Family Affairs

I started as a skeptic. In the middle of my residency at Cincinnati Children’s Hospital Medical Center (CCHMC), one of our general pediatric inpatient units piloted a different way to do rounds focusing on “family-centered care.” Initiated by a core group of nurses, physicians, and families working together, the program became a central piece of an institution-wide effort to successfully garner a “Pursuing Perfection” grant from the Robert Wood Johnson Foundation. The grant was based on the Institute of Medicine’s 2001 report, “Crossing the Quality Chasm,” that included patient-centeredness as one of six key principles to guide health-system reform.1

I was skeptical about family-centered rounds because the change didn’t seem that radical to me: I prided myself on keeping my patients’ families informed about the plan of care. I did not appreciate how fundamental a shift “family-centeredness” required.

In 2003, the Committee on Hospital Care of the American Academy of Pediatrics (AAP) published in Pediatrics a policy statement about family-centered care. Included in the statement was the following sentence: “[C]onducting attending physician rounds (i.e., patient presentations and rounds discussions) in the patients rooms with the family present should be standard practice.”2

The core of what family centered means is the patient or family is in control of the decision-making process—not the physician.

It seemed straightforward, but it has required a significant and fundamental shift. In this article I discuss my experience and perceptions as a resident and hospitalist at CCHMC as it implemented the Institute of Medicine and AAP goal of family-centered rounds (FCRs).

What FCRs Look Like

Preparation for FCRs begins at admission. Ideally, at that time families are informed by both residents and nurses that during the following morning rounds will take place in the patient’s room. The family’s permission/preference is sought, but the team’s preference to round in the room is explained. Given published literature that some patients are upset by bedside rounds, it seems imperative to give the family a choice in how rounds are conducted.3 In practice, most families (more than 90%) choose to have rounds in the room.

On rounds the next day, the admitting intern or medical student enters the room to verify the family’s preference, and then the whole team enters the room. Team structure varies, but at a minimum a team includes interns, a senior resident, an attending, and a nursing representative.

The fundamental shift in my understanding has been how care changes when the plan is discussed and formulated with a family as opposed to simply being told to a family.

The team starts by introducing themselves by name and role to the family. The intern or medical student then presents the history and physical, and the plan for the day is discussed with the family (if confidentiality is an issue—e.g., adolescent issues—the relevant information and discussion of how that information will be shared with the family is reviewed before entering the room).

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