Patient and FamilyCentered Care Patient and FamilyCentered Rounding

Patient- and Family-Centered Care & Patient- and Family-Centered Rounding: An introduction and guide to bedside interdisciplinary rounding Jeffrey D. Schlaudecker, M. D. Assistant Professor of Family Medicine University of Cincinnati Associate Program Director Assistant Director of Inpatient Family Medicine The Christ Hospital/University of Cincinnati Family Medicine Residency

Objectives • 1. Describe the key elements of patient- and familycentered care (PFCC) and patient- and family-centered rounding (PFCR) • 2. List examples of how patient- and family-centered rounding can improve patient safety, staff satisfaction, and resident physician education • 3. Explain how patient- and family-centered rounds differ from traditional models of hospital care on an academic hospital unit • 4. Describe specific examples of barriers and solutions to adopting patient- and family-centered rounding

What is patient- and family-centered care? • An innovative approach to health care Patients • Grounded in mutually beneficial partnerships • All ages • All health care settings • www. familycenteredcare. org Providers Families

What are the core concepts of patient- and family-centered care? • • Dignity and Respect Information Sharing Participation Collaboration

Patient- and Family-Centered Care Core Concepts • Dignity and Respect Health care practitioners listen to and honor patient and family perspectives and choices. Patient and family knowledge, values, beliefs and cultural backgrounds are incorporated into the delivery of care. www. familycenteredcare. org

Patient- and Family-Centered Care Core Concepts • Information Sharing Health care practitioners communicate and share complete and unbiased information with patients and families in ways that are affirming and useful. (“It’s not called: Show everyone how smart you arecentered care”) Patients and families receive timely, complete, and accurate information in order to effectively participate in care and decision-making. www. familycenteredcare. org

Patient- and Family-Centered Care Core Concepts • Participation Patients and families are encouraged and supported in participating in care and decisionmaking at the level they choose.

Patient- and Family-Centered Care Core Concepts • Collaboration Health care leaders collaborate with patients and families in policy and program development, implementation, and evaluation; in health care facility design; and in professional education, as well as in the delivery of care. www. ipfcc. org

Patient- and Family-Centered Rounding • What is it? – A model of communicating and learning between the patient, family, medical professionals, and learners – Traditionally described on an academic inpatient ward setting – Bedside interdisciplinary work rounds – Pt and family share in control of management plan – (vs. traditional teaching rounds) • Johnson BH. Family-centered care: Four decades of progress. Families Systems & Health. 2000; 18: 137– 56.

The Traditional Model of Rounds ▼ Timing primarily based on physician schedule. ▼ Information primarily transmitted from physician to patient. ▼ Goals for hospitalization are not always explicit. ▼ Other members of the care team are not necessarily present. ▼ Teaching of students takes place separately.

Basics of Being at the Bedside • Patient- and Family-Centered Rounds start at admission – Elicit family preferences – Explain process and roles – Nurse and/or MD driven • Clarify family or patient preference in the morning – Those who opt in far outnumber those who opt out the morning of rounds (>90% opt in)

Basics of Being at the Bedside • Non-verbal core concepts – Positioning of team and key members to include family – Respecting family’s space – Eye contact and body language • Verbal core concepts – Introductions: Names and roles – Invitation to participate: “Please interject…” – Member of team: “You are the expert…. ”

Basics of Being at the Bedside • Multidisciplinary presence and role – Patient/family – Bedside nurse – Charge nurse/discharge planner – Allied health: Respiratory Therapy, Nutrition, Social Work… – Attending physician – Trainee physicians and nurses

Patient- and Family-Centered Rounds • Patients and families are viewed as partners, not visitors. • Patients and families have a range of choices in how they can participate in rounds. • Efforts are made to schedule rounds to fit family availability. Cincinnati Children’s Hospital Medical Center 2008 Recipient of Picker Award for Excellence in the Advancement of Patient. Centered Care

Family-Centered Rounding Logistics at TCH • Always begins with choice! • Performed with both new and follow-up pts • Takes place at the bedside

FCR Logistics • Resident ascertains pt/family wishes on admission; reviews process prior to rounds; invite relevant health-care team members • Members of team introduced • Process explained • Case presented • Discussion/Questions • Follow-up explained

Logistics at TCH • “Level the playing field” – Critical importance for family and pt to feel like integral members of team • Process explained – "The most important thing we do on rounds is make the plan for the day. While we're the experts on medicine, you're the expert on you and your family. Together we'll make better decisions. “ – "I'm going to review the story so our entire group understands what brought you to the hospital. Please feel free to add or correct anything as I go along. " – "I'm going to review for the team what happened in the last 24 hours. Your input will be very important. "

TCH Family Medicine Experience: – Launched 10/07 on geriatric ACE unit: since expanded to all units on all appropriate patients – Not for everyone – Very high pt/family satisfaction – Better teaching – More efficient care – Safer care

Enhanced Patient Safety • Improved discharge planning • Case manager and social worker involved earlier – Able to identify barriers to timely discharge • Pt & family involved in choosing followup plan that works for them – When, where, with whom • Aware of follow-up plan – Increased awareness of events of hospitalization

Literature Search • Strong evidence that patients like bedside rounds; suggested key elements for success: – Introductions – Nurse presence – Use understandable language – Allow/invite patients to participate – Special care with physical exam/social history – Knoderer HM. Inclusion of parents in pediatric subspecialty team rounds: Attitudes of the family and medical team. Acad Med. 2009; 84: 1576 -1581.

Literature Search • Learners initially don’t like bedside presentations, but become comfortable with experience – Initially learners worry about family discomfort, but with experience perceive families prefer to participate • Family-centered rounds challenges us to move beyond our comfort zone and approach uncertainty at the bedside.

The Evidence • MCGHealth in Augusta, GA • Neuroscience Center of Excellence • 3 years after implementing patient- and family-centered initiatives, including conducting rounds at the bedside with patients and families: – Patient satisfaction 10 th to 95 th percentile – LOS ↓ 50% – Nursing staff vacancy rate 8% to 0% – Increased faculty and trainee satisfaction

More Evidence • Concord, NH Cardiac Surgery Program – Following initiation of collaborative rounds – Mortality decreased by ½ – Increased patient satisfaction (to 99 th percentile nationally) – Greater staff satisfaction – “Flat Hierarchy” saves lives Uhlig, P. N. , Brown, J. , Nason, A. K. , Camelio, A. , & Kendall, E. (2002). System innovation: Concord Hospital. The Joint Commission Journal on Quality Improvement, 28(12), 666 -672.

Developed with Patient and Family Advisors Critical Care Tower Vanderbilt University Medical Center

http: //www. vanderbilthealth. com/traumasurvivors/

More Evidence. . . Cincinnati Children's Hospital Medical Center: Rounds take 20% longer • Overall daily time per patient is reduced Patients/families benefit • 85% participate; satisfaction increased Staff feel more knowledgeable about the care plan Errors in orders decreased from 9% to 1% Education improved • ▼ Faculty, students, and residents all report increased satisfaction Muething, S. E. , et. al. (2007). Family-centered bedside rounds: A new approach to patient care and teaching. Pediatrics, 119(4), 829 -832.

Family-Centered Rounds: A Pediatric Hematology/Oncology Unit Resident: – – “I learned how to explain things to families” “Its especially helpful for interns who may seek to model their own interactions after what they have witnessed. Family: – – – • “Now I feel like part of his care” “We were helpful with clarifying her background” “This gives me more opportunity to connect with the doctor” Knoderer HM. Inclusion of parents in pediatric subspecialty team rounds: attitudes of the family and medical team. Acad Med 2009; 84: 1576 -81.

Family-Centered Rounds (FCR): Staff Attitudes “I can better understand the patient's care plans” FCR: 91% SA/A CR: 6% SA/A “I feel I am working on a team to care for patients” FCR: 92% SA/A CR: 28% SA/A • Rosen, P. , et. al. (2009). Family-centered multidisciplinary rounds enhance the team approach in pediatrics. Pediatrics, 123(4), e 603 -e 608.

Resident Attitude n=81

Patient- and Family-Centered Rounding Common Concerns Teaching will be pushed aside • Learning occurs in ways not possible in conference room or lecture hall. • Physicians learn to be comfortable with uncertainty (families already are!) Muething, S. E. , et. al. (2007). Family-centered bedside rounds: A new approach to patient care and teaching. Pediatrics, 119(4), 829 -832.

Patient- and Family-Centered Rounding Common Concerns Not enough time! • Time used more efficiently: saves time – Concord Hospital Adult Cardiac/Thoracic Step-down Unit: staff felt slight increase in time early in day, saves time later. – 2009 Adolescent Medicine Unit(Pittsburgh) » Added 2. 7 minutes per patient – 2007 Cincinnati Children’s Hospital Medical Center: added 20% time to rounds – Knoderer HM. Inclusion of parents in pediatric subspecialty team rounds: Attitudes of the family and medical team. Acad Med. 2009; 84: 1576 -1581.

“The How To” for Patient- and Family-Centered Rounds 1. Just do it. 2. Explain “why” every time with every patient. – Soon everyone will believe you!

“The How To” for Patient- and Family. Centered Rounds 3. Review patient list to determine if there are some patients who may not benefit for patient- and family-centered rounds. – Personal preference. – Altered mental status with no family. – Sensitive social/health issues

“The How To” for Patient- and Family-Centered Rounds 4. At the doorway: – Intern goes in first: asks permission (again). – As group comes in, reminds patient/family why rounds are conducted in this manner. – Ground rules, introductions

“The How To” for Patient- and Family-Centered Rounds 5. In the room: – Discuss with team (including patient and family). • Switch pronouns to engage listeners: “You” not “she. ” – Give patient permission to “tune out. ” • “I’m going to run through all of your lab results for the team. I will translate the important ones for you at the end. ” – Ask nurse and patient and family for input at selected times. • Its family-centered rounds NOT family-dominated discussion.

“The How To” for Patient- and Family-Centered Rounds 6. Ask permission to teach. – Patient and family should know when someone is teaching and not specifically discussing their case 7. The Conclusion. – Strong summary and “Plan for the Day. ” – Who is on call. – When someone will return.

Common Pitfalls • It must be mutually beneficial. – Not “show smart you are” rounds – Not “family-dominated rounds” – Physicians set collaborative tone for encounter • It's still a presentation. – Beware the pragmatics of speech! – Condense the History and Physical information. • It can't take all day. It shouldn't take all day. – Residents need feedback on presentation technique. – Not everything written can nor should be said!

Selected References: • • (1) Sisterhen L, Blaszak R, Woods M, Smith C. Defining family-centered rounds. Teaching and Learning in Medicine 2007; 19(3): 319 -322. (2) Rosen P, Stenger E, Bochkoris M, Hannon MJ, Kent C. Family-centered multidisciplinary rounds enhance the team approach in pediatrics. Pediatrics 2009; 123: e 603 -e 608. (3) Cypress BS. Family presence on rounds: A systematic review of literature. Dimens Crit Care Nurs. 2012; 31(1): 53 -64. (4) Rappaport DI, Ketterer TA, Nilforoshan V, Sharif, S. Family-centered rounds: Views of families, nurses, trainees, and attending physicians. Clin Ped 2012; 51(3): 260 -266. (5) Latta LC, Dick R, Parry C, Tamura GS. Parental responses to involvement in rounds on a pediatric inpatient unit at a teaching hospital: a qualitative study. Acad. Med 2008; 83: 292 -297. (6) Knoderer HM. Inclusion of parents in pediatric subspecialty team rounds: Attitudes of the family and medical team. Acad Med. 2009; 84: 1576 -1581. (7) Rappaport DI, Cellucci MF, Leffler MG. Implementing family-centered rounds: Pediatric residents’ perceptions. Clin Ped. 2010; 49(3): 228 -234. (8) Barry MJ, Edgman-Levitan S. Shared Decision Making - The Pinnacle of Patient-Centered Care. N Engl J Med. 2012; 366: 780 -781.

Thank You More information: Institute for Patient- and Family. Centered Care www. ipfcc. org jeffrey. schlaudecker@uc. edu