Transcript Lessons Learned - Quality & Health

Rounding for Outcomes
Hourly Rounding
Lessons Learned
Georgia Hospital Association
Karen Cook, RN
Objectives
Describe the evidenced based results proven to
occur when implementing hourly rounds
Describe the behaviors needed to accomplish an
effective hourly round
Describe the lessons learned about hourly
rounding and the accountability systems necessary
to hardwire the process
Rounding for Outcomes
PROACTIVE plan to engage, listen to, communicate with,
build relationships with and support important people
Employees Physicians Patients and Families Departments Served
Structured mechanism to ensure we create a quality, safe
and compassionate environment by obtaining ACTIONABLE
information from those closest to the situation
Method to coach/reward and recognize staff in real-time
fashion (as communicated by their direct supervisors)
Link to a person of “authority”
A thoughtful plan to differentiate your facility from others by
providing distinctive communication around specific
questions to create a great place for employees to work
Types of Rounding
Rounding on Employees and Physicians
Rounding on Patients/Families
Rounding on Customers Served
Senior Leader Rounding
Hourly Rounding on Patients
Define the Term “Hardwired” Rounding
90% of leaders rounding with the prescribed
frequency, utilizing good skills, to elicit
actionable reward/recognition and process
improvements that are documented and
followed up on.
These are trended and reported to give a more
global organizational perspective.
Patient Care Model
Hourly
Rounding
Bedside Shift
Report
Nursing and
Patient Care
Excellence
Individualized
Patient Care
Discharge
Phone Calls
Evidence-Based Leadership Strategy To
Achieve HEN Goals - 2013
What is Hourly Rounding?
What is it?
 A plan to proactively interact with patients every hour during the day
using focused key words to assess needs (pain, position, personal
needs and patient education)
 A care model to help return care to the bedside
 A plan to help achieve our goal to “always” deliver exceptional
clinical quality care in a safe and compassionate environment
Why do it?
 Evidence supports a decrease in patient anxiety, falls, skin
breakdown, and nursing steps as well increased patient satisfaction
 It allows nurses to provide more care at the bedside
 It is just good patient care
 There is no other initiative that impacts the patient perception of
quality care as this ONE does.
Evidence-Based Quality
Most Common Reasons for Call Light Use
Eight Behaviors of Hourly Rounds – More
Than 3 P’s
Hourly Rounding Behavior
Expected Results
1.Use Opening Key words
Creates efficiency
“checkin’ on ya” won’t suffice
2. Accomplish scheduled tasks
Contributes to efficiency
3. Address 3 P’s (pain, potty, position)
Quality indicators – falls, decubitis, pain
management
4. Address additional comfort needs
Improved patient satisfaction on pain,
concern and caring, efficiency
5. Conduct environmental assessment and Contributes to efficiency, teamwork
ensure bed technology is correctly utilized
6. Ask “Is there anything else I can do for
you before I go, I have time?”
“Call me if you need me” decreases
efficiency.
Improves patient satisfaction on teamwork
and communication
7. Tell each patient when you will be back
Contributes to efficiency
8. Document the round
Quality and accountability
Hourly Rounding on Patients is NOT…
Reactive when call light goes off
Fly by
Being “in the room” all the time
Happenstance or when there is “time”
Visiting - without ensuring quality of care
Our Goal is to Deliver Excellent Quality Care
Composite
Response Scale
Nurse courtesy and respect
Nurses listen carefully
Nurse explanations are clear
Doctor courtesy and respect
Doctors listen carefully
Doctor explanations are clear
ALWAYS1,
Did you need help in getting to bathroom? 2
Staff helped with bathroom needs
Call button answered
Yes No (screening question)
ALWAYS, Usually, Sometime, Never
ALWAYS, Usually, Sometime, Never
Pain Management
Did you need medicine for pain? 2
Pain well controlled
Staff helped patient with pain
Yes, No (screening question)
ALWAYS, Usually, Sometime, Never
ALWAYS, Usually, Sometime, Never
Communication of
Medications
Were you given any new meds? 2
Staff explained medicine
Staff clearly described side effects
Yes, No (screening question)
ALWAYS, Usually, Sometime, Never
ALWAYS, Usually, Sometime, Never
Did you go home, someone else’s home, or to
another facility? 2
Staff discussed help need after discharge
Written symptom/health info provided
Area around room kept quiet at night
Room and bathroom kept clean
Willingness to Recommend
Own home, Someone else’s home, Another facility (screening
question)
YES, No
YES, No
ALWAYS, Usually, Sometime, Never
ALWAYS, Usually, Sometime, Never
DEFINITELY YES, Probably Yes, Probably No, Definitely No
Hospital Rating Question
0 to 10 point scale (percent 9 and 10 reported)
Nursing Communication
Doctor Communication
Responsiveness of Staff
Discharge Information
Individual Question
1Response
2For
Question Summary
Usually, Sometime, Never
ALWAYS, Usually, Sometime, Never
ALWAYS, Usually, Sometime, Never
ALWAYS, Usually, Sometime, Never
ALWAYS, Usually, Sometime, Never
ALWAYS, Usually, Sometime, Never
used to calculate the question score is designated by capital letters
analysis purposes, it is important to know which areas have screening questions because the sample size will be lower than the other areas
#1 Lesson Learned
You won’t be successful without CNO engagement
and nurse leader rounding on patients hardwired
FIRST
This requires every patient rounded on every day by
a trained person of authority, random hourly
rounding validation rounds and process for CNO to
round for reward and recognition of hourly
rounding behaviors
Nurse Leader Rounding – Key to Accountability
1.
Use opening key words and/or actions to introduce yourself and manage
up others. Refer to the white board and ensure is updated.
2.
Ask 2-3 questions about specific initiatives:

We focus on meeting your needs, and with that in mind, the staff are
to be in the room every hour asking about pain, position and
bathroom needs. Has this been your experience?

In the last 24 hours, have you had to use your call bell to ask for
pain medicine?

Hourly rounding is just one way we provide quality care on this unit
and I see that Jane has recently been in to do your hourly rounds, I
will make sure and tell her you mentioned the great care you are
getting on this unit.
3.
Conduct environmental assessment. Use closing key words and/or
actions including setting expectation that a caregiver will return within the
hour.
4.
Review patient’s rounding log for compliance. Provide immediate
feedback to staff – both with celebrations / recognition and coaching
Nurse Leader Rounding Improves
Patients’ Perception of Nursing Quality
Increase in Percentile Ranking for HCAHPS Measure "Nurses Always
Communicated Well" Following Implementation of Nurse Leader Rounding
1st Qtr after
Implementation
4%
Avg Percentile Rank Improvement Among Partners Implementing Nurse Leader Rounding
0%
National Average Percentile Rank Improvement
2nd Qtr after
Implementation
3rd Qtr after
Implementation
4th Qtr after
Implementation
5th Qtr after
Implementation
6th Otr after
Implementation
4%
0%
9%
5%
11%
5%
16%
5%
25%
10%
Source: The graph above shows a comparison of average percentile rank improvement using the Studer Group partner database compared to CMS data
based on 3Q09-2Q10.
#2 Lesson Learned
We didn’t connect to the WHY for the staff and to
clinical quality for patients
Improved HCAHPS and Patient Satisfaction results
are OUTCOMES. This is done to reduce anxiety,
to prevent complications, to provide better quality
care and NOT to improve patient satisfaction
scores.
Call Light Reductions
After Implementing Rounds
What’s in it for you?
What’s in it for patients?
•Less patient complaints
• Reduced anxiety – trust in caregiver
•Returns care to the bedside
•Safer care, reduce falls (50%) and
HAPU (14%)
•Maybe, even get a lunch break
13,216
Call Light Rings
•More control over daily schedule
15,000
•Improved perception of quality care
(+12 points)
9,316
8,315
12,000
9,000
6,000
1 Hour Rounding/29 beds avg
 37.8% reduction
3,000
0
Pre-Rounding
* Reduction for one-hour was
statistically significant (p=.000)
Weeks 1-2
One Hour
Weeks 3-4
Coaching Tip: Connect to the “WHY”
Decrease LNS and AMA for safety, quality and peace of
mind
Decrease call lights for time savings, safety and disruptions
Decrease falls for safety, quality and peace of mind
Decrease patient & family anxiety
Decrease patient & family approaching desk for
confidentiality and work satisfaction
Increase communication
Increase patient satisfaction to improve payer mix, patient
loyalty, decrease patient complaints and decrease litigation
#3 Lesson Learned
We need to engage staff in using key words to
improve communication with patients
Key words reflect a communication style that
improves the quality of information provided.
Key times are defining moments that:
Occur during times of vulnerability like needing help to the
bathroom or pain management
Are what patients remember
Affect the perception of the total hospital experience
Share the WHAT and the WHY (not about scripting)
Why are Key Words Important?
Reflects organizational behavior standards
Reduce patient anxiety
Improve patient perception of care
Improve coordination of care
Decrease law suits
“Being Kept Informed” was the MOST important
characteristic when “returning to a hospital for
future visits.”
2007 McKinsey Survey of >2,000 patients with commercial insurance or Medicaid
Coaching Tips: Introduction of the Process
An important part of providing you with individualized care
and excellent service is hourly rounding. You will be visited
by one of your caregivers
EVERY HOUR from 8 a.m. to 10 p.m.
And
EVERY TWO HOURS from10 p.m. to 8 a.m.
During




this time we will be:
Checking on you and your well-being
Monitoring your comfort and pain
Helping you move and change positions
Attending to personal needs (such as assisting
you with toileting, bringing personal items within
reach, hygiene needs and anything else to make
you more comfortable)
Your caregivers also will make sure that you have easy
access to the:

Telephone, bedside table, water or other
beverages, and glasses

Urinal and/or bedpan and waste basket

Call light for assistance
What does this mean to YOU, your family and visitors?
It means that we are anticipating your personal needs and
monitoring your well-being on an active, hourly basis so that
your family and visitors can focus on your recovery.
You may receive a survey after you go home. We hope that
you will take the time to give us your feedback. We use
your feedback to recognize our staff and know how to
improve.
If you have any concerns, please notify
Immediately so we can address them.
HOUSTON NORTHWEST MEDICAL CENTER
Delivering Clinically Excellent Care
“On this unit, one of our care team
members will be coming in to see you
every hour during the day. You will see
either me or Jackie, our certified nurse
assistant. I have worked with Jackie
for two years and she is excellent. We
will be checking on your comfort such
as we will make sure we are helping
manage any pain you might have, help
you change position, help you to the
bathroom and make sure you have
everything you need.” We call this
hourly rounding and we do it to make
sure you are safe and we are always
meeting your needs.”
Coaching Tip: Reinforce With Written Word
t
The Action Plan – Doctors and Nurses
Best Practice: Use key words and body language
“I want to do everything I can to keep you as
comfortable as possible.”
“Keeping your pain managed is important. Tell me
about your pain right now.”
“I (or your nurse) will be checking you every hour.”
Remember eye contact, not rushed and empathy
Best Practice: Explain meds/acknowledge
progress
New medication dosing and side effects
“Your pain is now being controlled with 3mg rather
than 6mg of medication”
Coaching Tip: “Is This Patient Safe?”
#4 Lesson Learned
You won’t be successful without a robust system
of training and validating competency. This
includes annual competency and ongoing skills
validation.
Coaching Tip: Training Process
Attend one-hour training session
What is hourly rounding, why is it important, how to do it
Expected impact
Documentation – logs
Validation
Role play in skills lab to build confidence
Manager/Director responsible for validation/competency
Reinforce annually
Include in general and nursing orientation
Conduct Hourly Rounding Lab
Sample Role Play Scenarios in patient care setting
set
Assess the Hourly Rounding competency each
participant with real time feedback
Utilization of hourly rounding log
Next Steps: Once you leave lab, staff will
incorporate coaching into daily practice
Hourly Rounding Implementation Schedule
Create tools
for toolkit
Educate staff
members via
multiple training
sessions and skills
lab
Identify pilot units
and all units to
renew
implementation
Dec
•Gather
information to
include metrics
on call lights, pt
sat scores, falls
and testimonials
Create baseline
graphs for
tracking key
metrics
Jan 15
•Share AJN
article, 101
answers and
customized
tools including
commitment
statement and
unit posters
Jan 30
•Leaders to round
and validate
behaviors and
logs daily
•Review and
address barriers
or resistance
•Reinforce the
need for
documentation
and accept no
excuses
Highlight success
stories including
results and
testimonials
Feb 15
Feb 28
• Directors to incorporate
hourly rounding into
supervisory meeting
• CNO to round on each
unit at least once/mo to
gather information from
front line staff on hourly
rounding implementation
•Respect the “nomeeting zone” to allow
managers to round
Verify
competency
and key
behaviors on
each unit
March 15
•Internal coaches
to verify
behaviors and
validate
competency of all
managers during
coaching sessions
•Incorporate
rounding training
in orientation
#5 Lesson Learned
And “Soft” validation does not work!
"Sara, I appreciate being able to shadow you and
validate your hourly rounding skills. I think you did a
great job. The only thing I didn't hear was you using
the closing key words. I'll go ahead and check you
off but please be sure to do them next time."
Coaching Tips: Validation
Validation mandatory
Inspect what you
Expect!
Managers will verify staff
are doing hourly rounds
on their individual units
All caregivers should be
validated annually – this
is not just an RN or PCT
initiative
Other Ways to Validate
1. Directly observe hourly rounding on the unit
2. Leader rounding on patients
 Verify hourly rounding is occurring by asking
patients and their families
3. Leader rounding on staff
 Ask them what is working well with HR
 Highlight a WIN during Huddles
4. Discharge phone calls or survey
5. RESULTS
# 6 Lesson Learned
All staff must participate in sharing responsibilities
to accomplish the rounds and they need to have a
disciplined plan to execute, including a buddy
system as back-up.
If you try to delegate this to one person or one role,
you will not accomplish all the potential results or it
will not be sustainable.
Samples
#7 Lesson Learned
You won’t get and sustain results without
maintaining logs perpetually
Rounding Log
Please place your initials in the corresponding time box after round has been complete. **Round is only complete if all 8 Key Behaviors have been done.**
6:00
7:00
8:00
9:00
10:00
11:00
12:00 13:00 14:00
15:00
16:00
17:00
22:0019:00 20:00 21:00 23:00
18:00
MM/DD/YY
Sunday
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Eight Key Behaviors:
1) Use opening key words
2) Perform scheduled tasks
3) Address the 5 P's-Pain, Potty, Position, Possesion, Plan of Care
4) Assess additional comfort needs
5) Conduct environmental assessment
6) Use closing key words and/or actions
7) Explain when you or others will return
8) Document the round on the log
Initials:
Signature:
Initials:
Signature:
Key:
S= Patient Sleeping
R = Patient in Radiology
E = Room Empty
OR = Patient in Surgery
P = Procedure in Process
CT = Patient in C.T. Department
PT = Phyisical Therapy
Initials:
Signature:
Initials:
Signature:
1:002:00
3:004:00
5:006:00
Coaching Tips: Logs
Hourly Rounding℠ Logs are
Non- Negotiable if you want to
achieve desirable results
Visible representation to
patient/family of excellent, safe,
quality care to reduce anxiety
During rounds, nurse leaders
ensure logs represent hourly
rounding behaviors are
completed (R/R top performers)
#8 Lesson Learned
The 3P’s need to be modified for implementation
on specialty units. Take the time to ensure you
have defined the right behaviors.
OB-SKIP
(Supplies, Komfort, Information, Personal needs)
ED-PPD
(Pain, Plan of Care, Duration)
ICU
(Pain, Position, Plan of Care, Alarms)
Track and Monitor
Patients’ Perception of Care = Quality
Vascular Catheter-Association Infection
#9 Lesson Learned
This is for the patients comfort not ours
There has to be pain/consequences
False documentation of log
Lack of compliance
Refusing to use eight behaviors
#10 – Lessons Learned
Success is dependent on leadership
Train and validate all staff
Reward top performance and coach opportunities
Reinforce the WHY, connect to safe patient care
Track impact and communicate results
• Patient satisfaction by unit and HCAHPS
– Nurse communication, pain, responsiveness
• Falls, pressure ulcers, and other core measures
• Call lights
Audit the rounding logs
Round on patients to confirm behaviors
Post results from rounding – thank you notes
Communicate results in Supervisory Monthly Meeting
In Summary
 Is nurse leader rounding hardwired?
 Do you have nursing leadership engagement?
 Have you engaged staff?
 Are you training and “hard” validating?
 Are you tracking outcomes and communicating results?
 Are the tactics such as logs bringing value?
 Are you holding people accountable for compliance?
 Have you customized the behaviors to fit your area?
 Do you deliver on your mission of patient-centered care?
Do you have a culture of ALWAYS?
Process Improvement – Hourly Rounding
•Achieve quality goals and
improve publicly reported
metrics
•Ensure consistency of
evidence-based key tactics
•Track and trend results and
impact of behaviors
•Evaluate consistency in
implementation
•Understand key drivers
and current performance
•Review and customize
available tools and
resources
•Educate staff on hourly
rounding and implement on
inpatient units