Frequently Asked Questions
One of the most common barriers to implementing patient- and-family centered rounds seems to be that physicians are not able to observe other physicians practicing patient- and family-centered rounds. Observing through the video vignettes may give ideas on how to implement them.
What are some of the disadvantages to patient- and family-centered rounds? How can we overcome them?
- Some hospitals may not have private rooms. Rounds could be held in the room as long as the patient and family are aware the conversation will not be private and they give permission to proceed. Other options would be to ask the family to join you for rounds in the hallway or the conference room. All of these options involve some discussion of HIPPA with the family.
- It can be difficult to pick the optimum time for rounds − when the patient is not sleeping, having a test or otherwise out of the room. Family members may also not be able to be at the hospital continuously. The staff person who explains patient- and family-centered rounds can inform the patient and family when rounds typically occur. If families and nurses know in advance, they may be able to more effectively coordinate their presence in the rooms. In some circumstances, rounds can be scheduled at other times of the day.
- Nurses may be reluctant to participate. When first implementing patient- and family centered rounds, begin practicing them on floors or nursing units where most people are excited to embrace the new idea. In addition to patients and families, include nurses and other healthcare providers in the planning and discussing of how to implement your plan. Our experience shows that nurses and families are glad to hear that physicians value their opinions and want to work with them.
- In certain situations, the team may need to discuss abnormal findings or sensitive topics. Before entering the room, the team can strategize about how to address the findings or topics.
- Practicing patient- and family-centered rounds may take a little more time, especially in the morning. However, residents and interns feel they receive fewer pages and questions from nurses and other healthcare providers later in the day. Since everyone discusses and hears the same message at the same time, fewer clarifications are needed. Overall, attending physicians, residents and interns do not feel practicing patient- and family-centered rounds is less efficient.
- In some situations, the healthcare team is not sure how to proceed or what is specifically wrong with the patient. Families have reported they understand there may be uncertainty and they appreciated hearing and being part of the discussion. They would rather be told what is known or not known about the condition of the patient than be left out of the discussion. Patient- and family-centered rounds provide the opportunity for everyone to discuss the situation at the same time and to decide on the best plan for the day.
- A large team may overwhelm a patient and his family. Before entering the room, the team can decide with the patient and family who should be involved with rounds. Each patient and family can make their own best choice.
- Confidentiality / adolescent issues may be a concern. The team should plan how to handle these issues before entering the room. We have found that open communication about confidentiality beginning at the time of admission can mitigate many of these issues.
- In some instances, the patient and family may need more time to discuss the situation. The healthcare team may not have the time to fully address the patient’s and family’s concerns during rounds. We have found if the team explains the situation and requests to schedule time after rounds, the patient and their families find that approach to be acceptable. Likewise, families may not be present for rounds and the team (or members of the team) may need to return to the patient’s room later to make sure everyone has a chance to have input on care plans.
The vignettes do not work well on their own as a “how to” video. We recommend that a group of people watch the videos together and discuss them. Watching in a group stimulates valuable discussions among providers about the perceived benefits and obstacles of partnering with patient and families. No performance depicted in the videos is perfect. Rather, the vignettes are intended to stimulate group discussion of what went well and what could have been done better. While somewhat dramatized, the videos capture many common mistakes made by teams new to the process.
Any organization may use the videos in training as long as Cincinnati Children’s is cited as the source.
First, remember that this requires a culture change and will take time. You will never be “ready,” so start practicing and you will learn as you go. Begin with physicians and nurses who are ready to try patient- and family-centered rounds. Gain experience and success; then let your initial supporters become your local champions.
Initially, we began practicing patient- and family-centered rounds and then implemented a formal policy. The policy will not change culture. Culture change will lead to policy change.
Patient- and family centered rounds have developed over a number of years. At Cincinnati Children’s, we generally follow the steps outlined below.
The patient and family decide on how rounds should be conducted. At admission, staff members explain rounds and outline options for patient and family involvement. After addressing confidentiality issues, the family’s preference is marked on a card and taped outside the patient’s door. Some of the options:
- The team rounds in the room with the patient and family.
- The family joins the team in the hallway for rounds.
- The family chooses not to be involved in rounds but prefers that the physicians and nurses meet with them after rounds.
- The family indicates if they wish to be awakened during rounds if they are sleeping.
A decision is made on who needs to be involved in rounds and if any information needs to be discussed before entering the room. This is the optimal time to discuss sensitive patient or family issues (e.g., suspected nonaccidental trauma or confidential test results) and to discuss how this information will be shared with the patient and family. The team members also decide individual roles and responsibilities. Ideally, rounds should occur with the parents present. The team also puts on any necessary personal protective equipment.
A team member enters the room and confirms that the family is ready for rounds.
- The team enters, stands in a semicircle and introduces themselves to the patient and family.
- Introductions help make the family feel they are partners in the rounding process. Families have told us they prefer to have all members of the team introduce themselves and describe their role. Parents’ preferences on how they would like to be addressed should be respected.
- A team member briefly clarifies the purpose of rounds and encourages patient and family involvement.
- A couple of phrases to use 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 the medical experts, but your are the experts on your child; together we will do a better job of caring for your child.”
- Common language is used to share and summarize information and to develop the care plan for the patient.
- The resident or medical student making the presentation maintains eye contact with the patient and family. The use of medical jargon is kept to a minimum, and if a technical term must be used, the term is explained to the family using common language.
Physicians, nurses other key team members and the patient and family contribute information during the rounding process.
- The patient’s clinical course over the last day is reviewed. Daily plans are made and agreed upon. Discharge goals are discussed on the first day the team rounds and are reviewed and updated on a daily basis. The date and time of discharge are also discussed each day and are updated throughout the hospital stay.
- A team member inputs orders in real time into a computerized clinical order entry system.
- While one team member issues orders, another enters them electronically. The team participates in “write down / read back” to confirm orders are accurate.
Throughout this process, the attending physician observes the interns’ understanding of the patient’s condition and the family’s and staff’s comfort levels.
- The attending physician uses verbal and nonverbal cues to better understand each family’s concerns and ability to carry out the plan. The attending physician can immediately address any issues and model methods to address families with particular fears, anger, confusion or misunderstanding.
- Senior resident and attending physicians may ask the families for permission to conduct additional teaching in the room. If allowed, this provides the senior resident or attending physician an opportunity to involve parents in teaching. Alternatively teaching can be done 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.
Our hospitalists believe that 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, frightened families, dysfunctional families and angry families. 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 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 uncertainty and we feel better hearing the discussions. Now we know the residents are getting direct input from more experienced physicians.”
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 uncertainty and we feel better hearing the discussions. Now we know the residents are getting direct input from more experienced physicians.”
We would not practice our old approach; patient- and family-centered rounding is a new way of thinking. Truly partnering with patients and families requires a new mind set. It entails recognizing that the patient and her family are indeed experts about her needs and values, an achievement that will fully engage them in the care process.
Once staff begins to practice patient- and family-centered rounding, they quickly see the benefits. Sharing stories of how care is improved and how errors are avoided can be powerful tools. Families can play an enormous role in setting expectations and spreading the news of patient- and family-centered rounds.
Once staff begins to practice patient- and family-centered rounding, they quickly see the benefits. Sharing stories of how care is improved and how errors are avoided can be powerful tools. Families can play an enormous role in setting expectations and spreading the news of patient- and family-centered rounds.
- Several “steps” are completed at once. Handled during rounding would be: discussing and developing the care plan with the family, discussing and developing the care plan with the nurse and other healthcare workers and beginning to plan for discharge. Since everyone is involved in the same discussion, fewer follow-up pages are needed.
- 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 show model behaviors for the learners, in addition to teaching medical knowledge and how to interact with the family.
- The teacher can teach students, residents and interns at the same time the team teaches the family about the patient’s condition.
- Every member of the team and family hears a consistent message.
- Patients and families play a role in teaching students, interns and residents.
Contact Us
Email family-centered@cchmc.org and one of our physicians working with patient- and family-centered rounds will respond.
To speak directly to a physician, contact Michael Vossmeyer, MD, at 513-636-1956 or mike.vossmeyer@cchmc.org.
3333 Burnet Avenue, Cincinnati, Ohio 45229-3026
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