Hospital leaders create and carry out strategic plans for their institutions, ideally based on the best information available. However, quality improvement experts have begun to realize that many leaders are actually too insulated from “facts on the ground.” It may be efficient to rely on vertical chains of command for knowledge, but this often doesn’t fully capture what’s happening on the frontlines of patient care. Senior leaders at McLeod Regional Medical Center in Florence, South Carolina, decided the best way to gain a thorough understanding of their hospital — what was working well and what wasn’t — was to connect more directly with frontline staff, care delivery processes, and patients themselves.
The Background: McLeod Regional Medical Center
, part of McLeod Health, is a large acute care hospital serving 12 rural counties with a population of close to one million. Located in Florence, a city of about 30,000 in northeast South Carolina, McLeod is in the heart of South Carolina’s Pee Dee region, named for the Indian tribe that originally inhabited the area. As a Pursuing Perfection
hospital, and one of 278 hospitals participating in a quality demonstration project sponsored by the Centers for Medicare and Medicaid Services (CMS) and Premier, Inc., McLeod has distinguished itself as a leader in improving care processes and patient outcomes.
The Situation: At McLeod, quality underlies all strategic planning. The Board of Directors holds the hospital’s leaders accountable for improvement in three areas: safety, science, and service. At each monthly Board meeting, senior staff present detailed reports — including data — on the progress of various quality initiatives related to each of the three key areas.
- Establish and Oversee System-Level Aims for Improvement at the Highest Board and Leadership Level
- Align System Measures, Strategy, and Projects in a Leadership Learning System
- Channel Leadership Attention to System-Level Improvement
- Get the Right Team on the Bus
- Make the Chief Financial Officer a Quality Champion
- Engage Physicians
- Build Improvement Capability
Many, if not all, of these points involve engaging senior leadership in the day-to-day work of improvement.
Leadership Patient Rounds came into use at McLeod in 2003. Sometimes called Executive (or Leadership) WalkRounds
, and modeled on clinical rounds, the idea is to bring a different set of eyes and ears to the patient’s bedside on a regular basis. At McLeod, Leadership Patient Rounds take place every weekday morning, from 8:30 to 9:00 AM, without fail. It takes the team about two weeks to cover the entire hospital.
McLeod senior leaders conducting
their daily Leadership Patient Rounds
McLeod’s “rounding” group consists of a wide range of key executives: the chief executive officer and chief of staff; the chief financial officer; the chief information officer (a nurse by training); the chief nursing officer; and the vice presidents of medical services, clinical effectiveness (also a nurse), support services, human resources (another nurse), patient care services, and facilities.
“We don’t just visit patients haphazardly,” explains Donna Isgett, RN, MSN, Vice President of Clinical Effectiveness. “We are each assigned to specific units and we have a clear agenda.” The agenda — which guides the conversations they have with patients — is based on unit-specific patient satisfaction survey results. “We know what the key drivers of satisfaction are on each unit, and we focus on those,” says Isgett.
One of the keys to this concept is understanding that the primary drivers of patient satisfaction can differ depending on the type of unit. For example, says Isgett, “On a short-stay, observation unit, the key driver is the overall teamwork of the staff, the admission process, and the discharge instructions. On the oncology unit, the key drivers of satisfaction are the nurses’ understanding and caring manner and the room accommodations.”
During the rounds, the administrative leaders try to learn how well the hospital satisfies patients’ needs. “We might ask questions like, ‘Are the nurses and doctors working together as a team?’ or ‘Did you have any problems with admission?’” says Isgett.
Sometimes the hospital has new initiatives that require feedback from patients, such as when McLeod introduced new barcode technology in 2003 to help prevent medication errors. And not surprisingly, when administrative staff stop at a patient’s bedside, they often learn about specific problems patients are experiencing, such as confusion about medications or uncertainty about discharge plans. In these cases the leader will relay the concerns to the appropriate caregiver or manager. “A patient told me she was having trouble with discharge planning,” says Donna Isgett. “So I contacted the director of discharge planning and asked her to visit the patient. I’ll stop back later to ask the patient if her concerns were addressed.”
Often, says Isgett, she and her fellow executives hear praise for specific individuals or services, and they make sure to relay that information to the right people as well.
Alva Whitehead, MD, is an internist by training, and now serves as McLeod’s Vice President of Medical Services. For him, making rounds as an administrator can be challenging. “I sometimes have trouble taking off my physician’s hat,” he says. “I want to get into the history of the diagnosis. But I try to remember that I am there as a facilitator for the patient.”
Whitehead also admits that for physicians caring for patients on the various hospital units, the concept of McLeod’s CEO or head of facilities stopping by to talk with patients can be disconcerting. “If we had had Leadership Patient Rounds when I was practicing, my first reaction would have been, ‘What in the world are you doing here?’” he says. But McLeod’s leaders have worked hard to create a culture of teamwork in which everyone is encouraged to work together to solve problems. Respect is an important part of that equation, says Whitehead. “Just as we knock on the patient’s door to get permission to come in, when we enter the unit we get permission from the unit staff to enter their world.”
Dr. Whitehead believes executive rounding has several benefits. “Patients appreciate it,” he says. “They are impressed that the CEO is coming to their room and asking how things are working. It also helps the nursing staff, because we get to know them, and see what they do and what their days are like.” Whitehead says that, after a period of adjustment, even physicians welcome executive rounds. “They see it as an opportunity to grab us and let us know what they’re thinking.”
But of course the biggest benefit of Leadership Patient Rounds is that leaders gain invaluable insights — insights probably not available in any other way — into what matters to the patients they serve. Donna Isgett offers an example. “We have a new palliative care program here, and it is very expensive to run and the reimbursement is inadequate. On paper, it’s a money-loser. But I visited with a patient and family that had benefited from those services, and to hear them and see their tears about how wonderful the program was, that’s something you could never learn from a report.”
Or, she says, a patient tells her about a long wait in the emergency department before getting admitted. That’s vital information for a hospital trying to improve efficiency and patient flow.
“It makes a big difference in your perspective when you start each day with patients,” Isgett says. “It reminds us of why we are in the business. It re-roots us in the organization’s mission, and I think we make decisions differently as a result.”
Senior leaders debrief after each morning’s rounds, and meet weekly to review performance data and improvement project progress. The strong culture of teamwork and a focus on identifying and fixing problems has fostered achievements such as a reduction in the rate of adverse drug events from higher than four per thousand in 2002 to less than 0.7 per thousand for most of 2004. McLeod has also achieved a ranking among the top performers in the CMS/Premier demonstration project
What Team Members Say: “We are very oriented toward problem solving. We don’t deny problems; we focus on them and work to solve them. And we are very team oriented; we never try to fix things alone. We work together.” — Donna Isgett, RN, MSN, Vice President of Clinical Effectiveness
“Patient Rounds make it clear to our patients and our staff that even the most senior leaders are focused on quality. When people see the CEO pick a piece of trash up off the floor, it reminds them that everything matters, and everyone can make a difference.” — Alva Whitehead, MD, Vice President of Medical Services
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