Quality Improvement Project for Hospital

Involuntary Rounding

Novant Health Forsyth Medical Center is part of the largest healthcare system in the state of North Carolina. In 1887 during the summer Reverend Henry O. Lacy whom was the pastor of the St. Paul’s Episcopal Church. During this time the Reverend was seeing that the city was growing and needed a growing healthcare system. The members of the Ladies Twin City Hospital Association (an organization that a group of women developed so women were able to get medical care), thought that they could help make Reverend Henry O. Lacy vision come alive. The women from this organization decided to gather money from their household to open a hospital inside the home of Martin Grogan located on North Liberty Street, and up to 10 patients were allowed at a time with a five-dollar co-pay for a week. While the hospital in Martin Grogan house was being ran, the women of the association was finding ways to collect more money to expand the hospital. The mayors of Winston and Salem decided to contribute twelve dollars a month and by the end of four years they had raised $5,000. After the raising the $5,000, they were able to open the Twin City hospital with twelve private rooms, two psych wards, and one operating room. This became overcrowded for the patient and not having enough funding and equipment, the Twin Hospital was then moved to Brookston Avenue. In 1912 Winston citizens approved bonds and wanted the Twin City hospital to be built on East Fourth Street; which two years later accepted their first patient. In 1959 another bond was approved, and Forsyth Memorial Hospital was built on Silas Creek Parkway on 77 acres; which officially opened in 1964. In 1984 the property of the hospital was transferred from Forsyth County to Carolina Medicorp Inc (CMI) (nonprofit organization). With this transfer the hospital had to give quality care to the citizens of Forsyth County. Novant Health became the first health system to be revalidated for the Health Information and Management Systems Society Analytics Stage7 Ambulatory Award; which was for their use of the electronic health record.

Forsyth Medical Center is a governed by the Joint Commission for Accreditation of Healthcare Organization. The JCAHO is an independent nonprofit organization that sets the standards in which the healthcare quality is measured by the Americans as well as worldwide (Forsyth Website). Being accredited by the Joint Commission is very important because this means that the healthcare system is giving quality effective care to the patient populations. The process of being accredited is a rigorous process such as unannounced sure that takes about 18 to 36 months and there are 10 competent needs to be addressed in the surveys. Some of the components includes survey-planning session, leadership sessions, a competence assessment process, and or individual tracers that follow the experience of the care of individuals through the healthcare system such as the safety culture assessments. Forsyth has also been awarded the American Nurses Credentialing Center (ACC) award. This award is only awarded to five percent of hospitals that are nationwide and have proved that they have the highest level of nursing care. Forsyth Medical Center became a Magnet hospital due to this award and showing their quality in nursing care. The Magnet recognition should mean to a nurse that education is important with the development of autonomy and leading to greater bedside mannerism (Nursing World). This also gives the patients the best quality care and very well knowledge nurses to take charge of their care and to be an advocate for those patients. Lastly, Forsyth Medical Center is accredited for specific units at the hospital.

 Novant Health Forsyth Medical Center uses the National Database of Nursing Quality Indicators. The NDNQI is a national nursing database that provided quarterly and annual reporting of structure, process and outcome indicators (Montalvo,2007), to be able to evaluate the nursing care at unit level. The purpose of the NDNQI is to find a link between the nursing staff and the patient outcomes already being identified. The patient’s outcomes during the stay is what NDNQI is collecting and at Forsyth Medical Center the database collects patients who have fallen, C. Diff, and HAI’s (hospital-acquired infections) such as CLABSI which is a bloodstream infection for patient who had central lines. It is important for these types of quality indicators to be collected because you want to make sure that the facility is providing safe practice. So, having a decrease in numbers will be evidence that quality care is being performed.

The seventh floor on the north tower known as 7N is the orthopedics unit. This unit has (30 beds) the unit director is Rachel Fountain and the assistant directors are Travis Radcliff, and Morin Ande whom is on the night shift. Patients that are admitted on this floor typically are hip replacement, knee replacement, hand and wrist, foot and ankle, and spine such as the neck and back. The back patients are the majority of the population on 7N. The nurse-patient ratio on this unit is based on the patient’s acuity level but normally the nurses are assigned to 5 to 6 patients. The unit has been on a shortage which resulted in the nurses having 7-10 patients.

On 7N the unit has not experienced a sentinel event which is an “unexpected occurrence involving a patient death or serious physical or psychological injury or the risk of one. (Cherry & Jacob,2018)”.  But in the Novant Health Forsyth Medical Center the acute care units such as the ICU has the been the number unit whom to have sentinel events. In the year of 2016 they had a total of 156 falls after patients coming back from surgery causing bleeding, death, and sending the patient back into surgery. Due to this on several occasions the facility has now decided to revise their policies and procedures for fall and fall injuries. Strategies that have been implemented are yellow arm brands, neon yellow bedside signs and a No Pass Zone sign. The No Pass Zone is to “reinforce that belief that all team members have a role in fall prevention (Novant Health,2017)”.  This mean that everyone on the unit have to work as a team and they all will help each other when caring for the patients. If patient is ringing the call bell and or there is a request if their nurse is not able to assist with the client, then another team member cannot pass that patients room without responding and giving that assistance. The facility uses the Root Cause Analysis (RCA) and Run charts for problem solving.  The RCA is a “method of problem solving that help to identify how and why an event occurred (Cherry & Jacob,2018)”. The RCA is under the control of The Joint Commission to focus on the system and process as a whole not on an individual level.

 Novant Health Forsyth Medical Center has a Patient Experience program within each unit there is a partner. This partner of the patient experience program does rounding for majority of the patients on that unit. They ask the patients questions such as “how their overall experience has been at the hospital”. They also ask how their experience has been on the specific unit they are on”. The patient experience partners also send out a survey once the patient is discharged in either the mail or they will get an email.  With 7N being an orthopedic unit, the unit questions are focused on pain management and response to call bell (Flowers et al,2016). Within the past year or two 7N has had to really look at pain management due to late responses to the call bell. 

With the Patient Experience bringing about this issue, this brings up the Quality Improvement that will be addressed.  Being on 7N has showed that intentional rounding is very important for the patients on this particular unit. Intentional Rounding is a “structured approach whereby nurses conduct checks on patients at set time to assess and manage their fundamental care needs” (Ford-Johnston,2014)”. With intentional rounding this give the nurse the time to be able to give their patients their care in a timely manner, while also checking on the patient at intervals through the day. At times nurse believe that they go into the patient’s room introduce themselves, take their vitals, do an assessment, and once that is done they need to come back when it is medication time. With this it causes an increase in the use of the call bell, and with intentional rounding you want to be able to decrease the use of the call bell. In the article “Intentional Rounding: facilitators, benefits and barriers it stated that “Intentional Rounding (IR) is important in engendering confidence in the patient that their needs will be attended to on a regular basis” (Flowers,2016). When a patient has a nurse that is constantly checking and caring for their needs this makes gives the patient the confidence that his or her nurse cares and will do anything to make sure that he or she is taken care of while in the hospital. This change only will make a big difference on surveys once everyone starts to truly utilize it. Showing a patient that you do not care, can be harder for you as the nurse. On 7N with the patient constantly using the call bell this makes the patient think that are not the priority.

Quarterly the Patient Experience partner takes the data from surveys and have one on one talks with the unit director, to discuss the comments and numbers from the survey data. This will show if the unit is making any progress or still the same. The question that stick out the most is “Do the nurses answer the call bell in adequate time?”, since October of 2016 there has been a decrease in the numbers. In October of 2016 there, overall score was a 63.6% and as of September of 2018 the overall score was a 42%. This shows there was a drastic decrease in almost a year of collecting data from the patient experience survey, and this shows that nurses are not implementing intentional rounding. The policy is that the nurse has 15 to 20 minutes to get to the patient after he or she calls from the call bell.  As soon as the patient calls out the MUR (Medical Unit Receptionist) will call the nurses to let them know what patient need may be. Within 15-20 minutes the MUR has to follow up with the patient to make sure his or her need has been met. With the results given it shown that the nurses are not coming within the 15 to 20-minute time periods or having someone else checking to see what the need maybe. Nurses do have multiple patients that they have to assist with and some will have a higher acuity than other patients, so at times they may get caught up with one patient longer than expected.  The nurses in the article, (The implementation of intentional rounding using participatory action) research stated, “Intentional Rounding has been created for a more rewarding nursing environment such as improved time management (Harrington et al, 2013)”. Intentional Rounding will allow the nurses an opportunity to learn time management and prioritize his or her patient load.

 Intentional rounding is also important on 7N because this unit consist of patients coming back from surgery and they are in need of their pain medications. A patient being in pain can result in discomfort and even anxiety, so being attentive to this population of patients is very critical and important. When given a narcotic the nurses are supposed to re-assess the patient within 90 minutes after the medication is given. This is where the intentional rounding should come into play making sure that patient is comfortable, if the medication seems effective, and or if the patient needs anything. At time the nurses forget that the patient is the only one that knows what his or her pain level is. So even though the patient may have been given medication the medication may not be effective for their pain level, and this can result in ignoring the patient when they call out to the MUR.  Margaret S. Hannan, Heather Margonari, and Elizabeth A. Schlenk stated, “Nurses’ competency in pain assessment could potentially improve patient outcomes and satisfaction” (2017). This goes back to being consistent with the intentional rounding and being able to educate the nurses on managing a client pain. The nurses are required to take a pain management class from this unit due to high quality of patient needing pain medications. They are also expected to have the updated pain level from the patient written on the white board as well as the next scheduled dose of medication. This is supposed to give the patient an insight on where they are in their progress and when they can expect to have schedules medications and as needed medications (PRN).

When talking about a QI problem having key stakeholders are very important because they take interest in the organization and support the organization in any way they can to make it successful. A key stakeholder can be directors, employees, government agencies, suppliers and maybe even owners. In this case of the Involuntary Rounding the unit directors, and the patient experience partners definitely have a key role in this problem. The unit directors and the experience partners looking at the monthly surveys and discussion on whether their numbers have increased or decreased from the previous month. The numbers have not changed they have to figure out ways to improve the numbers such as having individual meetings and letting the unit staff know what they need to work on. The unit directors are very involved in making sure that the unit looks good as a whole and making sure that the staff are given the appropriate care to the clients. They take into the considerations the numbers and the feedback from the staff to see where the disconnect is coming from. Majority of the reasons are because they have too many patients or they may get caught up with one patient longer than another. The unit directors have also assessed if the MUR’s are answering the phone adequately and letting the nursing staff know about their call in a sufficient time frame. The call from the MUR is a very important start to the care of the patient, and this is because if the MUR does not tell the nursing staff then he or she will not be aware of the call. The MUR’s and the nursing staff are also a team on the unit, they have to be able to communicate to each other to know the concerns of the patient.

In order to fix the QI problem, the staff has to become a team and work as one. Being able to work as a team can make a big difference with how the unit is ran, sometimes reaching out for others can truly make a difference. Even though the nurse may not have that patient but being attentive to that patient and looking into his or her concern can make the satisfaction of the patient increase in numbers. This can also make the patient feel like he or she is being heard by someone even though it is not their nurse. Team building activities such as game night, or even workshops that talk about team building can be ways that will help the staff grow and want to be become a team. Working in the hospital there are always ways of continuing your education, and with the nurses it would be important for them to take a workshop and or a class on the importance of involuntary rounding. At times it takes a person to go back to the basics to help them refresh on what they may have forgotten while working in the real world. Once a month the nursing staff would have to take a class that is centered around this topic and or patient satisfaction. Being in these classes will give the nursing staff new ways on how to approach the situation and bring the ideas to the unit for the other staff members. Everyone may learn something different from the class and may see the class differently and bringing everyone’s thoughts together will help with team building. Taking the classes will show the staff that involuntary rounding is important, and it takes a team to accomplish the goal. Also the unit directors should introduce the staff to the “Caring around the clock model” (Bloodworth, Hutchings, & Ward,2013). Hutchings brought about this model in order to get the nursing staff to understand why they are making rounds and what they need to do during the rounds. Many of the nurses may feel that they do not know when to round and what they should be doing during the hourly rounding time. Introducing this model would help the nurses on the unit take the time out to round on their patients. The way this model works is that when the nurse is about to leave the patients room he or she must write a time on the whiteboard when they will be back to check on the patient. The nurse must incorporate the four P’s into the rounding which consist of, “positioning, personal needs, pain, and placement” (Moore,2017). This will give the patient a sense that the nurse will not forget about him or her as the patient and give the nurse a chance to learn how to use time management skills. The caring around the clock model makes the nurse accountable about going back into the patient room at a certain time during the day, and if the nurse uses the model adequately it will reduce the use of the call bell. Reducing the number of the use of the call bell is the number goal of involuntary rounding. The nurse must have a log with the patient’s room number and the times that they planned on going into the room, this will show that the nurse is using the model. The use of the log is a way that the unit managers will be able to collect data to see if the plan has been effective and the nurses are sticking to the plan as well. Having the monthly meeting with the patient experience partner would still continue to see if the numbers have increased and also doing rounding’s with the patient experience partner to hear the comments from the patients face to face. Implementing these new tools to address the problem can potentially work because it is giving the nurse a new outlook on how to manage their patients on a daily. The nurses are not only getting educated in the classroom but from their unit directors as well using a new model that they are not used to. Normally when something new is implemented many of the nurses are willing to accept that change, and this will show the patients that the nurses are very serious about their care and needs. Taking these precautions will show the patients that they are the main priority and they will not need the call bell because the nurse is attentive. Lastly, getting the feedback from the patients and the employees as well to get an insight to see if the new tool are becoming effective.

Quality improvement projects are not an easy task to come up with and being able to find solutions are not as easy either. It takes a lot of planning and communication to be able to figure out what things are working and what is not. This goes back to having that team work relationship because if staff do not want to change then the problem will never get addressed. Working in the hospital everything is centered around the patient, so as nurse you have to make sure that you are doing everything you can to make that patient feel comfortable in the position that they are in. They already feel vulnerable, so you have to make them feel like they are wanted at the hospital and that they are not just another patient in the hospital seeking care. So, answering that call bell and being present when you are needed is very important to that patient whether you realize it or not. Even as a nurse you can identify problems that you may see on the unit and come up with solutions. This will show that you are very interested in your unit, and you want nothing but the best. Even though the hospital is one big place each unit are looked at individually and as the nurse you want to make sure that your unit is one of the best units there is in the hospital. You want people to leave your unit and the hospital knowing that you made a difference in their life. That is the main focus of nursing and having these QI projects will make the focus be true on a daily. It may not take one day to fix but as long as you are taking steps into the right direction things will start to work out well and the data will improve.

References

• About us. (n.d.). Retrieved October 13, 2018, from https://www.novanthealth.org/forsyth-medical-center/about-us.aspx
• Bloodworth, K., Hutchings, M., & Ward, P. (2013). ‘Caring around the clock’: A new approach to intentional rounding. Nursing Management (through 2013), 20(5), 24-30. Retrieved from http://ncat.idm.oclc.org/login?url=https://search-proquest-com.ncat.idm.oclc.org/docview/1442757707?accountid=12711
• Bradley, S., Harrington, A., Jeffers, L., Kelman, S., Killington, G., & Lindale, E. (2013). The implementation of intentional rounding using participatory action research. International Journal of Nursing Practice, 19(5), 523-529. doi:10.1111/ijn.12101
• Certifications. (n.d.). Retrieved November 7, 2018, from https://www.novanthealth.org/forsyth-medical-center/quality/certifications.aspx
• CHERRY, B., & Jacob, S. R. (2018). CONTEMPORARY NURSING: Issues, trends, & management (7th ed.). S.l.: MOSBY.
• Flowers, K., Johnson, M., Langdon, R., McIlwrath, M., Wainwright, C., & Wright, K . (2016). Intentional rounding: Facilitators, benefits and barriers. Journal of Clinical Nursing, 25(9-10), 1346-1355. doi:10.1111/jocn.13217
• Forde-Johnston, C. (2014). Intentional rounding: A review of the literature. Nursing Standard, 28(32), 37-42. doi:10.7748/ns2014.04.28.32.37.e8564
• Hannan, M., Margonari, H., & Schlenk, E. (2017). Quality improvement initiative on pain knowledge, assessment, and documentation skills of pediatric nurses. Pediatric Nursing, 43(2), 65-70.
• Magnet Recognition Program | ANCC. (n.d.). Retrieved November 7, 2018, from https://www.nursingworld.org/magnet
• Maya Angelou Women’s Health & Wellness Center. (n.d.). Retrieved October 13, 2018, from https://www.novanthealth.org/home/services/womens-health/maya-angelou-womens-health–wellness-center.aspx
• Montalvo, I., (September 30, 2007)  “The National Database of Nursing Quality IndicatorsTM (NDNQI®)” OJIN: The Online Journal of Issues in Nursing. Vol. 12 No. 3, Manuscript 2.
• Moore , A. (2017). Intentional rounding: Assessing the evidence. Nursing Standard (2014+), 31(42), 18. doi:http://dx.doi.org.ncat.idm.oclc.org/10.7748/ns.31.42.18.s21
• PDF. (2017). Novant Health https://www.novanthealth.org/Portals/92/novant_health/documents/careers/nursing/1444_NAR%202016_digital.pdf
• The Joint Commission. (2018). Retrieved November 7, 2018, from https://www.jointcommission.org/accreditation/accreditation_main.aspx