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

Nursing and Patient Care Excellence

Individualized Patient Care Bedside Shift Report 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 2. Accomplish scheduled tasks Creates

efficiency

“checkin’ on ya” won’t suffice Contributes to

efficiency

3. Address 3 P’s (pain, potty, position) 4. Address additional comfort needs 5. Conduct environmental assessment and ensure bed technology is correctly utilized 6. Ask “Is there anything else I can do for you before I go, I have time?” 7. Tell each patient when you will be back Quality indicators – falls, decubitis, pain management Improved patient satisfaction on pain, concern and caring,

efficiency

Contributes to

efficiency

, teamwork “Call me if you need me” decreases

efficiency

. Improves patient satisfaction on teamwork and communication 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 Nursing Communication Doctor Communication Responsiveness of Staff Pain Management Communication of Medications Discharge Information Individual Question Question Summary Nurse courtesy and respect Nurses listen carefully Nurse explanations are clear Doctor courtesy and respect Doctors listen carefully Doctor explanations are clear Did you need help in getting to bathroom? 2 Staff helped with bathroom needs Call button answered Did you need medicine for pain? 2 Pain well controlled Staff helped patient with pain Were you given any new meds?

2 Staff explained medicine Staff clearly described side effects 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 Hospital Rating Question Response Scale ALWAYS 1 , Usually, Sometime, Never ALWAYS, Usually, Sometime, Never ALWAYS, Usually, Sometime, Never ALWAYS, Usually, Sometime, Never ALWAYS, Usually, Sometime, Never ALWAYS, Usually, Sometime, Never Yes No (screening question) ALWAYS, Usually, Sometime, Never ALWAYS, Usually, Sometime, Never Yes, No (screening question) ALWAYS, Usually, Sometime, Never ALWAYS, Usually, Sometime, Never Yes, No (screening question) ALWAYS, Usually, Sometime, Never ALWAYS, Usually, Sometime, Never 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 0 to 10 point scale (percent 9 and 10 reported) 1 Response used to calculate the question score is designated by capital letters 2 For 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.

2.

3.

4.

Use opening key words and/or actions to introduce yourself and manage up others. Refer to the white board and ensure is updated.

 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.

Conduct environmental assessment. Use closing key words and/or actions including setting expectation that a caregiver will return within the hour.

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 0% 4% Avg Percentile Rank Improvement Among Partners Implementing Nurse Leader Rounding National Average Percentile Rank Improvement 2nd Qtr after Implementation 0% 4% 3rd Qtr after Implementation 9% 5% 4th Qtr after Implementation 11% 5% 5th Qtr after Implementation 16% 5% 6th Otr after Implementation 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

?

•More control over daily schedule •Less patient complaints •Returns care to the bedside •Maybe, even get a lunch break

13,216

15,000

9,316

12,000 9,000 What’s in it for patients?

• Reduced anxiety – trust in caregiver •Safer care, reduce falls (50%) and HAPU (14%) •Improved perception of quality care (+12 points)

8,315

1 Hour Rounding/29 beds avg



37.8% reduction

6,000 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 Attending to

personal needs positions

(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

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 Identify pilot units and all units to renew implementation Educate staff members via multiple training sessions and skills lab Create baseline graphs for tracking key metrics Highlight success stories including results and testimonials Verify competency and key behaviors on each unit • Gather information to include metrics on call lights, pt sat scores, falls and testimonials Dec Jan 15 • Share AJN article, 101 answers and customized tools including commitment statement and unit posters Jan 30 Feb 15 Feb 28 • Leaders to round and validate behaviors and logs daily • Review and address barriers or resistance • Reinforce the need for documentation and accept no excuses • 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 “ no meeting zone ” to allow managers to round 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.

5.

Discharge phone calls or survey 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 18:00 19:00 20:00 21:00 22:00 23:00 1:00 2:00 3:00 4:00 5:00 6:00 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 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: Initials: Signature: Initials: Signature:

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