Family-Centered Rounds in Practice
The staff at Cincinnati Children's Hospital Medical Center are working through the best ways to implement family-centered rounds and teach its concepts. Below are some answers to frequently asked questions about starting family-centered rounds:
Could you please give us some guidance as to how to begin, how to set up the rounds, and get buy in from all involved parties?
First, remember that this is a culture change and will take time. You will never be "ready," so start practicing Family-Centered Rounds and learn as you go. Begin practicing Family-Centered Rounds with physicians and nurses who are already believers. Gain experience and success; then let your initial supporters become your local champions.
Do you have a hospital policy that guides these rounds?
Initially, we began practicing Family-Centered Rounds and implemented a formal policy in years 3 to 4. Policy will not change culture. Culture change will lead to policy.
Does Cincinnati Children's follow certain steps?
Family Centered Rounds has evolved over a five year period. At Cincinnati Children's, we generally follow the steps below:
- The family decides how rounds should be conducted. At admission, staff explains rounds and how families can be involved. Families choose their level of involvement:
- Team entering the room during rounds
- Family comes into the hallway during rounds
or - Family is not directly involved in rounds but has physicians and nurses meet with them later in the day
After addressing confidentiality concerns, the family's preference is marked on a card and taped outside the patient's door. The card also lets the family indicate if they wish to be awoken during rounds.
The team decides who needs to be included on rounds and if any information should not be discussed in front of the family. This is the optimum time to discuss sensitive family issues (e.g. suspected abuse, child going to Social Service later today). The team also decides who will fulfill what role. Ideally, rounds are conducted with the parents present, if the parents indicated on the card that they want to be present. If an interpreter is necessary, make sure the interpreter is available before entering the room to begin rounds. The team also puts on gowns, masks, or any other protective gear needed. The resident or intern enters the room and confirms that the family wishes to be involved before bringing in the entire team. The team enters, stands in a circle, and introduces themselves to the families. Introductions seem to help families feel they are true partners in the process. Some teams introduce key members and others introduce all members of the team. A team member may ask if it's okay to turn off the TV. Patient's intern or student briefly clarifies the purpose of rounds and encourages family involvement. A couple of catch phrases are, "I'm going to tell his or her story but if there is anything you feel is inaccurate please speak up" or "We are not speaking at you we want to talk with you. We are the medical experts but you are the experts on your child, together we will do a better job." A team member inputs orders into a wireless computer. While one team member issues orders, another enters them electronically. The tam participates in "write down/read back" to confirm orders are accurate. The intern or student uses medical and lay language to summarize medical information and the plan for the patient. He or she alternates eye contact between the team and the family. He or she then states when they are about to make the plan and asks the family to become involved in decisions. The team spells out discharge goals for every patient, every day so the family knows what is happening and what to expect. One member of the team documents the discharge goals and these are posted in the patient's room. Nurses and other key staff members (e.g. Nutritionist, OT/PT, Child Life Specialist) contribute information regarding the patient's condition over the last 24 hours and the ability to carry out the proposed plan. Throughout this process, the teaching attending observes the interns' understanding of the patient's condition and the family's and staff's comfort levels. The teaching attending uses verbal and non-verbal queues to better understand each family's concerns and ability to carry out the plan. The teaching attending can immediately address any issues and model methods to address families with particular fears, anger, confusion, or misunderstanding. Senior residents and teaching attendings may ask families permission to conduct additional teaching in the room. If allowed, this provides the senior resident or attending an opportunity to involve parents in teaching. Alternatively, teaching can be carried on in the hallway or conference room in the more traditional manner. Teaching that is directly relevant to the care of the child is most likely to be valued by everyone, including the family.How is teaching affected by family-centered rounds?
Our hospitalists believe our teaching has improved immensely. We teach residents and students how to interact with families in ways we were unable to teach in a conference room. We model approaches with agreeable families, scared families, dysfunctional families and angry parents. We show how to interact when there is uncertainty and how to interact after an error has occurred. Students and residents lead the discussion, and we observe their performance and are able to later give feedback.
We teach openly after asking the family for permission. Families routinely tell us they are not bothered by multiple opinions. In fact, some say, "We knew there was disagreement and we feel better hearing the discussions. Now we know the residents are getting direct input from supervisors."
Does family-centered rounds mean conducting "traditional" rounds in the patient's room in front of the family?
Practicing family-centered rounds is not doing our old approach in front of families. Family-centered rounds is a new approach. Truly partnering with families requires a new mind set. To level the playing field, we tell families, "We are the experts in medicine, but you are the experts about your child. Together we make better decisions and give better care. We cannot do it without you."
Once staff has said this to families every day for a year or two, they start to believe it. They learn stories of how care was improved and errors were avoided. Families can play an enormous role in setting expectations and spreading the news of family-centered rounds. Please include families on your team in the beginning.
What are some of the advantages to family-centered rounds?
- Several "steps" are completed at one time. Rounding, discussing / deciding the plan with the family, discussing/deciding the plan with other health care workers (e.g. nurse, nutritionist), and beginning to document discharge orders are handled during the family-centered rounds. Since everyone is involved in the same discussion, fewer pages are needed later. (e.g. Since the nurse is aware of the plan, he or she is less likely to need to call the resident or intern with questions.)
- Physician / patient / family relationships are improved by open communication.
- Teacher-Learner relationships are improved.
- The teacher has the opportunity to directly observe the learners interacting with families.
- The teacher has the opportunity to role model for the learners. In addition to teaching medical knowledge and how to interact with the family.
- Family-centered rounds provide the team an opportunity to clarify their roles (before entering the patient's room).
- The teacher can teach residents and interns at the same time the team teaches the family about the patient's condition.
- The family is central to the child's health; family-centered rounds provide a wonderful way to involve the family in the child's care and decisions about the child's care.
- Every member of the team and family member hears the same consistent message.
- Parents play a role in teaching interns and residents.
What are some of the disadvantages to family-centered rounds? How can we overcome them?
- Some hospitals may not have many private rooms. If the patient is not in a private room, the rounds can be held in the room with the other family present as long as the family is aware that the conversation will not be private and consents to proceed. Other options include asking the other family to step out of the room, using the hallway or a conference room. Nearly all of these options require some discussion of HIPAA with the family The family is central to the child's health; family-centered rounds provide a wonderful way to involve the family in the child's care and decisions about the child's care.
- It can be difficult to pick the optimum time for rounds when the patient is not sleeping, having a test, attending classes or playing in the playroom. The staff person who explains family centered rounds and helps the family fill out the card can say when rounds are typically conducted. If the parents and nurse know in advance, they may be able to prevent the child from being given a test or playing during rounds. The parents can indicate on the card if they want to be awoken if they are asleep when the team arrives.
- Nurses may be reluctant to participate. Nurses are not the only people in the hospital who may be reluctant to participate. When first implementing family-centered rounds, begin practicing them with floors or units where most people are excited to embrace the new idea. Include nurses in the planning and discussing of how to implement family centered rounds. Our experience shows that nurses are glad to hear that attendings, residents, interns, and families value their opinions and want to work with them. Remember to include other interested health care workers (e.g. nutritionists, OT/PT, Child Life) as well.
- In certain situations, the team may need to discuss abnormal findings or sensitive topics. Before entering the patient's room, the team decides if certain sensitive topics (e.g. suspected abuse) should not be discussed. This is the time to decide how and when to address certain issues.
- Practicing family-centered rounds may be less efficient and take more time. Our experience has found that rounding takes a little more time in the morning; however, residents and interns feel they receive fewer pages and questions from nurses and other health care providers later in the day. Since everyone discusses and hears the same message at the same time, fewer clarifications are needed later. Overall, attendings, residents, and interns feel practicing family centered rounds does not take more time.
- In certain situations, the intern, resident, attending team is not sure how to proceed or what is specifically wrong with the patient. Families have reported that they appreciate hearing the discussion and uncertainty. They would rather be told what may or may not be happening with their child than left out of the discussion. Someone will have to communicate a message to the family at some point. Family-centered rounds provide the opportunity for everyone to discuss the situation and decide on the best plan for that day.
- A large team can overwhelm families. Before entering the room, the team can decide who needs to be involved. The family chooses if they want to participate in family-centered rounds or want the rounds to be conducted without them. Each family can make the best choice for them and their child.
- Confidentiality / Adolescent issues
- In some cases, the parent may need to be explained the issue in greater detail and this may take more time. If the parent was not educated about his or her child's issue during family-centered rounds, the resident, intern, or nurse will have to explain the issue to the parent later. If the parent has a question, he or she will rightfully ask someone which may involve the nurse paging the resident later in the day. By educating the parent with everyone else, the parent hears the same consistent message. This also allows the lead resident and attending the opportunity to make sure the parent understands what the team is saying and what is happening with his or her child.
