Hourly rounding is key contributor to patient-centered care at high-performing hospitals

Healthcare experts talk a lot about the importance of delivering “patient-centered” care, but how do hospital and ED administrators move the needle on such an elusive target? Researchers from Johns Hopkins University decided to seek answers to this question by investigating the practices used by 52 of the hospitals with the highest scores on the Hospital Consumer Assessment of Health Care Providers and Systems (HCAHPS), the survey that is commonly used to gauge patient impressions of their hospital experience.

“There have been many studies trying to explore this topic mainly in outpatient settings, but very little has been done within the hospital environment,” explains Hanan Aboumatar, MD, MPH, the lead author of the research, an assistant professor of medicine at Johns Hopkins University School of Medicine, and a member of the Johns Hopkins Armstrong Institute for Patient Safety and Quality in Baltimore. “Patients and families are very overwhelmed in the hospital. So many things are happening, they might have a lot of questions, there might be some concerns and major decisions to be made. Thoughtful attention to how care can be delivered in a better way is really needed.”

Through interviews with organization leaders and medical personnel at high-performing hospitals, investigators came up with a series of core best practices they say are most associated with patients reporting their needs were a priority during their hospital or ED stay, and that they had a positive experience.

When it comes to improving responsiveness, the practice most commonly cited was proactive nurse rounding, reported by 83% of the queried hospitals.

“This involves every nurse on the unit passing by every one to two hours, checking on the patients, making sure they are not in any pain, repositioning them, helping them to get to the restroom, and asking them if they need anything else,” Aboumatar observes. “When you employ something like that, obviously it is very hard initially to implement; it is in some ways a change of practice, because typically we are more reactive than proactive in these types of services.”¹

While Aboumatar’s study refers to rounding in all areas of the hospital, the concept is certainly not new to ED administrators, although many experts concur that it can be particularly challenging to make the practice stick in the fast-paced ED environment. Nevertheless, there is also wide agreement that when done effectively, regular rounding in the ED can provide a powerful booster shot to anemic patient satisfaction scores.

Reset patient expectations

“Creating some sort of model where we are purposefully going into the rooms on a regular basis and touching base with the patients resets their expectations, and then really demonstrates to the patients that we care about them and that we are there for whatever needs they might have on a proactive basis,” explains Eric W. Heckerson, EdD, RN, FACHE, a coach/consultant for the Nashville, TN-based Health Stream Engagement Institute.

When teaching the practice to healthcare professionals, Heckerson says he commonly uses an aviation analogy.

“If I am on the tarmac waiting to take off, I would much rather hear from the pilot every once in a while [to say], ‘here is where we are, here is what is going on,’ [and that] we haven’t been forgotten,” he says. “This just gives us an expectation about where things are going as opposed to wondering, because no information makes people wonder what is going on. Is something wrong? Did they lose me?”

A common criticism of rounding is that it takes too much time away from frontline clinicians who are already overburdened with important clinical tasks. However, Heckerson maintains this is not really the case.

“It actually saves time by making sure patient needs are handled more proactively rather than reactively,” he notes. “If you go into a room and purposefully check on what they need, and just really quickly mention what is on the white board, and ask whether there is anything else that you can get for them before you leave, there is an opportunity for patients to [get their questions answered] right then and there as opposed to being on the call bell in a few minutes.”

Heckerson says he has worked with many busy EDs all over the country and has yet to see one where clinicians are too busy to round regularly on patients. However, he recommends involving ED technicians and other personnel in rounding to spread around the responsibility.

“Nurses round at the top of the hour and the techs round on the half hour,” he says. “That way, we know everyone is touching base with patients on a regular basis.”

Some of the high-performing organizations in Aboumatar’s study reported they would play music on the hour as a reminder to staff that it is time to round on patients. Heckerson is less of a stickler about the precise time interval between rounds in the ED as long as staff are rounding on a regular basis.

Get leaders involved

Heckerson acknowledges achieving buy-in for regular rounding is a challenge. He recommends administrators spend as much time as possible on the “why” when presenting the concept to staff.

“It has a very nice effect on the patient experience,” he says. “But [it’s important] to help staff understand that is not the only reason [to round].”

For example, Heckerson recommends spending time talking about the impact regular rounding can have on patient safety and quality, because these issues resonate with ED personnel. However, even a good presentation about rounding, along with early staff buy-in, will not be enough to cement the practice into the daily routine for long, he acknowledges. To do that, Heckerson advises all leaders participate in rounding.

“I like to see the senior leaders — the C-suite — round in the ED on a regular basis. Not every day or all the time, but if the staff sees senior leaders rounding ... they say, ‘OK, I think I have to play my part in that, too,’” Heckerson notes. “That is the way I teach it. You teach the leader rounding first, and then you go to the staff rounding.”

Indeed, in Aboumatar’s study, 62% of the high-performing organizations who were queried about their practices employed leadership rounding. Aboumatar stresses they weren’t referring to traditional executive rounds, where an executive might appear in the unit once a month as part of an executive improvement team.

“This was much more intimate engagement where the leaders view [rounding] as part of their job, and they are held accountable for doing that part of their job, and they build ways to make sure they can do that part of the job,” Aboumatar explains. “We were seeing organizations where leaders [were booking on their calendars] one or two hours every day to round.”

Aboumatar notes this kind of engagement changes priorities.

“It says to the people in the hospital that our leaders are much more engaged with us,” she says. “It allows for channels of communication that were not there, so they can hear people close up, whether that involves the patients or the frontline clinicians with whom they are interacting.”

Address pain, plan of care, duration

Stephanie Baker, RN, MBA, CEN, the emergency services division leader for the Studer Group, a healthcare consulting firm based in Pensacola, FL, says rounding in the ED is about PPD: pain, plan of care, and duration.

“If you look at the key drivers across the country for the ED patient perception of care and what is going to help people feel engaged and satisfied with their experience — those are really the top three drivers,” she says.

“Patients care about pain management in the ED, they want to know what is going to happen, and they want to know when, so every hour an ED nurse should certainly check on patients and make sure that if any patient has pain that they are managing that pain,” she explains.

For instance, nurses should gauge whether patients are experiencing more or less pain since they last provided them with medication, and they should consider any other comfort measures that should be taken to address pain, Baker explains.

“If the patient has an ankle sprain, obviously they need to ice and elevate,” she says. “Acuity will drive how frequently we should see our patients. Obviously, sicker patients are going to need more frequent attendance than once per hour, but if we are talking regular ED patients who are fairly stable, then the research shows that [once per] hour works well and that patients respond well to that.”

Patients also need to be updated at least once per hour on what their plan of care is in terms of where they are in the process and what they can expect in the next 60 minutes, Baker notes.

“If we reset that clock for the patient about every hour, that shows compassion, it shows we care about them as a person, it keeps them informed, it reduces their anxiety, and it helps them feel involved,” she explains.

Baker encourages staff to be specific when discussing lab timeframes.

“Don’t say the labs will be back in a little bit because [patients] don’t understand that. They think that means 20 minutes and we think it means an hour and a half, so we really encourage [ED personnel], as they are talking about a plan of care, to talk about a reasonable duration and also to use real time to do that.”

In addition to addressing PPD, Baker stresses that before leaving a patient’s room nurses should always ask patients if they have any questions or if there is anything else they need.

“A lot of the high-performing EDs we are coaching and working with — even though they may still have patients who are in the ED for three or four hours — they can still maintain at about the 90th percentile on patient perception of care if they are using the rounding [process] very specifically and keeping patients informed,” Baker explains.

Commit to full training

With such results, why do many EDs struggle to implement rounding? Baker suggests many hospital and ED administrators underestimate the amount of training and follow-up that are required to cement rounding into routine practice.

“People say, ‘let’s start rounding on people,’ and the next day they try to roll it out, and it rolls out poorly,” she explains. “A lot of times there is not adequate training.”

The training should cover what the purpose of rounding is, as well as what the practice brings to the table in terms of patient safety, efficiency, and the patient experience. However, Baker notes that personnel also need to see and experience how effective rounding should be done.

“We don’t just say, ‘go out there and round.’ We actually take [ED personnel] through simulations, and we show them what ‘right’ looks like, and we perform validations with them, so they walk away with competency,” she explains. “You are not going to get success in the outcomes you want if you simply ask patients how it is going. That is not an hourly round; you don’t get any benefit from that and results can, in fact, decline.”

Once full training has taken place, leaders need to take responsibility for making sure staff members are routinely rounding on patients, and that they are doing it effectively; they can do this by regularly rounding on patients themselves, Baker offers.

In fact, Baker says when she rolled out hourly rounding in her own ED, she rounded on patients every day, asked them when they last saw their nurse, and what the nurse shared with them while in the room.

“This gave me validation that not only had I trained the staff [effectively], but that the patients were feeling it and that they were able to articulate that it was happening,” she explains. “Then I would share that [patient feedback] with the staff during huddles every day. You have to have a ‘trust but verify’ system.”

Baker suggests that when people fail at implementing hourly rounding, it is usually because they have not committed to full training or they have not provided accountability feedback.

“If you are not sharing results about whether [the team] is getting better or not, people tend to fall back to what they know and do,” Baker says. “When you are rolling out behavioral tactics [like rounding], you have to treat them just like clinically technical tactics. You are not going to let someone put in an IV line if they don’t know how to do it … you are not going to leave it to chance.”

While Baker is a big proponent of hourly rounding, she notes that it should not necessarily be the first step that struggling EDs take to improve the patient experience.

“If your staff are not explaining things [well to patients] or using a white board, you’ve got to go back to basics before you can even think about having success with more specific and targeted rounds,” she says. “I always tell leaders this is not the first tactic to roll out.”

How can you tell that rounding is making a difference? It is difficult to pinpoint the impact of any one particular tactic, Heckerson notes.

“People always ask me what the secret is to [improving the] patient experience, and I am not sure there is any one thing,” he says. “I think tools and tactics act in synergy.”

For example, calling to check on patients after they have been discharged is almost an extension of the rounding concept, Heckerson offers. In Aboumatar’s study, more than half (54%) of the high-performing organizations surveyed reported that they performed post-discharge phone calls to patients.

A process of calling patients after discharge requires a team effort. At time of discharge, it is a best practice to have the discharge nurse or technician advise the patient (or family) that a follow-up call may be received, and to confirm a correct phone number. Otherwise, many phone numbers obtained during the registration process turn out to be inaccurate, and the process fails in a high percentage of attempts.

“You have people checking pretty regularly on you when you are in the ED, and then you go home and get another phone call,” Heckerson says. “Organizations that are really knocking it out of the park are the ones that have figured out ways of doing both of those things … but it is really hard to quantify [the impact] of any single tactic.”

Aboumatar’s findings lend credence to this view.

“These [high-performing] organizations moved beyond thinking about [a high-level] patient experience as a nicety,” she observes. “They thought about it in a different way, in a way that is much more tied to the mission and what they are all about.”

In this context, the patient experience relates to tasks such as making sure that every patient understands what you are telling them, that they know how to take care of themselves when they return home, and that they have the help they need after discharge, Aboumatar notes.

“It changes your perspective about the importance of … improving the experience of people in your hospital entirely,” she says. “All the [high-performing] organizations we have talked with have really worked on multiple levels and employed multiple strategies to get from a place where there is less attention to patient centeredness of care delivery to a place where they are really performing highly in terms of the patient experience.”

REFERENCE

1. Aboumatar H, et al. Promising practices for achieving patient-centered hospital care: A national study of high-performing U.S. hospitals. Med Care 2015;53:758-767.

SOURCES

• Hanan Aboumatar, MD, MPH, Assistant Professor of Medicine, Johns Hopkins University School of Medicine, and Member, Johns Hopkins Armstrong Institute for Patient Safety and Quality, Baltimore. E-mail: [email protected].
• Stephanie Baker, RN, MBA, CEN, Emergency Services Division Leader, Studer Group, Pensacola, FL. Email: [email protected].
• Eric W. Heckerson, EdD, RN, FACHE, Coach/Consultant , Health Stream Engagement Institute, Nashville, TN. Email: [email protected].