Beverly M. Ford
Hourly Rounding: A Strategy to Improve Patient
Satisfaction Scores
P
atient satisfaction is an important phenomenon in the health
care industry. Health care organizations continually seek innovative
approaches to boost patient satisfaction scores. Several studies uncovered nursing behaviors essential to
patient satisfaction. Patients value
the nurse-patient relationship, as well
as time spent with them, continuity of
care, trust, compassion, respect, safety, understandable instructions, and
service quality. They also appreciate
reliability, responsiveness, and effective communication (Andaleeb,
Siddiqui, & Khandakar, 2007; Cheng,
Yang, & Chiang, 2003; Davis, 2005;
Fan, Burman, McDonell, & Fihn,
2005). Satisfaction surveys are used
to identify, measure, and track key
determinants of satisfaction (Pearson
Assessments, 2007).
The Committee on Quality
Health Care in America has worked
with the Institute of Medicine
(IOM) on the nation’s quality of
care since 1996, developing a new
paradigm for health care delivery
based on logic and evidence of
patient needs. The IOM (2001) purported successful care will serve
the needs of the patient, keep the
patient fully informed, allow the
patient to retain control through
more active participation, and be
mindful of patient values and preferences. Sofaer and Firminger
Beverly M. Ford, MSN, RN, BC, CMSRN,
is a Medical-Surgical Charge Nurse,
Baltimore Washington Medical Center,
Glen Burnie, MD.
188
(2005) supported these findings in
a study based on the aims and
rules in previous IOM reports.
They noted, “If we are truly to
achieve a health care system that
is patient-centered, we must continue to search for creative ways to
elicit, and heed the voice of the
patient” (p. 555).
Safety weighs heavily in patient
satisfaction. The Joint Commission
provides its accredited health care
organizations with a list of National
Patient Safety Goals and mandates
the requirements necessary to
improve patient safety (The Joint
Commission, 2008). Problematic
areas of health care are identified
with evidence-based and expertbased solutions designed to protect
patients (The Joint Commission,
2009). Examples of safety goals
include reducing risk of patient
harm related to falls, preventing
pressure ulcers, and enhancing
medication administration. Nurses
directly impact all these areas with
routine nursing care delivery.
Satisfaction is the perception
of the patient. Because nursing
services play a major role in
patient satisfaction, quality of care,
and safety, organizations continually must seek new ways to
improve these critical services.
One strategy called hourly rounding is a suggested method to
address these issues (Studer
Group, 2007). Hourly rounding is a
new, proactive approach to organizing nursing care that has garnered positive results; its focus on
patient-centered care has led to
notably improved patient satisfaction scores.
Purpose
The use of a proactive hourly
rounding strategy to improve
patient satisfaction is described.
Inspired by the work of Meade,
Bursell, and Ketelsen (2006), staff
at Baltimore Washington Medical
Center (BWMC) piloted hourly
rounding on several units.
Although results from this study
are not yet available, a brief case
study can demonstrate how results
at BWMC may compare to the
national study. The study’s purpose was to determine if patient
satisfaction increases significantly
as the new strategy is implemented.
Background
Baltimore Washington Medical
Center, a 311-bed facility that is
part of the University of Maryland
Medical System, is located on the
busy Baltimore and Washington,
DC, corridor. BWMC’s 2,600
employees cared for more than
200,000 patients in 2009. BWMC
was named the only Solucient® Top
100 Hospital in Maryland or the
District of Columbia in 2006
(Lanham, 2007). The award, which
is now known as Thompson
Reuters, benchmarks hospital performance across the nation in specific areas, including quality of
care, patient perception of care,
finance, and efficiency (Thompson
Reuters, 2010).
BWMC recently completed a
major expansion project to broaden emergency and critical care
services, and added women’s care
services in response to the needs
of the surrounding community. As
MEDSURG Nursing—May/June 2010—Vol. 19/No. 3
a result, nursing services continue
to expand. Leaders determined it is
crucial to maintain and/or exceed
the high standard of care as expansion occurs.
Patient satisfaction at BWMC is
monitored currently by the Jackson
Healthstream Organization and
uses the new Hospital Consumer
Assessment of Healthcare Providers
and Systems survey. This is a tool
co-developed by the Centers for
Medicare & Medicaid Services and
the Agency for Healthcare Research
and Quality (AHRQ). It provides a
nationally standardized and publicly reported benchmark of
patients’ perception of their care
(AHRQ, 2008).
What Is Hourly Rounding?
Developed by the Studer Group,
hourly rounding is another way of
organizing existing work. Its purpose is to anticipate and meet
patient needs routinely, and ensure
patient safety (Shaner-McRae,
2007). Rounding allows information
to be gathered in a structured way,
addressing problems before they
occur (Studer Group, 2005). Hourly
rounding addresses patient needs
proactively.
How Is Hourly Rounding
Performed?
Specific scripts and tactics for
hourly rounding provide consistency and continuity of patient care,
leading to better outcomes and
greater satisfaction (Leighty,
2006a). In the Studer study (Meade
et al., 2006), staff explained to
patients they would be checking on
them hourly to enhance their safety and address personal needs.
Staff members were taught to enter
the patient room, identify themselves, and tell patients they were
present to do their rounds (Wood,
2005). Scheduled tasks, such as
dressing changes or medication
administration, were performed.
Before leaving the room, nurses
addressed the four Ps: pain, personal needs, positioning, and
placement (Studer Group, 2007) as
the most frequent reasons patients
use the call light. Immediately
before leaving the room, staff asked
the patient if anything else was
needed, emphasizing they had the
time to address any needs. When
MEDSURG Nursing—May/June 2010—Vol. 19/No. 3
everything was completed, the
patient was informed a health care
staff member would return within
an hour to round again (Leighty,
2006a). Knowing someone will
return in an hour allowed patients
to cluster requests and alleviates
anxiety, contributing to their safety
and well-being (Wood, 2005). These
behaviors contributed to increased
patient satisfaction scores.
A Closer Look at the Four Ps
A specific set of actions are
addressed during each rounding
session. These actions, generally
clustered into four areas, are
designed to meet patient needs
and foster a relationship with each
patient (Meade et al., 2006). These
areas are described below.
Pain. The provider asks the
patient, “How is your pain?” After
identifying patient pain intensity,
the provider offers appropriate
measures as needed, including
position changes, guided imagery,
deep breathing exercises, diversion activities, and medication. Asneeded medications are offered
when a dose is due. Other comfort
measures such as mouth care are
implemented, and fluids are
offered.
Personal needs. The provider
asks the patient, “Do you need to
use the bathroom?” Toileting times
are scheduled with the patient,
with assistance offered as needed.
The provider remains with the
patient who requires assistance to
the bathroom or bedside commode and then assists the patient
back to the chair or bed.
Positioning. The provider checks
patient positioning and inquires,
“How can I make you more comfortable?” Risks of skin breakdown are
identified when the provider turns
the patient, performs hygiene, provides skin care, fluffs pillows, and
straightens linens. Turning schedules are observed, with all patients
who cannot turn independently
assisted with repositioning at least
every 2 hours. This includes keeping
heels up to help reduce heel pressure.
Placement. The provider verifies accessibility of possessions
and asks, “Do you need us to move
the call light, phone, water pitcher,
trash can, over-bed table, or any
other possessions within reach?”
Items used most frequently must
remain within easy reach of the
patient.
Hourly Rounding at BWMC
Following the same format as
the research by Meade and colleagues (2006), the study unit maintained call light logs on patients for
a 2-week period prior to rounding.
The researcher received approval
to test hourly rounding out on her
assigned patients for a 3-week period. Quantitative call light data were
collected during this time, along
with data from rounding logs and
discharge phone calls made to
those patients within 48 hours of
discharge. To serve as controls, a
random sample of patients who did
not receive hourly rounds also
were tracked for call light use and
results of the follow up discharge
phone survey. Results were analyzed and compared to the national
data.
Findings
During the 3-week period, the
researcher rounded on up to nine
patients per day (maximum of six
patients at any given time). The 51patient sample included 29 females
(57%) and 22 males (43%). Patients
ranged in age from 21 to 90, with
the mean age 58. All patients were
alert, oriented, and able to communicate their needs to nursing staff,
and received hourly rounding by
one nurse.
Call light logs from the case
study showed a 52% decline in call
light use after initiating hourly
rounding (see Figures 1 and 2 for
description of call light use). This
decrease in call light use reflected
results of the national study
(Meade et al., 2006), and has substantial implications for nursing.
With less interruption by call lights,
units are quieter and nurses have
more time to concentrate on
patient care and charting.
No falls were reported during
the study period, possibly due to
the higher frequency of patient
contact. However, no additional
data were collected because of the
brevity of this study. When the
study is completed, results are
expected to be similar to the
national findings.
189
Figure 1.
Results by Category for Call Light Usage Before Initiation
of Hourly Rounding
Pain
19%
Other
58%
Personal Needs
14%
Error
8%
Positioning
1%
Placement
0
Figure 2.
Results by Category for Call Light Usage after Initiation
of Hourly Rounding
Pain
17%
Other
57%
Personal Needs
12%
Positioning
5%
Error
7%
Discharge phone calls to
patients who received hourly
rounding reflected their satisfaction
with their overall care. Their comments on specific areas of nursing
care reflected the perception of
receiving superior care by nursing
staff, including pain management,
comfort, and safety. Other responses included patients’ satisfaction
when staff members took the time
to listen to them.
190
Placement
2%
Clinical Implications
Call light use. With call lights
ringing less, the nurse spends more
time on patient care instead of
going from room to room dealing
with issues as they arise. During
nursing rounds, the nurse gets a
good grasp on the patient’s needs
and uses the opportunity to plan
with the patient. The patient knows
nursing staff members will return
as promised, and uses the call light
less frequently.
Patient falls. Hospitals that
incorporate hourly rounding note
positive improvements in patient
safety; patient falls occur less frequently (Meade et al., 2006). When
staff members round on patients
every hour and address basic
needs, such as toileting and placement of personal items, risks for
falls decrease. Patients are less likely to get out of bed when personal
needs are met.
Pressure ulcers. Turning and
repositioning are considered basic
nursing care. When nursing staff
members maintain regular turning
and positioning schedules with
their patients, pressure ulcer rates
on inpatient cases can decrease by
up to 56% (Studer Group, 2007). In
patients with existing wounds, regular turn schedules contribute to
the healing process.
Patient satisfaction. According
to Christine Meade, chief researcher
in the nationwide Studer studies on
hourly rounding, increased nursing
presence leads to better quality of
care which in turn has a positive
effect on patient satisfaction scores
(Leighty, 2006a). Using specific
scripts and eliciting key information
from the patient about personal
needs allows the nurse and patient
to develop a plan of care that is optimal for both players. Satisfaction
was 92%-98% in Meade’s national
studies (Leighty, 2006a; Meade at al.,
2006; Studer, 2007).
Nursing satisfaction. Nursing
care is more efficient and less
stressful when hourly rounding is
performed. Hourly rounding frees
more nursing time and decreases
frustration by optimizing shift time
utilization (Leighty, 2006a). Could
this strategy help to keep more
nurses at the bedside in the midst
of the current nursing shortage
(Meade et al., 2006)?
Conclusion
Hourly rounding is “about
engaging the patients – going in
and finding out their needs and
accomplishing tasks” (Leighty,
2006b). Mary Shepherd, RN, nursing project and Magnet® program
director, The Methodist Hospital,
Houston, TX, noted, “...rounding is
a common sense approach to
patient care, but it is not always
common practice” (Sigma Theta
MEDSURG Nursing—May/June 2010—Vol. 19/No. 3
Tau International, 2006). Nurses,
proactive with rounding, “are finding their shifts less stressful, their
time more productive, and patient
safety and satisfaction scores hitting all-time highs” (Leighty,
2006b). The positive results of
rounding exceed expectations in
most facilities where the strategy
has been used. Consistent hourly
rounding is a key for improving
safety and quality of care; it
results in fewer call light interruptions, allowing nurses to organize
their time better and reduce
stress. Additionally, patients are
less anxious. Hourly rounding contributes in several key areas to
achievement of high levels of
patient satisfaction, including
quality of care and patient safety
(Meade et al., 2006).
Pearson Assessments. (2007). Patient satisfaction surveys. Retrieved from
http://survey.pearsonassessments.com/
audience/patient.htm
Shaner-McRae, H. (2007). Notes on nursing.
Retrieved from http://www.fahc.org/
Nursing/nursing_contribution/NON_200
7/02-07_NON.pdf
Sigma Theta Tau International. (2006).
RNews capsules. Retrieved from
http://www2.nursingsociety.org/RNL/4Q
_2006/columns/rnews_capsules.html
Sofaer, S., & Firminger, K. (2005). Patient perceptions of the quality of health services.
Annual Review of Public Health, 26,
513-559.
Studer Group. (2005). The magic of rounding:
Quint Studer brings a leadership technique from medicine into the world of
business. Retrieved from http://www.
studergroup.com/dotCMS/knowledge
AssetDetail?inode=111088
Studer Group. (2007). Hourly rounding supplement. Retrieved from http://www.mc.vanderbilt.edu/root/pdfs/nursing/hourly_roun
ding_supplement-studer_group.pdf
The Joint Commission. (2008). 2008 National
Patient Safety Goals: Hospital program.
Retrieved from http://www.jointcommission.org/PatientSafety/NationalPatientS
afetyGoals/08_hap_npsgs.htm
The Joint Commission. (2009). National
Patient Safety Goals: Evaluating safety
and quality using the national patient
safety goals. Retrieved from http://www.
jointcommission.org/GeneralPublic/NPS
G/gp_npsg.htm?print=yes
Thompson Reuters. (2010). New 2009 100
top hospitals: National benchmarks
study. Retrieved from http://www.100top
hospitals.com/top-national-hospitals/
Wood, D. (2005). Rounding cuts call-light use.
Retrieved
from
http://w3.rn.com/
news_news.asp?articleID=14521&page
=RN%5FNews&Profile=RN%5FNews&
Headline=Rounding+Cuts+Call%2DLigh
t+Use
Additional Reading
Studer Group. (2006). Improve clinical outcomes with hourly roundingsm.
Retrieved from http:/studergroup.com/
newsletter/Vol1_Issue7/fall2006_sec1.h
tm
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