Nursing, the levels of Vice President, AssociateDirector, Clinical Director, Assistant Director, Supervisor,Senior Clinical Nurse, and Staff Nurse were consolidatedto: Vice President, Clinical Director, Clinical Nurse Manag-er, and Clinical (staff) Nurse (see Figure 1).

A new Vice President of Nursing with a strong back-ground in professional practice was recruited by the hospi-tal to redirect and strengthen the nursing service. Leader-ship for each Care Center would be provided by two codi-rectors: one a Clinical Director and one an Operational Di-rector. The Clinical Director was to be a role clearly de-fined as a registered nurse with a minimum of a Master’sdegree in nursing and demonstrated leadership and exper-tise in a clinical specialty. The nurse would be responsiblefor all clinical services within the Care Center. The Opera-tional Director, prepared at the Master’s level in businessadministration, would be responsible for the business andsupport functions. Together, the codirectors would managethe Care Center, which encompassed all decentralized ser-vices, creating a “mini-hospital.” Care Center Directors as-sumed responsibilities previously held by centralized ad-ministrative personnel, such as support services, quality as-sessment and improvement, addressing patient complaints,marketing, labor relations, and risk management.

The first order of business for the codirectors was to as-semble a management team within the Care Center. For Ma-ternal-Child Health, it included the selection of 12 clinicalnurse managers, one for each patient care unit and out-reach/educational programs, and two Operational Man-agers, one for business (which included admitting, unit re-ceptionist, and billing staff) and one for support (which in-cluded housekeeping, transportation, and supply manage-ment). Each manager would have administrative and finan-cial responsibility for the decentralized departmental budgetsand 24-hour responsibility. Absent were charge nurses or as-sistant nurse managers—relics of the old hierarchical system.

Evening, night, and weekend leadership support was re-designed. The role of the off-shift Nursing Administrator,reporting to a Clinical Director, was created. The new ad-ministrative role was realigned within the Care Centerstructure to cover two Care Centers while on duty. Theformer title of Supervisor, reporting to a separateEvening/Night Director, was eliminated. The new adminis-trative role, for which incumbent supervisors were invitedto apply, reported directly to the Clinical Director, thus cre-ating one management team.

Once the majority of the management team was estab-lished, the Care Center leadership met on several occasionsto develop a common vision and philosophy for Maternal-Child Health (see Figure 2). The new leadership teamagreed that a core value of the Care Center was family-cen-tered care. Families are at the heart of caring for womenand children. According to Bolman and Deal (1997, p.346), “caring—one person’s compassion and concern foranother—is both the purpose and the ethical glue that holda family together...A caring family, or community, requiresservant-leaders who serve the best interests of the familyand its stakeholders.” Thus, we began to design a new, car-ing, family-centered philosophy for patients and staff. Thevision and philosophy of the Maternal-Child Health CareCenter was consistent with the mission of the hospital(founded in 1862 to serve New York’s poor immigrantcommunity): provide service to the community, qualitycare, research, and education.

To design each Care Center, interdisciplinary teams wereconvened. For inpatient Maternal-Child Health, which in-cluded 220 inpatient beds and 5,000 annual births, thisrepresented four teams that worked over a period of 15months. Initially, two teams were charged: one for Laborand Delivery (L&D) and another for Postpartum services.Both teams ran simultaneously and were led by one of theCodirectors and facilitated by a group leader expert in PFC

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Figure 2: Maternal-Child Health Care Center Vision.

The Mount Sinai Maternal-Child Health Care Center will be aleader in providing all aspects of care to children, women, andchildbearing families. This will be accomplished throughpatient-focused care and the utilization of all resources atMount Sinai. Outreach to the community will be pivotal in therestoration and maintenance of health. Through an interdisci-plinary family-centered approach, the Care Center will providefamilies with care, treatment, and education, which willenable them to return to the community and maintain health.

Philosophy:

The Maternal Child Health Care Center will provide:

� A continuum of quality care, provided through the modelof patient-focused care.

� A caring and friendly, family-centered environment.� An atmosphere for optimal adjustment, growth, and

development of our clients and their families.� Respect for all families, traditional and nontraditional, as

families are the stabilizing unit of society.� Primary Nursing, coordinating care through collaboration.� Outreach to the community.� Health education and maintenance to our clients, their fam-

ilies, our community, and professional health colleagues.� Scholarly clinical practices based upon and supportive

of research.� A fiscally responsible environment.� Care that meets the individual cultural and spiritual needs

of clients and their families.

Kathleen Leask Capitulo is Clinical Director, Maternal-Child Health CareCenter, and Associate Hospital Director, Mount Sinai Medical Center, NewYork. She can be reached via e-mail: DrKathieRN@hotmail.comMarta Cuellar Silverberg was Operational Director, Maternal Child HealthCare Center, and Associate Hospital Director, Mount Sinai Medical Center,New York.

redesign. Membership on the team consisted of representa-tives from each discipline, department, and service withinthe area being redesigned, as well as the Clinical and Oper-ational Managers.

In addition to nursing and business operations, core ser-vices would be decentralized, including Social Work, Uti-lization Management, Respiratory Therapy, Pharmacy, Nu-trition, Physical Therapy, Occupational Therapy, ChildLife, Communication Disorders, Housekeeping, Admitting,and Transportation. Calculation of resources to be decen-tralized was accomplished by analysis of the history of thearea’s use of corresponding core services over the past year.For example, assuming that the inpatient obstetric unitshad consumed $400,000 in housekeeping services for thepast year, $400,000 from the core housekeeping depart-ment would be reallocated to the Care Center less savingsof 10% to 15% for staff positions and 30% for superviso-ry positions. Therefore, the Care Center would receive10% to 30% less of the resources, for assuming 100% ofthe decentralized activity.

Key savings and improvements would be accomplishedby process redesign subgroups of the redesign teams,which would identify opportunities to change traditional,often bureaucratic, processes and redesign them to in-crease efficiency and enhance value for patients. Redesignteams met weekly for 4 consecutive hours. Leaders, facili-tators, and subgroups met more frequently, reviewing thework in progress. Monthly presentations were made to anExecutive Reengineering Committee, chaired by the Hos-pital’s Director. To inaugurate each team, each memberparticipated in a 2-day workshop lead by a professionalfacilitator skilled in PFC and group process.

Job RedesignPrior to the implementation of the Care Centers, an inter-disciplinary committee from all areas of practice createdmultiskilled, nonprofessional jobs that would be used inthe Care Centers. In addition to the leadership and profes-sional positions, three ancillary positions were created:

• Patient Care Associate is responsible for assisting nurseswith patient care. This position combined the work pre-viously performed by nursing assistants, EKG techni-cians, dietary aides, and phlebotomists.

• Support Associate is responsible for housekeeping andtransporting patients. This work combined the work previ-ously done by housekeepers, transporters, and messengers.

• Business Associate is responsible for unit receptionistwork, decentralized admitting, medical record manage-ment, and birth and death certificate completion. This po-sition combined work formerly done by unit receptionists,registrars, admitting clerks, and birth certificate clerks.

Prior to implementing these positions, agreements withthe collective bargaining unit (CBU) representing these jobswere made. These agreements directed the interviewing, ed-ucation, and selection of current employees for the new po-sitions. The new jobs provided promotional opportunitieswith increased salaries. The agreements also provided job

security for full-time CBU staff employed prior to a mutu-ally agreeable date.

The MCH Redesign Teams also identified the need forthree additional positions, which were created during theredesign phase:

• Materials Coordinator is responsible for ordering, man-aging, and distributing supplies and equipment.

• Obstetrics Technician is responsible for scrubbing in theL&D operating rooms and providing patient care assis-tance and transportation. The team agreed that in L&Da surgical technical role was preferred to that of PatientCare Associate. Therefore, nursing assistant positionswere converted by the redesign team to Obstetrics Tech-nician and no PCAs were included in L&D.

• Patient Flow Coordinator is responsible for supervisionof the admitting and patient-flow processes.

Incumbent staff whose jobs were being eliminated (e.g.,Unit Clerks, Nursing Assistants, Registrars, and EKG Tech-nicians) received letters inviting them to apply for the newpositions. The new “associate positions” required passingexams that tested necessary skills for the new positions. A 4-week course was given to applicants and individual tutoringwas made available, when needed. Managers interviewedcandidates and selected applicants based upon length of ser-vice, performance history, and skills. Employees who wereunable to pass the exams were reassigned to non-Care Cen-ter support positions and offered additional training. Unlikethe ancillary personnel, staff nurses did not have to reapplyfor new jobs. The Staff Nurse position was renamed ClinicalNurse to reflect a new nursing professional practice model.

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Figure 3: Obstetric Process Redesign Teams.

� 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 scrub—Ob. 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

Process RedesignProcess redesign, totallyrecreating a process (e.g.,admitting and visiting pa-tients), is an importantcomponent of developingPFC. Small redesign teamscreated flow charts formajor processes. For ex-ample, the original ma-ternity admitting processrequired 18 pages to dia-gram, was inefficient,cumbersome, and wasdeemed unfriendly by pa-tients. Teams recreatedprocesses, reducing thenumber of steps and elim-inating “hand-offs” toother personnel. For ex-ample, in obstetrics 20 process redesign teams werecharged (see Figure 3). The teams were comprised of repre-sentatives from all disciplines and role categories (see Fig-ure 4). In the last month of design, the L&D and Postpar-tum teams were combined to refine and coordinate thework of the teams.

Feedback from patients was key in redesigning the sys-tems. Patient-focused group interviews (FGIs) were held foreach redesign team to elicit suggestions and feedback. Atthe beginning of the focus group, participants were toldthat “we’re about to redesign the maternity and pediatricservices and wanted their [patients’] input.” Two questionswere asked: “What do we do that we should change?” and“What do we do well that we should keep?”

Groups were facilitated by a focus group expert fromthe Human Resource Department. Care Center Codirectorsattended as nonparticipant observers. Data were analyzedand major themes were identified. Feedback from the FGIswere shared at redesign meetings with team members andincorporated into the redesigned processes. For example, inObstetrics, patients voiced their lack of satisfaction withvisiting hours, which were perceived as limited and puni-tive; the lack of a comprehensive breastfeeding program,although they highly valued the lactation consultants; frag-mented nursing care; the transfer of mother and baby sepa-rately from L&D to Postpartum; and the antiquated ma-ternity facility. In the Neonatal Intensive Care Unit (NICU),parents identified the need for more chairs and clocks, andbetter continuity of nursing care. In Pediatrics, parents andchildren voiced a desire for a “child friendly” menu andmore amenities for patients and parents.

As a result of the redesign, visiting-hour policies were dra-matically changed and an open, family-centered visiting envi-ronment was created. Previous maternity visiting policies lim-ited grandparent and sibling visiting to only 2 hours duringthe afternoon. Other family and friends were welcomed only

during the evening for 2 hours. Husbands were welcomed atany time during the day. New policies were predicated on anew definition of family: anyone who is designated by the pa-tient to have a significant role in her or his life. Family visitingwas open throughout the day. Children became welcomedvisitors, even in L&D. In Maternity, the new process bands aprimary visitor (spouse, significant others, partners, or any-one designated by each mother), the mother, and the new-born. Primary visitors are now welcomed at any time, includ-ing 24-hour visiting in single rooms. Recommendations weremade to families to keep visits short to promote the mother’srest and to limit the number of individuals in the room at anyone time for safety reasons.

A major theme of the patient FGIs was the need for lacta-tion support. Hence, a Breastfeeding Committee was launchedthat created an institution-wide effort to promote a “BabyFriendly” environment, the gold standard of the World HealthOrganization, recognizing hospitals that support breastfeedingfamilies. Other changes resulting from FGI findings included:creating child-friendly menus, and the purchase of rockers,clocks, and sleeper chairs in Pediatrics. In Obstetrics, a majorrenovation to create single-room maternity care has beenplanned based on patient input from the FGIs.

Primary NursingA major redesign effort was the adaptation of Clifford’s(1990) professional practice model for Mount Sinai’s Nurs-ing Department, including primary nursing. Oversight forthe discipline of Nursing provided by the Vice President forNursing as the Chief Nurse Executive, and the Nursing Ex-ecutive Committee, comprised of the Clinical Directors, Di-rector of Nursing Professional Practice and Informatics,and Director of Nursing Education, Recruitment, and Re-tention. At a local level, Nursing was under the auspices ofeach Care Center’s Clinical Director. In Obstetrics, a re-design team planned and implemented primary nursing,

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Figure 4: Obstetric Redesign Team Members.

Labor & Delivery (L&D) Team Postpartum Team

� Clinical Director, Coleader � Operational Director, Coleader� Administrator, non-MCH, Coleader � Postpartum Clinical Nurse Manager, Coleader� Clinical Nurse Manager, L&D � Clinical Nurse Manager, Postpartum� Medical Director, L&D � Director of Newborn Medicine� Clinical Nurse, L&D � Clinical Nurse, Postpartum� Operational Manager � Operational Manager� Nursing Assistant, L&D � Nursing Assistant, Postpartum� Blood Bank Supervisor � Assistant Director of Social Work for MCH� Clinical Engineer � Attending Obstetrician, Faculty� Attending Obstetrician, Faculty � Attending Obstetrician, Voluntary� Attending Obstetrician, Voluntary � Lactation Consultant� Director of Newborn Medicine� Social Worker� Social Work Supervisor� Ambulatory Care Manager, Obstetrics� Anesthesiologist

creating a mother-baby nursing model. The PostpartumUnits were then renamed Mother-Baby Units.

Primary nursing empowered the nursing staff by enhanc-ing the primary nurse’s accountability and responsibility forcoordinating all care for a self-selected caseload of patients.The Clinical Nurse Manager functioned as a coach, men-tor, and clinical consultant. Within this model, ClinicalNurses communicate directly with all members of thehealthcare team. Physicians no longer walk onto the unitseeking reports on patients from the charge nurse. Instead,a state-of-the-art computerized bed-board system identifiesthe name of the patient, physician, and primary nurse, andis used to facilitate communication with all disciplines, en-hancing direct communication between physicians and pri-mary nurses. In the absence of a primary nurse, an associ-ate nurse is identified. As much as possible, the associatenurses who care for a patient are limited, to promote conti-nuity. The relationship established between a primary nurseand the patient and family is one of the guiding principlesof the Nursing Department of MSH (Smith, 1997).

Central to the development of the profession of Nursingat MSH was a change in Nursing’s ‘esprit de corps. Nurs-ing was no longer viewed as a department or a service, butrather 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 execu-tives. Nurses were accountable for their own practices,with the community of nurses fostering partnerships withnursing and nonnursing colleagues.

PediatricsThe three general Pediatrics units were redesigned from adevelopmental, age-related model, to a clinical model, cre-ating a Respiratory Unit, a Hematology/Oncology Unit,and a Cardiac/GI and other specialties unit. Initially, severalmembers of the redesign team resisted the concept of aclinical model. Politics, power, and rivalries among the clin-ical subspecialties denied identification of clinical needs.For example, the idea of identifying an asthma/respiratorycluster of patients was unpopular. However, the work ofthe team was guided by data. A smaller group of nursesand physicians poured through hundreds of pages of data,validating that asthma and respiratory illnesses were theprimary admitting diagnoses in pediatrics. Hence, a Respi-ratory Care Unit (RCU) was created. The transition to theclinical model would require that specialties and staff be re-located to other pediatric units. At one large meeting thatincluded members of all redesign teams, the decision forclinical allocation of specialties was made. The issue was sohighly charged that the group insisted on taking an anony-mous ballot. Nurse members of the group called their col-leagues to ensure that they would be present to vote.

EducationPrior to the implementation phase of redesign, all staffwere involved in educational programs, preparing them fortheir new roles, interdisciplinary work, and building rela-

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 receivedspecialized education on asthma, including medications,nebulizer advancement, discharge planning, and patient ed-ucation. Team-building sessions were held for the unit-based teams, using consultants from the Hospital’s Organi-zational Development Department. Team-building sessionsallowed seasoned staff an opportunity to express their loss-es and concerns about the change and helped them to buildnew, interdisciplinary relationships, an essential componentof the PFC model.

A separate group, coordinated by the Director of Nurs-ing Professional Practice and Informatics and a PrimaryNursing Steering Committee, oversaw the Primary Nursinginitiative, including planning, education, and roll-out.Classes were held for every clinical nurse, nurse manager,and advanced practice nurse prior to the implementationphase of Primary Nursing.

Challenges and OpportunitiesRedesign to PFC was replete with challenges. Some mem-bers of the Care Center teams had great difficulty in plan-ning and implementing change. At the inception of the re-design meetings, some physicians were skeptical of the au-tonomy and power embedded in the Care Center Directorpositions. Some did not want to accept that the Directorswere empowered to lead the redesign efforts and imple-ment the necessary changes in patient care delivery systemsand processes.

Some physicians were adamantly opposed to changingthe visiting hours, stating that the hospital must function“in loco parentis” for patients and limit visits from pa-tients’ family, children, and friends. Initial meetings aboutvisiting hours were akin to a tennis volley with a key physi-cian opposing any liberalization of visiting and the ClinicalDirector attempting to build a new “family-centered phi-losophy” that did, in fact, welcome open-family visits. Asillustrated in Negotiating at an Uneven Table (Kritek,1994, p. 242), “in discussing conflict resolution, it helps todifferentiate between those who come to a negotiation to`claim’ that they must prevail and those who come to a ne-gotiation to `create’ a solution to the conflict.” The physi-cian was claiming and the Clinical Director creating. To re-solve the conflict, the discussion was refocused on the big-ger issue: creating patient-focused care with satisfied cus-tomers. Feedback from patient focus groups was shared aswell as a survey of other academic medical center’s visitinghours. Allies for the change, including other physicians andthe hospital’s Director, were identified. Ultimately, visitinghours were changed.

While nursing staff in Pediatrics embraced primary nurs-ing, several Postpartum nurses were unhappy about movinginto the Mother-Baby model. They voiced opposition to theManager and the Director. When implemented, some evencomplained to physicians and a few to patients. Individualswere referred to the vision of the Care Center. While staff

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were encouraged to verbalize concerns to leadership, it wasmade clear that it was unacceptable to complain to patients.

Coordinating hundreds of members of different disci-plines under the umbrella of the Care Center and the di-rection 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 withclearly identified roles working together in partnership viasharing and coordination...facilitated through consultationand communication.” Monthly meetings with the CareCenter Directors and all professionals, involvement ofmultiple disciplines in Care Center projects (such as com-munity outreach), and the overall success of the Maternal-Child Care Center helped facilitate team spirit and positiveworking relationships.

The initial chaos of redesign was accompanied by posi-tive fanfare in support of staff. Grand opening parties wereheld for all staff on the official date of a unit’s joining theCare 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 CareCenter award ceremonies honored staff who contributed toteamwork, service, and excellence. The new leadership teamfollowed the principles of team building: to nurture, devel-op, and build rather than criticize. It recognized that “forpeople to excel and to go beyond previous performance,they must continually learn, stretch themselves, and, on oc-casion, fail,” necessitating support, respect, trust, and nur-turing behavior (Kent, Johnson, & Graber, 1996, p. 33).

PhysiciansEvery redesign team included physician members. From theoutset, the Care Center quality assurance and improvementstructure required cochairs: the Clinical Director and aphysician. Maternal-Child Health was fortunate to have aphysician member of both the Pediatric and Obstetric fac-ulty, who shared the Care Center’s vision and values, andagreed to serve in that capacity.

In the Care Center model, physician participation con-tinued through the development of Physician’s AdvisoryCommittees. Initially, two advisory committees—one forPediatrics and one for Obstetrics—were chaired by theCodirectors. The committees were comprised of the Codi-rectors, all Care Center managers, and voluntary and full-time physician representatives of the major areas of prac-tice. They functioned as a conduit of information and a fo-rum for physicians to have their opinions and needs heard.Three years later, as Care Centers became more seasoned,the MSH’s Board of Trustees attempted to elevate the im-portance of the physician committees. Hence, the commit-tees were renamed Physician Steering Committees and, inMaternal-Child Health, reconstituted as a combined Pedi-atric and Obstetric meeting.

OutcomesThe outcome indicators used for evaluating the redesignwere quality, patient satisfaction, cost, and medical

record/chart return. It was important to include chart re-turn because prior to redesign, several medical recordswere misplaced and, consequently, significant dollarscould not be billed to insurers. Results in the first yearwere positive. For the Maternal-Child Health Care Cen-ter, 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 4.1in 1996 and 1997 after redesign. These changes werestatistically significant (p = 0.05). Despite challengeswith the oldest facility in the medical center, Maternal-Child Health has maintained its lead in patient satisfac-tion with an overall score of 4.2 in 2000. Patient com-plaints and complimentary letters were also analyzed. Inthe first year after implementation of PFC, complaintswere reduced by 50% and complimentary letters roseover 100%.

Outcomes resulting from the change in delivery systemare consistent with William’s (1997, pp. 61–62, 67) find-ings that the “model of patient-focused care takes into ac-count the patients’ perspective of care, which provides formore personalized care.” PFC reduces anxiety and en-hances “patients’ feeling hope, comfort, confidence, assur-ance, and mental stability and wellness. Patient-focusedcare defined as holistic nursing care empowers both thenurse and the patient and provides a healing and growthfulatmosphere for the patient.”

Length of stay was significantly reduced in inpatient pe-diatrics with the adoption of the clinical model. Groupingpatients with similar clinical needs, although from differentage groups, gave staff an opportunity to become experts intheir area of clinical practice. On the Respiratory Unit, staffbecame the leaders in the creation of an InterdisciplinaryClinical Pathway (IDCP) for Inpatient Pediatric Asthma.With the staff’s enhanced expertise, a 50% reduction inlength of stay for pediatric asthma was realized.

One year after aggregating respiratory patients on oneunit, improvements in clinical care and reductions in lengthof stay spawned new redesign efforts. The Respiratory Unit(RU), initially 24 beds that frequently overflowed to anoth-er Pediatric Unit, no longer needed 24 beds. The unit wasrelocated to a smaller area, allowing for a census of 12 to16 patients. This permitted an expansion of the PediatricIntensive Care Unit (PICU), which badly needed additionalbeds, having had to refer emergent, tertiary pediatric casesto other PICUs in the city.

When aggregated on one unit, we found that the censusof asthma patients had predictable seasonality: hospital ad-missions from late September to May—with peaks in Oc-tober, November, and April—with few admissions fromJune to early September. As a by-product of redesign theMaternal-Child Health Care Center was able to close theRU for a period of 4 months, from mid-May to mid-Sep-tember, resulting in an annual savings of approximately$600,000. No staff positions were eliminated. Instead, pe-diatric nurses in the RU were offered voluntary reassign-ments for the summer to vacant positions on other pedi-atric units. However, several nurses chose to take 1 or 2months 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 ClinicalDirector suggested that the Hospital negotiate with theNursing bargaining unit—the New York State Nurses As-sociation (NYSNA)—to create 8-month nursing positions.Because of the positive experience and the history of nonursing lay-offs in Pediatrics, NYSNA agreed to the 8-month positions.

Three years after implementation, Primary Nursing hasbegun to permeate the culture. Consistent with findings byBrider (1992, p. 27), “patients are getting more directcare.” Unlike other reengineering models in which RNs arebeing replaced by unlicensed personnel, and RN-to-patientratios are 1:10 on the day shift and 1:15–20 on nights (Fa-gin, 1999), hours per patient day at MSH have increasedslightly, patient satisfaction has improved, and costs havedeclined. These results are supported by Kovner and Ger-gen (1998) who found a significant relationship betweennurse staffing and quality of care.

Unit-based clinical leadership has been essential to themodel’s success. Prior to the implementation of PFC, al-though there was a long chain of nursing hierarchy, supervi-sors covered two units. In the MSH model, there is nowone Clinical Nurse Manager for each unit. Onsite leader-ship has many advantages: mentoring of new staff, clinicallyexpert consultation, problem solving, performance improve-ment, staffing, labor management, staff evaluation, and rolemodeling. On several units with histories of excessive sick-time usage and concomitant over-time for sick time replace-ment, the presence of an onsite Clinical Nurse Manager re-duced sick-time by one-half and overtime by two-thirds. Ona unit with 75 full-time equivalents (FTEs), annual savingsexceed $500,000. In some areas (e.g., Obstetrics, PICU,NICU, Pediatric Asthma) Clinical Nurse Managers are sup-ported in their work by Clinical Nurse Specialists (knownas Clinical Coordinators at MSH) who provide clinical ex-pertise, consultation, project management, and have inputinto staff’s clinical performance evaluations.

Pilon (1998) reported that combining all clinical, busi-ness, and support functions into an solitary associate posi-tion created competition for associates’ time for whichmanagers were unprepared. Frequently, the generic associ-ate was forced to decide which task to complete first: feed-ing a patient or cleaning a room. This was not a problemin The MSH model because the business functions andsupport functions were delineated within a framework ofteamwork. Staff of the Maternal-Child Health Care Centerwere rewarded twice in the fist 2 years with 6% bonusesbased upon an incentive compensation plan linked to theoutcome indicators.

“In a nutshell, patient-focused care is a construct thatadvocates simplifying the care...by focusing on the expectedoutcomes for the patient rather than the multiplicity oftasks of each department. Actual dollar savings accruefrom the reduction of personnel expense. As personnel arecross-trained, fewer people are needed to fulfill the essentialfunctions...The organization of care delivery patterns yieldsless hierarchy and [fewer] associated support and clericalpersonnel” (Jones, 1997, pp. 3, 5).

Continued change in healthcare is inevitable. Stability,job security, and permanence have been etched out of thehealthcare vocabulary, and replaced by redesign, change,and restructuring. A proliferation of models for change hasconfused healthcare leaders, staff, and consumers. Furthercompounding the confusion is the use of similar or identi-cal names (e.g., patient-focused care) for very differentmodels borne out of different philosophical and conceptualframeworks. The savvy professional and consumer need tolook beyond the label, analyze the structure of the model,and critically examine the outcomes. Under scrutiny, manyalleged patient-focused care models are, instead, “wolves insheep’s clothing.” Some, such as the proprietary healthcarechains that now virtually monopolize the southwest, aremore obvious; others require a closer look.

MSH’s journey toward patient-focused care has beenchallenging, requiring vision, perseverance, commitment,and guts. Yet, it has been, perhaps, the greatest opportunityto create and transform a traditional, albeit complex,health system—through a scholarly, participative process—into a family and friendly community-like hospital. Likeother restructuring and change efforts, our work will neverbe completed. ✜

Acknowledgments

The authors thank Thomas Smith, MS, RN, Vice Presidentand Chief Nurse Executive, Mount Sinai Hospital, andHussein Tahan, DNSc(c), RN, for their support in the de-velopment of this article.

ReferencesBolman, 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), 26–33.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 Prac-

tice, 11(3), 1–7.Kent, T., Johnson, J., & Graber, D. (1996). Leadership in the formation of

new health care environments. Health Care Supervisor, 15(2), 27–34.Kovner, C., & Gergen, P. (1998). Nurse staffing levels and adverse events

following surgery in U.S. hospitals. Image, 30(4), 315–321.Kremitske, D., & West, D. (1997). Patient-focused primary care: A model.

Hospital Topics, 75(4) 22–28.Kritek, P. (1994). Negotiating at an uneven table. San Francisco: Jossey-

Bass, 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 Fo-

rum, 37, SS1–SS9.Williams, S. (1997) Caring in patient-focused care: The relationship of pa-

tients’ perceptions of holistic nurse caring to their levels of anxiety.Holistic Nursing Practice, 11(3), 61–68.

http://www.nursingcenter.com MCN 305

Lamaze Internationalhttp://www.lamaze-childbirth.com/International Childbirth Education Association, Inc. http://www.icea.org/Institute for Family Centered Carehttp://www.familycenteredcare.org/

Maternity Care Coalition http://www.momobile.org/

ONLINE

306 VOLUME 26 | NUMBER 6 November/December 2001

Continuing Education

b. the previous year’s consumption for each ser-vice plus 10% to 30% of that amount.

c. the previous year’s consumption for each ser-vice minus 10% to 30% of that amount.

9. Work previously performed by transporters andmessengers is now the responsibility ofa. patient care associates.b. support associates.c. business associates.

10. Supervising the admitting process is now theresponsibility ofa. patient care associates.b. business associates.c. patient flow coordinators.

11. As a result of patient focus groups, the codirectors learned that obstetric patientswanted morea. chairs.b. clocks.c. visiting hours.

12. New policies at the Maternal-Child Health Care Center were based on defining the family asa. 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 aa. service.b. community.c. department.

14. One of the key outcome indicators used toevaluate the redesign wasa. chart return.b. staff satisfaction.c. physician acceptance.

15. According to Jones (1997), patient-focusedcare defines its focus asa. 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 excepta. understanding the organization’s cultural

structure.b. reaggregating patients and staff.c. designing job roles that fulfill work needs.

3. Restructuring the maternal-child service wasguided by the overriding principle ofa. staff retention.b. risk reduction.c. quality of care.

4. In addition to the staff nurses, staffing wasrestructured to include which of the followingthree layers of management?a. clinical director, clinical nurse manager, and

supervisorb. clinical director, assistant director, and clini-

cal nurse managerc. vice president, clinical director, and clinical

nurse manager5. Two codirectors staff each care center in

the new design, one with expertise in theappropriate clinical nursing specialty and theother credentialed and experienced ina. managed care.b. business administration.c. holistic health.

6. A traditional role that was eliminated in theredesign was that ofa. unit receptionists.b. charge nurses.c. admitting staff.

7. The Maternal-Child Health Care Center’svision specifies providing families with which of the following?a. care, treatment, and educationb. service, dignity, and health promotionc. care, financial support, and customer service

8. Budgetary allowances for core servicesequaleda. the previous year’s consumption for each

service.

General Purpose: To describe the transition of a large,traditional, provider-focused obstetric and pediatric pro-gram into a patient-focused, family-centered, maternal-child 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-cen-tered model of care.

2. Discuss the various steps and phases involved in theredesign process.

3. Outline the roles and responsibilities of specific staffpositions in the new model.

To earn continuing education (CE) credit, follow theseinstructions:1. Read the article on page 298. Complete sections A, B,

and C* on the enrollment coupon below (or a photo-copy). Each question has only one correct answer.

2. Send the coupon with your $14.95 registration fee to:Continuing Education Department, LippincottWilliams & Wilkins, Inc., 345 Hudson Street, 16thFloor, New York, NY 10014.

Within six weeks you’ll be notified of your test results.A passing score for this test is 11 correct answers. If youpass, you will receive a certificate of completion. If youfail, you have the option of taking the test again at noadditional cost. This continuing nursing education (CNE)activity for 2 contact hours is provided by LippincottWilliams & Wilkins, which is accredited as a provider ofcontinuing education in nursing by the American NursesCredentialing Center’s Commission on Accreditation andby the American Association of Critical-Care Nurses(AACN 9722), Category O. This activity is also providerapproved by the California Board of Registered Nursing,Provider Number CEP11749 for 2 contact hours.Lippincott Williams & Wilkins is also an approvedprovider of CNE in Alabama, Florida, and Iowa, and holdsthe following provider numbers: AL #ABNP0114, FL#FBN2454, IA #75. All of its home study activities areclassified for Texas nursing continuing educationrequirements as Type I.*In accordance with Iowa Board of Nursing administrativerules governing grievances, a copy of your evaluation of thisCE offering may be submitted to the Iowa Board of Nursing.

Questions 1. The patient-focused care model

employs which of the following models of governance?a. autocraticb. decentralizedc. hierarchal

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

2 HOURS

MCN CE also available online at www.NursingCenter.com

Lippincott Williams & Wilkins, Inc., CE Home Study Enrollment Coupon Creating Patient-Focused, Family-Centered, Maternal-Child and Pediatric HealthcareCE Credit: 2 Contact Hours • Fee: $14.95 • Registration Deadline: December 31, 2003

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4. a ❏ b ❏ c ❏

5. a ❏ b ❏ c ❏

6. a ❏ b ❏ c ❏

7. a ❏ b ❏ c ❏

8. a ❏ b ❏ c ❏

9. a ❏ b ❏ c ❏

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11. a ❏ b ❏ c ❏

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14. a ❏ b ❏ c ❏

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