How-to Guide: Multidisciplinary Rounds

Transcription

1 HOW-TO GUIDE Hw-t Guide: Multidisciplinary Runds Updated February 2015 AN IHI RESOURCE 20 University Rad, Cambridge, MA ihi.rg Hw t Cite This Material: Hw-t Guide: Multidisciplinary Runds. Cambridge, Massachusetts: Institute fr Healthcare Imprvement; February (Available at

2 IHI s Hw-t Guides address specific health care interventins that hspitals and/r entire health systems can pursue t imprve the quality f health care. Hw-t Guides present the key evidence-based care cmpnents fr a particular tpic, describe hw t implement these interventins, and recmmend measures t gauge imprvement. IHI initially develped Hw-t Guides as part f the 100,000 Lives Campaign and the 5 Millin Lives Campaign. The Institute fr Healthcare Imprvement (IHI) is a leading innvatr in health and health care imprvement wrldwide. Fr mre than 25 years, we have partnered with visinaries, leaders, and frnt-line practitiners arund the glbe t spark bld, inventive ways t imprve the health f individuals and ppulatins. Recgnized as an innvatr, cnvener, trustwrthy partner, and driver f results, we are the first place t turn fr expertise, help, and encuragement fr anyne, anywhere wh wants t change health and health care prfundly fr the better. Cpyright 2015 Institute fr Healthcare Imprvement. All rights reserved. Individuals may phtcpy these materials fr educatinal, nt-fr-prfit uses, prvided that the cntents are nt altered in any way and that prper attributin is given t IHI as the surce f the cntent. These materials may nt be reprduced fr cmmercial, fr-prfit use in any frm r by any means, r republished under any circumstances, withut the written permissin f the Institute fr Healthcare Imprvement.

3 Cntents Intrductin 4 What Are Multidisciplinary Runds? 4 Why Is It Imprtant t Cnduct Multidisciplinary Runds? 5 Ptential Impact f Multidisciplinary Runds 5 Key Cmpnents f Reliable Multidisciplinary Runds 6 Develp and Refine Yur Aim fr Runds 6 The Structure f Runds Is Essential 7 Leadership Is Key 7 Engage the Patient and Family 8 Measurement Matters 8 Examples f Success 9 Bn Securs St. Mary s Hspital, Richmnd, Virginia 9 Santa Rsa Memrial Hspital, Santa Rsa, Califrnia 12 Using the Mdel fr Imprvement 13 Sample Small Tests f Change 14 Tips fr Getting Started 14 Additinal Tips fr Implementing Multidisciplinary Runds 15 Segment Patients 15 Script Questins 15 Spread Slwly 16 Expand Participatin 16 References 17 Institute fr Healthcare Imprvement ihi.rg 3

4 Intrductin Multidisciplinary runds, a mdel f care in which multiple members f the care team representing different disciplines cme tgether t discuss the care f a patient in real time, have prven t be a valuable tl in imprving the quality, safety, and patient experience f care. Many hspitals have achieved reduced patient days, reduced central line days, and increased crdinatin f care thrugh the use f multidisciplinary runds. Organizatins that have been successful in implementing multidisciplinary runds ften start in the intensive care and critical care units, and cnduct multidisciplinary runds with multiple members f the care team (physicians, nurses, and ancillary clinicians and staff) seven days a week, develping daily gals fr every patient. Additinally, sme hspitals have successfully invited families int their regular runding prcess and have implemented multidisciplinary runds n nn-critical care units. What Are Multidisciplinary Runds? Multidisciplinary runds are a patient-centered mdel f care, emphasizing safety and efficiency, that enable all members f the team caring fr patients t ffer individual expertise and cntribute t patient care in a cncerted fashin. 1 With multidisciplinary runds, disciplines cme tgether, infrmed by their clinical expertise, t crdinate patient care, determine care pririties, establish daily gals, and plan fr ptential transfer r discharge. Many hspitals have reprted imprved cmmunicatin and cllabratin amng members f the care team, mre reliable adherence t prcess measures, and better patient utcmes thrugh the use f multidisciplinary runds. Althugh the effects f multidisciplinary runds have nt been heavily researched, frmal peer-reviewed studies have fund similar results. In ne study, researchers at St. Luke s Hspital fund that the adptin f multidisciplinary runds in the medical intensive care unit resulted in imprved prcess and utcme measures. Fr example, the use f multidisciplinary runds has resulted in imprved cmpliance with the IHI Ventilatr Bundle and a significant decrease in ventilatr-assciated pneumnia. 1 In anther study, researchers studied the impact f a three-part interventin that included daily multidisciplinary runds. Here, the interventin resulted in a psitive effect n the cmmunicatin and cllabratin amng physicians and nurses. 2 The imprtance f including pharmacists in daily runds has als been researched. Including a pharmacist n the ICU runding team t make recmmendatins regarding dsage r frequency adjustments was fund t significantly reduce adverse events. 3 A study in Archives f Internal Medicine reprts that multidisciplinary care teams appear t be assciated with a lwer risk f death amng patients in the intensive care unit. Accrding t the authrs, Multidisciplinary runds may facilitate implementatin f best clinical practices such as evidence-based treatments fr acute lung injury, sepsis, and preventin f ICU cmplicatins. Pharmacist participatin n runds is assciated with fewer adverse drug events and alne may be assciated with lwer mrtality amng ICU patients. Multidisciplinary runds may als imprve cmmunicatin between health care prviders. 4 Institute fr Healthcare Imprvement ihi.rg 4

5 Why Is It Imprtant t Cnduct Multidisciplinary Runds? In its 2001 reprt, Crssing the Quality Chasm: A New Health System fr the 21st Century, the Institute f Medicine identifies cntinuity f care as ne f the key areas f cncern in patient care delivery. 5 T frequently, decisins related t the care f a patient ccur withut input frm the key prviders, including nursing, pharmacy, scial wrk, respiratry therapy, nutritin, physicians, physical therapy, and ccupatinal therapy. As a result, cmmunicatin breakdwns ccur, resulting in fragmented and pr quality care. Sme key benefits f implementing multidisciplinary runds are nted belw. Effective multidisciplinary runds can be a pwerful vehicle fr: Crdinating care amng disciplines Reviewing current patient status Clarifying patient gals and desired utcmes Creating a cmprehensive plan f care Multidisciplinary runds prvide a frmal mechanism fr daily cmmunicatin amng the care team, patients, and families regarding: Identificatin f safety risks Identificatin f daily gals Multidisciplinary runds facilitate prtcl r guideline use and understanding amng the care team, prviding: A cnsistent apprach Educatin and teaching pprtunities Multidisciplinary runds prvide cnsistency fr prcess imprvement Ptential Impact f Multidisciplinary Runds Althugh the literature n the effectiveness f multidisciplinary runds is still fairly small, many hspitals have demnstrated an impact n the fllwing utcmes: Imprved cmmunicatin and teamwrk acrss caregivers, which has been shwn t be an imprtant cntributing factr t high levels f safety and reliability f care Reduced errrs Reduced ventilatr days Reduced central line days Reduced length f stay Imprved flw f patients thrugh levels f care Institute fr Healthcare Imprvement ihi.rg 5

6 Expedited discharge planning Increased cllabratin and satisfactin amng all members f the multidisciplinary team Key Cmpnents f Reliable Multidisciplinary Runds Many hspitals acrss the US have successfully implemented multidisciplinary runds. There are a variety f runding mdels, including teaching runds, safety runds, and runds that fcus n the patient s discharge frm the hspital. IHI uses the term multidisciplinary runds t mean any type f runding that enables key members f the team caring fr the patient t cme tgether and ffer expertise in patient care. Key cmpnents f reliable multidisciplinary runds include the fllwing: Develp and refine yur aim fr runds The structure f runds is essential Leadership is key Engage the patient and family Measurement matters Develp and Refine Yur Aim fr Runds Imprvement requires setting an aim. An rganizatin will nt imprve withut a clear and firm intentin t d s. The aim shuld be time-specific and measurable; it shuld als define the specific ppulatin f patients that will be affected. Agreeing n the aim is crucial; s is the allcatin f peple and resurces necessary t accmplish the aim. What d yu want t accmplish? Withut a specific fcus, multidisciplinary runds culd becme t time cnsuming and verwhelming fr thse invlved. Declaring a fcus, an aim, is the fundatin fr selecting team members, identifying questins t be addressed, and defining measures. The aim fr multidisciplinary runds can be based n a select grup f patients (such as patients with a specific diagnsis), deviance frm the care plan, r a safety cncern. The aim shuld als include specific infrmatin regarding where (e.g., a specific unit), hw much (e.g., by 80 percent ), and by when (e.g., by May 1, 2015 ). An agreed-upn aim will enable the staff t fcus n specific questins, t keep the runds as efficient as pssible, and t prevent them frm mrphing int a lng and ptentially verwhelming prcess. Examples f specific aim statements fr multidisciplinary runds are as fllws: The intermediate medical care unit (IMCU) will cnduct daily multidisciplinary runds including at least fur disciplines and dcument daily gals n each patient by December 31, By June 2015, 4 Suth will cnduct daily multidisciplinary runds and dcument transitin gals fr each patient that is 3 r mre days pstperative. Institute fr Healthcare Imprvement ihi.rg 6

7 By March 31, 2015, 80 percent f all nenatal intensive care unit (NICU) bedside runding will include a summary in parent-friendly language f all tests, labs, and prcedures cmpleted ver the previus 24 hurs. By February 28, 2015, during multidisciplinary runds n the cardivascular services unit (CVSU) and IMCU, clinical care gals and patient-/family-identified needs and/r gals will be addressed fr 90 percent f each unit s patients. The Structure f Runds Is Essential Structure is vital t keep the runds mving at a reasnable pace and t ensure prper attentin t the fcus f the runds. Key cncepts t remember in develping the structure fr runds include: assign leadership, select team members frm multiple disciplines wh help meet the gals f the runds, restate the fcus f the runds while in the patient rm, and develp daily care gals. Leadership Is Key A reliable leader, with a defined rle and respnsibilities, can ensure that the multidisciplinary runds team starts and ends n time, ntes during runds are captured, and fllw-up ccurs. Remember, yu are requesting several persnnel frm multiple departments t participate in runds, and starting 10 minutes late r allwing the runds t wander frm the designated fcus is disrespectful f everyne s time. Teams are mre successful when they have unambiguus, fcused aims. Setting numerical gals clarifies the aim, helps t create tensin fr change, directs measurement, and fcuses initial changes. Once the team sets the aim, they need t be careful nt t back away frm it deliberately r drift away frm it uncnsciusly. The recruitment f the actual runding team n each unit may lk different frm department t department. The fcus f the runds will dictate the discipline(s) that are essential t the runds. Be as efficient as pssible when selecting team members, engaging nly thse peple wh are mst critical t the runding prcess and t meeting the gals f the runds. Many hspitals have fund that using the structure f multidisciplinary runds t identify daily gals fr each patient is an effective apprach. Setting individual patients gals helps fcus the effrts f the care team and priritizes the wrk fr that day. Ideally, patients and their families are present and participate in setting these gals, t maximize their alignment with the patient's wishes. Each patient is n a path t mve beynd the current care setting, whether thrugh transfer t a mre r less intensive level f care within the hspital; discharge t hme, rehabilitatin, lng-term care, r hspice; r thrugh care decisins that allw natural death t ccur. Daily gal setting helps define the steps necessary fr these varius paths and clarifies what needs t be accmplished befre transfer r discharge can ccur. Sme hspitals have als fund it helpful t fcus n gals that highlight safety risks fr particular patients. Setting daily gals invlves three key steps: 1) Determine the key gal r gals fr that day; 2) Dcument the gals s they are readily accessible t the care team and the patient and family; and 3) Prvide daily feedback and reflectin n the gals t refine and reset them fr the current day. Institute fr Healthcare Imprvement ihi.rg 7

8 Examples f daily gals: Discntinue xygen by 4 PM Wean ff vaspressrs by midnight Mbilize patient t walk 20 feet Initiate hspice referral Many teams have develped checklists r scripts t ensure the key aspects f multidisciplinary runds are addressed while in the patient rm and t ensure that time during runds is used wisely. 6 Checklists include the key elements f the runds such as discharge cncerns, daily gals, and actins t be taken. Engage the Patient and Family Inviting families t participate in runds can be pwerful, as families have a unique perspective n the needs f patients. Befre inviting families t participate, ensure that the prcess f multidisciplinary runds is cnsistent and structured. It is necessary t have a cnversatin with family members prir t jining runds, an rientatin that intrduces them t the fcus, rutines, and expectatins f the runding prcess. Psting the times, dates, and patients included in runds can be valuable fr bth families and team members. Fr example, n a medical-surgical flr yu might pst a sign the day befre scheduled runds that says, Runds with Nursing, Physical Therapy, and Pharmacy tmrrw at 9:15 AM. Runds t be cnducted n patients in rms 407, 410, 414, 427, 431, 433, and 441. Family members are invited t attend. When runds begin, start with a brief intrductin t the patient and family member, state the purpse f runds, and encurage their participatin as a necessary part f the prcess. Family members may have input int the care f the patient bth during the hspital stay and at discharge, and will appreciate seeing the care team wrk tgether t fcus n the patient. Psting daily gals in patient rms may als prmpt questins frm family members wh may nt have jined runds; these are great pprtunities t invlve the family in cnversatin abut patient care gals at any time f day. Studies in several hspitals cncluded that engaging patients and families in multidisciplinary runds had many benefits, especially with regard t cmmunicatin with prviders, being part f the care team, and active decisin making. 7,8 Measurement Matters Measurement is essential t learn which changes in the multidisciplinary runding prcess yu are testing result in imprvement. Imprved patient utcmes are an imprtant measure f success and shuld be expected ver time with the implementatin f multidisciplinary runds. 9 In additin, in rder t btain helpful data that infrms the initial testing f multidisciplinary runds, teams may chse t track daily r weekly prcess measures such as: Number f days per week that multidisciplinary runds ccur Number f disciplines invlved in multidisciplinary runds Percentage f patients with a dcumented daily gal in their patient recrd Institute fr Healthcare Imprvement ihi.rg 8

9 Bundle cmpliance, such as the IHI Ventilatr r Central Line Bundles (Fr mre infrmatin n bundles and bundle cmpliance, see the IHI white paper, Using Care Bundles t Imprve Health Care Quality. 10 ) In additin t tracking measures related t the ccurrence f and participatin in multidisciplinary runds, imprvement teams shuld identify the key care-related prcess measures that may be included n the daily gal sheet. The daily gal sheet includes key cmpnents f care specific t the patient and can be used t help structure runds and keep the discussin during runds fcused. Data n these prcess measures can be encuraging t staff as multidisciplinary runds evlve. In additin t the prcess measures mentined abve r ther measures identified by each rganizatin s runds team, hspitals have fund multidisciplinary runds als have an impact n a number f key utcme measures, including: Length f stay ICU patient days Central line days Ventilatr days Number f pharmacy changes (such as discntinuing an antibitic, decreasing r eliminating narctics as patient cnditin imprves, etc.) Examples f Success Bn Securs St. Mary s Hspital, Richmnd, Virginia Bn Securs St. Mary s Hspital, a 391-bed nn-prfit cmmunity hspital in Richmnd, Virginia, has achieved imprved utcmes with multidisciplinary runds by implementing prcesses and tls that fcus n patient and family needs and gals, and n anticipating length f stay (LOS) and discharge. Three nursing units with different patient ppulatins participated in IHI s Expeditin n Engaging Patients and Families in Multidisciplinary Runds, implementing actins with their unit-specific runds team members, including nurses, prviders (physicians and nurse practitiners), care/case managers, and thers (e.g., pharmacists, nutritinists, rehabilitatin therapists, respiratry therapists, and diabetes treatment crdinatrs). On the intermediate medical care unit (IMCU), the entire care team cnducts multidisciplinary runds as a grup. The nurse prvides infrmatin n the patient/family needs and gals that have been identified during change-f-shift handver as well as the current fcus f care, and team members share additinal knwledge and/r discipline-specific assessments, plans, and actins fr care during runds. Nurses have develped a guide sheet fr reference in preparatin fr multidisciplinary runds that enables runds t be a cnversatin fcused n patient care versus caregivers being put n the spt t present needs. In the cardivascular services unit (CVSU), the multidisciplinary runds are cnducted at the bedside and include the patient and family. The runds team has benefited frm Pcket Card Guides (see Figure 1) that include prmpts fr identificatin f patient stated gal/cncern fr the Institute fr Healthcare Imprvement ihi.rg 9

10 day and discharge plan. The guide als includes key quality-f-care elements and a readmissin assessment, t cue discussin amng the runds team abut any cnsideratins that need t be addressed with interventins. Figure 1. Cardivascular Services Unit (CVSU): Example Pcket Card Guide with Discharge Plan and Patient Gal The 5 East medical-surgical unit has benefited frm a guide sheet and Advanced Practice Nurse supprt as they fcus n the patient s gal/cncern fr the day and anticipated discharge. The medical-surgical unit and the IMCU and CVSU als use a Stp Light Inter-Disciplinary (Discharge) Runds (SLIDR) whitebard, which has imprved cmmunicatin abut anticipated length f stay fr the purpses f patient planning, interventins, and prgressin. Tenant Health System case managers shared the SLIDR frmat at a natinal cnference, and Bn Securs St. Mary s Hspital has adpted the prcess with sme f its patient ppulatins and made mdificatins fr their specific unit-based needs. SLIDR Bards at the nurses statin use a clr-cded legend t reflect the patient s anticipated discharge, transitin in care, and/r length f stay (see Figures 2, 3, and 4). Staff use the visual clr reference n the SLIDR Bard and/r the Pcket Card Guides during multidisciplinary runds t address plans with patients, families, and runds team members. A patient s current status is identified n the SLIDR Bard by placing their rm number under the apprpriate clr legend clumn as fllws: RED YELLOW GREEN GREEN P 2 r mre days befre likely discharge 1 day befre likely discharge Ready fr discharge tday Discharge when pending items are cmpleted (e.g., diagnstic study, lab, r cnsult) Institute fr Healthcare Imprvement ihi.rg 10

11 BLUE PURPLE Patient ready fr transfer t lwer level f care r ther care facility LOS greater than MD-nted LOS r DRG LOS Als, the SLIDR Bard display prvides an verview fr all unit and interdisciplinary team members regarding the ptential patient ppulatin and unit activity at any given time. Figure 2. Prgressive Surgical and Bariatric Unit (PSBU): Example SLIDR Bard with Clr Legend Figure 3. SLIDR Bard fr 5 East Medical-Surgical Unit, Shwing Discharge Status Institute fr Healthcare Imprvement ihi.rg 11

12 Figure 4. SLIDR Bard fr Intermediate Medical Care Unit (IMCU), Shwing Discharge Status After implementing these prcesses and tls, utcmes fr the abvementined units include the fllwing imprvements: Patient and family participatin, knwledge, and understanding f care and selfmanagement; Team cllabratin, cmmunicatin, and chesiveness; Knwledge transfer and learning pprtunities fr all participants; and Multidisciplinary runds tls and resurces are available and used t supprt care delivery and enhance cmmunicatin. Santa Rsa Memrial Hspital, Santa Rsa, Califrnia Santa Rsa Memrial Hspital is a 278-bed acute care hspital that is a part f the St. Jseph Health system in Califrnia. After identifying an increase in the number f falls in several nursing units, Santa Rsa implemented multidisciplinary runds as ne tactic fr imprving safety. As part f their Adult Patient Falls Cntainment Prject, the team implemented hurly runding by nursing leaders, engaged patients and families in these runds, and put evidence-based prtcls int practice t reduce falls. In additin t instituting multidisciplinary runds, senir leaders als did their wn runds t interview staff and patients using runding tls, fllwed by a 30-minute huddle and debrief with executive leaders and nursing directrs and managers. This apprach has led t a reductin in harmful (categry 3-5) falls (see Figure 5) and significant reductin in csts. Institute fr Healthcare Imprvement ihi.rg 12

13 Figure 5. Adult Patient Falls at Santa Rsa Memrial Hspital Nte: The arrws in the bar chart dente when multidisciplinary runds were implemented n varius nursing units as part f Santa Rsa s falls-reductin effrts. Using the Mdel fr Imprvement In rder t mve this wrk frward, IHI recmmends using the Mdel fr Imprvement. Develped by Assciates in Prcess Imprvement, the Mdel fr Imprvement is a simple yet pwerful tl fr accelerating imprvement that has been used successfully by hundreds f health care rganizatins t imprve many different health care prcesses and utcmes. The mdel has tw parts: Three fundamental questins that guide imprvement teams: What are we trying t accmplish? Hw will we knw that a change is an imprvement? What change can we make that will result in imprvement? The Plan-D-Study-Act (PDSA) cycle t cnduct small-scale tests f change in real wrk settings by planning a test, trying it, bserving the results, and acting n what is learned. This is the scientific methd, used fr actin-riented learning. Implementatin: After testing a change n a small scale, learning frm each test, and refining the change thrugh several PDSA cycles, the team can implement the change n a brader scale fr example, fr an entire pilt ppulatin r n an entire unit. Spread: After successful implementatin f a change r package f changes fr a pilt ppulatin r an entire unit, the team can spread the changes t ther parts f the rganizatin r t ther rganizatins. Yu can learn mre abut the Mdel fr Imprvement n IHI.rg. Institute fr Healthcare Imprvement ihi.rg 13

14 Sample Small Tests f Change Using the Mdel fr Imprvement, teams cnduct small tests f change t start their imprvement wrk. With this apprach, team members can learn quickly what wrks r hw changes need t be refined befre full implementatin. The examples belw demnstrate small tests t implement multidisciplinary runds that cme frm ne f the rganizatins participating in IHI s Multidisciplinary Runds Expeditin. Nte the size and scale f the test: it s very fcused and specific. It wuld nt take much time t plan each test, d it, learn if it wrked, and then test it again n the same scale r expand the scale f the test. Hspitals that have created a successful multidisciplinary runding system have fund that there are many areas they need t test prir t implementatin: time, lcatin, structure, attendees, and a useful frm fr guiding the prcess and dcumenting daily gals. Each aspect invlves a series f tests r PDSA cycles. Small test examples: Tmrrw, Kelly (the bedside nurse n the unit team) will test the daily gal sheet adapted frm anther hspital n her tw patients. On Mnday, Matt (the staff nurse n the unit team) will meet at 9 AM with Kate (the unit manager), Dr. Pattersn (the intensivist), and J Ann (the assigned case manager) t rund n his tw patients. Tips fr Getting Started Implementing multidisciplinary runds can seem like an verwhelming challenge. If yur team tries t d everything and include everyne at nce, it may well prve t be impssible. Belw are a few tips we have learned frm thse rganizatins that have successfully implemented multidisciplinary runds. Leverage existing runding prcesses: Enlist ne r tw staff members wh see the ptential f implementing multidisciplinary runds. If graduate medical educatin runds are currently in place, seek supprt frm the Department Chair t plan and test multidisciplinary runds. Stating the aim f multidisciplinary runds will assist in either adapting a current runding prcess r gaining the participatin f huse staff. It may be necessary t cnsider an additinal prcess fr multidisciplinary runds, a mre structured, faster runding prcess that is separate frm the traditinal graduate medical educatin teaching runds. Dn t allw traditinal graduate medical educatin teaching runds t be a barrier t develping a prcess fr multidisciplinary runds. Seek willing participants: If unable t engage physicians in testing multidisciplinary runds, start with ther disciplines (such as nursing and respiratry therapy, r nursing and pharmacy). Start small, test small and ften: One test, ne day, ne time, ne staff, develp ne daily gal fr the patient. PDSA cycles may include testing at different times f the day, different days f the week, r n different shifts. Institute fr Healthcare Imprvement ihi.rg 14

15 Chse ne prcess t fcus n at a time: Take int cnsideratin the staff invlved in the initial testing and chse a key fcus. In an intensive care unit, the fcus may be Ventilatr Bundle cmpliance, whereas n a pstperative surgical unit it maybe activity prgressin after surgery. Develp and dcument a daily gal fr each patient: This task encurages all participants in multidisciplinary runds t cntribute and share in a cmmn, shrt-term gal. Be specific fr example, Extubate patient by 10 PM r Walk in hall twice befre bedtime. Dcumenting and psting the daily gal in the patient s rm allws everyne wh enters the rm t ask abut, cntribute t, and assist with the cmpletin f the gal. Use a shrt, simple tl t help guide multidisciplinary runds: This tl may be a daily gal sheet r runds checklist develped by the runding team. Such tls can help add structure and expedite the runds. 11 Cnsider including supprt services (e.g., scial wrker, pastral care) in runds ccasinally (1 t 2 times per week). Track interventins initiated during runds and prvide feedback n effectiveness t staff; this can be encuraging and supprt cntinued imprvement. Additinal Tips fr Implementing Multidisciplinary Runds Segment Patients In areas utside the ICU, the prspect f starting multidisciplinary runds n a large unit with 30 r mre patients can be intimidating. Segmenting patients can help ensure that runds are cnducted n a specific grup f patients. Fr example, runding n a medical telemetry flr with a high vlume f cngestive heart failure (CHF) patients can prvide an pprtunity t rund n CHF patients t ensure cmpliance with prtcls and discharge plans. On a pstperative cardivascular surgery flr, runding n each patient n pst-p Day 3 can ffer an pprtunity t ensure prgressin f the patient and set a gal fr discharge. By segmenting ppulatins fr runds n individual units, the structure f runds can prvide a unique pprtunity fr cnsistency amng staff, ensuring cmpliance with prtcls, and the develpment f cmmn daily gals. Script Questins During runds, scripting fcused questins can be key in building relatinships amng participants. Simple yes-r-n questins ften becme rutine and dn t ffer much in the way f discussin. Instead f asking yes-r-n questins, cnsider mre pen-ended questins that elicit cntemplatin and participatin by the grup. Scripting the questins, even writing them n the gal sheet r using a lg that cntains thught-prvking questins, requires staff t think abut why r when a task r interventin is apprpriate. Fr example: Cmpliance with Ventilatr Bundle Sedatin vacatin: When is the sedatin vacatin scheduled? Institute fr Healthcare Imprvement ihi.rg 15

16 Readiness t wean: Has this patient been assessed fr readiness t wean? What needs t happen fr this patient t be extubated? Central line r urinary catheter: Why is the central line in? What needs t happen t get the urinary catheter remved fr this patient? Discharge: What needs t happen s the patient can be discharged? Spread Slwly After pilting multidisciplinary runds n ne r tw units, it can be tempting t spread the changes quickly thrughut the facility. Begin spreading the changes t ther areas r units ne at a time. Because each unit has its wn unique rutines and prviders, it s imprtant t take time t discuss pprtunities with unit staff, set an aim fr runds, and test changes. Each unit will have different rutines, patient ppulatins, and disciplines serving patients, s testing the time f day at which runds will ccur is critical. Expand Participatin Participatin in runds will be different fr mst every unit, as well. Fr example, an rthpedic flr may develp runds with physical therapy, while an ICU step-dwn unit may incrprate respiratry therapy and pharmacy. Sme departments have very few peple (e.g., palliative care, scial wrk, physical therapy), s including these services in runds must be well thught ut. Depending n the patient ppulatin, determine the necessity f and ability t include these disciplines. Test having sme ancillary services participate in runds every ther day (Mnday/Wednesday/Friday); this prvides an pprtunity t learn and cllabrate ften, just nt every day. Institute fr Healthcare Imprvement ihi.rg 16

17 References 1 Burger C. Multi-disciplinary runds: A methd t imprve the quality and safety f critically ill patients. Nrtheast Flrida Medicine. 2007;58(3): Vazirani S, Hays RD, Shapir MF, Cwan M. Effect f a multidisciplinary interventin n cmmunicatin and cllabratin amng physicians and nurses. American Jurnal f Critical Care Jan;14(1): Kucukarslan SN, Peters M, Mlynarek M, Nafziger DA. Pharmacists n runding teams reduce preventable adverse drug events in hspital general medicine units. Archives f Internal Medicine. 2003;163: Kim MM, Barnat AE, Angus DC, Fleisher LF, Kahn JM. The effect f multidisciplinary care teams n intensive care unit mrtality. Archives f Internal Medicine Feb;170(4): Cmmittee n Quality f Health Care in America, Institute f Medicine. Crssing the Quality Chasm: A New Health System fr the 21st Century. Washingtn, DC: Natinal Academies Press; 2001: Herrin R, Desai T, Cldwell G. Quality and safety at the pint f care: Hw lng shuld a ward rund take? Clinical Medicine. 2011;11(1): Cypress BS. Family presence n runds: A systematic review f literature. Dimensins f Critical Care Nursing Jan-Feb;31(1): Rsen P, Stenger E, Bchkris M, Hannn MJ, Kwh CK. Family-centered multidisciplinary runds enhance the team apprach in pediatrics. Pediatrics Apr;123(4):e603-e Lamba AR, Linn K, Fletcher KE. Identifying patient safety prblems during team runds: An ethngraphic study. BMJ Quality and Safety Aug;23(8): Resar R, Griffin FA, Haraden C, Nlan TW. Using Care Bundles t Imprve Health Care Quality. IHI Innvatin Series white paper. Cambridge, MA: Institute fr Healthcare Imprvement; Multidisciplinary Runds: Critical Care Unit Nurse Handff Tl. Institute fr Healthcare Imprvement ihi.rg 17

18 Institute fr Healthcare Imprvement 20 University Rad Cambridge, MA USA