Petras, Denise M. DNP, RN-BC; Dudjak, Linda A. PhD, RN, FACHE; Bender, Catherine M. PhD, RN, FAAN
Today's dynamic healthcare environment demands that healthcare providers explore and implement various strategies to be successful in providing patient care. The Institute of Medicine has challenged healthcare organizations to commit to improving the quality of healthcare by providing safe care that's evidence based, patient centered, timely, efficient, and equitable.1 Without question, any action taken to create change in patient care management must keep in focus the need to produce high-quality, efficient, and effective outcomes while being mindful of safety, quality, and patient satisfaction.
Patient rounding is a relevant methodology to positively impact patient outcomes. As a proactive strategy to meet patients' needs, the evidence has demonstrated that rounding reduces the number of call light episodes, which can ultimately reduce the number of times a patient needs to actively make a request, improve patient satisfaction by providing an avenue for nursing staff to connect with the patient, and improve quality of care by fostering patient safety.2–6 Scheduled contact with patients allows caregivers to intercept and remove risks, manage situations that contribute to patient falls, and institute prompt repositioning as a way to maintain skin integrity. Rounding can enhance teamwork when patients and staff work together, thereby improving efficiency of nursing care and staff satisfaction.2 A proactive versus responsive approach to managing patient requests via a structured rounding process operates on the premise that anticipating patient needs leads to better overall patient management.
We implemented a structured patient rounding program as a pilot quality improvement initiative to better organize nursing care to improve patient satisfaction, reduce patient call light episodes, and improve patient safety by reducing falls.
Gathering the data
The setting for this pilot was an advanced medical-surgical unit of an 87-bed, long-term, acute care (LTAC) hospital located in a metropolitan suburb; this hospital was part of a large, for-profit LTAC and inpatient rehabilitation hospital system. The hospital comprised three nursing units, two of which provided care for complex specialty patients who required ventilator support or telemetry monitoring; the third unit provided care for complex medical-surgical patients. This unique setting presented the challenge of caring for chronically, critically ill patients who had spent weeks or months in an ICU because of untoward outcomes related to their short-term acute stay; these patients had increased physical and emotional needs related to their multiple comorbidities. Because of the demands of caring for LTAC patients, a strategy was needed to foster improved patient satisfaction as a measure of quality and nursing efficiency.
Baseline data were collected on call light episodes, patient satisfaction, and patient falls followed by the implementation of the pilot rounding program and subsequent collection of the same data during a 4-week period of rounding. The CNO, in collaboration with the pilot unit's nurse manager, provided primary support during implementation of the initiative to ensure completion of staff education, distribution of relevant documentation materials, and communication/problem-solving with staff.
In the month before the pilot implementation, staff members were instructed on a call light data collection process for the purpose of determining their unit's baseline call light rate. Data subsequently were collected for 2 weeks on call light frequency using a preprinted form that listed common reasons patients may activate their call lights.2,6,7 Each morning at approximately 8 a.m., call light forms were placed on the doors of the patients' rooms by the nurse manager, designee, or nursing supervisor and the previous day's forms were collected. Each time a staff member answered a call light, he or she documented the time and reason for the call light on the form. A log was placed on the call light console at the nurses' station to record the reason for call light episodes that were managed from the nurses' station.
During the baseline call light data collection period, a total of 479 call light episodes were recorded by staff responding to call lights, for an average of 34.2 call light episodes per day or 11.4 per shift. The reasons for call light use were tabulated in order from highest to lowest frequency: toileting need (208); request for an item or action (78); automatic call lights that were triggered by patient alarms, such as pulse oximeters connected to the call light system (62); positioning needs (55); pain medication (27); patient called about alarm (17); need for other medication (15); request for ice/water/tissues (11); and patient had a question for the nurse or physician (6). There were no call lights recorded for a change in patient condition.
In addition, there were 26 call lights recorded at the call light console at the nurses' station. Sixteen of these calls required the attention of a nurse or unlicensed assistive personnel; of the remaining 10, seven were mistakes, two already had caregivers in the room, and one was managed from the nurses' station.
Patient fall data from the pilot unit were reviewed for the 3 months before implementation of the rounding program. During this period, an average of 3.6 falls per month (without injury) was documented. The fall rate for the pilot unit was 4.3 per month in the year before the rounding pilot. The average daily census on the pilot unit for the previous quarter was 24 patients.
Formal patient grievances (complaints) filed with the patient advocate for the previous quarter on the pilot unit were reviewed as a measure of patient satisfaction with the hospital experiences. During this time period, there were a total of 15 patient grievances received from patients on the pilot unit (as recorded by the patient advocate), for an average of five per month for the quarter. Patient grievances were defined as concerns that couldn't be resolved within the day of receipt and required further intervention by the patient advocate, including a formal letter of resolution that was sent to the complainant within 7 days of the complaint. The concerns identified in the formal grievances related to nursing care and included, but weren't limited to, issues such as limited display of compassion, inadequate communication, delay in call light response, multiple patient moves, and a disruptive roommate.
Following the call light data collection period, multiple education sessions were conducted for staff on all shifts to introduce the pilot project and review the purpose of the rounding project, staff roles, the rounding script, documentation requirements, and the subsequent 4 weeks of call light data collection. During these education sessions, the relevance of the baseline call light data collection was explained. Two rounding information boards were placed in the pilot unit nurses' lounge to display research and anecdotal articles on the rounding process; an envelope was also provided for written staff feedback. Staff members who were temporarily reassigned to the pilot unit from another unit were oriented to the rounding process by the charge nurse, as was any nursing instructor who presented on the unit with nursing students. Communication describing the rounding initiative was also provided to all hospital department managers.
The structured rounding program pilot began on the first Monday of the month and continued through day 28, for a total of 4 weeks. A 2-hour rounding protocol was selected based on the ratio of licensed to unlicensed staff on the pilot unit. Every 2 hours, licensed nursing staff members were responsible to round on their assigned patients; unlicensed staff assisted as requested by the licensed staff. At the beginning of the shift, staff members introduced themselves to their patients, wrote their names on the white boards in the patients' rooms, and explained the rounding procedure.
During the rounding process, the nurse assessed the patient's need for toileting, positioning, and pain management and ensured the close proximity of personal items (such as the call light, television remote, and tissues). Before leaving the room, staff members asked the patient if there was anything else they could do while in the room. They also reminded patients that they were available as needed between the scheduled rounding times and could be summoned by using the call light.
Dated rounding documentation records containing 4 days of information were placed on all patient bulletin boards (using the same process as the baseline call light data collection process) and were completed by staff members who performed the rounding activities. The records were printed on red paper to be easily noticed in patient rooms. Spot checks of rounding records were made by the unit manager to reinforce the importance of recording rounding data. During the 4 weeks of rounding, call light data were also collected following the same process used during the baseline call light data collection.
A total of 729 rounding episodes were recorded for all patients on the pilot unit during the 4-week pilot. Rounding episodes were to be documented for each day of the pilot, resulting in potentially 12 recorded episodes of rounding for each 24-hour period. Upon review of the rounding records, it was discovered that the number of rounding episodes recorded each day wasn't consistent. The most frequently occurring documentation pattern found was four episodes of recorded rounding in a 24-hour period. There were a total of 20 records that had no documented rounding episodes in a 24-hour period. On some of the records, the staff wrote the reason for not performing rounding during a particular hour, such as the patient wasn't in the room (at therapy or out of the building).
There was also a pattern noted in the frequency of recorded rounding episodes related to shifts (the night shift staff recorded the rounding episodes more consistently), as well as to when specific staff members were working (several nurses more consistently documented rounding on their shifts). Also worth noting is that during the first 3 days of the pilot, there was a higher number of documented rounding for all 12 episodes for a 24-hour period. Subsequently, there was a decline in the full documentation of all rounding episodes as the pilot progressed.
Call light frequency was tallied for a total of 23 of the 28 days in the pilot period; 5 days were excluded because no call lights were recorded during those days or call light data collection sheets were absent. During this period, a total of 531 call light episodes were recorded by staff, for an average of 23 per day or 7.7 per shift. No call light episodes were recorded on the call light console at the nurses' station. A total of 542 reasons for the call light episodes were recorded. This total differs from the total number of call light episodes because, on several occasions, multiple needs were recorded as the reason for a single call light episode. Consistent with the results from the data collected during the baseline period, toileting was the primary reason for a call light episode, followed by the request for an item, positioning needs, pain medication, automatic alarm, and need for ice/water/tissues. The lowest areas of need recorded were patients requesting other medications, calling about an alarm in their rooms, questions for the nurse or physician, and a call to report a change in condition.
The other two outcomes measured included falls and grievances. There were a total of four falls without injury on the pilot unit during the month that the rounding initiative was implemented. Of the four falls, one patient fell twice. One formal grievance was recorded by the patient advocate during the pilot. The grievance involved a night nurse who documented on the rounding record that the patient was sleeping at 6 a.m. so she didn't wake the patient to assess her needs. However, this patient had been incontinent, which was discovered by the patient's spouse who arrived within 1 hour of the last rounding of the shift.
Did rounding increase patient satisfaction?
The patient rounding quality improvement initiative produced findings to support literature evidence that structured rounding can positively impact the patient experience. Small, yet favorable, changes in patient satisfaction and patient call light episodes occurred as a result of the pilot despite the presence of challenges in the environment that impacted the implementation process. Table 1 provides a summary comparison of baseline and pilot data.
Although rounding episodes were documented, a review of the rounding records revealed an inconsistency in documentation. Anecdotal comments by staff members included that they were often so busy with daily activity that one rounding episode blended into the next and they weren't able to achieve the consistency dictated by the rounding protocol. It also was possible that the rounding may have been performed but wasn't documented. The finding that the night shift more consistently documented rounding episodes may lead one to speculate that the implementation of structured rounding merely formalized existing shift practices, resulting in more consistent documentation compliance. Based on feedback from night shift staff members, as well as observation of their work patterns, the 2-hour rounding episodes were consistent with their typical routines.
Positive changes in both call light episodes and patient complaints were realized as a result of the pilot. During the baseline data collection, there were 34.2 call light episodes per day or 11.4 per shift. During the rounding pilot, there were 23 call light episodes per day or 7.7 per shift, reflecting a small decrease of 11.2 calls per day or an average of 3.7 calls per shift compared with the baseline data. The reasons and percentage of total call light episodes at baseline and during the pilot were similar, although the total number of episodes decreased. These findings were consistent with the reasons that patients typically use their call lights. In the 3 months before the pilot, 15 formal patient grievances were recorded by the patient advocate, for an average of five grievances per month. During the pilot, one formal patient grievance was received.
Finally, there were four falls without injury during the pilot, with one patient falling twice. Compared with the previous 2 months, falls doubled during the pilot month. The one variable that changed during the rounding month compared with the 2 previous months was an increase in patient volume on the pilot unit and a decrease in the nursing hours per patient day. However, compared with the previous quarter average, the fall rate was virtually unchanged. It was also noteworthy that the pilot unit fall rate averaged 4.3 falls per month in the previous year.
Limitations and challenges
The main limitation of the pilot was the small sample size and length of time for testing. There were challenges during the rounding pilot that introduced variability and may have precluded the potential to realize more significant positive change in the variables than were achieved. The hospital experienced a change in administrative leadership, with subsequent shifts in operational expectations and uncertainty regarding the future direction of the hospital and its senior leadership. The patient census, which had been low before the pilot month, increased during the month of the pilot study and, at one point, surged beyond what the organization had experienced in the previous 3 years. The overall increase in patient volume significantly impacted the census on the pilot unit and the ratio of licensed to unlicensed staff, resulting in increased productivity demands that were difficult to meet.
Limited financial and human resources also may have played a role in the outcome of the pilot. Staff development sessions were planned during work hours to avoid overtime. Staff members had difficulty leaving the bedside to attend in-services and were often distracted, interrupted, or anxious to return to patient care, which may have compromised their ability to focus during the education. Also, given the limited human resources available, it wasn't possible to monitor 100% of rounding compliance 100% of the time.
The way to happier patients
The purpose of the patient rounding pilot as a quality improvement process was to implement an evidence-based practice to determine its impact on promoting patient safety, quality, and satisfaction. Based on the preparation, process, and findings of this pilot, opportunities to refine the rounding initiative to ensure a more successful outcome were realized. The pilot was successful in that it produced positive changes in outcomes related to call light frequency and patient grievances, which further supported the existing evidence. It was also a valuable learning process for the leadership and staff involved in its undertaking. The outcomes that were realized as a result of this quality improvement project served as a guide and impetus for the subsequent implementation of a hospital-wide rounding initiative. (See Table 2.)