3.1 Golisano Children’s Hospital and Family-Centered Rounds
The Golisano Children’s Hospital at Strong Memorial Hospital, a division of the University of Rochester Medical Center, is the area’s only children’s hospital. This 124-bed hospital is a referral center for seriously ill or injured children from the 17-county Finger Lakes region. Golisano Children’s Hospital adopted the concept of family-centered rounds from Cincinnati Children’s Hospital Medical Center with the hope that the rounds would allow its residents to carry out family-centered care in suboptimal circumstances (e.g., inpatient resident teams with multiple attendings and semiprivate rooms). Family-centered rounds are morning work rounds that are conducted with as many of the persons responsible for a child’s care as possible present at the bedside. Together they assess the patient’s status and formulate plans for the day based on formally stated discharge criteria. The rounds include read-back and confirmation of orders entered via a wireless laptop brought into the patient’s room. Assessing and discussing a patient’s status relative to formally stated discharge criteria means that discharge can be anticipated and prepared for in advance. This approach should result in more timely discharges and maximized continuity of care. At the time of this site visit, Golisano Children’s Hospital had recently completed a 4-month pilot project on the use of these rounds on its three pediatric non-critical-care inpatient floors.
3.2 Decisionmaking Process
The front-line staff and upper administrators at Golisano Children’s agreed that family-centered rounds are “the right thing to do.” The idea of implementing family-centered rounds at Golisano Children’s was spearheaded by residents who felt the need to return to the bedside and improve communication within the care team and with family members. This grassroots effort was enthusiastically joined by nurses, who immediately recognized the benefits of improved communication, clarity of the care plan, increased efficiency of their workday, and improved ability to advocate for their patients. Most important, all recognized that rounding with families would provide an immediate benefit to the patients:
“The main thing is that we wanted the patients to feel like they were a part of the process and to give them a way to empower them to take better care of their children by giving them better information and we wanted them to feel safer in their environment in terms of knowing what to expect and that they would know what would happen next. Then, of course, we wanted them to feel satisfaction with the care when they left.”
In addition to immediate benefits offered by family-centered rounds, residents, nurses, and hospital leadership felt that introducing such rounds would gradually change the paternalistic medical care model:
“A number of us had the philosophy that the old medical model of paternalistic medicine in which the doctors dictate the care to the patient as the high and mighty source of information was wrong. The main thing was to change the decisionmaking locus from the physician alone to a collaboration between the physicians and the family.”
“What’s a little hard for [some providers] to understand is that families become experts on their child’s health. They have different residents and faculty each time they are admitted who don’t have history. It’s a matter of convincing faculty that involving families would lead to better decisionmaking. It requires humility not typically had by experts.”
“We don’t go there to demonstrate a patient to the medical student, but we go there to serve the needs of the children and the family as collaborators rather than experts. It’s a totally different philosophy… .[I]t kills doctors to give up that God-like status.”
To move this effort forward, a group of residents and nurses discussed the logistics of the process and studied how the floors were run at that time, what changes would be needed, how to present the idea to faculty and other residents and obtain their buy-in, and whom to contact in the administration. They made presentations to others at faculty meetings and parent groups and arranged numerous meetings with senior administrators, such as the associate chair for clinical affairs, the chief of inpatient care, and the chair of the Department of Pediatrics, to make “a good idea” become reality.
As residents and nurses presented the concept of family-centered rounds to their upper management, it was embraced with great appreciation. Two decisionmakers explained that they had practiced family-centered rounds early in their careers and that this practice should not have been forgotten in the first place:
“When I started medical school and residency, that’s what we did … and learned a heck of a lot at the bedside. We never should have got rid of this… . I was armed with their [residents] push to get back to the bedside and then I began to reflect on my old career. One of the real joys of practicing pediatric cardiology is interaction with the family and a long-held belief that the family is part of the decisionmaking process… . So how do we, as role models, begin to reinvigorate this with our new trainees?”
“My own historical view weighed most heavily. When they [innovation champions] described it to me, I said that’s not how you do rounds? They said no, we haven’t done that in a long time. That is the way general pediatrics was done 800 years ago when I was a resident… . I said that this explains what I have been seeing. Who stewards the patient between admission and discharge? Nobody. What drove my decision was that the shift to the new model seemed causally related to deterioration in investment in the care team. My sudden realization was that all my complaining about what had become of patient care over the years was related to this change.”
In addition to recognizing the benefits presented by residents and nurses, senior administrators viewed it as an effective new way to train the residents and meet the mandate of teaching and evaluating the trainees in six competency domains: patient care, communication skills, professionalism, systems-based practice, practice-based learning and improvement, and medical knowledge. Senior administrators also recognized that family-centered rounds would improve other areas, including safety and quality. It was expected to improve the medication reconciliation process and reduce medication errors, because medication regimens would be discussed with the entire team and family and prescriptions would be entered during rounding into a portable laptop. Family-centered rounds were expected to improve the discharge process and timing, reduce the length of stay, increase patient turnover, and prevent readmissions. Finally, the family-centered rounds innovation aligned Golisano
Children’s with Institute of Medicine goals of providing patient-centered and efficient care and would enable them to meet the Joint Commission on Accreditation of Healthcare Organizations and Accreditation Council for Graduate Medical Education requirements.
Benefits to the patients and families, resident learning, and overall staff morale were the most important criteria in decisionmaking at the highest level of organizational authority:
“The most important things to me were: What was the best for the patients and families? What was the best for the learning process for my residents and fellows? What was the best for the morale and sense of being part of a family and being heard by staff on patient floors? Frankly, I thought that the reason that this won is that for all three of those priorities, family-centered rounding was better than any other model. [It was the] best way for actual decisions that got made and enacted for families. [It was the] best [way] for my residents and fellows to learn. [It was the] best way to get nurses, social workers, pharmacists, etc., to feel part of the team. Everything weighed on the same side of the ledger. The other things—timing, etc.—those secondarily had to be attended to but it didn’t weight heavily in whether I thought this was a good idea.”
As the adoption of family-centered rounds was coming to fruition, residents and nurse champions made two trips to Cincinnati Children’s, where a new model of safer, more efficient family-centered rounds had been developed. The purpose of sending a group of providers there was to educate them about family-centered rounds by creating an opportunity to observe them in practice and to get further buy-in. Because Golisano Children’s recognized that its staff had no prior experience in doing family-centered rounds, it invited one of the champions from Cincinnati Children’s to present a Grand Rounds in Rochester, so all of its staff would have an opportunity to see how family-centered rounding is done in practice. As one leader recognized, “It would have been difficult to approve this [innovation] without Cincinnati’s experience.”
3.2.1 Gathering Evidence
Because this innovation did not involve the use of new equipment and did not require hiring additional staff, decisionmakers and champions of family-centered rounds at Golisano Children’s did not anticipate that much cost would be associated with its implementation. However, they were interested in monitoring the effectiveness of this innovation and evidence for its outcomes, such as time of discharge, time spent in rounding, length of stay, and assessment of resident competencies, in order to reinforce their decision. Although some preliminary data were available from Cincinnati Children’s, certain areas of effectiveness had not been studied. As a result, a general academic pediatrics fellow took on the role of change agent for implementation and evaluation of this activity, supported by the residents and nurses in the form of a steering committee.
In the process of stimulating the interest and buy-in for practicing family-centered rounds, the steering committee engaged in further evaluation of potential risks to patient care and existing efficiencies that might be associated with implementing this evaluation:
“We had many discussions initially in terms of making any decision that would jeopardize patient care, and as we went through the entire project we could not see where there would be any cases where we would jeopardize care or interfere with care. One of the primary risks that we felt that we had if we interfered with the flow of work by starting these rounds was that we didn’t want to decrease the efficiency that was already there. In fact, that was one of the earliest process goals that for the first month we would not increase the time that it took to round and we would not increase the number of medication errors. All of our measures of efficiency, initially, we wanted not to see indicators that we were having an adverse impact. Then we wanted to see, as the project got up and running, some improvements.”
These concerns, planning logistics, and domains of evaluation were addressed by generating a logic model. Evaluation measures included:
- Assessing the success in implementing family-centered rounds by measuring the extent of completion of critical-activity checklists during rounds.
- Measuring efficiency by looking at discharge times and length of stay categorized by primary diagnosis.
- Measuring change in medication safety by studying medication error rates obtained from medicine reconciliation performed during family-centered rounds and from the hospital’s medical error reporting system.
- Assessing patient and family satisfaction through Press Ganey pediatric inpatient survey results.
- Assessing resident competencies through a competencies survey compiled by the pediatric program director.
Champions and decisionmakers at Golisano Children’s considered implementing family-centered rounds on a pilot basis but concluded that doing so would introduce confusion for residents, nurses, and families, especially when families had multiple admissions and were located on a different floor during each admission. Building on the success of introducing family-centered rounds in Cincinnati Children’s, Golisano Children’s leadership agreed that they would proceed with widespread adoption of this innovation at the time that they were set to start its implementation.
The leadership also recognized that family-centered rounds would potentially encounter significant barriers if the entire care team (i.e., attending physicians, resident team, nurses, social workers, and pharmacists) was involved at the beginning. To make implementation smoother, the decision was made to start family-centered rounds with the house staff only and to involve the rest of the care team gradually.
3.2.2 Addressing Resistance
Golisano Children’s leadership recognized that instituting family-centered rounds would bring about a change in the culture of their organization. Such changes are always difficult, and the leadership anticipated that some staff would be more amenable than others.
Despite shared recognition of the need for family-centered rounds, decisionmakers expected some resistance. Some staff questioned the benefits of this innovation and saw it as something that would be time consuming and inconvenient. However, the steering committee’s knowledge of the methods used at Cincinnati and those excellent results helped them overcome such resistance and gain buy-in:
“Knowing that somebody else had tried it and that it was well received helped them to get over the objections. It is helpful to have some kind of example of previous success.”
Another effective strategy for getting staff buy-in was the way in which the decisionmaking process was skillfully rolled out as shared consensus building rather than the top-down approach sometimes practiced by less experienced decisionmakers:
“The trick is not in the decisionmaking, but rather the way in which you implement and roll out to those who do not agree with you. If you come in as a bull in a china shop, I would have been deposed. There is a process that I wouldn’t call decisionmaking but rather a process by which you make others feel like the decision was theirs in the first place. You must be willing to change if you realize the data are not what you thought they were. Some of it is tweaking your decision, some of it is consensus building… . Some will be happy, some won’t. Then, you have to shepherd the decision through the process. You go to those who didn’t want to do it and ask how to make it work. I never make a decision in a vacuum. I often make a decision alone.”
However, the most important force in moving this innovation forward despite some resistance was the power of devoted champions supported by leadership:
“There has to be will for carrying it out by people responsible for talking to patients.”
“I knew we would be met with resistance. We needed early adopters… . I don’t care how much others don’t like process—as far as patients and families are concerned, it is the right thing to do. We’ll either pull you or push you—I don’t care which.”
“An important lesson, you need somebody very high up, the chair or close to chair driving these innovations and to be saying to [certain staff], ‘You will do this and will get over transparency problems and involve families because that will result in better care.’”
3.3 Decisions Not to Adopt
One decisionmaker at Golisano Children’s Hospital explained that it is fairly rare for them to consider an innovation but decide not to adopt it:
“If we see a problem, we talk about it, formulate something to do about it, and continue it. We don’t walk away from it.”
They did share a few examples of cases in which they did not proceed with adoption of an innovation they considered: lung disease treatment guidelines and the addition of a medication reconciliation component to their rounding that involved the nurses and residents reviewing the medications in the patients’ rooms twice a week. The primary reason they had not moved forward with adopting the lung disease treatment guidelines was a lack of staff needed to implement them and manage the resulting data. They trialed but ultimately did not adopt the medication reconciliation component because of the perception of many house staff that it was a net time drain. This aspect of medicine reconciliation will be readdressed in the future, however, after the basic features of family-centered rounding are accepted as part of the prevailing culture.
Our efforts to learn about decisionmaking processes that did not result in adoption generated an important discovery. The highly successful family-centered rounds described earlier had been considered for adoption previously by this same organization, and the leadership had decided against adopting it. Six years ago, a major proposal was put forth in the facility to start a family-centered rounding program, and key decisionmakers decided not to adopt it at that time. After studying the prospect of adoption of this innovation for an extended period, Golisano’s leadership felt that the prerequisite to implementing family-centered rounds was having private rooms and hiring discharge facilitators. The resources required to add a discharge facilitator on each floor were deemed to be more than the organization was willing to invest at that time. The facilities did not change, and discharge facilitators were not added. The group cited differences in the level of resident buy-in and in the prevailing medical atmosphere to explain why this innovation was recently adopted and implemented:
“I think [resident buy-in] is one of the things that made this part successful. They are the ones who are doing it. You have to have buy-in from the people who are participating. Things that come down from upper management … aren’t going to happen until there is either a consequence for not doing it or you get buy-in from those who are doing it because it’s a good idea.”
“There’s such a huge difference thanks to the Institute of Medicine Report … all the focus on quality, the competitiveness of hospitals, you don’t get any business unless you have patient satisfaction. There’s a huge difference in the entire health world.”
A final important difference was the existence of a model and data on implementation—Cincinnati Children’s Hospital Medical Center—when the decision was recently made to adopt this innovation. No similar model existed when the proposal was prepared and submitted 6 years ago.
3.4 Lessons Learned
The adoption and implementation of family-centered rounds at Golisano Children’s Hospital is clearly a success story. Looking at the decisionmaking process retrospectively, the leadership indicated that they would not do anything differently if they could do it again. Eradicating the process of “rounding in front of a computer screen” and returning to a process that had worked well for senior staff years ago brought them closer to the patients, improved the teamwork and communication within the care teams, and was obviously “the right thing to do.” As one member of the leadership explained:
“I don’t think I would do anything differently. In some ways, this was an easy one. I didn’t have people coming to me saying ‘No way!’ It was good for the patients, the families, the physicians, and the staff. I didn’t have anybody telling me negatives.”
With respect to implementation, our informants simply said that they would have involved families earlier. Obtaining input from patients on how best to meet their needs earlier in the process would have yielded important discoveries, such as the best time of day to conduct rounds. Traditionally, rounds are conducted early in the morning when families are not available or ready to participate.
Golisano Children’s adoption of family-centered rounds has been highly successful. In deciding to adopt this innovation, the decisionmakers in this system were able to build on evidence from Cincinnati Children’s. They supplemented this evidence with baseline data and feedback obtained during a trial period. One key decisionmaker explained that this trial period provided early evidence of success by demonstrating the feasibility of the innovation’s implementation, but further evidence will be required to tangibly show that it helped:
“The 3- or 4-month trial is only enough to say ‘uh oh, this is bad.’ To say something helped or is neutral, we will need longer. It told us it is feasible; it improved family and resident satisfaction and improved the morale of nurses. We may find out a year from now that it looks the same, but we didn’t spend a mint on it. The early look and pilot is to see if there is something that we are not thinking of that will make this a disaster. If yes, you haven’t expended tons of time, people, etc. Then you can ask the inverse.”