Journal of Pediatric Nursing (2015) 30, e9–e15
An Interactive Evaluation of Patient/Family Centered Rounds on Pediatric Inpatient Units1 J. Michelle Palokas DNP, RN-CPN a,⁎, Ladonna Northington DNS, RN, BC b , Robin R. Wilkerson PhD, RN b , Barbara J. Boss PhD, APRN, FNP-BC, ANP-BC b a
Batson Children's Hospital, Children's of Mississippi, Jackson, MS University of Mississippi School of Nursing
b
Received 29 May 2014; revised 16 November 2014; accepted 18 November 2014
Key words: Patient/Family centered rounds; Family centered care; Interprofessional
In order to provide excellent patient care and customer service, patient rounds should be efficient, effective, and timely. Also, essential healthcare team members should be present in rounds, to ensure interprofessional collaboration. Patients and families should also be included in rounds, to ensure accurate information is relayed and to ensure involvement in care planning. The purpose of this inquiry was to conduct an interactive evaluation with organizational stakeholders of patient/family centered rounds on pediatric inpatient units of a large academic medical center using a plan, do, study, act (PDSA) model. © 2015 Elsevier Inc. All rights reserved.
PATIENT AND FAMILY-centered care continues to be supported by a growing body of research. The movement toward involving the child and family in planning, delivery, and evaluation of health care is grounded in collaboration among patients, families, physicians, nurses, and other health care team members. In 1986 Public Law 99–457 was passed which required that the entire family be treated as the recipient of services for children with special needs. The family-centered care legislation suggested that family members be allowed to determine their own involvement in decision-making regarding health and education services for their child (Rosen, Stenger, Bochkoris, Hannon, & Kwoh, 2009). Additionally, one of the six specific aims for improvement as outlined in Crossing the Quality Chasm: A New Health System for the 21st Century was to “provide care that is respectful of and responsive to individual patient preferences, needs, and values, and ensure that patient values guide all clinical decisions” (Institute of 1 No funding required; no commercial financial support. This information was presented as a Capstone Presentation on April 16, 2014 to interested parties at the University of Mississippi Medical Center School of Nursing. ⁎ Corresponding author: J. Michelle Palokas, DNP, RN-CPN. E-mail address: [email protected].
http://dx.doi.org/10.1016/j.pedn.2014.11.005 0882-5963/© 2015 Elsevier Inc. All rights reserved.
Medicine, 2001, p. 3). A policy statement issued in 2003 by the American Academy of Pediatrics concluded with 15 specific recommendations for providers to successfully integrate family-centered care in hospitals and other systems of care. Some of these recommendations were as follows: a) “Pediatricians should actively consider how they can ensure that the core concepts of family-centered care are incorporated into all aspects of their professional practice,” and b) “Pediatricians should promote the active participation of all children in the management and direction of their own healthcare, beginning at an early age and continuing into adult care” (American Academy of Pediatrics Committee on Hospital Care, 2003, pp. 693–694). Several nursing organizations also support patient/family centered care and recognize the vital role that families play in the health and well-being of infants, children, and adolescents. These nursing organizations include the American Nurses Association (ANA), American Association of Critical-Care Nurse (AACNs, and the Society of Pediatric Nurses (SPN) (Institute for Patient/Family Centered Care, 2010). Patient/Family centered rounds are interprofessional rounds conducted in collaboration with the child and their families, and are just one way to improve communication among the
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healthcare team members and recipients of care. Patient/ Family centered rounds can aid in moving organizations towards embracing family-centered care and can provide benefits to the physicians, nurses and other health care team members, as well as the child and family. A few of the most commonly perceived patient/family centered rounds benefits include “increased family involvement and understanding” and “effective team communication” (Mittal et al., 2010). Involving the child and family in rounds can provide physicians with a better understanding of the patient and the disease they are attempting to treat. Discussions with the family may also elicit information that would otherwise be impossible or difficult to obtain by the health-care team, especially in a timely manner (Schleien, Brandwein, & Stasiuk, 2013). Since the physician is likely to receive more accurate information by utilizing this rounding process, improved care planning and clinical outcomes are anticipated (American Academy of Pediatrics Committee on Hospital Care, 2003). Patient/Family centered rounds provide the child and family an opportunity to be heard, and empower them to be active participants in their health care planning and decision-making (Schleien et al., 2013). Improved communication among the health care team and with the child and family has the potential to improve patient perceptions, which could improve the organization's patient satisfaction scores. Additionally, patient/ family centered rounds have a potential to produce the following outcomes (Institute for Healthcare Improvement, 2010): • • • • • • •
REDUCED errors, REDUCED ventilator days, REDUCED central line days, REDUCED length of stay, IMPROVED patient flow, EXPEDITED discharge planning, and IMPROVED safety and reliability of health care.
In order to provide excellent patient care and customer service, communication among caregivers should be efficient, effective, and timely. In addition, children and their families should have the opportunity to be included in those discussions, to ensure accurate information is relayed and to provide an opportunity for patient/family input into care planning. Unfortunately, in our hospital, the rounding process prior to implementation of patient/family centered rounds did not promote collaboration among team members, nor provide the patient/family a consistent opportunity to be involved in their own healthcare decision making. If the hospital continued to utilize that traditional rounding process, staff was likely to continue seeing the effects of lack of communication among team members and patients/ families, including: patient satisfaction scores reflective of lack of communication among team members, increased length of stay, increased medical errors, a decrease in safety and quality of care, and decreased patient flow. In order for the patient/family centered rounds initiative to be successful, stakeholder buy-in and involvement is imperative. As Harris, Roussel, Walters, and Dearman
(2011) explain, “the significance of collaboration and communication with the stakeholders cannot be understated” (p. 58). For an initiative or program to succeed, it is imperative to involve organizational stakeholders from the beginning, to provide intermittent progress checks, and to respond to and address concerns throughout implementation (Harris et al., 2011). Therefore the purpose of this project was to conduct an interactive evaluation with organizational stakeholders of patient/family centered rounds on inpatient units at a pediatric hospital in an academic medical center using a plan, do, study, act (PDSA) model. During this interactive evaluation, the goal was to engage the organizational stakeholders in reflecting, identifying problems, and offering solutions during the implementation process.
Methods Setting and Participants This pediatric hospital, which opened in 1997, is the only hospital in the state dedicated to the care and treatment of injured and sick children. With an average of more than 9,000 admissions per year, patients may receive treatment for common childhood illness, chronic conditions, trauma, or life-threatening diseases. The inpatient areas include a pediatric intensive care unit (PICU), a pediatric step-down unit, a hematology/oncology unit, a general pediatric unit, a post-surgical unit, a cardiac step-down unit, and a pediatric psychiatry unit. The setting for this interactive evaluation was all inpatient areas in the children's hospital, excluding the intensive care unit and the pediatric psychiatric unit. The intensive care unit was already conducting nurse-led, interprofessional rounds at the bedside of the child; and the pediatric psychiatric unit conducts interprofessional rounds in the conference room while on speaker phone with a parent or caregiver. The participants for this evaluation, also known as the organizational stakeholders, were the direct care nurses who work on these units, along with the attending physicians who admit to these units, who electively agreed to informal interviews and survey completion. The accessible population included approximately 160 nurses and 150 attending physicians.
Change Process The idea of patient/family centered rounds actually originated in patient satisfaction committee meetings. The patient satisfaction vendor, NRC Picker, provided valuable information regarding patients' and families' perspectives of care received. Based on a priority matrix report provided by the vendor, several items were identified as “top priority” for improvement in the organization. These items included: doctors' courtesy/respect, nurses' courtesy/respect, doctors listened carefully, nurses listened carefully, nurses explained things understandably, doctors explained things understandably, nurses discussed worries and concerns, confidence and trust in the doctor, confidence and trust in the nurse, and parent/ guardian input in care.
Interactive Evaluation of Patient/Family Centered Rounds While discussing these opportunities for improvement among the patient satisfaction committee, it was noted that staff nurses had also expressed concerns regarding the tremendous decrease in their own communication with the physicians since the implementation of the electronic health record (EHR.) Since the inception of the EHR in June 2012, it had not been imperative that the physician be physically present at the nurses' station, since there were no longer any physical charts. Since their physical presence was not necessary, it was possible that the physicians were spending less time at the nurses' station; therefore, there was less opportunity for communication with the nurses. The interprofessional patient satisfaction committee quickly noted that the majority of the items discussed at the meetings seemed to revolve around communication or the lack thereof. In the process of developing an action plan to improve communication, the committee members began to search for and discuss options; hence, the birth of patient/ family centered rounds. In late 2012, an interprofessional group was formed to plan a pilot patient/family centered rounds implementation. Original participants included the chairman of pediatrics, the inpatient clinical director, the director of quality and care coordination, a nurse manager, a nurse educator, and multiple physicians. The decision was made to begin the program on the pediatric post-surgical unit since a smaller number of physicians generally admit to this unit. After implementation on this unit, the roll-out of patient/family centered rounds continued, one unit at a time. An admission handout was created to provide the families with rounding expectations. A new dry erase board was
Figure 1
e11 affixed in each patient room near the exit. The location of the dry erase boards provided the caregiver and family an easy view, especially when exiting the room; however, a passerby would not be able to view the information. This dry erase board provided space for the physician, nurse, and technician names, along with space for documentation of daily goals. A flow diagram was also created to use as an educational supplement for the nurses and physicians who would be involved in the rounds (Figure 1). The nurse manager and educator provided education and expectations to the direct care nurses on the implementing unit. The chair of pediatrics and the inpatient clinical director held meetings with those physicians who had admitting privileges, to explain the initiative in detail. The patient/family centered rounding process was actually implemented on the first inpatient unit in early March 2013. The plan, do, study, act (PDSA) model for improvement and an interactive evaluation approach were used for this quality improvement project. The PDSA model was used to test change in the real work setting once the team established its membership and acknowledged measures that could determine whether the change leads to an improvement in the process or program. Using PDSA cycles, small scale changes gave the organizational stakeholders the opportunity to see if the proposed change worked. An interactive evaluation approach, as described by Owen (2007), is concerned with “focusing evaluation on organizational change and improvement, in most cases on a continuous basis, and a perspective that evaluation can be an end in itself, as a means of empowering providers and participants (p. 217).” Intensive onsite study, including observation and interview, is directly related to the interactive evaluation
The initial patient/family centered rounds flow diagram.
e12 method, all of which were used for during this program implementation. The implementation team originally planned to meet monthly to discuss findings, create/document PDSA cycles, and implement changes. It soon became apparent, however, that when changes needed to be implemented quickly, monthly meetings were not sufficient communication. And often, frequent and short notice meetings could not be scheduled due to the busy schedules and prior commitments of the team members. So, many times communication of the team plans and initiatives took place via email. Plans and initiatives were also discussed at the monthly patient satisfaction committee meetings, for which all original implementation team members receive invitations.
Data Collection Interviews
J.M. Palokas et al. Table 1
Data collection questions.
Interview questions Are you currently conducting or participating in patient/family centered rounds on your patients? If you are participating, what are the obstacles? If you are participating, what positive outcomes have you observed? What negative outcomes have you observed? What would make it easier/more efficient to do patient/family centered rounds? Are there any other thoughts or ideas regarding patient/family centered rounds that you would like to share? Electronic survey questions Are you doing patient/family centered rounds on your patients? • Yes-Always • No-Never • Sometimes • Other If you are not doing patient/family centered rounds, what are the obstacles? • N/A-I am doing PFCRs • Lack of physician participation • Lack of nurse participation • Other If you are doing patient/family centered rounds, what positive outcomes have you observed? • N/A-I am not doing PFCRs • Better communication with families • Better communication with the healthcare team • Other What would make it easier/more efficient to do patient/family centered rounds?
Informal one-on-one and/or group interviews were conducted by the evaluator from the time of implementation and throughout the next year. The evaluator rounded almost daily on the inpatient units and had the opportunity, at that time, to informally interview the nursing and physician participants of patient/family centered rounds. The evaluator interviewed employees who had the opportunity and were willing to provide feedback. Normally, these interviews occurred in a private location near the nurses' station of the respective unit to ensure confidentiality. The evaluator used six questions (Table 1) to guide the interviews with the organizational stakeholders. If a PDSA was ongoing, the evaluator asked more focused questions about the proposed changes to the process instead of the previously mentioned six questions. Feedback gained from the interviewees was written in a designated journal as field notes. In these field notes, the interviewer documented whether the interviewee was a physician or nurse and the unit location of the interview. Additional information collected for physicians included area of specialty. Additional information collected for nurses included current degree and years of experience. At least once a month, the field notes were transcribed into an email and sent to the implementation team and the organizational stakeholders of the units which had already implemented the new rounding process.
The survey link was sent to the direct care nurses and physicians via email. The staff members had approximately 2 weeks to complete the electronic survey. The collected data were organized and disseminated to the implementation team and the organizational stakeholders. Applicable graphs and the responses to questions were also presented in a PowerPoint presentation at patient satisfaction committee meetings.
Electronic Survey
Direct Observation
A 2-month post-implementation, electronic survey was created by the original implementation team and conducted on each of the involved units. After 2 months, the staff should have had ample time to become familiar with the new rounding process. The implementation team decided on four simple questions to elicit feedback from the stakeholders. These questions and possible responses are listed in Table 1. The stakeholders could choose all answers that they felt applied to the question. The survey was created in SurveyMonkey. Information about SurveyMonkey can be found at: surveymonkey.com.
The evaluator randomly observed the patient/family centered rounding process, starting at original implementation and over the course of the year, to capture interactions of the organizational stakeholders. The goal of this type of observation was to note the differences in rounding among different teams. The evaluator documented any relevant findings in the previously mentioned, designated journal, as field notes. No identifying information was collected during any of these data collection processes. This information was also disseminated via email to the implementation team and the organizational stakeholders.
Interactive Evaluation of Patient/Family Centered Rounds
Results Over a 1 year period, a total of 119 interviews were documented. Each interview typically lasted 5 minutes or less, which resulted in an approximate total interview time of 10 hours. The interviewees included 101 nurses, 2 nurse practitioners, and 16 physicians. Of those 101 nurses, 32 held an ADN degree, and 69 held a BSN degree or higher. The average number of years of experience for the nursing interviewees was 5.44 years. Of the physicians who were interviewed, specialties included general pediatrics, urology, GI, orthopedics, general surgery, and cardiology. Data analysis was ongoing throughout the interactive evaluation. The evaluator led interprofessional discussions via email and at the monthly patient satisfaction committee meetings to review the findings from the data collection. Analyses of the data included identifying any recurring ideas or themes for improvement or changes to the patient/family centered rounding process. Once ideas for change were identified, the PDSA model was used to plan and implement the changes. Based on the ongoing data collection, the implementation team and organizational stakeholders determined if permanent changes to the original implementation and/or flow of patient/family centered rounds should occur. The nurse manager and nurse educator on each unit were also instrumental in identifying opportunities for improvement to the process and determining if changes should be permanent, as they often communicated with the organizational stakeholders. During the year of implementation, using the recurring ideas and themes, six ideas for change were carried out using the PDSA model. Of the six PDSAs conducted, five permanent changes were made to the overall rounding
Figure 2
e13 process, including: 1) physicians communicating set rounding times, when possible, 2) physicians calling out on the call light as a way of notifying the nurse that they are ready to round, 3) nursing staff providing communication notepads in the children's rooms, 4) nursing staff bringing a workstation on wheels (WOW) to the child's room for rounding, and 5) the surgery team appointing the NP as the “designee” for the attending in the rounding process. After these changes in process, the original flow diagram was updated to include the components (Figure 2). Based on all of the data collection methods, the most common nursing themes identified were that nurses were not aware of, or were not notified when the physician was on the unit and ready to round or that nurses often times could not round at the time the physician was ready to round (due to other patient care needs or other physician teams already rounding on the unit). The most common theme from the physician perspective was that they could not find the nurse at the time they needed to round. It is important to note that due to the feedback from the organizational stakeholders, much of the effort during this year long evaluation phase was focused on basic sustainment of the program and processes, instead of making major changes to the process. The implementation team spent much time and effort encouraging the organizational stakeholders to continue following the initial processes despite the barriers, and encouraging accountability for all involved. During implementation, the organizational stakeholders often spoke of making the process “easy” and “quick”, which is apparent in the PDSA cycles. The two most common ideas to improve rounds or make rounds more efficient, as communicated by the stakeholders,
The updated patient/family centered rounds flow diagram.
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were to notify the nurse when the physician was ready to round and to set a specified rounding time. And though the idea of set rounding times was added to the process of patient/family centered rounds, there were only a small number of physicians who could or were willing to accommodate this request. During the data collection process, nurses and physicians alike frequently recommended that the organization purchase a wearable voice-controlled device that enables instant two-way communication. They argued that this two-way communication device would allow the physician to quickly find the nurse and let her know that rounds were about to begin.
Limitations
Discussion
Recommendations
The data collection process of observing the teams during the rounding process proved to be very difficult for the evaluator's schedule due to the “unknown” of when the physicians would be rounding and how long the rounding process would last. Although several formal interviews were conducted for this quality improvement project, due to the nature of the role of the evaluator, information regarding the patient/family centered rounds process was gleaned almost daily from communication with organizational stakeholders, which was not always documented as field notes. Much like Williams, Ramani, Fraser, and Orlander (2008), Gonzalo, Chuang, Huang, and Smith (2010) reported, the organizational stakeholders seemed to value rounding at the bedside but noted that one of the major barriers to the patient/family centered rounding process was time constraints. Throughout the evaluation process, many stakeholders indicated during the interviews that having other patient responsibilities or duties interfered with getting to the child's bedside at the time of rounds. Also, similar to the study conducted by O’Leary et al. (2010) the direct care nurses, particularly, reported during interviews and on the surveys that patient/family centered rounds improved the communication among the healthcare team, which can lead to an improved climate of teamwork. Interestingly, just as this project was concluding, Sharma et al. (2014) reported that the use of a hands-free communication device improved nursing attendance at patient/family centered rounds from 47% to 80%. This evidence supports the recommendation of purchasing a hands-free communication device, as often voiced by the organizational stakeholders during the interviews. Although the Institute for Healthcare Improvement (2010) suggests that patient/family centered rounds have the potential to produce outcomes such as: reduced errors, improved patient flow, and improved safety and reliability of healthcare, there is limited literature to support that patient/ family centered rounds have produced such outcomes. To understand the true impact of this initiative, outcomes need to be identified, and data collection to test these outcomes must occur.
Future directions should include involvement of the child and family in the evaluation process. By not involving the child and family initially, this prevented them from dealing with the minute details of the initial implementation phase of the program. If any changes to the process are made after involving the patient/family in the evaluation process, the flow diagram will need to be edited, as necessary. Also, an organizational policy will need to be created to outline the details and expectations related to the new rounding process. For sustainability of the program, new nurses and physicians should be educated on this process and expectation during their on-boarding and orientation. Area pediatricians who have admitting privileges to the organization also need to receive consistent information regarding the process and expectations with patient/family centered rounds. Based on feedback from the organizational stakeholders, it is recommended that the organization purchase a wearable voice-controlled device that enables instant two-way communication. The implementation team should also identify outcomes for a product evaluation, which can provide findings from which a judgment of the worth of this initiative can be determined. These outcomes may include those identified by the Institute for Healthcare Improvement (2010) such as improved patient flow and expedited discharge planning. Once outcome data are identified, data collection needs to be initiated. Data collection has the potential to engage the stakeholders even more in the new rounding process. Other examples of outcome data might include: patient satisfaction, employee satisfaction, length of stay, and reduced errors. Finally, the implementation team should create a plan and timeline for the purposeful addition of other healthcare team members (respiratory therapy, social work, physical therapy, residents) to the rounding process to continue to move the organization toward a genuine culture of family centered care.
During the data collection process, it was noted that the evaluator performing the interviews and observations was an indirect supervisor of many of the interviewees, which could have influenced organizational stakeholders' behaviors or answers. Another possible limitation of this inquiry is that no outcome data have been identified or collected, so the effectiveness and efficiency of this program is currently unknown. Though the literature states that many positive outcomes can result from this type of rounding process, there currently are no data to support the claims in the literature.
References American Academy of Pediatrics Committee on Hospital Care (2003). Familycentered care and the pediatrician’s role. Pediatrics, 112, 691–696.
Interactive Evaluation of Patient/Family Centered Rounds Gonzalo, J. D., Chuang, C. H., Huang, G., & Smith, C. (2010). The return of bedside rounds: An educational intervention. Journal of General Internal Medicine, 25, 792–798. Harris, J. L., Roussel, L., Walters, S. E., & Dearman, C. (2011). Project planning and management. Sudbury, MA: Jones & Bartlett Learning. Institute for Healthcare Improvement (2010). Improvement map. Getting started kit: Multidisciplinary rounds. Retrieved December 15, 2012 from http://www.ihi.org/knowledge/Pages/Tools/ HowtoGuideMultidisciplinaryRounds.aspx Institute for Patient/Family Centered Care (2010). Core concepts of patient/ family centered care. Retrieved November 15, 2014 from http://www. ipfcc.org/pdf/CoreConcepts.pdf Institute of Medicine (2001). Crossing the quality chasm: A new health system for the 21st century. Washington, D.C.: National Academies Press. Mittal, V. S., Sigrest, T., Ottolini, M. C., Rauch, D., Lin, H., Kit, B., et al. (2010). Family-centered rounds on pediatric wards: A PRIS network survey of US and Canadian Hospitalists. Pediatrics, 126, 37–43.
e15 O’Leary, K. J., Wayne, D. B., Haviley, C., Slade, M. E., Lee, J., & Williams, M. V. (2010). Improving teamwork impact of structured interdisciplinary rounds on a medical teaching unit. Journal of General Internal Medicine, 25, 826–832. Owen, J. M. (2007). Program evaluation: Forms and approaches (3rd ed.). New York, NY: Guilford Press. Rosen, P., Stenger, E., Bochkoris, M., Hannon, M. J., & Kwoh, C. K. (2009). Family-centered multidisciplinary rounds enhance the team approach in pediatrics. Pediatrics, 123, 603–608. Schleien, C., Brandwein, A., & Stasiuk, L. (2013). Do families play a role in deciding their own involvement in family centered rounds? Pediatric Critical Care Medicine, 14, 235–236. Sharma, A., Norton, L., Gage, S., Ren, B., Quesnell, A., Zimmanck, K., et al. (2014). A quality improvement initiative to achieve high nursing presence during patient-and family-centered rounds. Hospital Pediatrics, 4, 1–5. Williams, K. N., Ramani, S., Fraser, B., & Orlander, J. D. (2008). Improving bedside teaching: Findings from a focus group study of learners. Academic Medicine, 83, 257–264.
An Interactive Evaluation of Patient/Family Centered Rounds on Pediatric Inpatient Units1 J. Michelle Palokas DNP, RN-CPN a,⁎, Ladonna Northington DNS, RN, BC b , Robin R. Wilkerson PhD, RN b , Barbara J. Boss PhD, APRN, FNP-BC, ANP-BC b a
Batson Children's Hospital, Children's of Mississippi, Jackson, MS University of Mississippi School of Nursing
b
Received 29 May 2014; revised 16 November 2014; accepted 18 November 2014
Key words: Patient/Family centered rounds; Family centered care; Interprofessional
In order to provide excellent patient care and customer service, patient rounds should be efficient, effective, and timely. Also, essential healthcare team members should be present in rounds, to ensure interprofessional collaboration. Patients and families should also be included in rounds, to ensure accurate information is relayed and to ensure involvement in care planning. The purpose of this inquiry was to conduct an interactive evaluation with organizational stakeholders of patient/family centered rounds on pediatric inpatient units of a large academic medical center using a plan, do, study, act (PDSA) model. © 2015 Elsevier Inc. All rights reserved.
PATIENT AND FAMILY-centered care continues to be supported by a growing body of research. The movement toward involving the child and family in planning, delivery, and evaluation of health care is grounded in collaboration among patients, families, physicians, nurses, and other health care team members. In 1986 Public Law 99–457 was passed which required that the entire family be treated as the recipient of services for children with special needs. The family-centered care legislation suggested that family members be allowed to determine their own involvement in decision-making regarding health and education services for their child (Rosen, Stenger, Bochkoris, Hannon, & Kwoh, 2009). Additionally, one of the six specific aims for improvement as outlined in Crossing the Quality Chasm: A New Health System for the 21st Century was to “provide care that is respectful of and responsive to individual patient preferences, needs, and values, and ensure that patient values guide all clinical decisions” (Institute of 1 No funding required; no commercial financial support. This information was presented as a Capstone Presentation on April 16, 2014 to interested parties at the University of Mississippi Medical Center School of Nursing. ⁎ Corresponding author: J. Michelle Palokas, DNP, RN-CPN. E-mail address: [email protected].
http://dx.doi.org/10.1016/j.pedn.2014.11.005 0882-5963/© 2015 Elsevier Inc. All rights reserved.
Medicine, 2001, p. 3). A policy statement issued in 2003 by the American Academy of Pediatrics concluded with 15 specific recommendations for providers to successfully integrate family-centered care in hospitals and other systems of care. Some of these recommendations were as follows: a) “Pediatricians should actively consider how they can ensure that the core concepts of family-centered care are incorporated into all aspects of their professional practice,” and b) “Pediatricians should promote the active participation of all children in the management and direction of their own healthcare, beginning at an early age and continuing into adult care” (American Academy of Pediatrics Committee on Hospital Care, 2003, pp. 693–694). Several nursing organizations also support patient/family centered care and recognize the vital role that families play in the health and well-being of infants, children, and adolescents. These nursing organizations include the American Nurses Association (ANA), American Association of Critical-Care Nurse (AACNs, and the Society of Pediatric Nurses (SPN) (Institute for Patient/Family Centered Care, 2010). Patient/Family centered rounds are interprofessional rounds conducted in collaboration with the child and their families, and are just one way to improve communication among the
e10
J.M. Palokas et al.
healthcare team members and recipients of care. Patient/ Family centered rounds can aid in moving organizations towards embracing family-centered care and can provide benefits to the physicians, nurses and other health care team members, as well as the child and family. A few of the most commonly perceived patient/family centered rounds benefits include “increased family involvement and understanding” and “effective team communication” (Mittal et al., 2010). Involving the child and family in rounds can provide physicians with a better understanding of the patient and the disease they are attempting to treat. Discussions with the family may also elicit information that would otherwise be impossible or difficult to obtain by the health-care team, especially in a timely manner (Schleien, Brandwein, & Stasiuk, 2013). Since the physician is likely to receive more accurate information by utilizing this rounding process, improved care planning and clinical outcomes are anticipated (American Academy of Pediatrics Committee on Hospital Care, 2003). Patient/Family centered rounds provide the child and family an opportunity to be heard, and empower them to be active participants in their health care planning and decision-making (Schleien et al., 2013). Improved communication among the health care team and with the child and family has the potential to improve patient perceptions, which could improve the organization's patient satisfaction scores. Additionally, patient/ family centered rounds have a potential to produce the following outcomes (Institute for Healthcare Improvement, 2010): • • • • • • •
REDUCED errors, REDUCED ventilator days, REDUCED central line days, REDUCED length of stay, IMPROVED patient flow, EXPEDITED discharge planning, and IMPROVED safety and reliability of health care.
In order to provide excellent patient care and customer service, communication among caregivers should be efficient, effective, and timely. In addition, children and their families should have the opportunity to be included in those discussions, to ensure accurate information is relayed and to provide an opportunity for patient/family input into care planning. Unfortunately, in our hospital, the rounding process prior to implementation of patient/family centered rounds did not promote collaboration among team members, nor provide the patient/family a consistent opportunity to be involved in their own healthcare decision making. If the hospital continued to utilize that traditional rounding process, staff was likely to continue seeing the effects of lack of communication among team members and patients/ families, including: patient satisfaction scores reflective of lack of communication among team members, increased length of stay, increased medical errors, a decrease in safety and quality of care, and decreased patient flow. In order for the patient/family centered rounds initiative to be successful, stakeholder buy-in and involvement is imperative. As Harris, Roussel, Walters, and Dearman
(2011) explain, “the significance of collaboration and communication with the stakeholders cannot be understated” (p. 58). For an initiative or program to succeed, it is imperative to involve organizational stakeholders from the beginning, to provide intermittent progress checks, and to respond to and address concerns throughout implementation (Harris et al., 2011). Therefore the purpose of this project was to conduct an interactive evaluation with organizational stakeholders of patient/family centered rounds on inpatient units at a pediatric hospital in an academic medical center using a plan, do, study, act (PDSA) model. During this interactive evaluation, the goal was to engage the organizational stakeholders in reflecting, identifying problems, and offering solutions during the implementation process.
Methods Setting and Participants This pediatric hospital, which opened in 1997, is the only hospital in the state dedicated to the care and treatment of injured and sick children. With an average of more than 9,000 admissions per year, patients may receive treatment for common childhood illness, chronic conditions, trauma, or life-threatening diseases. The inpatient areas include a pediatric intensive care unit (PICU), a pediatric step-down unit, a hematology/oncology unit, a general pediatric unit, a post-surgical unit, a cardiac step-down unit, and a pediatric psychiatry unit. The setting for this interactive evaluation was all inpatient areas in the children's hospital, excluding the intensive care unit and the pediatric psychiatric unit. The intensive care unit was already conducting nurse-led, interprofessional rounds at the bedside of the child; and the pediatric psychiatric unit conducts interprofessional rounds in the conference room while on speaker phone with a parent or caregiver. The participants for this evaluation, also known as the organizational stakeholders, were the direct care nurses who work on these units, along with the attending physicians who admit to these units, who electively agreed to informal interviews and survey completion. The accessible population included approximately 160 nurses and 150 attending physicians.
Change Process The idea of patient/family centered rounds actually originated in patient satisfaction committee meetings. The patient satisfaction vendor, NRC Picker, provided valuable information regarding patients' and families' perspectives of care received. Based on a priority matrix report provided by the vendor, several items were identified as “top priority” for improvement in the organization. These items included: doctors' courtesy/respect, nurses' courtesy/respect, doctors listened carefully, nurses listened carefully, nurses explained things understandably, doctors explained things understandably, nurses discussed worries and concerns, confidence and trust in the doctor, confidence and trust in the nurse, and parent/ guardian input in care.
Interactive Evaluation of Patient/Family Centered Rounds While discussing these opportunities for improvement among the patient satisfaction committee, it was noted that staff nurses had also expressed concerns regarding the tremendous decrease in their own communication with the physicians since the implementation of the electronic health record (EHR.) Since the inception of the EHR in June 2012, it had not been imperative that the physician be physically present at the nurses' station, since there were no longer any physical charts. Since their physical presence was not necessary, it was possible that the physicians were spending less time at the nurses' station; therefore, there was less opportunity for communication with the nurses. The interprofessional patient satisfaction committee quickly noted that the majority of the items discussed at the meetings seemed to revolve around communication or the lack thereof. In the process of developing an action plan to improve communication, the committee members began to search for and discuss options; hence, the birth of patient/ family centered rounds. In late 2012, an interprofessional group was formed to plan a pilot patient/family centered rounds implementation. Original participants included the chairman of pediatrics, the inpatient clinical director, the director of quality and care coordination, a nurse manager, a nurse educator, and multiple physicians. The decision was made to begin the program on the pediatric post-surgical unit since a smaller number of physicians generally admit to this unit. After implementation on this unit, the roll-out of patient/family centered rounds continued, one unit at a time. An admission handout was created to provide the families with rounding expectations. A new dry erase board was
Figure 1
e11 affixed in each patient room near the exit. The location of the dry erase boards provided the caregiver and family an easy view, especially when exiting the room; however, a passerby would not be able to view the information. This dry erase board provided space for the physician, nurse, and technician names, along with space for documentation of daily goals. A flow diagram was also created to use as an educational supplement for the nurses and physicians who would be involved in the rounds (Figure 1). The nurse manager and educator provided education and expectations to the direct care nurses on the implementing unit. The chair of pediatrics and the inpatient clinical director held meetings with those physicians who had admitting privileges, to explain the initiative in detail. The patient/family centered rounding process was actually implemented on the first inpatient unit in early March 2013. The plan, do, study, act (PDSA) model for improvement and an interactive evaluation approach were used for this quality improvement project. The PDSA model was used to test change in the real work setting once the team established its membership and acknowledged measures that could determine whether the change leads to an improvement in the process or program. Using PDSA cycles, small scale changes gave the organizational stakeholders the opportunity to see if the proposed change worked. An interactive evaluation approach, as described by Owen (2007), is concerned with “focusing evaluation on organizational change and improvement, in most cases on a continuous basis, and a perspective that evaluation can be an end in itself, as a means of empowering providers and participants (p. 217).” Intensive onsite study, including observation and interview, is directly related to the interactive evaluation
The initial patient/family centered rounds flow diagram.
e12 method, all of which were used for during this program implementation. The implementation team originally planned to meet monthly to discuss findings, create/document PDSA cycles, and implement changes. It soon became apparent, however, that when changes needed to be implemented quickly, monthly meetings were not sufficient communication. And often, frequent and short notice meetings could not be scheduled due to the busy schedules and prior commitments of the team members. So, many times communication of the team plans and initiatives took place via email. Plans and initiatives were also discussed at the monthly patient satisfaction committee meetings, for which all original implementation team members receive invitations.
Data Collection Interviews
J.M. Palokas et al. Table 1
Data collection questions.
Interview questions Are you currently conducting or participating in patient/family centered rounds on your patients? If you are participating, what are the obstacles? If you are participating, what positive outcomes have you observed? What negative outcomes have you observed? What would make it easier/more efficient to do patient/family centered rounds? Are there any other thoughts or ideas regarding patient/family centered rounds that you would like to share? Electronic survey questions Are you doing patient/family centered rounds on your patients? • Yes-Always • No-Never • Sometimes • Other If you are not doing patient/family centered rounds, what are the obstacles? • N/A-I am doing PFCRs • Lack of physician participation • Lack of nurse participation • Other If you are doing patient/family centered rounds, what positive outcomes have you observed? • N/A-I am not doing PFCRs • Better communication with families • Better communication with the healthcare team • Other What would make it easier/more efficient to do patient/family centered rounds?
Informal one-on-one and/or group interviews were conducted by the evaluator from the time of implementation and throughout the next year. The evaluator rounded almost daily on the inpatient units and had the opportunity, at that time, to informally interview the nursing and physician participants of patient/family centered rounds. The evaluator interviewed employees who had the opportunity and were willing to provide feedback. Normally, these interviews occurred in a private location near the nurses' station of the respective unit to ensure confidentiality. The evaluator used six questions (Table 1) to guide the interviews with the organizational stakeholders. If a PDSA was ongoing, the evaluator asked more focused questions about the proposed changes to the process instead of the previously mentioned six questions. Feedback gained from the interviewees was written in a designated journal as field notes. In these field notes, the interviewer documented whether the interviewee was a physician or nurse and the unit location of the interview. Additional information collected for physicians included area of specialty. Additional information collected for nurses included current degree and years of experience. At least once a month, the field notes were transcribed into an email and sent to the implementation team and the organizational stakeholders of the units which had already implemented the new rounding process.
The survey link was sent to the direct care nurses and physicians via email. The staff members had approximately 2 weeks to complete the electronic survey. The collected data were organized and disseminated to the implementation team and the organizational stakeholders. Applicable graphs and the responses to questions were also presented in a PowerPoint presentation at patient satisfaction committee meetings.
Electronic Survey
Direct Observation
A 2-month post-implementation, electronic survey was created by the original implementation team and conducted on each of the involved units. After 2 months, the staff should have had ample time to become familiar with the new rounding process. The implementation team decided on four simple questions to elicit feedback from the stakeholders. These questions and possible responses are listed in Table 1. The stakeholders could choose all answers that they felt applied to the question. The survey was created in SurveyMonkey. Information about SurveyMonkey can be found at: surveymonkey.com.
The evaluator randomly observed the patient/family centered rounding process, starting at original implementation and over the course of the year, to capture interactions of the organizational stakeholders. The goal of this type of observation was to note the differences in rounding among different teams. The evaluator documented any relevant findings in the previously mentioned, designated journal, as field notes. No identifying information was collected during any of these data collection processes. This information was also disseminated via email to the implementation team and the organizational stakeholders.
Interactive Evaluation of Patient/Family Centered Rounds
Results Over a 1 year period, a total of 119 interviews were documented. Each interview typically lasted 5 minutes or less, which resulted in an approximate total interview time of 10 hours. The interviewees included 101 nurses, 2 nurse practitioners, and 16 physicians. Of those 101 nurses, 32 held an ADN degree, and 69 held a BSN degree or higher. The average number of years of experience for the nursing interviewees was 5.44 years. Of the physicians who were interviewed, specialties included general pediatrics, urology, GI, orthopedics, general surgery, and cardiology. Data analysis was ongoing throughout the interactive evaluation. The evaluator led interprofessional discussions via email and at the monthly patient satisfaction committee meetings to review the findings from the data collection. Analyses of the data included identifying any recurring ideas or themes for improvement or changes to the patient/family centered rounding process. Once ideas for change were identified, the PDSA model was used to plan and implement the changes. Based on the ongoing data collection, the implementation team and organizational stakeholders determined if permanent changes to the original implementation and/or flow of patient/family centered rounds should occur. The nurse manager and nurse educator on each unit were also instrumental in identifying opportunities for improvement to the process and determining if changes should be permanent, as they often communicated with the organizational stakeholders. During the year of implementation, using the recurring ideas and themes, six ideas for change were carried out using the PDSA model. Of the six PDSAs conducted, five permanent changes were made to the overall rounding
Figure 2
e13 process, including: 1) physicians communicating set rounding times, when possible, 2) physicians calling out on the call light as a way of notifying the nurse that they are ready to round, 3) nursing staff providing communication notepads in the children's rooms, 4) nursing staff bringing a workstation on wheels (WOW) to the child's room for rounding, and 5) the surgery team appointing the NP as the “designee” for the attending in the rounding process. After these changes in process, the original flow diagram was updated to include the components (Figure 2). Based on all of the data collection methods, the most common nursing themes identified were that nurses were not aware of, or were not notified when the physician was on the unit and ready to round or that nurses often times could not round at the time the physician was ready to round (due to other patient care needs or other physician teams already rounding on the unit). The most common theme from the physician perspective was that they could not find the nurse at the time they needed to round. It is important to note that due to the feedback from the organizational stakeholders, much of the effort during this year long evaluation phase was focused on basic sustainment of the program and processes, instead of making major changes to the process. The implementation team spent much time and effort encouraging the organizational stakeholders to continue following the initial processes despite the barriers, and encouraging accountability for all involved. During implementation, the organizational stakeholders often spoke of making the process “easy” and “quick”, which is apparent in the PDSA cycles. The two most common ideas to improve rounds or make rounds more efficient, as communicated by the stakeholders,
The updated patient/family centered rounds flow diagram.
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were to notify the nurse when the physician was ready to round and to set a specified rounding time. And though the idea of set rounding times was added to the process of patient/family centered rounds, there were only a small number of physicians who could or were willing to accommodate this request. During the data collection process, nurses and physicians alike frequently recommended that the organization purchase a wearable voice-controlled device that enables instant two-way communication. They argued that this two-way communication device would allow the physician to quickly find the nurse and let her know that rounds were about to begin.
Limitations
Discussion
Recommendations
The data collection process of observing the teams during the rounding process proved to be very difficult for the evaluator's schedule due to the “unknown” of when the physicians would be rounding and how long the rounding process would last. Although several formal interviews were conducted for this quality improvement project, due to the nature of the role of the evaluator, information regarding the patient/family centered rounds process was gleaned almost daily from communication with organizational stakeholders, which was not always documented as field notes. Much like Williams, Ramani, Fraser, and Orlander (2008), Gonzalo, Chuang, Huang, and Smith (2010) reported, the organizational stakeholders seemed to value rounding at the bedside but noted that one of the major barriers to the patient/family centered rounding process was time constraints. Throughout the evaluation process, many stakeholders indicated during the interviews that having other patient responsibilities or duties interfered with getting to the child's bedside at the time of rounds. Also, similar to the study conducted by O’Leary et al. (2010) the direct care nurses, particularly, reported during interviews and on the surveys that patient/family centered rounds improved the communication among the healthcare team, which can lead to an improved climate of teamwork. Interestingly, just as this project was concluding, Sharma et al. (2014) reported that the use of a hands-free communication device improved nursing attendance at patient/family centered rounds from 47% to 80%. This evidence supports the recommendation of purchasing a hands-free communication device, as often voiced by the organizational stakeholders during the interviews. Although the Institute for Healthcare Improvement (2010) suggests that patient/family centered rounds have the potential to produce outcomes such as: reduced errors, improved patient flow, and improved safety and reliability of healthcare, there is limited literature to support that patient/ family centered rounds have produced such outcomes. To understand the true impact of this initiative, outcomes need to be identified, and data collection to test these outcomes must occur.
Future directions should include involvement of the child and family in the evaluation process. By not involving the child and family initially, this prevented them from dealing with the minute details of the initial implementation phase of the program. If any changes to the process are made after involving the patient/family in the evaluation process, the flow diagram will need to be edited, as necessary. Also, an organizational policy will need to be created to outline the details and expectations related to the new rounding process. For sustainability of the program, new nurses and physicians should be educated on this process and expectation during their on-boarding and orientation. Area pediatricians who have admitting privileges to the organization also need to receive consistent information regarding the process and expectations with patient/family centered rounds. Based on feedback from the organizational stakeholders, it is recommended that the organization purchase a wearable voice-controlled device that enables instant two-way communication. The implementation team should also identify outcomes for a product evaluation, which can provide findings from which a judgment of the worth of this initiative can be determined. These outcomes may include those identified by the Institute for Healthcare Improvement (2010) such as improved patient flow and expedited discharge planning. Once outcome data are identified, data collection needs to be initiated. Data collection has the potential to engage the stakeholders even more in the new rounding process. Other examples of outcome data might include: patient satisfaction, employee satisfaction, length of stay, and reduced errors. Finally, the implementation team should create a plan and timeline for the purposeful addition of other healthcare team members (respiratory therapy, social work, physical therapy, residents) to the rounding process to continue to move the organization toward a genuine culture of family centered care.
During the data collection process, it was noted that the evaluator performing the interviews and observations was an indirect supervisor of many of the interviewees, which could have influenced organizational stakeholders' behaviors or answers. Another possible limitation of this inquiry is that no outcome data have been identified or collected, so the effectiveness and efficiency of this program is currently unknown. Though the literature states that many positive outcomes can result from this type of rounding process, there currently are no data to support the claims in the literature.
References American Academy of Pediatrics Committee on Hospital Care (2003). Familycentered care and the pediatrician’s role. Pediatrics, 112, 691–696.
Interactive Evaluation of Patient/Family Centered Rounds Gonzalo, J. D., Chuang, C. H., Huang, G., & Smith, C. (2010). The return of bedside rounds: An educational intervention. Journal of General Internal Medicine, 25, 792–798. Harris, J. L., Roussel, L., Walters, S. E., & Dearman, C. (2011). Project planning and management. Sudbury, MA: Jones & Bartlett Learning. Institute for Healthcare Improvement (2010). Improvement map. Getting started kit: Multidisciplinary rounds. Retrieved December 15, 2012 from http://www.ihi.org/knowledge/Pages/Tools/ HowtoGuideMultidisciplinaryRounds.aspx Institute for Patient/Family Centered Care (2010). Core concepts of patient/ family centered care. Retrieved November 15, 2014 from http://www. ipfcc.org/pdf/CoreConcepts.pdf Institute of Medicine (2001). Crossing the quality chasm: A new health system for the 21st century. Washington, D.C.: National Academies Press. Mittal, V. S., Sigrest, T., Ottolini, M. C., Rauch, D., Lin, H., Kit, B., et al. (2010). Family-centered rounds on pediatric wards: A PRIS network survey of US and Canadian Hospitalists. Pediatrics, 126, 37–43.
e15 O’Leary, K. J., Wayne, D. B., Haviley, C., Slade, M. E., Lee, J., & Williams, M. V. (2010). Improving teamwork impact of structured interdisciplinary rounds on a medical teaching unit. Journal of General Internal Medicine, 25, 826–832. Owen, J. M. (2007). Program evaluation: Forms and approaches (3rd ed.). New York, NY: Guilford Press. Rosen, P., Stenger, E., Bochkoris, M., Hannon, M. J., & Kwoh, C. K. (2009). Family-centered multidisciplinary rounds enhance the team approach in pediatrics. Pediatrics, 123, 603–608. Schleien, C., Brandwein, A., & Stasiuk, L. (2013). Do families play a role in deciding their own involvement in family centered rounds? Pediatric Critical Care Medicine, 14, 235–236. Sharma, A., Norton, L., Gage, S., Ren, B., Quesnell, A., Zimmanck, K., et al. (2014). A quality improvement initiative to achieve high nursing presence during patient-and family-centered rounds. Hospital Pediatrics, 4, 1–5. Williams, K. N., Ramani, S., Fraser, B., & Orlander, J. D. (2008). Improving bedside teaching: Findings from a focus group study of learners. Academic Medicine, 83, 257–264.
