Perspectives on the Acute Care Continuum

The Acute Care Continuum is the integration of urgent, emergent, inpatient and post-discharge care of patients with acute medical conditions. 

Inpatient Rounding to Improve the Patient Experience (Part 1 of 2)

8/17/2016 6:51:25 PM | 10 comments

Putting patients first requires more than providing outstanding clinical care. It requires care that addresses every aspect of a patient’s encounter with the hospital, from parking to emergency department wait time to the inpatient stay. In this two-post series, we’ll look at two hospitals that launched inpatient rounding programs to improve the patient experience.
Today, two ED leaders share how inpatient rounding sparked engagement across the entire organization.
About two years ago, our ED decided to develop real-time processes to handle service failures. We hoped that the program would help uncover issues that could be addressed before the patient left the hospital. Research shows that when patients who have a less-than-optimal service experience are recovered, their satisfaction transcends the level of loyalty of a patient who had a positive experience.
First and foremost, providing an optimal patient experience is the right thing to do for patients. But it’s also important for a number of other reasons:
  • The Centers for Medicare and Medicaid now ties reimbursement to HCAHPS scores.
  • Patient experience in the ED mirrors overall hospital experience, so it’s important to start a patient’s journey on the right foot.
  • Patient satisfaction surveys are useful but don’t allow a hospital to address service problems in a timely manner.
With 75 percent of our hospital admissions originating in the ED, we wanted to implement a service recovery program to identify ED service failures in real-time. So we decided to start rounding on inpatients who had been admitted from the ED. Although our initial goal was to improve the patient experience by providing a better mechanism for service recovery, we soon realized that we had started a cultural movement within our hospital.
Knocking on Doors
This wasn’t our first experience with inpatient rounding. About a year earlier, hospital administration had asked managers to do leadership rounding where nurse managers and directors would visit patients on the units. However, we didn’t see significant gains in patient satisfaction or HCHAPS scores, because managers didn’t feel a sense ownership or pride in doing task-oriented rounding.
We needed a different approach.
To start, we didn’t spend months going through committees or seeking buy-in from administration. The two of us simply started knocking on the doors of patients the day after they were admitted from the ED.
It was a very informal process. We simply talked with patients about their experience in the ED: what went well and what could have been better. We discovered that inpatient rounding really doesn’t take a lot of time, but taking a few minutes to authentically connect with patients makes a world of difference to them.
We had patients break down and cry that someone cared enough to check on them the next day. One woman ran into my (Dr. Pillar's) arms when we came in to visit her husband. He had just received a terminal diagnosis and was going into hospice, so knowing we cared meant a lot to her.
As ED providers, we had never experienced that before. Traditionally, we take care of the patient in the ED and then send them off to the next place.
With inpatient rounding, we have the opportunity to let patients know we’re still thinking about them and are able to ask them how we could have improved their experience. Patients have a venue for providing immediate feedback, and they see a unified team caring for them. When patients experience teamwork, they feel safe. And partnering with patients and their families in validating their issues or concerns is a powerful way to regain and promote loyalty.
A Little Empathy Goes a Long Way
As physicians, by the time we hit residency, we often have the empathy pounded out of us. Nearly everything we do is task- and process-oriented, which is important in delivering excellent clinical care. But when we lose perspective and the ability to connect with a patient because we’re focused on the tasks we need to perform and the 10 patients waiting to be seen, we’re sacrificing that patient’s experience at that time.
We can provide the right diagnosis and excellent service every time, but if we don’t serve it up with an experience where the patient feels valued and cared for, then the patient won’t want to come back.
Starting a Revival
Once we had established a system for inpatient rounding, we encouraged other ED providers to join in. Although the concept was initially met with reluctance by a few partners, physicians began coming in a half hour before their shifts to round on patients. And once they began doing inpatient rounding, they fell in love with it.
Providers quickly realized that the vast majority of comments from patients and family members are positive. Nobody in this environment gets enough positive reinforcement, and partners quickly recognized the benefit of starting their shift on a positive note.  And what a great thing to start your shift on a positive note!]
Of the complaints we receive, about 15 percent are unrecoverable. Most patients who have a complaint simply want to know that someone took the time to listen, own the problem, and not make excuses. A powerful phrase to communicate ownership of the issue(s) and engage the patient/family while helping to diffuse a potential adversarial situation is:

I can understand your frustration(s). This might not be my fault, but it’s my problem. Thank you for taking the time to bring this to my attention.

The timing of service failure identification is important, because it’s much more meaningful and effective to address a complaint while the patient is still in the hospital than deal with it on the backend when you receive a letter or phone call a week or two later. Since we started inpatient rounding, the number of service issues has decreased tremendously.
Positive or negative, we shared the feedback we received about the noise level, cleanliness, communication, and other issues with the ED nurses and other staff during our morning and evening shift huddles. It truly was a magical experience to see the entire ED become engaged and enthusiastic about the patient experience!
Several months after starting our inpatient rounding initiative, we realized we had a revival going on.
Breaking Down Silos
When inpatient nursing units saw how engaged ED physicians and nurses were in caring for patients throughout their entire hospital stay, they soon became part of the process. The entire hospital saw the momentum of positivity and energy that resulted from the ED’s inpatient rounding project, and we were subsequently nominated by the other departments in the hospital to receive the “Southwest Healthcare Heart Award.” This award recognizes the department that has been the most influential in promoting the hospital’s mission and values.  Additionally, it wasn’t long before Board of Governor members were requesting to round with us and share the experience.
The ED nurses and physicians were seen as leaders and role models in the patient experience. We became known as the team to call upon when there was a difficult situation with a patient.
Breaking down silos in the hospital was not an explicit objective of our inpatient rounding program. But looking back, it was clearly one of most powerful influences in eliminating barriers between departments and increasing engagement across the organization.
Taking It on the Road
It was an honor to share our best practices at the Cleveland Clinic’s Patient Experience Summit a year ago. We responded to a call for posters prior to the conference, and ours was one of 17 selected out of 176 submissions.
As the largest patient experience summit in the world, the event drew 2,100 people from 32 countries and 45 states. It was a wonderful chance to share our story and also to deepen our knowledge.
This fall, we plan to participate in a Cleveland Clinic webinar/podcast on improving the patient experience. And we are currently preparing to roll out our patient experience program to other CEP America sites across the country.
Instituting inpatient rounding to improve the patient experience doesn’t take a great deal of monetary resources or human resources. It’s about instituting culture change and leading by example. It’s about getting out of your comfort zone and authentically engaging patients and families in ways that encourage possible criticism about their experience and using that information to build a better patient experience — the kind of experience you’d want for yourself and your family members.
In our second post on inpatient rounding, Perspectives will highlight a CEP America practice site that takes a slightly different approach to inpatient rounding, with similarly positive results.

Evan Houck
This is hands-down the best patient satisfier I have seen to date. Showing that you care enough to visit them during their moment of profound vulnerability brings the "culture of caring" to it's apex. Thank you, Ed and Julia, for introducing this practice to me. I have additionally found this to be an incredible satisfier for me personally...who needs resiliency training when you doing inpatient rounding?!? As one of my partners recently stated, "The best way to show that you care is to actually care." It's not rocket surgery...
8/29/2016 12:58:01 PM

Tiffany Hackett
Thank you for taking time to share this great practice. This work really exemplifies our culture of caring in action.
8/19/2016 12:23:21 PM

Seth Thomas
What a great practice! What an outstanding value-added practice for our hospital partners! I've done it a handful of times to address service failures but never thought of the value on a much more grand scale. It's like doing callbacks on steroids but only more meaningful and with greater impact. Makes me think about FaceTiming or telemedicine follow-ups for discharged patients.
8/18/2016 12:24:57 PM

Do Kim
It was inspiring to read how the program evolved to make a tremendous impact on patient care and the way it transformed the hospital's cilture. Thank you for sharing your experience!
8/18/2016 12:21:03 PM

Anne Bruce
This is a fantastic article and yes, empathy goes a long, long way. Patients "feel" it when others are at least trying to understand. As the pull quote in this article conveys, it may not be the staff's fault, but someone is trying to under the frustration of the matter and they are willing to listen and help. Great piece!
8/18/2016 11:16:49 AM

Gregg Miller
What a great idea. Usually ED docs make it upstairs only to respond to a Code Blue -- I'm sure this must have been a much more pleasant experience! I hope your work can inspire more hospitals to emulate such a great program.
8/18/2016 9:17:54 AM

Josh Tamayo-Sarver
Fabulous idea. Not only does it allow human connection with the patient and family (when there is not the pressure to manage a busy department), it also enables a much better understanding of what happens from the patient/family perspective after admission. That understanding alone is invaluable in addressing the admitted ED patient's anxiety about "what happens to me next." Kudos to an exceptional program.
8/18/2016 9:17:24 AM

Andrea Kamenca
Thank you for leading such an important effort to authentically connect with patients and raise the level of kindness and compassion in healthcare. As someone with an aging and medically complex parent, I know that compassion, empathy and kindness make all the difference!
8/18/2016 6:58:38 AM

Nic Curry
Great idea and program. The patient and families' voice is so important towards being able to provide high quality, patient-centered care. Thank you for sharing!
8/17/2016 11:43:42 PM

Rick Newell
What a great program. Connecting with patients and their families and hearing their feedback is such an important reminder of why we all do what we do. Thanks for sharing and looking forward to Part 2 in this series.
8/17/2016 10:08:04 PM