Rounding with Empathy: Transforming Care with Real-Time Patient Feedback

Added on May 23, 2019

Rounding with Empathy: Transforming Care with Real-Time Patient Feedback
By Whitney Fishburn

Real-time patient feedback is transforming culture and care at Vanderbilt University Medical Center (VUMC). Since implementing a closed-loop rounding platform that focuses on empathy in nurse–patient communication, the center has also seen significant gains in patient experience scores and overall performance improvement.

After years of struggling to achieve any meaningful levels of rounding compliance, leadership at VUMC decided to digitally standardize the process to encourage accountability and sustainability. Leadership also sought to more effectively leverage patient feedback.

In July 2015, five of the center’s 30 patient care units were digitized using iRound, a closed-loop rounding platform that tracks a number of indicators, including which patients have been rounded on and by whom. After a three-month pilot period, the app was rolled out with a training program to most of the remaining units over the course of two months.

“We wanted to hardwire the process and focus on getting the nurse leaders into the room, talking with the patients and families, and then using iRound to document [the rounds],” Lara Mead, VUMC’s director of service measurement and improvement, said during a webinar on rounding.

With a singular focus on improving rounding compliance, nurse leaders established a goal to round every day of the week. This responsibility fell mainly to unit managers and clinical staff leaders who split their time between charge nurse duties and overseeing cohorts of about 20 nurses. Backup for the ambitious new rounding standards was provided by relief staff leaders and patient flow nurses whose primary duties were administrative and patient discharge. The initial target range was for the leaders to round on at least 50% of patients, in hopes of ultimately reaching 80%. With the center’s typical daily census, that meant between 400 and 650 patients seen per day. 

After two years, 85% of respondents to VUMC’s integrated HCAHPS/Press Ganey post-discharge survey reported that a nurse leader had rounded on them at least once during their stay, indicating compliance goals had been met. In addition, real-time data provided insight into compliance trends per unit and per individual, allowing targets to be customized, which improved staff buy-in.

The new rounding protocol also led to notable improvements in nurse engagement, culture, and service. “Employees felt more engaged, because patients were recognizing them in the moment and leaders were hearing it in the moment,” Mead said, adding that the leaders themselves were excited to return to their roots and work bedside with patients, something they enjoyed but were increasingly unable to do because of other added responsibilities.

The real-time feedback also promoted transparency and on-the-spot problem solving, which in turn triggered a cultural shift whereby nurses felt empowered to advocate for their patients. They also could focus on service recovery efforts by tracking data trends that pointed toward opportunities for improvement through better interdepartmental communication. 

Shifting Focus from Quantity to Quality

While rounding compliance goals had been met, there was a lack of sustained, significant improvement in patient experience performance, telling leadership that something was still missing. “We realized we needed to shift our focus from quantity to quality,” Mead recalled. “We needed to be sure we were having meaningful conversations with patients and families.”

This epiphany coincided with a scheduled medical records platform switch, something leadership was already concerned would interfere with the overall patient experience. “If there was ever a time we needed to focus on figuring out how to make this experience better and understand the patient experience, it was now,” Marie Glaser, VUMC’s associate nursing officer, said during the webinar.

A service committee was formed to explore how best to standardize the patient experience and ensure responsibility, accountability, support, consultation, and communication with all stakeholders in meeting both patient experience and rounding compliance goals.

After reviewing the two years’ worth of patient feedback, the committee recommended changing the binary iRound feedback form to an open-ended one. “We wanted a dialogue, not a routinized yes-or-no kind of approach,” Glaser said. The idea was to augment the learnings from iRound by helping nurses learn how to exchange information with patients, develop a rapport, and allow patients to direct where the conversation would go.

The introduction of the new rounding feedback form and subsequent protocol changes was done with a top-down approach in which leaders trained direct reports and peers, giving feedback about what they observed and developing unit-specific checklists that all nurse leaders were to follow when rounding. An hour-long training module emphasizing compassionate care, best practices, and weekly “empathy” reminders was also employed.

The top-down approach was reinforced with the use of “performance boards,” which serve as visual aids during weekly executive team huddles. The boards grid patient experience and other related initiatives per fiscal year against additional information such as monthly scorecards, weekly targets, and service committee-identified actions to drive performance improvement.

Similar performance boards are displayed across the units where they are customized to provide visual context during each shift’s huddle. Leveraging real-time patient feedback from bedside shift reports and purposeful rounding, unit leaders use the boards to track unit-specific trends, determine goals and action plans, and recognize staff efforts.

Over the course of a year, one unit’s top-box percentile rank by discharge date went from 41 to 93, through the unit manager’s repeated use of the board to visually depict for her team the direct correlations between what patients were saying at that time, what actions could be taken using the best practices learned, and performance data.

Using performance boards to show how real-time feedback intersects with goals, actions, and results has become a key part of VUMC’s performance improvement journey, according to Glaser, who said that the center is currently working to integrate Lean tools into the performance board as part of its shared governance model.

Since VUMC began hardwiring the rounding with empathy behavior into the units, systematizing real-time data collection, and visually depicting what is gathered, its patient experience scores have improved dramatically. Among VUMC patients who reported being visited by a nurse leader, the medical center ranked in the 88th percentile for Overall Rating, compared with the 10th percentile among patients who said they had not been visited by a nurse leader. Further, nurse leader rounding was associated with an 82nd percentile ranking for performance on the nurse communication item, which has been identified as a key rising tide measure, compared with a 2nd percentile ranking when the rounding was not observed. Similar differentials were observed across all the nursing-sensitive patient experience outcomes.

Since October 2017, when VUMC implemented its change to a new medical records platform, inpatient experience scores have trended into the top third percentile for Overall Rating. “We really attribute this to our empathetic rounding and having that service committee fully integrated and underway now that we have more accountability and our focus on compassionate care,” Mead said.

Moving from the yes-or-no questions to open-ended feedback was a key decision, Glaser said. “Once nurses get into the habit of asking yes-or-no questions, to break that is challenging,” she explained. “They are trying to get through a list versus really listening to what the patient is saying and moving in the direction that the patient wants to go.” Making the transition required a lot of retraining, she noted.

Another important lesson, according to Mead, was not to overstaff rounding with backup and lower-level nursing staff, because patients’ perceptions of their concerns being heard and addressed were higher when only nurse leaders and unit managers conducted the rounds.

Future fine-tuning of rounding with empathy at VUMC will focus on improving the experience for patients admitted through the ED, integrating iRound with patients’ electronic medical records to track rounds directly to the patient rather than the room number, and ensuring that all inpatients are rounded on within the first 24 hours of admission.