“RAP Rounding”
Regular Assessment of Patient’s
basic needs
Ruth King
Nurse Manager
Sandringham Hospital
RAP Rounding
• RAP Rounding background
• RAP Rounding implementation at the Alfred
• Results and evaluation
• RAP Rounding at Sandringham
Background
Three issues were identified as important driving factors in The Alfred
introducing RAP rounding. These were:
• Challenges of decreasing patient risk and improving the quality of
patient care
• Local research around the timeliness and quality of the nurse-patient
interaction
• Patient feedback
Implementation Across Alfred Hospital
• 2 pilot areas – 4GMU and 6 West commenced in Jan 10
• 2 additional ward areas each month with final ward areas implementing in
August 2010
• Ward areas were provided with tool kit – including FAQ sheets and
information leaflets for staff
Implementation and Evaluation Aims of RAP
Rounding
Proactively meet
patients’ needs
Indicators/
Measures
Data Source
When
Considerations


Call bell use
% of nursing
time spent at
bedside
Nurse-patient
interactions




Number of call bells
LEAN Observation
OPTIC
Feedback from
sample of patients
(see tool)
Baseline and repeat post 3-6 months
Baseline and repeat post 3-6 months
Baseline and repeat post 3-6 months
Weekly
Who to collect data?
If/when ward involved in LEAN project
When ward becomes involved in OPTIC
Falls rate
Pressure injury
rate

Nursing audit
program
Riskman
Nursing audit
program
PUPPS
Baseline and repeat as per audit plan
Baseline and repeat as per audit plan
Annual
Existing data
Existing data
NET promoter
score
Patient complaints
and compliments
Baseline and repeat as per ward
audit process
3 monthly
Baseline and repeat
To be provided by Patient Liaison Officer
PCNI
Iterative staff
feedback
Staff ‘Claims,
Concerns & Issues’
exercise
Annual
During implementation phase
Pre-implementation and repeat at 6
weeks
Measures Nursing Stress, Workload,
Empowerment, Satisfaction
Collect during implementation
Staff satisfaction’ will need to be
extracted from data raised by staff
under ‘Claims, Concerns & Issues’,
eg, expect to see increase in claims
and decrease in issues raised
Rounding
communication tool
Compliance audit
tool
Daily during implementation for 8
weeks
Repeat as required
Collect during implementation
Focuses on identification of issues and
barriers that impact on the
implementation process, in addition to
% compliance

Improve patient
safety and risk
management





Increase patient
satisfaction

Patient
satisfaction


Increase staff
satisfaction

Staff
satisfaction



Implementation of
Rounding
Process

% compliance
with performing
Rounding
hourly


Quality Indicators Pre-Implementation
The Alfred
70
7
60
6
50
5
40
4
30
3
20
2
10
1
0
Jan- Feb- Mar- Apr- May- Jun09
09
09
09
09
09
Jul- Aug- Sep- Oct- Nov- Dec- Jan- Feb- Mar- Apr- May- Jun09
09
09
09
09
09
10
10
10
10
10
10
Extreme/Major (ISR 1 & 2)
Moderate (ISR 3)
Total No. Falls
Jul- Aug- Sep- Oct- Nov- Dec- Jan- Feb- Mar10
10
10
10
10
10
11
11
11
Linear (Total No. Falls )
0
Falls with Extr/Major or Moderate
Outcomes
Total No. of Falls/Month
Falls with Serious Injury 2009-2011
Survey – “Essentials of Nursing Care”
• Nursing assessment, planning, implementation and evaluation with patient and
family
• Discussing with patient their needs for the shift
• Evidence of assessment and ongoing care
• Timely attention to needs
• Care is proactive rather than reactive
• “ Pain, hygiene ADL’s, toileting” – essential nursing care every shift
Patient feedback – Pre Implementation
• Call bells not answered, or staff pop in and don’t come back.
• “Too long for nurses to answer call bell”
• “Only that sometimes, especially at night, there can be no call response, or over 45mins. This
can be a problem is a need is urgent.”
• “Place is deserted at night no one answers my bell”
• Help with ordering meals, eating, & water
• Personal hygiene: help with pans, commodes and toilets; cleaning up after ‘accidents’
• Help with washing and keeping clean in bed (“my bed was a jungle”)
The Aim of RAP Rounding
• Proactively meet patients’ needs
• Improve patient safety and risk management
• Increase patient satisfaction
• Increase staff satisfaction
RAP Rounding Design
The model includes:
• A nurse asking the patient at the beginning of the shift what is important to
them to achieve/occur during the shift, followed by
• One-hourly rounding assessing patients pain management, toileting needs,
mobility/change of position needs, checking environment is free of clutter
and all the items the patient needs are to hand, and
• Before leaving, asking the patient “is there anything I can do for you? I have
the time.”.
Quality Indicators – Post Implementation
RAP
rounding
introduced
Jan 2010
No falls with
ISR 1 or 2
during this
time
Patient Feedback – Post Implementation
• The nurses are very good, the rounding is fantastic! You don’t feel isolated
anymore. I had a recent hospital admission where no one communicated with you,
it was scary and lonely. It isn’t like that here, the nurses are very attentive and
caring. They do a fantastic job, they are always there when you buzz.
• As a wife of a patient I can say that I and my family speak very highly of the care,
patience and nursing care. The nurses are most caring and diligent of his needs.
• Rounding is a fabulous idea. All of the nurses were wonderful, very attentive and
caring. They would explain what was happening each day. It made you feel less
anxious as you knew they were always around.
Outcomes – Post Implementation
• Reduction in patient call bell use
• Reduction in falls with injury (ISR 1 & 2)
• Increased patient satisfaction
• Decreased patient complaints related to nursing care
• Increased staff satisfaction
How are we doing 2012?
Decrease in RAP rounding compliance- process is no longer practiced
consistently across the Alfred Campus
– Shift in local and organisational priorities
– Changes in bed models (increasing bed numbers)
– Staff attention and retention
– Environmental factors
Learnings
•
•
•
•
•
•
Rounding “champions” – to lead the way, influence the team
Regular evaluation of the process and outcomes measures
Interpretation of results – numbers vs. outcomes
Strong nursing leadership
Engagement of staff, patients and visitors
Change to nursing care delivery system – RAP rounding in
isolation
• Feedback
- Patients
- Staff
Sandringham Hospital 2012
• Improving Care group – models of nursing care
• National Accreditation Standards
• Nursing Care Delivery – including bedside handover, RAP rounding and
changes to documentation.
• Commenced on all inpatient wards in August 2012
Pre- Implementation – Quality Indicators
Pre Implementation – Survey and Audits
Buzzer Audit March 2012
•
60% buzzer occasions were related to toileting, pain and requests for environmental (buzzer, food etc) assistance next most prevalent
reasons.
•
Up to 5 mins to answer buzzer with one occasion of 12mins to answer buzzer.
Documentation Audit
•
Average score 1.9 shows deficit in appropriate documentation, particularly “purpose of hospital stay”, “evaluation of patient progress”,
“referrals and follow up referrals” and “discharge planning”.
•
Medico-Legal – average score is 60%
Patient Feedback
•
9 out of 55 complaints relating directly to nursing care between August 2011- August 2012
Implementation and Evaluation
• Review of existing resources and development of Sandringham nursing care
delivery system tools and resources focusing on risk assessment and clinical status
• Implementation date set for all inpatient ward areas
• Education sessions for staff run over 4 week period with all nursing staff attending
• Development of patient information leaflets with information about RAP rounding,
handover and nursing care expectations
• Daily audit schedule developed including rounding compliance (tick sheet audit) and
patient satisfaction surveys
• FAQ and information sheets for nursing staff
• Weekly “Claims, Concerns and Issues” sessions for staff
• Formation of local area working groups
Post-Implementation – Quality Indicators
Nursing Care
Delivery system
implemented
Post Implementation – Survey and Results
RAP Rounding compliance
•
>85% compliance shift by shift
Documentation Audit Results
•
Average score of 3.69 for August and September.
•
Medico Legal section average score of 90%
Patient Satisfaction Surveys
•
88% of patients surveyed rate their satisfaction between 8-10
•
89% of patients feel involved in their care
•
90% of patients are seen hourly or more frequently with all of the remaining 9% seen within 2 hours
Learnings
• Tick sheet is key to implementation phase of RAP rounding introduction
• Engagement of nursing leadership group is key
• Introduction of RAP rounding as part of nursing care delivery system appears to have
benefit over introduction in isolation
• Patient satisfaction survey is the most reliable indicator that process and principles are
practiced
• Providing patient with information provides accountability of nursing staff
Summary
RAP rounding across Alfred Health has contributed to
•
A reduction in the number of falls with injury (ISR 1 & 2) (during the first 12 months of
implementation)
• A significant improvement in patient satisfaction relating to nursing care and
communication
• A reduction in the amount of call bell usage across the organisation
• Sustainability remains the greatest issue in the success of RAP rounding as a risk
reduction and prevention strategy