Beverly M.

Ford

Hourly Rounding: A Strategy to Improve Patient Satisfaction Scores

atient satisfaction is an important phenomenon in the health care industry. Health care organizations continually seek innovative approaches to boost patient satisfaction scores. Several studies uncovered nursing behaviors essential to patient satisfaction. Patients value the nurse-patient relationship, as well as time spent with them, continuity of care, trust, compassion, respect, safety, understandable instructions, and service quality. They also appreciate reliability, responsiveness, and effective communication (Andaleeb, Siddiqui, & Khandakar, 2007; Cheng, Yang, & Chiang, 2003; Davis, 2005; Fan, Burman, McDonell, & Fihn, 2005). Satisfaction surveys are used to identify, measure, and track key determinants of satisfaction (Pearson Assessments, 2007). The Committee on Quality Health Care in America has worked with the Institute of Medicine (IOM) on the nations quality of care since 1996, developing a new paradigm for health care delivery based on logic and evidence of patient needs. The IOM (2001) purported successful care will serve the needs of the patient, keep the patient fully informed, allow the patient to retain control through more active participation, and be mindful of patient values and preferences. Sofaer and Firminger

Beverly M. Ford, MSN, RN, BC, CMSRN, is a Medical-Surgical Charge Nurse, Baltimore Washington Medical Center, Glen Burnie, MD.

(2005) supported these findings in a study based on the aims and rules in previous IOM reports. They noted, If we are truly to achieve a health care system that is patient-centered, we must continue to search for creative ways to elicit, and heed the voice of the patient (p. 555). Safety weighs heavily in patient satisfaction. The Joint Commission provides its accredited health care organizations with a list of National Patient Safety Goals and mandates the requirements necessary to improve patient safety (The Joint Commission, 2008). Problematic areas of health care are identified with evidence-based and expertbased solutions designed to protect patients (The Joint Commission, 2009). Examples of safety goals include reducing risk of patient harm related to falls, preventing pressure ulcers, and enhancing medication administration. Nurses directly impact all these areas with routine nursing care delivery. Satisfaction is the perception of the patient. Because nursing services play a major role in patient satisfaction, quality of care, and safety, organizations continually must seek new ways to improve these critical services. One strategy called hourly rounding is a suggested method to address these issues (Studer Group, 2007). Hourly rounding is a new, proactive approach to organizing nursing care that has garnered positive results; its focus on patient-centered care has led to notably improved patient satisfaction scores.

Purpose
The use of a proactive hourly rounding strategy to improve patient satisfaction is described. Inspired by the work of Meade, Bursell, and Ketelsen (2006), staff at Baltimore Washington Medical Center (BWMC) piloted hourly rounding on several units. Although results from this study are not yet available, a brief case study can demonstrate how results at BWMC may compare to the national study. The studys purpose was to determine if patient satisfaction increases significantly as the new strategy is implemented.

Background
Baltimore Washington Medical Center, a 311-bed facility that is part of the University of Maryland Medical System, is located on the busy Baltimore and Washington, DC, corridor. BWMCs 2,600 employees cared for more than 200,000 patients in 2009. BWMC was named the only Solucient Top 100 Hospital in Maryland or the District of Columbia in 2006 (Lanham, 2007). The award, which is now known as Thompson Reuters, benchmarks hospital performance across the nation in specific areas, including quality of care, patient perception of care, finance, and efficiency (Thompson Reuters, 2010). BWMC recently completed a major expansion project to broaden emergency and critical care services, and added womens care services in response to the needs of the surrounding community. As

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a result, nursing services continue to expand. Leaders determined it is crucial to maintain and/or exceed the high standard of care as expansion occurs. Patient satisfaction at BWMC is monitored currently by the Jackson Healthstream Organization and uses the new Hospital Consumer Assessment of Healthcare Providers and Systems survey. This is a tool co-developed by the Centers for Medicare & Medicaid Services and the Agency for Healthcare Research and Quality (AHRQ). It provides a nationally standardized and publicly reported benchmark of patients perception of their care (AHRQ, 2008).

everything was completed, the patient was informed a health care staff member would return within an hour to round again (Leighty, 2006a). Knowing someone will return in an hour allowed patients to cluster requests and alleviates anxiety, contributing to their safety and well-being (Wood, 2005). These behaviors contributed to increased patient satisfaction scores.

other possessions within reach? Items used most frequently must remain within easy reach of the patient.

Hourly Rounding at BWMC

Following the same format as the research by Meade and colleagues (2006), the study unit maintained call light logs on patients for a 2-week period prior to rounding. The researcher received approval to test hourly rounding out on her assigned patients for a 3-week period. Quantitative call light data were collected during this time, along with data from rounding logs and discharge phone calls made to those patients within 48 hours of discharge. To serve as controls, a random sample of patients who did not receive hourly rounds also were tracked for call light use and results of the follow up discharge phone survey. Results were analyzed and compared to the national data.

A Closer Look at the Four Ps

A specific set of actions are addressed during each rounding session. These actions, generally clustered into four areas, are designed to meet patient needs and foster a relationship with each patient (Meade et al., 2006). These areas are described below. Pain. The provider asks the patient, How is your pain? After identifying patient pain intensity, the provider offers appropriate measures as needed, including position changes, guided imagery, deep breathing exercises, diversion activities, and medication. Asneeded medications are offered when a dose is due. Other comfort measures such as mouth care are implemented, and fluids are offered. Personal needs. The provider asks the patient, Do you need to use the bathroom? Toileting times are scheduled with the patient, with assistance offered as needed. The provider remains with the patient who requires assistance to the bathroom or bedside commode and then assists the patient back to the chair or bed. Positioning. The provider checks patient positioning and inquires, How can I make you more comfortable? Risks of skin breakdown are identified when the provider turns the patient, performs hygiene, provides skin care, fluffs pillows, and straightens linens. Turning schedules are observed, with all patients who cannot turn independently assisted with repositioning at least every 2 hours. This includes keeping heels up to help reduce heel pressure. Placement. The provider verifies accessibility of possessions and asks, Do you need us to move the call light, phone, water pitcher, trash can, over-bed table, or any

What Is Hourly Rounding?

Developed by the Studer Group, hourly rounding is another way of organizing existing work. Its purpose is to anticipate and meet patient needs routinely, and ensure patient safety (Shaner-McRae, 2007). Rounding allows information to be gathered in a structured way, addressing problems before they occur (Studer Group, 2005). Hourly rounding addresses patient needs proactively.

Findings
During the 3-week period, the researcher rounded on up to nine patients per day (maximum of six patients at any given time). The 51patient sample included 29 females (57%) and 22 males (43%). Patients ranged in age from 21 to 90, with the mean age 58. All patients were alert, oriented, and able to communicate their needs to nursing staff, and received hourly rounding by one nurse. Call light logs from the case study showed a 52% decline in call light use after initiating hourly rounding (see Figures 1 and 2 for description of call light use). This decrease in call light use reflected results of the national study (Meade et al., 2006), and has substantial implications for nursing. With less interruption by call lights, units are quieter and nurses have more time to concentrate on patient care and charting. No falls were reported during the study period, possibly due to the higher frequency of patient contact. However, no additional data were collected because of the brevity of this study. When the study is completed, results are expected to be similar to the national findings.

How Is Hourly Rounding Performed?

Specific scripts and tactics for hourly rounding provide consistency and continuity of patient care, leading to better outcomes and greater satisfaction (Leighty, 2006a). In the Studer study (Meade et al., 2006), staff explained to patients they would be checking on them hourly to enhance their safety and address personal needs. Staff members were taught to enter the patient room, identify themselves, and tell patients they were present to do their rounds (Wood, 2005). Scheduled tasks, such as dressing changes or medication administration, were performed. Before leaving the room, nurses addressed the four Ps: pain, personal needs, positioning, and placement (Studer Group, 2007) as the most frequent reasons patients use the call light. Immediately before leaving the room, staff asked the patient if anything else was needed, emphasizing they had the time to address any needs. When

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Figure 1. Results by Category for Call Light Usage Before Initiation of Hourly Rounding

Pain 19%

Other 58%

Personal Needs 14%

Error 8%

Positioning 1% Placement 0

Figure 2. Results by Category for Call Light Usage after Initiation of Hourly Rounding

Pain 17%

Other 57%

Personal Needs 12%

Positioning 5% Error 7% Placement 2%

Discharge phone calls to patients who received hourly rounding reflected their satisfaction with their overall care. Their comments on specific areas of nursing care reflected the perception of receiving superior care by nursing staff, including pain management, comfort, and safety. Other responses included patients satisfaction when staff members took the time to listen to them.

Clinical Implications
Call light use. With call lights ringing less, the nurse spends more time on patient care instead of going from room to room dealing with issues as they arise. During nursing rounds, the nurse gets a good grasp on the patients needs and uses the opportunity to plan with the patient. The patient knows nursing staff members will return as promised, and uses the call light less frequently.

Patient falls. Hospitals that incorporate hourly rounding note positive improvements in patient safety; patient falls occur less frequently (Meade et al., 2006). When staff members round on patients every hour and address basic needs, such as toileting and placement of personal items, risks for falls decrease. Patients are less likely to get out of bed when personal needs are met. Pressure ulcers. Turning and repositioning are considered basic nursing care. When nursing staff members maintain regular turning and positioning schedules with their patients, pressure ulcer rates on inpatient cases can decrease by up to 56% (Studer Group, 2007). In patients with existing wounds, regular turn schedules contribute to the healing process. Patient satisfaction. According to Christine Meade, chief researcher in the nationwide Studer studies on hourly rounding, increased nursing presence leads to better quality of care which in turn has a positive effect on patient satisfaction scores (Leighty, 2006a). Using specific scripts and eliciting key information from the patient about personal needs allows the nurse and patient to develop a plan of care that is optimal for both players. Satisfaction was 92%-98% in Meades national studies (Leighty, 2006a; Meade at al., 2006; Studer, 2007). Nursing satisfaction. Nursing care is more efficient and less stressful when hourly rounding is performed. Hourly rounding frees more nursing time and decreases frustration by optimizing shift time utilization (Leighty, 2006a). Could this strategy help to keep more nurses at the bedside in the midst of the current nursing shortage (Meade et al., 2006)?

Conclusion
Hourly rounding is about engaging the patients going in and finding out their needs and accomplishing tasks (Leighty, 2006b). Mary Shepherd, RN, nursing project and Magnet program director, The Methodist Hospital, Houston, TX, noted, ...rounding is a common sense approach to patient care, but it is not always common practice (Sigma Theta

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Tau International, 2006). Nurses, proactive with rounding, are finding their shifts less stressful, their time more productive, and patient safety and satisfaction scores hitting all-time highs (Leighty, 2006b). The positive results of rounding exceed expectations in most facilities where the strategy has been used. Consistent hourly rounding is a key for improving safety and quality of care; it results in fewer call light interruptions, allowing nurses to organize their time better and reduce stress. Additionally, patients are less anxious. Hourly rounding contributes in several key areas to achievement of high levels of patient satisfaction, including quality of care and patient safety (Meade et al., 2006).
References
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Pearson Assessments. (2007). Patient satisfaction surveys. Retrieved from http://survey.pearsonassessments.com/ audience/patient.htm Shaner-McRae, H. (2007). Notes on nursing. Retrieved from http://www.fahc.org/ Nursing/nursing_contribution/NON_200 7/02-07_NON.pdf Sigma Theta Tau International. (2006). RNews capsules. Retrieved from http://www2.nursingsociety.org/RNL/4Q _2006/columns/rnews_capsules.html Sofaer, S., & Firminger, K. (2005). Patient perceptions of the quality of health services. Annual Review of Public Health, 26, 513-559. Studer Group. (2005). The magic of rounding: Quint Studer brings a leadership technique from medicine into the world of business. Retrieved from http://www. studergroup.com/dotCMS/knowledge AssetDetail?inode=111088 Studer Group. (2007). Hourly rounding supplement. Retrieved from http://www.mc.vanderbilt.edu/root/pdfs/nursing/hourly_roun ding_supplement-studer_group.pdf The Joint Commission. (2008). 2008 National Patient Safety Goals: Hospital program.

Retrieved from http://www.jointcommission.org/PatientSafety/NationalPatientS afetyGoals/08_hap_npsgs.htm The Joint Commission. (2009). National Patient Safety Goals: Evaluating safety and quality using the national patient safety goals. Retrieved from http://www. jointcommission.org/GeneralPublic/NPS G/gp_npsg.htm?print=yes Thompson Reuters. (2010). New 2009 100 top hospitals: National benchmarks study. Retrieved from http://www.100top hospitals.com/top-national-hospitals/ Wood, D. (2005). Rounding cuts call-light use. Retrieved from http://w3.rn.com/ news_news.asp?articleID=14521&page =RN%5FNews&Profile=RN%5FNews& Headline=Rounding+Cuts+Call%2DLigh t+Use Additional Reading Studer Group. (2006). Improve clinical outcomes with hourly roundingsm. Retrieved from http:/studergroup.com/ newsletter/Vol1_Issue7/fall2006_sec1.h tm

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