Communication is one of the most important aspects of the healthcare experience. This is true for the patient, but it also holds for the staff. The better the communication, the smoother the process — and the more lacking the communication, the more frustrating the process.
Multidisciplinary rounds (also called interdisciplinary rounds at some organizations) should center on positive communications that keep processes running smoothly.
“The purpose of rounds is to be with the different disciplines — including case management, respiratory, physical therapy, nursing, physicians — to discuss the plan of care and ensure that everyone is on the same page,” explains Jill Rogers, vice president of performance improvement for Kaufman Hall.
During this time of collaboration — which is most effective when it takes place every morning for every patient — providers meet to talk through the patient’s plan, anticipated discharge date, and any barriers.
“Without rounds, case management is busy working on discharge planning while nursing is caring for the patient, both likely with different ideas on the patient’s plan of care,” Rogers explains. “In the meantime, the family may be getting mixed messages, which makes it difficult for them to coordinate their lives to plan for the discharge of their family member.”
When rounds are conducted well, everyone has a chance to see the big picture at least once a day. “We’ve become very task-oriented in nursing with all of the documentation, and sometimes we’re not looking at the big picture of a medical plan,” she says. “During multidisciplinary rounds, everyone has something different to contribute.”
Rogers shares an example of what could happen without that daily communication: “The case manager may talk to the patient and family and find that the patient was independent at home, so the plan is set for them to go back home. But if they don’t see that patient every day or there is little to no daily communication with nursing, a change in the patient’s condition may arise that the case manager is not aware of. There may be a plan for the patient to go home — but just before discharge, nursing says that they tried to get the patient out of bed but it took two nurses and physical therapy was just consulted. Now, you have to look at finding a skilled nursing facility at the last minute (which may require an insurance authorization). If there were multidisciplinary rounds, collaborative communication would be ongoing, and these surprises would be minimized or averted altogether.”
Situations like this might seem minor, but they can easily add on a day to a day and a half to a patient’s length of stay. For patients and their families, even hours added on to the stay can cause dissatisfaction.
“We may have the best-laid discharge plans, but if the case manager doesn’t know the events that happened overnight, such as a patient fall or change in their medical condition, the discharge plan can be completely disrupted,” Rogers explains.
Sometimes, nothing has changed for the patient, but a roadblock arises. For example, a patient might need a central or PICC line inserted to be discharged with IV antibiotics, but they are bumped off the schedule. This is the only piece holding up the patient’s discharge. Knowing about this early enough gives the care team some flexibility.
“If barriers are communicated with the multidisciplinary team early in the day, we can ask, ‘Can we get into the schedule?’” Rogers says. “Normally, we can work those types of barriers out because everyone understands the urgency of getting patients discharged on time, especially if there are patients in the ED on gurneys. If the patient just needs a line or something gets missed, sometimes we have a chance to get those things worked out, especially when in communication with the physician.”
One of the biggest advantages to rounds is the increase in the ever-important communication and collaboration of the care team — but only if managed right.
Rogers reiterates that for multidisciplinary rounds to be worth the time and effort, they need to be performed well. That means rounds should be scripted, focused, and timely.
“Following a script helps keep everyone on track and prevents the team from forgetting to discuss the basics,” she explains. “You need a quality control process put into place to monitor the rounds from time to time to make sure the team is on script and the purpose and outcome is what you’re working to achieve.”
Rogers suggests “sustain[ing] the rounds in the manner in which they were implemented or intended to be” and preparing a script for what the team should cover in as brief a time as possible. The script should normally include questions such as:
- Is the patient eating?
- Is the patient ambulatory?
- Is the patient at baseline function?
- Is the patient’s bowel function normal?
- Is the patient still on track for a certain discharge date?
According to Rogers, staying on script is one way to keep on task during the rounds and ensure pertinent information is not falling through the cracks. Similarly, the talk should focus on patients for the full amount of time, ensuring no conversation becomes too lengthy or goes off-topic.
“If we’re just getting together to chat and we’re not focused, the rounds just get really long and we’re getting into a conversation that needs to be taken offline,” says Rogers. “The team needs to stay on track so that attendees can get back to work. The round leadership needs to steer the conversation back on track. Ultimately, if the rounds start to take too long or aren’t focused, people will stop coming to them.”
Another way to help the team stay on task is to designate someone to assign action items and follow-up. This helps avoid wasting time discussing something that has already been managed or completed.
“You must have a way to close the loop to ensure that the action items you talked about today actually get done,” Rogers says. “You don’t want to be talking about the same thing the next day. If the team leadership can quickly touch base in the afternoon, it can prevent situations like, ‘Oh, the order didn’t get put in for the COVID test that we need before discharging to skilled nursing, so the patient will have to be discharged tomorrow instead of this afternoon.’”
Staying focused during rounds also helps prevent the unnecessary “extras” that sometimes happen during an inpatient admission. Rogers describes how a patient who might be due or overdue for a test or procedure, like a colonoscopy, might end up getting scheduled for it because they’re “in the hospital anyway.” She noted rounds often help providers avoid adding these extras that can be performed on an outpatient basis rather than lengthening the stay. Focusing on why a particular patient is in the hospital, and discussing that with the interdisciplinary team, can keep patients on track for discharge.
Since the discharge process often begins the day of admission, it makes sense that barriers and psychosocial issues would be included in the discussion on day one, rather than the day of discharge.
As for the rounds themselves, keeping these short and to the point makes it more likely that everyone will be motivated to attend. Beginning rounds earlier in the morning, closer to 8 a.m., is best practice to stay on schedule and be ready for any last-minute challenges.
“Once you start getting toward 11:30 a.m. or later, it can be difficult to get anything done to expedite getting that patient discharged, like checking a lab one more time,” Rogers says. “It’s quite difficult to complete those tasks if rounds are late in the afternoon. There’s just not enough time.”
To encourage other disciplines to attend rounds, it is important that meetings are succinct and quick — perhaps one to two minutes per patient, maximum — so everyone can get back to work. With 20 patients on a unit, it should be possible to complete rounds within about 30 minutes since patients who are going to be discharged will not require a full discussion.
The Tangible Benefits
The benefits of multidisciplinary rounds do not end with improved communication and collaboration. The real, tangible results include shorter length of stay, greater patient and family satisfaction, and consistency of care. In some cases, hospital readmissions are reduced. In almost all cases, this results in a smoother discharge process.
“Rounds allow everyone to better plan for the discharge,” Rogers shares. “It allows the family time to go out and look at facilities and decide where they really want to have their loved one in skilled nursing. Or, it can help them coordinate work schedules for pickup at the hospital.”
Rogers also notes multidisciplinary rounds can bring patients and their families up to date on the care plan. If communication is clear and consistent, there is less chance of confusion.
Likewise, excellent communication with the attending physician ensures the case management team is familiar with the care plan. Since case management’s role is not to create the plan, but to help remove implementation barriers, it is imperative to set aside time for this discussion.
“From an insurance perspective, having a discharge plan and discussing it with the physician helps case managers behind the scenes, especially when insurance may affect the care plan, what’s covered, and more,” Rogers says. “Better decisions can be made once we have determined the patient’s level of functioning and the physician has given the plan. Then, we can start having conversations with the patient that consider what insurance is going to pay for. It might affect where they go for six weeks of antibiotics treatment, for example, or we might decide it is better for them to go home to handle the antibiotics themselves or have a family member do it.”
When case managers are trying to plan their day and make the most of their hours, meetings might not top the to-do list. However, case managers cannot afford not to round, precisely because rounds help them prioritize their day and determine the next best step.
“Sometimes we ask, ‘Where do I begin when I have a lot of patients?’” she says. “As we’re talking through a medical plan and discussing patients, it becomes clear who and how we can discharge in the next 24 to 48 hours. Then, we can prioritize those patients who are getting close to discharge. This can help even when we’re completely overwhelmed, or people are out and the department is figuring out how to prioritize the day.”