PEDIATRICS Vol. 123 No. 4 April 2009, pp. e603-e608 (doi:10.1542/peds.2008-2238)
ARTICLE |
Family-centered Multidisciplinary Rounds Enhance the Team Approach in Pediatrics
Departments of a Pediatrics
d Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
b Division of Rheumatology
c Department of Pediatrics, Children's Hospital of Pittsburgh, Pittsburgh, Pennsylvania
e Division of Rheumatology, Veterans Administration Pittsburgh Healthcare System, Pittsburgh, Pennsylvania
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ABSTRACT |
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 TOP ABSTRACT METHODSRESULTSDISCUSSIONCONCLUSIONSREFERENCES |
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OBJECTIVE. The objective of this study was to determine the impact of family-centered multidisciplinary rounds on an inpatient pediatric ward. We hoped to (1) gain a better understanding of the patient and family experience with family-centered multidisciplinary rounds, (2) measure hospital staff satisfaction with family-centered multidisciplinary rounds compared with conventional rounds, and (3) understand the time commitment for family-centered multidisciplinary rounds and conventional rounds.
METHODS. A quasi-experimental design was undertaken during a 2-week period. During the first week, the hospital staff conducted conventional rounds. Families were surveyed daily, and the staff were surveyed at the end of the week regarding their experiences. During the second week, newly admitted patients received family-centered multidisciplinary rounds at the bedside. Again, both families and staff were surveyed. Observers recorded the interactions between families and staff and measured the time required to conduct rounds.
RESULTS. A total of 27 patients were admitted during the 2-week study period. No significant differences were found in family satisfaction between conventional rounds and family-centered multidisciplinary rounds. A total of 53 surveys were collected from staff members. The staff reported better understanding of the patients' medical plans, better ability to help the families, and a greater sense of teamwork with family-centered multidisciplinary rounds compared with conventional rounds. It required an additional 2.7 minutes per patient during rounds for family-centered multidisciplinary rounds. With family-centered multidisciplinary rounds, the family affected the medical decision-making discussion in 90% of cases.
CONCLUSIONS. Family-centered multidisciplinary rounds is a method of conducting inpatient hospital rounds that fosters teamwork and empowers hospital staff. The patient and family are engaged in and are the focal point of the rounds. Staff members are able to hear everyone's perspective and give input. The impact on staff satisfaction and the family's ability to participate in their care is significant.
Key Words: family-centered • staff retention • bedside rounds
Abbreviations: FCMDR—family-centered multidisciplinary rounds • CR—conventional rounds • UPMC—University of Pittsburgh Medical Center
Family-centered care legislation was passed in 1986 with Public Law 99–457.1 The law required that the whole family be treated as the recipient of services for children with special needs, with family members deciding the ways they want to be involved in decision-making about health and education services for their child.2,3 The 2001 Institute of Medicine report Crossing the Quality Chasm: A New Health System for the 21st Century made patient-centeredness 1 of its "6 aims for improvement."4 In 2003, in their policy statement, the American Academy of Pediatrics advocated for an attending's medical decision-making to occur in the patient room with the family present as a standard of practice.5 In 2007, Cincinnati Children's Hospital was the first to describe their experience of transforming their culture to achieve that standard.6
Family-centered care is actually an older concept that arose in the 1960s. The idea that families are collaborators with the health care team7 was founded during the advocacy movements for people with disabilities and for parents of children with special health care needs.8 In the past several years, there has been growing interest in the implementation of family-centered care in pediatrics.9 Family-centered care is delivered by recognizing several key elements10:
- the family is the child's source of support;
- children and families are unique and diverse;
- parents are expert caregivers for their children;
- family-centered care enhances staff competence;
- there should be collaboration between families and health care providers; and
- family-to-family networking and support should be facilitated.
- increased time demands on medical staff;
- intimidation of families by large groups of staff;
- hesitance of staff to discuss sensitive issues in front of families;
- fear of trainees' and students' seeming ignorant in front of families; and
- lack of confidentiality for patients in shared rooms.
At our institution, the hospital will be moving to a new, green, paperless facility in the spring of 2009. The new environment will foster family-centered care as the standard. Although the concept of family-centered rounds has face validity, there are limited data on its benefits. We undertook a brief study at our institution with a quasi-experimental design to try to gain a better understanding of the following:
- patient and family experience with FCMDR;
- value for staff of FCMDR; and
- difference in time commitment for FCMDR versus conventional rounds (CR).
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METHODS |
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TOPABSTRACTMETHODSRESULTSDISCUSSIONCONCLUSIONSREFERENCES |
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This study was performed on an inpatient adolescent ward at a tertiary-care academic children's hospital in Pittsburgh, Pennsylvania. The study was approved by the University of Pittsburgh Medical Center (UPMC) institutional review board. All participants underwent the consent process according to a standard protocol. Informed consent for participation in the surveys was obtained from the patients, families, health care staff, and medical students.
Survey participants included patients and their parents or legal guardians who were admitted to the adolescent unit during the last 2 weeks of July 2007. Inclusion criterion was age 12 to 22 years. Survey exclusion criterion was lack of parental consent or lack of patient consent as a result of developmental delay or psychiatric illness.
The distribution of participants to the 2 different types of bedside rounds was predetermined. Patients who were admitted during the first week of the study were assigned to receive CR. CR involved the care team's meeting in a conference room to discuss each patient on the team in detail, consisting of overnight events, changes in physical examination findings, relevant laboratory or radiographic studies, and an assessment and treatment plan for the day. Each patient was presented by the most junior member of the team caring for that patient. Relevant teaching points were discussed. The care team for CR consisted of a teaching attending, a senior resident, an intern, a fourth-year medical student, and a third-year medical student. Members of the UPMC Center for Quality Improvement and Innovation observed rounds daily. After CR, the care team members dispersed to the inpatient unit to carry out the treatment plans, which consisted of discussing patients individually with the admitting attending physician and hospital staff, completing progress notes, and writing orders.
Patients who were admitted during the second week of the study were assigned to receive FCMDR. FCMDR involved the care team's meeting on the inpatient unit to make bedside rounds. The care team consisted of a teaching attending, the admitting attending physician, a senior resident, an intern, a fourth-year medical student, third-year medical students, nurses, a care coordinator, a social worker, and a pharmacist. Members of the UPMC Center for Quality Improvement and Innovation observed rounds daily. Rounds were conducted in the patient rooms with the patient and the family or legal guardian. Siblings and other family members were invited to stay for rounds if agreeable to the patient and the parent. On the first morning of admission, a care team member would ensure that the patient and the family members were comfortable with the team's entering the room to conduct rounds. Before the start of the presentation, the patient and the family were invited to interrupt during the case history if there was any information that they would like to add to the patient's story. Each patient was then presented by the most junior member of the team. The presentation included overnight events, changes in physical examination findings, relevant laboratory or radiographic studies, and an assessment and plan for the day. After the initial presentation, input was actively sought from the patient, the parents, and the rest of the care team. The patient and the family volunteered changes or asked questions. The care coordinator discussed services needed for discharge. Relevant teaching points were discussed either in the patient's room or immediately outside the room. A computer on a mobile cart was available during rounds, and orders were entered, computerized prescriptions were written, and discharge paperwork was collected. After FCMDR, the care team then disbursed to fulfill their responsibilities.
Informed written consent was obtained for each eligible patient and his or her legal guardians after morning rounds. Patients and parents were given a brief written survey to fill out at the end of each morning during their hospital stay. The survey included 5 statements regarding their understanding of medical care, communication with staff, and perception of teamwork among staff. The patients and families recorded their level of agreement with each statement on a 5-point Likert scale from "strongly agree" to "strongly disagree." Time data and observational data regarding the rounds were collected by members of the UPMC Center for Quality Improvement and Innovation. Bedside rounds were timed. For CR, the observer would start timing the discussion when the case report began. The timing ended with the end of the patient discussion. For FCMDR, the observer started the timing when the family was introduced to the team members before the beginning of the case presentation. The timing ended when the conversation ended and the team began to walk out of the patient's room.
Informed written consent was obtained from each staff member who participated in rounds during the 2-week study period. At the end of the first week, the house officers, students, and nurses who were involved with CR were surveyed. At the end of the second week, the social workers, care coordinators, pharmacist, and other care team members who were involved in FCMDR were surveyed. The surveys included 6 statements regarding understanding of patient care plans, ability to manage family concerns, and the perception of working as a team. The staff recorded their level of agreement with each statement on a 5-point Likert scale from "strongly agree" to "strongly disagree."
Descriptive statistics were used to summarize the sociodemographic and clinical data of the patients (Table 1). The patient and staff survey responses were analyzed by using the Mann-Whitney-Wilcoxon test to compare the CR and FCMDR groups. Time data were analyzed by using a Student's t test to compare CR and FCMDR.
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RESULTS |
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TOPABSTRACTMETHODSRESULTSDISCUSSIONCONCLUSIONSREFERENCES |
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During a 2-week period, 27 patients were admitted to the adolescent inpatient ward. Twelve patients were admitted during the week of CR. Fifteen patients were admitted during the week of FCMDR. Of the 27 patients admitted, only 10 could be surveyed. Seventeen patients were not surveyed: 8 had developmental delay, 6 lacked parental involvement, 2 were younger than 12 years, and 1 had a mental illness.
During the 2-week study period, 36 patient and parent surveys were collected. During the first week (CR), 14 surveys were collected. During the second week (FCMDR), 22 surveys were collected. A parent or legal guardian was present during the rounds for 58% of the encounters. All of the parents or guardians who were present during the rounds agreed to participate in family-centered rounds and take the survey. There were no significant differences in patient satisfaction between families who experienced CR and those who experienced FCMDR (Table 2).
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During the 2-week study period, 53 staff and student surveys were collected. At the end of the first week, the surveys were completed by 18 staff members who were involved with CR. The surveys were completed by 15 nurses, 1 pediatric resident, 1 fourth-year medical student, and 1 third-year medical student. At the end of the second week, the surveys were completed by 35 staff members who performed FCMDR. The surveys were completed by 18 nurses, 4 pediatric attending physicians, 2 pediatric residents, 3 fourth-year medical students, 2 third-year medical students, 2 social workers, 1 pharmacist, 1 care coordinator, 1 asthma educator, and 1 clinical care assistant. Compared with the group surveyed during the week of CR, staff members reported greater understanding of the patient's plan of care, a greater feeling of working on a team, improved communication between family and staff, and greater ability to deal with families' concerns with FCMDR (Table 3).
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During CR, the average time for discussing each patient was 7.5 minutes. During FCMDR, the average time of encounter was 10.2 minutes per patient (t = 1.83, P = .07).
During FCMDR, the patient's or parents' input was assessed as having impact on the plan of care discussion in 90% of interactions. These discussions were initiated by the families, in the form of either provision of information or questions that they asked about the patient's care. The topics for these family initiated discussions included
- addition of historical information that led to hospitalization;
- additional clarification of discharge medications;
- explanation of laboratory results;
- pain management;
- additional review of discharge instructions with regard to activity and medical follow-up;
- clarification of medical jargon; and
- patient adherence with medications.
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DISCUSSION |
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TOPABSTRACTMETHODSRESULTSDISCUSSIONCONCLUSIONSREFERENCES |
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We undertook a brief study with a quasi-experimental design to understand better the impact of family-centered rounds in pediatrics. Our study quantified the difference in time between conducting CR and FCMDR. Although the rounding period during FCMDR took longer, this difference is not statistically or clinically significant. Our patient numbers were limited during the 2 weeks. Because our study was conducted on an adolescent ward, it may have limited generalizability to the wider pediatric population.
A significant finding of our study was the high level of staff satisfaction during the week of FCMDR. The surveys were mostly completed by nonphysicians (87%). This seems appropriate given that >80% of the hands-on care provided in a hospital is by nonphysicians.10 The staff felt strongly that CR did not facilitate teamwork and did not enhance communication with the families. Staff felt that they were a part of a team with the use of FCMDR. Nurses completed 63% of the staff surveys.
With the current nursing shortage in health care, one can see how the use of family-centered rounds might help with the retention of nursing and other staff. Multidisciplinary care implies that all members of the health care team are important in the care of the patient, not just the physicians. In the CR model, the doctors were in a conference room making decisions while other staff members were excluded from the decision-making process. In the FCMDR model, all members of the patient's health care team, including the patient and his or her family, were present simultaneously. The patient, family, nurses, and other staff all had the opportunity to discuss their insights with the physicians. The experience was one of empowerment for the parties involved.
Our study showed no difference in satisfaction between families who received CR and those who received FCMDR. This may be attributed to our small sample size. Other studies have demonstrated the benefits to families while implementing family-centered care.11–19
Inpatient health care delivery should be a seamless experience for the family. When the members of the care team visit the family separately, it is impossible for everyone to know the details of the conversations between staff and the family. With all team members in the room at the same time, the staff can hear everyone's point of view and address the family's concerns simultaneously in real time. Such a system fosters teamwork and breaks down communication silos.
In 1999, the cardiothoracic team at Concord Hospital in New Hampshire changed the format for morning rounds to a FCMDR model.18 All caregivers (surgeons, nurse practitioners, physician assistants, pharmacists, bedside nurses, dieticians, physical therapists, occupational therapists, social workers, spiritual caregivers, and outpatient coordinators) would meet at the same time with the patient and the family.19 A "collaborative communication cycle" was instituted whereby a preset checklist of topics would be covered, including input from family, pharmacist, therapist, dietician, social worker, and medical staff.18
Concord Hospital found that their mortality rate for its open-heart surgery patients decreased by more than half within 2 years of adopting its FCMDR model.18 The group also surveyed 15 of their staff members regarding FCMDR compared with 16 staff members regarding their CR. The results showed increased scores with the family-centered approach with the following items18:
- sense of common purpose;
- sense of personal/collective power;
- listen actively to each other;
- share responsibility for leadership;
- problem-solving process apparent;
- feel respected;
- feel good about team membership; and
- sense of collaboration and team spirit.
The Concord group believed that meeting every weekday for 10 to 15 minutes per patient allowed patients and staff to have their questions answered, discuss treatment strategy, and identify problems. Most practitioners had found that the FCMDR required an investment of time up front, but it saved time during the course of the day.18 Our study showed an increase in time spent discussing each patient with FCMDR; however, we did not study the effects of FCMDR on the potential time savings achieved outside the rounding period.
Another example of the impact of family-centered care comes from MCG Health System in Augusta, Georgia.20 Three years after implementation of family-centered care in the Neuroscience Center of Excellence, the unit enjoyed the following successes: decrease in medical error rate by 62%, decrease in nursing staff vacancy from 7.5% to 0%, increase in patient satisfaction from 10th percentile to 95th percentile, and decrease in length of stay in neurosurgical unit by 50%.20
Since our study, the pediatric hospitalist group has been a champion for change in our institution. The hospitalists have made major changes in the rounding routine to ensure family-centered rounds on the inpatient wards. Our hospital culture is shifting toward one of family-centered care.
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CONCLUSIONS |
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TOPABSTRACTMETHODSRESULTSDISCUSSIONCONCLUSIONSREFERENCES |
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Our brief study on FCMDR in pediatrics found a significant impact on staff satisfaction. Additional study will be needed to measure the impact of FCMDR as a component of family-centered care in pediatrics in terms of staff retention, medical error rate, length of stay, and work efficiency.
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ACKNOWLEDGMENTS |
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Support for this study was provided by the UPMC Center for Quality Improvement and Innovation and the Children's Hospital of Pittsburgh of UPMC departments of nursing, pharmacy, social services, and care coordination.
We thank Dr Basil J. Zitelli, Dr Amber Hoffman, and Beth Lewis for insights on family-centered care in pediatrics.
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FOOTNOTES |
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Accepted Jan 6, 2009.
Address correspondence to Paul Rosen, MD, MPH, MMM, University of Pittsburgh School of Medicine, Department of Pediatrics, Children's Hospital of Pittsburgh, Children's Hospital Drive, 45th and Penn, Pittsburgh, PA 15201. E-mail: paul.rosen{at}chp.edu
The authors have indicated they have no financial relationships relevant to this article to disclose.
| What's Known on This Subject Family-centered care in pediatrics has face validity. Qualitative studies have reported benefits to families, patients, and staff. There are few quantitative data on its benefits in pediatrics.
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| What This Study Adds This study offers quantitative data on the impact of family-centered bedside rounds on pediatric hospital staff. It also quantifies the difference in time between family-centered rounds and conventional rounds.
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PEDIATRICS (ISSN 1098-4275). ©2009 by the American Academy of Pediatrics
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