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).
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 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.