Quality and Safety Needs Assessment: Hourly Rounds

HOULY ROUNDS 10

Quality and Safety Needs Assessment: Hourly Rounds

Michael D. Czechowskyj

Ferris State University

Abstract

In today’s changing healthcare climate the industry is now being paid based on quality of care provided and their outcomes rather than the quantity of patients seen or procedures done. With quality and safety in health care being the focus, there is a gap that has been identified in how to increase both quality and safety. The solution to that gap is completing proper patient hourly rounds. Hourly rounds are defined as purposeful rounding on patients to help meet and anticipate their needs. This is done to increase patient satisfaction and decrease nursing sensitive indicators like falls and pressure ulcers. This paper will discuss the need for proper hourly rounds followed by a plan that is intended to implement hourly rounds properly.

Keywords: hourly rounds, culture, nursing rounds, implementation

Quality and Safety Need Assessment: Hourly Rounds

Introduction

The organization I am working with, like many others in the nation, is working on decreasing the incidence of falls, pressure ulcers, and other nurse sensitive indicators (NSIs). Concurrently they are working on increasing patient satisfaction and the overall health care experience. There are many programs out there that work at addressing one certain NSI. There are also good ideas and projects around how to improve patient satisfaction scores. One process change that addresses multiple NSIs and patient satisfaction at the same time is proper hourly rounds.

The organization continues to struggle with high fall rates, high pressure ulcer rates and some units have poor patient satisfaction. There are pockets of excellent work but as an overall system there is still work to be done. The organization has tried to implement hourly rounds a few different times to help reduces some of the NSI’s and increase patient satisfaction but it has never stuck. There needs to be a strategic role out of hourly rounds using both a literature review and a proper change management tool. If this is done successfully the organization should see a decrease in NSI’s and an increase in patient satisfaction.

This document will describe the needs assessment used to build a case for the implementation of hourly rounds. It will also explain different change management tools and select the one to be used for this project. After the tool is identified a plan will be proposed for the implementation of hourly rounds. Lastly, any new ideas identified during this process will be assessed further to see if they can be disseminated to advance the nursing profession through publication or sharing at conferences.

Needs Assessment

The organization I am working with is a 500+ bed urban teaching hospital. It is also a Magnet organization and making sure they maintain their Magnet designation is very important to the hospital and their nursing division. In order to maintain Magnet designation they must meet or exceed the benchmark for NSI more than 50% of the time. Currently many units are not meeting this requirement in the area of falls, unit acquired pressure ulcers, and patient satisfaction. With hospitals also looking to improve Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) scores to maintain their level of reimbursement, there is a focus on patient satisfaction here as well. There are many different reasons why the organization is not meeting these goals so the need for a gap analysis was identified.

There are many different methods to reduce individual metrics like falls or patient satisfaction individually, but the literature suggests that implementing hourly rounds can impact all of the three areas identified as a concern for the organization. So to clarify the gap in getting to our end results there needs to be an understanding of what proper hourly rounds actually look like.

Hourly rounds have many names; comfort care rounds, nursing rounds, hourly rounding, structured nursing rounds interventions, are just some to name a few (Gardner, Woollett, Dayl, & Richardson, 2009: Meade, Bursell, & Ketelsen, 2006; Krepper, et al., 2014; Tucker, Beiber, Attlesey-Pries, Olson, & Dierkhising, 2012). No matter what you call them they are basically the structured rounding of nursing staff with the purpose of anticipating the patient’s needs. Some needs the nursing employees try to anticipate are around cleanliness of the rooms, toileting needs, pain needs, and general patient comfort. When these needs are met the patient has a better experience. A literature review by Halm (2013) reports an increase in patient satisfaction in 8 out of 9 studies. This tells me that patients like hourly rounds and they also find value in them.

The benefits of hourly rounds are directly related to patient satisfaction and patient safety. Hourly rounds have been shown to positively reduce the number of falls (Tucker et al., 2012). In one study they were shown to reduce the number of pressure ulcers as well (Rondinelli, Ecker, Crawford, Seelinger, & Omery, 2012). Patient satisfaction has already been discussed and with these numbers being related to health care reimbursement they now mean more than ever. When evaluating HCAHPS for patient satisfaction, if the organization is off the mark it could cost them millions. Looking at patient safety, we see that hourly rounds could reduce patient falls as well. The average cost of a fall has been reported as $13,361 (Wong, Recktenwals, Jones, Waterman, Bollini & Dunagan, 2011). The average cost of a pressure ulcer is $43,180 (Jenkins, & O’Neal, 2010). With price tags like that, any reductions would not only help our patients but would help save money. These are more benefits of hourly rounds.

To determine how hourly rounds can help all areas in which the organization is lacking a fishbone diagram can be used. This helps identify the gaps in implementing a change like this. Please refer to Figure 1. for more detail on the gap identified.

Quality Improvement Model

After the gap analysis is completed then the real work can be done to complete this change. Using Lean methodology, a change like this can be broken into different sections and worked on incrementally to achieve the goal of hourly rounds. A plan can best be developed to implement the change by separating each part of the diagram in Figure 1. Let’s look at the environment first.

If the environment on the nursing units is more structured then they can work more efficiently and have more time to do hourly rounds on their patients. Using the 6S process as a process for improving the environment is a good first step. The steps in this process include; Sort, Straighten, Shine, Standardize, Sustain, and Safety. Using a process like 6S to improve the nurses work flow can increase hourly rounds because the nurse will have everything they need. Also, redesigning room assignments will help the nurses work flow and reduce travel time. The nurse’s assignments should have all their patient rooms in a row or in a pod. If the nurse can see all of their rooms then they can address their patient’s needs more quickly.

The next bone in the diagram is standard work. Creating standard work for when the employees enter and exit a room will create less variability in practice and therefore better results. This can be done by a check list as well as standard scripting for when the nurses enter or exit the room by prompting the patient to identify their needs in the moment. These standard work documents can be housed in each room and they will serve as a reminder to the staff regarding what work needs to be done.

The next bone from Figure 1 is investment in people or employees. They will need to complete an education program to learn the new standard work process, how to use the tools, how assignments will be made, and most importantly the rationale behind the change. One model that can be incorporated into this change is the Influencer Model for change. The Influencer Model for change at its core, takes 6 categories; 1.making the undesirable desirable, 2.surpass your limits, 3.harness peer pressure, 4.finding strength in numbers, 5.designing rewards and demand accountability, 6.changing the environment. Using at least 4 of these categories will greatly improve your chances of making the change successful (Patterson, Grenny, Maxfield, McMillan, & Switzler, 2008).

The last bone on the fishbone diagram is having the right tools. To set the employees up for success they need the right tools. This includes making sure all the rooms have the right beds for the patients that are at risk for skin break down. All the rooms need to have gait belts and bed/chair alarms accessible to the employees so they can use them when needed for high fall risk patients. They need to have the standard work documents available to them all the time. If these tools are in place then the employees can help prevent falls and pressure ulcers while providing great care to the patients.

Proposed Plan

How can the organization get this done? The implementation process happens in 4 steps. The first step is a complete literature review done by a CNS to make sure best practice and best evidence based tools are being used. The second step is education of the all nurses and nursing support staff. These classes will be taught by nurse educators and nursing leadership to stress the importance of this culture change and use the Influencer model as a guide for the education. The third step is the roll out date when leadership begins rounding. A date is picked and leadership presence remains 24 hours a day for a full week to help stress the importance of hourly rounds. Follow up with employees who are struggling with the change can also be done in real time. The schedule will be set ahead of time so all leadership can be present. The fourth step is evaluation and continued support of employees. Evaluation is done with audit tools and patient interviews. HCAHPS scores, fall rates, and pressure ulcer rates are tracked to see if there is an impact to these outcomes. The maintenance of this project is done with intermittent audits by leadership and peers on how well everyone is doing hourly rounds. If this is all successful the organization will see a culture change as well as an increase on their HCAHPS scores, fewer patient falls and less pressure ulcers will be reflected. With these scores moving in a positive trend there could be significant savings financially and improvement in patient safety.

The above plan would be implemented after the areas identified in the fishbone diagram have been fixed. There also needs to be new processes identified or policies written to help support and hold the employees accountable. Leadership rounding standards also need to be developed so every unit in the organization is the same. Once this is all set, there should be a successful implementation of hourly rounds.

Nursing Knowledge and Health Care Practices

Once this process has been rolled out to the organization there will need to be continued data gathering to determine if it has made a difference. The organization already has pre data related to falls, pressure ulcers, and patient satisfaction. Once there is enough post data to determine if this supports or disproves the current literature out there, then a publication of the information would need to be completed. If it supports the current literature then adding to the body of knowledge will help strengthen the case for other health care organizations to follow suit in implementing a process like this. If the data doesn’t improve then stopping or trying to fix the new practice would need to take place. Publishing those findings would then add to the debate of whether hourly rounds are successful and make a difference when it comes to NSI’s or patient satisfaction. Either way, there needs to be a publication to help grow the nursing knowledge out there and drive the best evidence based practice. Dissemination of the information at a conference or other facilities can help bring the process to life and advance care in those facilities.

Summary

When looking at the literature, hourly rounds have been successfully implemented in many organizations. Improvements have been seen in many areas including reducing falls and pressure ulcers while increasing patient satisfaction. The organization I work with has tried to implement hourly rounds a number of times but has been unsuccessful. Patient safety and improving patient outcomes are what every organization is striving for. I believe that if the strategies identified above are used a successful implementation and improvement in the care and outcomes of the patients we serve will be realized.

References

Gardner, G., Woollett, K., Daly, N., & Richardson, B. (2009). Measuring the effect of patient comfort rounds on practice environment and patient satisfaction: a pilot study. International Journal of Nursing Practice, 15(1), 287-293.

Halm, M. A. (2009). Hourly rounds: what does the evidence indicate. American Journal of Critical Care, 18(6), 581-584.

Jenkins, M. L., & O’Neal, E. (2010). Pressure ulcer prevalence and incidence in acute care. Advances in Skin & Wound Care, 23(12), 556-559.