Patient-Centered Care
Establishing Patient-Centered
Physician and Nurse Bedside Rounding
By Curtis M. Rimmerman, MD, MBA, CPE
In this article…
Cleveland Clinic launches a pilot rounding project
to improve patient care and physician/nurse
communication.
Cleveland Clinic, similar to most acute care hospitals
across the country, possesses high patient acuity and complexity requiring a multidisciplinary team effort to satisfactorily
address patient care needs and acute health care problems.
This is not solely comprised of the principal physician and physician consultants but extends to many care
providers including, but not limited to, nursing, transport,
phlebotomy, radiology, procedural and operating room personnel, environmental services, dietary, physical and occupational therapy, social services, and case management.
Coordination of these efforts is no easy task, and identifying a singular person in charge, while typically the principal physician, can be difficult depending upon the specific
patient needs.
We as a group have long recognized the opportunity
to improve patient care coordination at the bedside and
recently developed a pilot project of physician and bedside
nurse rounding that now has become hardwired on the
inpatient clinical cardiology service.
Challenges
The clinical cardiology service at the Cleveland Clinic
Heart and Vascular Institute is led by an attending staff physician who is assisted by at least two medical residents, two
medical interns and one or two medical students.
The patient census is limited to 20, and the patients are
characterized as acutely ill with many undergoing complex
procedures. Given the resident work-hour rules coupled
with being on-call in the hospital overnight, the residents
internally cross cover for each other.
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This creates added complexity for the nursing staff
when attempting to identify which house staff to notify
should a clinical question or concern arise, creating patient
care delays with the nursing staff spending valuable time on
the phone instead of at the bedside caring for their patients.
Communication can be fragmented with the default
instrument being the electronic health record. Although the
electronic health record is an outstanding advancement and
fully utilized at our medical center, when used as the sole
means of communication, inherent delays are present.
Additionally, nurse turnover for an individual patient
can be high given flexible scheduling, weekends and holidays, plus nursing patient assignments vary from day to day,
depending upon patient acuity.
A nurse caring for four patients may well have those
patients located in a noncontiguous area on the hospital
ward, purposefully divided by acuity as a best attempt to
create a balance of workload and responsibility among the
nurses. This often requires the nurses to care for patients
at a considerable distance from each other, given the size of
our hospital wards.
Impetus for change
Objectively, the bedside nursing staff spends more
time with a hospitalized patient and their family compared
to any other member of the health care team. In many
respects, they know the patient better by virtue of their
time spent and reflect an invaluable source of clinical
information with respect to:
• Patient progress
• Personal needs
• Skin wounds
• IV status
• Activity level
• Nutritional status
• Independent ambulation
capabilities
Nursing is in a position of strength by virtue of its continuity of care.
• Emotional concerns and family
dynamics
approach reflecting a concerted team
effort was the optimal direction for
our medical center. As we conceived
this pilot project, we recognized that
the physician may spend approximately 45 minutes at the bedside on
the day of hospital admission with
subsequent days encompassing at
most 30 minutes and often less.
This was a small percentage of the
patient’s day and overall hospital stay
and certainly a shorter total duration
compared to the bedside nurse. In our
mind, objectively semi-quantifying
the clinical time spent at the patient’s
bedside reinforced the importance of
bedside nursing as an even more valuable patient care resource.
We also soon realized through
establishing a joint physician nursing
bedside rounding program, we would
achieve a daily opportunity to mutu-
Nursing is in a position of
strength by virtue of its continuity
of care, be it for a continuous period
of one day or even more of an impact
when spanning consecutive days. A
mutual trust between the patient
and nurse can develop, creating an
environment for potential greater
information transfer from the patient
to the bedside nurse.
We further brainstormed about
how to positively impact our Hospital
Consumer Assessment of Healthcare
Providers and Systems (HCAHPS)
scores, especially in the domain of
nurse and physician patient communication.
We collectively decided that a
consistent multidisciplinary bedside
ally strategize and communicate
the plan and goals of care to the
patient and family with the principal
physician, house staff and bedside
nurse all present.
Should an additional issue arise
such as post-discharge disposition (e.g.,
skilled nursing facility versus home),
the case management team would be
contacted and join us for rounds on
that particular day. Other disciplines
including consulting physicians could
also be invited with a coordinated
timed visit arranged in advance.
Program essentials
• Engagement and commitment of
hospital leadership—The success
of this type of program requires a
cultural change and the full support of hospital leadership. As
the program evolves, the bedside
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Our nurses are spending more time at the bedside and
less time on the phone.
nurse gains both comfort and
confidence, offering patient care
suggestions to the principal physician in the presence of the patient.
In effect, the physician/nurse team
is a “pilot and copilot” equivalent
with this paradigm necessitating
acceptance at the highest hospital
levels for the program to succeed.
• Engagement and commitment of
nursing leadership—Through our
initial experience, our impression
is that nurses desire a larger voice
regarding the course of care for
their patients. They welcomed this
coordinated approach to patient
care. In our case, this has succeeded as we have had nursing
champions at the local hospital
ward level such as the nurse manager and assistant nurse managers endorse this program, leading
by example and regularly joining
rounds, establishing this program
as an expectation of new hires
and an expectation of established
nurses to serve as programmatic
role models.
• Engagement of the attending staff
physicians—This has been my role as
program champion, to communicate
the reasons behind bringing a joint
rounding process to the bedside. It
has been exceedingly well-received,
and any slow adopters have been
“accelerated” by the enthusiasm and
commitment of the nursing staff.
• Engagement of bedside nursing—
Our bedside registered nurses
have demonstrated great enthusiasm for this program. This has
been the most satisfying aspect
of this program as it has “closed
ranks” between the nursing and
physician groups, with nurses
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much more engaged in the plan
and goals for care for each of
their patients.
Program structure
At Cleveland Clinic, all bedside
registered nurses carry a personal
internal phone with a five-digit
extension. By 7 a.m. each day, an
assistant nurse manager prepares a
list of patient rooms and the name
and extension of the registered nurse
assigned to each patient.
When the clinical cardiology
team begins rounds, the registered
nurse is contacted and meets our
team promptly at the bedside provided she is not attending to an acute
patient care need. Often, a hallway
conversation ensues regarding the
patient’s clinical status over the past
24 hours.
Observations and input from the
registered nurse are sought, and a
preliminary joint plan prior to entering the patient’s room is developed.
We enter the patient’s room as a
team, continue our conversation with
the patient and family, and address
all patient care needs at that time.
We answer any questions that
may arise and demonstrate to the
patient and family that the clinical cardiology service is a collaborative team
approach between the attending staff
physician and the registered nurse.
Once we have completed our
evaluation and discussion with the
patient, we leave the room and ask
the bedside registered nurse to call
the next nurse on our list assigned to
our next patient. This sequence continues and is not completed until our
patient rounding is concluded.
Program benefits
This program was quickly adopted by both physicians and nurses, and
its success has exceeded our expectations. It has reflected a favorable
cultural shift and now represents
how we conduct our bedside rounds
on our clinical cardiology patients.
Specifically, the following benefits
have been observed:
• Coordinated care at the bedside—
A singular joint message regarding the plan and goals of care is
communicated to the patient and
family with clarity and uniformity,
minimizing confusion between
the physician and nursing team.
This is a jointly derived plan of
care where nursing input is sought
and received. Questions are also
jointly addressed, and the patient’s
anticipated schedule for the day
is delineated. Participation of the
patient and the patient’s family is
sought and encouraged.
• Nursing empowerment—Physicians
are now viewed as more approachable, and the nursing staff more
readily offers its input. They are
less afraid to “be wrong” and
instead have uniformly embraced
this program via a formal blinded
internal survey of participating
nurses put forth and concluded by
our office of patient experience.
• Improved patient care—The continuum of care has been accelerated. For instance, should IV
access be problematic, a joint
plan is developed. Inflamed IVs
are identified and changed, skin
breakdown is addressed more
quickly, and potential sources of
infection such as central lines and
Foley catheters are removed more
promptly. Activity levels, when
possible, are accelerated and posthospital disposition is addressed
earlier in the hospital stay, especially when a skilled nursing or
acute rehabilitation facility is a
likely possibility. Although too
early to fully assess, we anticipate a favorable reduction of inhospital complications and length
of stay. We also expect our patient
satisfaction to improve with fewer
formal complaints.
• Fewer phone calls—Since the plan
of care is communicated in a coordinated manner at the bedside,
less confusion results and fewer
phone calls between the nursing
and physician staff are required.
Our nurses are spending more
time at the bedside and less time
on the phone.
• Collateral benefit—Other cardiovascular medicine services such
as the section of heart failure and
cardiac transplantation are starting to see the program benefit
even though it has not been formally started in their area. The
nurses are arriving at the bedside
for rounds and are more readily
sharing their opinions. Although
anecdotal, this appears to be
real and should ease the roll-out
to other disciplines within our
department. Additional areas such
as the neurological institute are
taking notice and are planning to
adopt a similar program.
• HCAPS scores—Since program initiation, we have observed a significant improvement in our scores,
especially those pertaining to
nursing and physician communication. Although other initiatives
may also be contributing to this
positive development, the consensus is that physician and nursing
bedside rounding is making a substantive impact.
• Nursing retention—Although yet
to be proven, it is our hope that an
empowered nursing staff reflects
collectively higher job satisfaction
and increased nurse retention.
Program limitations
Sustained support and prioritization by hospital, physician and
nursing leadership is vital for success. Establishing and maintaining a
bedside physician and nurse rounding
program reflects a cultural shift for
many programs, and without continued champions at many levels the
program will not sustain itself.
Communicating program benefits and sharing improved HCAPS
scores will serve to sustain the program. Bedside registered nurses may
not be available at the time of rounds.
Other patient care needs can interfere with their availability.
In our experience, this occurs
in a minority of circumstances. The
program requires a daily list of the
patients and the nursing phone numbers. Without this list, efficient and
effective communication between the
rounding physicians and the bedside
registered nurses is not possible.
We have made a small investment in phone technology. In a short
period of time, this investment has
paid significant dividends.
We conducted a follow-up meeting with the nurse manager and assistant nurse managers, whose patients
were directly impacted by this program. Comments from that meeting
included:
comes back to positively impact
the overall experience of our
patients.”
In the end, patient-centered physician and nurse bedside rounding
at Cleveland Clinic has emerged as a
successful pilot program poised to be
expanded within the heart and vascular institute and beyond.
It places the focus of communication at the bedside with the patient
and family as core contributors to the
plan of care. This rounding approach,
in conjunction with a seamless
electronic health record, creates a
formidable set of patient care tools
to address the increasing complexity and acuity of our hospitalized
patients.
Curtis M. Rimmerman,
MD, MBA, CPE,
is the Gus P. Karos chair
of clinical cardiovascular medicine, director of
cardiovascular medicine
affiliate programs in the Robert and Suzanne
Tomsich Department of Cardiovascular
Medicine at the Heart and Vascular Institute
of Cleveland Clinic, Cleveland, OH.
RIMMERC@ccf.org
• “Enhanced communication and
interdisciplinary collaboration is
the main benefit. This can greatly
impact many areas of our patient
satisfaction/ HCAPS scorecard.”
• “Nursing is more apt to carry out
and understand what is driving
the plan of care. Cohesive communication across the continuum
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