Vol. 3 Issue 24
On the Hour
Hourly rounding at Mercy Medical Center Redding improves patient satisfaction
At Mercy Medical Center Redding, patient satisfaction is a very real commitment, with nurses rounding on their patients every hour to ensure all possible needs are addressed.
"Hourly rounding came about because leaders at Catholic Healthcare West (CHW) overall, and Mercy Medical Center Redding in particular, are vitally interested in improving patient satisfaction," said Midge Stafford, PhD, RN, vice president of patient care services and chief nurse executive. "We want nurses to become much more intimate with patients around the concept of service. We introduced a nursing bundle and part of that bundle involves rounding on every patient every hour of the day and at night while awake."
Whenever hospital leaders reviewed the results of patient satisfaction surveys, they were pleased with the overall results. Still, Stafford explained, there was a sense something was missing. "We found the technical aspects of nursing care were being met," she said. "But it's the friendly, home-like environment people miss, as well as the ability to participate in decision-making around their own plan of care.
"It's about safety, patient comfort and taking care of those vital things patients need on a regular basis," Stafford continued. "Hourly rounding identifies environmental concerns, such as placement of the over-bed table; patient comfort issues, in terms of needing a drink or a chance to go to the bathroom; elements of hygiene, including washing, turning and clean sheets; and pain control."
Changing Nursing Practice
When the nursing management team at Mercy attended CHW Nursing Boot Camp, they were excited about the potential of hourly rounding. "The nursing directors wanted to implement rounding for the whole patient population, rather than piloting it on one unit, but were quite realistic about how much change this would mean for the nurses at the bedside," Stafford recalled. "I went to my boss, Rick Barnett, president of the hospital, and said, 'For the next 3 months, I need the nursing directors on their units, rather than in meetings.' He supported us by canceling all meetings for that period of time."
Marianne Johnson, RN, lead house supervisor, affirmed that it took time and plenty of personal reassurances to establish hourly rounding as an integral part of nursing practice at Mercy. "The biggest hurdle we worked to overcome is the perception that hourly rounding is an additional responsibility," she said. "It's boiled down to having managers and directors there on the units, and rounding with the staff. We were excused from meetings for the first couple of months to accomplish this; when we did begin to get caught up in meetings again and took our eyes off the ball in June, our patient satisfaction scores dropped. Since then, we've really tightened up as leaders, going to meetings only if we receive meeting invitations with an agenda."
Johnson served as a cheerleader for the hourly rounding process and collaborated with other hospital departments to remove roadblocks that can get in the way of the rounding (see Sidebar: Removing Roadblocks). "It's important to role model customer service-oriented behavior," she emphasized. "We understand nurses are often in the room every hour anyway, but now hourly rounding encourages them to make those visits with a purpose."
Brian Busk, MSN, RN, clinical nurse educator, worked with Chris Meade, a consultant from the Studer Group to incorporate a process known as AIDET (see Sidebar: Implementing AIDET) into the hourly rounds. "Chris had done the research validating the impact of hourly rounding and its benefits to patients and staff, so she came here and did presentations to share that evidence base," he said. "We also developed 3x5 cards that contain key techniques and words to include in the hourly rounding interactions."
Busk emphasized hourly rounding, rather than adding to the nurses' workload, actually saves time. "We encourage staff to schedule their regular tasks, as well as bits of patient teaching, during those hourly visits," he said. "Chris told us when we're doing a task and get interrupted, it takes at least 4 minutes to answer that call light. When we do get back to where we were before the interruption, we need additional time to get back into the groove. In the end, hourly rounding makes your time, as well as your patient's time, flow much better."
Addressing Patient Concerns
Sarita McFarland, BSN, RN, a staff nurse on the oncology unit, was initially skeptical but soon came to appreciate the positive impact of rounds. "We already do so much as nurses, especially in terms of paperwork, and at first it felt like a burden to add the hourly rounding and checklists," she admitted. "We soon realized it just takes a few minutes to go up and down the hall, and it certainly saves time in the long run."
Staff nurses use white boards at each bedside to capture patient goals and other key information. "Every shift, the nurse assigned to the patient writes his/her name on the board and is introduced to the patient by the outgoing nurse," Stafford said. "We also ask, 'What would make your care here excellent?' You'd be surprised what you'll hear it can be anything from making a call home, to learning about a new drug that's been prescribed for them."
Regular rounds can make a big difference in patient safety, minimizing episodes of patients trying to get out of bed when their needs aren't being met. "Patients who are confused don't necessarily reach for the call light when they need help," McFarland said. "When I do go on my hourly rounds, I sometimes catch patients trying to get up by themselves when they truly need assistance. That lets us know they're a fall risk and we can plan our nursing care accordingly."
While interacting with the patient and family members, eye contact and a sincere tone of voice convey a genuine interest in meeting their needs. "Hourly rounding is very effective if done correctly," explained Kelly Waddell, RN, an oncology unit staff nurse. "It's important to follow the AIDET process, beginning with, 'I'm here to round on you. Are you comfortable? Is there anything I can get for you?' I always let patients know I'll be back to round again in an hour and conclude by saying, 'Is there anything else I can do for you?'"
Before implementing hourly rounding, administrators at Mercy conducted a call light survey that pinpointed a problem. "The thing that really became clear to me then was that while we had eliminated overhead pages to make our nursing units quieter, the call lights were ringing incessantly," Stafford said. "Now that we have hourly rounding, I don't hear those bells going off anywhere near as often, and we have fewer visitors at the desk as well."
Of course, patient issues always will arise between hourly visits, so call lights are an inevitable part of nursing. Still, Waddell noted, "There's definitely been a decrease in call lights dinging, because we deal with the patients' concerns up front and then let them know we'll be back very soon."
McFarland noted family members are reassured by hourly rounds and trust the nurse to return periodically. "In the past, a lot of family members used to come up to our unit coordinator at the desk and ask for things, but now they know we'll be there shortly and plan to ask us when we do come into the room."
Hospital leaders at Mercy Medical Center are in the process of conducting another call light survey to measure the improvement. "We're also working on making discharge phone calls a priority hospitalwide," McFarland said. "It will be the nurse's responsibility to call each patient within 24 hours of discharge. We'll be asking, 'Were your needs met during your hospital stay?' and 'How did your discharge go?'
Nursing units also are implementing bedside change-of-shift reports to replace audio-taped reports. "We'll have a brief discussion between the oncoming and outgoing nurses at the patient's bedside, and the rest of the information will be shared in a more private environment," McFarland said. "This process will allow patients to play a more active role in their own care planning."
As a house supervisor, Johnson shared an overview of the changes of the past months. "I'm so proud to be part of Mercy Medical Center Redding because everyone's heart is in the right place," she said. "It's our job as the leadership team to open the door to every one of those hearts, to help them embrace hourly rounding, as well as other activities that improve patient satisfaction."
Sandy Keefe is a frequent contributor to ADVANCE.
As nursing leaders at Mercy Medical Center Redding worked hand-in-hand with staff to implement hourly rounding, they soon identified a number of roadblocks that regularly interfered with the smooth flow of patient care on the nursing units. "So, now we have other departments rounding on the nursing staff to see what they need, to support the hourly rounding nurses are doing on their own patients," said Midge Stafford, PhD, RN, vice president of patient care services and chief nurse executive. "The pharmacist rounds to the units, asking staff, 'What's going well?' 'What do you need from us today?' How's XYZ going?' Dietary, PT, RT and environmental services also are doing these rounds, and I'm talking with purchasing now as well. That rounding between departments has really improved relationships and simplified problem-solving around shared concerns about patient care."
Improving Overall Processes
One of the most successful new programs at Mercy has been the introduction of the Room Perfect Program. "This program operates quite like a hotel, with the environmental service employee who cleans the room leaving a card that says 'Everything's been checked by so-and-so, and call this number if you have any problems,'" Stafford said.
Marianne Johnson, RN, lead house supervisor, emphasized the importance of keeping nurses on the nursing unit and at the bedside. "We improved some of our overall processes that got in the way of hourly rounding," she said. "For example, we looked at the overall scheduling of our inpatient radiological procedures and added two RNs in that department so our floor nurses don't have to stay for the entire procedure to care for patients with IVs or telemetry."
When nursing leaders looked at the time nurses spent in non-nursing tasks, they discovered an invaluable ally in the hospital's volunteers. "We found our nurses were constantly interrupted by visitors for non-nursing tasks," Johnson said. "It's so far to our cafeteria, and many of our visitors are elderly, so the volunteer department put together a courtesy cart that rounds to the units, providing coffee, tea, crackers and cookies. That regular rounding helps meet the needs of family members and other visitors, and nurses don't spend time answering questions about food service or providing directions to the cafeteria."
To reduce the amount of time nurses spend answering questions unrelated to patient care, hospital leaders installed some signage and maps. "We also station volunteers at the elevator doors that open near our nurses' stations to reduce the interruptions from people who just need directions," Johnson said. "The volunteers play a key role in keeping nurses where they belong – at the bedside."
When nurses at Mercy Medical Center Redding make hourly rounds on their patients, they incorporate the elements of the AIDET process developed by the Studer Group, an executive coaching firm devoted to service and excellence. "In many ways, hourly rounding is really nothing new, and it's actually part of what I was taught in nursing school 20 years ago," said Brian Busk, MSN, RN, clinical nurse educator. "Yet somehow we lost that concept along the way. The AIDET process brings in that traditional approach, along with some key questions to make sure we anticipate what the patient will be needing over the next hour and throughout the day."
Fundamentals of Customer Service
AIDET is an acronym that outlines the five fundamentals of patient-centered customer service within Catholic Healthcare West: acknowledge, introduction, duration, explanation and thank you.
Sarita McFarland, BSN, RN, a staff nurse on the oncology unit, described the various fundamentals. "During the acknowledgment (A), we go into the room, make eye contact and smile, acknowledge the patient by name and ask, 'Is there anything I can do for you?'" she explained. "It's important to stop what you're doing and focus on the patient during this interaction."
During the introduction (I) portion of the AIDET process, nurses welcome the patient to the hospital. "We introduce ourselves and our department, share our professional expertise and describe the role we'll be playing in the care of the patient that day," McFarland explained.
When talking about the duration (D) portion of AIDET, nurses share information about the activities planned for the day. "I let them know I'll be their nurse until the end of my shift at 7 p.m., tell them how long any scheduled procedures will take and say that I'll be making hourly rounds to find out their needs and to answer their questions," McFarland said.
The explanation (E) component of AIDET involves a step-by-step overview of what the nurse will be doing for the patient. "I'll let the patient know I'll be starting an IV, or helping him ambulate or whatever he might need," McFarland added. "As I explain those activities, I incorporate elements of patient education."
The thank-you (T) portion of AIDET focuses on appreciation. "We thank them for choosing Mercy Medical Center for their healthcare and ask if there's anything else we can do for them," McFarland told ADVANCE. "When I ask, 'Is there something I can do for you, something I can help you accomplish between now and the end of my shift?', we can identify goals together that we then write on the white board near the bed."
Midge Stafford, PhD, RN, vice president of patient care services and chief nurse executive, summarized what a patient might hear during this type of exchange. "There are key words we use as part of our AIDET process," she said. "We'll introduce ourselves by saying, 'Hello, Mrs. Smith, I'm Midge Stafford, a registered nurse, and I'll be taking care of you for the next 8 hours. I'll be here for the next 5 minutes checking your vital signs and your IV, and then I'll be back every hour. Is there anything else I can do for you right now?' And we'll conclude by saying, 'Thank you for trusting your care to us.'"