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Service Delivery Innovation Profile

Hourly Nurse Rounds Help to Reduce Falls, Pressure Ulcers, and Call Light Use, and Contribute to Rise in Patient Satisfaction


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Snapshot

Summary

Nurses and nursing assistants at Memorial Health System conduct hourly patient rounds designed to improve safety and address needs that otherwise would prompt use of call lights. During the rounds, they identify and address each patient's pain level, position, and comfort; offer toileting assistance; and ensure that all needed items are within reach. The nurse then documents key findings on a rounding log and reminds the patient that he/she will be visited again in about an hour. The rounding program has helped to reduce patient falls, pressure ulcers, and call light use, and contributed to significant improvements in patient satisfaction with nursing. (Given the numerous quality improvement programs within the health system, leaders cannot be sure of the degree to which the rounding program has been responsible for these results, although they believe it has been a substantial contributor.)

Evidence Rating (What is this?)

Moderate: The evidence consists of pre- and post-implementation comparisons of several metrics, including fall rates, pressure ulcer incidence, call light use, and patient satisfaction with nursing.
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Developing Organizations

Memorial Health System
Springfield, ILend do

Date First Implemented

2009
Original adoption of the program occurred in March 2009; however, staff were fully trained and educated between March and May 2010.

Problem Addressed

Patients often use call lights to summon nurses for both urgent and nonurgent problems. Excessive call light use often disrupts nurse workflow, which has negative implications for quality of care and nurse and patient satisfaction.1
  • Many nonurgent calls, most of which do not require a nurse: Patients use call lights for many reasons, including to request information and/or assistance with pain management, self-care tasks (such as toileting, ambulating, and eating), and comfort (such as repositioning or securing out-of-reach items). Many of these requests are not urgent and/or could be handled by someone other than a registered nurse (RN), such as a nursing assistant (NA).1
  • Negative impact on quality and nurse/patient satisfaction: Excessive call light use often disrupts nurse workflow, thus reducing the time available to provide needed medical care to patients and delaying response times to those truly needing nurse assistance. These delays can create safety risks (e.g., increased risk of a patient falling) and reduce patient satisfaction. Over time, excessive use can lead to nurse burnout and job dissatisfaction as well.1
  • Unrealized potential of regular rounding: Regular rounding offers an attractive alternative to the distraction and disruption caused by unpredictable call light use. Rounding allows nursing staff to address nonurgent requests proactively and respond to patient needs before they become urgent. Unlike call lights, rounding does not disrupt staff workflow, leading to the potential for higher quality of care and nurse satisfaction.1 However, relatively few hospitals employ this practice.

What They Did

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Description of the Innovative Activity

RNs and NAs at Memorial Health System conduct hourly patient rounds designed to improve safety and address needs that otherwise would prompt use of call lights. During rounds, they identify and address each patient's pain level, position, and comfort; offer toileting assistance; and ensure that all needed items are within reach. The nurse then documents key findings on a rounding log and reminds the patient that he/she will be visited again in about an hour. Key program elements include the following:
  • Designating rounding responsibilities: During start-of-shift assignments, the nurse manager on each unit designates responsibility for hourly rounding for the entire shift (day or night) to an RN or NA. Although both RNs and NAs are responsible for completing the rounds, the RN is accountable for ensuring that rounds occur on the shift.
  • Conducting rounds: As noted in the previous bullet, rounding is assigned to various individuals during the shift; however, when the RN enters the patient's room to provide care (e.g., administer medications) he or she also performs rounding duties for the patient for that hour and documents this activity on the "rounding log," which tracks rounding duties that have already been performed (see bullet below for more details). If the designated RN or NA becomes too busy caring for a high-acuity patient to complete the hourly rounds, he or she notifies a colleague who then performs the rounding during that hour. Key components of the rounding process are described below:
    • Greeting patient: The RN or NA greets the patient and states that he/she will be performing the hourly round. The RN or NA will generally not awaken a sleeping patient at night unless some assessment and/or intervention is required, such as turning a bedridden patient or checking an incontinent patient for cleanliness and skin integrity.
    • Identifying and addressing needs: The designated staff member identifies and addresses the patient's needs with respect to the "four P's"—pain, position, potty, and possessions. If pain levels are high, he or she will take appropriate action, such as providing comfort measures (e.g., repositioning to reduce pressure on the affected area), discussing pain management with the physician, and/or administering a prescribed pain medication. (The NA notifies an RN if medication needs to be administered.) If the patient is uncomfortable, the RN or NA will take steps to improve the situation, such as getting a blanket or pillow or helping to reposition the patient. The RN or NA also offers to assist the patient with toileting and makes sure that the patient can reach all necessary items (e.g., call light, telephone, television remote control, bed light switch, bedside table, tissues, water, garbage can). While taking these actions, the RN or NA works "out loud" by informing patients and family members what they are doing and why (e.g., “I am changing your position for your comfort and to keep your skin healthy.”).
    • Reminding about next visit: Before leaving, the RN/NA asks if the patient has any other needs (pausing to allow time for consideration of the question) and reminds him/her that someone will be back in approximately an hour for another visit.
    • Documenting rounding activities: At the end of the visit, the RN/NA completes a log that hangs in an easily visible location in the room. The RN/NA writes his or her name and checks "yes" or "no" for each of the four P’s to indicate whether they assessed the patient and provided an intervention.
  • Monitoring by nurse manager: The nurse manager on the unit reviews the logs during his/her daily rounds, confirming that rounding activities take place every hour and addressing any gaps with nursing staff if they do not. As an additional check, the nurse manager also asks patients if they are being visited by staff regularly.

Context of the Innovation

Memorial Health System in Springfield, IL, includes a 507-bed acute care nonprofit hospital (Memorial Medical Center) and two rural “critical access” hospitals (25-bed Abraham Lincoln Memorial Hospital and 25-bed Taylorville Memorial Hospital). With roughly 6,000 employees, the health system provided care to nearly 25,500 inpatients in 2010. Memorial Medical Center received Magnet recognition from the American Nurses Credentialing Center in 2006. Health system leaders decided to implement hourly patient rounding as part of a 2003 system-wide initiative known as the “Three Greats,” which embraced proactive activities geared toward achieving a great patient experience, making the system a great place to work, and producing great results.

Did It Work?

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Results

The rounding program has helped to reduce patient falls, pressure ulcers, and call light use, and contributed to significant improvements in patient satisfaction with nursing. (Given the numerous quality improvement programs within the health system, leaders cannot be sure of the degree to which the rounding program has been responsible for these results, although they believe it has been a substantial contributor.)
  • Fewer falls and pressure ulcers: Patient falls have declined by more than 50 percent since program implementation. Falls per 1,000 patients decreased from 4.52 during the first quarter of 2010 (before implementation) to 3.75 during the same period in 2011 (after implementation). Fall rates decreased even further (to 2.4 per 1,000 patients) in the second quarter of 2011. The incidence of pressure ulcers also declined by more than 50 percent (from 3.7 to 1.6 percent) between the first and third quarters of 2010.
  • Less call light use: A study of the use of call lights on four units over approximately 5 months decreased by nearly one-third, from 4,273 before implementation to 2,936 afterwards.
  • Higher patient satisfaction with nursing: Compared with other hospitals of the same size, patient satisfaction with nursing improved from the 23rd percentile in the first quarter of 2010 to the 67th percentile during the comparable period a year later. Satisfaction with response time to call lights improved from the 33rd percentile to the 67th percentile over the same time period.

Evidence Rating (What is this?)

Moderate: The evidence consists of pre- and post-implementation comparisons of several metrics, including fall rates, pressure ulcer incidence, call light use, and patient satisfaction with nursing.

How They Did It

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Planning and Development Process

Selected steps included the following:
  • Reviewing literature: The system administrator of organizational development assigned the task of overseeing implementation to one of the system’s organizational development consultants. She conducted a literature review to obtain details about the program (e.g., implementation process, potential benefits), which included a review of research by the Studer Group, a health care consulting firm located in Gulf Breeze, FL.
  • Designing and implementing training program: Based on her research, the consultant designed a proposed training program and worked to finalize it with nursing representatives, including the chief nursing officer, a doctorate-level nurse working on quality improvement, several nurse directors, and a nurse educator. Training included an initial (recorded) introduction from the hospital’s chief nursing officer; a presentation about the program, positioning it as an evidence-based practice to improve patient safety, workflow, and patient satisfaction; a review of how to use the rounding log; videotaped scenarios of rounding performed correctly and incorrectly; scripting suggestions; and role playing activities. All nurses within the health system attended the training, which was given more than 120 times. Nurse managers and director-level nurses attended all sessions provided to staff on their respective units.
  • Implementing unit by unit: The program was implemented on a unit-by-unit basis after training had been completed for staff on that unit; all units eventually implemented the program.

Resources Used and Skills Needed

  • Staffing: The program requires no new staff, as existing staff incorporate it into their daily routines.
  • Costs: Upfront costs included time spent by the organizational development consultant and nurse time to attend the training session (although no overtime costs were incurred). The program requires no ongoing operational expenditures.
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Funding Sources

Memorial Health System
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Tools and Other Resources

Tools related to the program, including a nursing competency checklist and 90-day action plan, can be obtained from the Studer Group at: http://www.studergroup.com/tools/tools_hourly_rounding.dot.

Adoption Considerations

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Getting Started with This Innovation

  • Highlight potential impact on quality: Although patient satisfaction is clearly important, nurses will likely be more enthusiastic about participating after learning of the potential benefits related to patient safety and quality of care.
  • Demonstrate nurse leader commitment: Having the nurse manager and nursing director attend all training sessions for staff on their units demonstrates their commitment to the rounding process, thereby ensuring frontline nurse buy-in.
  • Train staff to round purposefully: Staff should be taught to perform rounds in a specific and purposeful way, rather than casually “popping in” to ask patients if they need anything. Videotapes of ideal versus suboptimal rounding (e.g., a polite nurse appearing rushed and asking only general questions) can help to illustrate how to perform rounding correctly.

Sustaining This Innovation

  • Integrate into existing workflow as possible: To the extent possible, encourage nurses to incorporate rounding into the existing workflow. For example, in some cases rounding can be performed while a nurse is in the patient’s room providing other needed care, thereby eliminating the need for a separate visit during that hour.
  • Monitor program carefully: The nurse manager should spend considerable time and effort monitoring the rounding process, particularly during the first 3 months after implementation, when staff may try to take “shortcuts.” The nurse manager should emphasize accountability, letting each staff member know that his/her rounding activities and entries in the rounding log are important and will be reviewed.
  • Be patient: The program can take between 12 and 18 months to become "hard-wired" into nursing workflow.

More Information

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Contact the Innovator

Evy Ellis, MS, RODC, CPLP
Organizational Development Consultant
Organization Development
Memorial Health System
701 North First Street
Springfield, IL 62781
(217) 788-4585
E-mail: Ellis.Evy@mhsil.com

Innovator Disclosures

Ms. Ellis reported having no financial interests or business/professional affiliations relevant to the work described in this profile.

References/Related Articles

Wolf JA. On the Road—Memorial Health System: Journey to a “Great Patient Experience.” The Beryl Institute. December 2010. Available at: http://www.theberylinstitute.org/?page=ONTHEROAD1210.

Meade CM, Bursell AL, Ketelsen L. Effects of nursing rounds on patients’ call light use, satisfaction, and safety. Am J Nurs. 2006;106(9):58-70. [PubMed]

Footnotes

1 Meade CM, Bursell AL, Ketelsen L. Effects of nursing rounds on patients’ call light use, satisfaction, and safety. Am J Nurs. 2006;106(9):58-70. [PubMed]
Comment on this Innovation

Disclaimer: The inclusion of an innovation in the Innovations Exchange does not constitute or imply an endorsement by the U.S. Department of Health and Human Services, the Agency for Healthcare Research and Quality, or Westat of the innovation or of the submitter or developer of the innovation. Read more.

Original publication: November 23, 2011.
Original publication indicates the date the profile was first posted to the Innovations Exchange.

Last updated: November 06, 2013.
Last updated indicates the date the most recent changes to the profile were posted to the Innovations Exchange.

Date verified by innovator: October 22, 2012.
Date verified by innovator indicates the most recent date the innovator provided feedback during the annual review process. The innovator is invited to review, update, and verify the profile annually.

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