"Fully engaging patients and families in multidisciplinary rounds is not only better for patients, but it can also help with a range of issues for which hospitals are being held accountable," says Tammy Alvarez, MSN, RN, CCRN, faculty for the IHI Expedition on Engaging Patients and Families in Multidisciplinary Rounds. In this interview with IHI Communications Specialist Jo Ann Endo, she explains why effective rounding is more important than ever.
Q: Why is it so important to engage patients and families in multidisciplinary rounds? How do you make a case for it, especially when no one is mandating it?
Fully engaging patients and families in multidisciplinary rounds is not only better for patients, but it can also help with a range of issues for which we’re being held accountable, including readmissions and patient satisfaction scores. When patients’ families are actively involved in rounds, we’ve seen decreases in falls, readmissions for patients with congestive heart failure, and even sepsis.
Patients and families also bring valuable insights. When a patient is in the hospital, we just get a snapshot of what that patient looks like. Compare that to the person who really knows the patient, whether it’s a husband, a wife, a daughter, a sister, or a brother. There’s nothing like having those perspectives because sometimes the health care team moves so quickly that we don’t pick up on things that they may see or know.
Q: How does your organization engage patients and families in rounds?
I’ll use the ICU as an example. When patients are admitted, they are given an admission packet that includes information on the time of rounds, which is every day at a specific time, and then every night. Families are encouraged to attend, and we talk to the patient and the family about how we’re going to be reviewing the patient’s care for the day during rounds. We invite them to ask questions. It’s important for rounds to be structured, to explain how it works, and to make sure patients and families understand their input is valued.
Q: What are some of the reasons that some clinicians express uncertainty about engaging patients and families during rounds?
Generally, the biggest fear is that the patient, or the family, is going to be obstructive or intrusive in the rounding process. Part of that is fear of the unknown, so that fear does go away over time as the care team gets more comfortable with the process of including patients and families during rounds.
A team’s dialogue changes when families are there versus when families are not there. It’s important to realize that patients and families are part of the care team. When we engage families, and rounds are structured correctly, their complaints and concerns can be minimized because the family gets to see maybe up to 10 people on the care team participating in rounds, and their reaction is, “Wow, this is the team that really cares about my family member.” I think it instills confidence in patients and families when they see the communication and the structure.
Q: You said it sometimes changes the dialogue. In what way?
I’ve been a nurse for 25 years, and sometimes you hear people describe a “demanding” patient or family member. When the patient or family is part of rounds, you’re more likely to say something like, “The family has some significant concerns that we need to address.” Their presence forces you to look at the situation from their perspective because, at the end of the day, their perception is their reality. It’s our job to communicate to them and hopefully eliminate some of their concerns.
What I have seen is that patients and families want to know two things: They want to know that you care about their loved one, and they want to know that you’re competent. Making them part of rounds is a way to convey that. It’s also an opportunity to communicate about what’s happening. When families or patients are upset or concerned, it’s often because of a breakdown in communication.
Q: What are the biggest challenges for teams when it comes to engaging patients and families in rounds?
You definitely need to have executive leadership behind this and supporting it. If you don’t have that, that makes it a very big challenge.
People are also understandably worried that engaging patients and families might add more time to rounds. Actually, when you use a good process, the work can ultimately save you time. It will probably initially take more time, but with practice and a good structure, it will take less time, and the value of getting that input will become clear. You just have to be patient and stay the course. This is when leadership commitment is so important. Sometimes you need to remind people, “We’re committed to making this work. Leadership is behind this.”
Q: How does one make the case to leadership about why engaging patients and families in rounds is so important?
Since providers are being held accountable for HCAHPS and patient satisfaction scores, patient engagement is increasingly becoming a high priority for leadership in many organizations, so that’s one way to make the case. You can also highlight the support of patient engagement by the Institute for Healthcare Improvement and other organizations that are passionate about this work. Patient engagement has to be a strategic priority at the executive level.
Also, engaging patients is important not only for patient satisfaction, but also staff satisfaction. When we have staff that are truly engaged with our patients, patients appreciate that. There is a correlation between staff engagement and patient satisfaction; there’s nothing more empowering and more satisfying. Even though the relationships we, as the health care team, develop with our patients may only be for two or three days, when you develop that connection, when patients and families feel that they’re having real dialogue with their health care team, it’s very special. The work we do is extremely special. There are very few professions that allow you to help people in wonderful times and during some of the most difficult times. There’s something sacred about that.
Q: What are some tips you can share?
Ideally, you should start with people who are passionate and positive about engaging patients and families. You offer them some suggestions about how to structure rounds, and then you debrief after the first time to ask, “How do you think that went? Were there any uncomfortable moments for you?” You need to debrief right after you do the rounds, not a day later. If anything needs to be tweaked or changed for the next small test of change, you do it right then.
You definitely want to avoid starting too big. Invite your patient and family advisors to be part of constructing the process from their experience. Identify a unit, pick the time, pick the team, educate the team, communicate with the team, and then do a small test of change, one day, and then the next time tweak it based on your findings. It’s very important to start small because – we’ve seen this time and time again – when we fully implement something because we’re excited about it, and it doesn’t go so well, often the reaction is, “Oh, it didn’t go well, so we’re not going to do that again.” You end up having to do damage control.
Prepare the patient and their family so they feel comfortable. Sometimes families are intimidated by health care teams, and they’re reluctant to ask questions. Make sure they know questions are welcome and encouraged. You want to make sure you actually have a conversation.
Be sure to explain the purpose of rounds, and that your rounds have structure. It’s not that you can’t have some variability, but everybody needs to understand their role, how they’re presenting, and what they’re presenting, and there needs to be allotted time for the patient and family to ask questions.
Q: Do you ever have to remind teams to use less technical language?
I have been guilty of that myself, yes. It’s part of what needs to be built into the structure of rounds. You should be sure to explain a disease process, for example, and otherwise ensure patients and families understand a situation. You also want to ask questions to let them know they can ask questions. For example, you can say, “Is there anything we said that may not be completely clear?” Remembering to do that takes practice.
Q: You’ve been working on issues related to patient and family engagement for a number of years now. Why are these issues so important to you?
My brother, Mark, is 45 years old. I’m his caretaker. He’s developmentally delayed, legally blind, and has autism. I have been in situations with Mark when we have sought medical care that has been extremely wonderful. We’ve also had some really terrible experiences when he’s been sick or in the hospital, and it’s felt as if we were at the mercy of the health care team. The kind of vulnerability I’ve seen and felt in my own life with my brother has just raised my awareness. I’m very passionate about these issues. If I could go around the country and do this work, I would.