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December 2014, Volume 18, Number 6
Journal
Club Article
Round and Round We Go: Rounding Strategies to Impact Exemplary
Professional Practice
Nicole Reimer, BSN, RN, OCN®, and Laura Herbener, BSN,
RN, OCN®
The literature demonstrates that diverse rounding
methods have been shown to positively impact a wide variety of quality and
safety outcomes, as well as patient and staff satisfaction. Rather than
adopting one or two of these strategies, the concepts and recommendations from
the literature associated with rounding have formed the foundation for an
academic, community, Magnet® hospital to implement a compendium of
rounding efforts: patient rounds, interdisciplinary collaborative rounds, daily
clinical rounds by the unit educator and daily rounds by the unit manager,
quarterly unit rounds by senior nursing managers, and safety rounds by senior
executives. This article details each of these methodologies as implemented on
a 26-bed hematology/oncology unit. Positive outcomes perceived to be associated
with the rounds have been achieved for patient, employee, and physician
satisfaction, as well as clinical quality indicators.
A variety of rounding methods have been increasingly
implemented in healthcare settings to improve patient safety and positively
impact patient and staff satisfaction. At Lehigh Valley Hospital (LVH), an
academic, community Magnet® hospital, six types of rounds were
implemented within the inpatient, emergency, and ambulatory patient care areas
(see Table 1). This article details each rounding
methodology, including its purpose, structure, and outcomes, emphasizing
implementation on the 26-bed hematology/oncology inpatient 7C unit at LVH.
Literature Review
Most of the literature associated with rounding
methods relates to hourly patient rounds by healthcare personnel in an
inpatient setting; however, the seminal article on this subject is the
quasi-experimental research by Studer, Robinson, and
Cook (2010). The study demonstrated that a protocol incorporating specific
actions into patient rounds can reduce the frequency of patients’ call-light
use, increase their satisfaction with nursing care, and reduce falls (Meade, Bursell, & Ketelsen, 2006).
Other research reported that patient satisfaction
was the most common outcome, with statistically significant improvements noted
(Bourgault et al., 2008; Culley,
2008; Ford, 2010; Gardner, Woollett, Daly, &
Richardson, 2009; Meade et al., 2006; Tea, Ellison, & Feghali,
2008; Weisgram & Raymond, 2008). Studies also
focused on call-light use, finding reductions in use after implementing hourly
rounds (Bourgault et al., 2008; Meade et al., 2006; Weisgram & Raymond, 2008). A third variable
positively impacted by hourly rounds was staff satisfaction (Bourgault et al., 2008; Gardner et al., 2009; Leighty, 2007).
Collaborative rounding has long been supported in
the literature and continues to be a mainstay in rounding methodologies.
According to Edwards (2008), team rounding reduces the likelihood of error,
thus increasing patient safety. In addition, Vazirani,
Hays, Shapiro and Cowan (2005) reported increased collaboration among members
of the healthcare team, particularly between nurses and nurse practitioners.
Teaching rounds performed by a unit-based nurse educator
have been found to be conducive to staff development, particularly regarding
the cultivation of critical-thinking skills (Segal & Mason, 1998). This
professional development strategy prompts multiple outcomes, such as
documentation compliance, patient and staff satisfaction, and quality clinical
care.
Senior executive rounding is another methodology
reported in the literature. Termed “walk rounds,” the focus of a study by
Frankel et al. (2008) was to improve the safety climate and the staff perception
of patient safety through open dialogue and collaboration. Staff perceived that
the walk rounds had a positive impact on the facility’s safety climate and
patient safety. Campbell and Thompson (2007) corroborated those results in
their retrospective study of patient safety rounds. Through rounding, Studer et al. (2010) described how nurse leaders can
reinforce care delivery to patients, verify nursing actions, and recognize
their employees. Studer et al. (2010) noted that this
is “one of the most important actions . . . to improve patient perception of
courtesy and respect and of nurse communication as a whole” (p. 46).
The literature demonstrates that various rounding
methods have been shown to positively impact quality and safety outcomes, as
well as patient and staff satisfaction. Rather than adopting one or two of
these strategies, the concepts and recommendations from the literature
associated with rounding formed the foundation for the current article’s
authors to devise, implement, and evaluate a compendium of rounding efforts.
Rounding Methods
Hourly
Patient Rounds
Hourly patient rounds are intended to increase
patient safety and satisfaction of patients, family members, and staff. The aim
is to anticipate and address patient needs. Rounds are completed by an RN or
unlicensed assistive personnel every hour from 6 am to midnight and every two
hours from midnight to 6 am. For ease of memory and
standardization, the authors focused on pain, positioning, and personal needs.
A standardized electronic tool, the Patient Rounding Log, was used to monitor
completion. The tool is a part of the permanent medical record and has proven
useful when investigating quality issues.
Standardization is a key component in the hourly
rounding process within the hematology/oncology inpatient unit and throughout
the hospital (see Table 2).
Patients and families were notified that hourly rounding occurred in a
standardized manner, no matter the point of entry or unit placement. However,
because the oncology population demonstrates a heightened need for
uninterrupted rest, based on their condition and needs, patients would be
offered a customized rounding schedule.
Interdisciplinary
Collaborative Rounds
Interdisciplinary collaborative rounds are conducted
in a variety of ways, and several factors determined the methods used, such as
ideal times for family involvement, optimum times for physicians and other
members of the interdisciplinary team, and patient diagnosis. Despite the use
of various methods, the common purpose of collaborative rounds is to review the
current plan of care, determine care priorities, and resolve patient care
issues. Rounds always include the patient and family.
On the inpatient oncology unit, the
interdisciplinary team may include the patient’s primary nurse, attending
physician, oncology medical fellow, medical resident, advanced practice nurse,
physician assistant, pharmacist, and case manager. Rounds are completed daily
for every patient and twice daily for patients who require reevaluation because
of the acuity of their illness or who have complex discharge planning issues.
Two types of physicians complete rounds on the unit,
gynecologic oncologists (starting at 7 am) and hematologic oncologists
(starting at 9 am). The consistent times promote participation by all attendees
and ensure that a nurse does not have more than one physician rounding at the
same time. Buy-in for all disciplines to participate was driven from the onset
because each discipline quickly saw the value through gained efficiencies and
resultant patient and staff satisfaction.
Interdisciplinary collaborative rounds begin with a
presentation of an earlier assessment by one of the aforementioned team
members. All members of the collaborative team, inclusive of the patient and
family, then discuss and agree on the plan of care. Efforts are made to ensure
that every participant offers input. For example, the physician normally ends
the discussion by inquiring if there are any questions or if anyone has
anything else to add. Special emphasis also is made to encourage questions from
patients and family and then to ensure understanding of responses. This
normally is the responsibility of the primary nurse. Based on her established
relationship with the patient and family, she is aware of their issues and
concerns and makes certain, using strategies such as Teach Back, that these
have been addressed. This rounding approach is organized, efficient, and
predictable. For example, collaborative rounds for a patient with acute
leukemia focus on such things as determination of the appropriate chemotherapy
regimen, anticipated nadir, patient and family preference for managing
anticipated treatment side effects, and discharge needs.
Group dialogue through rounds can identify various
outcomes. In some instances, rounds identify that a consultation is needed with
an ancillary team member, such as a dietitian, spiritual counselor, and/or pain
management specialist. Clinical practice guidelines and other care standards
are found to require development or revision at other times.
Daily
Clinical Rounds by the Unit Educator
LVH has a unit-based educator role, termed a patient
care specialist (PCS). The role requires a master’s degree in nursing, and most
units have 1.0 full-time equivalent in the position. The PCS participates in
identifying, planning, and implementing educational programs within specialty
areas for hospital healthcare providers, patients, families, and/or community
groups.
The PCS conducts daily clinical rounds with staff
regarding their patients. The rounds began because bedside nurses expressed a
need for support by a clinical expert to facilitate critical thinking related
to their care delivery. As a result, the rounds promote patient safety,
collaboration of team members, and quality patient care. The rounding process
fosters a learning environment, promoting critical thinking and patient care
planning.
A more specific focus within the rounds is to
positively impact nursing-sensitive clinical outcomes and regulatory standards.
The PCSs within the medical-surgical division, working collaboratively with the
Nursing Quality Department staff, developed a comprehensive 125-indicator tool
to guide the rounding process and collect data. This template, referred to as
the Quality Bundle Tool, includes prioritized content in the format of a
quality checklist. Examples include documentation of fall and pressure ulcer
assessment scores and associated interventions in the plan of care.
The PCS conducts rounds from Monday–Friday, with one
nurse daily, and rotates to all shifts. Patients are selected by the PCS for a
variety of reasons, including complexity of care, patient and family knowledge
deficits, high risk for falls and pressure ulcers, request for follow-up by
unit manager, and the bedside nurse’s identified learning needs. The PCS
considers the patient’s history, plan of care, and current assessment and
engages the bedside nurse through focused questioning to critically think
through the care. For example, a PCS noted a fungal toenail in a febrile and
profoundly neutropenic patient. She led the nurse
through discussion to critically examine implications of the toenail to the immunocompromised patient.
Following rounds, the PCS communicates significant
findings to the entire healthcare team, as well as to patients and families.
That transparency for the neutropenic patient
prompted notification to an infectious disease consultant and a podiatry
consultation. In short, the educator rounds prompt opportunities for
improvement and risk reduction.
Daily
Rounds by the Unit Manager
All managers reserve 8–11 am from Monday–Friday for
responsibilities, including patient and staff rounds. The goal is to interact
with all patients and staff; however, realistically, prioritization often is
necessary. An organization-developed survey tool on an electronic tablet is
used by the manager to ensure question standardization and recording of answers
for data collection and follow-up. Patients are asked evidence-based standard
questions based on prioritized service and quality issues. Priority topics
include ensuring high reliability for adherence with standards for hourly
patient rounds, bedside shift report, and patient room communication white
boards.
Staff rounds are formal and require the manager and
staff to meet in a quiet location. The purpose is to build relationships and be
proactive versus reactive. Five standard questions related to those appearing
in the biannual employee satisfaction survey are used: What’s going well? Who
are the individuals that need to be recognized? Do you have the tools and
equipment to do your job? Where can we improve? What else would you like me to
know? Managers are able to gather information in a constructive way and in a
timely manner. The rounds enhance manager visibility and communicate to the
employees that their opinions are valued to create the ideal practice
environment.
Because oncology nurses are particularly vulnerable
to compassion fatigue (Perry, 2008), the oncology nurse manager pays specific
attention to possible signs and symptoms when rounding with staff. When noted,
the manager recommends interventions to avoid and/or mitigate compassion
fatigue (Reimer, 2013).
Any concern noted in patient or staff rounds that
relates to quality of care is promptly communicated to the involved nursing
staff. The manager then provides education and clarifies expectations,
promoting staff professional development. Positive comments are immediately and
personally communicated to the caregiver, and a commendation is placed in the employee’s
file.
Quarterly
Unit Rounds by Senior Nursing Managers
Members of the senior nursing management team,
including the chief nursing officer and the team that oversees multiple patient
care units, perform rounds on clinical units at least quarterly but often more
frequently. The primary goals are to recognize the work and dedication of the
staff related to patient care and to encourage discussion regarding
nursing-sensitive quality outcome metrics.
The rounding schedule is communicated prior to the
visit. The unit manager encourages her staff members to be prepared to relate
designated stories that illustrate their professional practice as well as
specific staff achievements. In turn, the senior leaders recognize and
congratulate these staff members.
The senior managers are on the unit for 20–30
minutes and make efforts to greet every caregiver. In addition, every unit has
a visibility board displaying the most recent nursing-sensitive quality
outcomes and goals as well as the number of staff recommendations made during a
designated week for nurse manager staff rounds. Nurse leaders use the
visibility boards to stimulate dialogue with staff. The rounds also are an
opportunity for unit staff to ask questions of the senior management
representative.
Safety
Rounds by Senior Executives
Senior hospital executives, including the patient
safety officer, the senior vice president of quality and safety (a physician),
and a representative of the senior hospital executive team (chief executive
officer, chief medical officer, and chief operating officer), conduct safety
rounds throughout the network, visiting one unit per month. The purpose of the
rounds is twofold: to demonstrate to frontline staff that the senior hospital
executives care about and are invested in the resolution of their safety
concerns, and for the senior hospital executives to be enlightened about the
depth of frontline staff’s concerns, witnessing firsthand their passion for
patient and staff safety.
Each rounding session includes frontline licensed
and non-licensed assistive personnel. Scripted questions, based on Institute
for Healthcare Improvement Idealized Design Group and Frankel (2011), are used
to facilitate the discussion of safety concerns and include the following.
·
“Have there been any near misses that almost
caused patient harm but didn’t?” (p. 4)
·
“Is there anything we can do to prevent the
next adverse event?” (p. 5)
Executives clearly share their expectations for
open, honest discussion at the beginning of the session. Their informal and
relaxed approach helps to create an open environment. The findings from the
discussion are then entered into an electronic database for tracking and
evaluation. All findings are shared with the entire senior executive team as
well as with the managers of affected areas, with status reports generated by
the patient safety officer on a quarterly basis until the issues are resolved.
Opportunities for improvement that are able to be
rectified easily are addressed quickly. Some suggestions that require
long-range planning but were accomplished included revisions to unit
architecture to promote medication safety, trials with wireless telephones in
patient rooms to eliminate the fall hazard caused by long cords, and purchase
of defibrillators for each area of the cancer center.
Findings
Quantitative
Outcomes
Quantitative evaluation of the rounding methods is
associated with four distinct metrics: nursing-sensitive patient outcomes and
patient, employee, and physician satisfaction. Hourly patient rounds and safety
rounds by senior executives were implemented in their current form in 2008; all
other rounding methods were instituted in 2008 and 2009. Therefore, metric time
frames include these years.
Among nursing-sensitive patient outcomes, trends
were identified for pressure ulcers, falls, and catheter-associated urinary
tract infections (CAUTIs). The overall trend for falls and pressure ulcers
decreased from fiscal year (FY) 2009 to 2013. The trends also
was true for CAUTIs, except for FY 2013 (see Figure
1).
Regarding patient satisfaction, two specific Press Ganey items were used as metrics: attention to special or
personal needs and adequate precautions to protect safety. Both of these items
demonstrated an upward trend (see Figures 2 and 3).
Formal employee satisfaction surveys are completed
at LVH every two years. Table 3 details the 2013
satisfaction scores for questions that could be perceived as associated with
the various rounding methodologies. Scores for all questions exceeded the
national work group and national comparisons of the database used (HealthStream™).
The most recent physician satisfaction survey asked,
“How satisfied are you with nursing care?” Ninety-seven percent of the staff
was either satisfied or very satisfied, which is the 93rd percentile
nationally. This score could be perceived as impacted by the rounding methods.
Qualitative
Outcomes
Qualitative outcomes have been achieved from the
rounds. For example, during the manager’s daily rounds, an actively dying
patient mentioned he was frustrated in his unsuccessful attempts to access the
Internet from his personal computer. The manager arranged for an information
services technician to immediately come to the patient’s bedside
to troubleshoot the issue. Within minutes, Internet access was obtained. In
addition, examples of issues that were identified and addressed during safety
rounds by senior executives include the following.
·
Soiled linen bags piled up in the soiled linen
storage areas on the weekends, preventing door closure. To address this issue,
additional weekend staff was hired to remove soiled linens.
·
Cords in patient rooms created a fall hazard
for patients, staff, and guests. The solution was to order special carabiner-type clips placed under the beds to hold cords
off the floor and away from traffic areas.
·
Staff described difficulty in obtaining IV
pumps and bed alarms when needed. Additional pumps and alarms were added to the
unit par levels.
Challenges and Recommendations
Challenges encountered are associated with change,
management, and lean theories. First, even after rounding processes were
established within the daily work and achieving successful outcomes, the unit
management team must continue to be vigilant to reinforce the efforts. For
example, the unit experienced periodic increases in patient falls and CAUTIs as
well as decreases in patient satisfaction scores below target goals. As soon as
those issues were noted, they were shared with staff to ensure transparency and
reinforce expectations, inclusive of rounding, to improve the deficiencies.
In the beginning of the project and on an ongoing
basis, staff engagement must be strategized. Staff champions should be
identified and promoted, and staff successes should be celebrated and rewarded.
Staff accountability to complete hourly patient rounds and collaborative rounds
is enhanced by communicating expectations to patients and families. In
addition, processes can be changed, particularly to correct something that is not
working. For example, in FY 2011, LVH researchers conducted an ethnographic
study to examine issues associated with hourly patient rounding (Deitrick, Baker, Paxton, Flores, & Swavely,
2012). A gap regarding the benefits of hourly rounding was identified between
administrators and staff, and clarity was lacking related to implementation of
hourly rounding into the patient care workflow. The study findings prompted
redesign of the rounding process in which direct care staff
were included on the redesign team, education and communication became
more robust, and staff performance was validated using a standard checklist.
Although lean theory promotes standardization
(Shook, 2008), it can be difficult within a large organization.
Because LVH is committed to lean principles, processes have been standardized
throughout the institution for all rounding methods, except interdisciplinary
collaborative rounds. The variations in these latter rounds are caused by
patient care unit structures, functions, and patient populations. For example,
a surgical unit may conduct rounds without the primary surgeon because he or
she being in the operating room during the time frame that other disciplines
and family members are available. The standardization communicates to staff, patients,
and families the commitment to consistent expectations that have proven
effective in producing positive outcomes.
Implications for
Nursing
Various rounding strategies can be tied to
qualitative and quantitative outcomes. By standardizing rounding structures and
processes throughout a healthcare setting, staff and patient expectations are
reinforced. However, even after establishing rounding processes within daily
work and achieving initial successful outcomes, continuous vigilance is
necessary to reinforce and validate processes. No single change can achieve
patient and staff satisfaction and exemplary clinical outcomes; instead,
multiple rounding methodologies can assist in goal attainment.
Implications for
Practice
Ø
Use a compendium of rounding strategies to
link qualitative and quantitative outcomes.
Ø
Be vigilant in reinforcing and validating
rounding processes within daily work after achieving initial successful
outcomes.
Ø
Standardize rounding structures and processes
throughout a healthcare setting to reinforce staff and patient expectations.
The authors gratefully acknowledge Kim S. Hitchings,
MSN, RN, NEA-BC, for her writing direction and assistance.
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Use
This Article in Your Next Journal Club
Nicole
Reimer, BSN, RN, OCN®, is a director of patient care services and
Laura Herbener, BSN, RN, OCN®, is a
patient care specialist, both at Lehigh Valley Health Network in Allentown, PA.
The authors take full responsibility for the content of the article. The
authors did not receive honoraria for this work. The content of this article
has been reviewed by independent peer reviewers to ensure that it is balanced,
objective, and free from commercial bias. No financial relationships relevant
to the content of this article have been disclosed by the authors, planners, independent
peer reviewers, or editorial staff. Reimer can be reached at nicole.reimer@lvh.com, with copy to
editor at CJONEditor@ons.org. (Submitted January 2014. Revision submitted March 2014. Accepted for publication March 15, 2014.)
Key words: rounding; collaborative rounds; patient
rounds; executive rounds; safety rounds; lean methods
http://dx.doi.org/10.1188/14.CJON.18-06AP
