Concerned about the rise in workplace violence across the United States, administrators at St. Louis-based SSM Health decided they needed to look for new solutions to the problem in their network of hospitals. What they came up with was a cultural shift of sorts that they refer to as “purposeful rounding,” a concept based on the idea that if security personnel are more integrated into the care team, there is a better chance of de-escalating behaviors so situations do not turn into major disruptions or violent acts.
First implemented in several hospitals in the summer of 2018, the health system has found that the approach has nurtured closer bonds and communications between security personnel and clinicians. In turn, this is making a difference in the number of incidents involving disruptive patient calls. Indeed, at one hospital, data show that the number of such calls to security was cut by half following implementation of the new approach.
Security personnel anticipate that there will be more fine-tuning in the months and years ahead. Still, they also believe they have hit on a winning solution that they can use without the need for big investments in added staff or technology.
The concept behind purposeful rounding grew out of a systemwide rapid improvement event, a tool SSM Health uses regularly to identify solutions to reduce waste, improve efficiency, and problem-solve, explains Todd Miller, CPP, regional public safety and security specialist for SSM Health.
“One of the more concerning issues that we have had for healthcare security nationwide is a rising trend for workplace violence, especially in high-risk departments [such as] the ED, behavioral health, and mother and baby units,” he says.
Consequently, in June 2017, SSM Health focused the rapid improvement process on finding new ways to reduce incidents of workplace violence more effectively. “All four of our states [Illinois, Oklahoma, Missouri, Wisconsin] were represented [at the event]. We had ED directors, behavioral health directors, and security leadership involved, as well as executive leadership,” Miller recalls. Purposeful rounding was one of the more promising ideas that emerged from this process.
Purposeful rounding is designed to identify troubling or potentially disruptive behaviors before they begin to escalate. This way, appropriate resources can align to prevent tempers or high emotions from potentially turning into something worse, Miller explains.
Considering security officers already round through high-risk areas to increase visibility and promote a law enforcement presence, purposeful rounding involves adding another layer to that process. Essentially, the role of the officer evolves so that he or she becomes another member of the care team, Miller observes.
“The expectation now is to work with the clinical staff and work with the team to communicate observations ... and even build a positive rapport with patients if it is appropriate,” he says. “It really revolves around having a more proactive approach and intervening before [a violent incident] occurs rather than traditionally being reactive where once someone is injured, security is called.”
Begin With Education
Implementing purposeful rounding involves first providing a sound base of education about de-escalation and recognizing behavioral indicators before a physically violent act occurs. “This includes doing live, scenario-based education with nursing staff and actors to try to create a team environment that allows [security personnel and clinicians] to train together and work together naturally,” Miller says. “The first time an officer and a nurse interact isn’t in a crisis; it is in training and understanding how they work together and have a more natural communication.”
Part of this educational phase involves learning how to use more facets of the rapport-building aspects of Crisis Prevention Institute training, a widely used methodology with which most healthcare personnel and security personnel are at least somewhat familiar. (Learn more about this training online at: https://bit.ly/2kxm9bk.)
This education and practice equips security personnel with the skills to effectively communicate with clinical staff as they are rounding, Miller explains. This is especially important when it comes to sharing observations about potentially troubling behaviors in patients or visitors.
“There is a constant stream of actionable information back to not only the department during a shift, but also for oncoming shifts so that they can align resources ahead of time, intervene if needed, build rapport if needed, and show an extra presence on the floor instead of being reactive once an incident occurs,” Miller shares. “Having a constant feedback loop of communication between nursing and security is the biggest part of purposeful rounding.”
In fact, Miller says that of all the units, security personnel are probably closest to the ED in terms of building a positive line of communication. While building a good rapport with clinicians is central to the concept of purposeful rounding, there are times when it is essential for security personnel to take an extra step with patients or visitors.
“Building a rapport with a high-risk patient before the patient escalates is a big deal,” Miller offers. “It is an attempt, at the very least, to initiate a positive interaction with the patient ... so that should [the patient] escalate, it is not just a uniform coming in after a crisis has started; it is Officer Jones who the patient met earlier.”
Another part of the cooperation between clinical and security leaders concerns determining when extra resources or more frequent security rounding is needed in a department. “It is based more on acuity [in a security sense, meaning higher risk] and is at the discretion of the clinical leaders,” Miller notes.
“If the ED is high-acuity or there are a lot of behavioral health patients or the nursing staff has been feeling that a greater security presence is needed, it is up to that shift leader or that director to say what is appropriate for that shift.”
Usually, such decisions are made in concert with a security shift supervisor and are the result of the strong bilateral communication that the purposeful rounding approach encourages, Miller adds. Such an approach helps to ensure that resources go where they are needed most. “What we didn’t want to do is use up resources in areas where the acuity [or risk] is low or where there are only a few patients,” Miller adds.
Kate Madden, BSN, RN-C, team leader for the neonatal ICU at Cardinal Glennon Children’s Hospital (part of SSM Health), notes that the implementation of purposeful rounding has been a welcome change for her staff.
“Our security team always had a great presence. They were immediately available, and we had a good relationship with them, but we were definitely in a reactive mode,” she explains. “That was the biggest shift, going from a reactive mode with a problem focus to being proactive and developing relationships.”
Prior to implementation, security staff provided Madden with information about purposeful rounding and what it would involve. She passed that information to staff during huddles and through a weekly newsletter. “Security officers then layered in what they were trying to do with the families [in the unit], but they also did that piece with the staff,” she says. “Having [the security officers] speaking with families and making friends and building relationships — that was very welcome because people were interested in having them around a little bit more.”
Now, rather than just rounding through the 65-bed unit, security officers will engage in conversation with staff nurses and ask them about any security concerns or anyone in the department who may need extra attention. For instance, it is not uncommon for parents under stress to pace or raise their voices. Sometimes, people will level accusations or start arguments with staff, Madden says. She recalls one couple that was under great stress because of their sick baby. They started bickering. “They were in a good relationship, but they had financial woes and then a sick baby as well,” Madden says. “They were missing work, they were worried about their jobs, and you can imagine how extremely stressed they felt.”
A security officer who had observed the bickering made an effort to get to know the couple. “In speaking to them and in proactively building a relationship, he was able to help them tap into some support services,” Madden recalls.
These were services that the nursing staff had told the couple about. However, because the security officer knew the couple and had been proactively supportive, he drew attention to the fact that they had been bickering. The officer indicated he was worried about them, Madden relates. Thus, she believes the information about the support services was received in a different way, helping defuse the tension and potentially preventing the couple’s bickering from turning physical.
In other instances, the security officer has passed helpful observations on to the nursing staff so they can take steps to intervene. “In building a relationship with one mom, the officer noticed a change and felt like she was escalating,” recalls Madden of one recent situation.
The officer told the staff nurse that he thought the woman was upset, so the nurse helped the woman talk through her feelings, Madden says.
“I think the mom was trying to put up too brave of a front and maybe let her guard down with the security officer instead of the nurse,” she says.
Madden explains that one of the things that has to happen for a person to de-escalate is for a “break” to occur.
“The goal of de-escalation is to control that break, for it to be a relief instead of a traumatic break,” she shares. “We want to give people a controlled break, a supported break.”
It is helpful for both security and nursing personnel to receive training in de-escalation techniques so that everybody knows what escalated behavior looks like and what they can do to provide that break before the behavior becomes unpleasant, scary, or dangerous.
“Just ‘unpleasant’ is stressful for families, too,” Madden adds. “No one wants to act like that, and we can really help people not to do that.”
So far, hospital administrators are encouraged by the results of the purposeful rounding initiative. One of the first hospitals to implement the approach found that “disruptive patient” calls to security declined dramatically after the procedure change.
“They did a four-month average before we started the purposeful rounding process. They had an average of 34.16 calls per month before purposeful rounding,” reports Miller, noting he is not permitted to reveal the specific hospital involved. Immediately following implementation of purposeful rounding, the average number of calls per month dropped to 15.75 for a similar four-month period.
“Something that dramatic shows that it wasn’t a fluke,” Miller says. “We’re excited. We’re positively encouraged that what we are doing has value or else we wouldn’t be doing it.”
Indeed, the implementation of purposeful rounding is now a systemwide initiative for SSM Health, including more than 20 hospitals in four states. Further, Miller notes that he is in the process of instituting a robust data collection process to understand the initiative’s results going forward, along with any tweaks and refinements to the process.
“We are so new to it right now, and we are being very deliberate,” he says. “I am looking forward to seeing the initiative evolve as we see what works and what can be improved upon, like any continuing process-improvement program.”
For other hospital or ED administrators intrigued by purposeful rounding and interested in pursuing a similar approach in their own settings, Miller advises them to clearly define the process they intend to put in place first and then track that process until it becomes standard practice. “Like any new process, you go through a period of fearing the unknown and fearing change,” he says. “However, once the infrastructure is put in place and staff can see the value, it gets easier.”
Further, Miller stresses that it is critical that both sides of the equation understand the importance of the purposeful rounding process.
“If one side is putting themselves out there to communicate more, it needs to be supported by the other side,” he advises. “If security personnel are taking the time to reach out to ED leadership, they need to be supported and feel like what they are doing has value or the program will die on the vine.”