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					                                                   Reprinted with permission from Marketing Health Services, Spring 2007, published by the American Marketing Association.




                                                                                                                                                                             23




                                                                              ROUND
                              One-hour rounding positively
                              influences patients and nursing
                              staff members.

                                                  Bounty                                                         By Christine M. Meade




                                                              he healthcare marketing profession has changed dramatically over the past



                                                   T          30 years. But what hasn’t changed is that clinical providers in a hospital
                                                              continue to have the greatest influence on patient and family perceptions of
                                                              a hospital or health system. Inseparability (i.e., patient and family perceive
                                                   the provider to be the service), one of the key constructs separating a good from a
                                                   service, is omnipresent in healthcare. And undoubtedly, service quality is one of the
                                                   most studied topics in marketing research over the last decade. A repeated theme in
                                                   the literature is that service quality—as consumers perceive it—is a function of (1)
                                                   what customers expect and (2) how well the organization performs in providing the
                                                   service. Patients form perceptions about the hospital and the quality of service they
                                                   receive when interacting with providers.
                                                       Unfortunately, marketing professionals don’t manage healthcare providers, and
                                                   often have little influence over them. They are shielded from the patient care experi-
                                                   ence, and aren’t directly responsible for customer service or complaint management.
                                                   Consequently, they aren’t really aware of service issues or patient, family, and
Caroline Smith/Getty Images




                                                   employee wants.



                                                                                                                                                  MHS Spring 2007
            This causes an organizational disconnect between mar-                              Study Description
         keters (trying to set expectations and build/establish positive                          A total of 22 hospitals and 46 nursing units participated;
         external reputations and perceptions) and the folks who are in                        however, we used only 14 hospitals and 27 units’ data in the
         causal positions to directly affect the development of expecta-                       final analyses. We eliminated eight hospitals and 19 units’
         tions, reputations, and perceptions. As all marketers know,                           data because of poor reliability. Every experimental unit had a
         promotional efforts cannot make up for poor patient service.                          corresponding control unit. There were two conditions in
         And negative word of mouth from poor service can destroy                              each experimental unit: (1) baseline measurement that lasted
         the many years—and millions of dollars—spent trying to                                for two weeks and (2) either one-hour or two-hour rounding
         build a good reputation. That is why my study with Amy L.                             on patients, which lasted for four weeks. Units doing the one-
         Bursell and Lyn Ketelsen—“Effects of Nursing Rounds on                                hour rounding completed one-hour rounds from 6 a.m. to 10
         Patients’ Call Light Use, Satisfaction, and Safety”—has mean-                         p.m. and then every two hours from 10 p.m. to 6 a.m., to
         ing and implications for marketers and hospital administra-                           respect patient sleeping patterns. Units doing the two-hour
         tors. A nurse designed it, and we performed it in inpatient                           rounding completed 12 rounds over a 24-hour period, every
         hospital units in April 2005. It was first documented in the                          two hours. In most units, the registered nurses and other
         September 2006 issue of the American Journal of Nursing.                              nursing staff members (e.g., certified nursing assistants,
                                                                                               patient care technicians) alternated the rounds.
                                                                                                          We divided the measurement of call light use
         Exhibit 1                                                                                     and reasons into two-week time periods, so we
         One-hour rounding                                                                             could compare the interventions (one-hour and two-
24                                                                                                     hour rounding) with the baseline. Therefore, at each
                                                                                                       hospital, the study lasted six consecutive weeks.
           Result                              Effect on hospital operations                           We used rounding logs and call light logs to docu-
                                                                                                       ment the (1) rounding completion and (2) reasons
           Reduction of 38.7%                  A reduction of 4,901 call lights per month,             for/counts of call lights. One-hour rounding was
           in patient call lights              for all units doing one-hour rounding,                  clearly the best practice.
                                               means nurses had 326 more hours per
                                               month for other aspects of patient care.
                                               Patients were more satisfied with the care
                                                                                                      Marketing and Administration
                                               that staff members delivered, and nursing
                                                                                                          This study focused on inpatients and their needs,
                                               staff members indicated they had more                  but a hospital can apply most of the philosophies
                                               time for patient care and less interruptions.          practiced in the rounding protocol with all the patients
                                                                                                      that it serves. If nursing staff members focus their
           Increase of 12 raw average          Happier patients means happier family                  efforts on meeting patients’ needs and ensuring that
           points on inpatient satisfaction/   members and increased positive word of
                                                                                                      they receive superior service, then it is a win-win for
           overall quality of nursing care:    mouth.
                                                                                                      everyone: patients, marketers, hospital administration,
           79.9-91.9 (.000 statistically
                                                                                                      and family members. This is because there are clear
           significant)
                                                                                                      benefits to hospital staff members doing rounding (all
           Decrease in falls of 50%            This means a total of $143,546 in savings.             of which lead to higher patient satisfaction): identifica-
                                               Falls cost a hospital an average of $11,042            tion of unmet needs, correction of service defects
                                               per fall.
                                                                                                      uncovered, relationship building, provision of
           Decrease in hospital-acquired       This means a total of $31,916 in savings.              enhanced service, and issue and problem solving.
           decubitus (lying down)              Hospital-acquired decubitus costs a hospi-                 Exhibit 1 outlines the key results of nursing staff
                                               tal an average of $15,958 per case.                    members’ one-hour rounding. These results speak to
                                                                                                      how all dimensions of a hospital benefit from this pro-
           • The nurses in this study agreed on four minutes as a good estimate of the                tocol, and how marketers are able to brag about the
             time it takes to respond to and complete a patient call light request.                   delivered service quality.
           • In reducing call lights by 37% using hourly rounding, the experimental
             units had 4,901 fewer call lights. This saved them 326 hours or the time                 Call Light Reasons
             of eight full-time equivalent employees, or FTEs (4,901 x four minutes =                    We recorded 108,882 call lights for this study,
             19,604; 19,604/60 minutes = 326 hours; and 326/40 hours per week =                       and developed 26 reasons to categorize why patients
             eight FTEs).                                                                             used them. The top seven were bathroom assistance
           • The experimental units answered 13,216 call lights in the baseline period,               (15.4%), intravenous/pump alarms (14.8%), accidental
             9,316 in the first two weeks of the study, and 8,315 in the second two                   push of call light (12.8%), miscellaneous (12.6%),
             weeks of the study.                                                                      pain medication (9.5%), needing a nurse (9%), and
                                                                                                      positioning assistance (4.1%).


     MHS Spring 2007
Call Light Reductions
    The experimental units doing hourly rounding reduced
patients’ call lights by an average of 37.8% over a four-week                                Rounding actions
period. This was statistically significant at the .000 level when
compared with the baseline period. Reductions by                       We gave the following instructions—actions to perform for patients
specific units ranged from 13%-75%.                                    during one-hour and two-hour rounding—to nursing staff members
    Strong management and daily oversight of the study and             in the experimental units. They checked and completed the items:
staff members were key factors in units achieving call light
reductions in excess of 45%. The units doing two-hour                  • Upon entering the room, tell the patient you’re there to do your
rounding reduced call lights by 18.9%. This wasn’t signifi-              rounds as promised (reliability and assurance).
cantly different from the baseline period. The frequencies of
                                                                       • Assess patient pain levels using a pain-assessment scale. If you are
patients’ requests—for the behaviors that nursing staff mem-
                                                                         not a registered nurse and the patient is in pain, then immediately
bers addressed in the rounding (see the “Rounding actions”
                                                                         contact one so he or she doesn’t have to use the call light for pain
sidebar)—all significantly declined for one-hour rounding.
                                                                         medication (responsiveness).
    For one-hour rounding: bathroom assistance went down
40%, pain medication went down 35%, positioning went                   • Put medication—as needed—on the registered nurse’s
down 29%, and intravenous/pump alarms went down 40%.                     scheduled list of things to do for patients, and offer the
For two-hour rounding: bathroom assistance went down                     dose when it’s due (reliability).
22%, pain medication went down 17%, positioning went
down 34%, and intravenous/pump alarms went down 22%.                   • Offer bathroom assistance (responsiveness).                                25
                                                                       • Assess the patient’s position and position comfort. Ask
The Literature Connection                                                whether he or she (1) needs to be repositioned and
    As mentioned, a nurse developed the protocol for this
                                                                         (2) is comfortable (empathy).
study. But, as those familiar with the marketing literature
can clearly see, the behaviors in that protocol center around          • Make sure the call light is within the patient’s reach (tangibles).
the marketing constructs representing the five dimensions
of SERVQUAL—one of the most popular assessment tools                   • Put the telephone within the patient’s reach (tangibles).
of service quality. Customers have consistently ranked the
                                                                       • Put the TV remote control and bed light switch within the
evolved set of dimensions as most important for service
                                                                         patient’s reach (tangibles).
quality, regardless of service industry. Additionally, many
follow-up studies have established that reliability is the most        • Put the bedside table next to the bed (tangibles).
important factor contributing to service quality, and tangibles
are the least important. The “Rounding actions” sidebar                • Put the tissue box and water within the patient’s reach (tangibles).
categorizes the rounding protocol behaviors into SERVQUAL’s
                                                                       • Put the garbage can next to the bed (tangibles).
dimensions:
                                                                       • Prior to leaving the room, ask: “Is there anything I can do
• Reliability is the ability to dependably and accurately                for you before I leave? I have time while I’m here in the room”
  perform the promised service.                                          (responsiveness).

• Responsiveness is the willingness to help customers and              • Tell the patient that a member of the nursing staff (use the names
  provide prompt service.                                                on the white board) will be in the room in an hour—or two hours,
                                                                         if a two-hour protocol is in use—to round again (reliability).
• Assurance is the knowledge and courtesy of employees,
  and their ability to convey trust and confidence.
• Empathy is the caring and individualized attention that
  the organization provides its customers.
                                                                    well as their normally scheduled responsibilities. Some also
• Tangibles are the appearance of facilities, equipment,
                                                                    wondered who would do the rounding, and stated they
  personnel, and communication materials.
                                                                    thought it should be a team effort—shared with registered
                                                                    nurses and other nursing staff members.
Discussion Points                                                       Yet at the end of the study, verbally reported anecdotal
    Initially, when we conducted the hospital training, nursing     data indicated that they were more satisfied with the addition-
staff members in the experimental units expressed concerns          al time they had to care for their patients and complete other
about whether they’d have time to perform the rounding as           tasks (e.g., charting, patient education). This is because the


                                                                                                                                  MHS Spring 2007
                                                                                    call light use (in terms of the proportion of calls patients made
                                                                                    in each major reason category) suggests some equivalence
                     Practical rounding for marketers                               between the control and experimental units. But the difference
                                                                                    in patient satisfaction between the one-hour and two-hour
           • Round on five inpatients and 10 outpatients weekly. Ask them about     rounding groups at baseline suggests that units in these
             their expectations compared with their experiences, and what the       groups might not have been equivalent. Or perhaps it sug-
             hospital can do better. Compile a monthly report, and directly work    gests that the hospitals were attempting to raise low patient-
             with managers and administration to fix what is causing problems.      satisfaction levels in specific units, by assigning them to a
             Address those issues in communications with staff members.             rounding protocol. It would be useful to repeat the study
                                                                                    using either random assignment or investigator-controlled
           • Call five dissatisfied inpatients and outpatients every week to
                                                                                    matching of units for important characteristics.
             “telephone round” on them, so you know what they expected and
                                                                                         In research that involves whole organizations, and a great
             why they were disappointed. Ask them what needs to be done to
                                                                                    deal of human interaction coupled with 24-hour operations,
             convert their low ratings to high ratings. Share these findings
                                                                                    it’s impossible to ensure that every nurse will perform the pro-
             with unit managers.
                                                                                    tocol and record data correctly during each patient encounter.
           • Round with nurse leaders, physicians, and patient relations repre-
             sentatives to discover what they’re hearing from staff members
             and patients. This will help you understand what needs to be
             improved—and within what time frame. Compose a statement
                                                                                         Healthcare organizations
26           of your findings for higher levels of administration.                   are challenged to make proven
           • Capture the good/positive comments from that rounding, to reward        interventions and procedures a
             and recognize staff members who provide patients with exemplary
             service. Give a service award of the month and special parking          part of habitual daily operations.
             place to employees whom patients recognize.

           • Use the information from these rounding experiences to encourage
                                                                                    Our thoughts are similar to what the Agency for Healthcare
             changes. These might include advanced throughput designs for
                                                                                    Research and Quality (Rockville, Md.) expressed when it com-
             faster service in outpatient departments, better signage, enhanced
                                                                                    pleted its nationwide study on patient safety. Report authors
             patient information guides, service improvement suggestion forms,
                                                                                    K.G. Shojania, B.W. Duncan, and K.M. McDonald write:
             and a service assistance hotline for patients—or for family mem-
                                                                                    “Although all those involved tried hard to include all relevant
             bers to report issues.
                                                                                    practices and to review all pertinent evidence, inevitably some
           • Work with department managers and human resources to plan              of both were missed. It is hoped that this report provides a
             training sessions around key patient expectations, so employees        template and plants a seed for future clinicians, researchers,
             are aware of what patients want. Help employees learn what to tell     and policy-makers as they extend and inevitably improve
             patients, and how to express it. This will ensure consistent conver-   upon this work.”
             sation with patients throughout the hospital, and seamless quality          It would have been redundant (and a possible irritation for
             irrespective of what department patients interact with.                patients) to get more patient-satisfaction data by making them
                                                                                    fill out another survey; therefore, we had to use data from
                                                                                    vendors. Our calculations are dependent on their data being
                                                                                    accurate and representative of the requested discharge dates.
                                                                                         At times, staff members floating between the experimental
         rounding reduced the number of call lights they had to                     and control units might have performed some of the rounding
         answer, thus freeing up time for alternate duties.                         protocol in the control units. Furthermore, nursing staff mem-
            Nursing staff members who performed one-hour rounding                   bers who are merely exposed to the idea of participating in a
         reported that units were quieter. They also reported that they             study of this nature might modify their behaviors, particularly
         were able to be more attentive and respond more quickly                    in baseline and control groups. Nursing managers’ abilities to
         when call lights rang, because the ring was no longer part of              facilitate the study varied, and some units experienced man-
         normal noise in the unit.                                                  agement changes during the study. It’s unclear to what degree
            Limitations. The study had a quasi-experimental design,                 these issues affected (1) the units’ performance and (2) the
         which doesn’t guarantee equivalence between groups. We                     variation in call light reduction among units.
         don’t know all of the factors that each hospital considered                     Future directions. It would be beneficial for hospital
         when making decisions about assignments to control or one-                 administrators, chief nursing officers, and nursing staff mem-
         hour and two-hour rounding groups. The comparability of                    bers to more closely track how well the reduced call light use


     MHS Spring 2007
enables the last group to redirect its time and energy to other          reduced them by 50%, so this is also a consistent level of
patient care tasks. Related issues also deserve further study.           hardwiring.
Can hospitals use any time gained from a reduction in call
light use to improve staffing patterns? If so, then how? Can             Hospitals have made marketing-oriented enhancements to
nursing staff members—aside from registered nurses—con-               help nursing staff members continually practice the rounding
duct rounds? If so, then under what circumstances?                    protocol:
   As with any training program, hospital leadership is a key         • Nursing staff members have laminated pocket cards, to
factor in successful implementation of an intervention in a             frequently remind them of actions to perform on rounds.
nursing unit. This is especially true for nurse managers, who
have to ensure that all nursing staff members are diligent in         • Rounding boards are mounted to the outside of patients’
carrying out the protocol. The hospitals and units that we had          doors, to ensure that rounding has occurred. Anyone
to eliminate from this study are evidence that full compliance          walking through the unit can easily monitor them.
with a new protocol doesn’t come easily, and that staff mem-
bers are sometimes reluctant to participate.                          • Eight hospitals print cards for nursing staff members to
                                                                        leave on bedside tables, so patients who are asleep during
Long-Term Follow-Up                                                     rounding will know that rounds occurred. The cards have
   Many people know from experience that it’s easier to do              space for staff members to write their names and the time
something for a short time than make it a part of everyday              they conducted rounds.
behavior. Similarly, healthcare organizations throughout the             This study’s findings suggest that one-hour rounding
country are challenged to make proven interventions and pro-          positively affects patient and nursing staff member welfare.         27
cedures a habitual part of daily operations—a process that            Considering the nursing shortage and the growing healthcare
Quint Studer, of the international executive coaching firm            demands of the baby boomer generation, nursing units could
Studer Group, describes as “hardwiring.” Given this under-            use a rounding protocol to achieve improved efficiency.
standing, we wanted to follow up with the hospital units that         This translates into greater work satisfaction—and possibly
participated in the call light study.                                 reduced fatigue/burnout and more satisfied patients. These
   Our purpose was to understand whether the units contin-            outcomes are always going to be good for hospital
ued the hourly rounding after the study, whether other hospital       marketers. MHS
units took on hourly rounding, what (if any) enhancements or
adaptations hospital units made to the actions adopted for the        Additional Reading
study, and how patient-satisfaction scores and fall rates changed     Meade, Christine M., Amy L. Bursell, and Lyn Ketelsen
from the beginning of the study. For the 14 hospitals whose           (2006), “Effects of Nursing Rounds on Patients’ Call Light
data we analyzed in the study, the results are impressive and         Use, Satisfaction, and Safety,” American Journal of Nursing, 106
imply the commitment and hardwiring of the rounding effort:           (9), 58-70.
• Most (85.7% [n = 12]) of the units continued the round-             Parasuraman A., V.A. Zeithaml, and L.L. Berry (1985), “A
  ing. The two that didn’t had management changes, and the            Conceptual Model of Service Quality and Its Implications for
  new manager was unable to sustain the behaviors.                    Future Research,” Journal of Marketing, 49 (4), 41-50.
• Most (92.8% [n = 13]) of the hospitals decided to expand            Parasuraman A., V.A. Zeithaml, and L.L. Berry (1988),
  the rounding to other units or the entire hospital.                 “SERVQUAL: A Multiple-item Scale for Measuring Customer
• Patient-satisfaction scores (i.e., overall quality of care in the   Perceptions of Service Quality,” Journal of Retailing, 64 (1),
  unit) continued to grow over the year. The average increase         12-40.
  in the mean score for all of these units was 8.9 points:            Shojania, K.G., B.W. Duncan, and K.M. McDonald (2001),
  from 79.9 to 88.8. (These are the latest ratings available          “Making Health Care Safer: A Critical Analysis of Patient
  to the hospital for at least a month, to ensure an adequate         Safety Practices,” Evidence Report/Technology Assessment,
  sample size.) The units in the study increased the average          43, 1-668.
  rating by 12 during it, so this is a consistent level of hard-
  wiring for these units.                                             Studer, Quint (2003), Hardwiring Excellence. Gulf Breeze, FL:
                                                                      Fire Starter Publishing.
• Two hospitals monitor percentage of excellent ratings
  rather than the average score. Their two units have                 About the Author
  increased excellent ratings by 41.85%: from 38.25% at the           Christine M. Meade is executive director of the Studer
  start of the study to 80.1% now.                                    Alliance for Health Care Research in Gulf Breeze, Fla. She may
• Falls decreased by an overall 60%. The units in the study           be reached at chris.meade@studergroup.com.


                                                                                                                         MHS Spring 2007

				
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