Presentation - Quality & Health

Report
Rounding for Outcomes
“What can Florence
teach us about
hardwiring Hourly
Rounding?”
Karen Cook, RN
Objectives
Articulate the difference between hourly rounding
and purposeful hourly rounding
Describe the behaviors needed to accomplish an
effective and purposeful hourly round
List strategies to overcome the common barriers to
successful hourly rounding
Hourly Rounding is Not New…
Throughout the night, she would move through the
dark hallways carrying a lamp while making her
rounds, checking on each patient and providing care
if needed. The soldiers were comforted by her
compassion, earning her the nickname, "The Lady
with the Lamp." Her care would forever change the
way hospitals treated patients. Most consider
Nightingale the founder of modern nursing.
Patient-Centered Care Delivery Model
Hourly
Rounding
Bedside Shift
Report
Nursing and
Patient Care
Excellence
Individualized
Patient Care
Discharge
Phone Calls
What is Hourly Rounding?
What is it?
 A plan to proactively interact with patients every hour during the day
using focused key words to assess needs (pain, position, personal
needs and patient education)
 A care model to return care to the bedside, truly patient-centered
 A plan to help achieve our goal to “always” deliver exceptional
clinical quality care in a safe and compassionate environment
Why do it?
 Evidence supports a decrease in patient anxiety, falls, skin
breakdown, and nursing steps as well increased patient satisfaction
 It allows nurses to provide more care at the bedside
 It reduces anxiety, worry and waiting
 It is just good patient care
 There is no other initiative that impacts the patient perception of
quality care as this ONE does.
Action Step #1
Randomly stop five front-line employees and ask
what is hourly rounding, why do we do it and what
do they think about it.
Are you proud of the response both in verbal and
nonverbal communication?
Do the employees connect to the WHY?
Ask them to go do a typical hourly round with you.
Round on the units and look for visual cues to
hourly rounding such as logs, trash on floor, bed
alarms/side rails, clutter, etc.
If you hear anything like this… you have
variance.
We are in the patient rooms all the time
Some of us are doing it but some are not
It doesn’t work on our unit… we are different
They don’t do it on evenings and nights
This “project” didn’t make our scores move… it does not
work
We “rolled it out” a long time ago, half the staff don’t even
know what it is
When can we take the logs down?
It’s just a bunch of paperwork for us and we already
document in the EMR
Action Step #2
Randomly ask at least five patients:
Tell me one of the questions that your care team
asks you when they come into do their hourly
rounds?
– We focus on meeting your needs, and with that in mind,
the staff are to be in the room every hour asking about
pain, position and bathroom needs. Has this been your
experience?
Have you had to use your call light to ask for pain
medicine in the last 24 hours?
Tell me what your nurse told you about our process
for hourly rounding on this unit?
If you hear anything like this… you have
variance.
They write something on the board over there
They stick their head in and ask if I need anything
They don’t do it on evenings and nights
They are too busy to be in here that much
I just call when I need them
I don’t REMEMBER
Connect to the WHY
If you hear anything like this… you have
variance.
Our manager told us we had to do it
They go around and check to see if the logs are
filled out – that is all they care about
There are times I have 6 patients, how am I
supposed to be in there every hour?
We have to report our compliance to the
corporate office, of course we are doing it
Eight Behaviors of Hourly Rounds – More
Than 3 P’s
Hourly Rounding Behavior
Expected Results
1.Use Opening Key words
Creates efficiency
“checkin’ on ya” won’t suffice
2. Accomplish scheduled tasks
Contributes to efficiency
3. Address 3 P’s (pain, potty, position)
Quality indicators – falls, decubitis, pain
management
4. Address additional comfort needs
Improved patient satisfaction on pain,
concern and caring, efficiency
5. Conduct environmental assessment and Contributes to efficiency, teamwork
ensure bed technology is correctly utilized
6. Ask “Is there anything else I can do for
you before I go, I have time?”
“Call me if you need me” decreases
efficiency.
Improves patient satisfaction on teamwork
and communication
7. Tell each patient when you will be back
Contributes to efficiency
8. Document the round
Quality and accountability
Most Common Reasons for Call Light Use
Time is Money
$36,660/yr
700 calls/wk=
46 hrs
One Call Light = 4 Minutes of Care Giver Time
Some do it very well…
“I am of certain convinced that the greatest heroes
are those who do their duty in the daily grind of
domestic affairs whilst the world whirls as a
maddening dreidel.”
“Notes on Nursing” Florence Nightingale 1854
Track By Low/Solid/High Performers
1:21
High
3:34
# of
calls
20
26-Jul-12
2:16
5:55
24
6
calls/pt.
2-Aug-12
2:07
5:18
6
1.5
calls/pt.
4
3-Aug-12
3:15
7:23
9
2.25
calls/pt.
3.5
4:25 13:53
10
2.5
calls/pt.
22
5.5
calls/pt.
Date:
25-Jul-12
12-Aug-12
14-Aug-12
Average call light
response time
1:09
3:18
Call
Rate
3
2.5
AVG Response
2
15-Aug-12
1:12
1:34
3
AVG Calls pr pt
0.75
calls/pt.
1.5
21-Aug-12
1:15
3:18
17
4.25
calls/pt.
1
22-Aug-12
1:13
3:06
23
4.6
calls/pt.
0.5
0
LOW
MIDDLE
HIGH
Action Step #3
Review your strategies for recognizing those staff
that do a great job with hourly rounding?
Can your managers say who their high performers
are with hourly rounding?
Have you shadowed them to see what they are
doing right?
Do you track call lights by staff members?
Do you highlight units that have improved in quality
metrics at public events like employee forums?
Everybody SAYS They Are Doing
Hourly Rounding
I think one's feelings waste themselves in words;
they ought all to be distilled into actions which bring
results.
“Notes on Nursing” Florence Nightingale 1854
Evidence-Based Quality
Do Our Words = Results?
88% of Georgia HEN Hospitals report they “ARE doing
hourly rounding”… but Georgia ranks 47th out of 50 states
in improvement in pain management
Georgia Hospitals
Responsiveness: Correlates to Quality
Responsiveness:
Correlates with Readmissions
Still A Priority…
“The very first requirement in a hospital is that it
should do the sick no harm.”
“Notes on Nursing” Florence Nightingale 1854
GA HEN Hospitals Falls
GA HEN Hospitals HAPU
Action Step #4
Standardize the process for tracking results:
Responsiveness, pain, nurse communication
Falls
HAPU
Reduced call lights
Where is this posted?
Can staff speak to the results?
What is the return on investment for improving?
Correlate Tactic With Results (ROI)
Action Step #5
“On this unit, one of our care
team members will be coming in
to see you every hour during the
day. You will see either me or
Jackie, our certified nurse
assistant. I have worked with
Jackie for two years and she is
excellent. We will be checking
on your comfort such as we will
make sure we are helping
manage any pain you might
have, help you change position,
help you to the bathroom and
make sure you have everything
you need.” We call this hourly
rounding and we do it to make
sure you are safe and we are
always meeting your needs.”
Have you standardized
the process of setting
expectations of hourly
rounding as part of
how you deliver care?
How do you know it
happens every time?
How do the staff
explain the logs to the
patient and family?
Hourly Rounding Reduces Anxiety
Apprehension, uncertainty, waiting,
expectation, fear of surprise, do a patient
more harm than any exertion.
“Notes on Nursing” Florence Nightingale 1854
Action Step #6
Are your logs a visual representation of your
quality to the patient/family?
Do they give you the information you need or are
they duplicative charting?
Rounding Log
Please place your initials in the corresponding time box after round has been complete. **Round is only complete if all 8 Key Behaviors have been done.**
6:00
7:00
8:00
9:00
10:00
11:00
12:00 13:00 14:00
15:00
16:00
17:00
22:0019:00 20:00 21:00 23:00
18:00
MM/DD/YY
Sunday
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Eight Key Behaviors:
1) Use opening key words
2) Perform scheduled tasks
3) Address the 5 P's-Pain, Potty, Position, Possesion, Plan of Care
4) Assess additional comfort needs
5) Conduct environmental assessment
6) Use closing key words and/or actions
7) Explain when you or others will return
8) Document the round on the log
Initials:
Signature:
Initials:
Signature:
Key:
S= Patient Sleeping
R = Patient in Radiology
E = Room Empty
OR = Patient in Surgery
P = Procedure in Process
CT = Patient in C.T. Department
PT = Phyisical Therapy
Initials:
Signature:
Initials:
Signature:
1:002:00
3:004:00
5:006:00
Action Step #7
How are you including the patient and the family in
discussions about hourly rounding
Safety
Patient-centered
Plan to be responsive if they find a need to use the
call light but goal is to not even have to use it
Be as SPECIFIC as possible to eliminate variance
and open door to misinterpretation
Key Words Are Not New Either…
“Always sit down when a sick person is
talking business with you, show no signs
of hurry, give complete attention and full
consideration… Always sit within view
so that when speaking to him, he does
not have to painfully turn his head
around in order to look at you. If you
make this act wearisome, you are doing
the patient harm. You cause harm also
by continuing to stand to you make him
continuously raise his eyes to see you.”
“Notes on Nursing” Florence Nightingale 1854
Our Goal is to Deliver Excellent Quality Care
Composite
Response Scale
Nurse courtesy and respect
Nurses listen carefully
Nurse explanations are clear
Doctor courtesy and respect
Doctors listen carefully
Doctor explanations are clear
ALWAYS1,
Did you need help in getting to bathroom? 2
Staff helped with bathroom needs
Call button answered
Yes No (screening question)
ALWAYS, Usually, Sometime, Never
ALWAYS, Usually, Sometime, Never
Pain Management
Did you need medicine for pain? 2
Pain well controlled
Staff helped patient with pain
Yes, No (screening question)
ALWAYS, Usually, Sometime, Never
ALWAYS, Usually, Sometime, Never
Communication of
Medications
Were you given any new meds? 2
Staff explained medicine
Staff clearly described side effects
Yes, No (screening question)
ALWAYS, Usually, Sometime, Never
ALWAYS, Usually, Sometime, Never
Did you go home, someone else’s home, or to
another facility? 2
Staff discussed help need after discharge
Written symptom/health info provided
Area around room kept quiet at night
Room and bathroom kept clean
Willingness to Recommend
Own home, Someone else’s home, Another facility (screening
question)
YES, No
YES, No
ALWAYS, Usually, Sometime, Never
ALWAYS, Usually, Sometime, Never
DEFINITELY YES, Probably Yes, Probably No, Definitely No
Hospital Rating Question
0 to 10 point scale (percent 9 and 10 reported)
Nursing Communication
Doctor Communication
Responsiveness of Staff
Discharge Information
Individual Question
1Response
2For
Question Summary
Usually, Sometime, Never
ALWAYS, Usually, Sometime, Never
ALWAYS, Usually, Sometime, Never
ALWAYS, Usually, Sometime, Never
ALWAYS, Usually, Sometime, Never
ALWAYS, Usually, Sometime, Never
used to calculate the question score is designated by capital letters
analysis purposes, it is important to know which areas have screening questions because the sample size will be lower than the other areas
Care Boards are FOR the PATIENT
WRITTEN Key Words
An important part of providing you with individualized care
and excellent service is hourly rounding. You will be visited
by one of your caregivers
EVERY HOUR from 8 a.m. to 10 p.m.
And
EVERY TWO HOURS from10 p.m. to 8 a.m.
During




this time we will be:
Checking on you and your well-being
Monitoring your comfort and pain
Helping you move and change positions
Attending to personal needs (such as assisting
you with toileting, bringing personal items within
reach, hygiene needs and anything else to make
you more comfortable)
Your caregivers also will make sure that you have easy
access to the:

Telephone, bedside table, water or other
beverages, and glasses

Urinal and/or bedpan and waste basket

Call light for assistance
What does this mean to YOU, your family and visitors?
It means that we are anticipating your personal needs and
monitoring your well-being on an active, hourly basis so that
your family and visitors can focus on your recovery.
You may receive a survey after you go home. We hope that
you will take the time to give us your feedback. We use
your feedback to recognize our staff and know how to
improve.
If you have any concerns, please notify
Immediately so we can address them.
HOUSTON NORTHWEST MEDICAL CENTER
Delivering Clinically Excellent Care
Coaching Tip: “Is This Patient Safe?”
A want of the habit of observing conditions and an
inveterate habit of taking averages are each of
them often equally misleading.
“Notes on Nursing” Florence Nightingale 1854
Training AND Validation
Skill labs can be used for training a skill or
validation of a skill.
You have to know the difference because the feedback
is framed differently
In Training skill labs, educators, content experts
and others can be used to give feedback.
In Validation skill labs, leaders are present to give
feedback and competency is checked.
Other Ways to Validate
1. Directly observe hourly rounding on the unit
2. Leader rounding on patients
 Verify hourly rounding is occurring by asking
patients and their families
3. Leader rounding on staff
 Ask them what is working well with HR
 Highlight a WIN during Huddles
4. Discharge phone calls or survey
5. RESULTS
Action Step #8
Do you have a plan for
caregivers to be validated
annually, just like TB skin
test?
Do you have a plan in place
to monitor those that choose
not to participate?
Are there clear
consequences for
optionality?
Inspect What You Expect
“Soft” validation does not work!
"Sara, I appreciate being able to shadow
you and validate your hourly rounding skills.
I think you did a great job. The only thing I
didn't hear was you using the closing key
words. I'll go ahead and check you off but
please be sure to do them next time."
Charge Nurse Role
“To be "in charge" is certainly not only to carry out the
proper measures yourself but to see that every one
else does so too; to see that no one either willfully or
ignorantly thwarts or prevents such measures. It is
neither to do everything yourself nor to appoint a
number of people to each duty, but to ensure that
each does that duty to which he is appointed.”
“Notes on Nursing” Florence Nightingale 1854
Action Step #9
Have you trained and validated all the charge
nurses on hourly rounding?
Are they clear on their authority to coach on
standardization of behaviors?
Are they the right person to support the culture of
effective hourly rounding?
How do you hear about the “wins” from hourly
rounding? And do you take as much time to
recognize them as you do gaps in performance?
Manager, Director and CNO Role
“Let whoever is in charge keep this simple question
in her head (not, how can I always do this right thing
myself, but) how can I provide for this right thing to
be always done?”
“Notes on Nursing” Florence Nightingale 1854
Sample Accountability Tools
“I attribute my success to this - I never gave or took
any excuse.”
― Florence Nightingale
Summary - Lessons Learned
Success is dependent on leadership
Reinforce the WHY, connect to safe patient care
Train and validate all staff
Reward top performance and coach opportunities
Track impact and communicate results
• Patient satisfaction by unit and HCAHPS
– Nurse communication, pain, responsiveness
• Falls, pressure ulcers, and other core measures
• Call lights
• Audit the rounding logs
Round on patients to confirm behaviors
Post results from rounding – thank you notes
Communicate results in Supervisory Monthly Meeting
“Were there none who were discontented with
what they have, the world would never reach
anything better.”― Florence Nightingale, Notes on Nursing: What It Is, and What It
Is Not

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