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 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 Care 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 help return care to the bedside • 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 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 • When can we take the logs down?
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
Time is Money $36,660/yr 700 calls/wk= 46 hrs One Call Light = 4 Minutes of Care Giver Time
“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
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
Do Our Words = Results? • 88% of Georgia HEN Hospitals report they “ARE doing hourly rounding”
Georgia Hospitals • HCAHPS results
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
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?
Value Based Purchasing CMS Quality-Based Payment Initiatives Will Put More Than 7% of Payment at Risk
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?
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?
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
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 • Directly observe hourly rounding on the unit • Leader rounding on patients • Verify hourly rounding is occurring by asking patients and their families • Leader rounding on staff • Ask them what is working well with HR • Highlight a WIN during Huddles • Discharge phone calls or survey • 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
“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