How four organizations structured interdisciplinary rounds

Ward leaders at Orange Hospital in New South Wales, Australia, recognized that their ward processes were not optimized to deliver effective patient care. Their ward rounds were failing to deliver good information fast enough to prevent mistakes and keep length of stay down.

To improve care, the team decided to pilot structured interdisciplinary bedside rounds (SIBR®), a program originally developed at Emory Healthcare in the US and adopted in parts of New South Wales, Australia, through the work of the Clinical Excellence Commission (CEC). Jason Stein, MD, associate vice chair for quality in the Department of Medicine at Emory University School of Medicine, helped the CEC adapt Emory’s model of care across hospitals in New South Wales, Australia.

Orange Health Service became the first organization in the state to implement a custom, structured, and efficient rounding process tailored to the Australian public system. Orange Hospital chose SIBR® because it addressed the common challenges of rounding through a highly structured yet flexible process.

At Orange Hospital, the team used the SIBR® methodology to focus on four critical components of rounding: maintaining full round attendance, keeping the rounds quick, actively involving the patient and family, and delineating clear next steps post-round.

Component 1: Proactively address barriers to full attendance

SIBR® rounds require all care team members be present for the round, but this can be extremely challenging to achieve when clinicians have differing schedules and outside responsibilities. The SIBR® methodology addresses this challenge by ensuring clinicians are unit-based and realigning their schedules to align with one another. However, that is a major shift for most clinicians, and will only work if they are fully onboard for the change.

At Orange, team leaders discussed the shift in staffing and rounding with each care team constituency. Leaders described what SIBR® rounds were and what changes were necessary. They also encouraged clinicians to tell them what problems SIBR® rounds would probably cause on the unit. This process allowed Orange to identify each groups’ barriers to change and make SIBR® work for them. Ultimately, leaders could show how the new model would benefit all clinicians.

Component 2: Ensure rounds are time efficient

SIBR® rounds reduce inefficiency by setting out clear guidelines for when the round will start, how long it will take, and how long each patient can be discussed. Orange Hospital found that even this structure wasn’t enough to maintain efficiency if clinicians came to the round unprepared to discuss their patients.

To maintain the round as a clear time for decision-making, leaders structured the morning hours prior to SIBR® rounding for information gathering. With medical and nursing rounds accomplished before SIBR® rounds, the team can come together quickly to make decisions on care changes before going back to their other work.

Component 3: Set aside time for patient and family participation

Involving patients and their families in decision-making processes is often seen as time consuming and is frequently left out of rounding processes. Orange Health used the SIBR® round structure to incorporate patient and family involvement into the rounding process without derailing the meeting. Each patient has dedicated time to ask questions or make comments on what the care team has discussed. If a question requires additional time, a team member commits to following up on the question after the round has finished.

Additionally, clinicians avoid using medical terminology when discussing care decisions. Instead, they use language the patients and families will understand.

Component 4: Track owners and next steps in real time

The team at Orange Health uses a standardized template to record discussion during the SIBR® round and update the patient’s plan for the day. The template has space for next steps to be recorded, and the team assigns clear task ownership at the end of each round. Next steps are typically larger tasks that are deliberately saved to be done after the round ends, to maintain round efficiency. Smaller tasks are completed during the round, as possible.

Key components of effective management of next steps include:

1. Using a standardized template to summarize the discussion, record the patient’s daily care plan, and update their estimated date of discharge
   
   
2. Generating a list of follow-up tasks based on the information shared during the round and assigning clear ownership
   
   
3. Saving all larger tasks or to be done for late so as not to derail the conversation

Results

Orange Hospital committed to a substantial change in rounding procedures when they decided to use the SIBR® rounding model. That commitment and the way in which Orange has implemented the rounds has paid off, with impressive improvements in both ward efficiency and quality metrics. Notably, they experienced a 9% decrease in average length of stay after one year of SIBR®.

Complex patients represent another obstacle to efficient and effective rounding. Rounding processes can be derailed by a small group of highly complex patients. These patients take considerable time to discuss, and appear in rounds day after day, wasting time for staff members not involved in their care. Over time this discourages participation, slowly undermining rounding quality and effectiveness.

Fraser Health Authority faced this situation: each round lasted for two hours on average, and complex patients represented the majority of that time. Over time, frustrated staff stopped attending rounds.

Fraser recognized that rounding would not be effective until this problem was resolved. Their solution was a dual rounding process that separates complex and noncomplex patients into separate rounding groups.

Fraser employs a risk assessment screen alongside clinical judgment to classify patients as “complex” or “noncomplex.”

Daily rounding on noncomplex patients continues as originally envisioned: each round now lasts only 20 minutes. Meanwhile, complex patients are discussed two to three times per week in one-hour sessions dedicated to managing difficult cases. A predetermined meeting agenda keeps discussion on track and ensures that only appropriate care team members are invited. Rounds focus on the results of the risk assessment for new admissions, patient status changes impacting discharge, and planned discharges in the next 24-72 hours.

Results

The new process was introduced in September 2011. By February 2012 Fraser had already achieved greater staff participation in rounds as well as a 20% increase in patients discharged within the hospital’s target length of stay.

Implementing highly structured interdisciplinary care conferences requires four key components:

• Create unit-based ownership. The structure that works for one unit may not work for another, so enable units to customize care conferences based on their own needs and preferences.
  
  
• Organize patients around providers, otherwise, physicians’ time will be divided across multiple units and they will not be able to attend conferences consistently. Cohort patients to ensure all physicians’ patients are located in the same area.
  
  
• Keep conferences focused with a clear agenda to ensure they are succinct and efficient. Limit care conference discussion to the most critical patient needs and limit (ideally eliminate) unnecessary discussion.
  
  
• Establish clear roles for key members of the care team attending the conferences. Clearly define what each team member is responsible for during conferences.

The following pages provide greater detail on each component, using examples from two organizations: Northwestern Memorial Hospital in Chicago, Illinois, and The Johns Hopkins Hospital in Baltimore, Maryland.

Component 1: Create unit-based ownership

Leaders at Northwestern Memorial Hospital in Chicago recommend that unit leaders planning to implement care conferences hold multiple planning sessions starting several weeks in advance of the rollout. There are two principal aims of these collaborative sessions. The first is to ensure the planned structure takes into account the unique needs of the unit. The second aim is to build a sense of shared ownership among unit providers and a commitment to making the structure work.

Unit leadership involved in planning included unit physicians, nurses, pharmacist, case manager, and social worker. Following planning sessions, leaders should have answers to the following questions:

1. When should we meet?
   
   
2. How long should we meet?
   
   
3. Where should we meet?
   
   
4. Who should we include in the conferences?
   
   
5. Should we stagger attendance of any care team members?
   
   
6. What items should we cover in the conferences?

Component 2: Organize patients around providers

If physicians must travel across multiple units and floors to see their patients, they will have difficulty attending interdisciplinary conferences consistently. Without physician attendance, interdisciplinary conferences will be less effective, since many decisions and action steps require physician involvement. With this in mind, Northwestern Memorial Hospital moved away from their legacy model in which physicians were assigned patients spanning multiple units and floors, to a model in which they prioritized assigning providers to patients on the same floor.

Component 3: Keep conferences focused

Even with the right people consistently in attendance, interdisciplinary conferences may not be productive or efficient unless they closely adhere to a clear agenda. To ensure interdisciplinary conferences are focused on the most important patient care needs, care team members at Northwestern Memorial use a unit-specific version of the tool shown below. Moreover, the teams at Northwestern stratify the time spent on each patient. The communication tool shown here is used only for patients who are new to the unit. For all other patients, the physician provides a brief update—usually two to three sentences—on each patient’s status and invites any needed input from the rest of the team.

Component 4: Establish clear roles

Listed below are the specific roles filled by caregivers during care conferences at The Johns Hopkins Hospital in Baltimore, Maryland. Notably, an important role is the facilitator—which is often filled by the unit’s charge nurse. This individual holds each care team member accountable for attendance, paces conferences appropriately, and ensures any required follow-up is completed in a timely manner.

Results

After implementing highly structured interdisciplinary care conferences, leaders at Northwestern Memorial Hospital reported greater agreement between care team members and meaningful reductions in adverse events.

Leaders at The Johns Hopkins Hospital observed an unexpected benefit following implementation of interdisciplinary conferences. Pharmacists saved an average of three hours per day as a result of shifting their workflow from rounding on every patient individually to participating in daily interdisciplinary care conferences. As a result, leaders at Johns Hopkins added new direct patient care responsibilities to pharmacists at no additional cost. Patient care responsibilities redistributed to pharmacists include high-risk medication screening, medication reconciliation, medication-related patient education, and post-discharge phone calls.