How to Manage Family-Centered Rounds

FCR Benefits for Hospitals and Health Care Systems

As health care prepares to fully adopt reforms and shift from volume-based to value-based payment systems, creating value in every patient encounter is vital. Conducting daily FCRs provide an dynamic venue for hospitals where daily rounds can incorporate evidence-based practice guidelines, prevent medication errors, ensure safety, reduce unnecessary tests and treatments, and improve transparency and accountability in care. This model can help hospital financially by meeting key quality and safety metrics and also help provide cost effective care through use and reinforcement of clinical pathways during rounds.

FCR Barriers

While many hospitals have adopted FCRs, many barriers to FCR implementation exist [10–14,18–23] (Table 1). Understanding these barriers and overcoming them are crucial for successful implementation. Conducting FCRs involve many aspects of care that happen during rounds. These include discussions about history, physical examinations, labs, and other tests; clinical decision-making and communication between parents and providers; team communication; teaching of trainees; discharge planning; and coordination of care [20]. Given all these aspects of care involved during rounds, being able to conduct multidisciplinary rounds in a timely and efficient way can be a challenge in a busy and dynamic inpatient setting.

Key identified FCR barriers have included physical constraints such as small patient rooms, large team size, patients being on multiple floors or units, infection control precautions leading to increased time involved with teams gowning and gloving; lack of training on FCRs for trainees and faculty; language and cultural barriers; family/patient concerns of privacy/disclosure of sensitive information; trainee’s fears of not appearing knowledgeable in front of families; and variability in attending physicians’ teaching style and approach to FCR [10–15,21].

Operationalizing Successful FCRs

Forming FCR Steering Committee: Developing Ground Rules

While there are many barriers to conducting efficient FCRs there are some that are unique to each institution. Therefore, for those institutions planning to initiate FCRs, the first step might be to form a FCR steering committee of key stakeholders who could review the current state, do a needs assessment for initiating FCRs, develop a structured and standardized FCR process and revise the FCR process periodically to meet the needs of the dynamic inpatient setting [10,12,14].

Defining and Identifying the FCR Process: Who, Where, and When of FCRs

The steering committee should clearly define FCRs and identify what FCRs would involve. For example, should FCRs involve complete case presentations and discussion in front of the parent or focused relevent H&P in a language that the parent understands? The steering committee should identify key elements/aspects of FCRs that would happen on daily rounds. For example: how should each patient receive information about FCRs? Should FCRs be offered to all patients? Do patients have options to opt-in or opt-out of FCRs on a daily basis or a one-time basis? Who should attend FCRs? For example, other than medical team, the bedside nurse and case manager should attend FCRs on a general pediatric service. Should the team round based on nursing assignments or resident assignments or in the order of room numbers? What should a typical rounding encounter involve? For example, each encounter should begin with the intern knocking on the door, asking parental permission for FCR team to enter the room, who should present, who should lead the rounds (the senior resident or the attending), who should stand where in the room? What should each encounter involve—for example, case presentation and discussion, parental involvement in decision-making, clarification of any parental questions, plan for that day, criteria for discharge and discharge needs assessment, teaching of resident and students, use of lay language etc. How should each rounding encounter end? Should the intern ask if parents have additional questions? It is important that the steering committee clearly identify these minute rounding details. Additionally, the committee should identify the rounding wards/area, the timing and duration of FCRs, how information about FCRs will be shared with patients and families, how trainees and attendees will be educated about FCRs and when are FCRs appropriate and when not. Defining the process early through stakeholder identification can reduce variability and create some standardization yet allow for individual style variations within the constraints of standardization. This will help reduced attending variability, which was cited as the most common FCR barrier by trainees.

As Seltz et al described, Latino families reported positive experiences with FCRs when a Spanish-speaking provider was involved. However, they report less satisfaction with telephone interpreters and did not feel empowered at times on FCRs due to language differences [23]. Addressing the language needs based on demographics and cultural needs will promote greater acceptance of FCRs [23].

Identifying and Defining Trainee Role 

Participating in the FCR can create anxiety for medical students and residents. Therefore, educating them about the FCR process and structure beforehand and clearly defining roles can help them conceptualize their roles and expectation and ease their anxiety with FCRs. This will require the steering committee to collaboratively discuss how each encounter would look during FCR from a trainee’s perspective. Who will present the case? The third- year medical student versus the fourth-year medical student or the intern or based on case allocations? How should the case be presented? Should it be short and pointed presentation versus complete history and physical examination on each patient? How long should an encounter last on a new patient and on a follow-up patient? Who will examine the patient? The student who is presenting the case, the attending, the intern who overlooks the student, or the senior resident? Who will answer the follow-up questions from a parent initially? Should the senior resident lead the team under the attending guidance? How will the senior resident be prepared for morning rounds? Using lay language when talking to parents should be encouraged and taught to trainees routinely during FCRs.

Identifying and Defining Clinical Teaching Styles