Rounds are rounds! And who has the time for them anymore anyway?
Staff know the difference between a high-value information and decision-making rich round versus four hours of clinical teaching or a safari round (O’Hare, 2008) through the darker recesses of the hospital. For rounds to be valuable they must be high value for everyone. For them to be high value and efficient, they have to be structured and interdisciplinary, not just multidisciplinary.
In multidisciplinary teams, individual professions treat the patient independently, with minimal inputs from other team members, and little to no focus on collective group work (Smith et al., 2018). Unfortunately, this is standard in many hospitals.
At various points in the day, the team members filter in and out of the patient’s ‘personal space’ completing their tasks and describing to the patient what they’ll do next. Each team member writes up their notes in the patient record using their preferred notation and language, then continue onto the next patient. Consequently, physicians have become orchestrator in chief – responsible for coordinating the independent inputs of other team members. While this is the norm, it is far from optimal. A natural consequence of this asynchronous care is clinical variation, uncertainty, and missed signals.
In asynchronous teams the variety of communication channels used to ‘support’ effective team collaboration can themselves be barriers to the formation of shared understanding, the common ground, between the team members about the patient (Kuziemsky and Varpio, 2010). Care progression is stifled and inefficient and patients inevitably become dissatisfied. For example, Nugus et al. (2010) reported that allied health team members in acute hospital settings typically believe opportunities for input into patient care to be ad hoc rather than systematic.
Attempts to achieve a shared clinical collaborative space and time have seen a shift towards multidisciplinary rounds in conference rooms. But these typically exclude the patient’s direct involvement. A common trend is for the charge nurse to represent the inputs of the bedside nurses. However, I have observed innumerable team rounds with patients in which the patient/family corrects the team’s misinformation or provides a new update: ‘I just did two laps of the unit’, ‘I had a bowel movement this morning’.
Patients are more complex than ever. Consequently, care delivery is an integrated collaborative process, across multiple providers and settings (Kuziemsky et al., 2011). Collaborative care delivery is an integrated continuum with multiple players, processes and tools. Collaboration itself should be a process of positive dialogues among clinicians and patients to address care needs (Abramson and Mizrahi, 2003).
Typically, decision making in collaborative care teams can take hours, and sometimes days to achieve as it involves obtaining input from multiple contributors to reach a decision (Kuziemsky et al., 2011). Hospital teams typically lack the common geography required to facilitate the shared time and space for the team to engage in collaborative decision making. This undermines the team’s ability to share inputs, resulting in delays and disruptions. Also, without sharing the same time and space it is difficult for care teams to actually become ‘teams’: there is no ‘forming’, ‘storming’, ‘norming’ and ‘performing’ (Tuckman and Jensen, 1977). The ‘team’ is more a loose knit collective. As a consequence, trust amongst the team is more difficult to establish.
Opportunities for collaborative care are further limited as a result of safari rounds, a lack of standardized workflows and processes, and daily professional schedules that are not designed to intersect and frequently compete. Patients, and team members, are frequently out of the loop and unsure of the plan. As a result, the patient chart becomes the primary mechanism through which insights are shared. Furthermore, common ground within the care team, the patient and their family becomes fragmented (Kuziemsky and Varpio, 2010). This erodes the team’s ability to deliver high-quality coordinated care and progress the plan efficiently forward.
Key information becomes hidden, profession specific language in the chart is at times hieroglyphic in terms of criticality and bewildering regarding readiness to transfer or discharge.
I don’t think the patient record was designed, or was ever intended, to be the de facto ‘clinical collaboration space’ for care teams. It is in effect a workaround masquerading as a collaborative decision-making support tool, resulting in the illusion of teamwork.
Unfortunately, hospitals have evolved into such complex monsters that coordinating the clinical team to coexist at the same time and space, daily, is often perceived an insurmountable task.
In contrast to multidisciplinary care, interdisciplinary teams focus on interprofessional learning and collaborative decision making, taking inputs from multiple stakeholders and synthesizing them together to form a cohesive plan. Interdisciplinary teams have shown significantly better results in nearly all measured dimensions compared to multidisciplinary teams (Körner, 2010)
Schmalenberg et al (2005) reported one study participant describing their multidisciplinary meetings as staff attending because they have to, everyone has their say in a unidirectional monologue report with no interaction or planning and “the faster they can get out, the better.” This was in contrast to another study participant who described their interdisciplinary meetings as “real collaboration”, where team members can discuss and disagree but understand the rationale for what they are being asked to do (Schmalenberg et al., 2005). Unfortunately, interdisciplinary rounds are hard to get right and reported outcomes have been mixed (Ratelle et al., 2019, Heip et al., 2021).
However, clinical microsystems focused on unit-oriented teams, patient-centered care processes with shared unit leadership and active monitoring of unit processes & outcomes have shown improvements across a range of measures (Clay-Williams et al., 2018, Basic et al., 2021, Schwartz et al., 2021). These clinical microsystems have taken the concept of interdisciplinary care further, by adding standardization, structure and governance.
Structured interdisciplinary rounds
A truly collaborative interdisciplinary care team includes the patient and family for a daily shared conversation about progress, emerging issues, the plan for the day and the plan for discharge. Furthermore, I believe it should happen at the bedside: the patient’s ‘safe space’ during hospitalization. The lead provider, bedside nurse, social worker, pharmacist etc. working in unison with the patient and family to progress care toward the shared goal. At 1Unit we call this process Structured Interdisciplinary Bedside Rounds (SIBR® rounds) (Stein et al., 2015). It follows a structure (6-steps), is customizable and flexible, yet doesn’t impose scripting.
Such a structure creates a very different clinical collaboration space for teams: interdependencies are discussed, changes in condition are more apparent, and the plan for the day and discharge are shared among the team and patient. To function efficiently, all team members must come prepared, i.e. have completed their primary data gathering and have their critical thinking ready to share with the team. This takes some engineering but is achievable for most units.
Collaboratively discussing a plan for the day and discharge as a team with the patient, repeatedly and reliably for each patient ensures that the plan is activated. Consequently, it also ensures early identification of any patient deviation from the expected trajectory. In this way, the team can engage in micro-adjustments to prevent patient decline. Less work and more clarity for all involved.
If your team rounds aren’t achieving this, I can see why you don’t think you have the time for them.
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Abramson, J.S. & Mizrahi, T., 2003. Understanding collaboration between social workers and physicians: Application of a typology. Social Work in Health Care, 37, 71-100.
Basic, D., Huynh, E.T., Gonzales, R. & Shanley, C.G., 2021. Twice-Weekly Structured Interdisciplinary Bedside Rounds and Falls among Older Adult Inpatients. Journal of the American Geriatrics Society, 69, 779-784.
Clay-Williams, R., Plumb, J., Luscombe, G.M., Hawke, C., Dalton, H., Shannon, G. & Johnson, J., 2018. Improving Teamwork and Patient Outcomes with Daily Structured Interdisciplinary Bedside Rounds: A Multimethod Evaluation. Journal of Hospital Medicine, 13, 311-317.
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Ratelle, J.T., Sawatsky, A.P., Kashiwagi, D.T., Schouten, W.M., Erwin, P.J., Gonzalo, J.D., Beckman, T.J. & West, C.P., 2019. Implementing bedside rounds to improve patient-centred outcomes: a systematic review. BMJ Quality & Safety, 28, 317-326.
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