Transcript Slide 1

Patient- and Family-Centered Care
&
Patient- and Family-Centered Rounding:
An introduction and guide to bedside
interdisciplinary rounding
Jeffrey D. Schlaudecker, M.D.
Assistant Professor of Family Medicine
University of Cincinnati
Associate Program Director
Assistant Director of Inpatient Family Medicine
The Christ Hospital/University of Cincinnati
Family Medicine Residency
Objectives
• 1. Describe the key elements of patient- and familycentered care (PFCC) and patient- and family-centered
rounding (PFCR)
• 2. List examples of how patient- and family-centered
rounding can improve patient safety, staff satisfaction, and
resident physician education
• 3. Explain how patient- and family-centered rounds differ
from traditional models of hospital care on an academic
hospital unit
• 4. Describe specific examples of barriers and solutions to
adopting patient- and family-centered rounding
What is patient- and family-centered care?
• An innovative approach to health
care
Patients
• Grounded in mutually beneficial
partnerships
• All ages
• All health care settings
•
www.familycenteredcare.org
Providers
Families
What are the core concepts of patient- and
family-centered care?
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Dignity and Respect
Information Sharing
Participation
Collaboration
Patient- and Family-Centered Care
Core Concepts
• Dignity and Respect
Health care practitioners listen to and honor
patient and family perspectives and choices.
Patient and family knowledge, values, beliefs and
cultural backgrounds are incorporated into the
delivery of care.
www.familycenteredcare.org
Patient- and Family-Centered Care
Core Concepts
• Information Sharing
Health care practitioners communicate and share
complete and unbiased information with patients
and families in ways that are affirming and useful.
(“It’s not called: Show everyone how smart you arecentered care”)
Patients and families receive timely, complete, and
accurate information in order to effectively
participate in care and decision-making.
www.familycenteredcare.org
Patient- and Family-Centered Care
Core Concepts
• Participation
Patients and families are encouraged and
supported in participating in care and decisionmaking at the level they choose.
Patient- and Family-Centered Care
Core Concepts
• Collaboration
Health care leaders collaborate with patients and
families in policy and program development,
implementation, and evaluation; in health care
facility design; and in professional education, as
well as in the delivery of care.
www.ipfcc.org
Patient- and Family-Centered Rounding
• What is it?
– A model of communicating and
learning between the patient, family,
medical professionals, and learners
– Traditionally described on an academic
inpatient ward setting
– Bedside interdisciplinary work rounds
– Pt and family share in control of
management plan
– (vs. traditional teaching rounds)
•
Johnson BH. Family-centered care: Four decades of progress. Families
Systems & Health. 2000;18:137–56.
The Traditional Model of Rounds
▼ Timing primarily based on physician schedule.
▼ Information primarily transmitted from physician
to patient.
▼ Goals for hospitalization are not always explicit.
▼ Other members of the care team are not
necessarily present.
▼ Teaching of students takes place separately.
Basics of Being at the Bedside
• Patient- and Family-Centered Rounds start at
admission
– Elicit family preferences
– Explain process and roles
– Nurse and/or MD driven
• Clarify family or patient preference in the
morning
– Those who opt in far outnumber those who opt
out the morning of rounds (>90% opt in)
Basics of Being at the Bedside
• Non-verbal core concepts
– Positioning of team and key members to include
family
– Respecting family’s space
– Eye contact and body language
• Verbal core concepts
– Introductions: Names and roles
– Invitation to participate: “Please interject…”
– Member of team: “You are the expert….”
Basics of Being at the Bedside
• Multidisciplinary presence and role
– Patient/family
– Bedside nurse
– Charge nurse/discharge planner
– Allied health: Respiratory Therapy, Nutrition,
Social Work…
– Attending physician
– Trainee physicians and nurses
Patient- and Family-Centered
Rounds
• Patients and families are viewed as
partners, not visitors.
• Patients and families have a range
of choices in how they can
participate in rounds.
• Efforts are made to schedule
rounds to fit family availability.
Cincinnati Children’s Hospital
Medical Center
2008 Recipient of Picker Award
for Excellence in the
Advancement of PatientCentered Care
Family-Centered Rounding
Logistics at TCH
• Always begins
with choice!
• Performed with
both new and
follow-up pts
• Takes place at the
bedside
FCR Logistics
• Resident ascertains pt/family wishes on admission;
reviews process prior to rounds; invite relevant
health-care team members
• Members of team introduced
• Process explained
• Case presented
• Discussion/Questions
• Follow-up explained
Logistics at TCH
• “Level the playing field”
– Critical importance for family and pt to feel like integral members of team
• Process explained
– "The most important thing we do on rounds is make the plan for the day.
While we're the experts on medicine, you're the expert on you and your
family. Together we'll make better decisions.“
– "I'm going to review the story so our entire group understands what brought
you to the hospital. Please feel free to add or correct anything as I go along."
– "I'm going to review for the team what happened in the last 24 hours. Your
input will be very important."
TCH Family Medicine Experience:
– Launched 10/07 on geriatric ACE unit: since
expanded to all units on all appropriate patients
– Not for everyone
– Very high pt/family satisfaction
– Better teaching
– More efficient care
– Safer care
Enhanced Patient Safety
• Improved discharge planning
• Case manager and social worker involved
earlier
– Able to identify barriers to timely discharge
• Pt & family involved in choosing followup plan that works for them
– When, where, with whom
• Aware of follow-up plan
– Increased awareness of events of
hospitalization
Literature Search
• Strong evidence that patients like bedside
rounds; suggested key elements for success:
– Introductions
– Nurse presence
– Use understandable language
– Allow/invite patients to participate
– Special care with physical exam/social history
– Knoderer HM. Inclusion of parents in pediatric subspecialty team
rounds: Attitudes of the family and medical team. Acad Med.
2009;84:1576-1581.
Literature Search
• Learners initially don’t like bedside
presentations, but become comfortable with
experience
– Initially learners worry about family discomfort,
but with experience perceive families prefer to
participate
• Family-centered rounds challenges us to move
beyond our comfort zone and approach
uncertainty at the bedside.
The Evidence
• MCGHealth in Augusta, GA
• Neuroscience Center of Excellence
• 3 years after implementing patient- and family-centered
initiatives, including conducting rounds at the bedside with
patients and families:
– Patient satisfaction 10th to 95th percentile
– LOS ↓ 50%
– Nursing staff vacancy rate 8% to 0%
– Increased faculty and trainee satisfaction
More Evidence
• Concord, NH Cardiac Surgery
Program
– Following initiation of
collaborative rounds
– Mortality decreased by ½
– Increased patient satisfaction (to
99th percentile nationally)
– Greater staff satisfaction
– “Flat Hierarchy” saves lives
Uhlig, P. N., Brown, J., Nason, A. K., Camelio, A., & Kendall, E. (2002). System innovation:
Concord Hospital. The Joint Commission Journal on Quality Improvement, 28(12), 666-672.
Developed with Patient and Family Advisors
Critical Care Tower Vanderbilt
University Medical Center
http://www.vanderbilthealth.com/traumasurvivors/
More Evidence. . .
Cincinnati Children's Hospital Medical Center:
Rounds take 20% longer
•
Overall daily time per patient is reduced
Patients/families benefit
•
85% participate; satisfaction increased
Staff feel more knowledgeable about the care plan
Errors in orders decreased from 9% to 1%
Education improved
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Faculty, students, and residents all report increased satisfaction
Muething, S. E., et.al. (2007). Family-centered bedside rounds: A new approach to patient care and
teaching. Pediatrics, 119(4), 829-832.
Family-Centered Rounds:
A Pediatric Hematology/Oncology Unit
Resident:
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“I learned how to explain things to families”
“Its especially helpful for interns who may seek to model their own
interactions after what they have witnessed.
Family:
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“Now I feel like part of his care”
“We were helpful with clarifying her background”
“This gives me more opportunity to connect with the doctor”
Knoderer HM. Inclusion of parents in pediatric subspecialty team rounds:
attitudes of the family and medical team. Acad Med 2009;84:1576-81.
Family-Centered Rounds (FCR): Staff Attitudes
“I can better understand the patient's care
plans”
FCR: 91% SA/A
CR: 6% SA/A
“I feel I am working on a team to care for
patients”
FCR: 92% SA/A
CR: 28% SA/A
• Rosen, P., et. al. (2009). Family-centered multidisciplinary rounds
enhance the team approach in pediatrics. Pediatrics, 123(4), e603-e608.
Resident Attitude
n=81
Patient- and Family-Centered Rounding
Common Concerns
Teaching will be pushed aside
• Learning occurs in ways not possible in conference
room or lecture hall.
• Physicians learn to be comfortable with uncertainty
(families already are!)
Muething, S. E., et.al. (2007). Family-centered bedside rounds: A new
approach to patient care and teaching. Pediatrics, 119(4), 829-832.
Patient- and Family-Centered Rounding
Common Concerns
Not enough time!
• Time used more efficiently: saves time
– Concord Hospital Adult Cardiac/Thoracic Step-down Unit:
staff felt slight increase in time early in day, saves time later.
– 2009 Adolescent Medicine Unit(Pittsburgh)
» Added 2.7 minutes per patient
– 2007 Cincinnati Children’s Hospital Medical Center: added
20% time to rounds
– Knoderer HM. Inclusion of parents in pediatric subspecialty team rounds: Attitudes of
the family and medical team. Acad Med. 2009;84:1576-1581.
“The How To” for Patient- and
Family-Centered Rounds
1. Just do it.
2. Explain “why” every time
with every patient.
– Soon everyone will believe
you!
“The How To” for Patient- and FamilyCentered Rounds
3. Review patient list to determine if there are
some patients who may not benefit for
patient- and family-centered rounds.
– Personal preference.
– Altered mental status with no family.
– Sensitive social/health issues
“The How To” for Patient- and Family-Centered
Rounds
4. At the doorway:
– Intern goes in first: asks permission (again).
– As group comes in, reminds patient/family why
rounds are conducted in this manner.
– Ground rules, introductions
“The How To” for Patient- and Family-Centered
Rounds
5. In the room:
– Discuss with team (including patient and family).
• Switch pronouns to engage listeners: “You” not “she.”
– Give patient permission to “tune out.”
• “I’m going to run through all of your lab results for the
team. I will translate the important ones for you at the
end.”
– Ask nurse and patient and family for input at
selected times.
• Its family-centered rounds NOT family-dominated
discussion.
“The How To” for Patient- and
Family-Centered Rounds
6. Ask permission to teach.
– Patient and family should know when someone is
teaching and not specifically discussing their case
7. The Conclusion.
– Strong summary and “Plan for the Day.”
– Who is on call.
– When someone will return.
Common Pitfalls
• It must be mutually beneficial.
– Not “show how smart you are” rounds
– Not “family-dominated rounds”
– Physicians set collaborative tone for encounter
• It's still a presentation.
– Beware the pragmatics of speech!
– Condense the History and Physical information.
• It can't take all day. It shouldn't take all day.
– Residents need feedback on presentation technique.
– Not everything written can nor should be said!
Selected References:
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(1) Sisterhen L, Blaszak R, Woods M, Smith C. Defining family-centered rounds. Teaching and
Learning in Medicine 2007;19(3):319-322.
(2) Rosen P, Stenger E, Bochkoris M, Hannon MJ, Kent C. Family-centered multidisciplinary
rounds enhance the team approach in pediatrics. Pediatrics 2009; 123:e603-e608.
(3) Cypress BS. Family presence on rounds: A systematic review of literature. Dimens Crit Care
Nurs. 2012;31(1):53-64.
(4) Rappaport DI, Ketterer TA, Nilforoshan V, Sharif, S. Family-centered rounds: Views of
families, nurses, trainees, and attending physicians. Clin Ped 2012; 51(3):260-266.
(5) Latta LC, Dick R, Parry C, Tamura GS. Parental responses to involvement in rounds on a
pediatric inpatient unit at a teaching hospital: a qualitative study. AcadMed 2008;83:292-297.
(6) Knoderer HM. Inclusion of parents in pediatric subspecialty team rounds: Attitudes of the
family and medical team. Acad Med. 2009;84:1576-1581.
(7) Rappaport DI, Cellucci MF, Leffler MG. Implementing family-centered rounds: Pediatric
residents’ perceptions. Clin Ped. 2010;49(3):228-234.
(8) Barry MJ, Edgman-Levitan S. Shared Decision Making - The Pinnacle of Patient-Centered
Care. N Engl J Med. 2012; 366:780-781.
Thank You
More information:
Institute for Patient- and FamilyCentered Care
www.ipfcc.org
[email protected]