Hourly Rounding: Closing the Gap between Patient and Provider Perceptions

Added on Mar 21, 2016

Hourly Rounding: Closing the Gap between Patient and Provider Perceptions
By Diana Mahoney
From Industry Edge March 2016

Patients who report that nurses and staff rounded hourly during their inpatient stay rate their overall care experience higher than those who observe no rounding behaviors, according to new research from the Institute for Innovation.

In a study of more than 100,000 patients across 108 organizations, patient-reported hourly rounding was positively correlated with patients’ ratings of their care experience overall and their likelihood to recommend the hospital to family and friends.

The research extends the body of evidence linking hourly rounding to patient experience outcomes by looking beyond organizational perceptions of best-practice implementation and examining whether, and to what degree, patients observe the relevant behaviors. The latter consideration — patient awareness and experience of leading care practices and staff behaviors — appears to be a linchpin in the success of improvement efforts. Further, patient feedback can be a powerful tool for assessing organizational fidelity to best practices.

“When instituting a practice, what most organizations overlook is the accountability and tracking of the adoption rate of the practice: how often it is actually done,” said Deirdre Mylod, PhD, senior vice president of Research and Analytics at Press Ganey and executive director of the Institute for Innovation. With respect to hourly rounding, for example, “rounding sheets on the patient door track how often the employee reported that the round occurred. All of those rounds may not have occurred, and when they did occur, not all may have been memorable. Moreover, such tracking sheets create added work for staff and often are not fully utilized to connect the data back to patient experiences.”

For the current investigation, researchers reviewed patient responses to the question “Did a staff member visit you hourly during your stay?” to determine whether the observation of hourly rounding behaviors influences patients’ perceptions of the care they received. The answer is a resounding yes, according to Mylod, who noted that, among patients who reported experiencing hourly rounding, significantly higher evaluations of care were observed in all areas across Press Ganey and HCAHPS measures.

Four sections of the Press Ganey survey — Nurses, Discharge, Personal Issues and Overall Assessment — had individual items in which the difference in mean scores between those who did and did not report rounding exceeded 10 points. For two items, the mean differences in favor of patients who observed hourly rounding exceeded 15 points: “Response to concerns and complaints made during your stay” (15.5) and “Promptness in responding to the call button” (15.1).

“Based on the findings, the patient experience of hourly rounding appears to influence the way a patient perceives nursing care overall, as well as many of the more intangible attributes of care,” said Mylod. “Notably, patients perceive the response to concerns and complaints to be higher when they have been visited on an hourly basis. This may reflect the opportunity to be asked about any concerns they have, the process of being listened to and the ability for a nurse or staff member to address the patient concerns in the moment and provide resolution.”

The dramatically higher scores for promptness in response to the call button may reflect the reduction in the frequency with which patients need to use the call button when hourly rounding is consistently practiced, Mylod explained. “The rounding process is expected to dramatically reduce the frequency with which patients need to use the call button, so nursing staff may be able to respond more quickly to patients when they do use the call system.”

Patient-reported hourly rounding has a similarly positive influence on HCAHPS measures in that patients who experience hourly rounding are more likely to report top box ratings across all HCAHPS measures. “The impact is most noticeable for the global items, as well as the areas of nurse communication and responsiveness,” Mylod explained.

The findings suggest that, among organizations reporting implementation of hourly rounding, the full benefit of the best practice can only be achieved when patients experience the key behaviors associated with it. In this regard, including custom survey questions to assess patient recall of specific behaviors can be an indicator of how well a given practice is being executed.

“When organizations use patient feedback on hourly rounding, I generally counsel them to first look at the proportion of patients who report hourly rounding happened and to interpret it not as how often rounding occurred but how often patients recalled that rounding occurred. That’s their adoption rate from the patients’ point of view,” said Mylod. Looking at the difference in patient experience scores between those who remembered experiencing hourly rounding and those who did not, “there should be a fairly wide gap indicating a more positive experience when rounding was recalled,” she said. “If the delta is not large, it may mean they are rounding in a perfunctory way but may not be executing it well in terms of actually meeting patient needs during the process.”

When there is discord between patient and organizational reports of hourly rounding, a number of tactics can be implemented to bridge the gap. One possibility is the adoption of checklists and logs, both to prompt certain activities and to document the steps that have been taken, Mylod suggested. “However, logs can lose their utility if they are completed retrospectively, not completed at all or not tied to results,” she said.

Peer or manager observation and feedback of the rounding process can also be effective. “This offers the opportunity for rich feedback about the quality of the interaction and is especially useful when the rounding process is new, although it can be time- and staff-intensive when used for long periods of time,” Mylod said.

The value of using patient feedback to evaluate how consistently certain staff behaviors occur depends on the nature of the behavior being evaluated. “The behavior must be something that occurs in front of the patient or has an outcome that is directly observable by the patient,” Mylod stressed. And the benefit of using patients as sources of feedback should be balanced with the burden it places on them to report on specific aspects of their care, she said, noting that the focus should be on those behaviors for which patient feedback will be actively used and shared for quality improvement initiatives.