PATIENT- AND FAMILY-CENTERED CARE:

Partnerships for Safety & QualityStaff Physician & Resident Physician Toolkit

Patient- and Family-Centered Rounds

Patient- and Family-Centered Care

▼ Healing Partner not Technical Operator

What is patient- and family-centered care?

▼ An innovative approach to health care

▼ Grounded in mutually beneficial partnerships

▼ All ages

▼ All health care settings

▼ www.ipfcc.org

What are the core concepts of patient- and family-centered care?

Mutually beneficial partnerships that emphasize:

▼ Dignity and Respect ▼ Information Sharing▼ Participation▼ Collaboration

Patient- and Family-Centered Rounding

▼ What is it? A model of communicating and learning among the

patient, family, medical professionals, and trainees.● Traditionally described

on an academic inpatient ward setting

Bedside interdisciplinary work rounds.

Patient and family share in the control of the management plan.

Johnson B. H. Family-centered care: Four decades of progress. Families Systems & Health. 2000;18:137–56.

The Traditional Model of Rounds

▼ Timing primarily based on physician schedule.

▼ Information primarily transmitted from physician to patient.

▼ Goals for hospitalization are not always explicit.

▼ Other members of the care team are not necessarily present.

▼ Teaching of students takes place separately, away from the bedside.

Patient- and Family-Centered Rounds

▼ Patients and families are viewed as partners in care and decision-making, not visitors.

▼ Patients and families have a range of choices in how they can participate in rounds.

▼ Efforts are made to schedule rounds to fit family availability.

www.cincinnatichildrens.org/aboutfcc/rounds

Cincinnati Children’s Hospital Medical Center

2006 Recipient of the AHA McKesson Quest for Quality Prize

2008 Recipient of Picker Award for Excellence in the Advancement of Patient-Centered Care

Family Presence In Rounds

▼ Ask the patient to define their family or other support persons and how they will be involved in care and decision-making as part of the admission process.

▼ Include the family/support person, according to patient preference, as another member of the health care team.

▼ Ask the patient to identify any family members who should not be included in discussions during rounds or nurse change of shift.

▼ “Level the playing field” Critical importance for

family and patient to be integral members of the team.

▼ Explain the process "The most important thing we do on rounds is make the plan

for the day. While we’re the experts on medicine, you’re the expert on you and your family. Together we’ll make better decisions.“

"I’m going to review the story so our entire group understands what brought you to the hospital. Please feel free to add or correct anything as I go along."

"I’m going to review for the team what happened in the last 24 hours. Your input will be very important."

Logistics

Physician—Birmingham VAMC

Patient- and Family-Centered Rounds

Simmons, J. M. (2006). A fundamental shift: Family-centered rounds in an academic medical center. The Hospitalist, 10(3), 45-46.

▼ Most orders and discharge paperwork are written and clarified on rounds—helps with efficiency for residents.

▼ With nurses, families, and physicians all communicating, “there is exponentially less confusion about the plan of care.”

▼ Discharge planning begins at admission and each member of the team contributes to carrying out and tracking well-defined goals.

▼ “A care plan, truly comes together and becomes maximally effective when family, nurse, and physician can listen to each other’s points of view.”

The Evidence

▼ Concord, NH Cardiac Surgery Program Following initiation of collaborative rounds

● Mortality decreased by ½● Increased patient satisfaction (to 99th percentile

nationally)● Greater staff satisfaction● “Flat Hierarchy” saves lives

Uhlig, P. N., Brown, J., Nason, A. K., Camelio, A., & Kendall, E. (2002). System innovation: Concord Hospital. The Joint Commission Journal on Quality Improvement, 28(12), 666-672.

Kendall, E. M. (2003). Improving patient care with collaborative rounds. American Journal of Health-System Pharmacy, 60(2), 132-135.

Collaborative Rounds in Cardiology

More Evidence

▼ MCGHealth in Augusta, GA

▼ Neuroscience Center of Excellence

▼ 3 years after implementing patient- and family-centered initiatives, including conducting rounds at the bedside with patients and families: Patient satisfaction 10th to 95th percentile LOS ↓ 50% Nursing staff vacancy rate 8% to 0% Increased faculty and trainee satisfaction

Developed with Patient and Family Advisors

Critical Care Tower Vanderbilt University Medical Center

http://www.vanderbilthealth.com/traumasurvivors/

More Evidence. . .

Cincinnati Children’s Hospital Medical Center:

Rounds take 20% longer▼Overall daily time per patient is reduced

Patients/families benefit▼85% participate; satisfaction increased

Staff feel more knowledgeable about the care planErrors in orders decreased from 9% to 1%Education improved

▼Faculty, students, and residents all report increased satisfaction

Muething, S. E., et.al. (2007). Family-centered bedside rounds: A new approach to patient care and teaching. Pediatrics, 119(4), 829-832.

Family-Centered Rounds: A Pediatric Hematology/Oncology Unit

Resident:▼ “I learned how to explain things to families”▼ “It's especially helpful for interns who may seek to

model their own interactions after what they have witnessed.

Family: ▼ “Now I feel like part of his care”▼ “We were helpful with clarifying her background”▼ “This gives me more opportunity to connect with the

doctor”Knoderer HM. Inclusion of parents in pediatric subspecialty team rounds:

attitudes of the family and medical team. Acad Med 2009;84:1576-81.

Family-Centered Rounds (FCR): Staff Attitudes

“I can better understand the patient’s care plans”FCR: 91% SA/A CR: 6% SA/A

“I feel I am working on a team to care for patients”FCR: 92% SA/A CR: 28% SA/A

Rosen, P., et. al. (2009). Family-centered multidisciplinary rounds enhance the team approach in pediatrics. Pediatrics, 123(4), e603-e608. Available from http://pediatrics.aappublications.org/cgi/content/abstract/123/4/e603.

Family-Centered Rounds:Resident Attitudes

▼ Family-Centered Rounds: Improved family satisfaction: 71% Increased family role in medical decision-making: 68% Improved safety: 39% (57% no effect on patient safety) Improved resident efficiency: 29% (36% unchanged,

36% decreased) 61% reported fewer requests for care plan clarifications

from families and staff after implementing family-centered rounds

Rappaport D. I., Cellucci M. F., & Leffler M. G. (2010). Implementing family-centered rounds: pediatric residents’perceptions, Clinical Pediatrics, 49, 228-34.

Family-Centered Rounds:Resident Attitudes

Rappaport D. I., Cellucci M. F., & Leffler M. G. (2010). Implementing family-centered rounds: pediatric residents’perceptions, Clinical Pediatrics, 49, 228-34.

Patient- and Family-Centered RoundingCommon Concerns

Confidentiality can be a sticky situation Critical need for patients and families to be fully

informed about the rounding process

HHS.Gov—HIPAAFAQs—Family

Patient- and Family-Centered RoundingCommon Concerns

Teaching will be pushed aside Learning occurs in ways not possible in conference

room or lecture hall. Physicians learn to be comfortable with uncertainty

(families already are!)Muething, S. E., et.al. (2007). Family-centered bedside rounds: A new approach to patient care and teaching. Pediatrics, 119(4), 829-832.

Patient- and Family-Centered RoundingCommon Concerns

Not enough time!

Time used more efficiently: saves time

● Concord Hospital Adult Cardiac/Thoracic Step-down Unit: staff felt slight increase in time early in day, saves time later.

● 2009 Adolescent Medicine Unit (Pittsburgh)

Added 2.7 minutes per patient

● 2007 Cincinnati Children’s Hospital Medical Center: added 20% time to rounds

Patient- and Family-Centered RoundsImplementation Strategies

▼ Provide patient/families informational and educational materials about rounds.

▼ Commit time for staff education and provide continuing support, reflection, and process improvement

Directly address staff concerns about confidentiality.

▼ Develop logistics/implementation plan.

1. Just do it.

2. Explain “why” every time with every patient. Soon everyone will believe you!

3. Review patient list to determine if there are some patients who may not benefit from patient- and family-centered rounds. Personal preference. Altered mental status with no

family. Sensitive social/health issues.

“The How To” for Patient- and Family-Centered Rounds

“The How To” for Patient- and Family-Centered Rounds4. At the doorway:

Intern goes in first: asks permission (again). As group comes in, reminds patient/family why rounds

are conducted in this manner.● Ground rules, introductions.

5. In the room: Discuss with team (including patient and family).

● Switch pronouns to engage listeners: “You” not “she.” Give patient permission to “tune out.”

● “I’m going to run through all of your lab results for the team. I will translate the important ones for you at the end.”

“The How To” for Patient- and Family-Centered Rounds

Ask nurse and patient and family for input at selected times.● It’s patient- and family-centered rounds NOT patient

and family-dominated discussion.

6. Ask permission to teach. Patient and family should know when someone is

teaching and not specifically discussing their case.

7. The conclusion. Strong summary and “Plan for the Day.” Who is on call. When someone will return.

Common Pitfalls

▼ It must be mutually beneficial. Not “show how smart you are” rounds Not “patient- and family-dominated rounds” Physicians set collaborative tone for encounter

▼ It’s still a presentation. Beware the pragmatics of speech! Condense the History and Physical information.

▼ It can’t take all day. It shouldn’t take all day. Residents need feedback on presentation technique. Not everything written can nor should be said!

Applying Patient- and Family-Centered Concepts to Rounds

Discussing the Benefits: A Group Exercise