By Toni Cesta, PhD, RN, FAAN
In the last issue of Case Management Insider, we began to explore the concept of interdisciplinary walking rounds. We reviewed why walking, or bedside, rounds are being promoted as best practice by the Institute for Healthcare Improvement and The Joint Commission. This month, we will discuss the elements of a walking rounds format and the role that the interdisciplinary team members play in the process. Each team member should be aware of his or her unique role so that rounds can be as streamlined as possible. Through standardization and the reduction in variation, rounds will go smoothly and timely.
The Elements of Effective Walking Rounds
When developing a rounding process or updating one in your organization, certain key components should be included. These key components include the following:
• Identify and refine goals for rounds. All members of the team should know the goals of the rounds. These goals should remain consistent regardless of the team member or the patient being discussed.
• Create a structure. Once a structure has been designed, the team must stick with that structure. Constantly changing the structure will confuse team members, lead to an increase in variation, and reduce the quality of the rounds.
• Leadership is key. The leader of the rounds should be consistent. The leader should be trained to ensure that he or she is prepared to manage and lead the rounds. Also, appoint a secondary leader to ensure consistent coverage.
• Appoint a standard time for rounds every day. Rounds should always be conducted at the same time. A standard time allows the team members to be prepared and available for the rounds. Rounds should always be mandatory for every team member.
• Engage with the patient and family. Including the patient and family in walking rounds is what differentiates walking rounds from other forms of rounds. This allows the patient and family to hear what each team member is reporting and to ask questions.
• Measure success. To ensure effective rounds, conduct regular assessments. Data to be included in these assessments will be discussed later in this series.
The Leader and Members of Walking Rounds
Hospitalists typically lead walking rounds. This can be problematic if the hospitalists are not unit-based, but patient-centric. If it is not practical for the hospitalist to lead rounds, then another designee should be assigned. This can be a nurse leader, case manager, or other physician.
Best practice tells us that rounds are best conducted in the morning, either before or after new admissions have been processed. This way, discharges can be handled after rounds are over.
There are key team members who must always be included in rounds. Other team members can always be added to enhance the rounding process, but this group includes the minimum number of members who should be in attendance:
- staff nurse;
- case manager.
These same team members also can participate in the afternoon huddle as was discussed in the last issue.
The Focus of Rounds
The two primary elements of walking rounds include coordination of care and communication. All activities and outcomes associated with rounds stem from these two elements.
Care coordination includes patient care activities among and between the disciplines. It also includes a review of the patient’s current status and provides for an opportunity to discuss and clarify the patient’s goals and expected outcomes. Through the coordination process, the team can develop a comprehensive plan of care that includes the perspectives and expectations of each discipline.
Communication also is critical to effective rounds. The following are key elements in the communication process:
- reiterate the goals of rounds;
- identify any current or future safety risks;
- educate the patient and family on status and expectations;
- ensure that all team members share a consistent message.
Communication for Rounds
When conducting daily rounds, communication can make or break success. Communication is the foundation of productive and successful teamwork. Consider these points as they relate to communication in walking rounds:
• Clear: Each team member must be as clear as possible. Each discipline should refrain from using jargon and abbreviations so that all attendees can easily follow the discussion.
• Complete: All components related to the patient should be included as necessary and discussed in as much detail as needed. If an extensive discussion is warranted, it can continue once the rounding process is complete.
• Brief: While communication on rounds should be complete, it also should be brief and without more detail than is necessary.
• Timely: Timely communication takes on two forms. First, each patient should take between 60 and 90 seconds; at times, a specific patient may require more or less than these benchmarks. Next, the information provided should be timely. Issues related to the patient that have no bearing on the current admission or discharge plan need not be discussed.
Without effective communication, teamwork cannot exist. In fact, you cannot have one without the other. Let’s review some of the most important reasons why communication and teamwork are so interrelated:
1. Prevents errors. Errors can be reduced or prevented through close communication and teamwork. As the team is discussing each member’s plan of care, this will be the time that errors can be uncovered. These might include things that were overlooked, or overutilization or duplication of resources. It also can uncover conflicts in the plan that might result in negative outcomes.
2. Minimizes strain. One of the major dissatisfiers for clinical team members is finding a colleague when you need them and when they are available. Trying to grab people on the fly can cause stress and strain on the professional relationship and between the team members. Much of this can be avoided when the team has a structured discussion each morning as a group.
3. Builds trust. Lack of trust within a team can often be related to poor communication between and among the team members. When the team rounds together, communication is enhanced as each team member can hear the other professional point of view and thinking process.
4. Fosters team adaptability. If the team members do not know what the other plans and concerns may be, it is impossible to make adaptations and alterations. They also may be suspicious of changes made by another team member if the rationale is not well understood. Rounds can help alleviate these concerns through direct communication and discussion.
5. Strengthens the team. Communication is well understood to be a team builder. If all team members are united, the team is strengthened. The whole is greater than the sum of its parts.
6. Increases effectiveness. For all the reasons listed in this section, rounds can increase the effectiveness of the team as a whole as well as each team member’s performance. Healthcare has become a complex process. Outcomes are clearly affected positively by a team mentality and better cooperation.
Key Structural Points for Developing Rounds
The following key structural points must be in place as you begin to embark on the journey of putting a best practice rounding process in place. The development of rounds, or the re-engineering of existing rounds, should be undertaken as any change process would be. Without a structured process, the likelihood of success is greatly diminished.
The first point is the assignment of leadership. The leader of the rounding process should be designated and standard. This means that one person is always the leader, with the exception of the days when they are not at work. By keeping the leader standardized, you can better ensure that the rounds are conducted in the same way every day.
The leader should be well trained and educated on the rounds in terms of philosophy, process, and expected outcomes. He or she should be held responsible for rounds starting and ending on time and for the outcome metrics.
The leader can be from any discipline but must be someone who is committed to the success of the rounds. The leader most often is a physician. Hospitalists can be an excellent choice for leading rounds, as they are available and part of the in-patient team. However, if the hospitalists are not unit-based, this may make their role as the leader of the rounds almost impossible. They would not know all the patients on the unit they are leading and would not necessarily be available. This problem supports the argument for hospitalists to be unit-based whenever possible.
The second key structural point is the selection of the specific team participants from the interdisciplinary team. The standard members should include the physician, the staff nurse responsible for the patient, and the case manager.
The additional members should be appropriate to the unit’s clinical specialty and other issues of relevance to the clinical area. For example, it might be appropriate to have a clinical pharmacist round on units where polypharmacy issues may be a problem. Geriatric units may be a good location within which to include the clinical pharmacist.
Conversely, on orthopedic or neurology units, adding a physical therapist to the rounding team would be appropriate. The point is to review the specific clinical needs of the unit and staff the rounding team appropriately. Be cautious to not overstaff the team — the members should be manageable and be directly caring for the patients.
One exception might be a pastoral care representative. Pastoral care staff may be important to include on a hospice unit, cancer, or geriatric unit. They may not be engaged with every patient, but they will be able to appropriately select patients while listening on rounds. This allows them to have a proactive approach to identifying patients, rather than reactive.
Setting Daily Goals
Rounds provide an opportunity for the team to set daily goals for the patient. By following this process, the team can ensure that they are moving the patient toward his or her daily outcomes.
The team should provide daily feedback so that the goals can be refined and reset if needed. During rounds, the team may determine that some goals have been completed or additional goals are needed. There also should be an overarching goal for the patient’s stay that should be discussed daily on rounds.
Walking rounds provide the opportunity for the team to discuss the daily goals with the patient and the family. When patients and family members understand the goals of care, they are much more likely to be active participants in the recovery process.
One helpful strategy is to document the goals for the day on the whiteboard in the patient’s room. Anyone caring for the patient can see the goals, but even more importantly, the patient and family can see them.
Examples of daily goals include the following:
- wean off oxygen and blood pressure medications;
- get the patient up and walking;
- ensure the patient can eat;
- perform medication reconciliation and ensure everyone understands the treatment plan.
Strategies for Getting Started
One of the first things to consider is the need to leverage any existing rounding processes. As we have discussed, walking and bedside rounds should never be merged with nursing change of shift or teaching rounds. However, if your hospital already uses some form of rounding, that should be taken into consideration. Components of existing rounds can be used as a starting point and can possibly be enhanced. In this way, the team that rounds will feel that you are taking the best of their rounds and building on them, rather than completely throwing them away. This can be a positive way of engaging with the team you are planning on working with to get started.
When conducting a change process, seek out willing participants. They may be those units that already have some form of rounds. Or it may be a unit where there is a hospitalist who is schooled in rounds or who has experienced them at another hospital.
In addition to finding the right unit to start with, another key to ensuring greater success with your first unit is to start small and test often. Starting small means that it may be most beneficial for you to start with that one unit and perfect the processes there before you move on to additional units. Evaluate the steps in the rounding process often as you roll out the first unit. The team should be educated on all of the components before you actively begin the rounds. A specific focus on scripting, time management, or expected outcomes can be helpful in ensuring greater success.
Once you are confident that the team members are educated in the structure, process, and expected outcomes of rounds, you can begin to test out the rounds. For example, a tracking tool can be used to document the start and stop times. The information tracked should be discussed with the rounding team regularly so that feedback can be elicited and changes can be made in a timely manner where needed. The team should be encouraged to give constructive feedback so that they remain engaged in the change process.
Segmenting rounds refers to organizing which patients might be cohorted together. Typically, this should be based on the staff nurse’s assigned patients. In this way, the staff nurse is only required to participate in rounds for the time it takes to round on his or her assigned patients. On average, this should not be more than 10 minutes.
As with anything, there can be exceptions to this rule. If the unit includes a specialty area, it would be beneficial to segment those patients so that rounds can take place with the specialty physician. Some examples include heart failure, respiratory, or surgical specialties. While this type of segmenting can make the rounds structure more complicated to implement, it provides an opportunity for the other members of the team to work directly with the specialty physician. This can provide for much greater efficiency and communication.
In this section of our series on walking rounds, we discussed the steps you may need to take in order to implement new rounds or refine existing rounds. Next time, we will discuss scripting and strategies each discipline can use to prepare for, participate in, and conclude rounds.