RAP Rounding Regular Assessment of Patient s basic needs Ruth King Nurse Manager Sandringham Hospital
RAP Rounding RAP Rounding background RAP Rounding implementation at the Alfred Results and evaluation RAP Rounding at Sandringham
Background Three issues were identified as important driving factors in The Alfred introducing RAP rounding. These were: Challenges of decreasing patient risk and improving the quality of patient care Local research around the timeliness and quality of the nurse-patient interaction Patient feedback
Implementation Across Alfred Hospital 2 pilot areas 4GMU and 6 West commenced in Jan 2 additional ward areas each month with final ward areas implementing in August 20 Ward areas were provided with tool kit including FAQ sheets and information leaflets for staff
Implementation and Evaluation - Aims of RAP Rounding Indicators/ Measures Data Source When Considerations Proactively meet patients needs Call bell use % of nursing time spent at bedside Nurse-patient interactions Number of call bells LEAN Observation OPTIC Feedback from sample of patients (see tool) Baseline and repeat post 3-6 months Baseline and repeat post 3-6 months Baseline and repeat post 3-6 months Weekly Who to collect data? If/when ward involved in LEAN project When ward becomes involved in OPTIC Improve patient safety and risk management Falls rate Pressure injury rate Nursing audit program Riskman Nursing audit program PUPPS Baseline and repeat as per audit plan Baseline and repeat as per audit plan Annual Existing data Existing data Increase patient satisfaction Patient satisfaction NET promoter score Patient complaints and compliments Baseline and repeat as per ward audit process 3 monthly Baseline and repeat To be provided by Patient Liaison Officer Increase staff satisfaction Staff satisfaction PCNI Iterative staff feedback Staff Claims, Concerns & Issues exercise Annual During implementation phase Pre-implementation and repeat at 6 weeks Measures Nursing Stress, Workload, Empowerment, Satisfaction Collect during implementation Staff satisfaction will need to be extracted from data raised by staff under Claims, Concerns & Issues, eg, expect to see increase in claims and decrease in issues raised Implementation of Rounding Process % compliance with performing Rounding hourly Rounding communication tool Compliance audit tool Daily during implementation for 8 weeks Repeat as required Collect during implementation Focuses on identification of issues and barriers that impact on the implementation process, in addition to % compliance
Quality Indicators Pre-Implementation The Alfred Falls with Serious Injury 20-2011 70 7 Total No. of Falls/Month 60 50 40 30 20 6 5 4 3 2 1 Falls with Extr/Major or Moderate Outcomes 0 Jan- Feb- Mar- Apr- May- Jun- Jul- Aug- Sep- Oct- Nov- Dec- Jan- Feb- Mar- Apr- May- Jun- Jul- Aug- Sep- Oct- Nov- Dec- Jan- 11 Feb- 11 Mar- 11 0 Extreme/Major (ISR 1 & 2) Moderate (ISR 3) Total No. Falls Linear (Total No. Falls )
Survey Essentials of Nursing Care Nursing assessment, planning, implementation and evaluation with patient and family Discussing with patient their needs for the shift Evidence of assessment and ongoing care Timely attention to needs Care is proactive rather than reactive Pain, hygiene ADL s, toileting essential nursing care every shift
Patient feedback Pre Implementation Call bells not answered, or staff pop in and don t come back. Too long for nurses to answer call bell Only that sometimes, especially at night, there can be no call response, or over 45mins. This can be a problem is a need is urgent. Place is deserted at night no one answers my bell Help with ordering meals, eating, & water Personal hygiene: help with pans, commodes and toilets; cleaning up after accidents Help with washing and keeping clean in bed ( my bed was a jungle )
The Aim of RAP Rounding Proactively meet patients needs Improve patient safety and risk management Increase patient satisfaction Increase staff satisfaction
RAP Rounding Design The model includes: A nurse asking the patient at the beginning of the shift what is important to them to achieve/occur during the shift, followed by One-hourly rounding assessing patients pain management, toileting needs, mobility/change of position needs, checking environment is free of clutter and all the items the patient needs are to hand, and Before leaving, asking the patient is there anything I can do for you? I have the time..
Quality Indicators Post Implementation RAP rounding introduced Jan 20 No falls with ISR 1 or 2 during this time
Patient Feedback Post Implementation The nurses are very good, the rounding is fantastic! You don t feel isolated anymore. I had a recent hospital admission where no one communicated with you, it was scary and lonely. It isn t like that here, the nurses are very attentive and caring. They do a fantastic job, they are always there when you buzz. As a wife of a patient I can say that I and my family speak very highly of the care, patience and nursing care. The nurses are most caring and diligent of his needs. Rounding is a fabulous idea. All of the nurses were wonderful, very attentive and caring. They would explain what was happening each day. It made you feel less anxious as you knew they were always around.
Outcomes Post Implementation Reduction in patient call bell use Reduction in falls with injury (ISR 1 & 2) Increased patient satisfaction Decreased patient complaints related to nursing care Increased staff satisfaction
How are we doing 2012? Decrease in RAP rounding compliance- process is no longer practiced consistently across the Alfred Campus Shift in local and organisational priorities Changes in bed models (increasing bed numbers) Staff attention and retention Environmental factors
Learnings Rounding champions to lead the way, influence the team Regular evaluation of the process and outcomes measures Interpretation of results numbers vs. outcomes Strong nursing leadership Engagement of staff, patients and visitors Change to nursing care delivery system RAP rounding in isolation Feedback - Patients - Staff
Sandringham Hospital 2012 Improving Care group models of nursing care National Accreditation Standards Nursing Care Delivery including bedside handover, RAP rounding and changes to documentation. Commenced on all inpatient wards in August 2012
Pre- Implementation Quality Indicators
Pre Implementation Survey and Audits Buzzer Audit March 2012 60% buzzer occasions were related to toileting, pain and requests for environmental (buzzer, food etc) assistance next most prevalent reasons. Up to 5 mins to answer buzzer with one occasion of 12mins to answer buzzer. Documentation Audit Average score 1.9 shows deficit in appropriate documentation, particularly purpose of hospital stay, evaluation of patient progress, referrals and follow up referrals and discharge planning. Medico-Legal average score is 60% Patient Feedback 9 out of 55 complaints relating directly to nursing care between August 2011- August 2012
Implementation and Evaluation Review of existing resources and development of Sandringham nursing care delivery system tools and resources focusing on risk assessment and clinical status Implementation date set for all inpatient ward areas Education sessions for staff run over 4 week period with all nursing staff attending Development of patient information leaflets with information about RAP rounding, handover and nursing care expectations Daily audit schedule developed including rounding compliance (tick sheet audit) and patient satisfaction surveys FAQ and information sheets for nursing staff Weekly Claims, Concerns and Issues sessions for staff Formation of local area working groups
Post-Implementation Quality Indicators Nursing Care Delivery system implemented
Post Implementation Survey and Results RAP Rounding compliance >85% compliance shift by shift Documentation Audit Results Average score of 3.69 for August and September. Medico Legal section average score of 90% Patient Satisfaction Surveys 88% of patients surveyed rate their satisfaction between 8-89% of patients feel involved in their care 90% of patients are seen hourly or more frequently with all of the remaining 9% seen within 2 hours
Learnings Tick sheet is key to implementation phase of RAP rounding introduction Engagement of nursing leadership group is key Introduction of RAP rounding as part of nursing care delivery system appears to have benefit over introduction in isolation Patient satisfaction survey is the most reliable indicator that process and principles are practiced Providing patient with information provides accountability of nursing staff
Summary RAP rounding across Alfred Health has contributed to A reduction in the number of falls with injury (ISR 1 & 2) (during the first 12 months of implementation) A significant improvement in patient satisfaction relating to nursing care and communication A reduction in the amount of call bell usage across the organisation Sustainability remains the greatest issue in the success of RAP rounding as a risk reduction and prevention strategy