Karen Cook, RN

“What can Florence teach us about hardwiring Hourly Rounding?”

Rounding for Outcomes

Objectives

Articulate the difference between hourly rounding and purposeful hourly rounding

Describe the behaviors needed to accomplish an effective and purposeful hourly round

List strategies to overcome the common barriers to successful hourly rounding

Hourly Rounding is Not New…

Throughout the night, she would move through the dark hallways carrying a lamp while making her rounds, checking on each patient and providing care if needed. The soldiers were comforted by her compassion, earning her the nickname, "The Lady with the Lamp." Her care would forever change the way hospitals treated patients. Most consider Nightingale the founder of modern nursing.

Patient-Centered Care Delivery Model

Hourly Rounding

Hourly Rounding

Individualized Patient Care

Individualized Patient Care

Bedside Shift Report

Bedside Shift Report

Discharge Phone CallsDischarge

Phone Calls

Nursing and Patient Care Excellence

What is Hourly Rounding?

What is it? A plan to proactively interact with patients every hour during the day

using focused key words to assess needs (pain, position, personal needs and patient education)

A care model to return care to the bedside, truly patient-centered A plan to help achieve our goal to “always” deliver exceptional

clinical quality care in a safe and compassionate environmentWhy do it? Evidence supports a decrease in patient anxiety, falls, skin

breakdown, and nursing steps as well increased patient satisfaction It allows nurses to provide more care at the bedside It reduces anxiety, worry and waiting It is just good patient care There is no other initiative that impacts the patient perception of

quality care as this ONE does.

Action Step #1

Randomly stop five front-line employees and ask what is hourly rounding, why do we do it and what do they think about it.

Are you proud of the response both in verbal and nonverbal communication?

Do the employees connect to the WHY?

Ask them to go do a typical hourly round with you.

Round on the units and look for visual cues to hourly rounding such as logs, trash on floor, bed alarms/side rails, clutter, etc.

If you hear anything like this… you have variance.

We are in the patient rooms all the time

Some of us are doing it but some are not

It doesn’t work on our unit… we are different

They don’t do it on evenings and nights

This “project” didn’t make our scores move… it does not work

We “rolled it out” a long time ago, half the staff don’t even know what it is

When can we take the logs down?

It’s just a bunch of paperwork for us and we already document in the EMR

Action Step #2

Randomly ask at least five patients:Tell me one of the questions that your care team asks you when they come into do their hourly rounds?– We focus on meeting your needs, and with that in mind,

the staff are to be in the room every hour asking about pain, position and bathroom needs. Has this been your experience?

Have you had to use your call light to ask for pain medicine in the last 24 hours?

Tell me what your nurse told you about our process for hourly rounding on this unit?

If you hear anything like this… you have variance.

They write something on the board over there

They stick their head in and ask if I need anything

They don’t do it on evenings and nights

They are too busy to be in here that much

I just call when I need them

I don’t REMEMBER

Connect to the WHY

If you hear anything like this… you have variance.

Our manager told us we had to do it

They go around and check to see if the logs are filled out – that is all they care about

There are times I have 6 patients, how am I supposed to be in there every hour?

We have to report our compliance to the corporate office, of course we are doing it

Eight Behaviors of Hourly Rounds – More Than 3 P’s

Hourly Rounding Behavior Expected Results

1.Use Opening Key words Creates efficiency“checkin’ on ya” won’t suffice

2. Accomplish scheduled tasks Contributes to efficiency

3. Address 3 P’s (pain, potty, position) Quality indicators – falls, decubitis, pain management

4. Address additional comfort needs Improved patient satisfaction on pain, concern and caring, efficiency

5. Conduct environmental assessment and ensure bed technology is correctly utilized

Contributes to efficiency, teamwork

6. Ask “Is there anything else I can do for you before I go, I have time?”

“Call me if you need me” decreases efficiency. Improves patient satisfaction on teamwork and communication

7. Tell each patient when you will be back Contributes to efficiency

8. Document the round Quality and accountability

Most Common Reasons for Call Light Use

Time is Money

One Call Light = 4 Minutes of Care Giver Time

700 calls/wk= 46 hrs

$36,660/yr

Some do it very well…

“I am of certain convinced that the greatest heroes are those who do their duty in the daily grind of domestic affairs whilst the world whirls as a maddening dreidel.” 

“Notes on Nursing” Florence Nightingale 1854

Track By Low/Solid/High Performers

Date: Average call light response time High

# of calls

Call Rate

25-Jul-12 1:21 3:34 20  

26-Jul-12 2:16 5:55 246 calls/pt.

2-Aug-12 2:07 5:18 61.5 calls/pt.

3-Aug-12 3:15 7:23 92.25 calls/pt.

12-Aug-12 4:2513:5

3 102.5 calls/pt.

14-Aug-12 1:09 3:18 225.5 calls/pt.

15-Aug-12 1:12 1:34 30.75 calls/pt.

21-Aug-12 1:15 3:18 174.25 calls/pt.

22-Aug-12 1:13 3:06 234.6 calls/pt.

LOW MIDDLE HIGH0

0.5

1

1.5

2

2.5

3

3.5

4

AVG Response

AVG Calls pr pt

Action Step #3

Review your strategies for recognizing those staff that do a great job with hourly rounding?

Can your managers say who their high performers are with hourly rounding?

Have you shadowed them to see what they are doing right?

Do you track call lights by staff members?

Do you highlight units that have improved in quality metrics at public events like employee forums?

Everybody SAYS They Are Doing Hourly Rounding

I think one's feelings waste themselves in words; they ought all to be distilled into actions which bring results.

“Notes on Nursing” Florence Nightingale 1854

Evidence-Based Quality

Do Our Words = Results?

88% of Georgia HEN Hospitals report they “ARE doing hourly rounding”… but Georgia ranks 47th out of 50 states in improvement in pain management

Georgia Hospitals

Responsiveness: Correlates to Quality

Responsiveness:Correlates with Readmissions

Still A Priority…

“The very first requirement in a hospital is that it should do the sick no harm.” 

“Notes on Nursing” Florence Nightingale 1854

GA HEN Hospitals Falls

GA HEN Hospitals HAPU

Action Step #4

Standardize the process for tracking results:Responsiveness, pain, nurse communication

Falls

HAPU

Reduced call lights

Where is this posted?Can staff speak to the results?

What is the return on investment for improving?

Correlate Tactic With Results (ROI)

Action Step #5

“On this unit, one of our care team members will be coming in to see you every hour during the day. You will see either me or Jackie, our certified nurse assistant. I have worked with Jackie for two years and she is excellent. We will be checking on your comfort such as we will make sure we are helping manage any pain you might have, help you change position, help you to the bathroom and make sure you have everything you need.” We call this hourly rounding and we do it to make sure you are safe and we are always meeting your needs.”

Have you standardized the process of setting expectations of hourly rounding as part of how you deliver care?

How do you know it happens every time?

How do the staff explain the logs to the patient and family?

Hourly Rounding Reduces Anxiety

Apprehension, uncertainty, waiting, expectation, fear of surprise, do a patient more harm than any exertion.

“Notes on Nursing” Florence Nightingale 1854

Action Step #6

Are your logs a visual representation of your quality to the patient/family?

Do they give you the information you need or are they duplicative charting?

Please place your initials in the corresponding time box after round has been complete. **Round is only complete if all 8 Key Behaviors have been done.**

6:00 7:00 8:00 9:00 10:00 11:00 12:00 13:00 14:00 15:00 16:00 17:00 18:00 19:00 20:00 21:0022:00-23:00

1:00-2:00

3:00-4:00

5:00-6:00

MM/DD/YY

Sunday

Monday

Tuesday

Wednesday

Thursday

Friday

Saturday

Eight Key Behaviors: Key:1) Use opening key words S= Patient Sleeping

2) Perform scheduled tasks R = Patient in Radiology

3) Address the 5 P's-Pain, Potty, Position, Possesion, Plan of Care E = Room Empty

4) Assess additional comfort needs OR = Patient in Surgery

5) Conduct environmental assessment P = Procedure in Process

6) Use closing key words and/or actions CT = Patient in C.T. Department

7) Explain when you or others will return PT = Phyisical Therapy

8) Document the round on the log

Initials: Signature: Initials: Signature: Initials: Signature: Initials: Signature:

Rounding Log

Action Step #7

How are you including the patient and the family in discussions about hourly rounding

Safety

Patient-centered

Plan to be responsive if they find a need to use the call light but goal is to not even have to use it

Be as SPECIFIC as possible to eliminate variance and open door to misinterpretation

Key Words Are Not New Either…

“Always sit down when a sick person is talking business with you, show no signs of hurry, give complete attention and full consideration… Always sit within view so that when speaking to him, he does

not have to painfully turn his head around in order to look at you. If you

make this act wearisome, you are doing the patient harm. You cause harm also by continuing to stand to you make him continuously raise his eyes to see you.”

“Notes on Nursing” Florence Nightingale 1854

Our Goal is to Deliver Excellent Quality Care

Composite Question Summary Response Scale

Nursing CommunicationNurse courtesy and respect ALWAYS1, Usually, Sometime, NeverNurses listen carefully ALWAYS, Usually, Sometime, NeverNurse explanations are clear ALWAYS, Usually, Sometime, Never

Doctor CommunicationDoctor courtesy and respect ALWAYS, Usually, Sometime, NeverDoctors listen carefully ALWAYS, Usually, Sometime, NeverDoctor explanations are clear ALWAYS, Usually, Sometime, Never

Responsiveness of StaffDid you need help in getting to bathroom? 2 Yes No (screening question)Staff helped with bathroom needs ALWAYS, Usually, Sometime, NeverCall button answered ALWAYS, Usually, Sometime, Never

Pain ManagementDid you need medicine for pain? 2 Yes, No (screening question)Pain well controlled ALWAYS, Usually, Sometime, NeverStaff helped patient with pain ALWAYS, Usually, Sometime, Never

Communication of Medications

Were you given any new meds? 2 Yes, No (screening question)Staff explained medicine ALWAYS, Usually, Sometime, NeverStaff clearly described side effects ALWAYS, Usually, Sometime, Never

Discharge InformationDid you go home, someone else’s home, or to another facility? 2

Own home, Someone else’s home, Another facility (screening question)

Staff discussed help need after discharge YES, NoWritten symptom/health info provided YES, No

Individual Question Area around room kept quiet at night ALWAYS, Usually, Sometime, NeverRoom and bathroom kept clean ALWAYS, Usually, Sometime, NeverWillingness to Recommend DEFINITELY YES, Probably Yes, Probably No, Definitely No

Hospital Rating Question 0 to 10 point scale (percent 9 and 10 reported)

1Response used to calculate the question score is designated by capital letters2For analysis purposes, it is important to know which areas have screening questions because the sample size will be lower than the other areas

Care Boards are FOR the PATIENT

WRITTEN Key Words

An important part of providing you with individualized care and excellent service is hourly rounding. You will be visited by one of your caregivers

EVERY HOUR from 8 a.m. to 10 p.m.

And

EVERY TWO HOURS from10 p.m. to 8 a.m.

During this time we will be:

Checking on you and your well-being Monitoring your comfort and pain Helping you move and change positions Attending to personal needs (such as assisting

you with toileting, bringing personal items within reach, hygiene needs and anything else to make you more comfortable)

Your caregivers also will make sure that you have easy access to the:

Telephone, bedside table, water or other beverages, and glasses

Urinal and/or bedpan and waste basket Call light for assistance

What does this mean to YOU, your family and visitors? It means that we are anticipating your personal needs and monitoring your well-being on an active, hourly basis so that your family and visitors can focus on your recovery. You may receive a survey after you go home. We hope that you will take the time to give us your feedback. We use your feedback to recognize our staff and know how to improve. If you have any concerns, please notify

Immediately so we can address them.

HOUSTON NORTHWEST MEDICAL CENTER Delivering Clinically Excellent Care

Coaching Tip: “Is This Patient Safe?”

A want of the habit of observing conditions and an inveterate habit of taking averages are each of them often equally misleading.

“Notes on Nursing” Florence Nightingale 1854

Training AND Validation

Skill labs can be used for training a skill or validation of a skill.

You have to know the difference because the feedback is framed differently

In Training skill labs, educators, content experts and others can be used to give feedback.

In Validation skill labs, leaders are present to give feedback and competency is checked.

Other Ways to Validate

1. Directly observe hourly rounding on the unit

2. Leader rounding on patients Verify hourly rounding is occurring by asking

patients and their families

3. Leader rounding on staff Ask them what is working well with HR Highlight a WIN during Huddles

4. Discharge phone calls or survey

5. RESULTS

Action Step #8

Do you have a plan for caregivers to be validated annually, just like TB skin test?

Do you have a plan in place to monitor those that choose not to participate?

Are there clear consequences for optionality?

Inspect What You Expect

“Soft” validation does not work! "Sara, I appreciate being able to shadow you and validate your hourly rounding skills. I think you did a great job. The only thing I didn't hear was you using the closing key words. I'll go ahead and check you off but please be sure to do them next time."

Charge Nurse Role

“To be "in charge" is certainly not only to carry out the proper measures yourself but to see that every one else does so too; to see that no one either willfully or ignorantly thwarts or prevents such measures. It is neither to do everything yourself nor to appoint a number of people to each duty, but to ensure that each does that duty to which he is appointed.” 

“Notes on Nursing” Florence Nightingale 1854

Action Step #9

Have you trained and validated all the charge nurses on hourly rounding?

Are they clear on their authority to coach on standardization of behaviors?

Are they the right person to support the culture of effective hourly rounding?

How do you hear about the “wins” from hourly rounding? And do you take as much time to recognize them as you do gaps in performance?

Manager, Director and CNO Role

“Let whoever is in charge keep this simple question in her head (not, how can I always do this right thing myself, but) how can I provide for this right thing to be always done?” 

“Notes on Nursing” Florence Nightingale 1854

Sample Accountability Tools

“I attribute my success to this - I never gave or took any excuse.” ― Florence Nightingale

Summary - Lessons Learned

Success is dependent on leadershipReinforce the WHY, connect to safe patient careTrain and validate all staffReward top performance and coach opportunitiesTrack impact and communicate results• Patient satisfaction by unit and HCAHPS

– Nurse communication, pain, responsiveness• Falls, pressure ulcers, and other core measures• Call lights• Audit the rounding logs

Round on patients to confirm behaviorsPost results from rounding – thank you notesCommunicate results in Supervisory Monthly Meeting

“Were there none who were discontented with what they have, the world would never reach anything better.”― Florence Nightingale, 

Notes on Nursing: What It Is, and What It Is Not