Patient satisfaction has long been one way that hospitals measured quality, albeit indirectly. The surgical services division of Rush University Medical Center, an academic medical center in Chicago, IL, planned and implemented a broader approach to measuring quality based on purposeful daily leadership rounding (PDLR) specifically focused on clinical quality and safety outcomes. This article summarizes the process used and highlights key outcomes that were achieved.
A brief review of the literature
For decades, healthcare institutions and their leaders worked to “assure” quality care. We focused on structures and processes, expiration dates, and packaging and equipment checklists in the belief that these measures would guarantee quality, and safety, in the patient care environment. Among the array of other indicators, patient satisfaction was also measured and used as a critical, indirect benchmark for quality care. However, today the healthcare narrative has shifted to a broader view of quality that incorporates quality, safety, and patient satisfaction in ways intended to improve the overall patient experience: patients receive high-quality care, are kept safe from preventable adverse events, and are treated well.
Hospital and nursing leaders have realized that rounding focused solely on patient satisfaction doesn’t work. To quote Nina Setia and Christina Meade’s 2009 article on discharge telephone calls, “Simply saying hello and not asking in-depth questions” will not provide the nursing leader with an overall assessment of the quality and safety standards within the unit, and will likely not lead to sustainable improvements in patients’ overall experiences.
Setia and Meade outlined an intervention in which nursing leaders’ rounding on inpatients was linked to postdischarge telephone calls. What the authors called “the most interesting insight” that emerged from their work is that “when a nurse leader rounds on patients, the patients feel better about the nurses caring for them.” Postdischarge telephone calls and the patients’ responses to these were bundled into the analysis of patient satisfaction. Carol Forde-Johnston’s 2014 review of intentional rounding examined 22 articles that specifically linked rounding (intention and/or hourly) to clinical outcomes or patient experiences. This analysis revealed widespread improvements in the reduction of falls and pressure ulcers as a result of intentional rounding. Forde-Johnston concluded that the “use of intentional rounding indicates that patients will benefit from regular communication in a safe and comfortable environment.”
Intentional rounding and its focus on patient-care provider communication have also been woven into efforts to transform care at the bedside (TCAB). A group of researchers reported on a project to change bedside care at four hospitals in Australia; using lean principles and pillars of TCAB, they found that clinical outcomes improved, nurses were able to spend more time with their patients, and patient satisfaction increased.
The Rush University Medical Center’s PDLR project was built on Kurt Lewin’s three-step model of change, which requires prior learning to be rejected and replaced. (For more detailed information, visit www.nursing-theory.org/theories-and-models/Lewin-Change-Theory.php). The three stages of change as applied to implementation of the PDLR nursing project, are as follows:
- Unfreezing (ready to change): finding a way to make it possible for people to let go of an old pattern that was counterproductive.
- Change (implementation): moving to a new level, which involves a process of change in thoughts, feeling, behavior, or all three.
- Freeze (refreeze and make it stick): establishing the change as the new habit so that it becomes the standard operation procedure.
Building on this framework, we were able to make a significant change, minimize any possible operational disruptions, and assure permanent adoption of the change. Habits and routine were carefully examined to evaluate their continued relevance, utility, and relationship to departmental and organizational goals. The implementation process involved not only a learning curve, but a period of transition and shift in resource allocation as well. Finally, care was taken to be sure that change would settle in permanently and become the new norm.
Implementing the PDLR trial program
The intention of the PDLR program was to shift the approach to healthcare delivery to incorporate a paradigm that assumes quality, safety, and satisfaction are equally important to both the satisfaction and outcomes of our patients. This new focus provides an opportunity to repurpose the work of daily nurse leader rounding. PDLR is a mechanism that validates the concept that service is about more than patient satisfaction indicators such as responsiveness, timeliness, and team caring practices, and result in improved outcomes in safety and quality as well as sustained improvement in selected nursing-sensitive clinical outcomes. This shift was implemented within the surgical services department of Rush University Medical Center, a large, urban, Midwestern academic medical center.
Nursing leaders from five acute care units (orthopedics; cardiovascular surgery and spine; neurosciences, transplant, and general surgery; ENT; and gynecologic and general surgery) that encompassed this department planned, implemented, and evaluated the change over the course of nearly a year. These units comprise 157 beds, with a total average daily census of 122 patients.
Change occurred in five phases:
Phase I. Changing the paradigm and establishing goals (Unfreezing). The leadership group participated in a day-long, off-campus retreat where they systematically reviewed the evidence-based literature that addressed PDRL and identified ways in which PDLR highlights both clinical quality and safety. The group examined past rounding strategies that had focused primarily on patient satisfaction or on “smiles over substance.”
Phase II. Aligning and defining style (Unfreezing, continued; Change). In contrast to some widely used, highly scripted approaches, each leader was tasked with developing her or his unique approach that would best reflect individual personalities and style. In addition, the different patient populations admitted to each units were taken into consideration. Leaders also took into account the often negative staff perceptions about scripting. As a result, it was decided that the new refocused leadership rounds would be unscripted and, it was hoped, a better reflection of leaders’ personal communication styles, personal warmth, and authenticity. However, the domains of quality, safety, and service were highlighted as non-negotiable, and were incorporated into each individual leader’s talking points. Several weeks were spent practicing and refining styles using the talking points, sharing what did and did not work, and exchanging best practices learned at the unit level.
Phase III: Developing leadership competency (Change, continued). The work to this point led to cautious optimism in relation to changing outcomes. The commitment was to embark on a trial of PDLR for 90 days and then reassess. Leaders were not asked to quantify data or submit written logs of rounds. Instead, emphasis was placed on “softer,” more qualitative improvements, such as stories of what the leader learned on rounds, reactions they received from patients, or patient interactions that were thought of as “wins.” These stories were shared during weekly team meetings and one-on-one meetings with senior leadership.
Phase IV: Optimizing (Change, continued). Following a 90-day trial of PDLR, leaders were asked to evaluate the implementation of PDLR. The results were overwhelmingly positive. Leader feedback included the following comments.
- “This is the most important part of my day… I have my finger on the pulse of the unit.”
- “I used to think we had a high patient fall rate due to our complex patient population, but now from purposefully rounding each day I realize that we do not have consistent practices regarding the prevention of falls. I wouldn’t have learned this unless I saw our gaps in practice first-hand.”
- “This has reconnected me to the patients, families, and the clinical care of the unit.”
- “I feel more connected to my staff. I now have clear reasons to reward and recognize the team.”
Phase V: Expanding to Sustain (Refreezing). Finally, to sustain momentum and provide a leadership presence 24/7, leaders identified two or three other staff members who would complete each unit’s PDLR team; these individuals included clinical educators, clinical nurse specialists, charge nurses, and select staff nurses who had achieved the top tier in the hospital’s clinical performance ladder. Because unit directors has been rounding in the context of the new paradigms for 90+ days, they led their teams in developing talking points, role playing, and dissemination of lessons learned. New team members were observed on at least three occasions and given feedback to ensure and comfort with the process. (See Timeline for change for a depiction of the process as it unfolded.)
Before the intervention, patient days for the five units equaled 33,100; postintervention, patient days equaled 33,400. The average age of patients interviewed in the preintervention phase was 56.6; the sample was predominantly white and female. Almost no change in demographic characteristics of patients was evident from the pre- to postintervention periods.
Risk-reduction statistics determined that the PDLR intervention resulted in a substantial reduction in the number of falls and falls with injuries (FWIs). (See Complication rates.) Although only one type of complication (falls plus hospital-acquired pressure ulcers [HAPU]) showed a significant reduction (127%), the magnitude of the reductions was large for both falls with injury (76%) and HAPU (178%).
In addition to quality and safety data, we also saw an improvement in overall patient experience scores in units performing PDLR versus those that did not. (See Comparison of patient experience scores.) Over a 1-year period, all domains except physician communication and communication about medications saw improvement in the overall percentile rank.
Implications for organizational change
Our year-long journey of implementing a PDLR program focused on quality, safety, and service resulted in a shift in context and viewpoint for our leadership team. Rounds are no longer focused on patient satisfaction and service recovery; instead, they are directly focused on clinical quality and safety. In fact, we now measure the success of our leadership rounding using our benchmarked clinical outcome scores rather than patient satisfaction scores.
We believe this paradigm shift has led to significant improvements in our clinical outcomes, and underscores the tenet that delivering both quality and safety is an essential part of effective nursing leadership and a critical component of our core business as healthcare providers. In addition to the quantitative impact that was described above, we have witnessed an equally significant positive response in leadership engagement. Time after time, leaders have described their investment in purposeful rounding as a game changer for the daily work of the nursing unit leaders. An added bonus was the change in staff perceptions related to leadership rounding. Staff no longer view rounds as a potentially negative or punitive event but as a way leaders identified quality care and opportunities for positive change.
We argue that the success of this program grew out of several strategies. First, scripting was not used. Leaders were expected to use their preferred communication styles based on what they knew and understood about themselves and their units. Second, the initiative focused on quality and safety rather than only on satisfaction or experience. Finally, we evaluated changes in patient outcomes rather than an analysis of logs, checklists, or reports.
Our focus is on more than just patient satisfaction. As James Merlino, MD, president and founder of the Association for Patient Experience explains, “The patient experience is not about making patients happy over quality. It’s about safe care first, high-quality care, and then satisfaction.” We have made an organizational change that with continued support and attention should allow us to sustain the gains we have made. Although it has not been determined when units outside the surgical services division will initiate a similar change in the focus of leadership rounding, plans are under way.
Susan Carroll, MS, RN, SCRN, is a lecturer at the University of Iowa College of Nursing, Iowa City, IA. Timothy M. Carrigan, PhD, RN, FACHE, is associate vice president of clinical nursing operation, Rush University Medical Center, Chicago, IL.
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