B E S T P R A C T I C E : S A C R E D H E A R T H O S P I T A L P E N S A C O L A, F L O R I D A
Today, due to organizations around the country that have implemented hourly rounding, patient falls are down. If every hospital in the country were rounding on inpatients hourly, the cost savings would be two billion dollars, and most importantly patients would receive better care. Skin breakdown is decreasing and call lights are down 37.8 percent so staff can do what they want to do, take better care of patients. In addition to patient care issues, Medicare just announced they would no longer be paying for patients who fall and have skin breakdown that are acquired while in the hospital. The hourly rounding tools just got better. We spent hundreds of hours in research, clinical and operational trials, preparing teaching kits and use of user groups to make sure the material works. With all of that, we find when more organizations implement the tools and techniques - people like you make the material better. In their work, Sacred Heart Hospital in Pensacola, Florida, created a best practice to focus on truly hardwiring the hourly rounds. We have found that organizations that use this tool, combined with the other methods recommended in hourly rounding, achieve better clinical results than those that do not use this tool. Due to our mission of making health care better, which we know is also your mission, we wanted to get this enhancement to you right away. Thank you for your dedication to doing work with such great purpose, it s worthwhile and makes a difference. Yours in Service Quint Studer 2
A. Overview of Organization Sacred Heart is a 476-bed acute care facility located in Pensacola, Fla., which includes Sacred Heart Hospital, Sacred Heart Children s Hospital and Sacred Heart Women s Hospital. In addition, Sacred Heart Health System, a member of Ascension Health, includes a 50-bed hospital Sacred Heart Hospital on the Emerald Coast located in Walton County, east of Destin, Fla. B. Hourly Rounding Outcomes and Results Five months after implementation with 10 nursing units on board, Sacred Heart is seeing the following results on the units that are practicing hourly rounding: Call lights reduced by 40-50 percent Patient falls were reduced by 33 percent Hospital-acquired pressure ulcer cases were reduced by 56 percent Overall patient satisfaction has increased 71 percentile points QUALITY: PATIENT FALLS REDUCED Patient falls were reduced by 33 percent for the units practicing hourly rounding. 100 90 FALLS 80 70 Patient Falls 60 50 40 30 20 10 0 Before Hourly Rounding After Hourly Rounding 3
QUALITY: SKIN BREAKDOWN REDUCED Hospital-acquired pressure ulcer cases were reduced by 56 percent on the units practicing hourly rounding. DECUBUTI 20 Nosocomial Decubuti 15 10 5 0 Before Hourly Rounding After Hourly Rounding In addition to hourly rounding, Sacred Heart Hospital is part of an Ascension system-wide goal to eliminate facilityacquired pressure ulcers as part of the ministry s HealthcareThat Is Safe initiative. In collaboration with the Institute for Healthcare Improvement, a comprehensive plan was developed which included participation in an International Pressure Ulcer Prevalence Study sponsored by Hill-Rom, purchase of new bed surfaces and implementation of a nursing driven SKIN bundle. SERVICE: PATIENT SATISFACTION INCREASED Overall patient satisfaction has increased 71 percentile points. 4
Patient Satisfaction Response: Nursing Breakdown: There were significant increases in the perception of nursing care specifically in promptness to call lights and pain control. NURSING QUESTIONS BASELINE CURRENT Nurses Overall 31 98 Friendliness / courtesy of the nurses 25 94 Promptness response to call 10 95 Nurses attitude toward requests 34 98 Attention to special / personal needs 50 99 Nurses kept you informed 42 98 Skill of the nurses 49 96 How well your pain was controlled 42 99 C. Hourly Rounding Implementation Sacred Heart Hospital in Pensacola, Fla., began training nurses in hourly rounding in November 2006. The hospital began with six pilot nursing units and now has 10 nursing units rounding hourly. Successful implementation of hourly rounding requires participation of all staff on the unit as well as consistent leader rounding. Variance in practices that are not addressed will produce inconsistent results and dissatisfaction including staff complaints. Call lights will not see significant decreases and patient satisfaction results will trend up then down. Sacred Heart credits their excellent outcomes to the hardwired accountability that they have placed into their implementation process. They have focused on ways to reduce individual variance from the start. The Hourly Rounding Dashboard Report (see Tool B) and the Competency Checklist (see Tool F) are key tools to hardwire in the process. One of the best hardwired tactics implemented has been the weekly hourly rounding meeting led by the CNO or director. This meeting includes leaders from all units currently participating in hourly rounding as well as those coming on soon. The meeting allows those involved an opportunity to understand the challenges, transfer learning and best practices and foster accountability. (See Tool A to review a sample agenda of this critical meeting.) Consistently connect to purpose by sharing patient or staff feedback about the impact hourly rounding serves. This will serve as the fuel that ignites the flame which in turn kindles the staff s passion. The Healthcare Flywheel turns as staff feel they have purpose, do worthwhile work and make a difference. 5
D: ONGONING A Foundation tactics in place Benefits of hourly rounding communicated B Staff training conducted Competency checklist and checkoffs conducted Related tools distributed (pocket, welcome and pillow cards distributed) C Hourly rounding begins 6 pilot units Hourly Rounding Conducted Leader Rounding Conducted Leaders round with purpose using specific questions Rounding questions posted in the staff lounge Leaders sign the rounding logs when rounding on patients Hourly rounding logs placed inside the rooms Positive Wins are Shared and Communicated Read positive patient letters to the staff Share results with the staff Review call light logs and recognize the nures and the unit secretary with the least call lights recorded E-round or send out a broadcast note weekly to associates to keep the positive impact of hourly rounding top of mind Prior Oct 2006 Nov 2006 Dec 2006 Jan 2007 Feb 2007 Mar 2007 Apr 2007 May 2007 C F G Weekly hourly rounding meetings begin Hourly rounding dashboard report created Four additional units begin hourly rounding D. Hardwiring Hourly Rounding: Sacred Heart Tools and Examples The following tools were created by Sacred Heart to hardwire accountability into their hourly rounding implementation process. They are provided as resources and examples to you. Tool A: Hourly Rounding Standardized Meeting Agenda Tool B: Hourly Rounding Dashboard Report Tool C: Hourly Rounding Welcome Cards Tool D: Hourly Rounding Pocket Cards Tool E: Hourly Rounding Pillow Cards Tool F: Hourly Rounding Competency Checklist Tool G: Hourly Rounding Flyer The 3 P s Tool H: Hourly Rounding Flyer The 4 P s Cultivating Patient Care Excellence Tool I: Hourly Rounding Flyer OB Unit Tool J: Hourly Rounding Call Light Log Tool K: Hourly Rounding Hourly Rounding Documentation Log Tool L: Sacred Heart Hourly Rounding Implementation Tips and Guidelines Cultivating Patient Care Excellence 6
TOOL A: STANDARDIZED MEETING AGENDA Purpose: A weekly hourly rounding meeting led by the CNO or director to drive accountability works well to accelerate and hardwire the process. The meeting goals include: understanding challenges, transferring learning and best practices, rewarding and recognizing success and holding leaders accountable for their results. Target: The meeting includes leaders from all units currently participating in hourly rounding as well as those coming on soon. WEEKLY MEETING AGENDA I What is working well? II What are the barriers? III Reward and recognize success IV Patient letters, stories and staff feedback V What are the tough questions staff asks? VI VII Leader reports on unit patient satisfaction results and reviews the percentage of competency checklists completed for the week What actions will nurse leaders take to improve their hourly rounding results? VIII IX Leaders exchange 24 hours worth of completed call light and rounding log to review and give each other feedback What have they learned at the meeting that they want to implement? X Next steps are discussed and agreed upon 7
TOOL B: DASHBOARD REPORT Purpose: Utilize a dashboard report to measure your unit s return on investment of their time and effort. Reporting includes (a) fall rate, (b) pressure ulcers, (c) call light volumes, (d) patient satisfaction, (e) pain question, (f) response to call light, (g) staff worked together as a team, (h) attitude toward personal requests, (i) attention to personal needs and (j) overall rating of care. Target: Leaders from all units currently participating in hourly rounding. SAFETY PATIENT SATISFACTION 5 EAST FALL RATE BASELINE PRESSURE ULCERS CALL LIGHT VOLUME N SIZE PAIN CONTROLLED RESPONSE TO CALL LIGHT STAFF WORKED TOGETHER AS A TEAM ATTITUDE TOWARD YOUR REQUESTS ATTENTION TO PERSONAL NEEDS OVERALL RATING OF CARE OVERALL PERCENTILE Dec-06 Jan-07 Feb-07 Mar-07 Apr-07 May-07 Jun-07 Jul-07 Aug-07 Sep-07 Oct-07 Nov-07 Dec-07 8
TOOL C: WELCOME CARDS Purpose: The welcome card given to every patient upon admission provides the key words meant to set expectations by contracting with the patient and educating the patient/family regarding hourly rounding. These cards, signed by the admitting nurse, are left in the patient s room to explain why we round hourly, and also to provide an access number if anything is needed during the patient s stay. Target: Welcome cards are provided to all staff involved in hourly rounding. 9
TOOL D: POCKET CARDS Purpose: Issue pocket cards to unit staff, float staff and new staff during orientation. Target: All staff performing hourly rounding. 10
TOOL E: PILLOW CARD Purpose: Pillow cards are used to place on the pillow when patients are out of the room for tests. They communicate to the patient that staff came by to check on them during hourly rounds. Target: All staff performing hourly rounding. 11
TOOL F: COMPETENCY CHECKLIST Purpose: This tool provides a competency checklist which documents the demonstration of hourly rounding competencies and behaviors. This competency checklist can be customized and adapted for any unit. Target: All staff involved in hourly rounding. COMPETENCY CHECKLIST DATE NAME DEPARTMENT EVALUATOR INTRODUCTIONS Knock on door prior to entering ask permission Manage up your skill or that of your co-worker Use good eye contact EXPLAIN UPON ADMISSION Explain the purpose of hourly rounding (initial visit) Use key words very good care Describe rounding schedule (6am-10pm q1hr. 10pm-6am q2hr.) UPDATE WHITE BOARDS Place name on white board Update nursing plan of care/goals for patient ADDRESS 3P S PAIN...POSITION...POTTY How is your pain? Are you comfortable? Do you need to go to the bathroom? ASSESS ENVIRONMENT Move items within reach (table, call bell, phone, water) PERFORM SCHEDULED TASKS Complete MD ordered treatments, procedures Complete nursing care as needed Administer scheduled medications CLOSING We will round again in about an hour Is there anything else that I can do for you? I have the time Document your rounding on rounding log SELF ASSESS EVALUATOR YES NO YES NO COMMENTS Give Welcome Cards to introduce hourly rounding to all patients (new admissions and transfers) We round hourly on our patients to ensure that you receive Very Good care. We round every hour between 6am - 10pm & every two hours between 10pm - 6am. We will not wake you if you are sleeping unless we need to. If anytime during your stay, you feel you are not receiving Very Good care, please let us know immediately so that we can address your concerns. Complete Self Assessment, practice and then have a Leader observe you 12
TOOL G: FLYER THE 3 P S CULTIVATING PATIENT CARE EXCELLENCE Purpose: This tool serves as a training tool and reminder of the 3 P s of Pain, Position and Potty. Target: Posted and provided to all units involved in hourly rounding using the 3 P s. 13
TOOL H: FLYER THE 4 P S CULTIVATING PATIENT CARE EXCELLENCE Purpose: This flyer provides a training tool and reminder of the 4 P s of Pain, Position, Potty and Possessions. It allows you to see how the hourly rounding behaviors can be customized depending on the patient needs. The 4th P Possessions reminds the staff to perform an environmental check and move items within the reach of the patient. Sacred Heart has adapted and used the 4 P s throughout most units. Target: Posted and provided to all units involved in hourly rounding using the 4 P s. 14
TOOL I: FLYER OB UNIT Purpose: This tool provides an example of how hourly rounding can be adapted for an OB unit. In the OB unit, they determined their patients needs to include Pain, Position, Questions and Supplies. These indicators were chosen because they addressed the reasons the call lights ring. Target: Posted and provided to OB units involved in hourly rounding using the 4 P s. 15
TOOL J: CALL LIGHT LOG Purpose: This log documents detailed information regarding the call lights by allowing the tracking of the reasons the call lights ring. This call light log is customized for use in an adult unit and is filled out by the unit secretary. The adult unit customization includes tracking pain, position, potty, possession, pumps, error and other. Note this log may be customized to any unit s needs. For example, the OB unit might add questions or supplies and a pediatric unit may include safety and supplies. Daily review by the manager will help to identify variances by a nurse enabling real time feedback and improvements to occur. Health unit coordinators take ownership by paging out messages to the nurses when the call light volume begins to increase. Target: Adult units implementing hourly rounding. ADULT CALL LIGHT LOG Unit Shift Date HUC Coordinator Day M T W Th F Sat Sun Check box each time the call light rings indicating reason, RN assigned to patient and the room number No# Pain Position Potty Possessions Pumps Error Other Room # RN Initials 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 Please turn these logs into your coordinator at the end of your shift Rev. 12.28.06 16
TOOL K: DOCUMENTATION LOG Purpose: This log is used for the staff to document hourly rounds. Staff are instructed to inquire about the P behaviors and document on the log the specific ones that they addressed. The logs are collected at the end of 24 hours and given to the charge nurse, reviewed and forwarded to the nurse manager for compiling data. This log is designed for an adult unit and can be customized and revised for any specialty unit. Target: Adult unit implementing hourly rounding. LOG Stamp Patient Information Date: Rm # Bed # Day M T W Th F Sat Sun TIME PERIOD STAFF INITIALS TIME ROUNDING PAIN POSITION POTTY POSSESSIONS COMMENTS In chart by exception, note patient need EVERY 1 HOUR ROUNDS 6 AM - 10 PM 6 AM 7 AM 8 AM 9 AM 10 AM 11 AM 12 PM 1 PM 2 PM 3 PM 4 PM 5 PM 6 PM 7 PM 8 PM 9 PM EVERY 2 HOUR ROUNDS 10 PM - 6 AM 10 PM 12 AM 2 AM 4 AM RN Name (Please Print) In RN Name (Please Print) In This is not part of the permanent medical record RN Name (Please Print) In RN Name (Please Print) In Tech Name (Please Print) In Tech Name (Please Print) In Other Name (Please Print) In Other Name (Please Print) In 17
TOOL L: SACRED HEART TIPS AND GUIDELINES Purpose: This document provides details of the implementation steps used at Sacred Heart. A sample overall timeline is provided and the detailed elements including foundational elements, training and hardwiring tools and tactics are included in the table below. Target: Organization and all nursing units. D: ONGONING A Foundation tactics in place Benefits of hourly rounding communicated B Staff training conducted Competency checklist and checkoffs conducted Related tools distributed (pocket, welcome and pillow cards distributed) C Hourly rounding begins 6 pilot units Hourly Rounding Conducted Leader Rounding Conducted Leaders round with purpose using specific questions Rounding questions posted in the staff lounge Leaders sign the rounding logs when rounding on patients Hourly rounding logs placed inside the rooms Positive Wins are Shared and Communicated Read positive patient letters to the staff Share results with the staff Review call light logs and recognize the nures and the unit secretary with the least call lights recorded E-round or send out a broadcast note weekly to associates to keep the positive impact of hourly rounding top of mind Prior Oct 2006 Nov 2006 Dec 2006 Jan 2007 Feb 2007 Mar 2007 Apr 2007 May 2007 C F G Weekly hourly rounding meetings begin Hourly rounding dashboard report created Four additional units begin hourly rounding 18
Item A: TIMEFRAME: Several months prior to implementation Item B: TIMEFRAME: Two weeks prior to implementation STEPS: Round on staff, send and manage up thank you notes, implement key words These are foundational tactics to the successful implementation of hourly rounding o When the staff feels valued and has the tools and equipment to do their job, they are more likely to be open to working on new behaviors o The success of hourly rounding is enhanced when all team members are participating Discuss the benefits of hourly rounding Designed to promote high quality patient care o Increases patient satisfaction by average of 12 raw points Provides health care that is safe o Reduces falls up to 50% o Reduces pressure ulcers up to 16% Increases efficiency for staff o Anticipates reasons why the call lights ring o Reduces call lights up to 38% o Saves nurses from 150 300 hours per month STEPS: Get a team together to discuss the pilot o Use this group to make decisions, plan and monitor processes Discuss hourly rounding in staff meetings o Share the results of the Studer Group research in the September 09, 2006 AJN Article o Solicit input from staff in the planning and implementation stages to encourage empowerment and a sense of pride in the process 19
Conduct Training o Select nursing units with strong leaders who have good communication skills for your pilot units o Make training mandatory o Train nurses, techs and unit secretaries o Train day and night shift Give staff a Competency Checklist and Hourly Rounding Pocket Cards o Competency checklist specific behaviors necessary to master hourly rounding o Pocket cards are quick reminders of the P behaviors o Have staff perform a self assessment o Staff then practice for one week prior to leader evaluating the staff s competency during hourly rounding Distribute Hourly Rounding Welcome Cards o The nurse admitting the patient uses the card to explain hourly rounding to the patient and describe what the patient can expect from the staff o Staff signs their name on the welcome card contracting with the patient to round hourly and address prescribed behaviors Distribute Hourly Rounding Pillow Cards o Use cards when patients are out of the room for tests o Card states Sorry I Missed You! We perform hourly rounding to ensure that you receive Very Good Care. Let us know if you need anything when you return. I will be back in about an hour. o Staff indicates time of round, signs their name and leaves the card and a mint [sugar free or regular] on the patient s pillow 20
One week after implementation date Item C: TIMEFRAME: Implementation Date Item D: TIMEFRAME: Ongoing Leaders complete Competency Checklists o Give staff an opportunity to complete a self assessment o Staff successfully completing check-offs receive a special retractable badge holder o Badge holder is a quick visual indicator at shift change of who has been trained on hourly rounding o Manager should not delegate this important function STEPS: Implementation begins STEPS: Leaders round with purpose Round daily to determine if patients are receiving Very Good Care and monitor to see if staff is prompting for the 3P behaviors. o If logs are complete but call lights are not reduced, staff are likely checking on patients or rounding hourly and asking, how is everything? Patients will commonly respond fine. The patient will then use the call light because the behaviors (3P s) were not addressed. Ensure that rounds occur on night shift and weekends Leader questions during rounding o Our goal is to round on patients every hour; did you receive our hourly rounding welcome card? o How are we doing with rounding? Are we offering assistance in positioning, pain and taking you to the bathroom? How about on night shift and on weekends? Post rounding questions in the staff lounge communicating that this is an open book test. Staff will go the extra mile when they know what is expected. 21
Ongoing Ongoing Sign the rounding logs when making leader rounds to demonstrate to the staff that you are reviewing their logs and communicate the importance of the staff signing the logs. Place the hourly rounding logs inside the rooms vs. on the outside of the room door allowing families to visualize the staff signing the log. Use of key words when signing will provide an opportunity to engage the family, enhance trust and promote care and concern. Hardwiring Have unit secretary send out pages or reminders immediately if call lights begin to increase Review call light logs daily to spot trends. Indicate room number and nurse s name on call light logs so training can be focused on the appropriate staff nurse. Develop a float packet with tools including a pocket card Include hourly rounding in nursing and tech unit coordinator orientation Incorporate hourly rounding competency goals into job evaluations Develop a plan up front to address shift change, breaks and confused patients o Decide who will change out logs every 24 hours o Adjust staff to cover call lights during shift change o Have staff round before going to lunch and when returning letting patients know that they will be at lunch and that someone will be back in about an hour o Automatically get confused patients up to the bathroom. Often, they will tell you they do not need to use the bathroom and then will immediately use the call light for the same request. Reward and recognize success Share results with the staff. The more the positive results are shared with the staff, the quicker understanding will come and behaviors will be reinforced. Review call light logs and reward and recognize both the nurse and the unit secretary with the least call lights recorded. 22
E-round or send out a broadcast note weekly to associates addressing one of the following topics to keep the positive impact of hourly rounding top of mind o Comments you are hearing from the patients o Positive staff comments and feedback o Call light percentage reduced o Hourly rounding stars of the week and why o Patient s perception of care patient satisfaction results Read positive patient s letters to the staff which will encourage them by reminding them why they went into health care Item E: TIMEFRAME: Weekly STEPS: Hourly Rounding Meeting o Initially schedule meeting weekly o Change to bi-weekly when patient s perception of care is indicating consistent practices The meeting should be led by CNO or Director (someone the leaders report to) to foster accountability and support cross learning. Include units currently doing hourly rounding and those planning to come up in the future. Agenda o What is going well? Share wins, letters, stories, staff feedback o What are barriers identified? Problem solve solutions o What are the tough questions? o Review the % of competency check sheets completed o Review the call light logs and daily rounding logs for the past 24-hour period o Review patient satisfaction results by unit for the week 23
o Leaders trade logs and give each other feedback based on what they are seeing o Leaders discuss actions for improving results o Next steps are discussed and agreed upon Item F: TIMEFRAME: Monthly STEPS: Hourly Rounding Metrics Create an Hourly Rounding Dashboard Report to measure your unit s return on investment for their time and effort o Fall rate o Pressure Ulcers o Call light volumes o Patient Satisfaction Pain Question Response to call light Staff worked together as a team Attitude toward personal requests Attention to personal needs Overall rating of care Item G: TIMEFRAME: After process is STEPS: Expand to other units in the hospital and begin same process. hardwired 24
SUMMARY: The implementation steps identified are the keys to hardwiring this important tactic. The nursing leaders at Sacred Heart have worked diligently to stay focused on the results that this can achieve for the patients and the staff. Here are examples of the key learnings and results we have experienced. Key Learnings Pilots do not have to be perfect, perseverance is key Allow units to revise logs, handouts etc. as long as main objectives can be met Communicate target dates and time lines Offer to discontinue keeping rounding logs when unit reaches and maintains greater than 95% patient satisfaction results for three months Celebrate successes often for winners and most improved Results Staff indicated less chaos, more control over their day and an uncanny feeling of calmness during a time of increased census. Now when call lights ring, the staff encourage each other by offering each other suggestions for a quick fix. As a result, their nursing patient satisfaction results have increased. Staff report stories of picking up clinical changes in patients during hourly rounds allowing in some cases to transfer the patient to higher level of care resulting in positive outcomes for the patient. Patient satisfaction early results: Nursing scores have increased 31% since baseline in two quarters; overall satisfaction has increased 45% since baseline in two quarters. Patient satisfaction current results: Overall satisfaction has increased 71% from baseline in six months. A patient recently stated the following in a letter: I wanted to take this opportunity to tell you how much I appreciate the wonderful compassionate care from the staff at Sacred Heart. I had to have a colon resection on 12/19/06, which needless to say, had me scared to death from the beginning. The fear remained, but, the kindness which I was shown and the excellent care that I received there far exceeded any expectations that I may have had. These nurses were so good and so attentive that I do not believe that I ever had to call for anything, because they would be in my room to check on me to see if I needed anything before I ever had time to ask. 25
913 Gulf Breeze Parkway, Suite 6 Gulf Breeze, FL 32561 Phone: 850-934-1099 www.studergroup.com 2007 Studer Group