The biggest challenge in establishing multidisciplinary rounds is getting everybody on the team to participate, says Tony Gorski, managing director of healthcare business at Huron Consulting Group.
“Nurses, case managers, social workers, and ancillary staff all work for the hospital, so it’s fairly easy to get them to participate. The challenge is to get the meetings to fit into the physicians’ schedules,” he says.
However, if the rounds are well planned and focused, most physicians will welcome them because they save time and eliminate multiple phone calls, he adds.
“Without multidisciplinary rounds, the physician may be contacted by nursing, social work, and the pharmacy individually regarding patient needs. It’s disparate, fragmented, and extremely frustrating,” Gorski says.
Disciplines involved in multidisciplinary rounds vary according to the patients, but typically include the core nursing staff, the case management team including social work, representatives from the finance and pharmacy departments, and the attending physician, Gorski says.
If the hospital doesn’t have hospitalists and community physicians are not interested in participating, the rest of the interdisciplinary team should round anyway, says Toni Cesta, RN, PhD, FAAN, partner and consultant in North Bellmore, NY-based Case Management Concepts.
She suggests inviting support staff, such as pastoral care or palliative care representatives, to participate one or two times a week.
“It is a best practice for the physicians to participate. It puts the entire team on the same page because they know the plan the physician has in mind, and what his or her parameters are for patient discharge,” says Jean Maslan, BSN, MHA, ACM, senior managing consultant for Emeryville, CA-based Berkeley Research Group.
But the challenge is to fit it into the physicians’ schedules, she adds.
To increase efficiency, Gorski recommends that physicians, nurses, case managers, and other staff be assigned by unit or floor.
Hospitalists are one of the big variables in multidisciplinary rounds because they often see patients in multiple units on multiple floors, points out Stefani Daniels, RN, MSNA, CMAC, ACM, founder and managing partner of Phoenix Medical Management, a Pompano Beach, FL, hospital case management advisory firm.
Daniels advocates “regionalization” of hospitalists — assigning them by unit or by service line — so they will work with the same team to provide care for the same group of patients and be accountable for their care. “This gives hospital leadership an opportunity to create a care team that includes a physician who is caring for a particular group of patients and is working closely with a care manager, a social worker, a pharmacist, a nurse manager, and other appropriate disciplines to provide consistent care for a patient population,” Daniels says.
Pharmacists can be a valuable participant in rounds, Maslan points out. They can provide input on the medication the patient is taking, or suggest a cheaper substitute for a discharge medication if the patient may not be able to afford the one prescribed.
Be flexible when you schedule the rounds, Maslan suggests. There usually aren’t enough physical therapists or pharmacists to attend rounds on every floor if they are held at the same time, she points out. “Many times, the case manager, social worker, and nurse can attend, but if rounding times aren’t staggered unit-to-unit, the team runs the risk of not having a physical therapist or pharmacist present,” she says.
Another solution might be to assign staff to the units where their expertise is most needed. For instance, physical therapists are essential for rounds on an orthopedic unit, and it would be beneficial to have a pharmacist present for interdisciplinary rounds in the ICU.
Walking rounds that include the case manager, nurse manager, pharmacist, and hospitalists and rounds in the patients’ room during shift change are popular with patients because it gives them a chance to participate in their care plan, Daniels reports. The rounds are an opportunity for all the key players, including hospitalists, to discuss the patients and each member of the team to their priorities for the day, she says.
Have the rounds in the patient room, alert patients in advance of the time they will take place, and invite them and their family members to participate, Cesta says. During the rounds, encourage patients to add input and ask questions, she adds. Tell the patients you will come back after rounds if they have a lot of questions.
“We encourage the family to be present so they will be involved in the plan, and they love it because they get a chance to ask questions and be involved. When family members are present, it improves satisfaction for everybody,” Cesta says.
Structured interdisciplinary bedside rounds (SIBR) bring patients and family members into the discussion, Gorski says. (For details on one hospital’s SIBR initiative, see related article in this issue.)
“The only way to get patients out the door faster and safely is to get them involved in the discussion about their own healthcare,” he says.
Healthcare providers aren’t going to make SIBR work perfectly in the first 30 days, Gorski says. “Staff have to be trained to train the patient to participate. Many patients are afraid to ask questions when the doctor comes in the room. The goal of SIBR is to take that wall away and include the patient in planning the care,” he says.
Based on her experience as a consultant, Maslan recommends holding rounds in a conference room, especially on medical-surgical units, rather than walking from patient room to patient room. “In working with hospitals, I’ve found that it is more efficient to hold the rounds in a room. With walking rounds, you have a whole group of people in front of the patient and family, and it’s difficult to get everything accomplished in a few minutes. The rounds end up taking a couple of hours and valuable team members start to fall off in attendance,” she says.