Continuous Improvement project breaks down barriers
When Kelly Hancock, DNP, RN, NE-BC, Executive Chief Nursing Officer of Cleveland Clinic, and her nursing leadership team select continuous improvement projects for the Zielony Nursing Institute, they consider one key question: What matters most? That core question, at the heart of Cleveland Clinic’s culture of improvement, encourages everyone – from management to caregivers – to align around, clarify and standardize practices that matter most.
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In the spring of 2016, nursing leadership chose purposeful hourly rounding as a top priority.
“Researchers found that purposeful hourly rounding keeps patients safe and improves outcomes, quality and the patient experience,” says Susan Coyne, BSN, RN, Senior Continuous Improvement Specialist for the Zielony Institute. “We have always believed in purposeful hourly rounding and had standard operating procedures in place for it. But we were inconsistent in our application and needed to understand why.”
Deborah C. Small, DNP, RN, NE-BC, then CNO of Cleveland Clinic Fairview Hospital, volunteered her hospital to spearhead the continuous improvement project on purposeful hourly rounding (Dr. Small has recently been appointed CNO of Cleveland Clinic London). In May 2016, a 25-bed medical-surgical and telemetry unit (5 Pavilion) and a 12-bed medical-surgical and telemetry unit (5 West) initiated the purposeful hourly rounding pilot. Soon after, a 36-bed medical-surgical unit specializing in oncology and women’s health (Parkview 1) joined the pilot.
The units held multiple meetings with leadership, continuous improvement staff, clinical nurses and patient care nursing assistants (PCNAs) to consider four main questions:
“The original policy for purposeful hourly rounding states that nurses should round on every patient, every hour and ask them about the four Ps,” says Katie Galvan, BSN, RN, CMSRN, Nurse Manager of 5 Pavilion and 5 West. The four Ps are:
“Nurses felt it wasn’t appropriate to ask those questions of every patient in the hospital and did not follow through in a systemic way when rounding,” says Galvan. To get to the root of the issue, the three med-surg units began self-auditing rounding practices. Nurses and PCNAs completed a simple audit log indicating whether they rounded each hour and assessed all four Ps (yes or no) and, if not, why.
Galvan and Matthew Frye, BSN, RN, CMSRN, nurse manager of Parkview 1, also had one-on-one conversations with caregivers about rounding that revealed their distress. “One nurse told me she was unable to go into each of her six patient rooms every hour,” recalls Galvan. “She felt like she was letting us down because she wasn’t able to do what we asked of her.”
Through the self-audits and one-on-one conversations with caregivers, Galvan and Frye discovered several reasons why purposeful hourly rounding wasn’t always accomplished, including the following:
Using data from self-audits, Frye created an Excel spreadsheet to analyze and graph the results. The spreadsheet helped med-surg unit teams better understand rounding compliance and non-compliance trends and specific barriers. Data were also used to examine trends over time and rounding compliance improvement.
Utilizing data and anecdotal evidence from caregivers, med-surg nurses began to consider what hourly rounding should look like and how to remove barriers. “No matter what, every single hour, 24 hours a day, someone should be rounding,” says Galvan. “That doesn’t mean we’re going to use the same language, ask the same questions or wake people up. Nurses now are empowered to round using the ‘observe vs. ask’ guidelines.”
Instead, caregivers considered patient circumstances. “Critical thinking and a focus on patients drive what caregivers do when they go into a room,” says Peg Homyak, MSN, RN, NE-BC, Director of Acute Care Services at Fairview Hospital. Sometimes nurses simply look in on the patient. Other times, they ask some or all of the four Ps. Nurses on 5 Pavilion created a visual management tool to help caregivers identify what hourly rounding should look like based on three basic criteria: Is the patient awake and a fall risk, awake but not a fall risk, or asleep?
To promote rounding adherence, a nurse manager dashboard was created that shows real-time current and previous-hour data in the electronic medical record. Rounding documentation non-adherence to standards of practice allows nurse leaders and charge nurses to initiate conversations with caregivers on barriers and potential resolution. For example, an assistant nurse manager noticed that a clinical nurse hadn’t documented rounding at midnight. In conversations, she discovered the caregiver was busy with a patient who had continuous bladder irrigation (CBI). The assistant nurse manager offered to deal with the CBI so the nurse could round on other patients.
Med-surg unit nursing teams also reviewed conflicting standard operating procedures (SOPs) on pain, sleep and delirium. They aligned SOPs with the new purposeful hourly rounding policy.
“The steps taken to improve hourly rounding consistency help the team understand the problems from a broad perspective, so that best solutions are implemented,” says Coyne. Improvements in rounding are reflected in Press Ganey survey scores for the three med-surg units. Between April and June 2016, the responsiveness score for the units was 62.7 percent. A year later the score rose to 70.7 percent. The quiet environment score for April through June 2016 was 51.6 percent. It increased to 75 percent between April and June 2017.
Equally important, the new purposeful hourly rounding process empowers caregivers. “It allows nurses to use critical thinking and judgment,” concludes Homyak. “And that’s exactly what we want them to do.”
When the three medical-surgical units at Fairview Hospital identified barriers to purposeful hourly rounding, they created solutions to remove those barriers. Here are examples of three obstacles to rounding and how they were addressed:
Barrier: Unit emergencies
Solution: Nursing staff created a unit workflow that clearly describes staff roles during times of emergency. It identifies the caregivers needed at the bedside during rapid response and code blue situations. It also details caregiver duties that can be dismissed after the emergency medical team arrives. The workflow places emphasis on rounding on other patients during emergencies.
Barrier: Full compliance with rounding decreases from 7 p.m. to 11 p.m.
Solution: The late evening timeframe coincides with high admissions, high-volume medication administration and staffing level changes from day to night shift. Med-surg unit nursing teams are striving to increase communication and accountability between peers during traditionally busy times. Teams have utilized role playing and brainstorming in small groups to help staff approach sensitive conversations, such as when a PCNA needs to ask an RN for help with rounding.
Barrier: Missed documentation of rounding in the electronic medical record (EMR).
Solution: During staff meetings, huddles and practice council meetings, med-surg unit leaders placed educational emphasis on accurate documentation. All staff received education on the rounding documentation feature within the EMR. In addition, staff perform random real-time feedback audits related to hourly rounds documentation.
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