Rounds help keep the treatment team on task
Daily meetings improve efficiency
At Mercy Medical Center in Canton, OH, multidisciplinary rounds have helped improve patient throughput and given the staff a sense of accountability, says Barbara Yingling, RN, BSN, MAed, Mercy Medical Center’s vice president of patient care services and chief nursing officer.
The hospital began organizing its multidisciplinary rounds in the summer of 2013 with the help of a consultant.
At the time, the hospital already had safety huddle rounds on the nursing units as well as hospitalwide safety huddles every morning at 8:30 attended by representatives from every department in the hospital.
"Most of the staff was accustomed to attending some kind of rounds every day, which made it easier to roll out the multidisciplinary rounds," she says.
At the time the hospital established multidisciplinary rounds, the case management department was undergoing a redesign aimed at extending the hours of coverage during the day and initiating weekend coverage, Yingling says.
A multidisciplinary committee designed the format for the rounds with input from representatives from all the units and departments involved. They established the expectations for the rounds, created a script, and developed tools to use, including a checklist that keeps rounds participants on task, and a tool for the management team to use when they audit the rounds to make sure the staff are covering all the bases, she says.
Members of the committee worked with the nursing education staff and the nursing director to educate all of the units on the multidisciplinary rounds process, she says.
"We educated the staff to be efficient with their time and for each individual to have their part of the round organized and ready to go," she says.
The team also met with the medical staff executive committee to inform them about the rounds and why they were being held. "We told them the goal is to cut down on the number of pages and telephone calls the physicians receive and to move patients faster and safely through the continuum of care," she says.
The rounds are held daily on each nursing inpatient unit. The time for the rounds, who attends, and who leads the rounds varies by unit. For instance, the intensive care unit (ICU) rounds are at 10 a.m. each day and last about an hour. The rounds are physician-led and attended by representatives from every discipline that cares for patients in the ICU along with pharmacy.
Participants in the rounds include nursing, case management, social work, nutritional services, and pharmacists. Representatives from occupational therapy and physical therapy participate in rounds on the orthopedic unit and others as needed. "We sometimes pull in other disciplines that are not routinely involved if we need them to discuss a particular patient," she says.
Currently, nursing leads the rounds. The goal is to have case management lead the rounds in the future when the new case managers brought on board when the department was redesigned learn their other duties and responsibilities, Yingling says.
The team goes over the plan for the day for each patient, anticipated length of stay, and what has to happen before the patient is discharged, she says.
"One challenge is getting physicians, especially the hospitalists, to attend. It’s not that they don’t want to participate. It’s that they don’t have the time. The hospitalists see patients all over the hospital, and there is no way they can juggle their time to attend rounds on every unit," Yingling says. When physicians can’t attend, the RN case managers and charge nurses contact them before the rounds to get their input and report back to them on what the team discussed about their patients.
The hospital also set up a process for the management team to attend the rounds and make sure the rounds meet all the expectations set out when the rounds were established, such as using the checklist and staying on the subject. The hospital’s Six Sigma team coordinates the audits and assigns Yingling and the other nursing directors to attend rounds on three to four units each month.
All of the RN case managers in the hospital meet every Wednesday for long-length-of-stay rounds, targeting patients who have been in the hospital for more than five days. "They discuss every patient, their barriers to being discharged, and brainstorm on what has to be done to move the patient along," she says.
The hospital has continued the housewide safety huddles. As chief nursing officer, Yingling attends along with the chief executive officer, chief operating officer, chief medical officer, and representatives from each unit and every department in the hospital. The team goes over a variety of safety issues, such as which patients are in restraints, which ones require a sitter, and why. They discuss "good catches," such as when a pharmacist noted an improper dose of medication ordered, and talk about anything that needs to be fixed. For instance, if there is a work order for a repair and it hasn’t been completed, a representative from maintenance is in the huddle and can look into it.
"If there is a length-of-stay issue or another case management issue, the case managers bring it up. The safety rounds go hand-in-hand with multidisciplinary rounds and give everyone a sense of accountability," she says.
As part of the redesign, the hospital increased the case management FTEs to expand the hours of coverage, she says. RN case managers are assigned to every unit and are available from 8 a.m. to 4:30 p.m. Two RN case managers work the same hours on Saturday and Sunday. Social workers work the same hours during the week. One social worker is on duty on weekends from 8 a.m. to 4:30 p.m.
Emergency department navigators/case managers are trained to cover inpatient case management issues as needed. Their hours of coverage are from 7 a.m. to 1 a.m. Monday through Friday and noon to midnight Saturday and Sunday. Their main priorities are placement of behavioral health patients, referrals to nursing facility, and insurance reviews, according to Yingling.
The hospital added the new role of case management assistant to help the RN case managers and social workers with faxing and clerical tasks and brought a new case management director on board, she says.
"We also identified which case managers would work best on which units and reassigned some of the staff. The new hours of coverage by case management and the multidisciplinary rounds have paid off for the department," Yingling says.