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Posted October 10, 2018

Improve Post-Acute Care with Hourly Rounds

By Jennifer Malatek, FACHE

As the senior population in the United States grows, the demand for post-acute care is expected to continue to rise. At the same time, this critical healthcare sector is often challenged with high employee turnover and tight staffing, all while expected to deliver quality patient care.

When turnover is high, quality of care and staff morale can suffer. How can post-acute organizations help employees proactively meet patient needs and improve quality of care without increasing staff levels? With volumes rising and staffing shortages looming, it's not enough to be reactive. Organizations must develop a solid, systematic patient care strategy that anticipates patients' needs. It may sound like a contradiction, but in an industry where fewer staff must care for more patients or residents, increasing and improving interactions can save time and improve quality.

For years, acute caregivers have utilized and experienced the benefits of some version of Hourly Rounding® or purposeful, structured interactions with patients. The tactic is well known by nursing leaders and has a proven track record for reducing call lights, falls and pressure ulcers while increasing patient experience metrics. But, how can rounding benefit post-acute areas of healthcare (skilled nursing, long-term care and inpatient rehabilitation facilities) where staffing mixes reflect a care model that places less emphasis on acute care and more on assistance with daily living and rehabilitation?

The Eight Behaviors of Hourly Rounding: Make Every Moment Count

Hourly rounds are a proactive way to approach and organize patient care. When completing hourly rounds, care providers perform eight specific behaviors that contribute to improved safety and efficiency. By using specific key words designed to reduce anxiety, staff shift how care is delivered and change the patient's perception of care. Changes can be as simple as prompting the patient to use the bathroom by saying, "Let's go to the bathroom now; our goal is to keep you safe," instead of a reactive statement, "Call me if you need me." The goal of the caregiver during these rounds is to make every moment count by addressing all the patient's needs before leaving the room.

Below is an example of how patient encounters can look.

Behavior

Action

1.
Use opening key words.

Greet the patient and review the plan of care for the day, discuss their schedule, including any appointments they have with other disciplines (lab, therapy). Write this information on the communication board so the patient knows what's ahead for the day.

2.
Perform scheduled tasks.

Perform scheduled tasks including administering medications, caring for any wounds and addressing the patient's personal needs/activities for daily living.

3.
Address the 3 P's: pain, potty, and position.
  • Pain: Discuss pain goals; inform the patient of their next available dose and document that information on the communication board.
  • Potty: Help the patient to the bathroom, if needed; proactively toilet patient before appointments such as therapy.
  • Position: As dictated by the care plan, reposition the patient in bed or move them to a chair; assist with activities of daily living (ADL) retraining.
4.
Assess additional comfort needs.

Make sure the room temperature is comfortable and the patient has items such as water, pillows and blinds open/closed.

5.
Conduct an environmental assessment.

Ensure the room is clean, safety measures are in place and all critical items are within reach -- call light, television control, glasses and phone.

6.
Before leaving, ask, "Is there anything else I can do for you? I have time."

Patients are more likely to verbalize an unmet need when you let them know you have the time to help. This prevents patients with limited mobility from trying to move on their own and risking a fall.

7.
Tell the patient when you will be back.

Build trust with your patients by returning as promised. When they know when you will return, they are willing to wait for your help.

8.
Document the round.

Enter the information collected during the round on the rounding log. Documentation enforces accountability and is also a visible sign to the patient and family that consistent rounding is a priority.

Purposeful rounding should be positioned as a way to organize care and communicate with patients while performing normal duties. When executed effectively, patients' needs are met so that staff have uninterrupted time before rounding on them again. Not only does consistent rounding make the day easier for staff and patients, but done correctly, it also positively impacts some of the top concerns of senior leaders, such as patient safety, perception of care, and employee and patient engagement.

Reduce Patient Falls

Falls remain one of the top safety concerns in skilled nursing facilities, inpatient rehabilitation hospitals, assisted living facilities and other post-acute care organizations. Many falls result from patients trying to get to the bathroom on their own. Patients in these environments tend to be more mobile and independent compared to acute care patients, but they can also misjudge their ability to get around by themselves. Furthermore, patients may be recovering from surgery or have neurological deficiencies that compromise their ability to move around safely. Rounding every hour (or every two as we often suggest for rehab and skilled nursing facilities) establishes a schedule for staff to help patients with their personal needs which mitigates the risk of falls.

Falls are both financially and emotionally damaging for organizations and patients. A fall can hinder a patient's recovery and may even require additional acute care. Even if a fall does not result in a physical injury, there is often a psychological impact on the patient, and by extension, their family. Moreover, falls carry a heavy financial burden for facilities. According to The Joint Commission, the cost of a fall with injury is approximately $14,000 or greater depending on the amount of care the patient needs.

Improve Patient Perception of Care and Engagement

Patients moving from acute care to a skilled nursing facility or an inpatient rehabilitation facility may be nervous about receiving a different level of care in an environment with an unfamiliar care model. However, regular rounding reassures patients and reduces their anxiety because they can trust that a caregiver will come around to see to their needs.

In addition, facilities with rehabilitation services typically operate in a scheduled environment where patients may leave their room for appointments with other caregivers throughout the day. While these appointments are necessary, they can also produce anxiety if patients don't understand when they will occur or how long they will last. Discussing the plan for the day, documenting it on the communication board and inviting questions conveys respect and engages the patient as a partner in their care plan. Patients feel secure when they know their schedule because they can coordinate their personal plans, like visits from family and friends.

Hourly rounds can also help retain staff and prevent burnout. When implemented successfully, employees will find that they are not constantly running after call lights, which can bring order to a chaotic day. Also, staff will discover they have more uninterrupted time to care for and connect with their patients, which many direct caregivers describe as the best part of their jobs. Together, these changes promote a better work environment for employees, leading to improved employee engagement. And, employees who are actively engaged with their work and company are less likely to leave their job, which means lower turnover.

It's a Paradigm Shift

The first step to implementing purposeful rounding in a post-acute setting is to stop thinking of it as added work. If an organization thinks they can't implement Hourly Rounding® because they don't have the staff or the time, the bottom line is that they won't be successful. The foundation of the tactic is that employees do the same work they have always done but reorganize those tasks differently during regular rounds to proactively manage care for the patient.

To get sustained improvement, organizations must execute the hourly rounds consistently. Leaders must also take the time to train their staff, validate their competency and give them the support they need to be successful. Over time, organizations will see improved patient safety, more engaged patients and reduced employee turnover.

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