Rounding for Outcomes
“What Can Florence
Teach Us About
Patient-Centered Care
Karen Cook, RN
Objectives
Articulate what is purposeful hourly rounding
Describe the behaviors needed to accomplish an
effective and purposeful hourly round and bedside
handover
List strategies to overcome the common barriers to
successful hourly rounding and bedside handover
Driving Performance
Patient-Centered Care Delivery Model
Hourly
Rounding
Bedside Shift
Report
Nursing and
Patient Care
Excellence
Individualized
Patient Care
Discharge
Phone Calls
What Do Staff “Think” About Hourly Rounds?
Scripts are fake
We don’t have time
This is about patient satisfaction
not quality
Patients get annoyed with us
checking on them every hour
Logs are stupid
Managers don’t care about us,
they just care about their dumb
reports to the Studer Group
What else?
Myth #1: Hourly Rounding Was
“Invented” By The Studer Group
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.
High Reliability Demands Simplicity
If we asked five front line staff this question – what
would we hear?
“What is hourly rounding and why do we do it?
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.
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
Myth #2: We Don’t Have Time
For Hourly Rounding
“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
Date:
Average call light response time
High
# of calls
Call Rate
25-Jul-12
1:21
3:34
20
26-Jul-12
2:16
5:55
24
6 calls/pt.
2-Aug-12
2:07
5:18
22
5.5 calls/pt.
3-Aug-12
3:15
7:23
17
4.35 calls/pt.
12-Aug-12
4:25
13:53
22
5.5 calls/pt.
14-Aug-12
1:09
3:18
15
3.0 calls/pt.
15-Aug-12
1:12
1:34
13
0.75 calls/pt.
21-Aug-12
1:15
3:18
10
2.0 calls/pt.
22-Aug-12
1:13
3:06
5
1 call/pt.
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
Staff is Already in the Room
0800
1600
0900
1700
1000
1800
1100
1900
1200
2000
1300
2100
1400
2200
1500
14
Myth #3: Hourly Rounding Is
Implemented To Improve Patient
Satisfaction
“The very first requirement in a hospital is that it
should do the sick no harm.”
“Notes on Nursing” Florence Nightingale 1854
Evidence-Based Quality
Responsiveness: Correlates to Quality
Responsiveness:
Correlates with Readmissions
Myth #4: Yup, We 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
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
GA HEN Hospitals Falls
GA HEN Hospitals HAPU
Correlate Tactic With Results (ROI)
Myth # 5
“We have to sign the logs or get
written up…we document in the
chart so the log is stupid.”
“How very little can be done under the spirit
of fear.”
“Notes on Nursing” Florence Nightingale 1854
Logs Are A Visual for FAMILIES and Patients
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
Nurse Leaders Round To Ensure Patients
“FEEL” Quality Care
Nurse leader rounding with targeted questions:
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?
Your Turn
Tell us about Hourly Rounding in YOUR hospital…
What is working well?
Where are there opportunities to improve Hourly
Rounding
Patient-Centered Care Delivery Model
Hourly
Rounding
Bedside Shift
Report
Nursing and
Patient Care
Excellence
Individualized
Patient Care
Discharge
Phone Calls
Myth #6: Scripting/Key Words
Make Us Sound Robotic
“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
Tell the Patient the “Why” of Hourly Rounding
“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?
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
Pause Before Leaving
“Is This Patient Safe?”
Care Boards are FOR the PATIENT
Your Turn
Tell us some examples of using key words in
YOUR hospital…
What is working well?
Where are there opportunities on your unit to use
key words to reduce anxiety?
Video Clip
Hourly rounding and care boards
What worked well
What are opportunities for improvement
Patient-Centered Care Delivery Model
Hourly
Rounding
Bedside Shift
Report
Nursing and
Patient Care
Excellence
Individualized
Patient Care
Discharge
Phone Calls
Myth # 7
Patients don’t like bedside shift
report
Apprehension, uncertainty, waiting,
expectation, fear of surprise, do a patient
more harm than any exertion.
“Notes on Nursing” Florence Nightingale 1854
Bedside Shift Report (Handover)
What is it?
Why is it
important?
The process of handing-over care delivery from one nurse to
another at change of shift at the patient bedside. This process
incorporates other concepts such as “managing up”, AIDET
communication, teamwork and creating a safe patient
environment. All necessary patient information is exchanged
in the patient room such as patient identifiers, safety checks,
medications, tests etc. This addresses basic patient rights by
keeping them patient informed and involved in their care. The
patient, and key caregiver/family members are INCLUDED in
the conversation as a partner in their care.
This process “transfers the trust” to the oncoming caregiver
and reduces patient anxiety. Through a real-time exchange
of information, the patient is involved in their care as well as
teamwork and accountability are strengthened with the caregiver team. It aligns with Magnet and Baldrige criteria and
National Patient Safety Goals
Bedside Handover Lessons
Reinforce the WHY, connect to safe patient care and to nurse
satisfaction
Address all barriers/resistance in training and ongoing in
huddles and other communication
Show what RIGHT looks like which includes engaging the
patient in their care – not just talking over their bed
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
Round on patients to confirm behaviors
Post results from rounding – thank you notes
Myth #8: We Do Bedside Handover
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
Other Ways to Validate
1. Directly observe the practice on the unit
2. Leader rounding on patients
 Verify bedside handover is occurring by asking
patients and their families
3. Leader rounding on staff
 Ask them what is working well
 Highlight a WIN during Huddles
4. Discharge phone calls or survey
5. RESULTS – especially nurse communication
Myth # 9: Management is in
charge of how we deliver care
“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
Myth #10: It won’t work on our unit
“I attribute my success to this - I never gave or took
any excuse.”
― Florence Nightingale
Thank Your For All YOU Do
“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