A fundamental shift: family-centered rounds in an academic medical center
by Jeffrey M. Simmons, MD
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
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).
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 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).
In my transition from early skepticism to passionate advocacy for FCRs, 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. Further, as an attending, I have learned the power of real-time verification of the information that the residents give me. In FCRs, families are encouraged to interject when the information is incomplete or inaccurate. Because the attending physician is more fully informed when decisions are being made on rounds, plans don’t routinely need to be altered later in the morning/afternoon.
Additional benefits include the fact that most orders and discharge paperwork are clarified and written on rounds, which has been an invaluable efficiency in the resident work-hours era. The most significant benefit of this process, though, is how much more reliable and sophisticated our plans have become. With nurse, family, and physician all communicating at the same time on rounds, there is exponentially less confusion about the plan of care. Discharge planning starts at admission, and each party acknowledges progression toward the well-defined goals. Residents (particularly cross-covering residents) get afternoon phone calls that a patient is ready to go, and can reliably just sign the order, knowing that follow-up plans, prescriptions, and criteria for discharge have been well defined that morning on rounds. Those calls from nurses that all physicians remember from training, “So and so needs a script, needs a note, needs home care orders signed ... ” occur less frequently because nurses are clarifying those needs on rounds.
We have learned much from data regarding participants’ perceptions of FCRs. Most of this early data was collected as part of routine customer service and staff satisfaction surveys, but some has been developed through more formal focus groups.
Some brief highlights of what we have learned to date: Family satisfaction, particularly in regard to their perception of involvement in their children’s care, is very high.4 More recently, in regard to units that do not use FCRs routinely, we have received critical comments from families about the difference in the quality of communication. Nurses comment that the discharge planning process has been greatly enhanced by FCRs. Echoing some of our family feedback, nurses noticed a void in discharge planning when rounds did not include families.
In addition, nurses indicate nurse-to-nurse communication at change of shift is better when nurses are included in rounds. Resident feedback is generally positive, particularly in regard to the enhanced efficiency and communication of FCRs. A vocal minority make it clear that FCRs need to be “done right” to balance resident’s educational needs with patient care. Participating attendings are nearly unanimous in the opinion that FCRs provide better care.5 Most also feel FCRs provide new, important educational opportunities, allowing for daily direct observation of trainees’ interactions with families. Echoing residents, attendings acknowledge it takes time to learn how to do FCRs well.
Further, ongoing quality assurance and improvement work has demonstrated decreased length of stay and increased discharge timeliness on units where FCRs are used extensively.
Probably the biggest barrier at CCHMC has been and continues to be attending physician buy-in. As I see it, at the core of attending physician reluctance is concern with sharing uncertainty in front of the family. The uncertainty issue cuts to the core of what family-centered means: The patient or family is in control of the decision-making process—not the physician. In practice at CCHMC, this concern has not been substantiated among the attendings participating in FCRs.5
Nurse-physician collaboration has been an intermittent barrier. For FCRs to reach their full potential, nurse and physician both need to actively participate and take responsibility for the process. A care plan truly comes together and becomes maximally effective when family, nurse, and physician can listen to each other’s points-of-view.
Many of the logistical barriers likely vary among institutions around issues like private rooms, computerized order entry, resident and nurse staffing, communication with referring or consulting physicians, and so on. While seeking for standardization across units, FCRs do look a little different within our institution depending on the logistical issues on specific units or with specific resident teams.
I am no longer a skeptic. While I have much to learn about how to make FCRs better, most days I feel FCRs enable me to be the doctor I hope to be: Families are informed, active participants in their children’s care; nurses are informed and empowered to make care more effective and efficient; residents get “work” done on rounds; and I get to consistently observe and model history taking, physical exam, and communication skills with physician trainees.
Fundamentally, FCRs have changed my appreciation of how to develop and teach a medical plan. I deliver better care when families are at the center of the presentation of information, the discussion of options, and the choice of plan for their children. TH
Dr. Simmons is an instructor in pediatrics at Cincinnati Children’s Hospital Medical Center, University of Cincinnati School of Medicine
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