More data, fewer problems: reducing varilability of structured interdisciplinary rounds
Top Results
Overview
SIBR1 Rounds are the gold standard of acute inpatient care, with 14 published papers showing significant reductions in harm, excess days, and patient & staff dissatisfiers. But anecdotally, SIBR sustainability seems hindered by performance variability. Could daily data on quality help?
Objectives
To investigate if daily SIBR rounds performance data could help to reduce performance variability and improve outcomes.
Methods
We began with the usual project management, training, and external expertise to launch SIBR on 2 units in spring 2022.
Then we added a novel monitoring strategy:
1. Measure: Track daily data on rounds quality and quantity, with help of unit’s charge nurse
2. Report: Automated hospitalist, team, and unit performance reports, using purpose-built tracking system
3. Act: Hospitalist and nurse leaders review reports weekly with external advisors to address emerging issues
For 7 months, ≥95% of daily team rounds were evaluated across the 2 units.
Results
We found that the process monitoring created transparency and accountability. These methods enabled leaders to rapidly remediate performance variability and track progress.
Strong results were observed across the triple aim: Patient Experience, Care Outcomes, and Throughput/Costs.
Process monitoring enabled leaders to rapidly remediate performance variability. The SIBR quantity & quality criteria are recorded each day by the charge nurse who is coordinating the SIBR round. The data is digitized by the unit administrator later in the morning, which takes approximately 60 seconds.
Leaders reviewed the reports weekly and intervened as needed – e.g., coaching outlier physicians, upskilling residents or reinforcing education points with nurses – which improved metrics such as duration and quality.
Where necessary, leaders reviewed the full set of data for the day(s) including any custom notes that have been added by the charge nurse to gain a better understanding of the context of the work environment that day and the issues highlighted, see example SIBR notes below.
“SIBR went well today, we had a great first full week. More good catches today from nursing, r/t bowel regimes and anticipated discharge needs for some. Everyone seems very invested in starting on time and what there (sic) role is.”
– SIBR Rounds Manager
“We had a lot of teaching during SIBR today that took up a lot of time. Also, the structure was not followed at the beginning, and I needed to redirect everyone, including nursing to the structure of SIBR. … I will address this asap! ”
– SIBR Rounds Evaluator
“Dr. X was awesome, he called each family while rounding and was still able to finish in 60min. He did a great job!”
– SIBR Rounds Evaluator
Also, strong results were observed across the triple aim:
Patient Experience
'Doctors explained things': Pre = 40%, Post = 63% (+58%)
'Doctors listened to you': Pre = 50%, Post = 83% (+66%)
'Rate the hospital': Pre = 36%, Post = 66% (+80%)
Care Outcomes
Mortality: Pre = 13.6%, Post = 10.4% (-23%)
30-day readmits: Pre = 17.7%, Post = 16.4% (-7%)
Falls: Pre = 2.4/1,000 patient days, Post = 1.1/1,000 patient days
Throughput
Length of Stay: Pre = 6.7 days, Post = 6 days (-11%)
Orders by 9, DC by 11: Pre = 49%, Post = 69% (+42%)
Process Metrics – Duration & Quality
Significant variation in round duration was identified between Hospitalists. Hospitalist specific box-and-whisker plots were generated to highlight the intra-group variation. For example, it was found that some Hospitalists were not adhering to the SIBR ground rule of coming prepared to SIBR. Instead they were completing their primary data gathering at the bedside requiring the rest of the SIBR participants to wait before beginning the 6-step SIBR communication protocol. This was a cause of frustration for the other team members. With these insights, Leaders are able to intervene and reset the expectations around coming to SIBR fully prepared. Why the focus about ‘Starting on time’? If there are delays in the round beginning, staff become frustrated and will start to question the value of the process when they have other responsibilities.
While the overall SIBR quality scores for both units are high, this level of performance is only achieved because of timely interventions when dips in performance are efficiently addressed.For example, as part of the process monitoring, if it is reported that ‘SIBR did not start on time’ a trigger alert is sent to the SIBR supporting team who can then notify the unit leaders about an issue to address, or to commend the team on continuing to deliver SIBR rounds when faced with challenges.
“SIBR started 1/2 hr late hospitalist assessed pt’s during rounds greater than 5 min a pt. It took 89 min for SIBR on only 8 pt’s – too long.”
– SIBR Rounds Manager
Looking at the SIBR quality data for the ONC unit, the rate of ‘adequately addressing the discharge plan’ criteria in the first month after launch was 73%, two months after launch it was 91% and three months after launch it was 93%, where it has remained at a minimum each month.
Conclusion
Our novel methods created transparency and accountability, which helped us standardize and streamline our practice of hospital medicine. Significant insights into both unit’s day-to-day frontline care delivery were apparent. The units continue to cope with significant levels of float pool and agency nurses to provide cover, due to wider staffing and recruitment issues. This is, unfortunately, a common cause for safety concerns in many hospitals and a knock-on effect of the impact of COVID-19 on nurse retention. Yet, this only reinforces the need for standardized care practices to cope with migratory staff who are unfamiliar with units norms and can at times exhibit less of a sense of ownership or accountability to unit performance and outcomes than fulltime staff. Float/agency nurses must adapt to a new rounding process and delivery of patient information that can be challenging without experience. While staff are oriented to the process when on shift and given a SIBR nurse prep sheet to help them prepare, there is still an element of content delivery that requires practice and some coaching to get to a high-quality. While some staff are ‘born to SIBR’, many require coaching and feedback. “For SIBR on this day we had all floats from the CCU (critical care unit, who had not launched SIBR at this stage), so we had to run through the SIBR structure and what their role is. It did go well even though some have never done it.” – SIBR Rounds Manager The oncology unit has become the de facto “practice unit” for hospitalists from other units to gain experience in SIBR, prior to launching on their own units. Two additional units have launched SIBR with 3 more planning to launch in spring/summer 2023. As a consequence, 7 hospitalists have worked and gained SIBR experience on the ONC unit, versus only 2 new hospitalists on the PCU. With each new hospitalist starting SIBR, there is a learning curve to overcome that can cause a drop in performance. This will reduce in time as more hospitalist units begin SIBR and a general fluency with the process develops. Patients on the SIBR units know what time SIBR rounds will occur, and where possible the team will call a designated primary carer. Restricted hospital visiting hours currently limit onsite family participation in SIBR, which may be revised in the future. Team rounds data continues to be collected and utilized as part of the weekly unit leadership meetings to manage performance. We believe that any clinical program seeking to improve outcomes and streamline physician workflow, interprofessional communication would likely benefit from the methods adopted as a process to standardize their hospitalist care delivery.
