the effect of dyad rounding on collaboration and patient

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The effect of dyad rounding on collaboration and patient The effect of dyad rounding on collaboration and patient

experience experience

Amy Christensen

Korby Miller

Jason Neff

Rusty A. Moore

ShaRee Hirschi

See next page for additional authors

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BYU ScholarsArchive Citation BYU ScholarsArchive Citation Christensen, Amy; Miller, Korby; Neff, Jason; Moore, Rusty A.; Hirschi, ShaRee; and Merrill, Katreena Collette, "The effect of dyad rounding on collaboration and patient experience" (2020). Faculty Publications. 5257. https://scholarsarchive.byu.edu/facpub/5257

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Authors Authors Amy Christensen, Korby Miller, Jason Neff, Rusty A. Moore, ShaRee Hirschi, and Katreena Collette Merrill

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16 January 2020 • Nursing Management www.nursingmanagement.com16 January 2020 • Nursing Management www.nursingmanagement.com

Copyright © 2020 Wolters Kluwer Health, Inc. All rights reserved.

By Amy Christensen, MSN, RN, NE-BC, FACHE;Korby Miller, MS; Jason Neff, MS; Rusty A. Moore, DO; ShaRee Hirschi; and Katreena Collette-Merrill, PhD, RN

Communication among the healthcare team is essential to providing high-quality patient care. In the hospital, nurses care for multiple patients during their shift. Physicians or advanced practice clinicians (APCs) visit

hospitalized patients daily to update orders, complete assessments, and contribute to care plans. One method to ensure that healthcare providers communicate effectively is interdisciplinary, or dyad, rounding in the hospital. This consists of purposeful rounding on each patient by the nurse and the physician or APC together to review the patient’s status and update the care plan.1 When healthcare providers and nurses round together, it improves communication, patients are more satisfied, and patient safety is increased.2-5

Interdisciplinary rounding isn’t a new concept. Teaching hospitals often have multidisciplinary

The effect of dyad roundingon collaboration

and patient experience

Quality Improvement Matters

NEW

www.nursingmanagement.com Nursing Management • January 2020 17



18 January 2020 • Nursing Management www.nursingmanagement.com

teams that round on patients at specific times. However, in non-teaching, regional or rural hospi-tals, admitting healthcare providers are also responsible for office visits or surgeries in addition to rounding on their patients in the hospital. Healthcare provider vis-its are spread throughout the day, making it challenging to collabo-rate directly with the nurse caring for the patient.

Interdisciplinary rounding improves teamwork among nurses and physicians and patient perceptions of care.3,4,6,7 It also influences the quality of care delivered.8-10 Despite clear evidence that interdisciplinary rounding improves care, many hospitals find the barriers diffi-cult to overcome.6,11 A systematic, rigorous, and sustained quality improvement (QI) approach is essential to successfully imple-ment interdisciplinary dyad rounding.5

The purpose of our QI project was to implement a systematic approach to dyad rounding using the PDSA (Plan, Do, Study, Act) methodology to answer the fol-lowing questions: 1) How would implementing dyad rounding affect patients’ perceptions of hospital care related to com-munication with their healthcare providers and nurses and care transitions? and 2) How would implementing dyad rounding affect nurses’ and healthcare pro-viders’ perceptions of collabora-tion and satisfaction about care decisions?

MethodsThis QI project was implemented at a 284-bed community hospital and Level II trauma center with an average daily census of 215

patients. The hospital has a com-bination of employed and affili-ated (nonemployed) physicians and APCs who admit and round on patients. It employs hospital-ists who see approximately 60% of the inpatients. The remaining patients are seen by a variety of specialists (obstetrics, orthope-dics, general surgery, urology, nephrology, neurosurgery, neu-rology, cardiology, and cardio-vascular surgery). The project was determined to be exempt by the hospital’s Institutional Review Board.

The project included the fol-lowing six steps: baseline mea-surements, standard operating procedures and education plan, implementation on one pilot unit then all medical-surgical units using a systematic process, adherence measurement, sus-tainability, and follow-up mea-surements.

Step 1: Baseline measure-ments. Baseline measures included patient perceptions of hospital care related to health-care provider communication, nurse communication, and care transitions; nurse and healthcare provider satisfaction with col-laboration about care decisions and dyad rounding; and nurse and healthcare provider percep-tions of dyad rounding.

Patient perceptions of hos-pital care were measured by Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) survey top-box composite scores for com-munication with nurses, com-munication with physicians, and care transitions. The score displays the percent of patients who reported that their nurses or physicians “always” com-

municated well and selected “strongly agree” for the care transition composite.12 The hos-pital contracted with an outside vendor for the baseline HCAHPS measurements. A random sample of adult patients was contacted by phone between 48 hours and 6 weeks after dis-charge to complete the survey.

Before implementation of dyad rounding in 2017, partici-pants (RNs, physicians, APCs, and ancillary staff) were sent a link to an online 16-item ques-tionnaire measuring collabora-tion, overall satisfaction, and per-ceptions of the dyad rounding process and two demographic questions (location and role).

Nurse and healthcare pro-vider satisfaction with col-laboration was measured by the Collaboration and Satisfaction About Care Decisions (CASCD) instrument. The CASCD is a 10-item instrument measured on a 1-to-7 Likert type scale. Cronbach’s alpha reliability is reported at .950.13 Respondents rate their agreement to state-ments about nurse and health-care provider collaboration.

In addition to the CASCD, overall satisfaction was mea-sured by one question (How satisfied are you with dyad rounding?) on a 1-to-5 Likert type scale (1 = very dissatisfied; 5 = very satisfied). Three open-ended qualitative responses measured perceptions of round-ing: What works well during daily physician/RN combined (dyad) patient rounds? What isn’t working well in daily phy-sician/RN combined (dyad) patient rounds? What change(s) could be made to improve the dyad rounding process?



Data analysisThe data were analyzed using descriptive statistics and assessed for normality. Mean scores for the CASCD and over-all satisfaction were compared before and after implementa-tion of dyad rounding and by type of role using a one-way analysis of variance. Qualitative data (perceptions of rounding) were analyzed using thematic analysis. Qualitative rigor was obtained by having two inde-pendent researchers review the qualitative data for themes, com-pare the findings, and come to a consensus. Qualitative themes were compared before and after implementation of rounding.

Step 2: Standard operating procedures and education plan. To assist in the development of the standard operating proce-dures and education plan, the team used the A3 QI approach. This approach is a “structured problem solving and continu-ous improvement approach” that augments the PDSA cycle.14 The plan included the develop-ment of nurse and healthcare provider standard work as an agreement on the methods to follow dyad rounding and a standard operating procedure consisting of a systematic guide to the dyad rounding process. See Figure 1 and Figure 2 for the standards of work.

A mandatory slide presenta-tion and training video that modeled the ideal rounding process were developed. Ideal rounding was defined as a daily visit with the nurse caring for the patient and the physi-cian or allied health clinician at the patient’s bedside. The hospital nurse administrator,

patient experience director, and one of the physician continuous improvement leaders presented the training. Stories from suc-cesses and safety catches on the pilot unit were shared with subsequent trainings.

Leaders (hospital admin-istrators, the unit manager, and continuous improvement consultants) also attended huddles at 6 a.m. and 6 p.m. on weekdays to obtain feedback, show support, clarify questions, identify barriers, and maintain focus. The schedule of leader visits was slowly tapered off over 6 weeks. Communication tools already used in the hos-pital were employed as part of the process.

Step 3: Implementation. The implementation of dyad rounding took approximately 6 months. Hospital departments were chosen to implement the new process in a specific order. The first department was chosen because hospital-ists provided most of the care and there was less variation in which nurses and healthcare providers would be working together. Implementation was augmented by mandatory stan-dardized education. However, to create more ownership of the process, nurses and unit secre-taries were encouraged to work out their systems for alerting nursing staff when a healthcare provider came onto the unit. Some of these unique systems included the healthcare pro-vider calling the unit ahead of arrival to alert staff, the health-care provider notifying the sec-retary when he or she arrived on the unit and the secretary notifying the nurses, alerts

on staffing boards, and use of nursing Bluetooth devices.

Step 4: Adherence measure-ment. Adherence audits were an essential part of the success-ful rollout process. Continuous improvement leaders worked with unit secretaries to create daily adherence spreadsheets listing each patient on the unit. If the day-shift nurse didn’t self-report dyad rounding by the end of the day, the unit secretary would approach the nurse and ask two questions: “Did dyad rounding occur on your patient today?” If yes, “Who was the healthcare provider who com-pleted dyad rounding with you?” It was expected that every patient listed on the spreadsheet would have a “yes” or “no” recorded. Data were tracked daily and feedback was given to the nursing team. Healthcare provider adherence data were displayed in the hospitalists’ office in plain view.

After approximately 8 months of tracking adherence postimple-mentation, the units moved to a sustainability audit. The project team met weekly during the first 6 months of implementation and then tapered to twice a month when the daily tracking ended and the sustainability plan was put in place.

Step 5: Sustainability. According to the Institute for Healthcare Improvement, “the key to sustaining improvement is to focus on the daily work of frontline managers, sup-ported by a high-performance management system that prescribes standard tasks and responsibilities for managers at all levels of the organization.”15 When the department reached




80% adherence with dyad rounding for at least 2 weeks, the sustainability plan was put into place. The plan entailed a quarterly weeklong adherence audit. The sustainability goal was to maintain 80% or above adherence with dyad rounding. If 80% wasn’t achieved dur-ing the assessment week, the department continued tracking until a 2-week average of 80% was obtained.

Unit managers were sent calendar reminders before the

sustainability audits took place to support the sustainability plan. Signs were created and distributed to all units. Simpli-fied tracking sheets were created to only assess if dyad rounding occurred and no longer cap-tured the healthcare providers’ name or specialty.

ResultsStep 6: Follow-up measure-ments. After dyad rounding adherence reached 80%, follow-up measurements were taken

using the same process as the baseline measurements. How-ever, the hospital changed ven-dors for the follow-up HCAHPS surveys. With the new vendor, patients were contacted by mail to complete the survey between 48 hours and 6 weeks after discharge.

Two hundred and seventy-seven participants completed the baseline survey from 14 departments and all 5 roles (patient care technician, nurse, APC, attending physician,

Figure 1: Nurse standard work

Key process: Dyad rounding; nurseTrigger:

Process performed by: Inpatient provider/nurse dyad roundingOwner: Version/date: 6/12/2017Date for review:

Timing Major steps Key points Reasons w hy

1. Review chart

2. Unit secretary/MD alert RN

3. Provider/RN huddle

4. Round on patient

5. Initiate new orders

• Review all the labs, tests, physician orders, assessments, and progress notes from all specialties

• Observe for physician/APC presence on unit

• Be available for rounding when possible

• Charge nurse identified as backup for rounding when needed

• Before entering room• Discuss new information,

concerns, and issues

• At bedside• Commit to sit (provider)• Use AIDET (provider and RN)• Care team solicit input from all

participants• Teach back with patient• Nurse update communication board

• Implement treatment plan in electronic health record

• Situational awareness• Prepare for needed discussion/

questions about plan

• Reduce wait times• Consistency of process and care• RN won’t always be available when

provider is rounding

• Share sensitive information • A shared mental model• Safety and quality (patient and care-

givers)

• Involves everyone• Best practice• Manages expectations for all• Teams are better than individuals—

all information is considered• Ensure patient understanding of

care plan• Avoid communication errors with

patient and care team

• Safety, timeliness, efficiency

ê Critical steps Ì Safety Visual cues 6 Timing › Tip



and nurse coordinator). Only 94 participants completed the follow-up survey from 14 departments and only 4 roles (no APCs completed the follow-up survey). The response rates were approximately 25% and 8%, respectively.

Before implementation of dyad rounding, the HCAHPS survey composite top-box scores and percentile rank (PR) for nurse communication, physician communication, and care transi-tions were 82.8% (PR = 37%), 82.9% (PR = 42%), and 65.7% (PR = 80%), respectively. Follow-ing the implementation of dyad rounding, the top-box scores

and PR increased for all three measures. (See Figure 3.)

The mean overall CASCD score for all participants was 5.3 before and 5.2, respectively. There was no significant dif-ference between the overall collaboration score before and after implementation of dyad rounding (F (1, 368) = .845; P = .358). There was also no dif-ference in collaboration by role or unit. There was a difference in one item on the scale (decision-making responsibilities for patient care are shared between nurses and physicians). How-ever, the mean score decreased from 5.3 to 4.9. (F (1,369) = 4.433;

P = .036). The Cronbach’s alpha for this project was .963 and .954, respectively.

Overall satisfaction with rounding was 3.7 before and 3.9 after implementation; however, this improvement wasn’t statis-tically significant (F (1, 352) = 2.289; P = .101). There was also no difference in overall satisfac-tion with rounding by role or unit.

Three themes (communication/collaboration, rounding process, and patient/family focus) were identified from the qualitative questions. These themes were present both before and after implementation of dyad round-

Figure 2: Physician standard work

Key process: Dyad rounding; physicianTrigger:

Process performed by: Inpatient provider/nurse dyad roundingOwner: Version/date: 6/5/2017Date for review:

Timing Major steps Key points Reasons why

1. Review chart

2. Notify rounding RN

3. Provider/RN huddle

4. Round on patient

5. Enter orders

• Review all the charts, labs, nurse comments, and progress notes from all specialties

• Notify RN via unit secretary or charge nurse

• Visual physician sees nurse on floor• If RN unavailable, see charge nurse

• Before entering room• Discuss new information, concerns,

and issues

• At bedside • Commit to sit (provider)• Use AIDET (provider and RN)• Care team solicit input from all par-

ticipants• Nurse update communication board

• Initiate care plan in electronic health record

• Situational awareness

• Initiate rounding process; situational awareness

• Share sensitive information • A shared mental model• Safety and quality (patient and care-

givers)

• Involves everyone• Best practice• Manages expectations for all• Teams are better than individuals

• Avoid communication errors

• Safety, timeliness, efficiency

ê Critical steps Ì Safety Visual cues 6 Timing › Tip




ing. However, the sentiment of the themes differed. Following dyad rounding, respondents expressed more collabora-tion, were more positive about the process, and felt rounding resulted in a more patient-cen-tered approach. (See Table 1.) The qualitative responses also cap-tured information on safety near-miss events (good catches) that occurred because of dyad round-ing. The following are three representative examples of how implementation of dyad round-ing improved care transitions, safety, and patient-centered care:• care transitions. A patient was to be discharged to a skilled nursing facility and the nurse was concerned about possible premature discharge. While rounding with the physician and patient, the nurse asked clarify-ing questions, which led the physician to extend the patient’s hospital stay.

• safety. During dyad rounding, the physician said verbally that he was going to order 2 units of blood for the patient. When the nurse looked later, the order was for 2 units of platelets. Had the nurse not rounded and heard the correct order, the opportu-nity to clarify the incorrect order would’ve been missed.• patient-centered care. Dyad rounding occurred with a patient and nine family members. The healthcare provider introduced the nurse and physician as part of the team, and the patient/family were able to ask clarify-ing questions. They reported how great it was to have them all there at once.

DiscussionThis QI project is an example of a systematic and rigorous approach to a hospital-wide improvement process. HCAHPS surveys showed improvement

in top-box scores, as well as PR. These findings are similar to other research identifying improved HCAHPS scores fol-lowing nurse-led interdisciplin-ary rounding and establishing that interdisciplinary rounds improved communication, awareness of clinical issues, and team building.4,7,11

Although the other quanti-tative measures (CASCD and overall satisfaction with dyad rounding) in this project failed to show statistical significance, these nonsignificant findings may be, in part, due to the low response rate for the follow-up survey. However, other studies found improvement in safety attitudes after implementing nurse-physician rounding. Specifically, Henkin and col-leagues reported that inter-professional bedside rounding improved nurses’ perception that they would feel comfort-able speaking up and physi-cian residents’ attitude that nurses’ input into patient care is well received.6

The qualitative results in our project suggest that imple-mentation of dyad rounding improved satisfaction with communication and had the potential to identify near-miss situations. In another project of interdisciplinary rounding on the ICU, a standardized approach using Lean meth-odology increased nurse par-ticipation in rounds from 36% to 72% on a surgical ICU and from 35% to 100% on a medical ICU.8 Bedside miscommunica-tion and errors were corrected in nearly half of the rounding episodes observed.8 These results are relevant because

Figure 3: HCAHPS survey before and after implementation of dyad rounding

60

*Percentage rank

Physiciancommunication

PR 50*84.7

PR 80*65.7

PR 82*66.5

Nursecommunication

Transitionsin care

65

70

75

80

85

90

PR 50*84.2PR 42*

82.9PR 37*

82.8

BEFORE percentalways/stronglyagree

AFTER percentalways/stronglyagree



nurse satisfaction with bedside interdisciplinary team rounds may support nursing retention and decrease errors.16 Further, failure in communication between nurses and physicians is associated with higher medi-cal errors and poor patient safety outcomes.9,10

Another important aspect of this project is the demonstra-

tion of sustainability. During the sustainability measures, all units except for one were able to demonstrate 80% sustain-ability within a few weeks. The adherence rates for our project are quite different from other reports, where only 58% adherence with bedside rounds was achieved across four medical teams.6 Sustain-

ability is an essential aspect of any QI endeavor. Indeed, Donnelly reported that 70% of organizational changes aren’t sustained.17 Further, Silver and colleagues claimed that for QI initiatives to be success-ful, they must be integrated into the workflow rather than seen as an add-on initiative.18 They recommended using a

Table 1: Qualitative themesTheme 1: Collaboration/communication

Before After

What works well “I wasn’t aware we were doing physician/RN combined rounding.”

“I like that I have a better picture of the patient’s plan of care.”

What doesn’t work well

“I feel sometimes that I’m the last one to know the plan of care. Then I have to call the physi-cian and sometimes get orders changed, which could’ve been avoided if I was there.”

“The physicians aren’t asking the nurses questions.”

Suggested changes “Have concerns listed by RN on the whiteboard.” “More interaction from nursing.”

Theme 2: Rounding process

Before After

What works well “When it does happen, it’s more of a coincidence rather than a planned event. But just being in the room at the same time as the physician is doing his or her rounds is a big first step.”

“When the RN coordinator calls and says the physician will be rounding in a few minutes, this helps so you can manage the time you have and finish any tasks that you’re in the middle of.”


“If I don’t make an effort to step in on physician rounding, I don’t hear the updated plan of care most times.”

“Not sure how to avoid it, but sometimes mul-tiple physicians are rounding on more than one of my patients. I can’t be all places all the time.”

Suggested changes “Physicians could let RN staff know when they’re going to round on their patient(s) so RNs have the opportunity to be at the bedside during the round and/or express concerns or bring up patient and RN questions before the round.”

“Set times for rounding. This would be difficult to arrange.”

Theme 3: Patient/family focus

Before After

What works well “Patient interaction with the care team to feel involved.”

“Patient and family satisfaction is high when they can see the team working together even if they don’t understand all the lingo and when they’re invited to ask questions.”


“Patients say the physician wasn’t in long and they forgot their question they had for them. Fam-ily members want to know what time [rounding will be].”

“Physicians need to continue to be awesome, but also ask nurses individually what’s going on with the patients. So, physicians can get a bet-ter understanding of patient status.”

Suggested changes “Anticipating guidance for patients, all team members feeling comfortable answering family questions.”

“Preparing the family and patient to participate actively in rounds, knowing how to reach the nurse in case he or she isn’t at the bedside.”




sustainability model before, during, and after implementa-tion initiatives, which includes addressing the organization’s contextual factors.18

Limitations and barriersThis QI project was limited because it was implemented only at one tertiary medical cen-ter, concentrated on increasing adherence with dyad rounding rather than the quality of the rounding process, and had a low response rate. Additionally, the baseline and follow-up sur-veys weren’t matched and the HCAHPS data collection methods changed after implementation. Another limitation was that the project didn’t address if the patient or family were present and interacted with the nurses and healthcare providers during dyad rounding.

The most significant barrier to implementing dyad rounding was the logistics of coordinating the healthcare provider sched-ule with the nurses to ensure that they would be in the room at the same time. This project identified that finding ways to improve coordination and smooth the transitions between patients helped the implementa-tion and sustainment of dyad rounding.

Interventions to decrease barriers to dyad rounding are essential for success. In one study, the amount of minutes per day spent searching for the right team member was significantly decreased follow-ing implementation of an app designed for this purpose.19 Use of this type of technology may address barriers to implement-ing dyad rounding.

Lessons learnedThe following are lessons learned during this QI project:• Identifying that the first goal was to get the nurse and healthcare provider in the room together was important.• Receiving support from admin-istration and key stakeholders was essential to success. Man-agers and charge nurses met weekly, even when their unit wasn’t scheduled to implement for several months.• Starting with a pilot unit, refin-ing the implementation, and then following a strategic rollout plan resulted in a stable process.• Obtaining data promptly and distributing them to key stake-holders facilitated sustainability.• Standardizing education and setting clear expectations were necessary. However, units adapted implementation to their unique circumstances.• The nurses and unit secretaries drove the success of the project. Nurses used innovative ways to engage healthcare providers.

Improving communicationCommunication between nurses and healthcare providers remains a problem in health-care. Dyad rounding is one method to improve communi-cation and identify potential communication-related errors. To sustain improvements, sys-tematic QI methods need to be rigorously applied. Although communication among the healthcare team is of utmost importance, teamwork and communication may be difficult to quantify. More research is needed to measure the effect of innovations such as dyad rounding quantitatively. NM

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Amy Christensen is a nurse administra-tor at Intermountain-Dixie Regional Medical Center in St. George, Utah. Korby Miller is the system director for experience of care at the Intermountain Healthcare Office of Patient Experience

in Salt Lake City, Utah. Jason Neff is the assistant vice president of con-tinuous improvement at Intermountain Healthcare in Salt Lake City, Utah. Rusty A. Moore is the continuous improve-ment medical director at Intermountain Healthcare in Salt Lake City, Utah. ShaRee Hirschi is a senior execu-tive assistant at Intermountain-Dixie Regional Medical Center in St. George, Utah. Katreena Collette-Merrill is an associate professor and associate dean of undergraduate studies at Brigham Young University College of Nursing in Provo, Utah, and a research consultant for Intermountain Healthcare.

The authors have disclosed no financial relationships related to this article.

DOI-10.1097/01.NUMA.0000617052.03686.74


the effect of dyad rounding on collaboration and patient

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