By Toni Cesta, PhD, RN, FAAN
In recent years, emerging best practice care rounding models have changed the face of how healthcare professionals perform rounds. Although these models result in better outcomes for patients, they remain an elusive, often misunderstood tool. When performed well, they can achieve better clinical outcomes, improved coordination of care, improved patient satisfaction, and shorter length of stay. This month, we will discuss how these models are designed and how they can be implemented to achieve desired outcomes.
The Joint Commission National Patient Safety Goal 2
The Joint Commission (TJC) developed a series of patient safety goals in 2009. Goal 2 was aimed at improving the effectiveness of communication among caregivers, including standardized handoff processes. Case managers must be aware of both vertical and horizontal communication.
Vertical communication occurs with those to whom we report or those who report to us; for example, communicating with a director or manager, a case management assistant, or a physician advisor.
Communicating with peers is considered horizontal. A majority of the work we do involves horizontal communication. Examples include staff nurses and other members of the nursing department, attending physicians, hospitalists, directors of radiology, laboratory, pharmacy, and other ancillary departments. It is critical that case managers maintain good communication channels with all members of the interdisciplinary care team.
TJC’s National Patient Safety Goal 2 emphasizes the importance of handoff communication. Crucial handoffs for case managers include:
- RN case managers and social workers;
- case management department staff and providers at the next level of care;
- staff nurses and case management staff;
- physician advisors;
- ED case management staff and inpatient case management staff.
It is during these handoffs that patient information is shared and exchanged. These handoffs should include information about the patient’s discharge planning process and insurance, family, social, or financial issues impacting his or her stay or discharge plan.
Strategies for effective handoffs include:
- Ensure communication is interactive and includes opportunity for questioning.
- Shared information should be as current as possible, including the patient’s plan of care, treatment and services, condition, and any anticipated changes. Also include information related to the discharge planning process, insurance issues, or family dynamics.
- Handoff communication should include a verification process for the received information, including repeat-back or read-back, as appropriate. There should be an opportunity for the receiver to review relevant patient historical data. These data may include previous care, treatment, and services.
- Limit interruptions during handoffs to minimize the possibility that information would fail to be conveyed or would be forgotten.
Handoff Communication Methods
There are a variety of methods used in hospitals that fall under the broad category of handoff communication. Some of these methods often are confused with interdisciplinary care rounds. Each method has different goals and objectives, but none should replace interdisciplinary rounds.
Change-of-shift rounds typically are conducted by the department of nursing, although hospitalists often use this technique as well. These rounds allow for the traditional interchange of clinical information during shift changes. They take place between staff RNs or hospitalists. They are not interdisciplinary, which separates them from other types of rounds.
Shift rounds address bedside care, assessment, and outcomes. Because of their heavy clinical focus, they should be conducted separately from other types of rounds and should never be incorporated with interdisciplinary care rounds.
Teaching rounds generally are used in teaching hospitals as a mechanism for educating medical students, interns, and residents. They provide an opportunity for the attending physician or hospitalist to lead an in-depth discussion of the patient’s clinical state, achievement of clinical goals, and expected outcomes. As with change-of-shift rounds, teaching rounds should not take place during interdisciplinary care rounds, nor should they replace them.
Patient Care Conferences
Patient care conferences are an adjunct to walking rounds. These typically occur when it becomes clear that there are additional information or issues that are too time-consuming for walking rounds. Patient care conferences may include a family member if necessary. Items that may be discussed during a patient care conference include end-of-life issues, family barriers or disputes, or other obstacles to a safe and effective discharge.
Huddles may come in many forms and with many different names. For this discussion, we will consider huddles as a mini version of patient care rounds. Huddles in this context are used as an adjunct, or follow-up, to the morning’s interdisciplinary rounds.
When the hospital holds interdisciplinary care rounds in the morning, huddles are conducted in the afternoon as a means of following up on any outstanding issues identified in the morning. The best way to conduct huddles is through routine schedule; however, there may be an occasion where an unscheduled, or impromptu, huddle may be necessary.
In attendance at the huddle should be the staff nurse responsible for the patients being discussed, the case manager, and the physician if possible. It also may be necessary to include the social worker if the outstanding issues or problems require his or her input.
It is important to plan for a huddle just as one would plan for any kind of rounds. It is best if scheduled huddles take place at the same time each day. A recommended time would be 2 p.m.; this time allows for any interventions that may need to take place before the end of the day.
Each discipline attending the huddle should come prepared with patient outcomes that have been reached, questions to be addressed to the other team members, or concerns that may need to be raised. It is not necessary to include every patient in the huddle; rather, those patients who have any outstanding issues that had been identified during the morning’s interdisciplinary rounds should be discussed.
Huddles allow the team to close the loop on anything that might delay or slow the patient’s care progression or achievement of expected outcomes. Clear delineation of each huddle member’s roles and responsibilities should be well understood in advance of starting any kind of huddle process.
Internal Patient Transfers
It is not uncommon for patients to be transferred from one nursing unit to another during the course of their hospitalization, or from the ED to an inpatient unit. During these patient transitions, case managers should ensure a standardized, consistent handoff process; otherwise, the case manager receiving the patient may have to duplicate work — which can increase the patient’s length of stay and otherwise slow the patient’s care progression.
A soft handoff should include a written summary from the staff member transferring the patient as well as any other needed documentation. The summary should include any issues specific to the patient’s care plan, discharge plan, family dynamics, and insurance, among other details. Hard handoffs include a verbal exchange of information in addition to any written materials.
Case managers and social workers should see handoff communication related to internal transfers as a hardwired and mandatory part of their daily practice.
Discharge and Interfacility Transfers
When the patient is discharged or transferred outside of an organization, a hardwired handoff process should be used. The process may be dependent on the patient’s destination once he or she leaves the hospital.
The following professionals should be included in the process:
- Nursing Home: Case management and the physician;
- Home Care: Case management;
- Acute Care: Physician, staff nurse, and case management;
- Home: Primary care provider;
- Home: Family and/or family caregiver.
When discharging a patient home, the family and/or family caregivers should be part of the handoff process. They should be given written and verbal handoff information so that they can participate in the patient’s care as comprehensively as possible. Never assume that family or family caregivers understand all that is necessary to take care of their loved one, even if they have done so in the past.
Each time a patient is transitioned, changes in the patient’s condition and/or care plan will require that up-to-date information be provided to the family so that the transition and the continuing care needs of the patient are adequate, with as few gaps in care as possible.
Interdisciplinary Care Rounds
Interdisciplinary rounds, including walking rounds, are a key care coordination strategy. Coordination and facilitation of care are among the key roles for RN case managers and social workers. It has become evident that interdisciplinary rounds are a key strategy for ensuring that the entire team is involved in the care coordination process and that these interventions take place in a timely manner.
Rounds, whether walking or in a conference room, provide a real-time and in-person exchange of information. They provide an opportunity for the goals and plan of care for each patient to be clear to all members of the patient’s care team. If structured properly, they provide a formal and organized approach to patient care.
Also, if they are structured as walking rounds, part of the process includes time at the patient’s bedside. By conducting rounds at the bedside, there is greater assurance that the patient and family receive consistent and accurate information. The patient and family will receive the information and the messages being conveyed once rather than multiple times from multiple members of the care team. There is less likelihood that information will be conveyed in a contradictory or redundant way, a major dissatisfier for patients and families. Finally, rounds increase the efficiency and safety of patient care.
Why Walking Rounds?
The National Academy of Medicine (NAM; formerly the Institute of Medicine) promotes the use of interdisciplinary care rounds as a means of promoting collaboration. NAM emphasizes that when performed properly, evidence-based clinical management processes can be used by the entire care team in a consistent way. Standardization can reduce variation and/or delays as the entire care team is together when decisions are being made.
Why walking rounds rather than conference room rounds? Walking rounds enable all members of the team caring for the patient to offer individual expertise and contribute to the patient’s care from their professional point of view. The various disciplines can come together to coordinate the patient’s care as a group rather than individually.
For example, the physician can provide the plan of care and expected outcomes for the patient; the case manager can discuss barriers to patient care progression; and the social worker can discuss family dynamics that may slow the discharge process. This format improves communication among and between the team members. Better communication results in better care, reduced cost, and improved patient outcomes. The Institute for Healthcare Improvement (IHI) and TJC have both documented their support for the use of walking rounds.
The Center for Patient Safety also has advocated walking rounds, saying that the old paradigm was to tell staff to figure things out and just get it done. In the new paradigm, in order for healthcare to have consistent results, healthcare providers must do things the same way every time.
Walking or bedside rounds are critical to patient flow and throughput. By organizing the work of the care providers as a team, delays can be identified and corrected. Redundancy can be reduced or eliminated.
As discussed above, rounds are not nursing report or physician change of shift. When rounds are reported as taking too long, this often is due to the team getting off topic or spending too much time on one patient. Rounds should focus on the following:
- the inpatient plan of care;
- expected outcomes of care;
- barriers to care;
- transitions in care (one level of care to another);
Now that we have set the stage for why rounds are so critical to improving patient care and outcomes, next month we will continue our discussion by reviewing how rounds should be organized and conducted to maximize their benefit and improve patient care.