EXECUTIVE SUMMARY

Multidisciplinary rounds that bring together the entire treatment team and, often, patients and family members, are a key in relieving the chaos that often occurs on the day of discharge.

  • The rounds increase communication and promote collaboration around the discipline by keeping everyone on the treatment team on the same page.
  • Rounds save time for case managers because they hear every discipline’s plans for their patients at the same time and everyone on the team avoids fielding multiple phone calls during the day.
  • Rounds should be carefully planned and strictly scripted with a strong facilitator to keep everyone on the subject and ensure that the rounds are short and productive.
  • Participants should include physicians, case managers, nurses, social workers, pharmacists, therapists, and, on occasion, support staff such as chaplains.

When patients are ready to be discharged from your hospital, is everyone scrambling to get orders filled and post-acute care lined up while the patient and family members fume because they can’t leave yet?

Do you spend a good part of your day fielding phone calls from other members of the treatment team, answering the same questions from several members of the team, and trying to reach physicians with questions?

Does the treatment team at your hospital rely so heavily on communicating through the electronic medical record that they rarely have actual face-to-face conversations about their patients?

When the team does get together, is the meeting disorganized and excruciatingly long, with little structure and little follow-up?

These scenarios may sound familiar to case managers at many hospitals, but they can be avoided if the entire treatment team gets together daily for a well-organized and short discussion of every patient they are responsible for, experts say.

The activities may be called “interdisciplinary rounds” or “multidisciplinary rounds” and the structure and participants may vary from hospital to hospital, but the purpose is to improve patient care and throughput by facilitating communication among team members.

“In the era of bundled payments and other value-based reimbursement programs, hospitals need better care coordination and lower costs. Interdisciplinary rounds are a no-cost strategy for improving care coordination at the bedside,” says Toni Cesta, RN, PhD, FAAN, partner and consultant in North Bellmore, NY-based Case Management Concepts.

Change-of-shift rounds, teaching rounds, patient care conferences, and huddles are all important but should not be a substitute for interdisciplinary rounds, Cesta says.

“Interdisciplinary rounds are an opportunity to engage the entire healthcare team,” she adds.

In many hospitals, workflow is extremely fragmented with dozens of holes, resulting in disjointed and uneven delivery of care, says Tony Gorski, managing director in the healthcare business at Huron Consulting Group, and co-founder and chief executive officer of MyRounding, a firm specializing in digital health solutions.

As a result, the activities that take place during the last 48 hours of the typical patient stay often are “controlled chaos,” Gorski says. “It’s like trying to herd cats or catch a pig. Everything is happening at the last minute and a lot of things fall through the cracks as the team struggles to get the patient out the door,” he says.

“For instance, the physician may need the results of a test before signing the discharge order, and everybody has to race to make the patient a priority. But often, the need for the test could have been anticipated at admission or early in the stay and discussed during multidisciplinary rounds, avoiding the last-minute scramble,” Gorski says.

Medication issues are sometimes responsible for delayed discharges when medications are prescribed at the last minute, Gorski says.

“There’s not usually a streamlined process to fill prescriptions quickly, and the nurses have to rush through the instructions on how to take medication. This causes anxiety and lack of patient satisfaction,” he says.

When the multidisciplinary teams meet every day and collaborate on carrying out what it takes to get the patient discharged on a given date, it eliminates the last-minute holdups, Gorski adds.

The Joint Commission and the Institute for Healthcare Improvement both consider interdisciplinary walking rounds a best practice, Cesta points out.

But despite this, many hospitals don’t have the rounds, or they implement them sporadically or half-heartedly, Gorski says. (For tips on how to organize the rounds, see related article in this issue.)

“Interdisciplinary rounds are a best practice, but I’m surprised by how many hospitals I visit that don’t have them. I don’t know how you can provide exceptional patient care unless everyone on the team communicates,” adds Jean Maslan, BSN, MHA, ACM, senior managing consultant for Berkeley Research Group, headquartered in Emeryville, CA.

Stefani Daniels, RN, MSNA, CMAC, ACM, founder and managing partner of Phoenix Medical Management, a Pompano Beach, FL, hospital case management advisory firm, reports that in her consultations with hospitals across the country, she has seen efforts at creating interdisciplinary team coordination with varying success. Daily huddles and walking rounds have been successful at some hospitals, but many clinicians struggle with interdisciplinary communication, she adds.

“I don’t see interdisciplinary coordination like I would hope to see. Many times, there’s just a bunch of people sitting around and talking about discharge planning. This not an interdisciplinary approach to providing the best care,” Daniels adds.

One problem is that hospital culture is not geared for the process of interdisciplinary collaboration, and many hospitals don’t have a way of fixing any glitches that impede patient flow, Gorski says. “Most hospitals have broken processes, and even though they have excellent people providing care for the patients, when the process is broken, they get average results,” Gorski says.

Gorski points out that process engineers in other settings spend their days fixing problems that affect the workflow, but it doesn’t happen at hospitals. “Ask leadership at the average acute care hospital how many processes have been changed to fix a broken patient flow problem, and they don’t know because hospital staff members don’t think that way,” Gorski says.

Multidisciplinary rounds are an opportunity for the team to work together to identify and fix the problems, he adds. When everyone who is caring for a patient gets together every day and talks through delivery of care for the patient, it can reduce readmissions, cut length of stay, and increase patient satisfaction, Gorski says. (For information on who should attend the rounds and where they should be held, see article in this issue.)

“If hospitals aren’t having daily interdisciplinary rounds that enable team members to communicate with each other on a daily basis, they’re missing a chance to move patients efficiently and effectively through the continuum,” Maslan says.

When the team stays on top of what’s going on with the patient every day, it can have a huge effect on length of stay, patient satisfaction, and readmission reduction, Maslan says. “If everybody is on the same page, discharge orders won’t be a big surprise and the staff won’t have to scramble to get everything done at the last minute,” she adds.

But it’s more than just improving length of stay and the bottom line, she adds. “Interdisciplinary rounds improve quality by putting everyone on the team on the same page and making sure the right things are done at the right time,” Maslan says.

Interdisciplinary walking rounds provide a real-time, in-person exchange of information on the goals and plan of care for the patient among all members of the team as well as the patient and family, Cesta says.

The rounds are an important tool for case managers because they hear the plan for all their patients in a small amount of time, rather than having to track down physicians and nurses during the day, Cesta says. By improving communication and teamwork and reducing duplication, the rounds can improve patient flow and help case managers anticipate discharge needs and expedite a smooth transition, she adds.