Standardized attending rounds to improve the patient experience: A pragmatic cluster randomized controlled trial
Background
At academic medical centers, attending rounds (AR) serve to coordinate patient care and educate trainees, yet variably involve patients.
Objective
To determine the impact of standardized bedside AR on patient satisfaction with rounds.
Design
Cluster randomized controlled trial.
Setting
500-bed urban, quaternary care hospital.
Patients
1200 patients admitted to the medicine service.
Intervention
Teams in the intervention arm received training to adhere to 5 AR practices: 1) pre-rounds huddle; 2) bedside rounds; 3) nurse integration; 4) real-time order entry; 5) whiteboard updates. Control arm teams continued usual rounding practices.
Measurements
Trained observers audited rounds to assess adherence to recommended AR practices and surveyed patients following AR. The primary outcome was patient satisfaction with AR. Secondary outcomes were perceived and actual AR duration, and attending and trainee satisfaction.
Results
We observed 241 (70.1%) and 264 (76.7%) AR in the intervention and control arms, respectively, which included 1855 and 1903 patient rounding encounters. Using a 5-point Likert scale, patients in the intervention arm reported increased satisfaction with AR (4.49 vs. 4.25; P = 0.01) and felt more cared for by their medicine team (4.54 vs. 4.36; P = 0.03). Although the intervention shortened the duration of AR by 8 minutes on average (143 vs. 151 minutes; P = 0.052), trainees perceived intervention AR as lasting longer and reported lower satisfaction with intervention AR.
Conclusions
Medicine teams can adopt a standardized, patient-centered, time-saving rounding model that leads to increased patient satisfaction with AR and the perception that patients are more cared for by their medicine team. Journal of Hospital Medicine 2017;12:143-149. © 2017 Society of Hospital Medicine
© 2017 Society of Hospital Medicine
Patient experience has recently received heightened attention given evidence supporting an association between patient experience and quality of care,1 and the coupling of patient satisfaction to reimbursement rates for Medicare patients.2 Patient experience is often assessed through surveys of patient satisfaction, which correlates with patient perceptions of nurse and physician communication.3 Teaching hospitals introduce variables that may impact communication, including the involvement of multiple levels of care providers and competing patient care vs. educational priorities. Patients admitted to teaching services express decreased satisfaction with coordination and overall care compared with patients on nonteaching services.4
Clinical supervision of trainees on teaching services is primarily achieved through attending rounds (AR), where patients’ clinical presentations and management are discussed with an attending physician. Poor communication during AR may negatively affect the patient experience through inefficient care coordination among the inter-professional care team or through implementation of interventions without patients’ knowledge or input.5-11 Although patient engagement in rounds has been associated with higher patient satisfaction with rounds,12-19 AR and case presentations often occur at a distance from the patient’s bedside.20,21 Furthermore, AR vary in the time allotted per patient and the extent of participation of nurses and other allied health professionals. Standardized bedside rounding processes have been shown to improve efficiency, decrease daily resident work hours,22 and improve nurse-physician teamwork.23
Despite these benefits, recent prospective studies of bedside AR interventions have not improved patient satisfaction with rounds. One involved the implementation of interprofessional patient-centered bedside rounds on a nonteaching service,24 while the other evaluated the impact of integrating athletic principles into multidisciplinary work rounds.25 Work at our institution had sought to develop AR practice recommendations to foster an optimal patient experience, while maintaining provider workflow efficiency, facilitating interdisciplinary communication, and advancing trainee education.26 Using these AR recommendations, we conducted a prospective randomized controlled trial to evaluate the impact of implementing a standardized bedside AR model on patient satisfaction with rounds. We also assessed attending physician and trainee satisfaction with rounds, and perceived and actual AR duration.
METHODS
Setting and Participants
This trial was conducted on the internal medicine teaching service of the University of California San Francisco Medical Center from September 3, 2013 to November 27, 2013. The service is comprised of 8 teams, with a total average daily census of 80 to 90 patients. Teams are comprised of an attending physician, a senior resident (in the second or third year of residency training), 2 interns, and a third- and/or fourth-year medical student.
