How to Manage Family-Centered Rounds
Faculty Development Program and Importance of “Safe Environment”
Developing an educational program to train faculty, trainee and staff about FCRs can help streamline FCRs. Conducting FCRs is a cultural change and focusing on early adopters is crucial. Muething et al’s model showed better acceptance of FCRs by interns than by senior residents. Being patient during change management is key to successful implementation. Anecdotal discussions during PAS workshops suggests that on an average programs have required 3 years to get significant buy-in and streamlining of FCRs [10,12].
Suboptimal attending behavior such as attending variability in the FCRs process and teaching strategies have been reported as FCR barriers [14,21]. Residents report attending physician as an important factor determining success of FCRs. As attending physicians typically are the leaders of the FCRs team, training faculty about conducting effective and efficient FCRs is crucial to successful FCRs. [12,21]. Key aspects of faculty development should include: (1) education about the FCR standard process for the institution, (2) importance of time management during rounds, including tips and strategies to be efficient, (3) teaching styles during FCRs, including demonstrating role modeling, and (4) direct observation of trainees and individual and team feedback to streamline FCRs. Role-plays or simulated FCRs might be a venue to explore for faculty development on FCRs [14,21].
Creating a “safe environment” during FCRs where each person feels comfortable and secure is vital to team work [7,12,21]. Often trainees are apprehensive or afraid due to medical hierarchy and this might prevent developing a teaching and learning environment. Trainees fear not appearing knowledgeable in front of families and student rotate too often to adapt to different attending styles [21]. Therefore, reassuring trainees that the goal of FCRs is to conduct daily inpatient rounding to ensure key aspects of FCRs are met without disrespecting and insulting any person on rounds and clarifying and reassuring trainees that their fear of not appearing knowledgeable is real and it will be respected, might help create a safe environment where FCR teams are not only conducting the daily ritual of inpatient rounding, and teaching but also ensuring that trainees are enjoying being the clinician and physicians that they want to be. Therefore, attending role modeling is crucial and it is no surprise that in multiple studies variability in attending rounding and teaching style was identified consistently as a FCR barrier.
Preparing for Daily FCRS: Team Work, Efficiency, and Time Management
Conducting daily timely and efficient rounds require daily preparation by teams. Prior to FCRs, teams should know about all of the patients on whom FCRs will be conducted including those who refused FCRs, if any. This can be done via a pre-round or card-flip rounding method where the teams discuss key diagnoses, indication for admission, and identify any outliers to conducting FCRs such as sensitive patient condition, patients refused FCRs, etc. Some institutions have incorporated these at “morning check out” or at morning “huddles.” These help faculty avoid any last minute surprises during rounds and helps with time management during FCRs [12]. Faculty can then plan on some anticipated “teaching moments” before rounds to keep the rounds flowing, for example, a physical exam finding, a clarifying history that can clinch a diagnoses, a clinical pearl, a complex medical case where the parent might share their story and knowledge, an interesting interpretation of a lab, an x-ray or MRI finding. Faculties are multitasking during FCRs by diagnosing and managing patient and learners and leading effective efficient and timely rounds where parental questions are answered, orders are written, to-do work is identified, discharge planning and care coordination is done and trainees stay focused and attend noon conference on time. This requires thoughtful planning before starting FCRs. Time management and managing priorities is key to positive team experiences of FCRs. Both starting and ending FCRs on time should be emphasized and reinforced continually.
Nurse Preparation for FCRs
Nurses are the frontline providers and educating them about FCRs process can help them better explain FCRs to patients and families. Nurses often know the minute details such as timing of an MRI, if the patient has vomited in the morning, or when the parents are coming, etc. This important information sharing during FCRs can help team prepare for the day and provide patients and families’ expectations for the day. Nursing participation can also enhance their knowledge about the thought process behind decisions and care plans and avoid additional time paging house staff to obtain clarification [12–15,21].
Trainee Preparation for FCRs
While pediatric residents do report that FCRs leads to fewer requests for clarifications from families and nurses after FCRs, many still harbor concerns about the time required for FCRs and the overall efficiency of rounds [14]. Educating trainees about the FCR process and explaining why FCRs are beneficial can help alleviate trainee anxiety around FCRs. Involving trainees in the FCR communication and creating a safe and nurturing environment during FCRs can further reduce trainee anxiety [21]. Parents who have attended FCRs with trainees report understanding that trainees are in training and that they have felt comfortable to see attending physician lead the trainees.
FCRs and Technology
Use of technology during FCRs can be helpful to write orders in real time, follow-up and share lab values and or imaging study with parents or teach students. The increasing use of technology on FCRs, such as computers and handheld devices, can help with rounding and teaching; however, it also has the potential to be a distractor and requires that the medical team remain vigilant that the patient and family are the focus of FCRs [26].
Efficiency Pearls
Certain strategies can be utilized to keep FCRs efficient:
- Orient the FCR team about FCR process
- Identify rounding sequence for the day so team can move efficiently between rooms. Identifying potential discharges for the following morning and discharging those patients before rounds can reduce rounding census and provide additional rounding time. Teams can identify approximate time spent in each room based on census, as rounding time is constant.
- Starting and ending FCRs at the allocated time is key to success of FCRs. Sometimes this might require the attending and senior resident splitting the last 1–2 patients to finish rounds on time.
- Prepare students and interns for effective and efficient yet complete presentations during rounds that reflect their knowledge and thought process rather than presenting the entire H&P.
- Keep teaching during rounds focused. As a resident reported, “attendings should keep it short and not go off on a half hour lecture during FCRs. On FCRs I want to hear bam…bam…bam! tidbits, little hints, clinical pearls. Things that you would not know and only see and know when you were there in the room [21].”
- Encourage and teach senior residents’ role as a leader and teacher [21].
- With a situation requiring more time talking to families, request to go back later in the afternoon so as to stay on track on FCR time.
- Faculty can review lab results and history and physical findings on new admissions before rounds to avoid surprises during FCRs and to save time. This can be done during pre-round/card flip/or morning huddle.
Limitations
This article is based on the authors’ review of literature, experience in conducting FCRs, and experience from leading and attending FCR-related workshops at annual pediatric academic societies’ meetings and annual pediatric hospital medicine meetings between 2010 and 2015. There are several limitations to this work. Firstly, the majority of FCR literature is based on perceptions and are not measured outcomes. In addition, how FCRs will apply on services with complex patients needs more study. Different institutions have different physical constraints as well as sociodemographic and cultural factors that might affect FCRs. Daily census among hospitals varies and rounding duration may vary for them.
Conclusion
Family-centered rounds are widely accepted among pediatric hospitalists in the US. Reported benefits of FCRs include improved parent satisfaction, communication, better team communication, improved patient safety and better education for trainees. Many barriers to efficient FCRs exist, and for programs planning to incorporate FCRs in their daily rounds it is crucial to understand FCR benefits and barriers and assess their current state, including physical environment, when planning FCRs. Having a period to plan for FCR implementation through key stakeholder involvement helps define FCR process and lay down a conceptual model suited to individual organization. Educating the team members including families about FCRs and developing a strong faculty development program can further strengthen FCR implementation. Special focus should be given to time management, teaching styles during FCRs, and creating a safe and nurturing environment for FCRs to succeed.
Corresponding author: Vineeta Mittal, MD, MBA, 1935 Medical District Dr., Dallas, TX 75235, vineeta.mittal@childrens.com.
