Introducing Family First Rounds
Family First Rounds started as an experiment. Today it's an essential part of how we care for patients and families.
The way doctors at Cincinnati Children's Hospital Medical Center used to make rounds was — and still is — standard procedure at most teaching hospitals. Every morning, senior physicians, residents and medical students met in a conference room to talk about how the patients did overnight and to develop the day's plan of care. Then they'd go out on the floor to visit patients, write orders and tell parents what they had decided to do.
"We used to think we were doing a good job if we told families what we were doing and asked them if they had any questions," comments Stephen Muething, MD. "Now we realize we're doing a good job when we really partner with families and help them make decisions."
Finding a Better Way
In 2001, as part of our application for the Pursuing Perfection initiative, Dr. Muething was leading a team charged with designing perfect care for children with bronchiolitis, a respiratory infection that brings many young children to the hospital every winter. The team knew from patient satisfaction surveys that families felt they were not involved in decision-making and did not feel ready to continue care at home after discharge from the hospital.
The team believed they could improve communication by redesigning rounds to bring together, at one time and in one place, all the individuals responsible for the care of the child — not just the physicians, but the nurses, therapists and other caregivers and the parents. Moving the discussion out of the conference room to the bedside would allow parents to participate in the discussion and decision-making.
A Test of Change
Dr. Muething agreed to test these ideas. "We didn't really have a model for this," he recalls. "We just decided to try it. So we picked a day and got started."
From that early test, a new system has evolved. The process has become well defined and standardized. A key element is called "Discharge When." Soon after the child is admitted to the hospital, the care team, including the parents, develops specific discharge criteria. Progress is discussed daily, during Family First Rounds. Patients are ready to go home when they meet their discharge goals and their parents are confident they understand and can perform any continuing treatment the child may need at home.
Spreading the Word
William Brinkman, MD, remembers an eye-opening experience during his first week as a fellow at Cincinnati Children's. He had just completed three years as a pediatric resident and one year as chief resident at another children's hospital.
"I had never made rounds where the discussions took place at the bedside, in the presence of children and parents. I was so focused on what the resident was saying, I didn't pay any attention to the parent."
He was surprised and more than a little embarrassed when Uma Kotagal, MD, senior vice president for Quality and Transformation, who was rounding with the team, pointed out that the patient's mother looked terrified. "She redirected everyone's attention to meeting the needs of the mother," Dr. Brinkman recalls. It was a startling and clarifying moment for him.
Creating a Video Teaching Tool
That experience led Dr. Brinkman to think about making a video as a teaching tool. When he, Dr. Muething and Michael Vossmeyer, MD, were invited to give a workshop about family-centered rounds at the 2005 national meeting of the Pediatric Academic Societies (PAS), they decided to produce the video. It would distill the key lessons about family-centered rounds they had learned over several years of experience.
And it would address the most common objections from physicians. "Most physicians can't even picture family-centered rounds because they've never seen it," comments Dr. Muething. Many have genuine misgivings: Families won't want it. It will scare them. It will take too long. Teaching won't be as good because we won't be as open in our discussion. The decisions we make won't be as good.
So the workshop needed to dispel these concerns while teaching the most important processes and communication skills for successful family-centered rounds.
The video they produced consists of a series of short vignettes. Each situation is enacted once to demonstrate common pitfalls and again to show a more family-centered approach.
The workshop was so successful, it was repeated at the 2006 PAS meeting, and physician groups from other teaching hospitals have visited Cincinnati Children's to learn about the way we make rounds. Through these and other outreach efforts, Cincinnati Children's is spreading that word that family-centered rounds is a simple but profound innovation.
