Clinical | Rounding with Heart

Rounding With Heart: The Road to Clinical Excellence

At 7:30 one morning, John Dent, MD, an attending physician on 4 East, a 28-bed acute cardiac unit, told a patient he was ready for discharge. “I assumed that meant I could get my clothes on, have my hep-lock taken out and wait for my wife to come get me,” the patient said. But it took more than another four hours before the patient could actually leave. Several caregivers visited the patient’s room, each giving different information about steps needed for discharge.

More than 50 caregivers from a cross section of disciplines listened as the patient described this experience at a recent Saturday planning retreat for Rounding with Heart. Through this new initiative, the group plans to introduce structured interdisciplinary bedside rounding (SIBR), a highly coordinated, collaborative patient care model, to 4 East.

The initiative aims to address of host of care delivery issues, including lack of coordination in care, by ensuring that caregivers from various disciplines who are treating a patient gather at the bedside daily and include the patient and family members in a discussion of issues like medication, patient safety, transition planning and patient and family preferences.

Like the Be Safe initiative, Rounding with Heart plays a key role in our organizational goals as outlined by Richard Shannon, MD, Executive Vice President for Health Affairs. “We launched Be Safe and I’m really excited about the launch of Rounding with Heart, which begins to move us from safety to clinical excellence,” Dr. Shannon said at the retreat. “I am committed to providing you with the resources you need to be successful. From this grassroots effort will come an opportunity to take Rounding with Heart across the organization.”

Conditions on 4 East
To better understand conditions on 4 East and opportunities for improvement, a 19-member planning team sought data on the current state of care using observations, evaluation of metrics and a staff survey.

The team looked at HCAHPS scores for the unit in several measures related to collaboration among staff and correlation of care, including communication with nurses, communication with doctors, discharge information, care transitions and how well staff took patient preferences into account. The unit scored at or below the 50th percentile in each area.

“If you have each caregiver working with patients one at time and then talking to each other erratically throughout the day, the patient never gets a cohesive message from the team,” said Dr. Dent. “Then the patient may begin to wonder, ‘Well who is really in charge? Who is keeping track of me through all this?’”

The team also collected data on staff perceptions, surveying about 40 physicians and 40 other caregivers separately. Among both groups, about one-fourth said doctors, nurses and staff always have highly effective collaboration and communication and a system exists to support good continuity of care. Few said physicians, nurses and staff always keep each other informed of patients’ care plans in a timely manner. “Both groups recognize there is significant care fragmentation that leads to unreliable communication and care,” said Brannelly Batman, manager of 4 East and a member of the planning team.

The results showed significant discordance between the groups in several areas. When asked whether they felt able to contribute to patients’ daily plans of care, most physicians answered “always” compared to less than half of other staff. Additionally, while all doctors agreed employees treat each other with respect, close to one-fifth of other caregivers were neutral, disagreed or strongly disagreed.

Dr. Dent said he believes the lack of respect some caregivers perceive is not because of blatant acts of disrespect, but because no one asks for their opinions or considers knowledge they’ve gained at the bedside. “It is quite likely that bedside staff whose special knowledge of patient conditions, concerns and preferences is routinely ignored by physicians in their care delivery will be at significant risk of psychological stress and disengagement,” Dr. Dent wrote in the report.

Understanding the Issues
Dr. Shannon noted that 4 East has been seeing increasingly sicker patients in recent years. Comparing the Health System’s case mix index with the 31 top academic medical centers in the country providing similar service, UVA ranked fifth in patient acuity. “Over the last several years as this has crept up, we haven’t reexamined the care delivery system,” Dr. Shannon said. “We can’t use a system that’s five years old to deal with a patient population that now ranks fifth in the country in terms of severity.”

He also said 4 East’s system is not designed to consistently provide an excellent patient experience. “Right now we achieve this through daily acts of heroism,” he said. “It requires someone really going above and beyond the call of duty, like a doctor coming in on a Saturday to discharge a patient.” Instead, excellence should be supported by “systemness,” Dr. Shannon said. “The system needs to be wired to deliver this result,” he said. “Rounding with Heart is a perfectly central place to begin this journey.”

Achieving the Ideal State
In his post-retreat report, Dr. Dent described an “ideal state” of care delivery on 4 East. “The ideal state of staff and patient and family communication is that patients and their families will be continuously and reliably updated on goals of care and evaluation and treatment plans,” he wrote. “They will see evidence of completely reliable interdisciplinary collaboration and coordination of care, including planning for transitions in care that begins immediately after admission, and continues after they leave the unit and return either home, or to a different setting.”

The team believes Rounding with Heart will create opportunities for cultivating the ideal state.
“When you bring everyone together, that gives patients a single, coordinated message at one time during the day,” Dr. Dent said. “They see that we have their best interest at heart, that we are communicating with them clearly and they benefit by having very clear coordination.”

Synchronization of the rounding process also enhances the care patients receive.
“The use of checklists will improve the reliability of rounds, including patient safety enhancements,” Dr. Dent added. “The critical feature of SIBR is that unwarranted variation in rounding performance is minimized through attention to standardization of the process.”

The initiative also will impact a number of key institutional programs and goals by:
• Making the environment safer for patients and caregivers
• Improving patient satisfaction
• Increasing collaboration between nurses and doctors
• Supporting interprofessional education
• Increasing workplace satisfaction among staff
• Moving the organization closer to Magnet status

Laying the Groundwork
At the July retreat, caregivers began planning the work that must take place before SIBR is launched on 4 East on October 13. That work includes determining when rounds will occur, who must be present and who may attend, the sequence in which information is exchanged, and team members’ individual responsibilities.
Retreat attendees broke up into small groups and identified key challenges the initiative may face, such as ensuring space and privacy for rounds, staff buy-in and communication before and after rounds.
The small groups also brainstormed solutions and will spend the coming months using them to create an implementation plan for the initiative.

Maria Seguerra, a 4 East nurse and retreat attendee, said she’s excited about beginning the initiative on 4 East. “I feel it will enhance the quality and efficiency of care we provide,” she said. “Not only will it improve communication, collaboration and team work between healthcare staff, it will allow patients and families to be active participants in plans of care.”

The planning team will also make site visits to other institutions using SIBR. Once the rounds are underway, the team plans to conduct audits of rounds to ensure the program is implemented properly.
The team will also use a number of metrics to measure success, including the five HCAHPS scores presented at the retreat, surveys of staff sentiment and staff engagement.

The team will follow these metrics, which are expected to improve with the implementation of Rounding with Heart:
• Length of stay
• Readmission
• Immunization rate
• MET calls
• Unexpected transfers to ICU and death
• Paging volume

Most importantly, the program will improve patient care by eliminating waste, Dr. Shannon said. “That’s why this initiative is critically important to both UVA and the nation,” he said.

– By Megan Welch, UVA Connect, 8/27/14