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Impact of Structured and Scheduled Family Meetings on Satisfaction in Patients Admitted to Hospitalist Service

Effective communication is key to patient satisfaction. Family meetings been shown to be effective in other settings such as critical care and palliative medicine. We evaluated the impact of scheduled and structured family meetings on patients admitted to the hospitalist service in terms of satisfaction with care delivery. More patients in the intervention group reported better understanding of their diagnosis, treatment plan, medications, and discharge plan. Based on these results, we advocate for structured and scheduled family meetings to be implemented as a communication tool for selected patients on the hospital medicine service to improve patient experience and satisfaction.


Introduction
Effective communication ensures patient safety and satisfaction as part of high-quality care (1)(2)(3)(4)(5). Family meetings, a way of ensuring reliable communication, often happen late in admission or at a critical decision point (1,6). Family meetings provide a structured platform for health care providers to share information (4). Family meetings should be ideally be planned in advance, happen in a timely manner and goal-oriented manner, involve key personnel involved in the patient's care, and address issues that are of importance to the patient (1,7).
The role of family meetings has been well studied in intensive care, palliative care, and pediatrics (1)(2)(3)(4)(5)(7)(8)(9)(10). There is evidence that family meetings done proactively and in a structured fashion in the intensive care unit (ICU) setting to share information about patients' illness, medications, prognosis, disposition and to allow opportunity for the patients and families to ask questions and express their perspective about their illness may reduce anxiety, depression, and post-traumatic stress in patients and families. Family meeting have also been shown to reduce time in ICU, allow for earlier withdrawal of care safely without patient suffering, and result in demonstration of respect for the patient's dignity and feelings about their care (1,8,9,11).
Studies have shown that hospitalist spend 24% of their time communicating with patients (12). However, there is a paucity of literature in regard to the role of family meetings performed for general medicine floor patients admitted under the care of a hospitalist. This patient experience improvement project was initiated to evaluate if scheduled and structured family meetings can improve awareness of the patients regarding their disease process, medications, prognosis, and discharge for those admitted under the hospitalist service in an academic tertiary care hospital.

Methodology
This patient experience improvement study included patients admitted on a single unit on the inpatient medicine service of a single hospitalist (H.S.G.) at an academic tertiary care hospital from October 2019 to February 2020. The project was exempted by the institutional review board of the State University of New York Upstate Medical University.
All patients older than 18 years and less than 90 years of age, with the current length of stay more than or equal to 5 days or with length of stay of 3 days including a weekend were included. One of the following criteria also needed to be met to be included in the study: Involvement of 2 or more consult services, plan or conduction of a procedure or cancellation of a procedure, new diagnosis of cancer, transfer from the ICU or a subspecialty service with primary length of stay more than or equal to 7 days, difficult to place (unable to be discharged for more than 5 days), initiation of a new long-term medication, nursing home residents without known health care proxy or code status, readmission status for the same complaint within previous 30 days, and nonverbal patients.
The patients in the control group included those patients who were admitted to the hospitalist's service during the months of October 2019 to December 2019 and met the inclusion criteria. The intervention group included patients admitted to the hospitalist's service during the months from January 2020 to February 2020. The intervention arm of the project was suspended due to the SARS-CoV-2 pandemic.
In the control group, a survey ( Table 1, Survey 1) was conducted on day 6 of admission after consent was taken. In the intervention group, the nursing supervisor arranged a family meeting on day 6. The health care team included the attending physician (H.S.G.), the bedside nurse, and other members involved in the care of the patient, as applicable. Thirty minutes were reserved for each family meeting. Consent was obtained from the patient or designated proxy or next of kin prior to the meeting and completion of the taken for the survey (Table 1, Survey 2).
During every family meeting, the health care team discussed the following aspects of care in a structured manner: 1. The reason for admission 2. Updates on investigations, testing, and radiological results 3. Consult service recommendations 4. Plan for procedures, as applicable (not including venous access) 5. Patient or caregiver questions related to new admission diagnosis 6. Information on new medications started during the current visit 7. Discharge plan including disposition such as plan for rehabilitation 8. Follow-up plan with primary care and subspecialists 9. Code status, goals of care, and health care proxy status addressed, if appropriate Periodic education was provided to the nursing supervisors and charge nurses about the family meeting project and its methods as well as goals.

Results
In the control group, 48 patients were offered the survey; however, 6 chose not to participate in the project. In the intervention group, 30 patients were offered the family meeting followed by the survey. Only 1 declined to participate. Of the 42 patients who took the survey in the control group, 19 (45.2%) were female and 23 (54.7 %) were male. The age in this group ranged between 24 and 89 years. The mean age was 69 years. Of the 29 patients in the intervention group, 14 (48.2%) were female and 15 (51.7%) were male. The ages ranged from 24 to 87 years and the mean age was 65 years.
The responses to administered surveys were compared between the 2 groups ( Table 2). In the control group, 34 (80.95%) patients felt that the understood their diagnosis mostly or completely, as opposed to 27 (93.1%) patients in the intervention group. Regarding their understanding of their treatment plan, 30 (71.4%) patients answered mostly or completely in the control group as opposed to 26 (89.6%) patients in the intervention group. Thirty (71.4%) patients in the control group mostly or completely understood their medications as opposed to 22 (75.8%) patients in the intervention group. No patients in either group reported that they mostly or completely understood the details of their procedures. In the control group, 24 (57.1%) patients were mostly or completely satisfied with their discharge plans as opposed to 26 (89.6%) patients in the intervention group. In terms of their opinion on whether they felt their concerns were addressed by the medical team, 38 (90.4%) patients in the control group answered mostly or completely compared to 25 (86.2%) patients in the intervention group. Majority of the patients in the intervention group (28 [96.5%] patients) felt the family meeting was impactful enough for them to recommend such meetings to be standard of care for other hospitalized patients.
The average time for a family meeting in the intervention group was 25 minutes (range, 15-30 minutes); 25 family meetings were held at the patient's bedside and of those, caregivers were present for 10 meetings.

Discussion
The literature supports the importance of involving patients and their families in the care by sharing their diagnosis, treatment plan, medications, details of procedures planned, and disposition (3). Family meetings shift the focus of care to patient and their family (4,7,10). We explored if conducting scheduled and structured family meetings for general medicine patients would lead to improved patient understanding of their care and satisfaction. In this pilot project, more patients in the intervention group reported better understanding of their diagnosis, treatment plan, medications, and discharge plan as opposed to the control group. This highlights the importance of providing a scheduled and structured opportunity in the form of family meetings to improve the communication between the care team and patients. By providing a reliable opportunity to ask questions, interact with a clearly identified care team, and discussing the care in a structured manner, these family meetings were effective in addressing key elements of care, lack of understanding of which often leads to dissatisfaction with care and not feeling prepared at the time of discharge.
Of note, fewer patients in the intervention group felt that the health care team addressed their concerns. We postulate that this is likely due to the increased amount of information provided during the family meetings, opening up the opportunity to explore the need for more than one such meeting to allow for a follow-up discussion. More importantly, almost all patients indicated that they felt that structured and scheduled family meetings should be considered the standard of care for admitted patients.
In this study, the family meetings were not sufficient to address the concern or questions related to planned procedure or surgery; however, the subset of patients requiring procedures was small. Due to the very small number of patients who were able to address this particular question and since most of the performed procedures were done close to the admission while the family meetings were done on the sixth day, we believe interpretation of this data is not feasible. A study specifically focused on addressing this aspect of inpatient care is warranted.
This study demonstrates the importance of a proactive and structured approach to conducting interdisciplinary family meetings for patients admitted to the internal medicine service, which often carry a significant portion of patients admitted to the hospitals. This pilot project reinforces the importance of family meetings in this setting, as has been noted in other settings. Further studies are needed to delineate the optimal duration, frequency, and setting of such meetings.

Limitations
This study is limited by the low number of patients enrolled since it was conducted over a limited time period and on the service of a single attending, thus limiting the generalizability of the findings. This project was also impacted by the COVID-19 pandemic as resources were directed toward surge preparation for the pandemic. At the beginning of the pandemic, newly instituted visitor restriction policies limited our ability to conduct bedside interdisciplinary meetings. The televideo Health Information Portability and Accountability Act (HIPPA) complaint tool was attempted to be used for family meetings but limitation on involvement of multiple family members, scare resources, and limited understanding of technology were all barriers. There was involvement of only one attending and hence, the results cannot be generalized.

Declaration of Conflicting Interests
The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding
The author(s) received no financial support for the research, authorship, and/or publication of this article.